Allergic bronchopulmonary aspergillosis. An increasingly common disorder among asthmatic patients.

Allergic bronchopulmonary aspergillosis (ABPA), an immunologic disorder, is characterized by bronchial colonization with Aspergillus species, resulting in chronic antigenic stimulation. Hallmarks of the disorder are asthma, cutaneous and serologic evidence of hypersensitivity to Aspergillus organisms, and fleeting pulmonary infiltrates. Diagnosis requires a high index of suspicion. Early diagnosis, aggressive therapy, and serial monitoring of serum IgE levels usually prevent progression of ABPA to bronchiectasis, pulmonary fibrosis, respiratory failure, and death.

Polymyalgia rheumatica. Clinical features and management.

Polymyalgia rheumatica is a clinical syndrome that occurs almost exclusively in older patients. It is characterized by muscle aching and stiffness and an elevated erythrocyte sedimentation rate. It must be distinguished from other common disorders, particularly polymyositis, fibromyalgia, and other chronic inflammatory or neoplastic diseases. A temporal artery biopsy should be done in patients with confirmed polymyalgia rheumatica and suspected coexistent temporal arteritis, which can have serious manifestations. Patients with polymyalgia rheumatica respond dramatically to low doses of corticosteroids, although prolonged daily treatment often may be needed.

Anemia in the elderly. Symptoms, causes, and therapies.

Anemia is common in the elderly, but it is not a normal manifestation of aging and should be evaluated as it would be in a younger person. History taking, physical examination, assessment of red cell morphology, and simple laboratory evaluations (ie, reticulocyte count, iron studies, vitamin levels, sometimes bone marrow examination) usually elucidate the cause. Hypoproliferation of red cells is the most common form of anemia in the elderly, caused more often by chronic disease or iron deficiency and less often by vitamin deficiencies or bone marrow infiltration. Anemia with an elevated reticulocyte count, seen less often in the elderly, suggests acute blood loss or hemolysis. In some patients, the cause is not obvious, and anemia is likely due to increased sensitivity of the hematopoietic system to multiple insults and decreased homeostatic reserve. Transfusions should be used judiciously in patients with symptomatic anemia who are likely to benefit from increased oxygen delivery after transfusion.

Modifying physician prescribing patterns of H2 receptor antagonists in an ambulatory setting.

Numerous studies have documented that primary care physicians prescribe H2 receptor antagonist medications for conditions other than those with approved indications. The Division of Ambulatory Care of the Maricopa County Department of Health Services used a three-physician review panel to confirm a similar prescribing pattern for these agents by physicians in its large ambulatory care system. Using current standards of practice as a guide, the panel determined that a change in physician prescribing patterns was necessary. Such modification was achieved through a comprehensive educational program. The new prescribing pattern resulted in a 10% reduction in the number of patients treated with H2 blockers and a 30% reduction in dosage and duration, for an estimated cost savings of $40,000 per year.