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Girl With Mildly Pruritic Maculopapular RashA 10-year-old girl has had a worsening rash for 1 week. The mildly pruritic, nontender eruption initially appeared on the child's thighs and then spread to the arms and face. The child's right hand, feet, and ankles have been swollen for the past 4 days, which has made ambulation intermittently painful.
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A Comparison of the Clinical Effectiveness and Cost-Effectiveness of Treatments for Moderate to Severe PsoriasisThis study investigated the clinical effectiveness and cost-effectiveness of treatments for moderate to severe psoriasis from a managed health care systems perspective. An analysis was conducted of randomized clinical trials evaluating biologic and oral systemic medications and phototherapy for patients with moderate to severe psoriasis.
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Counseling for Smoking Cessation Gets Its Own CPT CodesCHICAGO -- Physicians will be able to report smoking-cessation counseling efforts soon using two new Current Procedural Terminology (CPT) codes that address tobacco use specifically.
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Clostridium subterminale - Infection Secondary to an Open FractureClostridia are anaerobic, spore-forming, gram-positive bacilli that are ubiquitious in nature. They can be isolated from soil and the GI tract of animals and humans.1
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Boerhaave SyndromeAn 85-year-old white woman was brought to the emergency department (ED) with acute, severe left posterolateral chest wall pain of several hours' duration. The nonradiating pain was accompanied by shortness of breath. She denied palpitations, diaphoresis, syncope, or dizziness.
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Pheochromocytoma: Do You Know the Classic Triad of Symptoms?A 49-year-old man presents for a routine examination. He has a 15-year history of essential hypertension and a 7-year history of hypercholesterolemia and type 2 diabetes mellitus.
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Incomplete LV Rupture Secondary to MI: A Case of Intramyocardial DissectionMyocardial rupture is the most feared and often lethal complication of acute MI. It was a potential diagnosis for this patient who presented with sinus tachycardia, ST-segment elevation from V1 to V4, II, III, and aVF with associated Q waves. Follow the workup and outcome here.
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Disseminated Histoplasmosis in a Woman With History of Polymyositis and Possible DermatomyositisFor 3 days, a 28-year-old woman with a history of polymyositis and possible dermatomyositis had fever, chills, and nonproductive cough. She complained of rash, joint pain, and progressive immobility because of severe muscle weakness. For the past 6 years, she had been taking prednisone (60 mg/d), hydroxychloroquine (200 mg bid), and tramadol (100 mg q6h prn for pain).
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Preventive measures are still the best strategy Aspiration syndromes: Pneumonia and pneumonitis key words: Aspiration, Pneumonitis, Pneumoniaabstract: While the risk factors for aspiration pneumonia are similar to those for aspiration pneumonitis, the 2 syndromes have different presentations. Aspiration pneumonia tends to occur in older patients or in those with neurological diseases, and the aspiration is not usually witnessed. Aspiration pneumonitis is more likely to occur in patients undergoing anesthesia or in those with acute drug and alcohol overdoses, and the aspiration is often witnessed. The workup may include bedside assessment of the cough and gag reflexes, chest radiography, videofluoroscopic imaging, or fiberoptic endoscopy. Empiric antibiotic therapy should be avoided in most patients with pneumonitis; however, antibiotics may be indicated for those at high risk for bacterial colonization of oropharyngeal and gastric contents who have fever, increasing sputum production, or new infiltrates or for those who fail to improve within 48 hours. (J Respir Dis. 2007;28(9):370-385)
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Physician Groups Press Congress to Override SCHIP VetoWASHINGTON -- The AMA said it was "deeply disappointed" with President Bush's veto of the SCHIP reauthorization, and the American Academy of Pediatrics called the action "hurtful to children."
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McCain Health Plan Aims to Cut Costs to Forestall ImplosionWASHINGTON -- Republican presidential candidate John McCain unveiled a health plan today that focuses more sharply on reducing costs than providing coverage for the uninsured.
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Hand Injuries, Part 2:When you suspect blunt nerve trauma, referral to a hand surgeon is prudent-even without evidence of acute compartment syndrome. The same is true if you discover ischemia in any part of the hand after injury. Try to control hemorrhage with compression and elevation of the involved extremity. If this is unsuccessful, use a short-duration tourniquet. Do not attempt to clamp a bleeding vessel; the risk of causing serious nerve or tendon damage is too high. Avoid exploring wounds in the region distal to the midpalmar crease and proximal to the proximal interphalangeal flexor crease because of the high risk of damaging the flexor tendons and the annular ligaments in this region. Explore more proximal injuries cautiously to determine occult injury to the flexor tendon.
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COX-2 Inhibitor Therapy: When Is Monitoring Required?Q:Is periodic laboratory monitoring recommended for patients withosteoarthritis who are receiving long-term cyclooxygenase-2 (COX-2)inhibitor therapy and who have no GI or renal symptoms? Similarly,is laboratory monitoring recommended for women who take a selectiveCOX-2 inhibitor to alleviate menstrual cramps (eg, rofecoxib, 50 mg/d,3 to 5 days per month)?--Sarita Salzberg, MDColumbus, Ohio
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Drug Therapy in the Elderly:Numerous factors put elderly patients at risk for adverse drug events. On average, they take at least 6 medications a day, which increases the likelihood of drug-drug interactions. In addition, many drugs that are safe and effective in younger patients are inappropriate for older persons because of age-related changes and comorbid conditions that affect absorption, distribution, metabolism, and elimination. First-pass metabolism decreases with age, which may increase systemic absorption of some oral nitrates, ß-blockers, estrogens, and calcium channel blockers. The age-related rise in body fat increases the volume of distribution of lipid-soluble compounds, such as diazepam, and prolongs clearance. About two thirds of elderly persons have impaired kidney function; in these patients, the dosage of renally excreted drugs-such as digoxin-needs to be reduced. Other strategies for avoiding adverse drug events are detailed here.
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Invasive Fungal SinusitisWith advances in chemotherapy, transplantation, and the treatment of diabetes and HIV infection, fungal sinusitis has become increasingly recognized in patients in these at-risk groups.
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Man With Painful Shoulder AbscessFor 2 weeks, a 31-year-old man has had a nonhealing, painful abscess on his left shoulder. A week before presentation, he sought treatment at a walk-in clinic; the abscess was incised and drained, and he was given gatifloxacin.
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Psoas AbscessA 49-year-old woman with a history of alcoholic cirrhosis, esophageal varices, coronary artery disease, diabetes mellitus, and hypertension presented to the emergency department with a 2-day history of fever, chills, nausea, and back and abdominal pain. The pain began on the right side, progressed to the lower back, and radiated into the right anterior thigh and groin area.
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Case In Point: Coexisting Hodgkin disease and lung cancer in a patient with AIDSThe patient was a 41-year-old manwith a history of HIV infection diagnosed10 years before admission.He had been noncompliant withtreatment, and therapy with tenofovir,efavirenz, and lamivudinehad not been started until 2 monthsbefore admission, when he presentedto another hospital. At thetime, his CD4+ cell count was156/µL and his viral load was45,743 copies/mL. He also had ahistory of incarceration; had usedinjection drugs, cocaine, alcohol,and marijuana; and had a 20-packyeartobacco history.
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Chest Film Clinic: What caused persistent cough and dyspnea in this patient?A 65-year-old woman presented to her primary care physician with a 3-month history of worsening cough, now productive of copious blood-tinged secretions. She also reported a recent onset of fever and dyspnea. She denied any chest pain, chills, night sweats, and weight loss.
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The Obesity and Dementia LinkGrowing evidence suggests a link between obesity and dementia, but risk may be heightened or lowered, depending on age. In this study, early to mid-life obesity was linked with increased risk of later dementia.
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Obesity May Be Associated with Abnormal Bowel HabitsA recent study found that obese or severely obese patients have a 60% higher risk of chronic diarrhea vs those who are within a normal weight range.
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When to obtain cultures from patients with community-acquired pneumoniaAbstract: The use of sputum studies and blood cultures in patients hospitalized with community-acquired pneumonia (CAP) is somewhat controversial, and recommendations continue to evolve. A reasonable approach is to attempt to obtain sputum cultures from all patients before initiating antibiotic therapy. If antibiotics have already been given, sputum studies can be reserved for patients who are severely ill or who are at risk for infection with a resistant organism or an organism that is not covered by the usual empiric therapy. The Infectious Diseases Society of America and the American Thoracic Society both recommend obtaining blood cultures from all patients. However, cost considerations have led to alternative strategies, such as reserving blood cultures for those with severe CAP. (J Respir Dis. 2005;26(4):143-148)
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Lung IncidentalomaDuring the evaluation of a 61-year-old man who had sustained mild head and upper trunk injuries in a car accident, a right lower lobe consolidation was noted on the chest radiograph. There was no evidence of rib fracture. A chest CT scan with contrast showed a hilar mass that obstructed the lateral segmental bronchi of the right lower lobe. Atelectasis of the posteromedial segments of the right lower lobe and ipsilateral subcarinal adenopathy were also noted.
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Giant Bullous EmphysemaA 54-year-old man presented to the ED with palpitations identified as atrial flutter and RVR. Medical history included stage IV renal-cell carcinoma, end-stage COPD, NYHA class IV heart failure, and recent pulmonary embolism. A CT scan of the thorax was ordered.
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Persistent Headache in a Young WomanHeadache and nausea have bothered this 28-year-old for 3 days. Over-the-counter analgesics do not help. She reports the headache lessens during the day. What more do you need to know?
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Prevention as a Replacement for Breakdown MedicineMuch of health care today consists of treatment of disease. Few resources are allocated to prevent disease. Many treatments are not delivered optimally because of a lack of patient discipline and insufficient follow-up by physicians and other health care providers.
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Antimicrobial Resistance Update: Klebsiella pneumoniae CarbapenemasesThe rapid spread of Klebsiella pneumoniae carbapenemases (KPCs) is limiting the effectiveness of carbapenems in the treatment of multidrug-resistant infections. The resistance genes found in KPCs have been identified in other organisms as well and have properties that have raised concerns regarding their transmissibility and epidemic potential.
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Mycobacterium goodii Infection of a Total Knee ProsthesisMycobacterium goodii infection is uncommon and probablyoccurs via disruption of skin and bone integrity or theintroduction of a foreign body into viscera, namely implantationof a prosthetic device. We describe a case of nosocomial,total knee arthroplasty–associated M goodii infection thatrequired combined antibiotic and surgical therapy for clinicalmanagement. An infection control investigation revealed thatthe source of the organism might have been the water in theoperating room scrub faucets. [Infect Med. 2008;25:522-525]
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BMI Opens Door to Weighty DiscussionTo initiate a discussion with a patient about excess weight without causing embarrassment or offense, try reporting the patient's body mass index.
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Smallpox Vaccination: The Risks for Patients With Atopic DermatitisBecause of recent threats of bioterrorism, smallpox vaccination was reinstated in the United States earlier this year. Since January 2003, more than 35,000 civilian and public health care workers in 54 jurisdictions have been vaccinated.
