Knowledge of Pre- and Postexposure Prophylaxis for HIV Prevention Among Internal Medicine Residents in the United States

Prescription rates of pre-exposure prophylaxis (PrEP) have remained low among noninfectious disease providers in the United States despite almost a decade since their introduction. For future primary care doctors, residency is the optimal time to build practice patterns around HIV prevention. We assessed baseline knowledge of PrEP in specific pre- and post-exposure prophylaxis content areas among internal medicine trainees who completed the Physician Education and Assessment Center HIV learning module between 2013 to 2020 (N = 12,060). Resident baseline PrEP knowledge was universally low; despite rising awareness of antiretroviral therapy for PrEP in successive years following the nadir of 41% in 2014, still only 56% of residents affirmed this means of HIV prevention by 2020. Knowledge remained limited regardless of academic year, local HIV prevalence, or training program type. Online module completion increased competence across all content areas. There is still a deficit in HIV prevention knowledge across U.S. internal medicine residents, suggesting insufficient education and exposure to HIV-related care.

Infective endocarditis in people who inject drugs: A scoping review of clinical guidelines

BACKGROUND

The incidence of infective endocarditis (IE) among people who inject drugs (PWID) is rising worldwide. Multiple clinical guidelines differ on the management of this condition, and few guidelines comment on treatment for primary substance use disorder (SUD). A comprehensive comparison of these guidelines is lacking.

OBJECTIVES

To perform a critical review identifying key differences in clinical guideline recommendations for treating IE among PWID, focusing on the inclusion of recommendations for SUD treatment and the presence of stigmatizing language.

ELIGIBILITY CRITERIA

Recently published, English-language, society-developed clinical guidelines for the treatment of IE among PWID.

SOURCES OF EVIDENCE

PubMed, Google Scholar, and CINAHL Plus databases.

CHARTING METHODS

In line with Arksey and O'Malley's framework, a scoping review was adapted using Joanna Briggs Institute and PRISMA-ScR guidelines. Two reviewers independently performed database searches for clinical guidelines published between 2007 and 2020 that commented on the management of IE among PWID.

RESULTS

Ten clinical guidelines were included in the final analysis. Treatment recommendations varied with some societies proposing nonstandard care due to concern for return to drug use. Three guidelines include reference to addiction treatment. Only one guideline specifies the use of opioid agonist therapy for treating opioid use disorder and identifies the benefits of an addiction specialist consultation. Acute withdrawal management is not mentioned in any guideline. All guidelines utilized stigmatizing language to describe PWID.

CONCLUSIONS

Most guidelines do not address SUD treatment, despite its effectiveness in reducing adverse health outcomes. Future guidelines should address SUD treatment using patient-first language.

Treatment of opioid use disorder in primary care

Opioid use disorder (OUD) is a common, treatable chronic disease that can be effectively managed in primary care settings. Untreated OUD is associated with considerable morbidity and mortality-notably, overdose, infectious complications of injecting drug use, and profoundly diminished quality of life. Withdrawal management and medication tapers are ineffective and are associated with increased rates of relapse and death. Pharmacotherapy is the evidence based mainstay of OUD treatment, and many studies support its integration into primary care settings. Evidence is strongest for the opioid agonists buprenorphine and methadone, which randomized controlled trials have shown to decrease illicit opioid use and mortality. Discontinuation of opioid agonist therapy is associated with increased rates of relapse and mortality. Less evidence is available for the opioid antagonist extended release naltrexone, with a meta-analysis of randomized controlled trials showing decreased illicit opioid use but no effect on mortality. Treating OUD in primary care settings is cost effective, improves outcomes for both OUD and other medical comorbidities, and is highly acceptable to patients. Evidence on whether behavioral interventions improve outcomes for patients receiving pharmacotherapy is mixed, with guidelines promoting voluntary engagement in psychosocial supports, including counseling. Further work is needed to promote the integration of OUD treatment into primary care and to overcome regulatory barriers to integrating methadone into primary care treatment in the US.

Physician familiarity with diagnosis and management of hypertension according to JNC 7 guidelines

Physician knowledge of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines is unknown and may contribute to the prevalence of uncontrolled hypertension. Our objective was to determine physician knowledge of JNC 7 guidelines and whether online instruction could improve knowledge. A pretest served as baseline knowledge, and comparison with a post-test after completing an online didactic demonstrated improvement in knowledge. Participants included 1280 physicians at 45 internal medicine residency training programs. Average baseline knowledge of six concepts of hypertension was 51.2%. Attending physicians performed better than trainees on some but not all concepts (p<0.05). Third-year post-graduate trainees performed better than first-year trainees on some but not all concepts (p<0.05). Knowledge increased significantly on all concepts after completing the curriculum (p<0.05). The authors demonstrated that physician knowledge of JNC 7 guidelines is poor but can be improved by an online curriculum. Further study is needed to determine the impact of physician education on clinical outcomes in individuals with hypertension.

A patient with primary human immunodeficiency virus infection who presented with acute rhabdomyolysis

Primary human immunodeficiency virus (HIV) infection is usually symptomatic, and infected patients can present with a variety of symptoms. We describe a 51-year-old man who presented at our hospital with acute self-limited rhabdomyolysis and who was found to have primary HIV infection. Our case and other reports suggest that a diagnosis of primary HIV infection needs to be considered for patients who present with acute rhabdomyolysis.

Pericyte changes in branch retinal vein occlusion

The model of experimental branch vein occlusion (BVO) in the monkey offers the opportunity to examine retinal capillaries under stress. Electron microscopic morphometry was done on 812 capillaries of 13 eyes of cynomolgus monkeys, comparing 579 capillary collaterals of 9 BVO eyes with 233 normal capillaries of 4 control eyes. The tissue underwent the myosin subfragment-1 technique to decorate and quantify bundles of actin filaments in capillary pericytes. The duration of BVO was 2-48 months. Capillary collaterals of BVO eyes had an enlarged caliber, endothelial hyperplasia, and pericyte hypertrophy, but no proportional increase in basement membrane area. Collaterals near the inner plexiform layer (IPL) had a greater wall thickness, pericyte coverage, and actin coverage than collaterals near the outer plexiform layer (OPL). Pericyte hypertrophy was proportionate to caliber increase in OPL vessels and exceeded caliber increase only in IPL vessels. Actin coverage was proportional with the vessel dilation and size of pericyte cytoplasm in all vessels. These findings indicate that capillary collaterals in BVO are not equipped morphologically for an increased regulatory role in microvascular flow beyond their normal function.