Other

Question 1

What recommendations should be made re: EtOH consumption and what are the Mx options?

Answer 1

• No more than 2 standard drinks daily
• No more than 4 standard drinks on any one occasion

Mx

• Disulfiram (raises acetaldehyde levels)
• Acamprosate (reduces withdrawal symptoms)
• Naltrexone

Question 2

What conditions are associated with functional hyposplenism?

Answer 2

• EtOH liver disease
• Cirrhosis
• Coeliac disease
• Lymphoma
• Autoimmune disease
• IBD
• Whipple’s disease
• Chronic GVHD (eg HSCT)
• HIV
• Sickle cell disease

Question 3

How is suspected functional hyposplenism investigated?

Answer 3

• Howell-Jolly bodies
• Pitted erythrocytes > 4% of at least 2000 RBC in total
• Spleen scintigraphy with T99msulfur colloid => reduced uptake

Question 4

When should vaccination first doses be given pre- elective splenectomy or post- emergency splenectomy?

Answer 4

7-14 days pre-elective

>7 days post emergency

Question 5

What is the vaccination schedule for asplenia/hyposplenism?

Answer 5

Pneumococcus
- Conjugate => 5wks => Polysaccharide => 5yrs => Polysaccharide

Meningococcus

• Conjugate ACWY and recombinant B+ => 8 wks => repeat
• 5yrly Conjugate ACWY

Hib
- Conjugate Hib => no boosters required

Question 6

What are the live vaccines contraindicated in immunosuppressed individuals?

Answer 6

MMR
VZV
Oral polio
Yellow fever
Live typhoid
BCG

Question 7

What is involved in the management of HIV?

Answer 7

• CD4 count and viral load q3-6months (viral load should be undetectable after 3 months)

Meds

• Drug interactions
• Adherence to ART
• ART side effects

Infection prophylaxis

• If CD4 count of < 200 cells/μL or < 14% of lymphocyte count => Bactrim
• If CD4 < 50 cells/μL => azithromycin 1.2g PO weekly for MAC prophylaxis
• Influenza and pneumococcal vaccinations
• MMR and VZV vaccinations safe. Other live vaccines C/I.

Infection screening

• STI screens annually in MSM: chlamydia, gonorrhoea, syphilis
• Hep A and B vaccination. Aim HBsAb > 10
• Hep C screening annually if high risk

CVS

• Smoking cessation
• Weight loss: BMI, waist <94cm males, <80cm females
• Diet
• Exercise ~150min weekly
• EtOH max 2 drinks daily
• BP <140/90, or <130/80 if DM, albuminuria
• Lipids

Metabolic

• BSL
• eGFR and U/A q3-6m while on ART
• LFT q3-6m while on ART
• Osteoporosis risk Ax

Malignancy screening

• FOBT q2y from 50-75
• Mammo q2y
• PAP smear q1y
• Regular skin checks
• Consider PSA/DRE from age 50

Psychosocial

• Depression
• Drug use
• Housing, financial, social support
• Sexual and reproductive function

Question 8

What investigations are relevant in cognitive impairment?

Answer 8

TSH - hypothyroidism
B12 - deficiency
HIV
Syphilis
MRI brain - frontotemporal vs Alzheimer's

Question 9

Which patients should not be commenced on efavirenz for HIV?

Answer 9

Those with neuropsychiatric issues

Question 10

Which patients should not have abacavir?

Answer 10

HLA-B57*01 => hypersensitivity reaction

AMI

Question 11

Which HIV treatments may cause a rise in Cr?

Answer 11

• Cobicistat, Dolutegravir => reduce Cr excretion but do not affect renal function
• Tenofovir disoproxyl fumarate (TDF). TAF is better.