Written in appreciation of “100 Precepts for My House Staff” by Henry Schneiderman, MD, and dedicated to those fierce internist attendings who have bred fear, insight, and wisdom in so many of us (Part 1 in CONSULTANT, April 2009, page 270, and Part 2 on page 361 of the June issue).

The FDA would have broad public support for a behind-the-counter (BTC) classification for drugs. According to the results of a telephone survey conducted by Leo J. Shapiro & Associates, 67% of respondents said they would welcome the convenience of obtaining a drug without a prescription and after counseling by a pharmacist, even while they recognize that their insurance plan would not cover the cost of the BTC medication.

The FDA does not allow pharmaceutical manufacturers to promote unapproved uses of their products, saying that evidence of success with additional indications can be given to physicians only if they request it. But the agency is on the verge of amending that rule to make it much easier for pharmaceutical companies to promote such prescribing.

Mortality rates from heart disease and stroke are falling in the United States, but cardiovascular disease remains the leading cause of death, according to a report by the American Heart Association (AHA). An estimated 869,724 persons died of heart disease in 2004 compared with 911,603 persons in 2003. When considered separately from other cardiovascular diseases, stroke was the third leading cause of death in 2004. The number of deaths attributable to stroke that year was estimated to be 150,074, a decrease from 157,689 deaths in 2003.

Two studies confirm that colorectal cancer screening is significantly underused in the United States. In a study published online December 10 in Cancer, Gregory Cooper, MD, interim chief of gastroenterology at University Hospitals Case Medical Center in Cleveland and professor of medicine, Case Western Reserve University (CWRU) and the Case Comprehensive Cancer Center, and Tzuyung Doug Kou, MPH, CWRU, assessed a population-based sample of 153,469 Medicare beneficiaries without cancer beginning in 1998, the first year in which colorectal cancer screening was reimbursed under Medicare. The beneficiaries included 17,940 persons with 1 or more risk factors for cancer and 135,529 persons with average risk for cancer.

The rate of onset of type 2 diabetes and related hospitalizations is rising in young adults in the United States aged 20 to 29, according to results of a study published in the December issue of Diabetes Care.

Under a new ruling by the Drug Enforcement Administration (DEA), clinicians may begin issuing multiple prescriptions for Schedule II controlled substances when appropriate.

A research team led by Frederick Unverzagt, MD, associate professor of psychiatry, Indiana University–Purdue University, Indianapolis, found that older adults with pre-existing mild memory impairment benefit from cognitive training that does not rely on memorization as much as those with normal memory function.

Premenopausal women with major depressive disorder (MDD) have less bone mineral density (BMD) than those without MDD, according to findings of a study published in the November 26 issue of Archives of Internal Medicine.

A special thank-you goes out to the pharmacists, physicians, educators, and researchers who took the time to review manuscripts for Drug Benefit Trends in 2007.

When you start to examine the thyroid, patients frequently react instinctively by raising their head, thereby stretching the neck. Actually, such a reaction impedes precise palpation of the gland. Tell patients to keep their neck flexed forward, so as to ensure that the infrahyoid muscles of the neck are relaxed.

Patients who have had a cholecystectomy may have loose stools for several weeks or months. Over-the-counter and prescription antidiarrheals can provide temporary relief but can be costly and may produce constipation. Instead, try prescribing fiber therapy with methylcellulose (two 500-mg tablets daily or bid).

Doxycycline and potassium tablets can cause ulceration and severe burning of the esophagus if they get stuck and dissolve in that location. Gelatin capsules pose a heightened risk because they can adhere to the wall of the esophagus. To prevent this significant adverse effect, try the following:

A study published in the November issue of the Journal of Adolescent Health shows that young persons with asthma are twice as likely to have anxiety and depressive disorders than youths without asthma. Researchers at the University of Washington School of Medicine, Seattle; Group Health Cooperative (GHC); and Seattle Children’s Hospital Research Institute interviewed 1379 youths aged 11 to 17 years enrolled in the GHC HMO. Of the study participants, 781 had received a diagnosis of asthma or had been treated for asthma; 598 participants were randomly selected youths with no history of asthma.

Given the risk of skin cancer and the benefit of vitamin D production, what should I tell my patients about sun exposure?

London-based GlaxoSmithKline (GSK) plc and New York–based Pfizer Inc have announced they will combine their HIV drug divisions into a new company (Kelley T. Bloomberg News. April 16, 2009). GSK will hold an 85% share of the joint venture; Pfizer will hold 15%. According to a filing with the US Securities and Exchange Commission, GSK Senior Vice President Dominique Limet, a physician, is CEO-designate of the new company.

The lifetime cumulative risk of at least 1 abnormal ocular lesion for an HIV-positive person ranges from 52% to 100%. Ophthalmic involvement can occur during the early phase of HIV infection, and ocular lesions are mainly noted in the posterior segment.1,2

A 58-year-old man with type 2 diabetes, nephrolithiasis, and benign prostatic hyperplasia presented with bilateral periorbital ecchymoses and left subconjunctival hemorrhage. The ecchymoses had spontaneously appeared 3 days earlier; the patient had no history of trauma or falls. He also had difficulty in voiding, characterized by increased frequency, hesitancy, and diminished urine stream.

Persons with HIV infection frequently present with anemia from different causes, including use of antiretroviral therapy (typically zidovudine), iron deficiency, vitamin B12 deficiency, opportunistic infections (such as mycobacterial and fungal infections), chronic disease, AIDS-associated malignancies, autoimmune hemolysis, and direct effects of HIV infection itself. A frequently overlooked cause of chronic anemia in HIV-infected persons is parvovirus B19 coinfection.1-3 We present an illustrative case of unsuspected treatable parvovirus B19 infection in an HIV-positive person with chronic transfusion-dependent anemia initially attributed solely to zidovudine therapy.

Scrub typhus, which is caused by Orientia tsutsugamushi, has various systemic manifestations, including GI symptoms. We describe one patient with scrub typhus who presented with symptoms that suggested acute appendicitis and another who presented with symptoms of acute cholecystitis.