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This year, the American Academy of Allergy, Asthma, and Immunology (AAAAI) published guidelines for referring patients to an allergist/immunologist.1 The AAAAI's recommendations for patients with asthma were summarized in the July 2006 issue of

Two recent studies provide encouraging data about the effectiveness of voriconazole in the treatment of aspergillosis. One study found that voriconazole was effective in the management of subacute invasive aspergillosis and chronic pulmonary aspergillosis. The other study found that it was beneficial in the treatment of chronic cavitary pulmonary aspergillosis.

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.

My patient, in whom allergic rhinitis has been diagnosed, has been receiving weekly allergy shots since June 2003 for allergies to dust, grass, mountain cedar trees, and ragweed. She has benefited greatly from these shots. However, she complains that she sometimes smells "cigarette smoke" for periods of 2 to 3 days--even though she is never exposed to it. What might be the cause of this?

ABSTRACT: The number of medical therapies for patients with erectile dysfunction (ED) has increased in recent years because of our expanded understanding of the physiologic and neurologic causes of ED. Oral agents range from testosterone to antidepressants to phosphodiesterase inhibitors. Nitroglycerin and minoxidil have shown some effectiveness as topical agents. Alprostadil, which can be applied intraurethrally, is also effective as intracavernosal injection therapy. Prostaglandin E1 and papaverine are effective as intracavernosal injection agents. Some studies have shown that combined use of intracavernosal injection and oral therapy produces satisfactory erections.

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.

An 11-month-old infant was referred by his pediatrician for possible surgical correction of a bilateral entropion. The mother stated that her son's lashes appear to turn in on occasion; however, he never rubbed his eyes, the eyes were not red, and no discharge or drainage was noted.

The recent editorial by David T. Nash, MD, "OTC Statins: Panacea or Pandora's Box?" (CONSULTANT, July 2006, page 845), prompted a number of readers to write in. A selection of the comments received, along with a response from Dr Nash, appears below. Additional comments appear on www.ConsultantLive.com.

A 62-year-old man presents with a violaceous, nonpruritic eruption that arose 2 weeks earlier on the hands and feet, including the palms and soles, and spread to the arms and legs (Figure 1). Over the past 3 to 4 weeks, he has had malaise, nonproductive cough, and a decline in mental status but no fever, headache, nausea, light-headedness, hemoptysis, or melena.

When young children have an irritant in their eyes, it can be very difficult to get them to open their eyes so that they can be irrigated. To reduce the stinging and make opening the eyes easier, try putting a drop of an ocular anesthetic in each medial canthus while the child is supine; be sure to wait for it to seep in.- D. Brady Pregerson, MD Los AngelesMore Practical Pointers

The term "prehypertension" was introduced in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines to describe blood pressures (BPs) of 120/80 mm Hg to 139/89 mm Hg.1

Alopecia was noted on the right anterior scalp of a 53-year-old man who had been hospitalized for jaundice of 2 weeks' duration. The hairs in the affected area were broken off at various lengths (A). The patient, who was left-handed, repeatedly pulled individual hairs on his head; it was suspected that he occasionally swallowed them.He had a history of heavy alcohol consumption and end-stage liver disease.

To initiate a discussion with a patient about excess weight without causing embarrassment or offense, try reporting the patient's body mass index (BMI), saying something like the following: "Mr X, did you know that your BMI is 36?" Patients typically answer with something such as "No--what's a BMI?" This creates an easy opening for discussion of the comorbidities associated with excess weight and counseling about lifestyle changes.

The risk of complications (such as lactic acidosis) that can be associated with metformin increases in patients with renal insufficiency. At what creatinine clearance should this agent be discontinued?

A healthy 56-year-old woman, who is seeing you for her annual checkup, asks if she still needs to continue the calcium supplements she has been taking. She has heard reports on the evening news that calcium and vitamin D were of negligible value in women her age--and could even cause kidney stones. How would you respond? What is the latest thinking about calcium and vitamin D supplements for postmenopausal women?

Hepatomegaly is detected during the routine physical examination of a healthy 40-year-old woman who is employed as a secretary. She has noticed some fullness in the right upper abdomen for many years, but it has not been accompanied by pain or GI symptoms.

Recently, a well-designed crossover study assessed the risk of thrombosis during long flights.1,2 Included were persons with such risk factors as factor V Leiden mutation and oral contraceptive use. All 71 patients (15 men, 56 women) were studied (not randomized) in each limb of the protocol--in random order--during each of the following: an 8-hour flight, 8 hours spent watching movies, and 8 hours of typical daily living. Fifteen of the participants took oral contraceptives, 11 had the factor V Leiden mutation, and 15 had both risks.