A Quick Guide to Hepatitis C

hepatitis c

What is hepatitis and HCV?

Hepatitis is a general term for inflammation of the liver. Any number of conditions can cause hepatitis, but one of the more common causes is a viral infection from the hepatitis virus, of which there are three types: A, B, and C. Type A is a short-term infection often caused by consumption of a contaminated food or water source. Type B is also short-term, though chronic hepatitis can evolve from an HBV infection in some cases. This type is spread by blood, semen, or saliva from an infected organism entering the body of an uninfected one – IV drug use, sexual contact, and animal bites can all lead to an infection of Hepatitis B. Vaccinations for both Type A and Type B hepatitis exist.

Hepatitis C is of particular concern because the virus can remain dormant for decades, often failing to manifest symptoms until an infected person’s immune system is compromised by age or a separate medical condition. Untreated, Hep C can lead to cirrhosis, liver cancer, and death. It’s also a factor in the fastest growing cause of cancer-related deaths in America presently, hepatocellular carcinoma (HCC). In fact, HCV is the leading cause of HCC in the western world. There is no vaccine for Hepatitis C.

How is HCV spread?

Hep C isn’t spread by casual contact with a carrier or through a vector (mosquitoes, animals, or contaminated food products). Needle-sharing is presently the most common cause of an HCV infection. Prior to 1992 HCV was spread through blood transfusions, but rigorous screening of blood products has eliminated that concern. In some cases, sexual contact, sharing of contaminated razors, and contact with unsterilized tattoo needles has led to an HCV infection, though these are much less common causes of the disease. Finally, a baby born to a mother with HCV will also carry the HCV virus.

What are the symptoms of hepatitis?

An acute infection of hepatitis C manifests with fever, fatigue, abdominal pain often accompanied by nausea and vomiting, jaundice (a yellow discoloration of the skin and eyes), joint pain, clay-colored stools, and dark urine. Bear in mind, however, that an acute infection from HCV is less likely than a chronic infection, which typically manifests no symptoms and takes years or even decades to cause damage to the liver (in the form of scarring or cancer). Many carriers of HCV will have no reason to suspect they’re infected (and as carriers they can still infect another person with it).

Who should be screened for Hep B and why?

Anyone who’s ever been an IV drug user or shared needles should strongly consider HCV screening. Currently, there’s also a huge push for baby boomers (anyone born between 1945 – 1965) to receive HCV screening because of the risk from contaminated blood products. Moreover, because of the time required for HCV to cause liver damage, baby boomers entering middle age are now at the greatest risk for complications. In fact, baby boomers are five times more likely to have an HCV infection than the general population and may not even know it. Health care workers who’ve been exposed to HCV by needle-stick injury or handling blood products should be screened. Some experts also suggest that incarcerated individuals living in close contact with others should also be screened.

Getting an HCV screen promptly will help anyone with an HCV infection receive care to prevent the potentially serious side-effects of hepatitis.

What’s the procedure for HCV screening? 

The first step in HCV screening is a routine blood test ordered by your primary care provider (PCP). This test is used to determine the presence or absence of an antibody for HCV. However, a reactive antibody test (meaning the antibody is present) only indicates that the person is a carrier. To determine if an active HCV infection is present, a second test for HCV ribonucleic acid (RNA) is done (See: “Screening and Management of Hepatitis C,” American Nurses Association). Both tests are required for a positive diagnosis of HCV, however, because (for reasons we don’t fully understand), 1 in 4 people eliminate the hepatitis C virus on their own – meaning they will have the HCV antibody, but not the active infection. Baby Boomers take note: Medicare covers the cost of the PCP-ordered blood test for anyone born between 1945-1965. 

How is an HCV infection treated?

HCV used to be treated with interferons with limited success. However, since the introduction of a new class of drugs called direct acting antivirals (DAAs) in 2012, the success rate for eliminating HCV is now an impressive 90-95%.  DAAs are given as an oral medication with very few side-effects. Unfortunately, they’re also very expensive and this is a major barrier to treatment.

Summing Up

Hepatitis C is a viral infection of the liver, sometimes leading to an acute set of symptoms but most often developing over decades with little or no obvious symptoms in the carrier. However, this chronic form of hepatitis can lead to serious outcomes later in life – scarring of the liver (cirrhosis), liver or blood cancers (HCC), and death.

Anyone with a history of needle sharing/IV drugs use, Baby Boomers (individuals born between 1945 – 1965), and anyone who received blood clotting products or an organ transplant prior to 1992 should consider being screening for HCV through a routine blood test ordered by their provider.

Remember, no one can diagnosis or treat an illness except a qualified, licensed medical professional like your primary care provider. If you’re concerned about HCV, contact your doctor or APRN and schedule an appointment to discuss your concerns. 


Legal disclaimer: Advice offered on this website is for educational purposes only. The information herein is not intended for use to diagnose, treat, or manage any health conditions or offered as an intent to treat any individuals. ALWAYS consult your primary care provider with questions regarding your health.  

Managing You: Why You Must Keep a Personal Health Record

Pop Quiz:

  1. Who is your primary care provider?
  2. When was your Tdap vaccination? Tetanus? Most recent influenza shot?
  3. Did you have a physical this year? What were the results?
  4. What are the medications you’re currently taking, and what are the dosages?

If you did poorly, don’t beat yourself up – many Americans are unaware of how to keep track of their health. But think about it: do you keep your motor vehicle documents like registration and proof of insurance in a handy folder in your car, along with records of all the service work you’ve had done on it? Do you store your tax returns and important personal documents in a safe, convenient place at home? If you do, then why aren’t you doing the same about what is arguably the most important thing you possess – your body? Shouldn’t you be showing the same diligence, if not more, for your health and wellness?

Allow me to introduce the concept of the Personal Health Record.  Simply put, the PHR is a detailed library that contains all of the most up-to-date information from your electronic medical record (EMR) – the database held by your doctors and insurance providers for the purpose of medical coding and billing – and your own notes on your health. In contrast to the EMR, your PHR is yours to control, modify, and manipulate as you see fit. It can be used through a platform of your choice: an online database, an app for your phone, or – as in my case – a hard copy in a three ring binder with color-coded tabs.

If you’re familiar with pedometers, FitBit, or apps for your phone like CouchTo5k and Fooducate, you already understand a little of how a PHR works. Most Americans, in fact, have used a fitness or weight loss program or app at some point in their lives. You’ve probably written down how much exercise you did, or tracked your caloric intake for a diet, at some point in your life. Your PHR, however, is more complete, integrating the information your health care team already has into a more comprehensive picture of your biological profile. A good PHR can include your fitness routine and calories consumed, but also keeps track of much more. 

The benefit of maintaining a PHR is, of course, knowledge – and, thank you Sir Francis Bacon – ipsa scientia potestas est: knowledge is power. Here’s how one paper, in the Journal of American Medical Informatics, put it:

Personal health record systems are more than just static repositories for patient data; they combine data, knowledge, and software tools, which help patients to become active participants in their own care.

In other words, PHRs give you a variety of additional tools to manipulate data. For example, if you track you blood pressure daily, you can use you PHR to determine your average BP over the course of a week. You can form a data set for how many calories you’ve burned while exercising. Raw data is just the beginning; with the magic of mathematics, your basic data allows software programs to draw conclusions about your health, and advise changes when needed. (You can also manipulate the data yourself, if you’re so inclined.) The article continues:

One of the most important PHR benefits is greater patient access to a wide array of credible health information, data, and knowledge. Patients can leverage that access to improve their health and manage their diseases. Such information can be highly customized to make PHRs more useful. Patients with chronic illnesses will be able to track their diseases in conjunction with their providers, promoting earlier interventions when they encounter a deviation or problem. (The complete article is available here. The National Center for Biotechnology Information is a tremendous, free scientific resource by the way.)

This a critical conclusion: tracking your health improves your general well-being. If you’ve got up to date information, you can – as is described above – note quickly any deviations from the norm and get medical assistance faster. Keeping on top of your weight, having blood tests results on your white blood cell count, A1C, iron levels and much more, recording changes in your weight or sleep patterns, and so on allows you to make smarter decisions. Being conscious of your health on a daily basis gives you an advantage, too, when time is crucial. Often, it’s small symptoms that are overlooked or – worse – ignored that signal a serious health issue.  

And they’re not joking about speed and ease of communication, either. I get my office visit summaries, diagnostic images, test results, and more through MyChartPlus, and last time I had blood work done I had all of the lab results before my doctor did. I can also make, cancel, and reschedule appointments online or with my phone. My doctor can send me letters or messages through it, too.

So what should you include in your PHR, and how should you manage it? Well, the format is a matter of personal taste; you may prefer a desktop software program – as simple as a Word or Excel sheet or a more complete program created specifically as a PHR like Microsoft’s HealthVault (n.b., Microsoft ended support for the Healthvault for the Windows phone literally today, as this article was published. The online and desktop service seems to still be available). Web-based applications like MyMinerva or Dossia Health Management System give you the piece of mind of knowing your data is backed up offline – though, conversely, it comes with the risk of security breaches that could put your private medical information into someone else’s hands. For smartphone users, the MyMedical and OnPatient PHR apps are both great, but shop around to find the one you prefer. And, as I mentioned before, you can also keep your records in a well-organized binder – a bit old fashioned, I suppose, but easy to access and reference when you need it. I print my information from my EMR or get copies at the doctor’s office, and file them away for use when needed.  

As to what information to include, I am of the mind that more is better. I include a daily record of all my exercise, I take my vitals and record them each morning, and I even have flow sheets to monitor my diet. Full disclosure, however: I am of the “Type A” personality, to the degree that I color coordinate my pens to my scrubs, and my scrubs to my lunchbox.

Here’s a saner list of what you want to include, at a minimum, in your PHR: 

  1. Your prescriptions, the dosages of each, and the frequency of administration
  2. Your immunizations
  3. Your physicals, including the list of current health concerns/chronic illnesses and doctor’s report on your overall health
  4. Lab results – (blood work, biopsies) and imaging results – ultrasounds, X-rays, and the like.
  5. Your insurance information.
  6. Reports from any specialists you’ve seen, histories of any procedures (surgeries) performed
  7. Emergency contact information
  8. Your allergies to any medications and/or latex
  9. A copy of your living will, advanced directive, or any legal documentation of this sort (including DNRs)
  10. A journal with anything you’ve noticed or consider worth reporting (what are called Observations of Daily Living or ODLs). This can include simple reports such as, “I’ve had a dull pain in my side for the past three days,” or “I’ve been feeling nauseous a lot lately.”
  11. A brief record of your emotional/cognitive health and what you do to maintain it. This isn’t often recommended, but I think it’s important. Doing things you enjoy – and that reduce anxiety – are vital to good health. Making a record encourages you to remember to take care of your emotional being, too – through meditation, creative arts, gardening, a hobby, or whatever it is that gives you joy. 
  12. Your fitness routine and at least a sketch of your diet. 

It may seem daunting, but I ask you again to consider: aren’t you worth it? Don’t you deserve at least as much attention as your car? At least some experts think most of us just don’t care, and that’s why PHRs have yet to come into widespread use. Maybe they’re right. I prefer to think, however, that most people would embrace PHRs once they see how easy they are to use and the benefits they offer. Being “in charge” of your health is empowering. There’s a sense of pride in ownership when we are diligent monitors and protectors of this fleshy vehicle that carries us through life. Maintaining a PHR gives you a complete picture of your wellness, and with that knowledge you’re better prepared to make smarter choices for continued good health. 

One final note – if you need some information to get your PHR started, remember that the Health Insurance Portability and Accountability Act gives you the right to inspect and receive copies of all of your medical records, electronic or otherwise, upon request. Ask them what software program they use to manage your EMR, and how you can get a login ID and password to access all of your health information. If your PCP doesn’t offer an online EMR, ask that they do so (it’s 2016, come on).  

Note: This article also appears on medium.com.

‘One Month Thin’: The Skinny On Surgical Weight Loss

A look at the month following surgical weight loss – and how losing weight improves your life in just about every way.

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Though I’ve shared little about the subject on this blog, I’ve suffered from obesity for the better part of my adult life. I was always fit and trim as a child, and through most of my twenties maintained a healthy weight. It was around the age of 26 that I began to gain weight as a result of a poor diet and infrequence exercise. Hiking – a subject that I have covered here in detail – has been a great help, but like most Americans I’ve never been able to lose weight and keep it off.

By winter of 2014, I reached 260lbs, the highest I’ve ever weighed. Crucially, I’d developed two conditions co-morbid with obesity (as part of a general health status called “metabolic syndrome“): hypertension and high blood sugar. (My triglycerides were also high.) I knew that the combination of hypertension caused by obesity and diabetes was a deadly one; my life expectancy was surely lower than the statistical average for men in America.

I would look at my daughter and wonder if I’d see her graduate from college, get married, or have children of her own. River is clever and sufficiently literate about health and nutrition to know that obesity is a form of sickness. She would say that she wanted me to live to ninety, and I would flinch knowing that my weight and the ailments caused by it made that improbable.

And so it was that I decided to investigate surgical weight loss. The process itself, from an initial orientation to over a year of medical tests, visits with a dietitian, preoperative physicals, even a psychological evaluation, is a fascinating one. It’s something about which I will probably write in the future.

But for now, I’d like to discuss the immediate aftermath of my surgery – a vertical sleeve gastrectomy – and both the expected and unexpected outcomes I’ve experienced.

My surgery was on January 19. For 12 days prior, I had been on a highly restrictive diet meant to shrink my stomach and liver. My grandmother dropped me off at Hartford Hospital, and after checking in with Admissions, I was brought to the OR waiting area. A parade of patient care techs and nursing staff came through to check vitals and keep me occupied with paperwork. The anesthesiologist walked me through the risks of general anesthesia, and had me sign off on a consent form. Finally, my doctor arrived to look over all the pre-op work and see how I was feeling. This would be my final opportunity to back out of the procedure if I so desired.

I knew there were risks. Any surgery comes with them, and if you’re overweight, have diabetes, or high blood pressure, the danger increases. A sleeve gastrectomy also comes with a 0.3% chance of death, usually caused by a rupture in the stomach suture causing sepsis. But I knew this surgery was the right choice. I thought of River and the life that would be mine after all the hard work was done, and with that image I had the courage to say, “Let’s do this.”

The procedure was done in about an hour. Weight loss surgery in all forms is now done laparoscopically, a tremendous improvement on the invasive techniques required a few decades ago. (A laparoscope is a device with a camera. It’s inserted into the stomach, and the surgeon makes small incisions in the abdomen in order to complete the procedure while being able to see with laparoscope.)

I had a two day hospital stay following surgery. The staff on the OR floor – Bliss 8 at Hartford Hospital – were simply amazing. Under their diligent care, I was tested for fluid tolerances (tea, chicken broth, sugar-free popsicles, and water were all I could ingest) and monitored for complications. The ability to stand, walk the floor, pass gas, and urinate were the additional benchmarks required for discharge. Before leaving, I was given a detailed seven-week diet plan and a pile of prescription meds.

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Here’s what I’ve noticed in the month since I left the hospital.

First, my blood pressure began dropping. In fact, it began to drop during the pre-op, low-carb diet. Within two days of discharge, I was getting normal blood pressure readings (<120 / <80). Often, my pressure was too low due to hypovolemia (lack of sufficient blood volume) caused by insufficient hydration. Dehydration is the primary health concern after surgery, and my post-op diet called for 64 ounces of water per day. By three weeks after surgery, my diagnosis of hypertension was rescinded and I was taken off my hypertension medication. A huge win for my health.

For two weeks after surgery, liquids were all I could consume. I mainly drank protein shakes, water, and broths. I tried a number of brands – Atkins, Muscle Milk, Isopure – but to be honest, they all taste like chalk eventually. It may sound like a brutal diet, but another immediate effect of the gastrectomy (and this might seem obvious) is that I don’t feel hungry. At all. There are times, of course, when low blood sugar triggers the notion that I need to eat in my brain, but I never feel the ravenous pangs I felt before. Two weeks on liquids was a cinch.

During the two week liquid diet, I began monitoring my glucose levels. A week before surgery, my fasting blood sugar was 136, and my A1C (a measure of average glucose levels) was 6.5. Following surgery, my blood sugar immediately began dropping – now, my fasting blood sugar is around 70-80, and post-meal it’s 95-105. Perfectly normal.

At week three, I was allowed to add mushy foods – non-fat yogurt, oatmeal, low-fat ricotta cheese, and anything that could be pureed – to my diet. I experimented with pureed concoctions like ground turkey, gravy, and spices (thumbs up), or pureed hard-boiled eggs with paprika and lite mayonnaise (thumbs very much down). In addition to 64 ounces of water, I was to consume 70-90 grams of protein each day. The protein would help with healing and help my body get used to a low- to no-carbohydrate diet. So, the mantra provided by my dietitian was “Always choose protein first.” For the short term, that meant putting vegetables and fruits aside, and eschewing carbs almost entirely.

I began to notice a few other changes in the third and fourth weeks. For example, I had a lot more energy than I ever had before. Whereas once I would only feel rested with 9-10 hours of sleep, now I feel great after 7 or 8. Of course, I was also exercising nearly every day – I’ve hiked more in the past month than in the entire autumn of 2015 – and my resting metabolism was improving – evidenced by a resting heart rate of 65-75 bpm.

I was saving a lot of money, too. I found that halving my estimate of how much food I could eat wasn’t enough; I had to reduce it to a quarter or eighth of the portion that “seemed” right in my mind. (After surgery, the size of my stomach was about equal to a banana, or to a 4oz total capacity.) So suddenly a pound of lean beef lasts a month. A can of broth lasts a week. A batch of chili using the standard recipe needs to be frozen because I can never eat all of it before it goes bad. There was, unfortunately, considerable waste as I adjusted to this new way of eating. I used to shop like a bargain hunter, you know the mindset, the most food for the least price. Now, I look for the smallest servings and the highest quality ingredients. I can afford to get better quality meats and superior organic staples. I’ve completely eliminated processed sugars from my shopping list. I’m also saving money in unexpected ways – toilet paper, for example. (I won’t be too candid here, but suffice it to say that when you eat less, you need the bathroom less, too.) I don’t need to buy antacids – heartburn is a thing of the past.

At week two, I also began taking supplements. Because of the limited capacity of my stomach, I will need to take a daily multiple, B12, calcium, iron, and vitamin D supplements every day for the rest of my life. Getting used to this routine was a challenge, so I began tracking my supplements, diet, exercise, and vitals in a daily log. It’s been tremendously useful for staying on top of my fluid and protein goals, too.

A few cognitive changes related to the weight loss took me by surprise. First of all, my tastes changed. Prior to surgery, I despised mushrooms, but now find myself liking them. Rotisserie chicken or roast chicken used to be a favorite indulgence of mine; now I get nauseous at the thought of it. Fast foods, once a bane to my health and a craving I couldn’t shake, hold no appeal. Mostly I find myself jonesing for salads, fish, and – occasionally – Cheez-Its. But without the hunger pangs, I breeze right by the chips and snacks aisle at the store and think nothing of it.

I found my anxiety decreased and my mood improved. Feeling healthier and more fit brought me an inner peace and joy like I have not felt in my life before.  Prior to surgery, I set up a meditation area in my living room, complete with an indoor greenhouse and small waterfall. These, of course, helped me develop mindfulness practices that aid in keeping my grateful and happy in my life, but the diet and exercise – both tied to surgery – have made it easier still.

So, the big question: has it been worth it so far? I have to give a completely unqualified “yes.” Though I’m 47 pounds lighter, the real victory is the remission of the hypertension and diabetes, two serious health issues that I have successfully treated with the surgery. Prior to making a final decision, I went to a handful of friends who’ve also had weight loss surgery (mostly gastric bypass) in order to ask them if they were happy they had it done. The answer, from all of them, was nearly always the same: “It was best decision I ever made.”

I can now add my voice to their number, echoing their joy for the new life surgical weight loss – and their own hard work – gave them.