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September 2, 2014 Issue


Clinical Practice Points


Medical Knowledge

Antiretroviral-Free HIV-1 Remission and Viral Rebound After Allogeneic Stem Cell Transplantation. Report of 2 Cases

This study describes 2 patients with HIV who had allogeneic hematopoietic stem cell transplants with HIV-1–susceptible wild-type donor cells and achieved sustained HIV remission many weeks after stopping antiretroviral therapy. However, both patients later developed detectable virus in their blood, as well as the acute retroviral syndrome, prompting re-initiation of ART.

Use this study to:



Medical Knowledge
Patient Care

Fluid Resuscitation in Sepsis. A Systematic Review and Network Meta-analysis

This study of trial data examined the effect of different resuscitative fluids on mortality in patients with sepsis. It showed possible higher mortality with starches than with crystalloids and lower mortality with albumin and balanced crystalloids than with saline or starches.

Use this study to:

  • Ask your learners how sepsis, severe sepsis, and septic shock are each defined.
  • Ask them how they order intravenous fluids for a patient with septic shock. Which fluid do they use? At what rate? How do they evaluate the effect?
  • Ask what the differences are between “normal saline” and “Ringer lactate” solutions. What are the theoretical advantages of each? Why might normal saline resuscitation cause a hyperchloremic, nonanion gap metabolic acidosis?
  • An editorialist calls for a randomized trial to determine which fluid is better for the resuscitation of patients with septic shock. What do your learners plan to use for now?

Clinical Guideline


Medical Knowledge
High Value Care

Screening for Asymptomatic Carotid Artery Stenosis: U.S. Preventive Services Task Force Recommendation Statement

This updated guideline applies to adults without a history of transient ischemic attack, stroke, or other neurologic signs or symptoms. The Task Force recommends against screening for asymptomatic CAS in the general adult population.

Use this guideline to:

  • Ask your learners what the benefits might be of identifying asymptomatic CAS.
  • What are the harms? Ask your learners if the harms are from the ultrasound used for screening, or the “downstream” effects of a positive ultrasound result?
  • Ask your learners how they feel about commercial screening tests (e.g., mobile vans that offer multiple screening tests at once with instruction to the patient to follow-up with his or her physician). Use a recent opinion piece to frame your discussion. Do we consider “downstream” effects of a test adequately when we order it?


In the Clinic:

Medical Knowledge

Common Cutaneous Parasites

Yuk! Who gets scabies? What do the bites from bedbugs usually look like? This eminently practical review of common infestations provides the answers to key questions regarding the prevention, diagnosis, and treatment of these common pest infestations!

Use this review to:

  • Answer the multiple-choice questions provided at the end as a way of introducing a series of succinct teaching topics and messages. Log on and complete the questions to get CME for yourself!
  • Review the clinical presentations of bedbug, scabies, lice, and flea infestations. How are they treated?
  • What advice can you provide to patients to prevent re-infestations?


The Business of Medicine


Professionalism

Rethinking the Use of Physicians as Hired Expert Lecturers

GlaxoSmithKline recently announced that it will no longer hire physicians to lecture prescribers about its products. This commentary discusses possible motivators behind this decision and why physicians should welcome it.

Use this essay to:

  • Ask your learners if they have heard of “drug talks” or “drug dinners.” Do they know how much money a physician might be paid to give a talk on behalf of a pharmaceutical company? Would it influence how they thought about an attending physician as their teacher if the attending earned money in this way?
  • Ask how pharmaceutical companies try to influence physician prescribing. Do they think it works? Do they think the companies would continue these practices if they did not work?
  • Ask if they think that a speaker’s declaration of conflicts of interest allows learners to avoid being inappropriately influenced as they listen and learn from a presentation.


Systems-based Practice
Professionalism

Health Policy Basics: Physician Quality Reporting System

Several initiatives aim to shift our health care system toward a value-based purchasing system to improve the quality of health care. The Centers for Medicare & Medicaid Services (CMS) Physician Quality Reporting System (PQRS) uses a combination of incentive payments and payment adjustments to promote reporting of quality information. This article describes the PQRS and actions that clinicians need to take in 2014 to avoid penalties in CMS reimbursement in 2016.

Use this paper to:

  • Review with your learners what the reporting requirements are for eligible professionals in the PQRS.
  • Do your learners think that a 2% payment reduction for eligible professionals who do not successfully report in 2014 is a good idea?
  • Download the “Measures List” that is provided by the CMS. Review some of the reporting measures. Do your learners think these measures will accurately evaluate the quality of care being provided? What are the challenges in defining the measures to be used? What are the consequences for physicians and for patients if the measures are inappropriate?

mksap16

A 19-year-old man is evaluated in the emergency department for a 10-day history of fever, cervical lymphadenopathy, malaise and fatigue, sore throat, headache, and nausea, but no vomiting, diarrhea, abdominal pain, nasal congestion, or cough. He had a rash a few days ago that has resolved. He is sexually active with both men and women and does not use condoms.

On physical examination, temperature is 38.1 °C (100.6 °F), blood pressure is 110/88 mm Hg, pulse rate is 96/min, and respiration rate is 16/min. He appears uncomfortable but is not in distress. Significant lymphadenopathy is noted in the cervical, axillary, and inguinal regions. The oropharynx is erythematous with mildly enlarged tonsils but no exudate. Sclerae and conjunctivae are clear, and the skin is without rash. The remainder of the examination, including cardiac, joint, abdominal, and genital findings, is unremarkable.

Results of the heterophile antibody test, rapid streptococcal antigen test, HIV enzyme immunoassay, and rapid plasma reagin test are negative.

Which of the following is the most appropriate diagnostic test to perform next?

A. CD4 cell count
B. HIV nucleic acid amplification test
C. HIV Western blot assay
D. Repeat HIV enzyme immunoassay

Correct Answer
B. HIV nucleic acid amplification test

Key Point
Most persons in whom HIV infection develops experience an acute symptomatic illness within 2 to 4 weeks of infection, with symptoms ranging from a simple febrile illness to a mononucleosis-like syndrome.

Educational Objective
Diagnose the acute retroviral syndrome.

The most appropriate next diagnostic test is an HIV nucleic acid amplification test. This patient's medical history and timing of symptoms are typical of acute HIV infection. Although his symptoms could also represent infectious mononucleosis or syphilis, preliminary results for those conditions are negative. Most persons in whom HIV infection develops experience an acute symptomatic illness within 2 to 4 weeks of infection. Symptoms typically last for a few weeks and range from a simple febrile illness to a full-blown mononucleosis-like syndrome. Because patients lack an immune response during this period, virus levels tend to be very high, resulting in high levels of infectivity. Symptoms of acute HIV infection resolve with or without treatment, and most acute infections are undiagnosed. Patients presenting with symptomatic acute HIV infection (the acute retroviral syndrome) are usually in the “window period,” which may extend for 3 to 6 weeks, during which time seroconversion of the disease has not yet occurred and results of HIV antibody testing are negative. However, viral-specific tests, such as those for nucleic acid, are usually positive at quite high levels during this time frame and can be used to establish the diagnosis.

Measurement of CD4 cell counts is neither sensitive nor specific for HIV infection and should be performed only after the diagnosis of HIV is already established. The CD4 cell count can be normal in HIV infection, and conversely, can be depressed from many other conditions that can present similarly to acute HIV infection.

During the window period of acute HIV infection, antibody testing is unreliable. Therefore, antibody-based testing, whether by repeat enzyme immunoassay or Western blot, would not be useful.

Bibliography
Cohen MS, Gay CL, Busch MP, Hecht FM. The detection of acute HIV infection. J Infect Dis. 2010;202(suppl 2):S270-S277. PMID: 20846033

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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