Endocrinology

A 51-year-old man with hypertension, type 2 diabetes mellitus, and hypercholesterolemiapresents with a 1-hour history of substernal chest discomfort anddyspnea. He was given sublingual nitroglycerin in the emergency department,but his symptoms did not resolve.

For several months, a 16-year-old girl has had an asymptomatic papulosquamousdescending linear eruption on 1 leg.

A 34-year-old man has had Crohn disease for 12years. He presented initially with ileitis and has had 3surgeries for obstructive complications. Ileum resectionhas resulted in bile salt and fat malabsorption. Recently,the Crohn disease has spread to the large bowel. For thelast 2 years, he has also had seronegative spondyloarthropathy-another complication of Crohn disease.

Q:Is there a role for inhaled corticosteroids in chronic obstructivepulmonary disease (COPD)?

An 84-year-old woman presents with a 3-year history of slowly progressivememory impairment accompanied by functional decline. Thepatient lives alone but has been receiving an increasing amount of support from her 2 daughters,who accompany her to the appointment. The daughters first noticed that their mother was havingtrouble driving. About a year ago, she started forgetting family recipes. She also left food cookingon the stove unattended and burned several pans. Currently, the daughters are providing mealsand transportation, assisting with housework, and doing their mother’s laundry. They have becomeincreasingly alarmed because she takes her medications only sporadically, despite the factthat they fill her pillboxes and call her regularly with reminders. Their chief concern is whether itis safe for their mother to continue to live alone.

For 3 months, a 57-year-old woman has had a persistent green nail that is occasionallyslightly sore; the nail plate has lifted. Another physician prescribed a7-day course of levofloxacin for a suspected Pseudomonas infection; the treatmenthad no effect on the nail. A subsequent 7-day course of norfloxacin wasalso unsuccessful. The patient is otherwise healthy.

For the past 2 days, an elderly woman has had severe pain in and discharge from the right ear. She has diabetes, which is well controlled with anoral hypoglycemic agent, and eczematous dermatitis.

A 67-year-old woman who is being treated as an inpatient for head traumacomplains of vague tenderness during an abdominal examination. Othercomplaints are difficult to assess. She had been placed on an oxygen ventilator;however, her cognitive function and pulmonary function are improving, andher cerebral edema is diminished.

SAN ANTONIO -- The advent of endocrine therapy for breast cancer has raised a host of unanswered questions about who should get the new drugs, when, and what should be done about treatment side effects, researchers said here.

SAN ANTONIO -- Premature ovarian failure during breast cancer treatment may mean a better relapse free survival, according to Austrian researchers.

SAN ANTONIO -- Premature ovarian failure during breast cancer treatment may mean a better relapse free survival, according to Austrian researchers.

ABSTRACT: Age-related changes that affect drug distribution, such as increased total body fat, decreased muscle mass, and decreased total body water, necessitate reduction in the dosage of water- and lipid-soluble agents. Because creatinine clearance declines with age, the dosage of agents that are excreted primarily by the kidney must also be lowered to prevent toxicity. Examples include aminoglycosides, fluoroquinolones, penicillins, procainamide, lithium, angiotensin-converting enzyme inhibitors, and digoxin. A good rule of thumb to follow until creatinine clearance can be calculated is to reduce the total dose by half in frail elderly persons or in those with established renal disease. Anticholinergic agents should be used with caution because they are associated with urinary retention, heart block, constipation, dry mouth, blurred vision, sedation, and acute or chronic confusion in elderly patients.

ABSTRACT: Painful recurrent ulceration of gingival tissue suggests a secondary intraoral presentation of herpes simplex virus (HSV) infection. Unlike the lesions of HSV, lesions associated with coxsackievirus do not erupt in the anterior mouth but rather on the soft palate and pharynx. Furthermore, unlike HSV infection, coxsackie infections may recur, because there is considerable viral variation. Patients with atrophic or erythematous candidiasis report burning pain and a metallic taste. The typical patient with benign mucous membrane pemphigoid is a woman older than 50 years; the condition usually involves the attached gingiva around the teeth. The lesions of erythema multiforme may erupt on any intraoral mucosa; biopsy may be required to rule out other conditions with similar presentations.

If you notice labile thyroid-stimulating hormone (TSH) values in a patient receiving levothyroxine therapy for primary hypothyroidism, ask how he or she takes the medication. Levothyroxine should always be taken on an empty stomach (usually first thing in the morning) with water only; no other fluids, food, or medications should be consumed for 30 minutes afterwards.

During a routine checkup, a middle-aged woman asks you whether she should stop wearing moisturizers and makeup that contain sunscreen. She has read that increased sunlight exposure enhances vitamin D production, which may prevent certain types of cancer. What would you tell her?

BIRMINGHAM, England -- For early breast cancer, a fourth chemotherapy agent mixed in with a standard trio proved to make a superior adjuvant combination, researchers here reported.

A 48-year-old woman complains of finger and knuckle pain in her right hand of 1 year's duration. She is right-handed. The pain is located over the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the index and middle fingers. The pain has recently become more intense and now makes it difficult to sleep and to grasp objects.

If Rip Van Winkle were a primary care physician who fell asleep a generation ago and woke up today, what would he think? He would have missed the arrival of managed care. He wouldn't know what a hospitalist does. He might ask how this evasive concept called quality is measured . . . and then cringe at the idea of "report cards" and "pay for performance."

If Rip Van Winkle were a primary care physician who fell asleep a generation ago and woke up today, what would he think?

BOSTON -- Building computers may bestow an increased risk of several kinds of cancer, according to an analysis of a large mortality database available.

ROCHESTER, Minn. -- The widely used anti-aging supplement DHEA (dehydroepiandrosterone) has no beneficial effect on body composition, physical performance, insulin sensitivity, or quality of life, according to Mayo Clinic researchers.

NASHVILLE, Tenn. -- Weight, height, and race independently influence prostate-specific antigen (PSA) levels, and each may distort the risk of prostate cancer, researchers here reported.

LOS ANGELES -- PET scans suggest that mental fog and memory problems after chemotherapy and other adjuvant therapy, the chemobrain phenomenon, may be caused by metabolic changes in the basal ganglia and frontal cortex.

The normal thyroid-stimulating hormone (TSH) reference range at our laboratory is 0.35 to 5.5 mIU/L. When I am treating a patient with levothyroxine, I do not adjust the dosage if the TSH level is within this range and the patient is otherwise asymptomatic. A colleague tells me that I should be adjusting the levothyroxine dosage to keep the TSH level below 2 mIU/L. He feels that lower TSH levels are associated with improved lipid profiles.

Recent laboratory guidelines from the National Academy of Clinical Biochemistry indicate that more than 95% of persons with normal thyroid function have a TSH level of less than 2.5 mIU/L.

OTTAWA, Ontario -- A large study of women with cosmetic breast implants found they had a suicide rate over two decades that was 73% higher than the general population -- but the rate was similar to that of women who had other cosmetic procedures.

ABSTRACT: Subclinical hypothyroidism is associated with elevated low-density lipoprotein (LDL) cholesterol levels and several factors related to atherosclerosis, including increased C-reactive protein levels and impaired endothelium-dependent vasodilatation. However, considerable controversy exists about screening for and treating this thyroid disorder. Thyroxine therapy lowers elevated LDL cholesterol levels in patients whose serum thyroid-stimulating hormone (TSH) concentrations are higher than 10 mIU/L ; thus, most experts recommend treatment for such patients. However, there is no consensus regarding the management of patients with TSH levels of less than 10 mIU/L. Although the evidence supporting treatment of these patients is not compelling, it is reasonable to offer a therapeutic trial of thyroxine to those who have symptoms.

ABSTRACT: Our knowledge of chronic diseases has advanced significantly in recent decades, but patient outcomes have not kept pace. This is largely because the traditional acute care model does not adequately address the needs of patients with chronic disease. Patients play an active role in the management of chronic disease, and successful outcomes are highly dependent on adherence to treatment. Thus, clinicians need to have skills in coaching and encouraging as well as an awareness of factors in patients' backgrounds that are likely to affect their ability or willingness to follow treatment plans. Provider- and system-related factors, such as lack of reimbursement for counseling and high copayments, can also act as barriers to compliance. Among the strategies that can improve adherence are the use of community resources, multidisciplinary approaches, and regular follow-up.

The optimal approach to subclinical hypothyroidism continues to be debated. Experts disagree over screening for thyroid dysfunction, the threshold TSH level for treatment, and the upper limit of normal of the TSH reference range.

Over the past few decades, the management of chronic disease has assumed a greater role in health care. Diseases such as diabetes, chronic obstructive pulmonary disease, and depression have replaced acute disorders as the leading cause of morbidity, mortality, and health care expenditures.