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July 1, 2014 Issue


Clinical Practice Point


Medical Knowledge
Patient Care

Association Between Efavirenz as Initial Therapy for HIV-1 Infection and Increased Risk for Suicidal Ideation or Attempted or Completed Suicide

Postmarketing reports have suggested that efavirenz increases risk for suicide. This analysis of data from large randomized trials found that participants assigned to initial treatment for HIV with regimens containing efavirenz had an increased risk for suicidality.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Ask what the initial treatment options are for HIV infection. What are the contraindications and side effects of these agents? Use the ACP Smart Medicine HIV Disease for a concise review, including drug treatment tables.
  • What are the other components of initial therapy for HIV disease?
  • What psychiatric or neurologic problems are of particular concern in HIV-infected individuals?

Clinical Guidelines


Medical Knowledge
Patient Care

Screening for Hepatitis B Virus Infection in Nonpregnant Adolescents and Adults: U.S. Preventive Services Task Force Recommendation Statement

Screening for Hepatitis B Virus Infection: A Public Health Imperative

This clinical guideline recommends that individuals at high risk for HBV infection be screened for it and applies to asymptomatic, nonpregnant adolescents and adults who have not been vaccinated and other persons at high risk for HBV infection. An accompanying editorial argues that these recommendations are long overdue.

Use these papers to:

  • Review the recommendations. Ask your learners what the risk factors are for HBV (they are listed in the figure and in the editorial). The editorial believes a clearer enumeration of these risks is needed, noting that knowledge of them is needed to promote needed screening.
  • Ask your learners if they know the meaning of a recommendation’s grade. This one received a grade B (indicating high certainty that the net benefit is moderate or that there is moderate certainty that the net benefit is moderate to substantial). A 2004 guideline issued a grade D recommendation against screening asymptomatic persons for HBV infection. Why is it important to understand the meaning of the grades?
  • Ask your learners what criteria must be met for a screening test to be worthwhile. Use the freely available curricular material addressing this topic and other key concepts in the High Value Care Curriculum.
  • Answer the brief multiple-choice question to earn CME credit for yourself.


Patient Care
Medical Knowledge

Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline From the American College of Physicians

Screening Pelvic Examinations: Right, Wrong, or Rite?

Pelvic examination (excluding cervical cancer screening) is often used to screen women for pathology. After weighing the benefits and harms presented in an evidence review, the ACP recommends against performing screening pelvic examinations in asymptomatic, nonpregnant adult women. An editorial notes the deficiencies in the argument of professional societies advocating routine pelvic examination. The editorial also notes that the studies included in the evidence review underpinning the guideline might not have addressed the appropriate patient population.

Use these papers to:

  • Ask your learners what they look for when performing a “routine” pelvic examination. Have these examinations been worthwhile? Do they agree there may be harms?
  • Review the guideline and the editorial. Ask your learners whether screening should continue while more definitive evidence is sought, or whether the risks outweigh the established benefits and that the practice should cease.
  • Ask your learners what they plan to do. What will they tell their patients regarding “routine” pelvic examinations?

Medical Knowledge
In the Clinic

Osteoarthritis

This eminently practical and concise review provides answers to key questions related to the evaluation, diagnosis, and management of patients with osteoarthritis.

Use this review to:

  • Ask your learners what the differential diagnosis of osteoarthritis is. What historical and examination features help differentiate osteoarthritis from other causes of joint pain?
  • Review the pharmacologic treatment options for osteoarthritis. Ask what other interventions may be helpful.
  • When is joint replacement appropriate?
  • Download the already prepared teaching slides.
  • Use the multiple-choice questions provided at the end to introduce key learning points during a teaching session. Log on and enter your answers to the earn CME for yourself!

The Patient’s Perspective


Interpersonal and Communication Skills
Patient Care
Systems-based Practice

Patient- and Family-Centered Medical Education: The Next Revolution in Medical Education?

The importance of health care professionals partnering with patients and families has been recognized as an essential component of a high-quality, cost-efficient health care system. This commentary proposes changes in medical education and the training environment that have the potential to produce clinicians who are better able to address the needs of patients and their families.

Use this paper to:

  • Ask your learners how often they think they ask about their patients’ perspectives and preferences when providing care and making treatment decisions. Then, have them recall the last 10 patients they saw and ask themselves if they had indeed inquired about these issues.
  • Ask how often patients’ perspectives have altered what your learners thought would be the plan or approach to care. In what ways?
  • Review the questions and examples of patient and family’s perspectives provided in the table. How can you and your learners plan to address them more routinely?
  • Do your learners like the idea of adopting “SOAP2” notes (Subjective, Objective, Assessment, Plan, Patient’s Perspective)?

Humanism and Professionalism


On Being a Doctor: From Program Director to ALS Patient

Dr. Flannery tells of the struggles, triumphs, and inspirations that have surrounded his diagnosis with amyotrophic lateral sclerosis; the ensuing physical limitations; and the professional adaptations and collegial support that came with them.

Use this essay to:

  • Play an audio recording, read by Dr. Michael Lacombe.
  • Ask your learners what they believe they would fear most by such a diagnosis.
  • Does hearing Dr. Flannery’s experience alter how your learners might relate to other patients? Does hearing about a physician colleague’s experience with a devastating illness inspire a more acute sense of empathy when interacting with other patients? Why or why not?

mksap16

A 35-year-old man is evaluated during a routine follow-up visit. He was diagnosed with HIV infection 2 years ago. He started combination antiretroviral therapy with tenofovir, emtricitabine, and efavirenz and within 4 months had an undetectable HIV RNA viral load and a normal CD4 cell count. The patient has been adherent to his medication regimen. He is presently asymptomatic, feeling well, and having no problems with his medications.

The physical examination is normal.

Laboratory studies show an HIV RNA viral load of 275 copies/mL, with repeated results indicating 710 copies/mL. The CD4 cell count is normal. The remaining laboratory tests, including complete blood count, serum chemistries, and liver enzymes, are normal.

Which of the following is the most appropriate next step in the management of this patient?

A) Continue present medication regimen and follow up in 4 weeks
B) Discontinue present medication regimen and perform resistance testing in 1 week
C) Discontinue present medication regimen and repeat CD4 cell count and HIV RNA viral load in 4 weeks
D) Perform viral resistance testing and continue present medication regimen pending results

Correct Answer
D) Perform viral resistance testing and continue present medication regimen pending results

Key Point
In patients with HIV infection, resistance testing is appropriate in the setting of treatment failure as evidenced by suboptimally controlled viral loads (lack of suppressed viral loads or previously undetectable viral loads that have become detectable on repeated testing).

Educational Objective
Manage HIV treatment failure.

The patient should undergo viral resistance testing while continuing his present medication regimen, with a treatment change based on resistance testing results. Resistance testing is appropriate in the setting of treatment failure as evidenced by suboptimally controlled HIV RNA viral loads (lack of suppressed viral loads or previously undetectable viral loads that have become detectable on repeated testing). This patient is adherent to his antiretroviral therapy, and his previously undetectable viral load is now repeatedly detectable, indicating treatment failure. Resistance testing should be performed to guide the selection of a new treatment regimen. The present regimen should be continued to sustain partial suppression of the virus pending results of resistance testing. A new regimen can be instituted once resistance testing results become available.

Continuing the same therapeutic regimen in this patient with demonstrated treatment failure would lead to development of further resistance, higher virus levels, and an eventual decline in CD4 cell count.

Resistance testing should be done while the patient continues the current regimen. Discontinuing the regimen would allow a significant increase in viral load. Resistance testing done while the patient is not receiving therapy may be unreliable without the selective pressure of the medications to maintain the presence of mutations in the predominant virus population.

This patient requires antiretroviral therapy and has been tolerating it well. The Strategies for Management of AntiRetroviral Treatment (SMART) study showed that for such patients, therapy should be maintained and a drug holiday avoided because it is associated with increased complications and mortality.

Bibliography
Taylor S, Jayasuriya A, Smit E. Using HIV resistance tests in clinical practice. J Antimicrob Chemother. 2009;64(2):218-222. PMID: 19535382

This question is 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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