Injection drug use (IDU) has been a route for HIV transmission since the beginning of the epidemic.

As discussed by Mitty and colleagues,1 the proportion of HIV infections associated with injection drug use (IDU) has dropped dramatically across the United States, including the northeastern portion of the country.

This month’s Research Focus, “Trends in HIV Care, Part 1,” is a summary of a roundtable discussion with 4 health care providers from the AIDS Community Health Center (ACHC) in Rochester, NY.

Acute gouty arthritis is frequently misdiagnosed or diagnosed late in its clinical course, and therapy is often suboptimal. Because the treatment of gout as a chronic, progressive disease has not been standardized, optimal disease management remains a challenge.

I had prescribed oral iron sulfate, 325 mg tid, for a 35-year-old woman with severe iron deficiency anemia. Soon after the patient started therapy, she complained of dull, aching, continuous bone pain that was localized to the sternal region, both upper arms, and both thighs, without radiation. The pain resolved after her hematocrit had risen above 34% and iron replacement therapy had been discontinued.

Now that the holiday travel season is upon us, more of your patients may be taking to the skies. But some of them may have more serious problems to contend with than long lines, delayed flights, and missing luggage.

The median deductible for employees with individual coverage in PPO employer health plans jumped to $1000 in 2008, up from $500 in 2007 and $250 in 2000, according to the National Survey of Employer-Sponsored Health Plans, an annual report released on November 19 by Mercer (Figure). This significant increase was found among traditional PPOs, the most common type of plan (covering 69% of insured employees). Nearly four-fifths (79%) of employers imposed a deductible for PPO coverage in 2008 compared with about half (52%) of employers in 2000. For the survey, approximately 2900 private and public employers with 10 or more employees were interviewed in August and September.

In January 2006, the American College of Physicians (ACP) warned that primary care, rightly referred to as the backbone of the nation's health care system, was on the verge of collapse. The ACP noted then that few young physicians were going into primary care and that many of those already in practice were leaving.

The use of specialty pharmaceuticals in the United States continues to surge as more drugs enter the market and new indications are found for existing medications. Use of specialty drugs has dramatically improved clinical outcomes. However, while the health benefits of specialty pharmaceuticals are substantive, health care expenditures associated with the drugs can be significant, with some costing as much as $250,000 annually. Specialty medications accounted for 11.4% of pharmacy benefit spending in 2007, up from 5.6% in 2003. With the increasing use and higher costs of specialty medications, employers and health plans need to effectively manage distribution and utilization to ensure the most cost-effective use of these agents as possible. (Drug Benefit Trends. 2008;20:478-484)

Coronary artery disease (CAD), the most common form of cardiovascular disease in the United States, is the most costly type of cardiovascular condition to manage, according to the American Heart Association. Of the estimated $448.5 billion in total costs for cardiovascular diseases and stroke in 2008, CAD accounted for $156.4 billion, more than twice the cost of hypertension ($69.4 billion) and stroke ($65.5 billion) (Figure 1). Direct costs associated with CAD were $87.6 billion in 2008, of which prescription drug costs alone were $9.7 billion (Figure 2). Of the $68.8 billion in indirect costs for CAD in 2008, $58.6 billion were associated with lost productivity caused by increased mortality.

Combining antidepressants and cognitive-behavior therapy (CBT) is the most effective treatment for 8 in 10 children and teenagers with anxiety disorders, according to researchers led by John T. Walkup, MD, associate professor of psychiatry and behavioral sciences, and deputy director, division of child and adolescent psychiatry, Johns Hopkins Medical Institutions, Baltimore. Findings of the study were published in the October 30 issue of the New England Journal of Medicine. The study was funded by the National Institute of Mental Health (NIMH).

Sleep disturbance, especially insomnia, is common, with up to 25% of the population in industrialized countries reporting severe chronic insomnia.1 Medications to improve sleep patterns are plentiful but are not always effective. New research on sleep disturbance focuses on the role of the hypothalamic-pituitary-adrenal (HPA) axis.

Use of AstraZeneca’s Crestor (rosuvastatin calcium) reduced the number of deaths, myocardial infarctions (MIs), and strokes as well as the need for bypass or angioplasty procedures by 45% in apparently healthy persons. Lead researcher Paul M. Ridker, MD, MPH, professor at Harvard Medical School, and director of the Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Boston, and colleagues presented results of the AstraZeneca-funded JUPITER (the Justification for Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin) study at the 2008 Scientific Sessions of the American Heart Association held November 8 through 12 in New Orleans. Findings were published in the November 20 issue of the New England Journal of Medicine.

Seventy percent of prescription drug users said they would be very concerned if a drug they were taking was changed to another drug in the same class without their physician's knowledge (Cover Figure). Concerns are greatly reduced, although not eliminated, if the physician is aware of and consents to the change, according to findings of a survey released by the National Consumers League (NCL).

The federal government has less authority to set Medicare drug reimbursement prices than officials at the Centers for Medicare & Medicaid Services (CMS) had thought, according to a ruling by Judge Henry H. Kennedy Jr of the US District Court in Washington, DC, in a case (Hays v Leavitt [1:08-cv-01032-HHK]) filed by a person with chronic obstructive pulmonary disease. The patient, Ilene Hays, had received a prescription for DuoNeb, a combination inhalation drug made by Mylan’s Dey subsidiary.

ABSTRACT: The treatment of pulmonary arterial hypertension(PAH) is directed at the underlying cause, such as diastolicheart failure or chronic thromboembolic disease. Patients withidiopathic PAH or PAH associated with connective-tissue diseasewho have World Health Organization (WHO) functionalclass II or III PAH should receive a trial of oral bosentan, ambrisentan,and/or sildenafil; inhaled iloprost is an alternative oran additive agent. If patients fail to respond to these interventionsor if they have WHO functional class IV PAH, considersubcutaneous or intravenous treprostinil or epoprostenol. Theuse of these latter agents is much more complicated and maybe difficult to initiate in elderly patients. (J Respir Dis. 2008;29(12):468-474)

Actinomyces odontolyticus isa rare cause of pleuropericardialinfection, with only 1 caseidentified in the literature. Inthat instance, the infectionwas believed to be secondaryto gastric surgery. We present apatient with pericarditis andpericardial tamponade causedby A odontolyticus. The infectionoccurred after an ultrasound-guided subcarinalbronchoscopic needle biopsyperformed for a suspicious mediastinalmass found on a CTscan of the chest. We describethe case presentation, the microbiologyand treatment of Aodontolyticus infection, andthe classic features of pericarditisand cardiac tamponade.

ABSTRACT: Patients with obstructive sleep apnea (OSA) are at increasedrisk for motor vehicle crashes as a result of excessivesleepiness. However, a number of factors complicate risk assessment.For example, self-reported sleepiness and the severityof OSA do not appear to be good predictors of accident risk.Many persons with OSA do not accurately perceive their levelof drowsiness-self-reported sleepiness does not correlate wellwith objective measures, such as results of the Multiple SleepLatency Test. Moreover, it is not clear whether objective testscan reliably predict accident risk in the real world, as opposedto during simulated driving. The indications for-and benefitsof-restricting driving in patients with OSA have not been established.However, there is good evidence that the use of continuouspositive airway pressure significantly reduces the riskof crashes in these patients. (J Respir Dis. 2008;29(12):459-464)

•Coccidioides species, the cause of coccidioidomycosis, are endemic to the desert soils of the southwestern United States as well as northern Mexico and limited areas of Central and South America. The organisms can become airborne with disruption of the soil, either through natural causes or activities of humans or animals. Nearly all Coccidioides infections are acquired through the inhalation of airborne arthroconidia (spores).

Otological complications associated with varicella-zostervirus infection are common; however, tympanic membraneinvolvement is rarely reported. We describe a patient withherpes zoster in whom hemorrhagic otitis media with tympanicmembrane perforation developed. To our knowledge,this is the first report of an HIV-infected patient with thisunusual presentation. [Infect Med. 2008;25:561-562]