Anemia

How best to manage ulcerative colitis? Here: highlights from guidelines from the American College of Gastroenterology on assessment, treatment, indications for surgery, and cancer surveillance.

Ulcerative colitis affects about 500,000 persons in the United States and accounts for more than 30,000 hospitalizations and 1 million workdays lost each year. The exacerbations and remissions that characterize the clinical course of the disease can make its management particularly challenging. What is the optimal approach to treatment? And which agents are most effective for maintenance therapy?

Hands-on sessions markedly enhance the CME experience. New to the ACG Scientific Meeting in 2010, the hands-on workshop center proved to be one of the conference’s most popular offerings.

MRI scans of the kidneys of an 83-year-old woman with history of myelodysplastic syndrome are shown. Normal MRI scans are shown for comparison. The patient had intermittent episodes of dark-colored urine for years. Findings from repeated cystoscopies were normal.

A39-year-old man with a history of AIDS and nonadherence to highly active antiretroviral therapy (HAART) presented with frontal headache and scalp pain of 2 weeks' duration. These symptoms were accompanied by nausea, weight loss, and generalized weakness. Physical examination revealed a small, tender scalp lump, 2 × 2 cm over the left parietal area. The findings from the rest of the examination were unremarkable.

For every recognized case of celiac disease, 8 more remain undiagnosed. The reason for this disparity is contingent on the varying presentations of the disease.

A 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).

A 62-year-old woman presents with epistaxis from the right nostril. Thenosebleed has lasted about 90 minutes, and she has become alarmedby the amount of blood on the tissues and washcloth she has applied to hernose.

For 1 month, a 60-year-old white man has had increasing fatigue, generalized weakness, and exertional dyspnea. He becomes short of breath after he walks only 100 to 150 yards on level ground or climbs only 1 flight of stairs. In addition, he has unintentionally lost 12 lb in the past month and has experienced intermittent dysphagia with solid foods. He attributes this last symptom to long-standing gastroesophageal reflux disease (GERD), for which he regularly takes over-the-counter omeprazole.

My interest in mental health began before I was a psychiatrist-it started in a small Central American country where I arrived as a primary care physician in the early years of the Peace Corps.

THE CASE: A 77-year-old woman who has had shortness of breath and intermittent left flank pain for the past 2 to 3 days is brought by her family for evaluation. The dyspnea worsens when she lies down. She denies chest pain, back pain, and syncope. She has also had mild nonbloody diarrhea of 2 days’ duration but no vomiting or oral intake intolerance.

A 30-year-old man is admitted for profound, symptomatic anemia.

The development of drug-resistant strains of Mycobacterium tuberculosis has increased morbidity and mortality associated with tuberculosis (TB) and has greatly increased the costs of care for patients with this disease.

A 61–year–old man presented to the emergency department with diffuse lower abdominal pain, nausea, and severe diarrhea (20 episodes within the past 12 hours). His symptoms began the night before and had gradually worsened. He denied fever. His medical history was significant for hypertension.

When a patient with iron deficiency anemia fails to respond to oral iron supplementation, consider whether foods he or she is consuming may be contributing to malabsorption. Such foods include coffee and tea (because they contain tannins) and cola drinks (a result of their phosphate content). In addition, because achlorhydria may interfere with iron absorption, encourage patients to eat foods rich in vitamin

Here is a common clinical scenario. Your patient was admitted to the hospital with an acute myocardial infarction (MI). Intervention has been successful, and the patient's condition is now stable. The cardiologist is concerned about the patient's hemoglobin value of 9 g/dL. Active bleeding, hemolysis, and other potential causes of anemia (iron or vitamin B12 deficiency, for example) have been excluded. The decision is made to transfuse to raise the hemoglobin level above 10 g/dL.

A 50-year-old woman presents to the emergency department with severe dizziness, weakness, and dyspnea of 1 week’s duration. Ten days earlier, an upper respiratory tract infection (URTI) was diagnosed; over-the-counter cough syrup and acetaminophen were prescribed. However, the patient’s condition has steadily deteriorated since then. In addition, her urine has darkened over the past few days.

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.

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.

Premenstrual disorders affect many women in the United States. These disorders range in severity from the mild, bothersome symptoms that occur in more than 75% of women with regular menstrual cycles, to premenstrual syndrome (PMS) and, finally, to the most severe and disabling, premenstrual dysphoric disorder (PMDD). Nearly 5 million American women have PMDD.

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 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)

A 36-year-old man presents to the emergency department (ED) after a single tonic-clonic seizure. He has a history of numerous male sexual contacts. HIV infection was diagnosed 5 months earlier. At that time his CD4+ cell count was 66/μL and his HIV RNA level was 20,000 copies/mL.

Together the spondyloarthropathies form a group of overlapping chronic inflammatory rheumatologic diseases that show a predilection for involvement of the axial skeleton, entheses (bony insertions of = ligaments and tendons), and peripheral joints. They also may involve extraskeletal structures, especially the eyes, lungs, skin, and GI tract.

My patient is a middle-aged white man who has had an itchy rash on his upper body for the past 16 months. It consists of red raised bumps and resembles “prickly heat.”

A 92-year-old woman presents with sharp abdominal pain of 1 day's duration, accompanied by 1 episode of emesis. The pain is neither relieved nor exacerbated by food ingestion.

When diagnosing vitamin B12 deficiency, we routinely include a measurement of the methylmalonic acid (MMA) level in all patients whose B12 values are under 400 pg/mL. An elevated MMA level confirms B12 deficiency.

A 28-year-old woman presents with milky discharge in both breasts and throbbing occipital headaches of 4 months' duration. The headaches begin gradually, do not radiate, and have no apparent triggers or relieving factors.

Establishing the cause of chronic pain is crucial because treatment based on the mechanism of the pain is most likely to be successful.