Case Challenge #6

A 34 yo male with AIDS, currently on treatment for disseminated Histoplasmosis, is admitted with fever and hypotension. He has been on therapy for this infection for the last 4 months, and was doing well. However, he notes that he has become gradually more tired and has a decreased appetite. 2 days prior to this presentation, he underwent emergency surgery for a broken arm after a fall. After the procedure, he developed fever and hypotension on POD #1 and broad spectrum antibiotics were started. Currently, he remains febrile and has nausea, vomiting, and abdominal pain.

PE: Tmax 100.8, HR 115, BP 90/60. Abd TTP but no rebound.

Labs: WBC 12k (70% PMN, 5% Eos), h/h stable, Na 128, K 5.4, Cr 1.6, blood Cx ngtd.


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Clinical Pearls – Hidden Clue on Skin Exam

Pathergy phenomenon is when a small red bump or pustule occurs 1 to 2 days after a forearm is pricked with a sterile needle. This test is often associated with Behcet’s disease having a low sensitivity but high specificity for the disease, as a positive test supports a diagnosis of Behcet’s and is not definite. This past week’s NEJM had a case of a patient with newly diagnosed Behcet’s disease and a positive pathergy test. Click on the links below to read the article from NEJM and learn more from the Hopkins Vasculitis Center.


(image courtesy of The Johns Hopkins Vasculitis Center)

The Johns Hopkins Vasculitis Center – Behcet’s Disease

A 25-Year Old Man with Oral Ulcers, Rash, and Odynophagia 

Eculizumab and Atypical HUS

  • Eculizumab has shown greater efficacy than plasma therapy in the prevention and treatment of episodes of atypical haemolytic uraemic syndrome (aHUS)
  • Eculizumab may be considered as a first-line therapy in children with a first episode of aHUS as it avoids the complications associated with apheresis and central venous catheters
  • In adults, eculizumab can be used as a first-line therapy when aHUS diagnosis is undisputable, although plasma therapy should be used as a first-line therapy if uncertainty in diagnosis warrants further investigation
  • Evidence of plasma resistance or dependence should lead to a prompt switch to eculizumab; the sooner eculizumab is initiated, the better the recovery of renal function
  • Renal transplant candidates with a genetically determined risk of post-transplantation aHUS recurrence should be given a prophylactic protocol based on eculizumab if at high risk, and plasma exchange or eculizumab if at moderate risk
  • Eculizumab may be effective in curbing part of the inflammatory process involved in a subset of C3 glomerulopathies

Nature Reviews Nephrology 8, 643-657 (November 2012) | doi:10.1038/nrneph.2012.214

Prices For Health Care Procedures Now Online

Buying health care in America is like shopping blindfolded at Macy’s and getting the bill months after you leave the store, economist Uwe Reinhardt likes to say.

A tool that went online Wednesday is supposed to give patients a small peek at the products and prices before they open their wallets.

Got a sore knee? Having a baby? Need a primary-care doctor? Shopping for an MRI scan? shows the average local cost for 70 common diagnoses and medical tests in most states. That’s the real cost — not “charges” that often get marked down — based on a giant database of what insurance companies actually pay.

guroo 570






OK, this isn’t like for knee replacements. What Guroo hopes to do for consumers is limited so far.

It won’t reflect costs for particular hospitals or doctors, although officials say that’s coming for some. And it doesn’t have much to say initially about the quality of care.

Still, Guroo should shed new light on the country’s opaque, complex and maddening medical bazaar, say consumer advocates.

“This has the potential to be a game-changer,” said Katherine Hempstead, who analyzes health insurance for the Robert Wood Johnson Foundation. “It’s good for uninsured people. It’s good for people with high deductibles. It’s good for any person that’s kind of wondering: If I go to see the doctor for such-and-such, what might happen next?”

Guroo is produced by the Health Care Cost Institute (HCCI) working with three big insurance companies: UnitedHealthcare, Aetna and Humana, soon to be joined by a fourth, Assurant. The idea is to eventually let members of these plans use a companion site to see how differing provider prices affect their co-payments.

A nonprofit known for its cost and utilization reports, HCCI receives some industry funding but is governed by an independent board. This is its first tool for consumers.

Consumer advocates praised Guroo but cautioned that the movement toward “transparency” in medical prices is still in its very early stages. Data on insurer, employer or government Web sites are often limited or inaccurate. Consumer information from Fair Health, which manages another huge commercial insurance database, is organized by procedure code.

Even on Guroo, “the average user may not have a good sense of what they’re looking at and what they’re supposed to do with the resulting price,” said Lynn Quincy, a health care specialist at Consumers Union.

HCCI says its prices are what insurers pay for about 70 tests and “bundles” of services described in understandable terms so patients don’t need a medical textbook to figure out what they are. Users get the average as well as a range for local and national prices.

It plans to add more procedures later — all for “shoppable” services that can be scheduled, not emergency treatment of a heart attack.

“This at least arms consumers with information about the range of prices in their community [for] one of these care bundles,” said David Newman, HCCI’s executive director.

If you have a high deductible, for example, you might use Guroo as a starting point for checking prices from medical providers if your insurance company doesn’t provide such a tool.

That’s not the same as seeing provider-specific prices online, of course. But within a year, HCCI expects to let members of UnitedHealthcare, Aetna, Assurant and Humana track spending on a companion site and check how switching caregivers could lower their out-of-pocket costs.

Initially Guroo doesn’t have much information about quality of care, either, which is essential to help patients to make smart choices. Newman says that is coming, too. It’s also missing information for Alabama, Michigan and several other states.

BlueCross BlueShield of North Carolina set a high standard for disclosure recently by posting prices — doctor by doctor and hospital by hospital — based on its reimbursement rates, Quincy said. Guroo doesn’t do that.

Still, she said, it’s an important step.

Given its size, influence and openness, Guroo could become a dominant portal for health care prices, said Hempstead.

“Their stance as a neutral broker and the amount of data that they have and the amount of data that they’re going to have really puts them in a difference place,” she said.

Jay Hancock Kaiser Health News. KHN is a nonprofit national health policy news service. 

Advice for Physicians in Training: 40 Tips From 40 Docs

Remember how much your work matters, because health is important to everyone. You get to cure disease sometimes and offer comfort when you cannot. What you do makes a real difference in the lives of others, allowing you to leave the world a better place than you found it. And as if all that wasn’t enough, you actually get paid to do these things.


David Juurlink, Advice for Physicians in Training: 40 Tips From 40 Docs,The Winnower2:e142006.67645 (2014). DOI:10.15200/winn.142006.67645

Mechanical Ventilation 101

Dr. Weissler gave us an excellent talk on the basics of ventilator management. The information in these slides may literally help you save a life!

For some training on ventilator management, see our previous post.

(A note to our email subscribers: this post includes a powerpoint presentation that is only available on the actual website – click the link above to access the post!)

Extra-Intestinal Clostridium Difficile Infection

Dr. Arjun Gupta, a former Mayo Clinic Researcher and Resident Physician at the University of Texas Southwestern Medical Center, describes his article appearing in the November 2014 issue of Mayo Clinic Proceedings, and summarizes the risk factors, management, and outcomes of these rare, but increasingly identified infections. Available at:

(A note to email subscribers: to access the video presentation, please visit the blog website from the link in the title, above).

5 Things To Know About The Supreme Court Case Challenging The Health Law

The Affordable Care Act is once again before the Supreme Court.

On March 4, the justices will hear oral arguments in King v. Burwell, a case challenging the validity of tax subsidies helping millions of Americans buy health insurance if they don’t get it through an employer or the government. If the court rules against the Obama administration, those subsidies could be cut off for everyone in the three dozen states using, the federal exchange website. A decision is expected by the end of June.

Here are five things you should know about the case and its potential consequences:

1: This case does NOT challenge the constitutionality of the health law.

The Supreme Court has already found the Affordable Care Act is constitutional. That was settled in 2012’s NFIB v. Sebelius.

At issue in this case is a line in the law stipulating that subsidies are available to those who sign up for coverage “through an exchange established by the state.” In issuing regulations to implement the subsidies in 2012, however, the IRS said that subsidies would also be available to those enrolling through the federal health insurance exchange. The agency noted Congress had never discussed limiting the subsidies to state-run exchanges and that making subsidies available to all “is consistent with the language, purpose and structure” of the law as a whole.

Last summer, the U.S. Court of Appeals for the Fourth Circuit in Richmond ruled that the regulations were a permissible interpretation of the law. While the three-judge panel agreed that the language in the law is “ambiguous,” they relied on so-called “Chevron deference,” a legal principle that takes its name from a 1984 Supreme Court ruling that held that courts must defer to a federal agency’s interpretation as long as that interpretation is not unreasonable.

Those challenging the law, however, insist that Congress intended to limit the subsidies to state exchanges. “As an inducement to state officials, the Act authorizes tax credits and subsidies for certain households that purchase health insurance through an Exchange, but restricts those entitlements to Exchanges created by states,” wrote Michael Cannon and Jonathan Adler, two of the fiercest critics of the IRS interpretation, in an article in the Health Matrix: Journal of Law-Medicine.

In any case, a ruling in favor of the challengers would affect only the subsidies available in the states using the federal exchange. Those in the 13 states operating their own exchanges would be unaffected. The rest of the health law, including its expansion of Medicaid and requirements for coverage of those with pre-existing conditions, would remain in effect.

2: If the court rules against the Obama administration, millions of people could be forced to give up their insurance.

A study by the Urban Institute found that if subsidies in the federal health exchange are disallowed, 9.3 million people could lose $28.8 billion of federal help paying for their insurance in just the first year. Since many of those people would not be able to afford insurance without government help, the number of uninsured could rise by 8.2 million people.

A separate study from the Urban Institute looked at those in danger of losing their coverage and found that most are low and moderate-income white, working adults who live in the South.

3: A ruling against the Obama administration could have other effects, too.

Experts say disallowing the subsidies in the federal exchange states could destabilize the entire individual insurance market, not just the exchanges in those states. Anticipating that only those most likely to need medical services will hold onto their plans, insurers would likely increase premiums for everyone in the state who buys their own insurance, no matter where they buy it from.

“If subsidies [in the federal exchange] are eliminated, premiums would increase by about 47 percent,” said Christine Eibner of the RAND Corporation, who co-authored a study projecting a 70 percent drop in enrollment.

Eliminating tax subsidies for individuals would also impact the law’s requirement that most larger employers provide health insurance. That’s because the penalty for not providing coverage only kicks in if a worker goes to the state health exchange and receives a subsidy. If there are no subsidies, there are also no employer penalties.

4: Consumers could lose subsidies almost immediately.

Supreme Court decisions generally take effect 25 days after they are issued. That could mean that subsidies would stop flowing as soon as July or August, assuming a decision in late June. Insurers can’t drop people for non-payment of their premiums for 90 days, although they have to continue to pay claims only for the first 30.

Although the law’s requirement that individuals have health insurance would remain in effect, no one is required to purchase coverage if the lowest-priced plan in their area costs more than eight percent of their income. So without the subsidies, and with projected premium increases, many if not most people would become exempt.

5: Congress could make the entire issue go away by passing a one-page bill. But it won’t.

All Congress would have to do to restore the subsidies is pass a bill striking the line about subsidies being available through exchanges “established by the state.” But given how many Republicans oppose the law, leaders have already said they will not act to fix it. Republicans are still working to come up with a contingency plan should the ruling go against the subsidies. Even that will be difficult given their continuing ideological divides over health care.

States could solve the problem by setting up their own exchanges, but that is a lengthy and complicated process and in most cases requires the consent of state legislatures. And the Obama administration has no power to step in and fix things either, Health and Human Services Secretary Sylvia Burwell said in a letter to members of Congress.



Kaiser Health News (KHN) is a nonprofit national health policy news service. This KHN story also ran on NPR’s Shots blog., Kaiser Health News