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Lisfranc Ligamental InjuryAfter a fall during a soccer match 2 weeks earlier, a 26-year-old woman had pain of the right midfoot, with moderate swelling. The pain was aggravated with a normal gait and alleviated with an antalgic gait, specifically with inversion of the right ankle such that most of the weight from heel-strike through toe-off transmitted forces from the lateral calcaneus through the fifth metatarsus to the fifth phalanx.
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Heart Failure: Patient Selection and TreatmentABSTRACT: Angiotensin-converting enzyme (ACE) inhibitor therapy is recommended for all patients with heart failure (HF) and a reduced ejection fraction. It is generally initiated in the hospital at low doses as inotropic therapy is tapered. Angiotensin II receptor blockers may be a suitable alternative for patients who cannot tolerate ACE inhibitors. For patients who cannot tolerate either class of drug, a combination of hydralazine and a nitrate is recommended. ß-Blockers are first-line therapy for patients with current or previous symptoms of HF and reduced left ventricular function, as well as all patients hospitalized for HF. An aldosterone antagonist may be added to the regimen of patients with moderately severe to severe symptoms and reduced ejection fraction whose renal function and potassium concentration can be monitored.
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Managing Post-traumatic Stress Disorder: The Pharmacotherapy OptionFirst-line agents include selective serotonin reuptake inhibitors and venlafaxine.
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Case In Point: Fever and a chest wall mass in a young manCoccidioides immitis is a di-morphic fungus that causes pulmonary disease with a variety of clinical and radiographic presentations. Miliary pulmonary disease is very uncommon and is found almost exclusively in immunocompromised patients. The authors describe the case of an immunocompetent patient who had disseminated coccidioidomycosis with a miliary pulmonary disease pattern. Obtaining a careful travel history and considering regional fungal infections was integral to making a prompt diagnosis.
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Effect of Health Plan and Physician Clinic Collaboration on Increasing Omeprazole UseA proposal for a pilot project to save money for a health plan was developed collaboratively with a clinic manager and the medical director of a local clinic. The goal was to encourage and support physicians in changing the proton pump inhibitor (PPI) medication prescribed for patients from a brand-name PPI to omeprazole, a more cost-effective generic option. The health plan identified members who had filled a prescription for a brand-name PPI and asked their physicians to consider switching the patients’ therapy to omeprazole. If the physician agreed to the change, the clinic would then send a letter to the patient, in which the physician recommended the change along with a new prescription for omeprazole. Following successful implementation in the initial pilot clinic, the program was extended to 4 more clinics. After achieving significant cost savings at all 5 clinics, the health plan is now expanding the program to more clinics as well as considering launching similar programs targeting other medication classes. (Drug Benefit Trends. 2009;21:158-163)
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Case In Point: Erythema Ab IgneA 14-year-old African American boy presented during the winter months with a painless, nonpruritic, periumbilical rash that had been present for approximately 1 month. Initially bluish, the rash had become dark brown.
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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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Parkinson Disease: REFERENCES: EVIDENCE-BASED MEDICINE: RELEVANT GUIDELINES:ABSTRACT: Signs that strongly suggest Parkinson disease (PD) include unilateral hand tremor, slowed or decreased movement, and gait changes. Postural alterations include leaning forward or asymmetric shoulder height; the arm may not swing when the patient walks, or it may be held flexed at the elbow. Patients may report increasing difficulties in occupational and social functioning. Mimics of PD include essential tremor, normal pressure hydrocephalus, other neurodegenerative diseases, and drug-induced parkinsonism. Most patients report such nonmotor symptoms as sleep disturbances, visual difficulties, bowel and bladder problems, fatigue, depression, and anxiety. Cognitive impairment in many patients takes the form of slowing of memory and difficulty with visual spatial tasks and executive function. A more realistic treatment goal than tremor eradication is improved overall mobility.
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Incidental Lytic Lesion Seen on Chest RadiographChest x-ray in an older man confirmed a diagnosis of pneumonia but revealed an asymptomatic lesion in the left humerus. What is in the differential?
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Incidental Lytic Lesion Seen on Chest RadiographChest x-ray in an older man confirmed a diagnosis of pneumonia but revealed an asymptomatic lesion in the left humerus. What is in the differential?
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Boy With Ankle Pain, Erythema, and EdemaTHE CASE: A 7-year-old boy has had left ankle pain for 2 days. Neither he nor his mother can recall any recent trauma to the joint. He is usually very active, but he has been unable to bear weight on the left foot and has been resting in bed. His mother reports that he had some tactile fevers, which were transiently relieved with ibuprofen, and that he has been eating and drinking normally. Despite the application of ice and elevation, the ankle has become red and swollen.
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Transient ST Elevations and Conduction Delay After Traumatic Fracture of the SternumA 25-year-old man with no significant medical history was attempting to move a heavy container when he lost control and became pinned between the container and a concrete pole.
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Moles and Melanoma: REFERENCES:ABSTRACT: Melanomas usually do not arise from nevi; they are thought to result from UV radiation-induced DNA damage and genetic factors. The most important risk factors for melanoma are a personal history of atypical nevi, a family or personal history of melanoma, and large numbers of nevi. The ABCD criteria (asymmetry, border irregularity, color variegation, diameter larger than 6 mm) help identify early, thin tumors that might otherwise be confused with benign pigmented lesions. The E criterion has recently been added: an evolving lesion (one that shows any change in size, shape, symptoms, surface, or color) warrants prompt evaluation. If melanoma is suspected, total excision--rather than shave biopsy--is required. Melanomas that are detected and treated in the radial or early vertical phase have an excellent prognosis.
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Pleural EffusionCongestive heart failure and cirrhosis are the most common causes of transudative pleural effusions, while pneumonia and malignancy are responsible for the majority of exudative effusions. Plain chest films are valuable in confirming the presence of an effusion, providing clues to the cause, and directing the method of pleural fluid sampling. Thoracentesis is safe and simple, and it is diagnostic in about 75% of cases. Pleural biopsy is indicated for unexplained exudative effusions, most of which are found to result from malignancy or tuberculosis. Medical thoracoscopy, if available, is the procedure of choice for patients with these effusions. Thoracoscopy permits visually directed pleural biopsies and allows for therapeutic intervention at the time of diagnosis, obviating the need for subsequent invasive procedures.
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Scurvy, Pellagra, and Beri BeriA 38-year-old woman presented with bruising and pain of the lower extremities and dyspnea on exertion. She had had these symptoms for 3 weeks. She denied hematuria, melena, hematemesis, fever, or abdominal pain. Results of routine blood work showed a hemoglobin level of 6.4 g/dL (19 months earlier, this level was 15.8 g/dL).
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Batting Averages and Sex ImprovementHere’s a look at what’s new and interesting on the Web for health care professionals.
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Pulmonary Pearls: A 61-year-old woman with insidious onset of dyspneaA 61-year-old woman presented with progressive dyspnea of 5 months' duration. She first noticed dyspnea while engaged in her usual daily activities, and it gradually progressed in severity. A primary care physician prescribed bronchodilators without relief. She was subsequently referred for a pulmonary evaluation.
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Evidence-Based Perspective on Metabolic Syndrome and Use of AntipsychoticsSchizophrenia, a devastating mental illness that affects nearly 2.2 million Americans, is associated with high rates of morbidity and mortality.1 Persons with schizophrenia have a 20% shorter life expectancy than the general population.1,2 Furthermore, among persons with schizophrenia, there is an increased prevalence of metabolic syndrome characterized by a constellation of risk factors, including insulin resistance, abdominal obesity, dyslipidemia, hyperglycemia, and hypertension,3
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Polymicrobial Wound Infection and Nerve Injury Secondary to a Nonhuman Primate BiteNonhuman primate bites in the United States are rare. Mostphysicians have no experience managing them. The lesionsare initially treated in much the same way as human bites,although consultation with an infectious diseases specialist,surgeon, and veterinarian are recommended, especially formicrobial infection control and management. Of particularconcern is animal-to-human transmission of herpes B virus,which can be fatal. We report a case of polymicrobial simianbite wound infection with associated nerve injury in a12-year-old boy. [Infect Med. 2008;25:120-122]
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Bronchiectasis, part 2: ManagementSystemic antibiotics are the mainstay of the managementof acute exacerbations of bronchiectasis. Antibiotic selection should include coverage for Streptococcus pneumoniaeand Haemophilus influenzae; particular attention alsoshould be paid to the presence of Staphylococcus aureus andPseudomonas species. There is some evidence that long-termlow-dose macrolide therapy can reduce the incidence of acuteexacerbations and decrease sputum production. There alsomay be a role for the use of inhaled antibiotics in the treatmentof bronchiectasis. Airway clearance strategies, such as chestpercussion and postural drainage, are clearly useful in patientswith cystic fibrosis and may be useful in managing bronchiectasisin other patients. Surgical resection can be considered if apatient has localized disease that is refractory to medical managementor if he or she is unwilling to undergo long-term medicaltherapy. (J Respir Dis. 2008;29(1):20-25)
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Effects of Multidisciplinary Care of Heart Failure Patients at High Risk for Hospital AdmissionHeart failure (HF) is a complex clinical syndrome in whichthe heart is unable to deliver adequate cardiac output at normal fillingpressures. There are proven pharmacological and clinical management strategiesthat can improve care and reduce associated health care costs, but these areunderutilized. The Advanced Heart Failure Program (AHFP) was developed at theDorn Veterans Administration Medical Center to provide a comprehensivemultidisciplinary management approach to persons with advanced HF. Beforeenrollment in the AHFP, the average annual all-cause hospital admission rate was3.2 for the 217 HF patients. After enrollment in the AHFP and stabilization, themean all-cause hospital admission rate was 1.2. HF patients had an averageannual hospitalization cost of $28,936.32 before enrollment in the AHFP. Afterenrollment, average hospitalization cost dropped to $10,851.12 per patient.Taking into account the 50-week cost of $3036.14 for a patient enrolled in theclinic, participation in the AHFP was associated with a significant decrease inthe number of HF-related admissions, saving an average of $15,049.06 perpatient. (Drug Benefit Trends. 2008;20:54-59)
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HIV Infection: Clues to Timely DiagnosisEarly diagnosis enables patients to derive maximum benefit from highly active antiretroviral therapy (HAART). Primary care practitioners can play a key role in the timely identification of HIV infection.
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Economic Evaluation of a Prior Authorization Program for Biologic Response ModifiersSpecialty medications constitute the fastest-growing segment of drug spending under the pharmacy benefit. This study evaluated the impact of a specialty pharmacy prior authorization (PA) program on prescription drug costs for biologic response modifiers (BRMs) used in the treatment of persons with rheumatoid arthritis, juvenile rheumatoid arthritis, Crohn disease, ankylosing spondylitis, psoriatic arthritis, psoriasis, and other spondyloarthropathies. A retrospective, case-control, one-to-one matching approach based on patient age, sex, and client characteristics was used. Case clients were enrolled in the specialty pharmacy PA program from January 1 through December 31, 2005. The control group consisted of clients who were not enrolled in the program during this time. The average costs per eligible member per month (PMPM), for the total, plan, and member were $1.32, $1.29, and $0.03, respectively, in the case group, and $1.44, $1.41, and $0.03, respectively, in the control group. Clients who implemented the specialty pharmacy PA program for BRMs saved an estimated total cost of $0.12 PMPM. Implementing a specialty pharmacy PA program reduced BRM costs. (Drug Benefit Trends. 2008;20:26-31)
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Streptococcal Toxic Shock SyndromeA 44-year-old man presented to the emergency department (ED) with pain and swelling of the left ankle and a petechial rash in the pretibial area that developed the night before. He also reported "fluttering" in his chest.
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Thrombocytopenia: How Best to Determine the CauseABSTRACT: A scheme-based approach, supported by a simple mnemonic, can narrow the broad differential diagnosis of thrombocytopenia. This approach uses findings from the complete blood cell count and the peripheral smear to organize the possible causes of thrombocytopenia into those that affect only platelet count, those that produce both a low platelet count and hemolytic anemia, and those that produce disturbances in all 3 blood cell lines. Causes of isolated thrombocytopenia include viral infections, immune-mediated platelet destruction, congenital diseases, gestational thrombocytopenia, conditions in which splenomegaly is a prominent feature, antiphospholipid antibody syndrome, infectious diseases of bacterial origin, and drugs. Causes of thrombocytopenia in conjunction with hemolytic anemia include hemolytic uremic syndrome, thrombotic thrombocytopenia purpura, and disseminated intravascular coagulation. Disorders that produce disturbances in all 3 blood cell lines include aplastic anemia, myeloproliferative syndromes, myelodysplasia (both primary and secondary), myelofibrosis, myelophthisis, and several other diseases in which splenomegaly is prominent.
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What caused this patient's cough and mild hemoptysis?The authors describe a previously healthy patient who required surgical resection of a large mucoid tumor lined with atypical columnar epithelium. The diagnosis was mucinous cystadenocarcinoma, a rare type of pulmonary cancer that is difficult to identify.
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Blue NevusWorsening episodes of pain and bleeding from the lesion on the dorsum of her foot brought a 16-year-old girl to her physician's office. The spot had gradually enlarged since she first noticed it about 3 years earlier.
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Lactic Acidosis in an Infant Receiving HIV ProphylaxisZidovudine is safe and effective in reducing transmission of HIV from mother to infant but rare serious side effects do occur. Is it worth the risk?
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Diabetic Nephropathy: Early Clues, Effective ManagementNephropathy develops in about 30% of patients with diabetes. Screen for albuminuria at the time type 2 diabetes is diagnosed and within 5 years of diagnosis of type 1 diabetes.
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Trust Your Instincts When Treating Patients: Healthcare Career InsightsMust reads about the latest news and trends in healthcare careers. . .
