Blog Updates on Hepatitis - Inactivated Zoster Vaccine, Harvoni Cures Hep C patient & Opioids

Thanks for stopping by, here's your blog updates from around the web.

Harvoni Cures Hep C patient Brenda in Clinical Trial part 1

September 19, 2017

This week on Life Beyond Hep C we’re hearing Hep C patient Brenda’s courageous Hep C treatment fight and experience.

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All Swiss hepatitis C sufferers can access costly drugs like Harvoni

swissinfo.ch

All patients suffering from hepatitis C can be treated with the drugs Harvoni and Epclusa from next month, after the Federal Office of Public Health lifted ...

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Opioid overdoses shorten US life expectancy by 2½ months

By Nadia Kounang, CNN

Opioid drugs -- including both legally prescribed painkillers such as oxycodone and hydrocodone, as well as illegal drugs such as heroin or illicit fentanyl -- are not only killing Americans, they are shortening their overall life spans. Opioids take about 2½ months off our lives, according to a new analysis published in the medical journal JAMA.

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States expand investigation of opioid makers, distributors
Geoff Mulvihill, Associated Press - Houston Chronicle
Attorneys general from most states are broadening their investigation into the opioid industry as a nationwide overdose crisis continues to claim thousands of lives. They announced Tuesday that they had served subpoenas requesting information from five companies that make powerful prescription painkillers and demanded information from three distributors. Forty-one attorneys general are involved in various parts of the civil investigation.

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Addiction clinics need physician education, lifted restrictions to treat HCV

HCV Next - HEALIO - Meeting News
Opioid agonist therapy clinics represent an important conduit for people who inject drugs to receive information, screening and treatment for hepatitis C. Within these clinics, however, physicians and addiction specialists self-reported low competence regarding current HCV treatments. Additionally, policies that restrict treatment for current and recent drug users present an ongoing barrier.
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My 2 cents: College friend doing good work

Written by Karen Shuey - Staff Writer For Reading Eagle.

The proposal in Philadelphia would be modeled on a supervised injection center in Vancouver, British Columbia, called Insite that has showed tremendous promise over the last 14 years. Statistics show Insite has saved lives, proponents say, reversing nearly 5,000 overdoses since 2003, with no deaths. At the same time, studies show the center has prevented the spread of diseases such as HIV and hepatitis C and reduced dangerous litter, including needles strewn on local streets.
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Ontario study to lift six-month-sober rule for liver transplant patients

Tom Blackwell - National Post 

Faced with a widow's legal challenge, Ontario will transplant livers into almost 100 alcoholic-liver-disease patients, as evidence suggests they do as well as others.

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What parents should know about tattoos

Posted September 19, 2017,
Claire McCarthy, MD, Faculty Editor, Harvard Health Publications
These days, tattoos are increasingly common. According to a 2015 Harris poll, three in 10 American adults have a tattoo — up from two in 10 in 2012. They are particularly popular in young people; among Millennials, nearly half have a tattoo. To help parents make this tough decision, the American Academy of Pediatrics (AAP) released a clinical report entitled “Adolescent and Young Adult Tattooing, Piercing, and Scarification.” Here are some highlights — and some points parents and teens really need to talk about.
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Fighting Hepatitis in Cambodia: Beginnings and Endings
Theresa Chan - Theresa is an MSF doctor, currently working at a hepatitis C clinic in Cambodia.
Beginnings and endings have been leaking into my to-do list as well. Right now I’m working on writing the MSF guidelines for treating hepatitis C, which will be the basis for the Cambodian national guidelines one day when our clinic is turned over to the Ministry of Health, so even as we are recovering from the busy beginning of this clinic, we are contemplating its end.
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Inactivated Zoster Vaccine Soon to Be Approved — Should Patients Wait for It?
Paul E. Sax, MD - Contributing Editor NEJM Journal Watch 
For the last year or so, conversations with patients about getting the zoster vaccine have gone something like this:

Patient: So should I get the shingles vaccine? I saw an ad for it on TV.
Me:  Well, yes … and no.
Patient (confused — he/she has never heard me say anything but an enthusiastic “Yes!” to vaccines):  What does that mean?
Me:  There’s a better shingles vaccine coming soon, likely within a year. So I’d wait.

Now it looks like that wait is almost over.
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Can Restricting Fructose Intake Reduce Fatty Liver Disease in Children?
Kristine Novak - Dr. Kristine Novak is the science editor for Gastroenterology and Clinical Gastroenterology and Hepatology.
Reducing dietary fructose for as little as 9 days decreases liver fat, visceral fat, and de novo lipogenesis and increases insulin sensitivity, secretion, and clearance in children with obesity and metabolic syndrome, researchers report in the September issue of Gastroenterology. These findings support efforts to reduce sugar consumption.
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Only One-Quarter of Hepatitis C Patients Got Treatment Before Widespread DAA Use

SEPTEMBER 19, 2017

Gail Connor Roche - MD Magazine

Only one-quarter of patients worldwide with the chronic hepatitis C virus (HCV) received antiviral treatment before the widespread use of direct-acting antiviral (DAA) drugs, a review that considered almost 500,000 people has found.

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Adolescents With HCV Achieve 98% Cure Rate in Direct-Acting Antiviral Study
Gail Connor Roche - MD Magazine
Adolescents treated for hepatitis C achieved a 98% cure rate with a direct-acting antiviral drug (DAA) therapy, a study has found.
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HCV Drug Resistance: Infrequent, and Frequently Overcome
Kenneth Bender - MD Magazine
Hepatitis C virus (HCV) mutations that can resist drug treatment are infrequent, and are unlikely to withstand longer treatment durations or the addition of a synergistic drug, according to new analysis of resistance testing, treatment response and re-treatment interventions. Resistance testing does appear to Wyles and Luetkemeyer to be indicated, however, in patients with genotype 1a before treatment with elbasvir/grazoprevir (Zepatier, Merck), and should be considered prior to treatment with ledipasvir/sofosbuvir (Harvoni) for those with genotype 1a and cirrhosis or with prior NS5A treatment failure...
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Hepatitis A: frequently asked questions

Paul Sisson Contact Reporter The San Diego Union-Tribune

In an effort to combat a deadly hepatitis A outbreak, San Diego will begin washing streets in ...

Q: If I've had hepatitis B or hepatitis C am I immune to hepatitis A?

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Cannabis in Gastroenterology: Physicians Lack Answers as Patient Interest Peaks
Healio Gastroenterology, September 2017
Despite a lack of high quality evidence due to federal regulations on research, many state medical marijuana programs have designated GI conditions like severe nausea, inflammatory bowel disease (IBD) and hepatitis C as qualifying conditions, and studies show that many patients are self-medicating with marijuana. Experts agreed physicians should equip themselves to explain the known risks and benefits to inquiring patients, and understand the legal frameworks of their state medical marijuana programs.

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On Twitter
Tweeted By Don Crocock, Follow here--->  @dcrocock   
Rationale for cannabis-based interventions in the opioid overdose crisis
Harm Reduction Journal https://doi.org/10.1186/s12954-017-0183-9

Published: 18 August 2017

The growing body of research supporting the medical use of cannabis as an adjunct or substitute for opioids creates an evidence-based rationale for governments, health care providers, and academic researchers to consider the implementation and assessment of cannabis-based interventions in the opioid crisis.
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FDA - Inks Used in Certain Tattoo Kits Cause Infections

This article appears on FDA's Consumer Updates page, which features the latest on all FDA-regulated products.

Inks Used in Certain Tattoo Kits Cause Infections

Tempted to get a tattoo? Today, people from all walks of life have tattoos, which might lead you to believe that tattoos are completely safe.

But beware—there may be associated health risks.

Recently, the Food and Drug Administration (FDA) became aware of a problem after testing inks in home use tattoo kits marketed by White and Blue Lion, Inc. FDA has confirmed bacterial contamination in unopened bottles of the company’s inks.

According to Linda Katz, M.D., M.P.H., director of FDA’s Office of Cosmetics and Colors, using these inks for tattoos could cause infection. “FDA has confirmed one case of skin infection involving a consumer that used this company’s tattoo products,” Katz says, “and we are aware of other reports linked to tattoo products with similar packaging.”

Risks Can Be Severe
According to Katz, “Tattooing poses a risk of infection to anyone, but the risk is particularly high for those with pre-existing heart or circulatory disease, diabetes or compromised immune systems.”
She notes that injecting contaminated ink into the skin or using contaminated needles may result in infections at the site of the tattoo. Signs of localized infection include redness, swelling, weeping wounds, blemishes, or excessive pain at the site. If you experience any of these signs, seek medical care right away. Even after a localized infection has healed, the area may be permanently scarred.

Further, an infection that is left untreated or inadequately treated could spread through the bloodstream (a process known as sepsis). These infections may be associated with fever, shaking chills (rigors) and sweats. If these symptoms arise, treatment with antibiotics, hospitalization and/or surgery may be required.

Products Recalled, But Risk Remains
White and Blue Lion, Inc. recalled contaminated products on July 11, 2014, but FDA is still concerned that consumers and professional tattoo artists may be purchasing or using contaminated home tattoo kits and inks from other distributors.

Specifically, how can you identify kits and inks that you should not use because they may be contaminated? FDA advises you to watch out for inks intended for permanent makeup or traditional body tattoos that:

• have no brand name, carry a dragon logo, and/or are missing the name and place of business of the manufacturer or distributor,
• are sold singly and in kits containing anywhere from five to 54, or perhaps more, bottles of inks of various colors, and
• are marked with “Lotch” [sic] and Batch numbers, and “Date produced” and “Best if used by” dates.

“If you’re buying tattoo inks or getting a tattoo from a professional tattoo artist, you should first examine the products to determine whether the inks or kits meet the above descriptions,” cautions Katz.

FDA’s goal is to encourage consumers and tattoo and permanent make-up artists to take certain precautions and to urge potentially infected clients to seek medical care. “Reporting an infection to FDA and the artist is important in order for FDA to investigate, and to enable the artist to take steps to prevent others from becoming infected,” says epidemiologist Katherine Hollinger, D.V.M., M.P.H., from the Office of Cosmetics and Colors.

What to Do
Consumers and tattoo artists should do the following:

• Seek immediate medical care if you experience any signs of infection.
• Don’t use tattoo inks and kits that have no brand name, carry a dragon logo, and/or are missing the name and place of business of the manufacturer or distributor.
• Dispose of tattoo inks that meet this description.
• Do not use recalled kits.
• Report adverse events or side effects through FDA’s MedWatch Safety Information and Adverse Event Reporting Program.

Updated: August 7, 2014

For additional information addressing Hepatitis and tattoos visit:
The Official Blog of the Hepatitis and Tattoos Website
Part of the Hepatitis C Support Project and the HCV Advocate
Be sure to check out our other blogs: The HBV Advocate Blog and the The HCV Advocate News & Pipeline Blog

Reuters - Hepatitis C linked to ink

By Kathryn Doyle

NEW YORK | Thu Jan 24, 2013 2:23pm EST

NEW YORK (Reuters Health) - Researchers are hoping that people will do some research about where to get a tattoo, after a study found a link between body art and hepatitis C.

The new study found that people with the virus were almost four times more likely to report having a tattoo, even when other major risk factors were taken into account, co-author Dr. Fritz Francois of New York University Langone Medical Center told Reuters Health.

Although the study could not prove a direct cause and effect, "Tattooing in and of itself may pose a risk for this disease that can lay dormant for many, many years," Francois said.

About 3.2 million people in the U.S. have hepatitis C, and many don't know because they don't feel ill, according to the Centers for Disease Control and Prevention (CDC).

Hepatitis C is the leading cause of liver cancer and most common reason for liver transplants in the U.S. Some 70 percent of people infected will develop chronic liver disease, and up to 5 percent will die from cirrhosis or liver cancer.

For the current study, researchers asked almost 2,000 people about their tattoos and hepatitis status, among other questions, at outpatient clinics at three New York area hospitals between 2004 and 2006.
Researchers found that 34 percent of people with hepatitis C had a tattoo, compared to 12 percent of people without the infection.

The most common routes of contracting hepatitis C, a blood-borne disease, are through a blood transfusion before 1992 or a history of injected drug use. Injected drug use accounts for 60 percent of new hepatitis cases every year, but 20 percent of cases have no history of injected drug use or other exposure, according to the CDC.

Francois and his colleagues only included people with hepatitis C who did not contract it from these two other common sources.

After accounting for other risk factors, the difference between people with and without hepatitis was even greater, with four times as many tattoos in the infected group than for uninfected people, according to results published in the journal Hepatology.

"This is not a big surprise to me," Dr. John Levey, clinical chief of gastroenterology at the University of Massachusetts Medical School in Worcester, told Reuters Health. Earlier studies had found a link, but they were small and had not taken other risk factors into account as well as this new one did.
"This was one of the stragglers, and now we finally have some numbers for it," said Levey, who was not involved in the study.

Still, the CDC's Dr. Scott Holmberg said the link may not be quite as strong as the findings suggest, because some people who had used illegal drugs probably would not admit it, even on an anonymous questionnaire. And the researchers didn't rule out people who contracted hepatitis before getting their tattoo.

WHAT TO LOOK FOR IN A TATTOO PARLOR
Holmberg, of the CDC's viral hepatitis division, recommends people only have tattoos or piercings done by trained professionals.

"In the U.S., there have been no reports of hepatitis C outbreaks linked to professional tattoo parlors," told Reuters Health by email.

In 2012, 1 in 5 people reported having at least 1 tattoo, according to a Harris poll.
"There are very reputable places that use appropriate standards," said Francois. Tattoo parlors are not federally regulated, and standards vary by state and region, so it's up to the consumer to do their homework, he said.

The Alliance for Professional Tattooists recommend finding a tattoo artist who wears disposable gloves, a clean work space without blood spatters and single-use disposable needle kits.
Levey said he wouldn't prevent his two adult daughters from getting tattoos, but he would make sure they were aware of the hepatitis C risk first.

"A lot of their friends have tattoos, it's the cool thing to do," he said. "They're adults, they can make their own decisions. But I'd mention this to them, because the long-term consequences of hepatitis C are so serious."

SOURCE: bit.ly/UQ0lCA Hepatology, online January 12, 2013.

Tattoos and Piercings: A Review for the Emergency Physician

Complications of Tattoos

Tattoo complication rates show a prevalence of approximately 2% to 3%. Table 3 summarizes the complications associated with tattoos, many of which will be encountered by EPs. Most complications are related to infection that can be traced back to individual tattooist practicing a nonsterile technique. In particular, the jail and intravenous drug-using population is at risk for hepatitis B and C and methicillinresistant Staphylococcus aureus infection.^[10–12] Even syphilis has been transmitted by a tattoo artist licking the tattoo needle.^[13] Failure to recognize a tattoo as the source of a complication leads to incorrect therapy. In many cases the tattoo is not correctly linked to the medical problem because the patient may have multiple risky behaviors.

From Western Journal of Emergency Medicine

Tattoos and Piercings
A Review for the Emergency Physician

Michael Urdang; Jennifer T. Mallek; William K. Mallon

Posted: 12/19/2011; Western J Emerg Med. 2011;12(4):393-398. © 2011 Western Journal of Emergency Medicine

Abstract and Introduction
Abstract

Tattoos and piercings are increasingly part of everyday life for large sections of the population, and more emergency physicians are seeing these body modifications (BM) adorn their patients. In this review we elucidate the most common forms of these BMs, we describe how they may affect both the physical and psychological health of the patient undergoing treatment, and also try to educate around any potential pitfalls in treating associated complications.

Introduction

Tattoos and piercings (T&P) are ancient practices of body modification. The word tattoo comes from Polynesia and was first described by Captain Cook in 1769. The art form was named for the tapping noise made by a tattoo needle on the skin, which in the native tongue was tatau or tatu.^[1] Piercing, including the ear lobe, is also an ancient process, defined as the insertion of a needle to create a fistula for decorative ornaments. First recorded in the Middle East more than 5 thousand years ago, the practice is mentioned in Genesis 24:22 when Abraham asks his older servant to find a wife for his son Isaac. One of the gifts given to Rebecca, Isaac's new wife, by the servant was a golden earring. Since then, ear piercing has become so well accepted that most scientific literature excludes the ear lobe in the definition of body piercing.

Social acceptability of these practices varies widely from culture to culture. Catholicism and Judaism have banned the practice of tattooing.^[2] Esthetics, personal expression, religious views, communication, and style are all motivations for obtaining a tattoo or a piercing. Once relegated to the margins of society (bikers, military, sailors), tattoos and piercings are now common across all ages and both genders in what has been described as an epidemic. For the emergency physician (EP), tattoos and piercings have become important nonverbal clues about the patient's lifestyle and, furthermore, are increasingly the cause of an emergency department visit.^[3,4]

This review provides EPs with the tools to be able to assess the lifestyle or social background of their patients, to be able to understand the medical complications that may arise as a result of body modification, and to have a deeper understanding of the psychologic associations of tattooing and, when necessary, the relevance of the body modification to the current chief complaint.

Epidemiology

Within Western society there has been a shift from the stereotype of the tattooed sailors, who used tattoos to communicate their travel and services, the outsider biker of the 1960s (Hell's angels), and the gang members of the 1980s to the ornamental tattoo, which is now part of a collection of body modifications among women as much as men. Recent surveys completed in 2002 and again in 2006 have shown an increase in prevalence in tattoos within the US population.^[5,6] In 2002, a Harris poll showed a tattoo prevalence of 16%, whereas in 2006 a North American survey of 18 to 50 year olds found that 24% had tattoos and 14% had body piercings (excluding the ear). The surveys found that those who were tattooed were more likely to be less well educated, to have a high recreational drug use, and were less likely to show any religious affiliation.

Tattooing can be used to camouflage intravenous drug abuse, where it involves the antecubital fossa, and has an important place within generalized medical therapy. Its use is seen as a camouflage for dermatologic disease, can be added as a final stage in many plastic reconstructive procedures, and is also used for guidance in radiation therapy, endoscopic surgery, and ophthalmologic procedures.

Studies, which have looked at the epidemiology of piercings, have found that 2% of Americans report having piercings (not including the ear lobe) and that females get more piercings than men. Among young adults who have piercings there is a high rate of associated eating disorders.^[7] Studies also show that persons who get piercings are more likely to partake in risky activities, including drug taking and sexual promiscuity, and have a higher risk of incarceration. The educational status and income of persons with T&P are generally lower, although these educational and economic disparities are lessening as T&P becomes more mainstream (Table 1).^[8,9]

Medical Relevance for the Emergency Practitioner

There are several ways that T&P are relevant to the practicing emergency practitioner (Table 2).

Interpretive Relevance

For the EP, T&P presents a window to the lifestyle and life experience of the patient. Many questions relevant to the history can be answered by a review of the T&P present. Figures 1 through 4 show examples of information obtained from T&P. While interpretation is not as simple as it was 30 years ago, when sailors, military members, and gangs had the most tattoos, relevant information is often within reach of the observant EP.

Figure 1. "LW" is a gang affiliation meant to be seen when wearing sandals.

Figure 2. Mi vida Loca = My crazy life also seen as [ in many patients; in this case, "LOWCA" is a reference to low riders and the automotive culture associated with them. The gang is "Lowell Street," indicating a traditional Hispanic "turf gang" that is "loco"—crazy or brave.

Figure 3. Jiminy Cricket shown (a derogatory reference to the Crips, when called crickets or crabs), with the lipstick mark from a woman who loves him. The N and the E probably refer to northeast and the Chinese characters are of uncertain reference.

Figure 4. "Brown Pride" for racial identity as Hispanic or Latin; the anticubital fossa tattoos often cover intravenous drug abuse tracks, and the woman (right arm) is often the woman who "waits for him" during jail time. Yolanda is his girlfriend, and the left anticubital fossa tattoo is a tribute to a family member in the military, killed in service with "R.I.P.", or rest in peace, noted above.

Complications of Tattoos

Tattoo complication rates show a prevalence of approximately 2% to 3%. Table 3 summarizes the complications associated with tattoos, many of which will be encountered by EPs. Most complications are related to infection that can be traced back to individual tattooist practicing a nonsterile technique. In particular, the jail and intravenous drug-using population is at risk for hepatitis B and C and methicillinresistant Staphylococcus aureus infection.^[10–12] Even syphilis has been transmitted by a tattoo artist licking the tattoo needle.^[13] Failure to recognize a tattoo as the source of a complication leads to incorrect therapy. In many cases the tattoo is not correctly linked to the medical problem because the patient may have multiple risky behaviors.

Complications of Piercings

Complications of piercings are more common than those of tattoos and studies show rates as high as 9%. The types of complications include local or systemic infections, traumatic insertion, poor cosmesis, and rejection of foreign body, as well as migration and embedding.^[14] These are summarized in Table 4.

Jewelry is mainly body-site specific and made from metal. Metals used include stainless steel, gold, titanium, and various alloys. When these alloys contain nickel, there are associated allergic skin reactions and contact dermatitis. Specific complications relevant to the EP are summarized in Table 5. Rarer complications of piercings include bacterial endocarditis, tetanus, piercing migration with embedding, and even a case reported of appendicitis from a swallowed piercing that occluded the appendiceal aperture.^[15–18]

Psychologic Associations of Body Modifications

The EP should be more concerned about illnesses and suicidal behavior in those with body modifications. Tattooing correlates with the perception of decreased mental health, and tattooing and body piercing together correlate highly with increased "sensation-seeking" behavior.^[19] A study of young tattooed Korean males conducted in Korea, where body modification is considered part of counterculture, used the Minnesota Multiphasic Personality Inventory personality test and found high scores in items of psychopathic deviance and schizophrenia, suggesting that those with tattoos were impulsive, hostile, and prone to delinquent behavior.^[20] A data analysis of 4,700 individuals who responded to a Web site (www.bmezine.com) for body modification found a high frequency of abuse in the background of those who participated. This survey also found that 36.6% of the males had suicidal ideation and 19.5% had attempted suicide. For the females, a statistically significant higher suicidality rate was found, with percentage values of 40.8% and 33.3% respectively.^[21] Skegg^[22] noted that piercing was more common among women rated as having low constraint or high negative emotionality and was less common among those with high positive emotionality. Therefore, one can conclude that body piercing and tattoos, especially in females, could be a sign of suicidal behavior. However, no association has been found with eating disorders.^[7]

Some authors have attempted to show positive association for these body modifications. In a study of women with eating disorders, the authors suggested that body piercing could be seen as reflecting a positive attitude towards the body, an expression of care.^[23] In addition people with piercings are more likely to give attention to their physical appearance and are less likely to be overweight than people without piercings.^[22]

Removal of Tattoos and Piercings

Burris and Kim^[24] found that 50% of persons with tattoos express regret and wish for tattoo removal. The quest for tattoo removal reflects earlier poor decision making and an embarrassing stigma often perceived by the age of 40 years. Tattoos may cause immediate and delayed hazard to health and are not easy to remove. Delayed complications include development of allergic, hypersensitivity, or granulomatous reactions that require tattoo removal.^[25] On average, tattoo regret occurs 14 years after tattooing and has spawned a whole new industry. Nonprofit organizations also provide tattoo removal to gang members wishing to remove their tattoos (www.homeboy-industries.org). Tattoos can be removed by mechanical, chemical, or thermal methods.

Alternatives to permanent tattoos include the Indian technique of staining the skin with henna. This will fade over a period of 7 to 10 days. In the past year there has been the development of nonpermanent tattoo ink. This technique uses ink-containing beads that are deployed in the same method as used previously. However, the ink can be fully removed by single-pass laser treatment (www.freedom2ink.com) that dissolves the bead, allowing the dye to be exposed to enzymes, laser, and UV rays.

Source Medscape

Summary

Tattoos and piercings have become widespread practices that enjoy greater social acceptance than ever before. Body modification is important to the EP because it provides information about the "patient." The physician can learn a great deal about these patients via their body modification, including information of immediate relevance to their medical evaluation. Secondarily, T&P are directly responsible for an increasing number of emergency department visits due to both immediate and delayed complications. The EP armed with knowledge about T&P/body modifications can forge more functional doctorpatient relationships, obtain critical historical data, and provide better treatment and referral for this patient population.

*
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33. Gazzeri R, Mercuri S, Galarza M. Atypical trigeminal neuralgia associated with tongue piercing. JAMA. 2006;296:1840–1842.
34. Hadi HI, Quah HM, Maw A. A missing tongue stud: an unusual appendicular foreign body, Int Surg. 2006;91:87–89.
35. Maheu-Robert LF, Andrian LE, Grenier D. Overview of complications secondary to tongue and lip piercings. J Can Dent Assoc. 2007;73:327–331.
36. Simplot TC, Hoffman HT. Comparison between cartilage and soft tissue ear piercing complications. Am J Otolaryngol. 1998;19:305–310.
37. Gokhale R, Hernon M, Ghosh A. Genital piercing and sexually transmitted infections. Sex Transform Infect. 2001;77:393–394.