EVERYBODY GETS garden-variety tension headaches, but certain types of brain pain affect men more than women. Experts don't fully understand why, but stereotypical theories abound. Everything from business stress, tobacco and alcohol use and heavy lifting to overexertion at the gym have been blamed for male headaches. Whatever their origins, male headaches can range from mild to severe--and sometimes even debilitating. However, relief is at hand: There are several traditional and natural ways to mitigate these male-centric maladies.
Cluster busters
Of the 1 million Americans who suffer from cluster headaches, about 75 percent are men. Pain typically strikes several times during a 24-hour period, frequently between one and three hours after falling asleep, and lasts from 30 to 90 minutes at a time. Episodes can continue anywhere from 2 to 12 weeks. The attacks occur when the trigeminal nerve pathway at the base of the brain is activated by the hypothalamus, the brain's internal clock, for as yet undetermined reasons. Cluster headaches, which tend to peak in the spring and autumn, are rarely caused by an underlying serious brain condition like a tumor or aneurysm, but may be the result of a vascular disorder.
The intense pain--sometimes described as a red-hot poker in one eye--is usually accompanied by swelling, tearing, flushing, and nasal congestion on the affected side. (If you ever experience sudden, severe head pain with vomiting, weakness, or sensory impairment, seek medical attention immediately.) An injection of the migraine drug sumatriptan (Imitrex) is the most successful prescription response, according to the Cleveland Clinic Neuroscience Center in Ohio.
However, alternative approaches have plenty of scientific support. Irregular levels of melatonin, which frequently drop during episodes, could be a factor. In a study published in the journal Cephalalgia in 1996, patients reduced the frequency of cluster headaches by taking 10 milligrams of this natural hormone each evening for at least 14 days.
Because the worst symptoms of these headaches can come and go quickly, some treatments are applied through the nostrils for faster uptake. Anesthetic use of lidocaine spray is often prescribed, while another study in Cephalalgia in 1993 found that subjects who received nasal applications of capsaicin--the active ingredient in cayenne pepper--twice daily for seven days during episodes had a significant reduction in pain for the following 15 days. (Before trying intranasal capsaicin, get an OK from your doctor.)
Ayurveda offers an alternative solution. According to this ancient science, cluster headaches may be a result of a vata-dosha imbalance, says Vasant Lad, B.A.M.S., M.A.Sc., director of the Ayurvedic Institute in Albuquerque, N.M. His remedy to calm the agitating energy of vata: Spread warm ghee (clarified butter) around the inside of each nostril, or rub nutmeg oil on the temples.
Since part of headache pain is caused by the swelling of arteries that surround the brain and oxygen may reduce that swelling, oxygen therapy can be another effective strategem to employ at the beginning of an attack. "Inhaling 7 to 10 liters per minute of 100 percent oxygen via a face mask for 15 to 20 minutes has been shown to relieve pain in about 70 percent of cluster headache sufferers, say Marc S. Husid, M.D., a physician with the Walton Headache Center in Augusta, Ga.
In addition, people with low ionized-magnesium levels eased symptoms after receiving injections of magnesium sulfate, according to a 1995 report in Headache; however, oral magnesium supplementation was not evaluated.
Barbells and bedrooms
Exertion headaches kick in shortly after vigorous physical activity, such as heavy weight lifting or aerobics. To avoid sudden fluctuations in the blood vessels, cool down after intense training instead of stopping abruptly, and mix low-impact options like swimming or walking into your routine. Dehydration and low blood sugar could be triggers as well.
To prevent them, drink plenty of water--6 to 12 ounces every 15 to 20 minutes--during exercise, suggests Jeff Kotterman, L.M.S.N., director of the National Association of Sports Nutrition in San Diego. Within 30 minutes after a workout, eat a 1-to-3 ratio of protein (whey, turkey, or cottage cheese) to simple carbs (fruits like bananas, apples, and strawberries). If the pain returns, breathe slowly and deeply, ice the source of the pain, and rest in a dark room--or take a walk, preferably in fresh air.
Men are also more prone to sexual headaches, caused either by muscle contractions in the head and neck or by dilation of blood vessels just before orgasm. The vascular version, called orgasmic cephalalgia, involves a sharp pain around or behind the eyes that generally lasts for minutes but can linger for hours; it often occurs in men who also suffer from migraines. To take the pain out of your pleasure, slow down the pace and gradually increase sexual intensity. Beta-blockers used to treat migraines can be helpful; another option is to take aspirin or ibuprofen before intercourse. You could also take a break from the triggering activity--though most men would rather grimace and bear it.
COPYRIGHT 2006 Weider Publications
COPYRIGHT 2006 Gale Group
Monday, June 4, 2007
Teva Announces Tentative Approval for Generic Cozaar® Tablets
JERUSALEM -- Teva Pharmaceutical Industries Ltd. (Nasdaq:TEVA) announced today that the U.S. Food and Drug Administration has granted tentative approval for the Company's Abbreviated New Drug Application (ANDA) to market its generic version of Merck's antihypertensive agent Cozaar(R) (Losartan Potassium) Tablets, 25 mg, 50 mg and 100 mg. Final approval of this ANDA is expected in April 2010 when patent protection for the brand product expires.
Teva Pharmaceutical Industries Ltd., headquartered in Israel, is among the top 20 pharmaceutical companies in the world and is the leading generic pharmaceutical company. The company develops, manufactures and markets generic and innovative human pharmaceuticals and active pharmaceutical ingredients, as well as animal health pharmaceutical products. Over 80% of Teva's sales are in North America and Europe.
Safe Harbor Statement under the U.S. Private Securities Litigation Reform Act of 1995: This release contains forward-looking statements, which express the current beliefs and expectations of management. Such statements are based on management's current beliefs and expectations and involve a number of known and unknown risks and uncertainties that could cause Teva's future results, performance or achievements to differ significantly from the results, performance or achievements expressed or implied by such forward-looking statements. Important factors that could cause or contribute to such differences include risks relating to Teva's ability to rapidly integrate Ivax Corporation's operations and achieve expected synergies, Teva's ability to successfully develop and commercialize additional pharmaceutical products, the introduction of competing generic products, the impact of competition from brand-name companies that sell or license their own brand products under generic trade dress and at generic prices (so called "authorized generics") or seek to delay the introduction of generic product, the impact of consolidation of our distributors and customers, regulatory changes that may prevent Teva from exploiting exclusivity periods, potential liability for sales of generic products prior to a final resolution of outstanding litigation, including that relating to the generic versions of Allegra(R), Neurontin(R), Oxycontin(R) and Zithromax(R), the effects of competition on Copaxone(R) sales, including as a result of the expected reintroduction of Tysabri(R) into the market, the impact of pharmaceutical industry regulation and pending legislation that could affect the pharmaceutical industry, the difficulty of predicting U.S. Food and Drug Administration, European Medicines Agency and other regulatory authority approvals, the regulatory environment and changes in the health policies and structures of various countries, Teva's ability to successfully identify, consummate and integrate acquisitions, potential exposure to product liability claims, dependence on patent and other protections for innovative products, significant operations worldwide that may be adversely affected by terrorism or major hostilities, environmental risks, fluctuations in currency, exchange and interest rates, operating results and other factors that are discussed in Teva's Annual Report on Form 20-F and its other filings with the U.S. Securities and Exchange Commission. Forward-looking statements speak only as of the date on which they are made and the Company undertakes no obligation to update publicly or revise any forward-looking statement, whether as a result of new information, future developments or otherwise.
COPYRIGHT 2006 Business Wire
COPYRIGHT 2006 Gale Group
Teva Pharmaceutical Industries Ltd., headquartered in Israel, is among the top 20 pharmaceutical companies in the world and is the leading generic pharmaceutical company. The company develops, manufactures and markets generic and innovative human pharmaceuticals and active pharmaceutical ingredients, as well as animal health pharmaceutical products. Over 80% of Teva's sales are in North America and Europe.
Safe Harbor Statement under the U.S. Private Securities Litigation Reform Act of 1995: This release contains forward-looking statements, which express the current beliefs and expectations of management. Such statements are based on management's current beliefs and expectations and involve a number of known and unknown risks and uncertainties that could cause Teva's future results, performance or achievements to differ significantly from the results, performance or achievements expressed or implied by such forward-looking statements. Important factors that could cause or contribute to such differences include risks relating to Teva's ability to rapidly integrate Ivax Corporation's operations and achieve expected synergies, Teva's ability to successfully develop and commercialize additional pharmaceutical products, the introduction of competing generic products, the impact of competition from brand-name companies that sell or license their own brand products under generic trade dress and at generic prices (so called "authorized generics") or seek to delay the introduction of generic product, the impact of consolidation of our distributors and customers, regulatory changes that may prevent Teva from exploiting exclusivity periods, potential liability for sales of generic products prior to a final resolution of outstanding litigation, including that relating to the generic versions of Allegra(R), Neurontin(R), Oxycontin(R) and Zithromax(R), the effects of competition on Copaxone(R) sales, including as a result of the expected reintroduction of Tysabri(R) into the market, the impact of pharmaceutical industry regulation and pending legislation that could affect the pharmaceutical industry, the difficulty of predicting U.S. Food and Drug Administration, European Medicines Agency and other regulatory authority approvals, the regulatory environment and changes in the health policies and structures of various countries, Teva's ability to successfully identify, consummate and integrate acquisitions, potential exposure to product liability claims, dependence on patent and other protections for innovative products, significant operations worldwide that may be adversely affected by terrorism or major hostilities, environmental risks, fluctuations in currency, exchange and interest rates, operating results and other factors that are discussed in Teva's Annual Report on Form 20-F and its other filings with the U.S. Securities and Exchange Commission. Forward-looking statements speak only as of the date on which they are made and the Company undertakes no obligation to update publicly or revise any forward-looking statement, whether as a result of new information, future developments or otherwise.
COPYRIGHT 2006 Business Wire
COPYRIGHT 2006 Gale Group
Inflammatory lesions on every finger
A 25-year-old man presented with aching, swollen, scarlet lesions on the tips of all 10 fingers (Figure 1) following a three-day prodrome of worsening sharp pain in his thumbs, little fingers, and lips. His temperature was 38.2[degrees]C (100.8[degrees]F), and he was unable to fully extend his fingers because of throbbing pain. Small, round, crusted lesions resembling recently ruptured blisters lined his lips. Tense, pustular lesions surrounded by a bright border of erythema and some superficial desquamation encircled the fingertips (Figure 2). The patient denied any recent trauma or other lesions. No adenopathy was appreciated. His white blood cell count, blood chemistries, and transaminase levels were within normal limits.
[FIGURES 1-2 OMITTED]
Question
Based on the patient's history, physical examination, and laboratory tests, which one of the following is the correct diagnosis?
[] A. Pompholyx.
[] B. Herpes zoster.
[] C. Herpetic whitlow.
[] D. Endocarditis with Osler's nodes.
[] E. Paronychia.
Discussion
The answer is C: herpetic whitlow. Herpetic whitlow is in the differential diagnosis of any patient with a fingertip infection. Positive results from direct fluorescent antibody tests and viral cultures from the patient's oral and digital lesions confirmed type 1 herpes simplex virus (HSV) infection. Further history revealed that the patient regularly bit his nails.
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Herpetic whitlow is an HSV infection of the fingers and toes and may represent a primary infection or a secondary recurrence of type 1 or 2 HSV infection. It occurs primarily in medical personnel and in patients with herpetic stomatitis. Before the advent of universal precautions, herpetic whitlow occurred predominantly in health care professionals inoculated by infected patients. (1) The virus is transmitted via saliva, semen, cervical fluid, and active lesions, and often is introduced through direct contact. (2) Following a short incubation period, painful, coalescing vesicles with surrounding erythema develop. The vesicle fluid usually is serous but may appear purulent in patients with secondary infection. Low-grade fever, malaise, and regional lymphadenopathy also may occur. (3) Treatment involves inhibition of viral replication with acyclovir (Zovirax), valacyclovir (Valtrex), or famciclovir (Famvir); symptomatic pain relief; and treatment of bacterial superinfection. The course typically lasts a few weeks, and healing usually is complete.
Pompholyx, or dyshidrotic eczema, is a nonspecific reaction pattern of unknown etiology that preferentially affects the palms and sides of the fingers. (4) Painful pruritus precedes the appearance of bilateral, symmetrical, clear vesicles that progress to bullae. Desquamation, inflammation, and secondary infection often follow. Attacks normally subside spontaneously within two to three weeks.
Herpes zoster infection results from reactivation of the varicella zoster virus, which lies dormant in the sensory ganglia after primary infection. While its vesicular lesions resemble those of HSV infections, their key distinguishing feature is their distribution. (5) Herpes zoster vesicles typically form a dermatomal distribution throughout the affected nerve, while HSV vesicles form at the distal ends of affected nerves.
Osler's nodes are painful, swollen, violaceous subcutaneous nodules occurring mainly in the pulp of the fingers and toes. They are one of several cutaneous manifestations of bacterial endocarditis, and are caused by septic emboli from acute bacterial endocarditis or small-vessel perivasculitis in subacute bacterial endocarditis. (6)
Paronychia, a localized infection of the perionychium, may be acute or chronic and is characterized by pain, erythema, and swelling of the posterior or lateral nail folds, and subsequent superficial abscess. Acute paronychia commonly results from nail biting or trauma and is typically a mixed infection, with Staphylococcus aureus predominating, whereas chronic paronychia likely represents a multifactorial eczematous condition or fungal infection. (7)
REFERENCES
(1.) Jones JG. Herpetic whitlow: an infectious occupational hazard. J Occup Med 1985;27:725-8.
(2.) Yeung-Yue KA, Brentjens MH, Lee PC, Tyring SK. Herpes simplex viruses 1 and 2. Dermatol Clin 2002;20:249-66.
(3.) Spruance SL, Overall JC Jr, Kern ER, Krueger GG, Pliam V, Miller W. The natural history of recurrent herpes simplex labialis: implications for antiviral therapy. N Engl J Med 1977;297:69-75.
(4.) Crosti C, Lodi A. Pompholyx: a still unresolved kind of eczema. Dermatology 1993;186:241-2.
(5.) Chen TM, George S, Woodruff CA, Hsu S. Clinical manifestations of varicella-zoster virus infection. Dermatol Clin 2002;20:267-82.
(6.) Fitzpatrick TB, Johnson RA, Wolff K, Polano MK, Suurmond D, eds. Color atlas and synopsis of clinical dermatology: common and serious diseases. 3d ed. New York: McGraw-Hill, 1997:623.
(7.) Rockwell PG. Acute and chronic paronychia. Am Fam Physician 2001;63:1113-6.
Selected Differential Diagnosis
of Inflammatory Finger Lesions
Condition Characteristics
Pompholyx Painful pruritus with vesicles on palms
and sides of fingers
Herpes zoster Vesicles along a dermatomal
distribution
Herpetic whitlow Painful, coalescing vesicles with
surrounding erythema on fingers
Endocarditis with Painful, swollen, violaceous nodules in
Osler's the pulp of fingers and toes
Paronychia Pain, erythema, and swelling of the
posterior or lateral nail folds
RAMEY WILSON, M.D.
ALEX G. TRUESDELL, M.D.
TODD C. VILLINES, M.D.
Walter Reed Army Medical Center
Washington, D.C.
COPYRIGHT 2005 American Academy of Family Physicians
COPYRIGHT 2005 Gale Group
[FIGURES 1-2 OMITTED]
Question
Based on the patient's history, physical examination, and laboratory tests, which one of the following is the correct diagnosis?
[] A. Pompholyx.
[] B. Herpes zoster.
[] C. Herpetic whitlow.
[] D. Endocarditis with Osler's nodes.
[] E. Paronychia.
Discussion
The answer is C: herpetic whitlow. Herpetic whitlow is in the differential diagnosis of any patient with a fingertip infection. Positive results from direct fluorescent antibody tests and viral cultures from the patient's oral and digital lesions confirmed type 1 herpes simplex virus (HSV) infection. Further history revealed that the patient regularly bit his nails.
Advertisement
Herpetic whitlow is an HSV infection of the fingers and toes and may represent a primary infection or a secondary recurrence of type 1 or 2 HSV infection. It occurs primarily in medical personnel and in patients with herpetic stomatitis. Before the advent of universal precautions, herpetic whitlow occurred predominantly in health care professionals inoculated by infected patients. (1) The virus is transmitted via saliva, semen, cervical fluid, and active lesions, and often is introduced through direct contact. (2) Following a short incubation period, painful, coalescing vesicles with surrounding erythema develop. The vesicle fluid usually is serous but may appear purulent in patients with secondary infection. Low-grade fever, malaise, and regional lymphadenopathy also may occur. (3) Treatment involves inhibition of viral replication with acyclovir (Zovirax), valacyclovir (Valtrex), or famciclovir (Famvir); symptomatic pain relief; and treatment of bacterial superinfection. The course typically lasts a few weeks, and healing usually is complete.
Pompholyx, or dyshidrotic eczema, is a nonspecific reaction pattern of unknown etiology that preferentially affects the palms and sides of the fingers. (4) Painful pruritus precedes the appearance of bilateral, symmetrical, clear vesicles that progress to bullae. Desquamation, inflammation, and secondary infection often follow. Attacks normally subside spontaneously within two to three weeks.
Herpes zoster infection results from reactivation of the varicella zoster virus, which lies dormant in the sensory ganglia after primary infection. While its vesicular lesions resemble those of HSV infections, their key distinguishing feature is their distribution. (5) Herpes zoster vesicles typically form a dermatomal distribution throughout the affected nerve, while HSV vesicles form at the distal ends of affected nerves.
Osler's nodes are painful, swollen, violaceous subcutaneous nodules occurring mainly in the pulp of the fingers and toes. They are one of several cutaneous manifestations of bacterial endocarditis, and are caused by septic emboli from acute bacterial endocarditis or small-vessel perivasculitis in subacute bacterial endocarditis. (6)
Paronychia, a localized infection of the perionychium, may be acute or chronic and is characterized by pain, erythema, and swelling of the posterior or lateral nail folds, and subsequent superficial abscess. Acute paronychia commonly results from nail biting or trauma and is typically a mixed infection, with Staphylococcus aureus predominating, whereas chronic paronychia likely represents a multifactorial eczematous condition or fungal infection. (7)
REFERENCES
(1.) Jones JG. Herpetic whitlow: an infectious occupational hazard. J Occup Med 1985;27:725-8.
(2.) Yeung-Yue KA, Brentjens MH, Lee PC, Tyring SK. Herpes simplex viruses 1 and 2. Dermatol Clin 2002;20:249-66.
(3.) Spruance SL, Overall JC Jr, Kern ER, Krueger GG, Pliam V, Miller W. The natural history of recurrent herpes simplex labialis: implications for antiviral therapy. N Engl J Med 1977;297:69-75.
(4.) Crosti C, Lodi A. Pompholyx: a still unresolved kind of eczema. Dermatology 1993;186:241-2.
(5.) Chen TM, George S, Woodruff CA, Hsu S. Clinical manifestations of varicella-zoster virus infection. Dermatol Clin 2002;20:267-82.
(6.) Fitzpatrick TB, Johnson RA, Wolff K, Polano MK, Suurmond D, eds. Color atlas and synopsis of clinical dermatology: common and serious diseases. 3d ed. New York: McGraw-Hill, 1997:623.
(7.) Rockwell PG. Acute and chronic paronychia. Am Fam Physician 2001;63:1113-6.
Selected Differential Diagnosis
of Inflammatory Finger Lesions
Condition Characteristics
Pompholyx Painful pruritus with vesicles on palms
and sides of fingers
Herpes zoster Vesicles along a dermatomal
distribution
Herpetic whitlow Painful, coalescing vesicles with
surrounding erythema on fingers
Endocarditis with Painful, swollen, violaceous nodules in
Osler's the pulp of fingers and toes
Paronychia Pain, erythema, and swelling of the
posterior or lateral nail folds
RAMEY WILSON, M.D.
ALEX G. TRUESDELL, M.D.
TODD C. VILLINES, M.D.
Walter Reed Army Medical Center
Washington, D.C.
COPYRIGHT 2005 American Academy of Family Physicians
COPYRIGHT 2005 Gale Group
Danazol therapy for immune thrombocytopenic purpura
Immune thrombocytopenic purpura, a fairly common condition in children, is usually benign and self-limited, resolving spontaneously within a few months. Patients with significant bleeding usually respond to steroid therapy. Many types of therapy are recommended for chronic thrombocytopenic purpura, including steroids, splenectomy, immunosuppressive agents, vincristine and high-dose intravenous gamma globulin.
Weinblatt and associates report their experience with danazol, an attenuated androgen, in ten symptomatic children with refractory immune thrombocytopenic purpura. The patients ranged in age from 30 months to 17 years. All were initially treated with prednisone and either had a poor response to therapy or became steroid-dependent, with hemorrhagic symptoms occurring when steroid doses were reduced. Other methods of treatment, including high-dose intravenous gamma globulin, azathioprine, splenectomy or plasmapheresis, had been tried in some of the children but failed to raise the platelet counts.
Danazol therapy was begun at a dosage of 20 to 30 mg per kg per day in divided doses and was increased up to a maximum of 800 mg per day in older children. Nine of the ten patients exhibited improvement in platelet counts following danazol therapy. Response times varied from one week to one month. Steroid therapy could be withdrawn in most of the patients who had been receiving concomitant steroids. No liver function abnormalities or other significant adverse effects were associated with the use of danazol. (American Journal of Diseases of Children, December 1988, vol. 142, p. 1317.)
COPYRIGHT 1989 American Academy of Family Physicians
COPYRIGHT 2004 Gale Group
Weinblatt and associates report their experience with danazol, an attenuated androgen, in ten symptomatic children with refractory immune thrombocytopenic purpura. The patients ranged in age from 30 months to 17 years. All were initially treated with prednisone and either had a poor response to therapy or became steroid-dependent, with hemorrhagic symptoms occurring when steroid doses were reduced. Other methods of treatment, including high-dose intravenous gamma globulin, azathioprine, splenectomy or plasmapheresis, had been tried in some of the children but failed to raise the platelet counts.
Danazol therapy was begun at a dosage of 20 to 30 mg per kg per day in divided doses and was increased up to a maximum of 800 mg per day in older children. Nine of the ten patients exhibited improvement in platelet counts following danazol therapy. Response times varied from one week to one month. Steroid therapy could be withdrawn in most of the patients who had been receiving concomitant steroids. No liver function abnormalities or other significant adverse effects were associated with the use of danazol. (American Journal of Diseases of Children, December 1988, vol. 142, p. 1317.)
COPYRIGHT 1989 American Academy of Family Physicians
COPYRIGHT 2004 Gale Group
Generic Wellbutrin on tap for Eon - Generics Watch - Eon Labs gets approval for generic form of antidepressant
Eon Labs received the first tentative approval to make a generic form of the antidepressant Wellbutrin (bupropion) in 100 mg and 150 mg tablet strengths. Wellbutrin SR brought in $1.2 billion in sales for GlaxoSmith Kline last year. Wellbutrin's patent protections are set to begin expiring in June 2004.
Bupropion HCl was one of four approvals Eon Labs received in January. Other Eon approvals include the generic form of the type 2 diabetes treatment Glucophage (metformin HCl) in 500 mg, 850 mg and 1,000 mg strength tablets from Bristol-Myers Squibb and Eli Lilly's antidepressant Prozac (fluoxetine) in 10 g and 20 g capsule and 10 mg tablet versions.
COPYRIGHT 2002 Reproduced with permission of the copyright holder. Further reproduction or distribution is prohibited without permission.
COPYRIGHT 2002 Gale Group
Bupropion HCl was one of four approvals Eon Labs received in January. Other Eon approvals include the generic form of the type 2 diabetes treatment Glucophage (metformin HCl) in 500 mg, 850 mg and 1,000 mg strength tablets from Bristol-Myers Squibb and Eli Lilly's antidepressant Prozac (fluoxetine) in 10 g and 20 g capsule and 10 mg tablet versions.
COPYRIGHT 2002 Reproduced with permission of the copyright holder. Further reproduction or distribution is prohibited without permission.
COPYRIGHT 2002 Gale Group
Dream weaver: former Balanchine star Allegra Kent guides Miami City Ballet dancers in "La Sonnambula"
THE STORY CONCERNS A POET WHO APPEARS AT A BARON'S LAVISH PARTY AND BECOMES ENAMORED OF A COQUETTE (APPARENTLY THE HOST'S MISTRESS) SUBSEQUENTLY (WHEN THE GUESTS HAVE RETIRED FROM SUPPER) HE MEETS THE MYSTERIOUS SLEEPWALKER (THE HOST'S WIFE), IS DISCOVERED FOLLOWING HER TO HER ROOM BY THE JEALOUS COQUETTE, AND FINALLY IS STABBED TO DEATH BY THE ENRAGED BARON.
--TAKEN FROM WAITER TERRY'S SYNOPSIS IN REPERTORY IN REVIEW BY BY NANCY REYNOLDS
Earlier this year, my friend and dancing partner of the past, Edward Villella, the founding artistic director of the Miami City Ballet, invited me to Florida to coach three of his ballerinas--Jennifer Kronenberg, Deanna Seay, and Haiyan Wu--in the role of the Sleepwalker in George Balanchine's La Sonnambula.
This ballet (originally titled Night Shadow) and I go very far back together--in fact, back into the middle of the last century. In 1949 when I saw Night Shadow with Alexandra Danilova and Frederic Franklin in a Ballet Russe de Monte Carlo production, it was a "first time ever" experience for me. Even though I'd already decided on ballet as my career and begun studying, I'd never seen a dance performance of any kind. After seeing Night Shadow, my expectations were confirmed: Dancing would be my life's work. I was 11 years old.
Eleven years later, I would dance the starring role myself when Balanchine revived the ballet for me with the great Danish dancer Erik Bruhn as the Poet. And now Eddie was giving me the honor and opportunity to share recollections of those events with his company. I was delighted.
Today because of time and money pressures, ballets are taught as quickly and as efficiently as possible. Leisure to explore a role is a luxury. Yet stories and insights from interpreters of the past are valuable. Coaching is the transmission of ideas that bring a ballet to life, particularly when the choreographer is no longer available. Studying videotapes can help, but ideas and subtle details will be lost if video is the only source.
I was to have three days in Miami working with several casts in paired sessions. All the other dancers could attend rehearsals if they wanted to. And I was excited by the talent and dedication of the entire company. We worked in the large sunny Miami City Ballet studios, which have picture windows visible from the sidewalk. Casual strollers can watch classes and rehearsals while walking by. A generous concept.
For two hours on day one, I worked with the first cast--the lithe, lovely Jennifer Kronenherg and the romantic, handsome Carlos Guerra, her real-life fiance. As an already deeply engaged couple, there was an extraordinary rapport between the two of them. Even before we began, I could feel their unspoken love and empathy for each other. Jennifer wore a red strappy leotard and dark-colored tights pulled to her waist. I requested that she put on the nightgown--the white silken fabric of a phantasmagorical premise, a sleepwalker on pointe--for this ballet of the night and of the realm of undefined shadows and dreams. Dreams that can hold danger and hopes that can shatter in an instant.
Coaching by illustration, I stopped the first rehearsal to demonstrate one of the critical sections. When the Sleepwalker first enters, she moves on pointe in an ever quickening pace, finishing the phrase in a diagonal run forward, looking as if she might step over the boundaries of the stage itself. The audience gasps. Over 40 years ago in Moscow, Mr. B had taken the candle from me to demonstrate this section by running towards the brink of the vast stage of the Kremlin's New Congress Theater. While flying forward, he called out "Step over the footlights," and did so himself. For one second, I thought Mr. B was going to die, but he didn't--instead he gave the candle back to me. Balanchine possessed the brakes of a Rolls Royce.
While tracing the same trajectory for Jennifer and nay other new Sleepwalkers, I stopped just short of crashing into the studio's mirror. I wanted to startle the dancers. Balanchine loved to create the look of choreographic danger, synchronized with the end of a musical phrase for an intense emotional impact. His heroines often ignite our anxiety--think of the girl in "The Unanswered Question" from Ivesiana who falls from a great height; she is a sister of the Sleepwalker.
I explained to the cast how a performance is enhanced by using contrasting qualities of motion and sudden stillness. I constantly reframed my phrases to see which words most effectively transmitted my ideas. I also emphasized the spontaneous quality of the choreography--his action, her reaction.
On Day Two rehearsing with Deanna and her boyfriend Mikhail Nikitine, I ran to the side of the room to watch the moment leading up to an ever-deepening penchee arabesque from a better angle. I wanted to make sure the Sleepwalker and Poet were on an exact collision course, as the audience feels their trembling anticipation of new love and clearly sees her lips moving slowly toward his. At the exact second of the expected kiss, which, in Mr. B's design, never takes place, her head moves behind his. The audience tingles with regret. In another instant, the Poet tries to embrace the Sleepwalker. With entwining arms, he circles her body and descends to the floor. She seems to be caught, but then she steps away with eerie precision. The music crests and falls, emphasizing the Poet's expectancy and despair. The effect is stunning. I remember this moment so well from 1949. Rehearsing this section, Deanna Seay created a similar atmosphere with her unblinking eyes and her musicality. Enchanting Haiyan Wu emphasized the lyrical aspects of the role.
The elegy section is different. The Sleepwalker is searching for the Poet. She knows he is dead. The music has a measured solemnity. The walking, now done entirely off pointe, is a terrifying trance-like progression forward. Balanchine didn't want this part performed on the music. The Sleepwalker's light becomes a candle of mourning.
In the Sleepwalker's action of stepping over the Poet's body, there is resolution. She walks toward her chambers. The Poet's body is lifted on high by four men and placed in her arms. She exits backwards--a spectacular and astonishing ending. The viewer questions what has transpired. As I watched Jennifer practice this moment with Carlos draped over her shoulder, I was very moved. There was a sense of sorrowful knowledge on her expressive face.
After three days in Miami Beach, I had to return home and I missed the actual performances, but I heard they were beautiful. I felt I had given my various casts enough information with which to explore the work alone, with their ballet mistresses, Roma Sosenko and Iliana Lopez, and of course with Eddie.
Information and ideas can come from unexpected places. By chance, 45 years ago, I ran into Mme. Danilova at a bus stop where she demonstrated a moment from La Sonnambula for me. All at once I understood the value of looking backward, forward, sideways, or in any direction for inspiration.
Allegra Kent, a former principal of NYCB, is the author of an autobiography, Once a Dancer.
COPYRIGHT 2005 Dance Magazine, Inc.
COPYRIGHT 2005 Gale Group
--TAKEN FROM WAITER TERRY'S SYNOPSIS IN REPERTORY IN REVIEW BY BY NANCY REYNOLDS
Earlier this year, my friend and dancing partner of the past, Edward Villella, the founding artistic director of the Miami City Ballet, invited me to Florida to coach three of his ballerinas--Jennifer Kronenberg, Deanna Seay, and Haiyan Wu--in the role of the Sleepwalker in George Balanchine's La Sonnambula.
This ballet (originally titled Night Shadow) and I go very far back together--in fact, back into the middle of the last century. In 1949 when I saw Night Shadow with Alexandra Danilova and Frederic Franklin in a Ballet Russe de Monte Carlo production, it was a "first time ever" experience for me. Even though I'd already decided on ballet as my career and begun studying, I'd never seen a dance performance of any kind. After seeing Night Shadow, my expectations were confirmed: Dancing would be my life's work. I was 11 years old.
Eleven years later, I would dance the starring role myself when Balanchine revived the ballet for me with the great Danish dancer Erik Bruhn as the Poet. And now Eddie was giving me the honor and opportunity to share recollections of those events with his company. I was delighted.
Today because of time and money pressures, ballets are taught as quickly and as efficiently as possible. Leisure to explore a role is a luxury. Yet stories and insights from interpreters of the past are valuable. Coaching is the transmission of ideas that bring a ballet to life, particularly when the choreographer is no longer available. Studying videotapes can help, but ideas and subtle details will be lost if video is the only source.
I was to have three days in Miami working with several casts in paired sessions. All the other dancers could attend rehearsals if they wanted to. And I was excited by the talent and dedication of the entire company. We worked in the large sunny Miami City Ballet studios, which have picture windows visible from the sidewalk. Casual strollers can watch classes and rehearsals while walking by. A generous concept.
For two hours on day one, I worked with the first cast--the lithe, lovely Jennifer Kronenherg and the romantic, handsome Carlos Guerra, her real-life fiance. As an already deeply engaged couple, there was an extraordinary rapport between the two of them. Even before we began, I could feel their unspoken love and empathy for each other. Jennifer wore a red strappy leotard and dark-colored tights pulled to her waist. I requested that she put on the nightgown--the white silken fabric of a phantasmagorical premise, a sleepwalker on pointe--for this ballet of the night and of the realm of undefined shadows and dreams. Dreams that can hold danger and hopes that can shatter in an instant.
Coaching by illustration, I stopped the first rehearsal to demonstrate one of the critical sections. When the Sleepwalker first enters, she moves on pointe in an ever quickening pace, finishing the phrase in a diagonal run forward, looking as if she might step over the boundaries of the stage itself. The audience gasps. Over 40 years ago in Moscow, Mr. B had taken the candle from me to demonstrate this section by running towards the brink of the vast stage of the Kremlin's New Congress Theater. While flying forward, he called out "Step over the footlights," and did so himself. For one second, I thought Mr. B was going to die, but he didn't--instead he gave the candle back to me. Balanchine possessed the brakes of a Rolls Royce.
While tracing the same trajectory for Jennifer and nay other new Sleepwalkers, I stopped just short of crashing into the studio's mirror. I wanted to startle the dancers. Balanchine loved to create the look of choreographic danger, synchronized with the end of a musical phrase for an intense emotional impact. His heroines often ignite our anxiety--think of the girl in "The Unanswered Question" from Ivesiana who falls from a great height; she is a sister of the Sleepwalker.
I explained to the cast how a performance is enhanced by using contrasting qualities of motion and sudden stillness. I constantly reframed my phrases to see which words most effectively transmitted my ideas. I also emphasized the spontaneous quality of the choreography--his action, her reaction.
On Day Two rehearsing with Deanna and her boyfriend Mikhail Nikitine, I ran to the side of the room to watch the moment leading up to an ever-deepening penchee arabesque from a better angle. I wanted to make sure the Sleepwalker and Poet were on an exact collision course, as the audience feels their trembling anticipation of new love and clearly sees her lips moving slowly toward his. At the exact second of the expected kiss, which, in Mr. B's design, never takes place, her head moves behind his. The audience tingles with regret. In another instant, the Poet tries to embrace the Sleepwalker. With entwining arms, he circles her body and descends to the floor. She seems to be caught, but then she steps away with eerie precision. The music crests and falls, emphasizing the Poet's expectancy and despair. The effect is stunning. I remember this moment so well from 1949. Rehearsing this section, Deanna Seay created a similar atmosphere with her unblinking eyes and her musicality. Enchanting Haiyan Wu emphasized the lyrical aspects of the role.
The elegy section is different. The Sleepwalker is searching for the Poet. She knows he is dead. The music has a measured solemnity. The walking, now done entirely off pointe, is a terrifying trance-like progression forward. Balanchine didn't want this part performed on the music. The Sleepwalker's light becomes a candle of mourning.
In the Sleepwalker's action of stepping over the Poet's body, there is resolution. She walks toward her chambers. The Poet's body is lifted on high by four men and placed in her arms. She exits backwards--a spectacular and astonishing ending. The viewer questions what has transpired. As I watched Jennifer practice this moment with Carlos draped over her shoulder, I was very moved. There was a sense of sorrowful knowledge on her expressive face.
After three days in Miami Beach, I had to return home and I missed the actual performances, but I heard they were beautiful. I felt I had given my various casts enough information with which to explore the work alone, with their ballet mistresses, Roma Sosenko and Iliana Lopez, and of course with Eddie.
Information and ideas can come from unexpected places. By chance, 45 years ago, I ran into Mme. Danilova at a bus stop where she demonstrated a moment from La Sonnambula for me. All at once I understood the value of looking backward, forward, sideways, or in any direction for inspiration.
Allegra Kent, a former principal of NYCB, is the author of an autobiography, Once a Dancer.
COPYRIGHT 2005 Dance Magazine, Inc.
COPYRIGHT 2005 Gale Group
Diary: from a week in practice
Monday
Competitive sports can bring out the best in people, but once in a while, athletics also bring to light something unexpected. "This is going to sound weird, but my heart's not right," Hailey disclosed in a previous visit. She began having episodes of rapid heart-pounding lasting two to three minutes while she was participating in sporting events as a senior in high school. In college, the 20-year-old no longer played softball or volleyball, but she continued to have the same symptoms during strenuous activities. Hailey's resting heart rate was in the low 90s, and her blood pressure was 116/78 mm Hg. Her electrocardiogram was unremarkable. Results of a metabolic profile, thyroid function tests, and complete blood count were normal. An event recorder documented supraventricular tachycardia and episodes of atrial flutter with a rate around 250 beats per minute. Exercise was linked to the arrhythmia. I referred Hailey to a cardiologist, and she had electrophysiologic testing, which showed uncommon atrioventricular node reentry. Hailey chose to undergo intracardiac mapping with radiofrequency catheter ablation. Since the radiofrequency ablation was performed, she has been asymptomatic. Hailey was pleased that she doesn't require long-term treatment with medication. "Isn't technology wonderful!" she exclaimed at her visit today. "I'm really thankful that everything turned out okay." Hailey's relief and gratitude were nearly as heartwarming as the procedure.
Tuesday
"It's hard to believe that I was 200 lb of pure muscle," reflected Warren at his last visit. "Nowadays, I'm just 200-plus lb of muscle aches and pains," the 52-year-old coal miner lamented. He was particularly bothered by constant soreness of the muscles in his arms and legs. In light of the more than 30 years he had logged in the mines, Warren had already formulated a diagnosis. "I think my job has ruined me." The examination I performed at that visit revealed some arthritic changes of his knees, hands, and shoulders. No muscle tenderness, atrophy, or weakness was present, so myopathy seemed unlikely. One laboratory test showed intriguing results--an abnormal creatine kinase level of 632 U per L. His MB isoenzyme of creatine kinase (1.95 ng per mL), erythrocyte sedimentation rate (11 mm per hour), and white blood cell count (6,000 cells per mm3) were normal. I asked Warren to have some additional blood work done, but I wanted him to wait until he had been off work for a day or two. The new results arrived today. Warren's creatine kinase level remained elevated--324 U per L--but it was better. The results of the aldolase (4.9 U per L) and other tests including uric acid, antinuclear antibodies, and rheumatoid factor were normal. I knew strenuous activity could cause an elevation of creatine kinase, but was that the reason for Warren's problem? If it was, then what practical remedy could I offer him? I spent so much time reviewing the literature and thinking about the case that I gave myself tired eyes and a headache. For now, the diagnosis that makes the most sense is the one he came up with himself: work hurts.
Wednesday
Mrs. Mendell loved her peas. The 71 year old relished the vegetables grown in her garden. Today, I had my doubts that the affection was mutual. Mrs. Mendell had been eating lots of tomatoes and nuts lately, and for the past few days, she had experienced lower abdominal cramping and mild constipation. On examination, I found Mrs. Mendell had left lower quadrant abdominal tenderness and a low-grade fever. Bowel sounds were normal, a stool for occult blood was negative, and the results of a urinalysis were normal, but her white blood cell count was slightly elevated.
"You have a case of diverticulitis," I informed her. The diagnosis didn't faze her. "Don't all older people have that?" she inquired. I explained to her the difference between diverticulosis and diverticulitis. "I don't want that 'itis'," Mrs. Mendell said while wagging her finger at me. Outpatient treatment seemed appropriate, so I started her on ciprofloxacin (Cipro) and metronidazole (Flagyl). I asked her to alter her diet and return in a couple of days to be reexamined. "What am I going to do with all those vegetables I can't eat?" she thought aloud. The solution suddenly surfaced. "I bet you and your staff love tomatoes. I'll have my husband drop off a shopping bag of them later today."
Thursday
Bernadette mistrusts any doctor except her own and has misgivings about prescription drugs. The 60-year-old woman is a human matchstick--tall and lean with closely cropped red hair and a temper that is easily ignited. Not long ago, Bernadette developed a deep, aching pain in her left shin. She had not injured her lower leg and denied any other bone pain. Grudgingly, she consented to an x-ray of the tibia and a blood test. The radiologist reported changes consistent with Paget's disease of the bone. Further supporting the diagnosis were an elevated alkaline phosphatase level and normal serum calcium. Not surprisingly, Bernadette refused to see an endocrinologist or orthopedist. Because she had no kidney disease or esophageal problems, I asked her to consider treatment with a bisphosphonate agent: alendronate (Fosamax) for six months or risedronate (Actonel) for two months. "No thanks," she said. "If it ain't broke, don't go trying to fix it." To no avail, I explained how the changes associated with Paget's disease make the affected bone weaker and more likely to fracture. There was no way I was going to change this woman's mind. "You don't have to decide today," I said. "I'll be happy to discuss the problem again any time you like." It's hard to light a fire under some people. In Bernadette's case, gentleness may prove to be more effective than coercion.
Friday
Seven months ago, Joe awoke from a sound sleep with an awful pain in his big toe. "Tell me this isn't gout," he entreated. I wasn't able to oblige him. The first metatarsophalangeal joint of his right foot was swollen, warm, reddened, and exquisitely tender to light touch. His uric acid was 9.4 mg per dL and serum creatinine was normal. Treatment with indomethacin (Indocin) quickly stamped out his first episode of gout. Joe failed to follow my recommendations of a low purine diet, weight reduction, and limitation of alcohol intake. Three months later, his gout was back, and so was Joe. Another round of indomethacin provided rapid relief. Today, Joe returned with his third episode of gout. After this last flare is resolved, he will begin treatment for recurrent gout with allopurinol (Zyloprim) 100 mg a day and colchicine 0.6 mg twice a day. The dose of allopurinol will be increased gradually until his uric acid level falls below 6.0 mg per dL. "Is it safe to have a beer now and then with these medicines?" he asked sheepishly. Disappointed and frustrated, I let out a sigh. "Gotcha!" he laughed. Joe had seen the light; I hoped that we had seen the end of his gout.
Saturday/Sunday
"Look in my ear," Leah instructed me. "It's been hurting off and on for the past few months." I examined her ears and found nothing wrong with them. The 36-year-old elementary school teacher vigorously rubbed the skin in front of her right ear, which tipped me off to a possible diagnosis. Mild tenderness was present over the temporo-mandibular joint (TMJ). "Open wide and say 'Aah'," I directed her. A popping noise emanated from her right jaw. "That doesn't sound too good," she remarked. I noticed Leah had a limited ability to open her mouth wide. In addition, she had a crossbite. "You can blame your earache on TMJ disorder," I informed her. She began filling in some blanks about problems at work, occasional teeth grinding, and a fondness for chewing gum. I asked Leah to take ibuprofen as needed for her pain, apply moist heat to the TMJ, and gently massage the area. She would contact her dentist about a mouth splint, and we talked about ways to reduce stress. Before Leah left the office, I gave her a final assignment, "No clenching your teeth or chewing gum at school."
Tony Miksanek, M.D., has been a family physician for more than 20 years. Most of that time has been in solo private practice in Benton, a town with a population of about 7,000 in rural southern Illinois.
Address correspondence to Tony Miksanek, M.D., 712 Old Orchard Dr., Benton, IL 62812.
To preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario. Any resemblance to actual persons is coincidental.
COPYRIGHT 2005 American Academy of Family Physicians
COPYRIGHT 2005 Gale Group
Competitive sports can bring out the best in people, but once in a while, athletics also bring to light something unexpected. "This is going to sound weird, but my heart's not right," Hailey disclosed in a previous visit. She began having episodes of rapid heart-pounding lasting two to three minutes while she was participating in sporting events as a senior in high school. In college, the 20-year-old no longer played softball or volleyball, but she continued to have the same symptoms during strenuous activities. Hailey's resting heart rate was in the low 90s, and her blood pressure was 116/78 mm Hg. Her electrocardiogram was unremarkable. Results of a metabolic profile, thyroid function tests, and complete blood count were normal. An event recorder documented supraventricular tachycardia and episodes of atrial flutter with a rate around 250 beats per minute. Exercise was linked to the arrhythmia. I referred Hailey to a cardiologist, and she had electrophysiologic testing, which showed uncommon atrioventricular node reentry. Hailey chose to undergo intracardiac mapping with radiofrequency catheter ablation. Since the radiofrequency ablation was performed, she has been asymptomatic. Hailey was pleased that she doesn't require long-term treatment with medication. "Isn't technology wonderful!" she exclaimed at her visit today. "I'm really thankful that everything turned out okay." Hailey's relief and gratitude were nearly as heartwarming as the procedure.
Tuesday
"It's hard to believe that I was 200 lb of pure muscle," reflected Warren at his last visit. "Nowadays, I'm just 200-plus lb of muscle aches and pains," the 52-year-old coal miner lamented. He was particularly bothered by constant soreness of the muscles in his arms and legs. In light of the more than 30 years he had logged in the mines, Warren had already formulated a diagnosis. "I think my job has ruined me." The examination I performed at that visit revealed some arthritic changes of his knees, hands, and shoulders. No muscle tenderness, atrophy, or weakness was present, so myopathy seemed unlikely. One laboratory test showed intriguing results--an abnormal creatine kinase level of 632 U per L. His MB isoenzyme of creatine kinase (1.95 ng per mL), erythrocyte sedimentation rate (11 mm per hour), and white blood cell count (6,000 cells per mm3) were normal. I asked Warren to have some additional blood work done, but I wanted him to wait until he had been off work for a day or two. The new results arrived today. Warren's creatine kinase level remained elevated--324 U per L--but it was better. The results of the aldolase (4.9 U per L) and other tests including uric acid, antinuclear antibodies, and rheumatoid factor were normal. I knew strenuous activity could cause an elevation of creatine kinase, but was that the reason for Warren's problem? If it was, then what practical remedy could I offer him? I spent so much time reviewing the literature and thinking about the case that I gave myself tired eyes and a headache. For now, the diagnosis that makes the most sense is the one he came up with himself: work hurts.
Wednesday
Mrs. Mendell loved her peas. The 71 year old relished the vegetables grown in her garden. Today, I had my doubts that the affection was mutual. Mrs. Mendell had been eating lots of tomatoes and nuts lately, and for the past few days, she had experienced lower abdominal cramping and mild constipation. On examination, I found Mrs. Mendell had left lower quadrant abdominal tenderness and a low-grade fever. Bowel sounds were normal, a stool for occult blood was negative, and the results of a urinalysis were normal, but her white blood cell count was slightly elevated.
"You have a case of diverticulitis," I informed her. The diagnosis didn't faze her. "Don't all older people have that?" she inquired. I explained to her the difference between diverticulosis and diverticulitis. "I don't want that 'itis'," Mrs. Mendell said while wagging her finger at me. Outpatient treatment seemed appropriate, so I started her on ciprofloxacin (Cipro) and metronidazole (Flagyl). I asked her to alter her diet and return in a couple of days to be reexamined. "What am I going to do with all those vegetables I can't eat?" she thought aloud. The solution suddenly surfaced. "I bet you and your staff love tomatoes. I'll have my husband drop off a shopping bag of them later today."
Thursday
Bernadette mistrusts any doctor except her own and has misgivings about prescription drugs. The 60-year-old woman is a human matchstick--tall and lean with closely cropped red hair and a temper that is easily ignited. Not long ago, Bernadette developed a deep, aching pain in her left shin. She had not injured her lower leg and denied any other bone pain. Grudgingly, she consented to an x-ray of the tibia and a blood test. The radiologist reported changes consistent with Paget's disease of the bone. Further supporting the diagnosis were an elevated alkaline phosphatase level and normal serum calcium. Not surprisingly, Bernadette refused to see an endocrinologist or orthopedist. Because she had no kidney disease or esophageal problems, I asked her to consider treatment with a bisphosphonate agent: alendronate (Fosamax) for six months or risedronate (Actonel) for two months. "No thanks," she said. "If it ain't broke, don't go trying to fix it." To no avail, I explained how the changes associated with Paget's disease make the affected bone weaker and more likely to fracture. There was no way I was going to change this woman's mind. "You don't have to decide today," I said. "I'll be happy to discuss the problem again any time you like." It's hard to light a fire under some people. In Bernadette's case, gentleness may prove to be more effective than coercion.
Friday
Seven months ago, Joe awoke from a sound sleep with an awful pain in his big toe. "Tell me this isn't gout," he entreated. I wasn't able to oblige him. The first metatarsophalangeal joint of his right foot was swollen, warm, reddened, and exquisitely tender to light touch. His uric acid was 9.4 mg per dL and serum creatinine was normal. Treatment with indomethacin (Indocin) quickly stamped out his first episode of gout. Joe failed to follow my recommendations of a low purine diet, weight reduction, and limitation of alcohol intake. Three months later, his gout was back, and so was Joe. Another round of indomethacin provided rapid relief. Today, Joe returned with his third episode of gout. After this last flare is resolved, he will begin treatment for recurrent gout with allopurinol (Zyloprim) 100 mg a day and colchicine 0.6 mg twice a day. The dose of allopurinol will be increased gradually until his uric acid level falls below 6.0 mg per dL. "Is it safe to have a beer now and then with these medicines?" he asked sheepishly. Disappointed and frustrated, I let out a sigh. "Gotcha!" he laughed. Joe had seen the light; I hoped that we had seen the end of his gout.
Saturday/Sunday
"Look in my ear," Leah instructed me. "It's been hurting off and on for the past few months." I examined her ears and found nothing wrong with them. The 36-year-old elementary school teacher vigorously rubbed the skin in front of her right ear, which tipped me off to a possible diagnosis. Mild tenderness was present over the temporo-mandibular joint (TMJ). "Open wide and say 'Aah'," I directed her. A popping noise emanated from her right jaw. "That doesn't sound too good," she remarked. I noticed Leah had a limited ability to open her mouth wide. In addition, she had a crossbite. "You can blame your earache on TMJ disorder," I informed her. She began filling in some blanks about problems at work, occasional teeth grinding, and a fondness for chewing gum. I asked Leah to take ibuprofen as needed for her pain, apply moist heat to the TMJ, and gently massage the area. She would contact her dentist about a mouth splint, and we talked about ways to reduce stress. Before Leah left the office, I gave her a final assignment, "No clenching your teeth or chewing gum at school."
Tony Miksanek, M.D., has been a family physician for more than 20 years. Most of that time has been in solo private practice in Benton, a town with a population of about 7,000 in rural southern Illinois.
Address correspondence to Tony Miksanek, M.D., 712 Old Orchard Dr., Benton, IL 62812.
To preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario. Any resemblance to actual persons is coincidental.
COPYRIGHT 2005 American Academy of Family Physicians
COPYRIGHT 2005 Gale Group
Atazanavir : new recommendations if combined with tenofovir —and warning on Viagra, Cialis, and Levitra
On March 19, 2004 the FDA notified the public of new prescribing information and precautions for atazanavir (brand name Reyataz), if taken in combination with tenofovir (Viread)--and warned of risks with Viagra or similar drugs.
If atazanavir is taken with tenofovir, the blood level of atazanavir is decreased. Therefore it is now recommended that a small dose of ritonavir be taken in addition, to raise the blood level of atazanavir to compensate. All three drugs are taken together once per day, with food.
Also, Reyataz increases the blood level of Viread, which could increase its side effects. As a precaution, patients combining the drugs should be monitored for tenofovir side effects.
The new Patient Information flyer also warns that if atazanavir is combined with Viagra, Cialis, or Levitra, it could increase the risk of serious side effects of those drugs. Patients are advised not to combine atazanavir with any of these drugs unless their doctor tells them it is OK.
For more information see the new prescribing information for atazanavir, which will be posted at http://www.reyataz.com (we did not find it on the site on April 14). Also see the Patient Information flyer, which may be posted at the end of the prescribing information.
COPYRIGHT 2004 John S. James
COPYRIGHT 2004 Gale Group
If atazanavir is taken with tenofovir, the blood level of atazanavir is decreased. Therefore it is now recommended that a small dose of ritonavir be taken in addition, to raise the blood level of atazanavir to compensate. All three drugs are taken together once per day, with food.
Also, Reyataz increases the blood level of Viread, which could increase its side effects. As a precaution, patients combining the drugs should be monitored for tenofovir side effects.
The new Patient Information flyer also warns that if atazanavir is combined with Viagra, Cialis, or Levitra, it could increase the risk of serious side effects of those drugs. Patients are advised not to combine atazanavir with any of these drugs unless their doctor tells them it is OK.
For more information see the new prescribing information for atazanavir, which will be posted at http://www.reyataz.com (we did not find it on the site on April 14). Also see the Patient Information flyer, which may be posted at the end of the prescribing information.
COPYRIGHT 2004 John S. James
COPYRIGHT 2004 Gale Group
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