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Assess your knowledge, prep for the boards, and earn CME credits and MOC points with the best self-assessment program. The human papillomavirus (HPV) vaccine substantially reduces the incidence of low-grade neoplasia and genital warts (condyloma) for more than three years after vaccination, according to a new study. The data were gathered from two international randomized, controlled trials of the quadrivalent HPV vaccine (Gardasil) conducted by the vaccine manufacturer. Among participants who tested negative for the relevant HPV types at the start of the study, the vaccine was almost totally effective against lesions caused by HPV type 6, 11, 16 or 18: 96% effective for cervical intraepithelial neoplasia grade I, 100% for vulvar and vaginal intraepithelial neoplasia grade I and 99% for condyloma. New data about untreated HIV and expanded treatment options led a panel to update recommendations for antiretroviral therapy (ART) in U.S.
The International AIDS Society-USA guidelines recommend when to start ART, what type to choose, how to monitor and when to change therapies. When selecting a regimen, clinicians should consider resistance-testing results and predicted virologic efficacy, toxicity and tolerability, pill burden, dosing frequency, drug-drug interactions, comorbidities, patient and practitioner preference, and cost and affordability.
If an elevation in viral load occurs after complete suppression is achieved, physicians should consider poor adherence, drug-drug interactions, concurrent infections and recent vaccinations as possible causes before changing regimens. When changing regimens after first- or multiple-regimen failure, physicians should consider the stage of HIV, nadir and current CD4 cell count, comorbidities, treatment history, current and previous drug resistance tests, and drug interactions. Single-agent switches to decrease toxicity, avoid drug interactions, or improve convenience and adherence are possible, provided the potency of the regimen is maintained and drug interactions are managed. Infection with which of following is the most likely cause of this patient’s worsening kidney function?
Patients who tried rehabilitation instead of immediately having surgery on their torn anterior cruciate ligaments (ACL) did as well as patients who had early ACL reconstruction, a new study found.
The randomized, controlled trial included 121 young, active Swedish adults with acute ACL injuries. The primary outcomes of the study were knee pain, symptoms, function in sports and recreation and knee-related quality of life, compared at baseline and after two years. The study authors concluded that in this patient population, the strategy of early reconstruction with rehabilitation is not superior to rehabilitation with the option of delayed reconstruction. However, an accompanying editorial noted that two years of follow-up is insufficient to definitively determine the long-term effects of the strategy.
Screening all patients in the emergency department on a routine, opt-out basis modestly detected more patients with HIV, most of whom were late in the course of disease, reports a study that appears in the July 21 Journal of the American Medical Association. Researchers alternated routine opt-out rapid HIV screening and physician-directed diagnostic rapid HIV testing in four-month spans at Denver Health Medical Center, an urban public safety-net hospital with an approximate annual emergency department census of 55,000 patient visits between April 2007 and April 2009. The opt-out phase included 28,043 patients, of whom 6,933 patients (25%) completed HIV testing. The American Medical Association recently released the results of a new survey showing that Medicare’s elimination of consultation codes has had a negative impact on physician efforts to improve care coordination and reduced the treatment options available to Medicare patients.
The survey of 5,500 physicians also showed that many have taken cost-cutting steps to offset revenue losses from the elimination of these codes.
Prior to the release of the survey results, ACP joined with the AMA and other physician organizations in sending a letter requesting that CMS improve its policy. The 2009-2010 Report of the Executive Vice President is now available on ACP’s website as well as on the Regents' Information Center (RIC) and the Governors' Information Center (GIC).
The EVP Report outlines the year's events at the College, including new programs, services and clinical resources, as well as news in quality improvement, research and advocacy.
ACP, along with the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA), has released a clinical statement on heart failure. The statement further defines the skill set required of specialists treating patients with the most advanced forms of heart failure and those undergoing heart transplantation. Health Volunteers Overseas (HVO), an ACP-supported organization, announced the opening of a new internal medicine program in Bhutan at the National Referral Hospital (NRH) and the Royal Institute of Health Sciences (RIHS). ACP sponsors HVO's internal medicine overseas section, which supports training programs for internal medicine generalists and subspecialists in five international locations: Bhutan, Cambodia, India, Peru and Uganda. Volunteers in internal medicine who might be interested in serving HVO in Bhutan or any of their international sites can get more information online.

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. This presentation is typical for polyomavirus BK virus–induced nephropathy in a patient with a transplanted kidney.
After the first posttransplantation month, cytomegalovirus (CMV) is one of the infectious agents most likely to affect graft survival and cause life-threatening complications.
The Epstein-Barr virus may cause posttransplantation lymphoproliferative disease, but it is not known to cause nephropathy.
Human herpesvirus-8 infection causes Kaposi sarcoma and is associated with Castleman disease and primary effusion lymphoma but does not appear to cause hepatitis, encephalitis, or nephropathy. Polyomavirus JC virus may cause progressive multifocal leukoencephalopathy but not renal disease in patients with transplanted kidneys. Polyomavirus BK virus is a common cause of nephropathy in patients with transplanted kidneys. To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here. ACP offers different categories of membership depending on your career stage and professional status.
Ensure you're board-exam ready with ACP's Board Prep Ace - a multifaceted, self-study program that prepares you to pass the ABIM Certification Exam in internal medicine.
Licence fees: A licence fee will be charged for any media (low or high resolution) used in your project. When lesions caused by other HPV types were included, the vaccine’s effectiveness was substantially lower. The vaccine’s efficacy against low-grade lesions is important because these occur far more often than higher-grade lesions, and prevention can reduce patient anxiety, morbidity and health care costs, the authors noted. Current evidence supports combining two nucleoside reverse transcriptase inhibitors and a potent third agent from another class. To detect failure, testing of HIV-1 RNA should be repeated two to eight weeks after initiation, every four to eight weeks until suppressed, and then every three to four months for at least the first year. Testing for an isolated detectable viral load should be repeated to exclude errors or self-resolving low-level viremia.
At least two drugs, and preferably three fully active drugs, should be included and drugs from new classes should be considered.
Boosted protease inhibitor monotherapy is not recommended, except when other drugs raise issues of toxicity or tolerability. The patients were assigned to either rehabilitation plus early ACL reconstruction or rehabilitation with the option of later ACL surgery if needed. There were no significant differences between the groups’ improvement on these outcomes, and an additional post hoc as-treated analysis also found no significant differences in outcomes among patients who got early reconstruction, late reconstruction or no surgery at all. They noted that more than half of the potential reconstructions were avoided by employing the rehab with optional surgery strategy. The editorialist recommended that decisions about surgical reconstruction of ACLs be made based on the individual knee and patient.
Waiting, length of stay and boarding times differed slightly between the study phases, but were not clinically meaningful.
The College continues to look for opportunities to work with internal medicine subspecialty organizations to find viable solutions to this problem.
As advances in cardiac care have improved longevity and quality of life for patients, the demand for specialty care to manage the care of these patients has risen, the authors explain. A private, non-profit organization, HVO designs and implements clinical and didactic education programs in child health, primary care, trauma and rehabilitation, essential surgical care, oral health, blood disorders and cancer, infectious disease, nursing education, and wound management.
Voting continues through Monday, August 2, with the winner announced in the August 3 issue. Polyomavirus BK virus is acquired asymptomatically early in childhood by as many as 90% of all persons.
CMV infection typically involves the gastrointestinal tract and is associated with fever, pain, ulcerations, and hepatitis.

Posttransplantation lymphoproliferative disease is characterized by symptoms suggestive of infectious mononucleosis followed by a progressive deteriorating course that may involve the brain, liver, bone marrow, and transplanted organ. It is automatically sent to all College members who have an e-mail address on file with ACP. Four weeks ago, she developed herpetic lesions on her right posterior thorax in a T7 distribution. Close up of inflamed, pus-covered throat and tonsils of a patient with glandular fever (infectious mononucleosis).
Participants were excluded for a history of more than four sexual partners, abnormal cervical smear test results or pregnancy.
Overall, it was 30% effective at preventing cervical neoplasia grade I, 75% for the vulvar type, 48% for vaginal and 83% for condyloma.
The control group of the trial also allowed the researchers to estimate the overall incidence of condyloma in unvaccinated women, which they put at 1% per year. The patients in the delayed surgery group were more likely to have surgery on the meniscus. The diagnostic phase included 29,925 eligible patients, of whom 243 (0.8%) completed HIV testing.
A validated composite measure of emergency department crowding showed no differences between routine and physician-directed screening.
The statement aims to provide a roadmap for physicians who are interested in training in this area. In more than 25 resource-poor countries, HVO volunteers train, mentor, and provide critical professional support to clinicians who care for the neediest populations in the most difficult of circumstances. CMV alone does not lead to nephropathy, although it may have additive effects in the presence of the BK virus. She was treated with acyclovir, and the lesions healed; however, she has persistent severe burning pain. This acute viral infection is caused either by the Epstein- Barr virus or cytomegalovirus, both of which are members of the herpesvirus family. They were given three doses of the vaccine (which targets HPV types 6, 11, 16 and 18) or placebo. Patients who have changed therapy because of virologic failure need more frequent monitoring.
However, it may result in serious disorders in immunosuppressed patients and is an important cause of kidney allograft failure.
The follow-up was continued for 42 months, and the study was published online by BMJ on July 21. Even if one or more regimens have failed, the therapeutic goal should still be undetectable plasma HIV-1 RNA levels. The virus may be reactivated in 30% or more of kidney transplant recipients as evidenced by shedding of “decoy cells” (tubular or transitional cells with intranuclear viral inclusions) or viremia, which may be characterized by fatigue, myalgia, and malaise.
Following a physical exam, which medication is the most appropriate pharmacologic therapy for this patient's pain? Symptoms include high fever, sore throat and swollen lymph nodes, particularly in the neck.
Further confirmation can be obtained by identifying the virus in urine or blood or by kidney biopsy, which is the gold-standard diagnostic test. Quantification of the virus is useful in assessing and managing the effects of treatment, which may include reducing immunosuppressive therapy or using experimental medications, such as leflunomide, cidofovir, or fluoroquinolones.
Most patients recover within 4-6 weeks but frequently feel tired and run-down for a further two or three months.

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