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April 1, 2014 Issue

Clinical Practice Points


Medical Knowledge
Patient Care

Safety and Feasibility of a Diagnostic Algorithm Combining Clinical Probability, D-Dimer Testing, and Ultrasonography for Suspected Upper-Extremity Deep Venous Thrombosis. A Prospective Management Study

This study found that a noninvasive diagnostic algorithm safely and effectively excluded upper-extremity deep venous thrombosis, an increasing problem with the widespread use of central venous catheters.

Use this study to:

  • Ask your learners whether they have ever diagnosed an upper-extremity deep venous thrombosis. What caused it?
  • Review the clinical decision score and diagnostic algorithm employed in this study (the clinical probability was determined as shown in Table 1, and the diagnostic algorithm is shown in Figure 1). Do you think it is feasible?
  • Ask how upper-extremity deep venous thrombosis should be treated. You’ll note that the algorithm called for “treatment according to local policy.” What is your policy? What seems reasonable in the absence of direct evidence from clinical trials?

Medical Knowledge

Associations Between HIV Infection and Subclinical Coronary Atherosclerosis

This study explored the use of cardiac computed tomography in HIV-infected and uninfected men and discovered that infected men had a greater prevalence and extent of coronary artery plaque than uninfected men.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Review the noninfectious complications of HIV disease.
  • Ask what mechanisms might be responsible for the increase in atherosclerosis observed in men with HIV. Use the accompanying editorial to help frame the discussion.
  • Ask whether the prevention, evaluation, and treatment of coronary heart disease is different in patients with HIV.

Medicine, Ethics and Business


Professionalism
Interpersonal and Communication Skills

Why We Should Care About What You Get for "Only $99" From a Personal Genomic Service

This commentary discusses issues surrounding direct-to-consumer genetic testing. As the number or valid uses for genomic data increase, the author urges physicians to insist on data-driven testing and emphasizes the need for an infrastructure to deliver effective genome-based patient care.

Use this commentary to:

  • Ask whether anyone can describe 23andMe. Why did the U.S. Food and Drug Administration warn the company to cease its marketing?
  • Ask whether such companies should be required to demonstrate clinical benefits with the use of their products. Do all health-related products have to demonstrate benefit to be marketed?
  • What are the risks to a patient who obtains results from such a “personal genome service"?
  • What are the implications for healthcare providers? What do we need to know?

Medical Knowledge
Patient Care
In The Clinic:

Multiple Sclerosis

This concise review covers points that are essential in the diagnosis, treatment, and preventative care of patients with multiple sclerosis.

Use this review to:

  • Ask what symptoms and physical findings should alert you to the possibility of MS in your patient.
  • Ask about the overall approach to treatment of patients with MS. What medications are typically used, and what are their benefits and potential harms? When should immunotherapy be considered?
  • Download the already prepared teaching slides to help you teach.
  • Use the 4 multiple-choice questions provided at various points through your teaching session to introduce important topics. Be sure to log on and enter the answers to get CME credit for yourself!

mksap16

A 55-year-old man undergoes follow-up evaluation for worsened cholesterol levels. He has a history of multidrug-resistant HIV infection, but he has been responding well to his current antiretroviral regimen for the past 6 months. The patient follows a healthy diet and exercise regimen. He currently smokes cigarettes and has no family history of premature coronary artery disease. Medications are tenofovir, emtricitabine, raltegravir, and ritonavir-boosted darunavir.

Physical examination is unremarkable.

Laboratory studies:

Alanine aminotransferase 26 units/L
Aspartate aminotransferase 34 units/L

Cholesterol

Total 264 mg/dL (6.8 mmol/L)
LDL 170 mg/dL (4.4 mmol/L)
HDL 46 mg/dL (1.2 mmol/L)
Triglycerides 240 mg/dL (2.7 mmol/L)

Which of the following is the most appropriate management?

A. Encourage strict dietary lipid restriction and recheck lipid panel in 6 months
B. Start atorvastatin
C. Start fenofibrate
D. Start simvastatin

Correct Answer
B. Start atorvastatin

Key Point
Atorvastatin is effective for treating hyperlipidemia in patients with HIV infection and should be started at a lower dose in patients taking protease inhibitors to avoid drug interactions.

Educational Objective
Manage hyperlipidemia in a patient with HIV infection.

The most appropriate management of this patient is initiation of atorvastatin. Metabolic changes in patients with HIV infection can be caused by antiretroviral medications or the infection itself. HIV infection is associated with decreased total, HDL, and LDL cholesterol levels and increased triglyceride levels. Treatment with antiretroviral therapy tends to reverse some of these changes: total and LDL cholesterol increase, but HDL cholesterol remains decreased and triglycerides remain elevated. Some antiretroviral agents, including many protease inhibitors, are particularly associated with hyperlipidemia. This patient's LDL cholesterol level is still higher than goal (130 mg/dL [4.1 mmol/L]) despite diet and exercise. Treatment with a statin is therefore indicated. Atorvastatin has been shown to be effective in treating hyperlipidemia in patients with HIV infection; because of interactions with the protease inhibitor ritonavir, atorvastatin should be started at a lower dose.

This patient has a relatively healthy lifestyle except for smoking, and additional therapeutic changes would likely not have an adequately positive effect on his lipids given their current levels.

Reduction in LDL cholesterol, not triglycerides, is the primary goal of this patient's therapy, and a statin is a better choice than a fibrate for reducing LDL cholesterol levels.

Simvastatin is contraindicated in patients taking HIV protease inhibitors because of cytochrome P-450 drug metabolism interactions, which would raise simvastatin concentrations to dangerous levels.

Bibliography
Farrugia PM, Lucariello R, Coppola JT. Human immunodeficiency virus and atherosclerosis. Cardiol Rev. 2009;17(5):211-215. PMID: 19690471

This question was derived from MKSAP® 16, the Medical Knowledge Self-Assessment Program.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.

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