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March 18, 2014 Issue

Clinical Practice Points


Medical Knowledge
Patient Care

Hepatic Decompensation in Antiretroviral-Treated Patients Co-Infected With HIV and Hepatitis C Virus Compared With Hepatitis C Virus–Monoinfected Patients: A Cohort Study

This study examined the incidence of hepatic decompensation, defined as the presence of ascites, spontaneous bacterial peritonitis, or esophageal variceal hemorrhage, among patients with HIV and hepatitis C virus who are receiving antiretroviral therapy versus those with hepatitis C virus alone. Despite antiretroviral therapy, patients with HIV co-infection had a greater rate of decompensation than those with hepatitis C virus alone.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Review the screening and treatment guidelines for HCV with your learners. You can use a recent In the Clinic: Hepatitis C to quickly get the answers to fundamental questions. Who should be screened? When should clinicians consider antiretroviral therapy?
  • Ask your learners which other co-infections may occur. Consider discussions of human papilloma virus, hepatitis B virus, and varicella-zoster virus.


>Medical Knowledge
Patient Care

Association of Dietary, Circulating, and Supplement Fatty Acids With Coronary Risk: A Systematic Review and Meta-analysis

This study found that recommendations for diets high in polyunsaturated fats and low in saturated fats to prevent coronary artery disease are not strongly supported by existing evidence.

Use this study to:

  • Review lipid metabolism and available therapies.
  • Ask your learners whether they know the differences among commonly used diets, such as DASH (Dietary Approaches to Stop Hypertension), Atkins, and South Beach.
  • Ask your learners what they will tell their patients about dietary changes for the treatment of hypertension and for weight loss. Do they believe they should ignore diet?
  • Log on and get CME credit for yourself by completing the short quiz.

The Business of Medicine


Systems-based Practice
Interpersonal and Communication Skills
Practice Based Learning and Improvement

Variation in Diagnostic Coding of Patients With Pneumonia and Its Association With Hospital Risk-Standardized Mortality Rates: A Cross-sectional Analysis

This study examined the coding data used to calculate risk-standardized mortality rates for pneumonia in hospitals. The authors found variability in whether hospitals assigned a principle diagnosis of sepsis or respiratory failure instead of pneumonia and found that these differences may bias efforts to compare hospitals’ pneumonia outcomes.

Use this study to:

  • Ask your learners how diagnostic codes are generated for a patient’s hospitalization and how the codes are used.
  • Discuss payment models for hospital reimbursement (fee-for-service, diagnosis-related group, and bundled payments) and why documentation may affect both payment and severity indices. Have someone from your hospital’s compliance office discuss how each is defined and why each matters.
  • Ask how inaccuracies in coding might affect efforts at quality improvement.
  • Use the editorial to help frame your discussion.
  • Review the quality indicators monitored by Medicare and have your learners look up how your hospital compares with other local hospitals.

Medicine and Public Issues


Patient Care
Systems-based Practice

Health Policy Basics: Medicaid Expansion

This article reviews the expansion of Medicaid under the Patient Protection and Affordable Care Act after the Supreme Court ruling that state expansion would be optional.

Use this article to:

  • Ask your learners whether they know what Medicaid expansion means. Do they know whether your state has opted to expand Medicaid?
  • Ask what the implications of Medicaid expansion are for your patients.
  • Ask which patients qualify for Medicaid in your state. What does Medicaid provide for patients who have it in your state?
  • Invite a social worker to join the discussion. How hard is it for a patient to navigate the system to enroll?

Video Learning


Medical Knowledge
Patient Care

The Consult Guys: NPO Before Surgery; How Long?

A surgeon can “squeeze” your patient into the operating room schedule this afternoon to place her Hickman catheter, but she ate breakfast. Is that acceptable? Learn what we know about how long a patient must be NPO before a procedure and laugh as you do it with Drs. Merli and Weitz, the Consult Guys. Review the questions afterward as a fun way to reinforce what you’ve learned, and log on to get CME credit for yourself!


ACP Journal Club

Use the concise summaries and insightful critiques to choose a topic for journal club. Is angioplasty and stenting better than medical therapy alone for intracranial artery stenosis? How accurate are chest pain characteristics for detecting acute myocardial infarction? You and your residents can sign up for customized journal club alerts with ACP Journal Wise.


MKSAP 15 Question

A 20-year-old woman is evaluated in the emergency department for a 2-week history of malaise, fatigue, and mild jaundice. The patient has no significant medical history, but she uses injection drugs. She drinks alcohol socially.

On physical examination, the temperature is 37.8 °C (100.0 °F), the blood pressure is 128/70 mm Hg, the pulse rate is 100/min, and the respiration rate is 16/min. Examination reveals slight scleral icterus, needle puncture marks in the antecubital fossae, and hepatomegaly; there is no splenomegaly, cutaneous angiomata, ascites, or asterixis.

Results of laboratory studies are as follows: bilirubin (total), 4.6 mg/dL (78.7 µmol/L); aspartate aminotransferase, 580 U/L; alanine aminotransferase, 750 U/L; alkaline phosphatase, 145 U/L; albumin, 4.2 g/dL (42 g/L); hepatitis B surface antigen, negative; hepatitis B core antibody (IgG and IgM), negative; hepatitis C virus, antibody, negative; hepatitis A virus antibody (IgG and IgM), negative; drug and alcohol screens, negative. Ultrasonography shows hepatomegaly.

In addition to screening for HIV infection, which of the following is the most appropriate next diagnostic test?

A. Hepatitis B virus DNA
B. Hepatitis C virus RNA
C. Liver biopsy
D. MRI of the liver

Correct Answer
B. Hepatitis C virus RNA

Key Point
In possible acute hepatitis C virus infection in seronegative patients, the most sensitive diagnostic test is measurement of hepatitis C viral RNA.

Educational Objective
The patient has signs of an acute hepatitis, including elevated liver test results with concurrent fatigue, malaise, and jaundice, and a recent exposure putting her at risk for viral hepatitis (injection drug use). Acute hepatitis C virus (HCV) infection may occur as a result of injection drug use, and although most infected persons do not develop a clinically apparent acute hepatitis, approximately 20% develop an acute infectious episode. Infected patients may remain seronegative for longer than 8 weeks, and therefore, in this clinical setting with a possibility of recent HCV infection, the most appropriate test would be measurement of HCV RNA. HCV RNA can be measured by PCR-based methods or signal amplification technologies. Hepatitis B virus (HBV) DNA should be measured only if the patient is positive for hepatitis B surface antigen (HBsAg).

HBsAg appears in serum 1 to 10 weeks after an acute exposure to hepatitis B virus and is present in the blood prior to the onset of symptoms or liver aminotransferase elevation. IgM anti-HBc can be the only serologic evidence of HBV infection during the period between the disappearance of HBsAg and the appearance of anti-HBs. Since the serologic tests for HBV are negative in this symptomatic person with elevated liver chemistry tests, there is no value in measuring HBV DNA. Acute hepatitis C is associated with characteristic histopathologic features including steatosis, lymphoid aggregates, and bile duct damage. However, these findings are not specific for HCV and similar findings are associated with acute HBV infection. Liver biopsy in this setting will not lead to a specific diagnosis without complementary serologic testing. MRI of the liver will detail hepatic morphology but will not contribute any more to the diagnosis than the ultrasonography.

Bibliography
Strader DB, Wright T, Thomas DL, Seef LB; American Association for the Study of Liver Diseases. Diagnosis, management, and treatment of hepatitis C [erratum in Hepatology. 2004;40(1):269]. Hepatology. 2004;39(4):1147-1171. [PMID:15057920] - See PubMed

This question was derived from MKSAP® 15, 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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