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Perioperative medical management is challenging because of the rising complexity of patients presenting for surgical procedures. A key part of preoperative optimization is appropriate management of long-term medications, yet guidelines and consensus statements for perioperative medication management are lacking. Available resources use recommendations derived from individual studies and do not include a multidisciplinary focus on formal consensus. The Society for Perioperative Assessment and Quality Improvement identified a lack of authoritative clinical guidance as an opportunity to use its multidisciplinary membership to improve evidence-based perioperative care. The Society for Perioperative Assessment and Quality Improvement seeks to provide guidance on perioperative medication management that synthesizes available literature with expert consensus. The aim of this consensus statement is to provide practical guidance on the preoperative management of immunosuppressive, biologic, antiretroviral, and anti-inflammatory medications. A panel of experts including hospitalists, anesthesiologists, internal medicine physicians, infectious disease specialists, and rheumatologists was appointed to identify the common medications in each of these categories. The authors then used a modified Delphi process to critically review the literature and to generate consensus recommendations.

Life-changing progress has been made over the past 30 years in the treatment of HIV infection. HIV has transformed from an illness that resulted in one complication after another and nearly always resulted in death to a chronic illness that for most patients is more easily managed than diabetes or heart disease. Antiretroviral therapy (ART) is now simple and well-tolerated. The most important priority of HIV treatment is ensuring that people living with HIV stay on continuous, effective ART. ART, although not curative, suppresses the virus and allows the immune system to recover. Even when the CD4 count remains low, suppressive ART helps prevent opportunistic infections and other HIV related complications. (1) Suppressive ART is important not only to the individual living with HIV health but is an important public health goal since people living with HIV will not transmit HIV to their sexual partners if their viral load is undetectable. (2) A respectful, culturally appropriate patient–provider relationship is one of the most important factors in keeping people living with HIV engaged in care. (3) Persons living with HIV deserve both excellent HIV and primary care. Some communities have providers that are experts in both, but often people living with HIV receive the best care by collaboration between their primary care provider and an HIV expert. This article is written to help primary care givers who are not HIV experts provide appropriate primary care to their patients who are living with HIV and emphasizes issues that deserve additional attention in people living with HIV compared to the general population

Purpose: To present a case of subretinal abscess associated with pneumonia and meningitis caused by Cryptococcus gattii in an immunocompetent host. Observations: A 37-year-old man presented with sub-acute painless unilateral vision loss and a white submacular elevation. Systemic evaluation revealed a lung lesion and cerebrospinal fluid evidence of Cryptococcus gattii infection. Conclusions and importance: While Crypococcus neoformans has been well described as a cause of chorioretinitis in immunocompetent and immunocompromised hosts, this report demonstrates that Cryptocuccus gattii is a related uncommon pathogen to be considered in similar presentations. Submacular surgical debridement may be challenging and OCT imaging may be helpful to detect full-thickness retinal necrosis.

Infections of the urinary system may involve the lower urinary tract (confined to the bladder) or the upper urinary tract (pyelonephritis). The spectrum of urinary conditions ranges from asymptomatic bacteriuria, symptomatic urinary tract infection (UTI), and sepsis associated with UTI that requires hospital admission. The treatment of UTIs include antibiotics that can result in long-term alteration of the normal microbiota of the gastrointestinal tract and in the development of multidrug-resistant microorganisms. For this reason, a urine sample should be cultured to identify causative organisms and their antimicrobial susceptibilities.

Preexposure prophylaxis (PrEP) with daily tenofovir disoproxil fumarate/emtricitabine can reduce the risk of HIV infection by more than 90% for patients who are highly adherent. When considering PrEP, the first step is to determine the risk of HIV acquisition based on sexual risk behaviors during the past 6 months. Evaluation should include baseline HIV test, renal function estimate, and hepatitis B screen. Follow-up should be scheduled at 1 month and every 3 months thereafter. The need to continue PrEP should be reassessed on an annual basis, and PrEP should be continued for 1 month after the last high-risk exposure.

Objective To report the Mayo Clinic experience with coronavirus disease 2019 (COVID-19) related to patient outcomes. Methods We conducted a retrospective chart review of patients with COVID-19 diagnosed between March 1, 2020, and July 31, 2020, at any of the Mayo Clinic sites. We abstracted pertinent comorbid conditions such as age, sex, body mass index, Charlson Comorbidity Index variables, and treatments received. Factors associated with hospitalization and mortality were assessed in univariate and multivariate models. Results A total of 7891 patients with confirmed COVID-19 infection with research authorization on file received care across the Mayo Clinic sites during the study period. Of these, 7217 patients were adults 18 years or older who were analyzed further. A total of 897 (11.4%) patients required hospitalization, and 354 (4.9%) received care in the intensive care unit (ICU). All hospitalized patients were reviewed by a COVID-19 Treatment Review Panel, and 77.5% (695 of 897) of inpatients received a COVID-19–directed therapy. Overall mortality was 1.2% (94 of 7891), with 7.1% (64 of 897) mortality in hospitalized patients and 11.3% (40 of 354) in patients requiring ICU care. Conclusion Mayo Clinic outcomes of patients with COVID-19 infection in the ICU, hospital, and community compare favorably with those reported nationally. This likely reflects the impact of interprofessional multidisciplinary team evaluation, effective leveraging of clinical trials and available treatments, deployment of remote monitoring tools, and maintenance of adequate operating capacity to not require surge adjustments. These best practices can help guide other health care systems with the continuing response to the COVID-19 pandemic.

This chapter describes the transmission, diagnosis, disease history, care, associated infections and conditions, possible treatments, and lifestyle adjustments for living with an HIV infection.

The Conference on Retroviruses and Opportunistic Infections (CROI) is a major annual scientific meeting on HIV/AIDS and associated conditions. Tuberculosis (TB) is the number one cause of death among people living with HIV in developing countries and is the subject of numerous CROI presentations. This report will focus on the presentations at CROI that the author believes are most relevant to clinicians, the public health community and investigators interested in tuberculosis. Keywords: Tuberculosis, HIV, Poverty, Pharmacokinetics, Treatment, Diagnosis, Transmission

Background Pretravel consultation involves a face-to-face visit with a Travel Medicine expert and includes time consuming educating/counseling. Efficacy of electronic consultations for pretravel is unknown. We compared pretravel education via face-to-face consult to an electronic consultations combined with education via Video Supported PowerPoint for select travelers. Methods We conducted a prospective trial comparing pre-travel education via electronic consultations versus face-to-face consult. Study was conducted from May 2014 through May 2015. Results Pretravel surveys were completed by 100 in electronic consult arm and 94 in face-to-face consult arm; 67/100 (67%) in the electronic consult and 51/94 (54.2%) in the face-to-face group completed post-travel surveys. Both groups had similar baseline demographics. 36.2% of the face-to-face group felt the trip preparation could have effectively been accomplished through electronic consult, while 33% felt that a face-to-face consult was needed; in contrast, a majority (63.3%) of electronic consult group preferred the electronic consult. Pre-travel education effectiveness was similar in both groups. No statistically significant differences in responses were noted in both groups to 5 of the 6 knowledge assessment questions. A higher proportion (76/100; 76%) in the electronic consult group compared to 55.4% (51/94) (p = 0.0018) in face-to-face group chose the correct response regarding management of febrile bloody diarrhea. 53% reported behavior change to prevent travel related illnesses, with no statistically significant differences between the groups. Conclusions electronic consultation with Video Supported PowerPoint pre-travel education is as effective as education via face-to-face consultations and provides a viable alternative to face-to-face consultations in select travelers.

Background Pre-travel consultation involves an in-clinic face-to-face consult (F2F) with a Travel Medicine provider. F2F involves education/counseling which is time-consuming for both patients and providers. Although electronic consultations (synchronous and asynchronous) are well established in many subspecialties, pretravel eConsults are not well known. We compared pretravel education via F2F to an innovative hybrid electronic consultation (HeC) combined with a Video Supported PowerPoint (VSP) for selected travelers. Methods We conducted a prospective trial comparing HeC-VSP to F2F to determine the quality of pretravel education. Study was approved by the Mayo Clinic IRB. Patients were enrolled from May 2014 through May 2015. Patients in both arms were given pretravel and post-travel surveys. Exclusions included age less than 18 years, first trip to Africa, immunocompromised host, non-English-speaking traveler, or travel for longer than 4 weeks. Results 194 patients were enrolled; 100 in HeC-VSP and 94 in F2F arm completed pretravel survey. Post-travel survey was completed in 54.2% (51/94) of the F2F, 67% (67/100) in the HeC-VSP group. The groups are similar in demographics and prior travel experience (Table 1). 36.2% of the F2F group felt that the consultation could have been effectively accomplished through a video-based education, while 33% felt that a F2F was needed; in contrast a majority (63.3%) in the HeC-VSP group would not have preferred a F2F consultation. HeC-VSP-based pretravel education was similar compared with that provided via the F2F consults. There were no statistically significant differences in the responses obtained in both groups to knowledge assessment questions (Table 2) except for one question. A higher proportion (76/100; 76%) in the HeC-VSP group compared with 55.4% (51/94) chose the correct response (P = 0.0018) regarding management of bloody diarrhea with fever. Self-reported change in behaviors to prevent travel-related illnesses was reported overall in 53% of the patients with no statistically significant differences between the groups. Conclusion Nonsynchronous eConsultation combined with VSP provides a viable solution to provide pretravel education for a select travel population. Disclosures All authors: No reported disclosures.

Patients with human immunodeficiency virus (HIV) are living longer with their disease, as HIV has become a chronic illness managed with combination antiretroviral therapy (cART). This has led to an increasing number of patients greater than 50 years old living successfully with HIV. As the number of older adults with HIV has increased, there are special considerations for the management of HIV. Older adults with HIV must be monitored for drug side effects and toxicities. Their other non-HIV comorbidities should also be considered when choosing a cART regimen. Older adults with HIV have unique issues related to medication compliance. They are more likely than the younger HIV patients to have vision loss, cognitive impairment, and polypharmacy. They may have lower expectations of their overall health status. Depression and financial concerns, especially if they are on a fixed income, may also contribute to noncompliance in the aging HIV population.

The aims of this study are to evaluate the impact of a novel immunization curriculum based on the Preferred Cognitive Styles and Decision Making Model (PCSDM) on internal medicine (IM) resident continuity clinic patient panel immunization rates, as well as resident immunization knowledge, attitudes, and practices (KAP).A cluster-randomized controlled trial was performed among 143 IM residents at Mayo Clinic to evaluate the PCSDM curriculum plus fact-based immunization curriculum (intervention) compared to fact-based immunization curriculum alone (control) on the outcomes of resident continuity clinic patient panel immunization rates for influenza, pneumococcal, tetanus, pertussis, and zoster vaccines. Pre-study and post-study immunization KAP surveys were administered to IM residents.Ninety-nine residents participated in the study. Eighty-two residents completed pre-study and post-study surveys. Influenza and pertussis immunization rates improved for both intervention and control groups. There was no significant difference in immunization rate improvement between the groups. Influenza immunization rates improved significantly by 33.4% and 32.3% in the intervention and control groups, respectively. The odds of receiving influenza immunization at the end of the study relative to pre-study for the entire study cohort was 4.6 (p 0.0001). The odds of having received pertussis immunization at the end of the study relative to pre-study for the entire study cohort was 1.2 (p = 0.0002). Both groups had significant improvements in immunization knowledge. The intervention group had significant improvements in multiple domains that assessed confidence in counseling patients on immunizations.Fact-based immunization education was useful in improving IM resident immunization rates for influenza and pertussis. The PCSDM immunization curriculum did not lead to increases in immunization rates compared with the fact-based curriculum, but it did significantly increase resident confidence in communicating with patients about vaccines.

Background Over 80% of patients with hematologic malignancies develop some form of infectious complication, most commonly febrile neutropenia. Patients with febrile neutropenia have 10% mortality, which increases if antibiotic administration is delayed past 30 minutes. Studies have suggested β-lactam allergy may delay administration of antibiotic while putting patients at greater risk for inappropriate antibiotic choice and adverse effects stemming from this. We sought to describe the risks associated with β-lactam allergy in the neutropenic population. Methods We conducted a retrospective, descriptive study from January 2016 to December 2017 identifying patients with febrile neutropenia and a reported history of β-lactam allergy. Baseline characteristics, allergy data, treatment data, and outcomes were collected and analyzed. Results We identified 31 patients with febrile neutropenia and β-lactam allergy during this time period. Etiologies of neutropenia were hematologic malignancy (61.2%), stem cell transplantation (12.9%), solid-organ malignancy (22.6%), and autoimmune (3.3%). Reported reactions to β-lactams were rash (41.9%), hives (9.7%), anaphylaxis (3.2%), other (9.7%), and unknown (35.5%). Average time to antibiotic administration was 142.5 minutes. Antibiotic choice was cefepime (61.3%), piperacillin–tazobactam (6.5%), carbapenem (22.6%), fluoroquinolone (6.5%), cefepime and fluoroquinolone (3.2%), and vancomycin (58.1%). 51.6% received initial antibiotics consistent with the 2010 IDSA guidelines. Six patients underwent penicillin skin testing, all negative. 1 patient developed C. difficile infection, 1 developed MRSA colonization, and 3 developed VRE colonization. Mortality was 3.2% at 30 days and 16.1% at 90 days. Conclusion Our study estimated the antibiotic usage patterns and outcomes in patients with febrile neutropenia and reported β-lactam allergy. This showed low adherence to an established guideline for antibiotic choice in these patients. With rising antimicrobial resistance, there is a need to develop strategies to reduce inappropriate antimicrobial use, especially in patients with febrile neutropenia. Preemptive β-lactam allergy evaluation warrants further evaluation in the neutropenic population. Disclosures All authors: No reported disclosures.

Human immunodeficiency virus (HIV) has evolved from an illness that consistently led to death to a chronic disease that can be medically managed. Primary care clinicians can provide beneficial care to the individual patient and potentially decrease the transmission of HIV to others through appropriate HIV screening and recognition of clinical clues to both chronic and acute HIV. Most patients who take combination antiretroviral therapy experience immune reconstitution and resume normal lives. These patients benefit from the care of an experienced primary care clinician in addition to a clinician with HIV expertise. Primary care clinicians have expertise providing preventive care, including counseling regarding healthier lifestyle choices and managing cardiovascular risk factors, osteoporosis, hypertension, and diabetes, all of which have become increasingly important for individuals with HIV as they age. This article reviews the many important roles of primary care clinicians with regard to the HIV epidemic and care of patients with HIV.

Acute bacterial meningitis is an infectious disease emergency. The incidence of bacterial meningitis is estimated to be 3.0 cases per 100,000 person-years, and its overall case fatality rate is 25% in adults. Common predisposing conditions for community-acquired meningitis include acute otitis media, altered immune states, alcoholism, pneumonia, diabetes mellitus, sinusitis, and a cerebrospinal fluid leak. Risk factors for death among adults with community-acquired meningitis include age 60 years or older, altered mental status at presentation, pneumococcal cause, and occurrence of seizures within 24 hours of symptom onset.

To describe the history, objectives, statistics, and initiatives used to address challenges associated with the Mayo Clinic Visiting Medical Student (VMS) Clerkship Program.Mayo Clinic administrative records were reviewed for calendar years 1995 through 2008 to determine the effect of interventions to increase the numbers of appropriately qualified international VMSs and underrepresented minority VMSs. For numerical data, descriptive statistics were used; for comparisons, chi(2) tests were performed.During the specified period, 4908 VMSs participated in the Mayo VMS Program (yearly mean [SD], 351 [24]). Most students were from US medical schools (3247 [66%]) and were male (3084 [63%]). Overall, 3101 VMSs (63%) applied for and 935 (30%) were appointed to Mayo Clinic residency program positions. Interventions to address the challenge of large numbers of international students who participated in our VMS program but did not apply for Mayo residency positions resulted in significantly fewer international students participating in our VMS program (P.001), applying for Mayo residency program positions (P.001), and being appointed to residency positions (P=.001). Interventions to address the challenge of low numbers of underrepresented minority students resulted in significantly more of these students participating in our VMS program (P=.005), applying for Mayo residency positions (P=.008), and being appointed to residency positions (P=.04).Our findings suggest that specific interventions can affect the characteristics of students who participate in VMS programs and who apply for and are appointed to residency program positions.

© 2008 Mayo Foundation for Medical Education and Research A 39-year-old woman presented to our institution with a 4-month history of weight loss, nausea, malaise, and daily fever (temperature, 38.3°C-39.5°C). Her medical history was remarkable for type 2 diabetes mellitus and hypothyroidism. Her medications included levothyroxine and insulin. Born in Mexico, she lived in Texas with her husband and 2 children and was employed as a clerical worker. She did not smoke, drink alcohol, or use recreational drugs. She had not traveled to foreign countries and had no exposure to tuberculosis (TB) or contact with animals or ill people. Family history was noncontributory. Our patient’s fever occurred nightly and was first noted after an elective laparoscopic sterilization, performed at another institution. There were no complications during the procedure, and she was able to walk well the next day. At her 2-week postoperative visit at her local institution, she reported daily fever and described symptoms of nausea, fatigue, and pain on the left side of her abdomen. She denied any change in bowel habit or in respiratory, urinary, or other focal symptoms. Examination revealed lower abdominal tenderness, without guarding, but was otherwise normal.

Preventive medicine provides important benefits to all persons, including older adults; however, these benefits may be seen more clearly in younger adults than in older persons. Smoking cessation, proper nutrition, exercise, and immunizations are important regardless of age. The prevalence of illness increases as we age; at the same time, life expectancy decreases. All physicians and patients should consider the potential benefits of screening and treatment vs conservative management. We discuss lifestyle recommendations such as smoking cessation, exercise, and good nutrition, as well as the role of screening for cardiovascular disease, cancer, and sensory and other disorders. These recommendations are derived from evidence-based guidelines when available; issues not associated with established guidelines are discussed on the basis of best current thinking.

Clindamycin, metronidazole, and chloramphenicol are three antimicrobial agents useful in the treatment of anaerobic infections. Clindamycin is effective in the treatment of most infections involving anaerobes and gram-positive cocci, but emerging resistance has become a problem in some clinical settings. Metronidazole is effective in the treatment of infections involving gram-negative anaerobes, but it is unreliable in the treatment of gram-positive anaerobic infections and is ineffective in treating aerobic infections. Additionally, metronidazole is often the drug of choice in treating infections in which Bacteroides fragilis is a serious concern. Chloramphenicol is effective in the treatment of a wide variety of bacterial infections, including serious anaerobic infections, but is rarely used in Western countries because of concerns about toxicity, including aplastic anemia and gray baby syndrome.

A patient presented with oxalate-induced acute renal failure that was attributable to consumption of oxalate-rich fruit and vegetable juices obtained from juicing. We describe the case and also review the clinical presentation of 65 patients seen at Mayo Clinic (Rochester, MN) from 1985 through 2010 with renal failure and biopsy-proven renal calcium oxalate crystals. The cause of renal oxalosis was identified for all patients: a single cause for 36 patients and at least 2 causes for 29 patients. Three patients, including our index patient, had presumed diet-induced oxalate nephropathy in the context of chronic kidney disease. Identification of calcium oxalate crystals in a kidney biopsy should prompt an evaluation for causes of renal oxalosis, including a detailed dietary history. Clinicians should be aware that an oxalate-rich diet may potentially precipitate acute renal failure in patients with chronic kidney disease. Juicing followed by heavy consumption of oxalate-rich juices appears to be a potential cause of oxalate nephropathy and acute renal failure.

The Mayo human immunodeficiency virus (HIV) Clinic has been providing patient centered care for persons living with HIV in Minnesota and beyond for the past 20 years. Through multidisciplinary engagement, vital clinical outcomes such as retention in care, initiation of antiretroviral therapy and virologic suppression are maximized. In this commentary, we describe the history of the Mayo HIV Clinic and its best practices, providing a “Mayo Model” of HIV care that exceeds national outcomes and may be applicable in other settings.

Background Travelers' diarrhea (TD) is a significant problem for travelers. TD is treatable once it occurs, but few options for prevention exist. Probiotics have been studied for prevention or treatment of TD; however, very few combination probiotics have been studied. Therefore, the purpose of this study was to determine if prophylactic use of an oral synbiotic could reduce the risk of acquiring TD and reduce antibiotic use if TD occurred. Methods Healthy subjects traveling to an area of the world with an increased risk of TD were eligible. All subjects received pre-travel counseling and were provided antibiotics and antidiarrheals (loperamide) for use only if TD developed. The subjects were blinded and randomized to take two capsules of placebo or oral synbiotic (a combination of two probiotics and a prebiotic) called Agri-King Synbiotic (AKSB) beginning 3 days prior to departure, daily while traveling, and for 7 days after return. All subjects kept symptom and medication diaries and submitted a stool sample for pathogen carriage within 7 days of return. The study was powered to detect a 50% reduction in the incidence of TD. Results Of the 196 adults (over 18 years of age) enrolled in the study, 54.3% were female and 80.9% were younger than 60 years. The study randomized 94 people to the AKSB arm and 102 to placebo. The incidence of TD was 54.5% in the overall group with 55.3% in the AKSB arm and 53.9% in the placebo (p = 0.8864). Among the subjects who experienced diarrhea (n = 107) there was no significant difference in the proportion of subjects that took antibiotics versus those that did not take antibiotics (35% vs 29%, p = 0.68). AKSB was safe with no difference in toxicity between the two arms. Conclusions The prophylactic oral synbiotic was safe but did not reduce the risk of developing TD among travelers, nor did it decrease the duration of TD or the use of antibiotics when TD occurred.

Testing for HIV became available in the United States in 1985. Amazing gains in the understanding and treatment of HIV have been made during the past 25 years. HIV and other retroviruses cause a frequently symptomatic primary infection followed by a relatively asymptomatic period lasting months to years and a final stage of overt disease in most people. There are 2 types of HIV: HIV-1 and HIV-2. Most reported cases of HIV disease around the world are caused by HIV-1. HIV-2 is found predominantly in western Africa. Although HIV-1 and HIV-2 are clinically indistinguishable and have identical modes of transmission, HIV-2 appears to be less easily transmitted than HIV-1 and slower to progress to AIDS. Epidemiology, diagnosis, and treatment of HIV are also reviewed.

Background No published reports of studies have provided aggregate data on visiting medical student (VMS) programs at allopathic medical schools. Methods During 2006, a paper survey was mailed to all 129 allopathic medical schools in the United States and Puerto Rico using a list obtained from the Association of American Medical Colleges. Contents of the survey items were based on existing literature and expert opinion and addressed various topics related to VMS programs, including organizational aspects, program objectives, and practical issues. Responses to the survey items were yes-or-no, multiple-choice, fill-in-the-blank, and free-text responses. Data related to the survey responses were summarized using descriptive statistics. Results Representatives of 76 schools (59%) responded to the survey. Of these, 73 (96%) reported their schools had VMS programs. The most common reason for having a VMS program was "recruitment for residency programs" (90%). "Desire to do a residency at our institution" was ranked as the leading reason visiting medical students choose to do electives or clerkships. In descending order, the most popular rotations were in internal medicine, orthopedic surgery, emergency medicine, and pediatrics. All VMS programs allowed fourth-year medical students, and approximately half (58%) allowed international medical students. The most common eligibility requirements were documentation of immunizations (92%), previous clinical experience (85%), and successful completion of United States Medical Licensing Examination Step 1 (51%). Of the programs that required clinical experience, 82% required 33 weeks or more. Most institutions (96%) gave priority for electives and clerkships to their own students over visiting students, and a majority (78%) reported that visiting students were evaluated no differently than their own students. During academic year 2006-2007, the number of new resident physicians who were former visiting medical students ranged widely among the responding institutions (range, 0-76). Conclusions Medical schools' leading reason for having VMS programs is recruitment into residency programs and the most commonly cited reason students participate in these programs is to secure residency positions. However, further research is needed regarding factors that determine the effectiveness of VMS programs in residency program recruitment and the development of more universal standards for VMS eligibility requirements and assessment.

Seasonal influenza causes significant morbidity and mortality in the elderly, the very young and those with chronic illness, despite the availability of effective vaccines. The mortality and morbidity attributed annually to seasonal influenza are small in comparison to the potential mortality and morbidity of a novel highly pathogenic human influenza A virus strain. The current influenza A/H5N1 virus that has caused epidemics in poultry and is evolving to find new niches needs only to become more efficiently transmitted from human to human to cause the next pandemic. Vaccination is the intervention with the potential to save the most lives when a pandemic occurs. Pandemic awareness and preparedness are essential to decrease the predicted chaos, death and illness arising from the next influenza pandemic.

At present, there are 22 FDA-approved antiretroviral agents, which are categorised into four classes of drugs. Several others are in various stages of basic and clinical development. The authors of this paper review the general characteristics of each class of antiretrovirals, as well as individual investigational agents that are in advanced clinical development. A brief synopsis of US and WHO antiretroviral treatment guidelines is also provided.

Human immunodeficiency virus (HIV) infection is increasingly becoming a disease managed by HIV specialists. However, all primary care physicians have an important role that can affect the epidemic in the United States. These physicians must be able to appropriately identify patients at risk, screen for and diagnose HIV, provide counsel, and refer those who are infected to specialists. The primary care physician will often continue to provide medical care in collaboration with an HIV specialist. The patient will receive optimal care when the primary care physician is knowledgeable regarding HIV and the evaluation of the newly diagnosed patient. Through appropriate screening, evaluation, diagnosis, and counseling, the primary care physician will not only improve the care of the individual patient but also potentially decrease the spread of HIV. This article answers some of the questions that primary care physicians are likely to have when evaluating an adult with newly diagnosed HIV infection.

We appreciate Dr Bubb's feedback. It is true that we expected an increase in the percentage of our international visiting medical students (VMSs) who apply for residency positions at our institution as a result of our VMS program's new requirements that international medical students successfully complete the US Medical Licensing Examination (USMLE) Step 1 and Test of English as a Foreign Language (TOEFL) before being considered for our VMS program. Also, as we stated in the article, a corollary reason for the new requirements was our desire to reduce “the number of elective and clerkship slots taken by VMSs who did not intend to apply for [Mayo] residency program positions” in order to make these slots available to VMSs who did.1 Like other VMS programs,2 residency recruitment is a major objective of ours. Indeed, before the new requirements, we observed that only a minority of our international VMSs applied for a Mayo residency position (82/464 [18%]). Dr Bubb states that, after the new requirements were implemented, the percentage of international VMSs who applied for Mayo Clinic residency positions “nominally decreased” (34/205 [17%]). However, this change was not statistically significant (P=.80). Dr Bubb further states that we “neglect the fact that before implementation, international students were more likely to be appointed than US students (39% vs 31%).” However, this change also was not statistically significant (P=.16). Because of the new requirements, we expected that the absolute numbers of international VMSs applying for and participating in our VMS program as well as applying for, and being appointed to, our residency programs would correspondingly decrease. We agree that our new requirements discourage international medical students who have not taken the USMLE Step 1 and TOEFL from applying to our VMS program. As a result, it is possible that some international medical students who would be competitive for our residency programs will not visit our campus or participate in our VMS program. Notably, during 2009, 75 international VMSs participated in our VMS program, of which 32 (43%) applied for Mayo residency program positions and 11 (34%) were appointed to Mayo residency program positions. We are encouraged by these statistics that argue against Dr Bubb's concern that the new requirements adversely affect the culture of our VMS program and that international VMSs “concluded that the environment was not optimal for their educational needs.” Nevertheless, the effects of the USMLE Step 1 and TOEFL requirements deserve ongoing monitoring. Overall, we remain steadfast in our desire to attract the best and brightest international VMSs to participate in the Mayo VMS Program and recruit these students to our residency programs.

Preface.- Foreword.- Part I: Overview Chapters-Behavioral Interventions.- History of Behavioral Interventions in STD Control.- Behavioral Interventions for Sexually Transmitted Diseases: Theoretical.- Models and Intervention Methods.- Biomedical Interventions.- Part II: Intervention Approaches.- Dyadic, Small Group and Community-Level Behavioral Interventions for STD/HIV Prevention.- Structural Interventions.- STD Prevention Communication: Using Social Marketing Techniques with an Eye on Behavioral Change.- Partner Notification and Management Interventions.- Interventions in Sexual Health Care Seeking and Provision at Multiple Levels of the U.S. Health Care System.- Use of the Internet in STD/HIV Prevention.- Male Condoms.- STI Vaccines: Status of Development, Potential Impact, and Important Factors for Implementation.- Part III: Interventions by Population.- Behavioral Interventions for Prevention and Control of STDs Among Adolescents.- Biological and Behavioral Risk Factors Associated with STDs/HIV in Women-Implications for Behavioral Interventions.- STD Prevention for Men Who Have Sex with Men in the United States.- STD Repeaters: Implications for the Individual and STD Transmission in a Population.- Looking Inside and Affecting the Outside: Corrections-based Interventions for STD Prevention.- Sexually Transmitted Diseases Among Illicit Drug Users in the United States: The Need for Interventions.- Part IV: Understanding Methods.- Quantitative Measurement.- Qualitative Measurement.- From Data to Action: Integrating Program Evaluation and Program Improvement.- Cost Effectiveness Analysis.- From Best Practices to Better Practice: Adopting Model Behavioral Interventions in the Real World of STD/HIV Prevention.- Part V: Ethical and Policy Issues.- The Ethics of Public Health Practice for the Prevention and Control of Sexually Transmitted Diseases.- Policy and Behavioral Interventions for STDs.