General Health Issues

1
General Health Issues

• Ellis Frazier MD
• Family Healthcare Inc.
• 1049 Western Avenue
• Chillicothe, Ohio 45601
• mrdatafrazier_at_yahoo.com
• Portsmouth City Health Department Primary Care
  Clinic
• 605 Washington Street, 2nd Floor
• Portsmouth, Ohio 45662
• 740-353-8863, Ext. 241
• efrazier_at_odh.ohio.gov

2
Positive Life Style Changes

• Exercise
• Adequate Sleep
• Stress Reduction
• Stopping Smoking
• Limited Alcohol Drinking
• No Recreational Drugs
• Eating right
• Having supportive family/friends/pets
• Adherence to Antiretroviral Regimen

3
Primary Care Issues in HIV Care
4
Disclosures

• 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 Its all about the
  patient/client/customer.
• I am not Carey Dodrills or Julie Carvers
  lesser half Weve 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.

5
Objectives

• 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.

6
We as Primary care providers should at least

• 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.

7
Although a nice model it does not always work out
the best
8
Do you know how your providers communicate?

• 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?

9
Remember and promote this ONE message

• 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.

10
Role of the Primary Care Physician

• 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, PennsylvaniaEditorial Who
  should care for Patients with HIV/AIDS?

11
General Routine Exam and Timelines when they
should be done
12
General Routine Exam and Timelines when they
should be done
13
(No Transcript)
14
How much water should I drink each day

• 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

15
Is Diet Soda Bad for you

• 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.,

16
Does everyone need 7-8 hours of sleep

• there is "no magic number" for your sleep.
• There are two different factors that researchers
  are learning about a persons 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.

17
How much sleep does a person need?

• 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

18
Peggy Sue

• 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

19
What the things we want to do for this patient

• 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 didnt 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.

20
Certain illnesses are hard to distinguish so
further testing is necessary

• Anemia--fatigue
• Thyroid Disease--fatigue
• Depression--fatigue
• Substance Use--fatigue

21
Bobby Joe

• 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. Its Sunday (no work today) so his ID
  doctor office is closed and he doesnt want to go
  to the ER because he is afraid that his
  medications might be adjusted and he doesnt 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.

22
(No Transcript)
23
More on BJ

• 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

24
Ramona

• 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.

25
Some recent updates on HIV and heart disease risks

• 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!

26
Cholesterol

• 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 LevelCategory 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

27
Blood Glucose

• The American Diabetes Association acknowledges
  these as normal blood sugar for healthy people
  who do not have diabetes fasting/before eating lt
  100 mg/dl
• bedtime 120 mg/dl
• A1c blood sugar test (3 month blood sugar
  indicator)      lt6
• 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) lt180 mg/dl
• A1c blood sugar test (3 month blood sugar
  indicator)     lt7
• 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)     lt6.5

28
Quickies

• HIVAN?HIV associated nephropathy
• STD Testing
• Depression? The great mimicker

29
Other cardiovascular risk factors

• Triglyceride Level Category Less than 150 mg/dL
  Normal
• 150199 mg/dL Borderline high
• 200499 mg/dL High
• 500 mg/dL and above Very high

30
Cigarette smoking is the most important
modifiable cardiovascular risk factor among
HIV-infected patients.
31
Marion

• 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 dont 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??? Whats the problem here??

32
Resources www.aahiv.org www.aidsinfonet.org www.ai
dsinfo.nih.gov www.iasociety.org www.nrharural.org
www.aids-ed.org www.aids.gov www.aidsetc.org www.
aidsmeds.com www.thebody.com
33

• AIDS Education and Training Center
• Clinical Manual for Management of the
  HIV-Infected Adult
• www.aids-ed.org

34
A better way of approach to caring for people
35
Despite what I said We need your help

• 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.