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Many patients find cognitive behavioral therapy effective for management of their insomnia, but there aren’t enough clinical psychologists trained in the area.

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Lhermitte-Duclos disease is a rare, slow-growing, benign lesion of the cerebellum and is considered a hamartomatous tumor of the cerebellar cortex.

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A 3-day history of intermittent fainting spells brings a 49-year-old man to youroffice. His only significant medical history includes seasonal allergic rhinitis,for which he takes terfenadine, and mild depression, which is being treatedwith amitriptyline. A week ago, he began taking erythromycin, 500 mg qid,for acute pharyngitis.

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This 15-year-old boy presented with a 3-year history of gradual, bilateral breast enlargement. He was otherwise healthy and showed normal pubertal development.

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Telltale skin lesions of syphilis, gonorrhea, human papillomavirus infection, and Haemophilus ducreyi infection.

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For 2 days, a 49-year-old man with hypertension and hypercholesterolemiahas experienced light-headedness and fatigue.Based on the presenting ECG, what is the most likely cause of hissymptoms?A. Accelerated junctional rhythm.B. First-degree atrioventricular (AV) block.C. Mobitz type I (Wenckebach) second-degree AV block.D. Mobitz type II second-degree AV block.E. Third-degree AV block (complete heart block).

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Chest pain at rest brought this 42-year-old man to the ED. He had experienced the pain in the past but only on exertion. He appears well on arrival. What does the ECG show?

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A total of 50 health care professionals, including 25 health plan medical directors, 20 health plan pharmacy directors, and 5 pharmacy directors for pharmacy benefit management companies were surveyed regarding their perceptions of the value of 3 novel cancer therapies. The physicians and pharmacists were asked to estimate the monthly average wholesale price of each therapy, overall survival benefit of bevacizumab for treatment of persons with advanced colorectal cancer and erlotinib for treatment of persons with non–small-cell lung cancer, and progression-free survival benefit of sunitinib malate for treating persons with advanced renal cell carcinoma. Most respondents overestimated drug costs and underestimated survival benefit associated with these treatments. Mean incremental cost-effectiveness ratio for all drugs studied was approximately $170,000/quality-adjusted life-year (QALY). Cost-effectiveness ratios were lower than the $300,000/QALY cited by oncologists in another study but significantly higher than those for many other costly interventions. Our study findings reflect the need for a better understanding of the value of the clinical benefits of novel cancer therapies in an environment of product innovation but with resource constraints. (Drug Benefit Trends. 2009;21:120-130)

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Most of the symptoms of allergic rhinitis, including nasal obstruction, rhinorrhea, sneezing, and nasal itching, respond to intranasal corticosteroids administered once or twice daily. However, many patients also need to take an antihistamine for adequate control of symptoms. While an antihistamine/decongestant combination can provide symptomatic relief, it fails to address the inflammatory component of allergic rhinitis. Thus, combining an intranasal corticosteroid or oral leukotriene modifier with an antihistamine might be a more effective strategy. Factors that can facilitate treatment adherence include minimizing the number of daily doses, allowing patients to select their own dosing schedules, and providing written instructions. Specific immunotherapy can be beneficial in select patients whose allergic rhinitis symptoms are not sufficiently controlled by pharmacotherapy. (J Respir Dis. 2005;26(5):188-194)

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Consider this diagnosis when a patient presents with a history of rapid, diffuse hair loss. Telogen effluvium affects the entire scalp, but the crown and bitemporal areas may appear to be mainly involved if there is associated androgenetic alopecia.

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This lesion looks suspiciously like a malignant melanoma.

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The follow-up risk of death or an ischemic cardiovascular event that requires hospitalization is about 10-fold higher than the risk of hospitalization for major bleeding.

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The patient describes acute onset of chest pain with nausea and diaphoresis. The cardiac and pulmonary examinations are normal. What does the 12-lead ECG reveal?

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Allergic disorders are becoming more common. For example, about 20% of Americans have allergic rhinitis, which accounts for more than 10 million office visits each year. Most of these visits are to primary care clinicians.

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This 64-year-old woman has had rheumatoid arthritis for 15 years; her hands show classic rheumatic changes. She also had a leg ulcer that had failed to heal in 8 years despite three skin grafts.

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If a patient has had 2 appropriately administered doses of measles-mumps-rubella (MMR) vaccine and has a nonimmune response on a rubella titer (required in all pregnant women in Louisiana), should another dose of MMR vaccine be given? Is there any evidence that this would provide immunity to rubella?

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After cimetidine was releasedin the late 1970s,case reports of clinicallysignificant drug interactionsquickly emerged.1-3Controlled trials soon validated theseinitial clinical observations. Since1983, when a comprehensive reviewof cimetidine drug interactions waspublished,4 more interactions havebeen reported, as use of this agenthas increased because of cost constraintsand the rapid growth of managedcare. Examples of well-documentedinteractions are listed in theTable.

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The authors describe a woman who presented with severe pulmonary hypertension. A cardiopulmonary cause was initially sought, but thyrotoxicosis was the underlying cause.

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Signs and symptoms of organophosphate poisoning occur through an exaggerated cholinergic or nicotinic response at the neuronal synapse.

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A 12-month-old previously healthy boypresented to the pediatric emergencydepartment (ED) with a 10-day historyof fever, irritability, and anorexia.The patient’s mother had originallynoted the development of 3 erythematouspapules on the patient’s back, leftaxilla, and chest; these were followedby the onset of daily fevers, with temperaturesranging from 38.8°C to41.1°C (102°F to 106°F). The lesionsgrew progressively larger and erythematous,and became ulceratedwith central eschars.

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This discussion reviews the currently available antivirals and recommendations for their use in influenza prophylaxis and treatment. Because our understanding of 2009 H1N1 influenza is still evolving, some off-label use of medications is discussed and noted. Information on 2009 H1N1 is updated frequently, andreaders are encouraged to monitor advisories from federal, state, and local health agencies for up-to-date information. (Drug Benefit Trends. 2010;22:10-14)

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A 32-year-old Hispanic woman with AIDS presented with a 1-month history of diarrhea; abdominal bloating and cramps; loss of appetite; and pronounced fatigue, malaise, and weight loss. She had no fever or chills and was not vomiting. Her CD4+ cell count was 12/µL. Results of a routine microscopic examination of stool for ova and parasites were negative; an acid-fast stain of stool demonstrated oocytes of Cyclospora cayetanensis measuring 8.8 mm in diameter (pictured, magnification ×1,000). This is about twice the size of the Cryptosporidium parvum oocyte, which typically is 4 to 5 mm.

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A 45-year-old man was referred to our pulmonary clinic for progressive dyspnea and worsening asthma. His shortness of breath had been worsening over the past 2 years. He denied fever, weight loss, and other systemic complaints.

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A 65-year-old man experienced a hard fall 40 years ago, when he was a paratrooper: he landed on his right leg and sustained trauma to the right hip.

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A 6-cm midline tail-like soft tissue appendage was noted on the back of this newborn infant at the level of L5. An epithelialized mid-sacrum dimple was also present inferior to the appendage. The infant otherwise appeared to be normally developed.

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Determining the cause of generalized weakness can be a daunting task, since the differential diagnosis is vast. An overall approach to the patient who complains of generalized weakness is presented in our article

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A 31-year-old man presents with a2-week history of a constant, dull acheand hearing loss in the right ear. Healso complains of intermittent sharppains that are usually followed bydrainage through the external auditorycanal. Another practitioner diagnosedacute otitis media with tympanic membraneperforation, for which he prescribeda 10-day course of amoxicillin.The patient completed the regimen buthas obtained no relief.

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Asthma is one of the most common chronic diseases worldwide, and its prevalence--particularly among children--is increasing in many countries.1,2 In 1997, an estimated 9.6% of persons in the United States had asthma (Table 1).3

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After this 9-year-old boy complained of “growing too fast” during the past 1 to 2 years, his parents sought medical advice. He had no significant past medical history.