John Updike writes about Thanksgiving. Find his poem, Relatives, at Writers Almanac online [1]. (Once there, just scroll down to Thursday November 25.)
"The cousins buzz, the nephews crawl;
to love one's self is to love them all."
American College of Obstetricians & Gynecologists (ACOG) has issued a report on menopausal use of estrogens. Online I have only found a press release and a FAQ for patients [1, 2].
Soy has been shown to be ineffective. They also do not endorse black cohosh. SSRI's and lower-dose short term estrogens may be their suggestions.
While unsure of the mechanism of effect, nortriptyline more than doubled the six-month success (23% vs 10%) of smoking cessation when added to nicotine patch [1]. Dry mouth limited the blinding of the study (and may have been a mechanism of effect). This VA study adds to early reports about this inexpensive pill to help smoking cessation [2].
Nortiptyline was increased every four days starting at 25 mg nightly, with goal of 75 mg.
Drugstore.com nortriptyline price
25 mg (#90) = $19.00
75 mg (#30) = $13.00
Early invasive management is the best aproach for non-ST-segment elevation acute coronary syndromes (NSTE ACS). But it is not used in the majority of high-risk patients, according to the CRUSADE trial [1].
"Patients who underwent early catheterization were younger, more often male and white, more likely to be admitted to a cardiology service, and less likely to have CHF or renal insufficiency." They also were more likely to have private insurance than Medicare/Medicaid. In-hospital mortality was significantly lower in the early invasive care group (2.0 vs 6.2%).
A recent case was an older black man with Medicare and a creatinine of 2.4. The non-use of indicated angiography due to the presence of renal insufficiency is dubbed "renalism" in a recent paper [2]. Others have found that even in urgent situations an abbreviated dosing of acetylcysteine can help [3].
Case history
Worst flu-like illness ever, lasting longer than usual (ten days), with new occipital adenopathy, and ten days after the illness: a clumsy left hand.
Diagnosis
Primary HIV infection
(New conversion of HIV ELISA--now positive from negative six months ago. Western blot: indeterminate. Viral load: high. Lymph node biopsy: reactive adenopathy).
Resources
The UCSF HIV InSite [1, 2], has a 1998 review of primary HIV infection. The site is rich with information including an October 2004 review of HIV immunopathology by Lederman, Rodriquez and Sieg from Case Western Reserve University [3].
Comprehensive NIH HIV guidelines are available [4, 5]. Scott Friedstrom also recommends the Hopkins site [6]. (For patients a flash animation reinforces the importance of medication adherence to reduce drug resistance.)
Here is case report of acute disseminated encephalomyelitis (ADEM) in primary HIV infection [7 abstract] and more discussions of ADEM [8, 9].
The local AIDS Treatment Center is University of Cincinnati 513-584-6977. They are investigating whether antiviral treatment of primary HIV infection effects outcome.
A local volunteer resource, founded over twenty years ago, is AVOC [10].
Addendum:
Lederman et al recently used a topical agent to block vaginal transmission of monkey HIV [11, 12]. PSC-RANTES blocks the CD4 cell's CCR5 receptor attachment to the virus.
Mark Haddon's novel, The Curious Incident of the Dog in the Night-Time, will be discussed at the Cheviot Library on December 16 at 6:30 pm. Here is an online review [1], an author interview [2], some autism readings [3, 4, 5, 6], and more on the Monty Hall Problem [7, 8, 9].
Recommended to me by Fran Morely.
Quoting from a British Medical Journal review of another book, Autism and Creativity [10]
..."We hear a lot about autism these days, usually in connection with its devastatingly early onset and bleak prognosis. It is therefore of interest when a recognised authority on the subject claims that most of those whom he cites as 'the intellectual giants of the twentieth century' (including Einstein, Freud, Yeats, the philosophers Russell and Wittgenstein, and the mathematicians Ramanujan and Turing) had high functioning autism or Asperger's syndrome. Moreover, in this book, Michael Fitzgerald (professor of child and adolescent psychiatry at Trinity College, Dublin) advocates and consolidates a more positive perspective on autism: that this fascinating condition might be a necessary ingredient of human creativity, perhaps even the crucial ingredient."
[This article is free full-text online at bmj.org]
Addressing Wednesday's Noon Conference a piperacillin-tazobactam pharmaceutical representative said "We have looked...we cannot find a single article showing development of resistance to [piperacillin-tazobactam]."
Here is an article published October 29th from the Journal of Respiratory Clinical Care Medicine [1]. It suggests otherwise.
"To attain a better understanding of antibiotic cycling and its effects on the epidemiology of antibiotic resistance in Gram-negative microorganisms, two different antibiotic classes (quinolone and beta-lactam) were cycled during four 4-month periods in a surgical ICU...Primary endpoint of the study was the acquisition rate with Gram-negative bacteria resistant to the antibiotic of choice during each cycle... In all, 388 patients were included...Acquisition rates with resistant bacteria were highest during levofloxacin exposure (RR 3.2; 95%CI:1.4-7.1) and piperacillin/tazobactam exposure (RR 2.4; 95% CI 1.2-4.8)."
"...Potential for selection of antibiotic-resistant Gram-negative bacteria during periods of homogeneous exposure increased from cefpirome to piperacillin/tazobactam to levofloxacin..."
See also early posting [2].
Beyond wrist band barcodes, the FDA last month approved human-implantable radio frequency microchips (RFID) [1]. In 2000 the UCLA School of Law published an online summary of legal issues [2]. This week a patient pointed out Bible issues (Revelations, Mark of the Beast) [3].
I have not yet found the FDA decision online [4].
"What can I eat to avoid another gout attack?"
In an observational study dairy products, especially low-fat, were associated with less risk of gout [1]. Protein from vegetable sources seemed neutral in risk. But animal protein was associated with an increased risk.
So, one answer to our patient might be "...don't over-eat animal protein (like beef, lamb, pork or seafood). Low-fat dairy products might lower your risk. Protein from vegetables seems not to be associated with gout. A lower body weight and drinking less alcohol also may lower gout risk. These recommendations are not based on perfect evidence."
"Our study was observational; thus, we cannot rule out the possibility that unmeasured factors might contribute to the observed associations. Overall, however, our findings provide prospective evidence that meat consumption and seafood consumption are associated with an increased risk of gout, whereas consumption of dairy products, especially low-fat dairy products, is associated with a substantially reduced risk of gout. In contrast, moderate intake of purine-rich vegetables or protein is not associated with an increased risk of gout."
