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A 37-year-old white woman, previously in excellent health, presented to a local emergency department for evaluation of evolving left-sided weakness and a slight left facial droop.

New guidelines from the Centers for Medicare & Medicaid Services (CMS) that increase the number of compendia health insurers rely on to determine whether a drug use is appropriate will greatly expand the number of off-label uses of chemotherapy agents for which the agency will reimburse.

Levothyroxine is one of the most commonly prescribed medications for the treatment of persons with hypothyroidism and the suppression of thyroid neoplasms.1 Most persons with hypothyroidism require lifelong therapy with levothyroxine.

New data from UNAIDS show that several African countries with a high HIV prevalence have made significant gains in preventing new infections.

Employers and their employees are facing tough times in today’s economy. To stay competitive, employers must scrutinize all areas of business for cost-cutting opportunities, including health care benefits. Consumers, too, face challenges. In October, a Kaiser Family Foundation poll reported that the percentage of consumers who skipped dosages or split pills in the past year to save on medication costs had increased to 22%, up from 19% in April. The percentage of consumers who reported not filling their prescriptions rose from 23% to 27% over the same 6-month period.1

Much 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.

In August 2008, as part of its Critical Path Initiative, the FDA released a table listing genomic biomarkers that have established roles in determining drug response.1 This initiative, started in 2004, is aimed at identifying “patients likely to benefit from a treatment and patients more likely to respond adversely to a product,” according to the FDA’s Office of Management, Budget Formulation and Presentation.

Clinicians often override electronic medication safety alerts, according to study findings published in the February issue of the Archives of Internal Medicine, indicating that such systems need to be more selective to be truly useful.

Adults in the United States spent more on medications for diabetes and high cholesterol and other metabolic disorders than on any other class of medications in 2006. Expenditures for metabolic agents totaled $38.1 billion, or 18.3% of total outpatient drug expenditures for noninstitutionalized adults 18 years and older. In all, outpatient drug spending totaled $208.1 billion in 2006. Expenditures for the top 5 therapeutic classes accounted for $130.8 billion, or 62.9% of total expenditures. Findings are from the ongoing Medical Expenditure Panel Survey conducted by the Agency for Healthcare Research and Quality.

Although highly effective with a high benefit-to-risk ratio, highly active antiretroviral therapy has a variety of adverse effects, including metabolic, lipid, and bone toxicities. Importantly, renal toxicity has been associated with some of the more widely used agents, specifically from the NRTI and protease inhibitor classes.

The availability of highly active antiretroviral therapy has improved the survival and quality of life of patients infected with HIV. Clinicians are now focusing on the management of metabolic complications and previously unrecognized drug toxicities. The incidence and prevalence of kidney disease are increasing in older HIV-infected patients because of the widespread use of antiretroviral therapy.

In 1998, President Clinton declared HIV/AIDS to be a "severe and ongoing crisis" in the African American community and launched the

THE 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.

This rash erupted on the upper body of a 58-year-old woman in late August. It was mildly pruritic and nontender. The patient had not started any new medications and was not taking photosensitizing drugs. She had Sjögren syndrome; the rest of her history was noncontributory. Subacute cutaneous lupus erythematosus (SCLE) was diagnosed. SCLE typically affects white women aged 30 to 40 years.1 It presents as nonindurated, nonscarring, erythematous plaques with or without a fine scale that may progress into a diffuse, widespread, papulosquamous or annular lesion with central hypopigmentation or telangiectasia.

A 51-year-old man is admitted to the hospital with painful ulcers on both lower extremities, severe anemia, and a 45-kg (100-lb) weight loss over the past year. Pain from the ulcers prevents him from walking. The ulcers developed about 5 years earlier, as a result of his wearing high boots for work; they began as small sores and grew over time.

An 83-year-old man examined on admission for end-of-life care due to profound dementia. His wife states that his penis has not changed in appearance, but knows that he always had concerns about it. To her knowledge he never had trouble voiding. Patient too impaired to discuss any topic coherently. Wife considers it unlikely he would have disclosed any symptom of this type to her.

Painful cracks in the fingertips are a common problem, especially during cold weather. A simple but effective remedy is to have the patient apply petroleum jelly to the crack, cover it with an adhesive bandage put on with a bit of tension, and then place a second adhesive bandage over the first at right angles for reinforcement. Instruct the patient to leave the bandages on overnight and to reapply 1 or 2 more nights if needed. If a patient’s daytime activities permit it, the bandages can also be worn during the day.

During a review of systems, I find it helpful and timesaving to ask the patient if he or she experiences symptoms that are out of the ordinary for the typical person. For example, instead of asking “Do you have fevers, chills, or night sweats?” I ask “Do you have fevers, chills, or night sweats more than the average person?” I find this approach yields more useful responses: they indicate whether the patient perceives the symptom as significant.