American College of Physicians: Internal Medicine — Doctors for Adults ®


In the News
for the Week of 3-31-09


  • Updated HIV-infection guidelines stress use of antiretrovirals
  • Collaborative pain care offers modest, achievable benefits

Test yourself

  • MKSAP quiz: low-grade fevers, cough and pleuritic chest pain


  • Review indicates heightened heart failure risk for Hispanics

Medicare news

  • CMS seeks physician satisfaction input to grade its contractors

FDA update

  • Recalls of propafenone HCl, Zencore Plus supplements
  • Weight loss product alert expanded to include 72 products
  • Never share insulin pens or cartridges among patients

From ACP Internist

  • ACP Internist is online and coming to your mailbox

From the College

  • There's still time to submit your "memorable moment"

Technology resources

Cartoon caption contest

Physician editor: Darren Taichman, ACP Member


Updated HIV-infection guidelines stress use of antiretrovirals

Recently updated CDC guidelines stress the importance of using antiretroviral therapy to treat HIV-infected adults and teens with opportunistic infections that do not have specific treatments.

The guidelines, published in the March 24 Morbidity and Mortality Weekly Report, note that despite the availability of antiretroviral therapy in the U.S. and other countries, opportunistic infections continue to be the major cause of morbidity and mortality in HIV-infected persons. The authors recommend early initiation of antiretroviral therapy in most cases of acute opportunistic infection.

Other major changes to the guidelines include:

  • Information on the diagnosis and management of immune reconstitution inflammatory syndromes,
  • information regarding the use of interferon-gamma release assays for the diagnosis of latent Mycobacterium tuberculosis (TB) infection,
  • updated information concerning drug interactions that affect the use of rifamycin drugs for prevention and treatment of TB,
  • a section on hepatitis B virus infection, and
  • the addition of malaria to the list of opportunistic infections that might be acquired during international travel.


Collaborative pain care offers modest, achievable benefits

An achievable and affordable collaborative intervention for chronic pain offers modest improvement in outcomes, including depression, a new study found.

Existing guidelines for chronic pain are tough to implement in busy primary care practices with limited access to treatment components, said the researchers, who assessed a team approach they felt could be implemented in a primary care setting at a reasonable cost. Outcomes were published in the Journal of the American Medical Association.

The cluster-randomized, controlled trial drew upon five primary care clinics associated with the Portland, Ore. VA hospital. Pain management was done by the primary care physician in the clinic, who could refer patients to the main hospital's specialty pain clinic. The 401 patients had moderate or greater musculoskeletal pain lasting 12 weeks or longer. In the team approach, a care manager and internist jointly reviewed assessment results, developed treatment recommendations and communicated them to the primary care physician. Patients were encouraged to attend workshops that offered educational materials and a list of community resources. Care managers followed up by phone to re-administer screenings, assess goals and activities, and provide support.

Intervention patients showed greater improvements in pain-related disability. For example, patients with baseline Patient Health Questionnaire -9 score >10 (indicating at least moderate depression) showed greater improvement in depression severity if they received the intervention than if they received treatment as usual. While results were modest compared to other studies, the authors said it was possible a more intensive intervention might have resulted in more substantive effects.


Test Yourself

MKSAP quiz: low-grade fevers, cough and pleuritic chest pain

A 25-year-old man is evaluated for a two-month history of low-grade fevers, cough, night sweats, fatigue, pleuritic chest pain, and weight loss. The patient emigrated from Mexico almost two years ago and now lives in Central California.

On physical examination, his temperature is 38° C (100.4° F), pulse rate is 96/min and regular, respiration rate is 22/min at rest, and oxygen saturation is 94% on room air. There is diminished breath sound and vocal fremitus over the right hemithorax. The left lung is clear.

Peripheral blood leukocyte count is 9000/ μL (9 x 109/L), with 60% neutrophils and 35% lymphocytes. Liver function test results are normal. Chest radiograph shows a moderate right-sided pleural effusion with layering of 3 cm of free-flowing pleural fluid and no parenchymal infiltrates on right lateral decubitus chest radiograph.

Thoracentesis yields 1.0 L of minimally turbid, yellow fluid with test results as follows:

Laboratory Studies  
Pleural fluid cell count Leukocyte count 3000/μL (3 x 109/L) with 5% neutrophils, 85% lymphocytes, 1% mesothelial cells, and 1% macrophages
Total protein 5.5 mg/dL (55 g/L)
Lactate dehydrogenase 290 U/L
Glucose 80 mg/dL (4.44 mmol/L)
pH 7.36

Pleural fluid Gram, fungal, and acid-fast bacilli stains are negative. Tuberculin skin test is pending. Serologic tests for fungal organisms are negative. Cytologic evaluation for malignant cells is negative.

Which of the following is the most likely diagnosis?

A) Tuberculosis
B) Pneumococcal parapneumonic effusion
C) Pulmonary embolism
D) Malignant pleural effusion
E) Pleural effusion due to coccidiodomycosis

Click here or scroll to the bottom for the answer.



Review indicates heightened heart failure risk for Hispanics

Despite a lack of large-scale heart failure studies in Hispanic Americans, existing evidence suggests this fast-growing population may be particularly vulnerable to the condition and should be managed accordingly, a new review found.

Hispanics have excessive rates of diabetes, obesity, dyslipidemia, poorly controlled hypertension and metabolic syndrome, all of which may predispose an individual to heart failure, the review said. Hypertension and ischemic heart disease are already established risk factors in Hispanics, but the evidence suggests insulin resistance may play a significant role in the development of heart failure in this ethnic group as well, according to the review in the April 7 Journal of the American College of Cardiology.

Compared with whites, Hispanics with heart failure are more likely to be younger and underinsured and have a higher prevalence of abnormal left ventricular ejection fraction (LVEF), which often implies a worse prognosis in heart failure, the authors said. They are also less likely than whites or African Americans to have their LVEF assessed or to be discharged on angiotensin-converting enzyme inhibitor treatment, the review said.

Providers need to recognize the risk factors for heart failure in Hispanics, and be aware of the known disparities in care due to linguistic, socioeconomic and cultural differences, in order to manage Hispanic patients appropriately, the authors said. Future research trials should also adequately include Hispanic patients, and include subgroup analyses of different Hispanic nationalities, they said.


Medicare news

CMS seeks physician satisfaction input to grade its contractors

CMS launched its fourth annual health care provider satisfaction survey of Medicare fee-for-service contractors. The survey lets health care providers give CMS satisfaction feedback about its Medicare Administrative Contractors, who will now be expected to meet a minimum survey score from responding providers.

CMS is sending the survey, designed to be completed in about 20 minutes, to approximately 30,000 randomly selected providers, including physicians and other health care practitioners and others. Health care providers selected to participate in the survey will be notified this month. CMS will release a summary report in July 2009. More information is online.


FDA update

Recalls of propafenone HCl, Zencore Plus supplements

One lot of cardiac arrhythmia drug propafenone HCl 225 mg (Rythmol) is being recalled due to oversized tablets that could cause arrhythmias or low blood pressure in sensitive patients, an FDA alert said.

The oversized pills may contain slightly higher levels of the active ingredient of the drug, which has a narrow therapeutic index. The affected lot, number 112680A, was shipped to customers between October 15, 2008 and November 26, 2008, and has an expiration date of July 31, 2010.

Separately, the FDA also announced a recall of male enhancement supplement Zencore Plus, which was found to contain PDE5 inhibitor benzamidenafil. The latter can interact with organic nitrates and pose a sudden, life-threatening drop in blood pressure, the alert said.


Weight loss product alert expanded to include 72 products

The FDA last week expanded an alert on weight loss products with undeclared ingredients to include Herbal Xenicol, Slimbionic and Xsvelten.

Herbal Xenicol may contain the undeclared, active ingredient cetilistat, while Slimbionic and Xsvelten may contain sibutramine. The alert list now includes 72 products, with undeclared ingredients like fenproporex, fluoxetine and phenolphthalein that may cause high blood pressure, seizures, tachycardia, palpitations, heart attack, and stroke. The list of recalled products is online.


Never share insulin pens or cartridges among patients

Physicians shouldn't share insulin pens or cartridges among patients, even if the needles are changed each time, because the practice can transmit hepatitis viruses, HIV and other blood-borne pathogens, the FDA said in an alert last week.

The alert comes following a discovery that insulin pens may have been shared among at least 2,000 patients at one U.S. hospital in 2007-2009, and among fewer patients at a second hospital. Some of the patients subsequently tested positive for hepatitis C, though it isn't known if the relationship is causal.

The agency advised marking individual pens with patient names to discourage sharing, and making sure relevant staff members at health care facilities are educated about the practice.


From ACP Internist

ACP Internist is online and coming to your mailbox

Visit ACP Internist's Web site for the latest on:

  • Patient-centered medical home pilot. A group of physicians in southeastern Pennsylvania are among the lucky and proactive few practicing in some of the first payer-supported patient-centered medical homes in the country.
  • The placebo effect. Placebo use is common in internal medicine. But is it ethical? Experts examine the disconnect between the standards of medicine and how it's actually practiced in the office.
  • Stroke coverage. Tissue plasminogen activator (tPA) was the star of the show at the International Stroke Conference 2009, with much discussion of expanding its treatment window, and several studies presented on gender differences in tPA treatment. Also, the pros and cons of telemedicine vs. telephonic advice in treating stroke.

The full April issue of ACP Internist is online.


From the College

There's still time to submit your "memorable moment"

As part of a series of books on teaching, ACP Press has extended its deadline to May 1 to submit stories of memorable teaching moments. The first book in the series, to be published in 2010, will include a collection of vignettes about unforgettable moments in medical education, described by teachers or learners. Vignettes should be no more than 1,000 words. Submissions can be anonymous. Samples and submissions are available online.


Technology resources

Conference offers insight into HIT developments

An upcoming conference May 20-21 at the National Institutes of Health in Bethesda, Md., titled "Personal Electronic Health Records: From Biomedical Research to People’s Health," offers information about critical and recent developments in health information technology. More information and registration are online.


Cartoon caption contest

And the winner is …

ACP InternistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by Scott Selinger, fourth-year medical student at the University of Texas Health Science Center at San Antonio. He will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 275 ballots online to choose the winning entry. Thanks to all who voted!

We got your labs back and I can't say I was thrilled about all the red flags.

The winning entry: "We got your labs back and I can't say I was thrilled about all the red flags."

The winning entry captured 46.5% of the votes. The runners up were:
"Yes, the exam room door is open. And yes, I was raised in a barn." (28%)
"Then, I chase you around in a large labyrinth to see if you have cardiac or non-cardiac chest pain." (25.5%)

ACP Internist's cartoon caption contest continues next week.


MKSAP Answer and Critique

The correct answer is A) Tuberculosis

This item is available to MKSAP subscribers in Pulmonary and Critical Care Medicine: Item 14.

ACP's Medical Knowledge Self-Assessment Program (MKSAP) allows you to:

  • Update your knowledge in all areas of internal medicine
  • Prepare for ABIM certification or recertification
  • Support your clinical decisions in practice
  • Assess your medical knowledge with 1,200 multiple-choice questions

To order the latest edition of MKSAP, go online.

Tuberculous pleural effusion is the most likely diagnosis. The PPD is positive in about 50% to 70% of patients with tuberculous pleuritis at the time of admission. A negative PPD skin test therefore does not rule out the diagnosis of tuberculous pleuritis. In patients who are not anergic, the PPD will usually become positive within 8 weeks of the development of symptoms of tuberculous pleuritis. Parapneumonic effusion is usually associated with a neutrophilic pleocytosis. The clinical history is more suggestive of tuberculous pleural effusion than pulmonary embolism, in which illness is generally more acute. Malignant pleural effusion would be more likely in the absence of fever and in an older individual. The presentation and pleural fluid characteristic of fungal pleural effusion is similar to tuberculous pleural effusion, and the patient's residence in Central California increases the suspicion for coccidioidal effusion. However, fungal serologic studies usually reveal elevated titers of anti-coccidioides antibodies.

Pleural tuberculosis is more common in the lower socioeconomic groups and immigrants from countries endemic for tuberculosis. The presence of a positive tuberculin skin test with an otherwise unexplained exudative effusion suggests tuberculous pleurisy. A tuberculous pleural effusion most often develops from a cellular-mediated immune response to tuberculosis antigens. Usually, tuberculous effusions may develop up to 6 months after the primary infection as a manifestation of a delayed hypersensitivity reaction. Consequently, cultures of pleural fluid from patients with tuberculous pleurisy may be negative for the organism.

The typical clinical presentation includes nonproductive cough, chest pain, and fever and can suggest the alternative diagnosis of bacterial pneumonia. Radiography usually shows a unilateral, small-to-moderate effusion. Only one third of patients have an associated pulmonary infiltrate. On CT scan of the chest, however, a pulmonary infiltrate or nodule is found 75% of the time.

Most tuberculous effusions resolve without any specific therapy but about half of those who spontaneously resolve their pleural effusion will develop active tuberculosis within 7 years.

Key Points

  • Pleural effusion in tuberculosis is usually associated with a lymphocytic pleocytosis.
  • Tuberculous pleural effusion most often develops from a cell-mediated immune response to tuberculosis antigens.

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ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

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Copyright 2009 by the American College of Physicians.


Test yourself

A 67-year-old man is evaluated for a recent diagnosis of primary hyperparathyroidism after an elevated serum calcium level was incidentally detected on laboratory testing. Medical history is significant only for hypertension, and his only medication is ramipril. Following a physical exam and lab studies, what is the most appropriate management of this patient?

Find the answer

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