Category Archives: Clinical Updates

Screening for Hepatitis C

Test tube stock image from CDC

The following information is summarized from the article “Hepatitis C Information for Professionals” from the Center for Disease Control and Prevention 2015.

In the US there are approximately 3.2 million people with chronic Hepatitis C (HCV) infections, with a large number of patients unaware of their infected status. 60-70% of patients infected with Hepatitis C are asymptomatic or have mild illness at time of infection. It can take approximately 1-3 weeks after exposure before HCV RNA can be detected and 8-9 weeks before Hepatitis C antibody (HCV Ab) can be detected by clinical laboratory testing. 97% of patients infected with Hepatitis C will be HCV Ab+ within 6 months of exposure. Of those acutely infected with Hepatitis C, 70-85% will develop chronic HCV infections. With several new treatments for chronic Hepatitis C infections now available, there is a renewed emphasis on screening. According to CDC recommendations, Screening for Hepatitis C should start with a serum test for HCV Ab. Patients that test positive for HCV Ab should be subsequently tested for HCV RNA to differentiate between those exposed to Hepatitis C and those that are currently infected. Screening recommendations for specific populations are listed below.

Screening is Recommended

  • Adults born between 1945-1965 regardless of risk factors

  • Current IV drug users

  • Patients with history of IV drug use

  • Patients with certain medical conditions: Hemodialysis, elevated ALT of unknown origin, HIV

  • Recipients of blood transfusions or organ transplantation prior to July 1992

  • Recipients of clotting factors prior to 1987

  • Recognized Exposures: Needle sticks from HCV+ patient, Infants with HCV+ mothers. These patients with potential exposures within last 6 months, testing for HCV RNA or follow-up testing for HCV Ab >6 months after potential exposure is recommended.

Need for Screening uncertain

  • Tissue transplants (cornea, skin grafts, sperm/ova)

  • Non IV, drug users

  • Tattoos or body piercings

  • History of multiple sex partners or STDS

  • Steady sex partners of HCV+ individuals

Routine Screening Not Recommended

  • Healthcare workers without potential exposure history

  • Pregnant women

  • Non sexual household contacts of HCV+ individuals

  • General Population

Guidelines for the Use of Daily Aspirin for the Primary Prevention of Myocardial Infarction in Men and Cerebral Vascular Disease in Women

By Farah Kaiksow

The following information is summarized from the USPSTF March 2009 publication. Please note, the USPSTF is currently in the process of updating this publication.

  • Daily low-dose aspirin decreases the risk of myocardial infarction in men aged 45-79 years, but not in women.

  • Daily low-dose aspirin decreases the risk of ischemic cerebrovascular disease in women aged 55 to 79 years, but not in men.

  • Primary Care Physicians should recommend daily aspirin for men and women in the above age groups if their calculated risk of MI or ischemic CVD, respectively, outweighs their risk of gastrointestinal hemorrhage.

Population

Men
Age 45-79 Years

Women
Age 55-79 Years

Women
Age 55-79 Years

Women
Age 55-79 Years

Men and Women Over 80 Years

Recommendation

Encourage aspirin use when potential CVD benefit (MIs prevented) outweighs potential harm of GI hemorrhage.

Encourage aspirin use when potential CVD benefit (strokes prevented) outweighs potential harm of GI hemorrhage.

Do not encourage aspirin use for MI prevention.

Do not encourage aspirin use for stroke prevention.

No Recommendation

Grade

A

(High certainty that the net benefit is substantial.)

D

(Moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.)

I

(Insufficient Evidence)

For patients who do not take NSAIDs regularly and do not have a history of GI bleed or ulcers, the table below should be used to determine if the benefits of aspirin outweigh the risks of GI side effects.

10-year CHD risk for Men

10-year stroke risk for Women

Age 45-59 years

≥4%

Age 45-59 years

≥3%

Age 60-69 years

≥9%

Age 60-69 years

≥8%

Age 70-79 years

≥12%

Age 70-79 years

≥11%

Primary Care Physicians should use the following calculators to determine their patients’ 10-year risk of CHD or ischemic stroke:

  • Men (CHD)

  • Women (stroke)

Please note, the original stroke risk calculator (Western States Consortium) cited by the USPSTF is no longer available.

For patients who do take NSAIDs regularly or have a history of GI bleed or ulcers, Primary Care Physicians should carefully weigh the risks and benefits of daily aspirin as it more than doubles a patient’s risk of GI bleed or ulcer.

Clinical Update: Guidelines for Pneumonia Vaccinations in Adult Patients

By Farah Kaiksow, MD, MPP

The following information is summarized from the CDC’s Advisory Committee on Immunization Practices February 2015 publication.

Two pneumonia vaccines currently available for adults:

    • the newer 13-valent pneumoccocal conjugate vaccine (PCV13) which covers additional strains not included in the original PPSV23

    • and the 23-valent pneumococcal conjugate polysaccharide vaccine (PPSV23, also known as Pneumovax23).

    If your patient is 65 years or older and:

    • Has never received any pneumonia vaccine

    • Administer PCV13 first, followed in six to twelve months by PPSV23.

    • Has received PPSV23:

    • Administer 1 dose of PCV13 at least one year after PPSV23 was given.

    • Has received at least one dose of PPSV23 before the age of 65:

    • Administer PCV13 at least one year after PPSV23 was given, followed by another dose of PPSV23 six to twelve months after PCV13 was given and at least five years after the first dose of PPSV23 was given.

    • Has received PCV13 and not PPSV23 before the age of 65:

    • Administer PPSV23 at least six to twelve months after PCV13 was given.

    • Has received both PCV13 and at least one dose of PPSV23 before the age of 65:

    • Administer PPSV23 at least six to twelve months after PCV13 was given and at least five years after the first dose of PPSV23 was given.

    If your patient is 19 to 64 years and has one of the following conditions: congenital or acquired immunodeficiency, leukemia, multiple myeloma, congenital or acquired asplenia, HIV infection, lymphoma, solid organ transplant, splenic dysfunction, chronic renal failure, Hodgkin’s disease, iatrogenic immunosuppression, splenectomy, nephrotic syndrome, generalized malignancy, sickle cell disease or other hemoglobinopathies and:

    • Has never received any pneumonia vaccine:

    • Administer PCV13 first, followed in eight weeks by PPSV23, followed at least five years later by a second dose of PPSV23.

    • Has received at least one dose of PPSV23:

    • Administer PCV13 at least one year after PPSV23 was given, followed by another dose of PPSV23 at least eight weeks after PCV13 and at least five years after the first dose of PPSV23.

    • Has received two doses of PPSV23:

    • Administer PCV13 at least one year after the most recent PPSV23 was given.

    • Has received PCV13 and not PPSV23:

    • Administer PPSV23 at least eight weeks after PCV13 was given, followed with another dose of PPSV23 at least five years later.

    • Has received both PCV13 and only one dose of PPSV23:


    • Administer another dose of PPSV23 at least five years after the first dose was given.

    If your patient is 19 to 64 years old and has: chronic heart disease (including chronic heart failure and cardiomyopathies, but excluding hypertension), chronic lung disease (including COPD, ephysema, and asthma), chronic liver disease (including cirrhosis), diabetes mellitus, alcoholism, cigarette use, or lives in a nursing home or other long-term care facility:

    • Administer one dose of PPSV23.

    If your patient is 19 to 64 years old and has cerebrospinal fluid leaks or cochlear implants:

    • Administer PCV13, followed in eight weeks by PPSV23.

About the 504HealthNet & Tulane Internal Medicine Residency Program Clinical Update

Dear Friends and Colleagues,

504HealthNet and the Tulane Internal Medicine Residency Program are pleased to present you with the first quarterly Clinical Care Newsletter. 504HealthNet is a non-profit organization that represents the outpatient safety net providers for the Greater New Orleans area. Through work with member organizations like the Tulane Drop-in Center, Tulane/Ruth Fertel Clinic, and the UMC primary care clinics, 504HealthNet strives to ensure that everyone in the community has access to high quality primary care and behavioral health services.

In primary care settings it is often difficult to keep up on the most current guidelines. This newsletter seeks to distill some of the most useful articles that internal medicine/primary care track residents at the Tulane Internal Medicine Residency Program have found to improve their practice and the practice of their peers and mentors. Keeping providers at all levels informed about the latest advancements and updates in health care best practices is important to both Tulane and 504HealthNet, which is why we are creating this quarterly publication.

Topics for this issue focus on guidelines for daily aspirin use, screenings for diabetic neuropathy and Hepatitis C, and updates on recommendations for the different pneumonia vaccines.

It is our hope that this newsletter will be helpful for providers’ continued practice, and that you are able to go forward and care for those who need it most. To sign up for the electronic version please visit 504HealthNet.org.

Sincerely,

Susan Todd, MPAff
Executive Director
504HealthNet

Anjali Niyogi, MD, MPH
Assistant Professor, Department of Internal Medicine and Pediatrics
Tulane University School of Medicine