Although many effective pharmacological therapiesare available for patients with allergies, only allergen-specificimmunotherapy has been shown to have significant and longlastingtherapeutic and immunomodulatory effects in the managementof allergic rhinitis, allergic asthma, and venom hypersensitivity.Standard allergen immunotherapy consists of subcutaneousinjections of relevant allergens. It requires a buildupphase during which the dose of the vaccine is increased until atherapeutic (maintenance) level is achieved. This maintenancedose is usually continued for 3 to 5 years, and most patientscontinue to do well after injections are discontinued. Most patientstolerate immunotherapy well, but local reactions are notuncommon. Immunotherapy should be administered only in aphysician's office, because some patients may experience systemicanaphylactic reactions requiring immediate therapy.Even with newer therapies on the horizon, allergen immunotherapywill continue to have an important role in the treatmentof allergic diseases. (J Respir Dis. 2008;29(3):136-141)

The reported incidence of postthrombotic syndrome (PTS) after a first episode of deep venous thrombosis (DVT) is quite variable, depending on the measurement scale used and the severity. Most studies suggest that the rate is 20% to 50%, with symptoms ranging from minor skin discoloration to chronic swelling and ulceration.1 However, the incidence of symptomatic PTS was less than 5% in a population of patients who underwent orthopedic hip and knee arthroplasty, regardless of whether they experienced symptomatic postoperative DVT.2

The most common manifestation of oropharyngealcandidiasis (OPC) is pseudomembranous candidiasis, commonlyknown as "thrush," which appears as a whitish yellow,curdlike discharge on the mucosal surfaces. Other forms ofOPC include denture stomatitis, angular cheilitis, and glossitis.Patients with denture stomatitis are usually asymptomatic, butthe tissue beneath the denture is typically red and hyperplastic.Patients with angular cheilitis may complain of a burning sensationat the margins of the lips. Candidiasis involving thetongue can be exuberant and is usually associated with complaintsof a white tongue, taste alterations, and a burning sensationof the tongue. The diagnosis of OPC can be establishedby identifying typical fungal elements on potassium hydroxidepreparation or Gram stain of scraped material. Treatment optionsinclude clotrimazole, fluconazole, itraconazole, and nystatin.(J Respir Dis. 2008;29(3):128-135)

Microscopic polyangiitis is a potentially fatal disease if it is notrecognized and treated early. In the case described here, what initiallypresented as a postinfectious residual cough was actuallyactive pulmonary hemorrhage, severe anemia, and a crescenticglomerulonephritis. Significant improvement was achieved withhemodialysis and aggressive treatment with corticosteroids andcyclophosphamide. This case exemplifies a classic presentationof microscopic polyangiitis and demonstrates the importance ofan expeditious diagnostic evaluation and early treatment to preventrapid deterioration. Early recognition and highly aggressiveimmunosuppressive treatment achieved significant suppressionof the disease.

The major causes of chronic cough include upper airwaycough syndrome (UACS, formerly known as postnasal dripsyndrome), asthma, nonasthmatic eosinophilic bronchitis, andgastroesophageal reflux disease. In fact, one or more of these isthe cause of cough in the vast majority of nonsmokers who arenot receiving angiotensin-converting enzyme inhibitors andwho have no evidence of active disease on chest radiographs. Ahigh index of suspicion is required, because each of these conditionsmay present with cough as the sole symptom. BecauseUACS may be the most common cause, it appears reasonableto try empiric UACS therapy in patients in whom other causesare not evident at initial evaluation. In many cases, the combinationof a first-generation antihistamine and a decongestantmay be most effective. (J Respir Dis. 2008;29(3):113-122)

AN UNUSUALLY VIRULENT strainof adenovirus may be the cause ofillness in more than 140 persons,according to the CDC. Indeed, 10deaths have been reported over thepast year. Adenovirus serotype 14(Ad14) causes severe and sometimesfatal respiratory disease in patientsof all ages, even in healthy adults.

Recent advances in diagnostic testing have increased the likelihood that our current model of medical treatment will soon be supplanted, at least in part, by personalized medicine. With this change in the medical paradigm will come numerous benefits and opportunities for patients, caregivers, drug developers, diagnostics firms, and MCOs.

The first time I refused to go along with a physician’s directive, I was 8 months’ pregnant with my first child. My doctor wanted to order a glucose tolerance test to screen for gestational diabetes. I needed to drink a sugary cocktail and then be tested as my blood glucose levels first rose and then fell. Why? I asked. Wouldn’t this put undue stress on the baby? It didn’t make sense to me. I was not overweight and had no personal or family history or other risk factors that I could tell.

Back and neck problems are among the most commonly encountered symptoms in clinical practice. In 2002, an estimated 59 million US adults, or approximately 26% of the adult population, self-reported back pain in the previous 3 months, and 30.1 million US adults, or about 14% of the adult population, self-reported neck pain in the same period, according to a study by Martin and colleagues published in the February 13 issue of the Journal of the American Medical Association. Low back pain alone accounted for 2% of all physician office visits; only routine examinations, diabetes, and hypertension resulted in more office visits.

As more high-cost biologic drugs become part of standard care, the FDA has been under pressure to devise a way to allow generic versions of biologics to reach the market. Although competing industry interests have made it difficult for the agency and Congress to agree on such an approach, 2008 may be the year when that changes.

Medical residents with depression are approximately 6 times more likely to make medication errors than those without depression, according to a study published online on February 7 in the British Medical Journal. A team led by Amy M. Fahrenkopf, MD, instructor of pediatrics, Harvard Medical School, Boston, conducted the prospective cohort study.

Major depression is twice as likely to develop in post-stroke patients (approximately 20%) than in nonstroke patients of the same age.1 Other psychiatric symptoms that are also more common in post-stroke patients include minor depression, anxiety, anger, and inappropriate or excessive laughing or crying (emotional incontinence).2

Cumulative research with animal, normative, and clinical populations over several decades shows that the mechanisms underlying anxiety disorders differ from those of the normal emotion of anxiety. In persons with anxiety disorders, fear and tension are disproportionate to the actual threat and may be present when no real threat exists, thereby generating an expectation of danger and distorted perceptions related to danger and various types of threats. The most common anxiety disorders are social anxiety disorder (SAD), generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD). Persons with SAD can experience a wide range of social fears as well as severe functional consequences, whereas persons with GAD tend to experience emotional, interpersonal, and somatic symptoms of high levels of chronic anxiety. Persons with PTSD have vivid memories of and thoughts about a terrifying event or ordeal that lead to the development of anxiety, depression, and functional impairment. Effective treatment options-pharmacotherapy; psychotherapy, particularly cognitive-behavioral therapy; or a combination-can be discussed openly with the patient to make a collaborative, informed decision. A variety of medications can be used to successfully manage anxiety disorders, of which SSRIs and serotonin-norepinephrine reuptake inhibitors are the most effective. When properly used, medications can enhance a patient's own efforts to master anxiety; overcome fearful avoidance; and address troubling behaviors, patterns, or memories. (Drug Benefit Trends. 2008;20:101-113)

More US adults are taking more prescription medications, fueling $12 billion in additional spending during 2006 alone, according to the Geographic Variation in Prescription Utilization study released on February 13 by Express Scripts. The number of US adults with at least 1 prescription increased from 67% in 2000 to 74% in 2006, and the number of prescriptions per capita rose from 10.8 to 14.3 in the same period-a 32% jump.

American consumers want more from the health care system than they are currently getting. They want to have online access to their primary care physicians (PCPs) and medical records. They also want greater access to wellness programs and alternative treatments.

Many traditional PBMs have revenue streams that are not disclosed or shared with plan sponsors. These revenue streams include pharmaceutical manufacturer rebates, pharmacy network discounts and spread, and data sales. Such arrangements can result in a misalignment of incentives, making it difficult for plan sponsors to achieve the lowest costs possible. Partially transparent or "translucent" PBMs may disclose some but not all rebate revenues. Fully transparent PBMs identify and share all revenue streams with their plan sponsors. (Drug Benefit Trends. 2008;20:98-100)

A 22-year-old man presentedwith a 3-week history ofcough and hemoptysis withright-sided chest pain and decreasedoral intake associated with a 4.5-kg(10-lb) weight loss. Ten days beforehospital admission, he was involvedin a fistfight, which resulted in his arrest.He was taken to jail and placedin a holding cell for 3 hours. Shortlybefore his pulmonary symptoms developed,he was seen by his primarycare physician because he had a sorethroat and exudative tonsillitis, forwhich amoxicillin/clavulanate wasprescribed. He stopped taking theantibiotic after 3 days.

Nonhuman primate bites in the United States are rare. Mostphysicians have no experience managing them. The lesionsare initially treated in much the same way as human bites,although consultation with an infectious diseases specialist,surgeon, and veterinarian are recommended, especially formicrobial infection control and management. Of particularconcern is animal-to-human transmission of herpes B virus,which can be fatal. We report a case of polymicrobial simianbite wound infection with associated nerve injury in a12-year-old boy. [Infect Med. 2008;25:120-122]

Last month I reviewed key findings in HIV that were published within a 2-month interval near the end of 2007. I have extended that review here, reporting highlights of research announced in the last few weeks of 2007.

Public health experts once held high hopes that the female condom would give women worldwide the ability to protect themselves from sexually transmitted diseases.