HIV AIDS

A group of 18 senators have proposed to reverse a policy that imposes a lifetime ban on donating blood for men who have had any gay sex since 1977. In writing to the FDA Commissioner Margaret Hamburg, the lawmakers stressed that the science has dramatically changed since the ban was established in 1983 at the emergence of the HIV/AIDS crisis.1

As publicly funded health care payment programs have grown over decades because of demographic shifts and expansion of coverage, comparative effectiveness research (CER) has emerged to address value in health care. The American Recovery and Reinvestment Act of 2008 (ARRA) included $1.1 billion for CER initiatives, and the new health care legislation created the Patient-Centered Outcomes Research Institute, which will be funded with $500 million or more annually. In these efforts exist the promise to create informed decisions that will improve health care at both the individual and population levels.

Sporotrichosis is a fungal infection that typically results in cutaneous or lymphocutaneous disease, although other, more severe, life-threatening manifestations do occur. This article reviews updated treatment guidelines, which state that itraconazole has become the preferred therapy for most forms of infection. Amphotericin B remains the mainstay of treatment for severe cases, but lipid formulations are now preferred because of their more favorable toxicity profile. Also, fluconazole has been shown to be less effective than itraconazole and is no longer recommended except as an alternative for cutaneous and lymphocutaneous disease. [Drug Benefit Trends. 2010;22:49-52]

The US decision to freeze spending on HIV programs in several African countries has caused concern that some of the progress made in the global AIDS epidemic will be reversed.

As a screener and admissions committee member at our medical school (University of California School of Medicine at Davis), I am privileged to review the personal statements of many, many applicants who want to be doctors in spite of the recent hard times in our country that have led more than a few American physicians to believe that our profession is less valued and less desirable as a life work than it has been in the past.

The list of covered preventive services for Medicare beneficiaries has expanded to include screening for HIV infection, according to the Centers for Medicare and Medicaid Services. This test will now be available to Medicare beneficiaries at increased risk for HIV infection, including women who are pregnant and any Medicare beneficiary of any age who requests testing.1

Physical changes that occur in aging skin (eg, dryness and thinning) can result in pruritus and cause patients to rub, scratch, and pick at their skin. These activities produce various dermatoses and reactive changes in the skin, such as postinflammatory pigmentary alteration. Lichen simplex chronicus (LSC) develops as a physiological cutaneous response to repetitive scratching or rubbing. First-line treatment consists of topical corticosteroids and application of ice to reduce the sensation of itching. Like LSC, prurigo nodularis results from rubbing and scratching the skin. Treatment is similar; however, intralesional corticosteroids and UV therapy play more of a role because prurigo nodularis is more intensely pruritic than LSC.

What is the role of the primary care practitioner in the care of patients with HIV infection?Although the treatment of human immunodeficiency virus type 1 (HIV-1) infection is usually directed by subspecialists, many patients who are taking highly active antiretroviral therapy (HAART) continue to see their primary care physician. What is the most effective regimen-and what complications should we be on the lookout for?

We lie awake in our one-room hut before dawn listening to the cacophony of sounds emanating from the forest as the birds awake. The Bwindi Impenetrable Forest of Southwest Uganda contains over 350 species of birds, and it seems that they are all chattering to each other at once. The Bwindi Forest is also home to more than half of the world’s 650 mountain gorillas.

In 2010, CONSULTANT marks its 50th year of service to primary careclinicians. On our golden anniversary, it seems appropriate to reflect onthe challenges, rewards, and frustrations of current medical practice.

For 1 month, a 60-year-old white man has had increasing fatigue, generalized weakness, and exertional dyspnea. He becomes short of breath after he walks only 100 to 150 yards on level ground or climbs only 1 flight of stairs. In addition, he has unintentionally lost 12 lb in the past month and has experienced intermittent dysphagia with solid foods. He attributes this last symptom to long-standing gastroesophageal reflux disease (GERD), for which he regularly takes over-the-counter omeprazole.

For 3 months, a 43-year-old Bolivian woman had worsening thoracic and lumbar pain associated with tingling and tightness in the anterior upper and lower abdominal area, and numbness in the lower extremities. Her symptoms also included difficulty in walking (with frequent falls from imbalance), occasional urinary incontinence for the past few weeks, occasional afternoon low-grade fevers, and poor appetite with an associated 10-lb weight loss within the past 4 months.

A 31-year-old Bangladeshi man presented with dull, aching abdominal pain primarily in the right flank. The pain began a week after he underwent exploratory laparotomy for a perforated duodenal ulcer. He had been taking oxycodone/acetaminophen, docusate sodium, and omeprazole since the surgery.

Although the prevalence of tuberculosis (TB) in the United States continues to decline (from 2006 to 2007, the total number of TB cases declined 4.2%, from 13,779 cases to 13,293), the rate of decline has slowed in recent years.1 The rate in foreignborn persons is much higher than in US-born persons and appears to be increasing.1

For 10 days, a 55-year-old man had a productive cough and progressively worsening rightsided chest pain that was sharp, nonexertional, and worse with deep inspiration and movement. He denied hemoptysis, fevers, sick contacts, or recent travel.

Several days earlier, a 69-year-old man had a mild headache, fatigue, and tingling and prickly facial sensations. Shortly afterward, this painful, “weepy” rash developed on his forehead, upper cheek, and nasolabial folds and vision in the right eye became blurry. The patient’s history included type 2 diabetes mellitus, hypertension, and childhood varicella.

Scabies is often seen in axillary folds and the periumbilical area; severe nocturnal itching is a hallmark.

In response to the Practical Pointer "Cholesterol Mnemonic Aids Patient Education" (CONSULTANT, August 2008) about patients who have difficulty remembering the difference between HDL and LDL cholesterol, I use "H" is for happy and "L" is for lousy!

Although the future clinical implications of mutations in the H1N1 influenza virus remain unclear, these changes do not pose an immediate threat.

The Fifth International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention (IAS 2009) was held in Cape Town, South Africa, from July 19 to 22, 2009. More than 5500 delegates from more than 100 countries attended this annual event.

While the facts support the claim from the Centers for Medicare & Medicaid Services (CMS) that beneficiaries have “robust” choices in the sign-up period for 2010 Part D drug coverage plans that begins in November, the number of options available have continued to decline. At the peak in 2007, 1875 stand-alone Medicare drug plans were offered; this year, the number had shrunk to 1659, and the total for next year will be 1510.

No matter what primary care demographic your practice represents, it would be most unusual not to encounter patients infected with hepatitis C virus (HCV). Since HCV infection is chronic and can lead to cirrhosis (occurring in 20% of patients over a period of 10 to 20 years), decisions regarding its management, referral, and follow-up are of the utmost importance.

The medications currently approved for the treatment of insomnia include 9 benzodiazepine receptor agonist (BZRA) hypnotics and the selective melatonin receptor agonist ramelteon.

What meaning resides in the series as a whole? To me, it embodies deep-seated belief and central practice: the primacy of time spent with the patient, gathering meaningful information and building the relationship that is often the most powerful therapeutic instrument we have. From the second year of medical school I planned to become a good physical examiner. I hungered for patient contact amidst a sterile curriculum. Also, I arrogantly, short-sightedly failed to see how the unpalatable basic science years formed a crucial, deep, and rational foundation for clinical understanding. Thirty-five years on, I have honed my skills. But daily I doubt some findings and interpretations; any clinician who is always sure is a fraud and a fool.

A 30-year-old man is admitted for profound, symptomatic anemia.

The development of drug-resistant strains of Mycobacterium tuberculosis has increased morbidity and mortality associated with tuberculosis (TB) and has greatly increased the costs of care for patients with this disease.

More than half of travelers to the developing world experience a health-related problem during their trip, with 8% requiring medical attention on their return because of persistent symptoms. The GeoSentinel database, a collaborative effort among 31 travel medicine clinics on 6 different continents, suggests that the most common diagnoses in these persons continue to be malaria (24%), dengue fever (6%), acute traveler’s diarrhea (4%), and typhoid fever (2%).

For a month, an obese 50-year-old woman with type 2 diabetes mellitus, hypercholesterolemia, and hypertension had blurry vision in both eyes. During this time, she also had ataxia and right-sided numbness. For the past 2 days, she had had horizontal, binocular diplopia with right gaze.

Human infections with a novel influenza A (H1N1) virus were first identified in April 2009, with cases in the United States and Mexico. The epidemiology and clinical presentations of these infections are under investigation.

The recent report on an HIV-positive cardiothoracic surgeon in Israel has offered a contemporary perspective on the risks of transmission of HIV in health care settings, specifically surgical settings.