Download General Health Issues

Ellis Frazier MD
Family Healthcare Inc.
1049 Western Avenue
Chillicothe, Ohio 45601
[email protected]
&
Portsmouth City Health Department Primary Care Clinic
605 Washington Street, 2nd Floor
Portsmouth, Ohio 45662
740-353-8863, Ext. 241
[email protected]
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Exercise
Adequate Sleep
Stress Reduction
Stopping Smoking
Limited Alcohol Drinking
No Recreational Drugs
Eating right
Having supportive family/friends/pets
Adherence to Antiretroviral Regimen
I have no specific affiliation with any pharmaceutical company.
I am a primary care FP with almost 2 decades of experience of treating individuals living with
HIV and/or AIDS
I am here to provide some education and insight to the issues of routine health care of
individuals with HIV disease. Please try to listen, ask questions and remember to do the same
with anyone who is providing care to you (infectious disease clinician, internist, nurse,
pharmacist, mental health counselor and case manager). After listening ask questions to make
sure you understand what was discussed and to ensure you are involved actively in you health
care plan. Remember “It’s all about the patient/client/customer”.
I am not Carey Dodrill’s or Julie Carver’s lesser half– We’ve decided I am the good looking one
I will not be showing any nude photos of Kevin Sullivan or Michael McDonald in this
presentation . The individuals we will discuss are fictitious characters.
Participant will understand the role of several routine health
screening.
Participant will understand the importance of bilateral
communication with their healthcare provider(s).
The role of self-management will be reviewed. This is
different than “Self-Medicate”.
The importance of mental health care and dental health care
for HIV infected individuals.
Provide universal HIV screening
Counsel patients on prevention of HIV transmission
Counsel on risk reduction measures
Provide basic monitoring of labs and routine healthcare
services including health screening, immunizations, and
prophylaxis along with other primary care support
services that all patients should be entitled to based on age
appropriate guidelines of care.
Do your providers even know each other?
Do your providers send letters to each other or fax notes from
office visits?
Do they send copies of laboratory studies to each other?
Do they even know that you are seeing another specialist?
Whose responsibility is it to coordinate this?? Case manager?
Patient? Primary Care Provider? Husband? Wife?
Significant other?
The CDC has called for routine, voluntary HIV
screening of all patients aged 13-64 in all health care
settings. The agency issued:
“Revised Recommendations for HIV Testing of
Adults, Adolescents and Pregnant Women in Health
Care Settings"
in the Sept. 22, 2006 issue of Morbidity and Mortality
Weekly Report.
With 40,000 people becoming infected each year and with HIV+
patients living longer, there is definitely a need for more physicians to
assume the primary care and specialty care of these patients.
About One half of the HIV sub specialists in the US have been trained in
family or internal medicine.
HIV/AIDS is now considered “A chronic, manageable disease”,
perhaps not unlike diabetes, hypertension, or hyperlipidemia.
Jeffery Kirschner, D.O.
Medical director of the Comprehensive Care Clinic at Lancaster General Hospital, Lancaster, Pennsylvania—Editorial “Who should
care for Patients with HIV/AIDS?”
Exam
Timeline
Complete history
Update annually
Risk Assessment– smoking,
ETOH, illicit drug use, sexual
activity, domestic violence,
support systems
Update annually & brief risk
assessment at each visit for ongoing
appropriate screening & risk
reduction counseling
Complete physical exam
Annually
Vision
Annually by eye care specialist,
every 6 months with CD4 <100
Dental Exam
Every 6 months
Coronary Heart Disease Screen1
If applicable
Breast/Testicular Exam
Annually with physical
Mammogram
Annually after 40 y/o
Pap Smear/Pelvic Exam2
Every 6 months (annually after 2
consecutive negative Pap smears)
Discussion regarding HRT3
Perimenopausal women
Digital Rectal Exam/ PSA
Annually after 50 y/o, 45 y/o with
Exam
Timeline
Anal Pap Smear
Consider annually with h/o anal
receptive sex or HPV
Colon Cancer Screening5
Annually after 50 y/o
Screening for Osteoporosis
Consider in all patients on long-term
ARV especially in postmenopausal
women and men with
hypogonadism
STD /Hepatitis C Screen
Annually & as needed
Fasting Lipids
Annually after 35 y/o if not on ART,
every 6 months on ART
PPD
Annually, every 6 months for high
risk
Immunizations (Hepatitis A & B,
Pneumovax, Td, influenza,
Varicella)
See CDC guidelines
Depression Screen
Annually & as needed
Diet & Exercise
Every 6 months
Vaccine Type
Recommendation
Pneumococcal (polysaccharide)
Recommended for all; consider revaccination every 5 years.
If CD4 count is <200 cells/µL, may be less effective; revaccinate when
CD4 count increases in response to ART.
Hepatitis A Virus (HAV)
Recommended, for persons with chronic hepatitis C or hepatitis B,
injection drug users, men who have sex with men, international
travelers, and hemophiliacs. Consider for all, unless there is serologic
evidence of previous disease.
2 doses (0, 6-12 months)
Hepatitis B Virus (HBV)
Recommended, unless there is evidence of immunity (HBV surface
Ab+) or active hepatitis B infection (HBV surface Ag+, or HBV core Ab+
and evidence of HBV activity).
3 doses (0, 1-2, 4-6 months)
Influenza (inactivated vaccine)
Recommended (yearly)
Vaccination is most effective among persons with CD4 count >100
cells/µL and HIV RNA <30,000 copies/mL.
In patients with advanced disease and low CD4 cell count, inactivated
vaccine may not produce protective antibodies.
Live, attenuated cold-adapted vaccine (LAIV, FluMist) is
contraindicated in patients with HIV infection.
Tetanus-Diphtheria
Recommended (booster is recommended every 10 years in adults; or, if
injured, after 5 years)
Measles, Mumps, Rubella (MMR)
Recommended if indicated (eg, if contact with measles is likely through
travel or other exposures). For live vaccine, use caution in those with
low CD4 counts.
Consider for all susceptible people who are not severely
immunosupressed.*
Contraindicated in severe immunosuppression.
Varicella Zoster (VZV)**
Consider for asymptomatic patients with relatively high CD4 counts, if
they have no history of chickenpox and no evidence of immunity or
significant exposure.
Avoid in patients with advanced immunosuppression.
Avoid exposure to VZV, if possible. If someone without immunity to
VZV is exposed to VZV, administer VZIG as soon as possible, at least
within 96 hours.
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Replacement approach. The average urine output for adults is 1.5
liters a day. You lose close to an additional liter of water a day
through breathing, sweating and bowel movements. Food usually
accounts for 20 percent of your total fluid intake, so if you consume
2 liters of water or other beverages a day (a little more than 8 cups)
along with your normal diet, you will typically replace the lost
fluids.
Dietary recommendations. The Institute of Medicine advises that
men consume roughly 3.0 liters (about 13 cups) of total beverages a
day and women consume 2.2 liters (about 9 cups) of total beverages
a day.
Even apart from the above approaches, it is generally the case that if
you drink enough fluid so that you rarely feel thirsty and produce
between one and two liters of colorless or slightly yellow urine a
day, your fluid intake is probably adequate.
Mayo Clinic Report
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Drinking a reasonable amount of diet soda a day, such as a can
or two, isn't likely to hurt you. The artificial sweeteners and
other chemicals used in diet soda are safe for most people, and
there's no evidence that these ingredients cause cancer. Some
types of diet soda are even fortified with vitamins and
minerals. But diet soda isn't a health drink or a cure for weight
loss. Although switching from regular soda to diet soda will
save you calories, some studies suggest that drinking soda of
any type leads to obesity and other health problems. And
healthier choices abound. Start your day with a small glass of
100-percent fruit juice. Drink skim milk with meals. Sip water
throughout the day. For variety, try sparkling water or enjoy a
squirt of lemon or cranberry juice in your water. Save diet soda
for an occasional treat.
Mayo Clinic dietitian Katherine Zeratsky, R.D., L.D.,
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there is "no magic number" for your sleep.
There are two different factors that researchers are
learning about: a person’s basal sleep need – the amount
of sleep our bodies need on a regular basis for optimal
performance – and sleep debt, the accumulated sleep that
is lost to poor sleep habits, sickness, awakenings due to
environmental factors or other causes.
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one thing sleep research certainly has shown is that sleeping too
little can not only inhibit your productivity and ability to remember
and consolidate information, but lack of sleep can also lead to
serious health consequences and jeopardize your safety and the
safety of individuals around you.
For example, short sleep duration is linked with:
* Increased risk of motor vehicle accidents
* Increase in body mass index – a greater likelihood of obesity due
to an increased appetite caused by sleep deprivation
* Increased risk of diabetes and heart problems
* Increased risk for psychiatric conditions including depression and
substance abuse
* Decreased ability to pay attention, react to signals or remember
new information. National Sleep Foundation
PS is a 55 year old HIV+ female who recently lost her job as a school teacher . She
worked for nearly 30 years in the same school district . She began having problems
with increasing fatigue, weakness, irritability. She has missed several weeks of work
due to her symptoms. She was asked to resign from her job using.
She comes to see you and she reports these same symptoms. She denies any recent
exposure to health hazards. She has been HIV+ for 12 years and had been seeing her
regular ID doctor on a routine basis and reports that she has had no change in her
medication regimen and that her CD4 levels have been over 500 for over 4 years and
her Viral load has been undetectable for just as long. She does state she has missed the
last couple of appointments due to not wanting to miss any other days of work.
She has not traveled outside the US in a long time.
She does report tearfulness and problems with sleeping yet she always feels tired. She
attributes this to having gained 40 pounds over the last six months She is concerned
that her periods have been heavier than usual and have been occurring more frequently
(every month and lasting 3 weeks). She has been drinking 2-3 beer at night to help her
get to sleep
Ask more questions
Last GYN exam
Last time she actually did do blood work
Last hemoglobin
Ask about Diet
Ask about Family History
Thyroid Disease
Anemia
Depression
Cancer
Diabetes
Heart Disease
The PS reports that she has not had a PAP smear in 5 years because she hated the fact that she
always has to have a repeat because they have been abnormal due to previous infection with
HPV. She was told also she may need to have surgery. She didn’t want this. She admits to
being upset and depressed about because she missed the appointment that her ID doctor ‘s staff
made for her to see the GYN they told her she may need to have an endometrial biopsy.
Her hemoglobin was 8.0 which is low and her iron levels were low. Thyroid testing was normal.
Anemia--fatigue
Thyroid Disease--fatigue
Depression--fatigue
Substance Use--fatigue
26 year old single father of 2 construction worker who has been HIV+ for 2 years
reports to you he has been doing well except for family problems due to finances. He
is adherent to medications 100% of the time yet is frequently ill due to allergies,
recurrent sinus infections and headaches, problems with sleep and fatigue. He has not
had time or money to do the annual eye exam or semi-annual dental exam that his ID
doctor wanted him to keep up with.
He works hard his only vice is his smoking habit of 1-2 packs of cigarettes per day and
drinks ½ pot of coffee each day to get started with his day.
BJ has had several days when he worked in pain due to congestion, headache and even
having a fever. It’s Sunday (no work today) so his ID doctor office is closed and he
doesn’t want to go to the ER because he is afraid that his medications might be
adjusted and he doesn’t want this. Nor does he want to be admitted to the hospital and
have testing done because he cannot afford this. His children guilt him into going to
the Urgent care where he has a temp. of 99.9, he has treated and released being told to
complete the antibiotics, allergy medications, and to get more rest. He was strongly
urged to stop smoking, decrease his caffeine intake and to see a dentist.
So what are the issues here with BJ
Acute illness
Sinuses
Allergies
Fatigue
Chronic Problems
Sinus infection
Fatigue
Stressors- financial, being ill, responsibilities
Caffeine
Nicotine
Dental Disease
65 year old HIV+ female scheduled for her routine visit yet says she has to cancel
because she has been very ill. She has been doing well with her HIV medications
(antiretroviral), has not kept track of her sugars like we wanted because she would then
have to use the Insulin more and she just wants to keep on the pills. If she feels really
bad she will give herself a random dose of Insulin to keep from having a high “sugar
attack”
She did not get the last set of blood work that was asked for because her HIV labs
have been okay and she felt that I was just trying to put her on more medications
because she not been adhering to her diet and she knows her cholesterol will be higher
than the 325 level it was 6 months ago.
She denies diarrhea but is having night sweats. She missed the mammogram
appointment and also did not get her bone density study done. She did get her flu shot
last fall. She did promise to reschedule. Her main concern is that she is getting more
fatigued, short of breath and feels she needs some vitamins because she cannot even
vacuum her floors without getting short winded. She know that her 1 ½ -2 ppd
cigarette habit contributes to this shortness of breath.
The DAD trial 23,437 HIV-infected patients, most of whom were treated in
Europe, 345 developed myocardial infarction (MI) during 94,469 person-years of
observation. Overall, in a multivariate model, potent combination antiretroviral therapy
increased the risk for MI by 16% per year of exposure, compared with no treatment.
Although these findings certainly point to HIV treatment — and PI use in particular —
as risk factors for MI, we as clinicians must not infer that a "silent epidemic" of
cardiovascular disease exists that somehow negates the hugely beneficial effect of HIV
treatment overall. As nicely summarized by editorialists, the overall effect of
antiretroviral therapy on MI risk was quite small.
The surprising results from the SMART study, showing an increase in cardiovascular
events related to treatment interruption (ACC Nov 29 2006), suggest that the most
dangerous clinical state for the overall health of our patients is being off treatment
entirely — and, of course, smoking cigarettes!
Total Cholesterol Level Category Less than 200 mg/dL
Desirable level that puts you at lower risk for coronary heart disease. A cholesterol level of 200
mg/dL or higher raises your risk. 200 to 239 mg/dL Borderline high 240 mg/dL and above
High blood cholesterol. A person with this level has more than twice the risk of coronary heart
disease as someone whose cholesterol is below 200 mg/d
HDL Cholesterol Level
Category Less than 40 mg/dL (for men) Less than 50 mg/dL (for women)
Low HDL cholesterol.
A major risk factor for heart disease. 60 mg/dL and above
High HDL cholesterol.
An HDL of 60 mg/dL and above is considered protective against heart disease.
LDL Cholesterol Level Category Less than 100 mg/dL Optimal
100 to 129 mg/dL
Near or above optimal 130 to 159 mg/dL
Borderline high 160 to 189 mg/dL
High 190 mg/dL and above Very high
The American Diabetes Association acknowledges these as normal blood sugar for healthy
people who do not have diabetes: fasting/before eating < 100 mg/dl
bedtime 120 mg/dl
A1c blood sugar test (3 month blood sugar indicator)
<6%
What does the American Diabetes Association recommend for those with diabetes?
The American Diabetes Association recommends the following blood sugar goals for those with
diabetes:
before eating (pre-prandial plasma glucose) 90-130 mg/dl
1-2 hours after the beginning of eating (peak post-prandial plasma glucose) <180 mg/dl
A1c blood sugar test (3 month blood sugar indicator) <7%
What do other organizations recommend for blood sugar goals?
The American Association of Clinical Endocrinologists (endocrinologists are medical doctors
specializing in disorders including diabetes) recommends the following blood sugar goals for
those with diabetes: before eating (pre-prandial) 110 mg/dl
2 hours after eating (post-prandial) 140 mg/dl
A1c blood sugar test (3 month blood sugar indicator) <6.5%
HIVANHIV associated nephropathy
STD Testing
Depression The great mimicker
Triglyceride Level Category Less than 150 mg/dL Normal
150–199 mg/dL Borderline high
200–499 mg/dL High
500 mg/dL and above Very high
“Cigarette smoking is the
most important modifiable
cardiovascular risk factor
among HIV-infected
patients.”
Marion is a 46 year old HIV+ male with bipolar disorder who is brought in to see you
by his partner and ex-wife who both don’t know what to do with him he has stopped
taking his medications for his HIV and for his bipolar disorder. He has just spent
$32,000 of his recent disability settlement (on an internet investment project– a High
rise condominium complex in Wellston Ohio).
He has not slept in days and despite their lack of caring for each other the partner and
ex-wife want to know what to do to get him on his medications. They are both worried
that he will develop resistance to his medications and that he will need to change to
another regimen.
The patient is insisting on writing down details of “how you can improve your patient
flow efficiency and suggests you let him be your office manager”
What do you do??? What’s the problem here??
Resources
www.aahiv.org
www.aidsinfonet.org
www.aidsinfo.nih.gov
www.iasociety.org
www.nrharural.org
www.aids-ed.org
www.aids.gov
www.aidsetc.org
www.aidsmeds.com
www.thebody.com
AIDS Education and Training Center
Clinical Manual for Management of the HIV-Infected Adult
www.aids-ed.org
Research suggests that primary care
physicians do not routinely perform risk
assessments for HIV infection, often missing
clinically important risk behaviors and
failing to include HIV infection in the
differential diagnosis.