Answer to CC #18

Case challenge #18 presented a 68 year old Asian female with HIV admitted for fever and SOB. Three days prior to admission, she developed watery diarrhea, approximately 5-6 BM a day. The work-up revealed 40% Eos and stool O&P with larval forms.

CC18 

  • The correct answer is: Strongyloides Stercoralis!

    • General Information
      • Strongyloidiasis is a chronic parasitic infection of humans caused by Strongyloides stercoralis.
      • Transmission occurs mainly in tropical and subtropical regions but also in countries with temperate climates.
      • An estimated 30–100 million people are infected worldwide
      • Infection is acquired through direct contact with contaminated soil during agricultural, domestic and recreational activities.
      • Like other soil-transmitted helminthiases, the risk of infection is associated with hygiene, making children especially vulnerable.
    • Clinical Manifestations
      • Strongyloidiasis is frequently underdiagnosed because many cases are asymptomatic
      • Strongyloidiasis may cause intermittent symptoms that mostly affect the intestine (abdominal pain and intermittent or persistent diarrhea), the lungs (cough, wheezing, chronic bronchitis) or skin (pruritus, urticaria).
      • Infection may be severe and even life-threatening in cases of immunodeficiency.
      • Without appropriate therapy, the infection does not resolve and may persist for life.
    • Diagnosis
      • Most diagnostic methods lack sensitivity.
      • Locating juvenile larvae, either rhabditiform or filariform, in recent stool samples will confirm the presence of this parasite.
        • Ascaris, Necator, and Schistosoma will have eggs in the fecal smear, not larvae
        • Trichinella will have larvae in the muscle 
      • Other techniques used include direct fecal smears, serodiagnosis through ELISA, and duodenal fumigation.
    • Management
      • Ivermectin is the drug of choice, but is not available in all endemic countries.
      • Albendazole is also an option, but is considered less effective.

What species of Strongyloides-small

For more information, as Nico Barros or Fernando Woll, our resident Strongy scientists!

A Practical Guide to the Novel Anticoagulants

This morning, Dr. Craig Malloy, Richard A. Lange, M.D. Chair in Cardiology, gave an amazing update for internists on New Therapies fo Atrial Fibrillation. One of the most important topics covered was the noval anticoagulants, or NOACS. Here is a quick review for use in the clinic or hospital!

Dabigatran, rivaroxaban and apixaban are three new drugs that have different mechanisms of action, daily doses, and metabolic and elimination profiles.

Dabigatran (Pradaxa) is a direct thrombin inhibitor (it inhibits factor II) that has a half-life of about 12-14 hours and needs to be administered twice daily. It partially binds plasma proteins and can therefore be partially dialysed. Pradaxa is only eliminated renally: it is therefore contraindicated in patients whose creatinine clearance is

Rivaroxaban (Xarelto) is a direct factor X inhibitor with a half-life of 5-13 hours, but completely binds plasma proteins. It is administered once daily with evening meal in NVAF patients, and twice daily in those with DVT or PE. It is eliminated by the kidney and liver, and can be used at a lower dose if creatinine clearance is15 mL/min in NVAF patients; its use should be avoided in DVT/PE patients whose creatinine clearance is

Apixaban (Eliquis) is a direct factor X inhibitor with a half-life of 9-14 hours, but completely binds plasma proteins. It is administered twice daily and eliminated by kidney and liver. It should not be used if creatinine clearance is

NOAC trial comparisons

Turiel M, Galaverna S, Colombo C, Gianturco L, Stella D (2015) Practical Guide to the New Oral Anticoagulants. J Gen Pract 3:194. doi: 10.4172/2329-9126.1000I194

Causes of asymptomatic microscopic hematuria

Excellent board-review lecture today by Dr. Sambandam! He is a little clinical pearl, the causes of asymptomatic microscopic hematuria:

  • Benign essential Hematuria (37%)
  • Benign Prostatic Hyperplasia (24%)
  • Urethral Infection (21%)
  • Urinary Tract Infection (7%)
  • Nephrolithiasis (4%)
  • Urethral calculus (2%)
  • Bladder tumor (2%)
  • Renal Cyst (1.5%)
  • Renal tumor (0.5%)

“The Flipped Patient”

This past December in JAMA, Dr. Jeffrey Chi and Dr. Abraham Varghese from Stanford University published an op-ed article in the Viewpoint section titled “The Flipped Patient”. They discuss how electronic health records (EHR) have provided many advantages in care of patients but point out some unintended consequences to training of physicians. Has EHR moved us away from the patient’s bedside? Do we bypass asking about the family history and past medical history because it already auto-populates on the note template? Has the question, “What brings you to the hospital?”, become obsolete with the abundance of information provided in the EHR before you even see the patient? Click on the link below to read the rest the article! Thanks to Dr. Croft and Dr. Kazi for the article reference.

“Ultimately, however, the nature of medicine is the interaction of a vulnerable human being in distress with a caring empathetic team represented by other humans.”

The Flipped Patient

HIV Treatment at Diagnosis According to U.S. Officials!

Yesterday the U.S. National Institutes of Health announced the early termination of a trial (START-Strategic Timing of AntiRetroviral Treatment) looking at early treatment of HIV at diagnosis due to clear benefits seen in the study. They recommended patients who learn they are HIV positive should immediately be put on antiretroviral therapy as their study shows a significant survival benefit. The START trial showed that the risk of death or serious illness in patients randomized to early treatment was reduced by 53%. The findings are expected to impact global guidlines regarding HIV treatment. Current W.H.O guidelines recommend treating at CD4 of 500, but acknowledged that treatment at CD4 count of 350 was more practical in many poor countries. They are expected to release updated guidelines very soon. Of note, the CDC recommends immediate treatment at diagnosis of HIV but estimated that 37% of Americans with HIV actually have prescriptions for antiretroviral therapy. Check out the link below from the NIH that summarizes their announcement!

NIH-Starting antiretroviral treatment early improves outcomes for HIV-infected individuals

(photo from Susan Sterner/Associated Press)

Case Challenge #18

History of Present Illness

A 68 year old Asian female with HIV who presents with fever and SOB. Patient was in her usual state of health until approximately one month ago when she came to the ER with a three day history of cough and fever. She described a persistent dry cough associated with a burning sensation in her chest and occasional wheezing. In addition, she had SOB with even minimal exertion and felt very lethargic. She felt that her cough and SOB progressively worsened over the past week. Three days prior to admission, she developed watery diarrhea, approximately 5-6 BM a day. She denies N/V, melena, hematochezia.

Physical Exam

  • T 38.8, P 84, BP 108/62, R16, 99% RA
  • Lungs: diffuse expiratory wheezes bilaterally
  • Abd: soft, NT, slightly distended, NABS, no HSM

Labs/Imaging

  • CD4 316 and VL <48
  • CMP normal
  • wbc 21, hgb 8, plt 220
  • 35% Polys, 17% Lymphs, 8%, Monos, 40% Eos
  • CXR: heart size normal, patchy infiltrates in bilateral bases
  • Blood and urine cultures negative
  • Stool O&P shows larval forms

 Question

How will you be paid?

‘Milestone’ Rules Would Limit Profits, Score Quality For Medicaid Plans

 Sweeping proposals disclosed Tuesday would create profit guidelines for private Medicaid plans as well as new standards for the plans’ doctor and hospital networks and rules to coordinate Medicaid insurance more closely with other coverage.

“We are taking steps to align how these programs work,” said Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services, which proposed the rules.

Privatized Medicaid has grown rapidly as budget-pinched states have responded to commercial insurers’ promise to deliver care for a fixed price. Most beneficiaries of Medicaid — state programs for the poor run partly with federal dollars — now get care through contracted insurers.

The 653-page rule, which also would require states to establish quality ratings for Medicaid plans, constitutes the biggest regulation change to Medicaid managed care in more than a decade. The National Association of Medicaid Directors, a group of state officials, called it a “milestone.”

One proposal would require plans to assume, for rate-setting purposes, that they will spend at least 85 percent of their revenue on medical care.

Such a “medical loss ratio” target is similar to that required under the health law for other plans — but with a key difference. Unlike health plans sold through the law’s online marketplaces and elsewhere, Medicaid plans wouldn’t have to rebate the difference if they spend less than 85 percent.

But states would still “need to take that into account the next year” when they set new rates, thus limiting profits later, said Vikki Wachino, CMS deputy administrator. CMS is a division of the Department of Health and Human Services.

Jeff Myers, CEO of Medicaid Health Plans of America, an industry group, criticized the inclusion of the medical loss ratio standard, which supporters promote as ensuring plans spend a minimum amount on care instead of executive salaries and shareholder profits.

“We don’t believe a nationwide MLR is appropriate,” Myers said. A uniform profit standard across diverse states could limit plans’ ability to spend administrative dollars to fine-tune care coordination and quality, he said.

Generally, however, “we are very supportive of the direction they are going,” he said of CMS. He particularly praised the proposal to better align the Children’s Health Insurance Program, or CHIP, which aids families with children with moderate incomes, with Medicaid.

Led by giants such as UnitedHealthcare, Anthem, Aetna and Centene, private Medicaid plans generated nationwide operating profits of $2.4 billion last year, according to regulatory data compiled by Mark Farrah Associates and analyzed by Kaiser Health News.

medicaid regsAdvocates for the poor have complained that HHS’ regulation of Medicaid managed care has lagged behind the industry’s growth. Industry profits have sometimes come at the expense of denied care and inadequate doctor networks, they say.

A study last year by HHS’ inspector general found that half the doctors listed in official plan directors weren’t taking new Medicaid patients. Among doctors who were, one fourth couldn’t see patients for a month.

In Tuesday’s rules CMS proposed new standards for network adequacy that also allow wide flexibility to states. States would have to certify at least annually that Medicaid managed-care patients have sufficient access to doctors and hospitals, based on standards for numbers of medical providers per member, maximum distances required to travel for care and other criteria.

“This latest proposed guidance ensures that health plans and states have the flexibility to structure their programs and benefits to meet the unique health needs of their enrollees,” Dan Durham, interim CEO of America’s Health Insurance Plans, an industry lobby, said in a prepared statement.

Sarah Somers, an attorney with the National Health Law Program, which has long urged updates to federal regulations, praised proposed safeguards for Medicaid members with disabilities and limited English ability.

“The regulations governing network adequacy have some positive aspects,” she added. “But we are concerned that they do not contain the specificity that we recommended.”

The proposal also would establish a quality-rating system, perhaps similar to the star scores assigned to Medicare coverage for seniors, so members could compare plan performance. However Wachino said it was too early to tell what the ratings would look like.

Margaret Murray, CEO of the Association for Community Affiliated Plans, a group of not-for-profit Medicaid companies, said she was disappointed the quality standards wouldn’t apply to traditional Medicaid run by the states as well as private Medicaid plans.

“We think that managed care will come out ahead in that comparison,” she said.

In a victory for industry, the rules also propose to loosen marketing restrictions on insurers that offer Medicaid coverage as well as plans sold through the health-law marketplaces.

Some companies are counting on capturing customers moving from Medicaid to commercial plans or vice versa as the members’ incomes fluctuate. The new regulation would make it easier for insurers to let Medicaid beneficiaries know that the same company sells a plan through the marketplace.

The rules published Tuesday are only proposals. HHS will take comments until late July and issue final rules later.

Kaiser Health News (KHN) is a nonprofit national health policy news service. 

UTSW Faculty’s Publication Featured in Medscape!

Congratulations to Dr. Ishak Mansi from the division of General Internal Medicine at UT Southwestern for his recently published article, “Statins and New-Onset Diabetes Mellitus and Diabetic Complications: A Retrospective Cohort Study of US Healthy Adults” in the Journal of General Internal Medicine. Dr. Mansi’s findings were featured on the frontpage of Medscape this past week and has gained a lot of attention. According to Dr. Mansi and the authors, this is one of the first studies to show a connection between statin use and risk of diabetes in a generally healthy group. Click on the links below to read the summary of the article’s findings as well as the abstract!

Statins and New-Onset Diabetes Mellitus and Diabetic Complications: A Retrospective Cohort Study of US Healthy Adults

Statins Linked to Diabetes and Complications in Healthy Adults (Medscape) 

UTSW Internal Medicine

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