Allison Gilchrist, Associate Editor

ranging from 46,000 to 90,000 in the next decade, patients with hepatitis C virus (HCV) could be left with gaps in their care.

HCV is the most common chronic blood-borne infection in the United States. According to the CDC, an estimated 2.7 million to 3.9 million individuals have chronic HCV. As a growing number of payers cover HCV treatments for patients, convenient care clinicians will likely play a larger role in managing this population, so they’d do well to stay informed about HCV, its manifestations, and its treatments.

“I definitely think the retail clinicians can fill some of that void, at least in identifying the patients and potentially treating them if it’s a relatively straightforward case,” explained Jennifer Andres, PharmD, BCPS in an interview with

investigated the efficacy and safety of HCV care by nonspecialists. They enrolled patients from 2 community health centers in Washington, DC, and separated them into 3 treatment groups:

A specialist in infectious disease or hepatology group

Patients were treated with ledipasvir and sofosbuvir, and the primary outcome was unquantifiable HCV RNA viral load 12 weeks after the patients completed the therapy. The researchers found that the nurse practitioners achieved statistically the same rate of sustained virologic response as the specialists.

“I was not surprised by these findings, given the complex and specialized medical care that most nurse practitioners and physician assistants provide in the modern era,” lead study author Sarah M. Kattakuzhy, MD, of the Institute of Human Virology at the University of Maryland, told

. “Given the advent of simple therapeutic options, along with consensus guidelines, I do expect more nurse practitioners and physician assistants will care for HCV in community-based settings.”

By some measures, patients with HCV may even receive better care in the retail clinic setting than in the specialist setting.

“I think in the retail setting, [clinicians] can have a more direct, less rushed interaction with the patient,” Dr. Andres said. “In some cases, [clinicians] may have more information about the patient, such as what medications they’re taking and other characteristics that a specialist in one building who doesn’t speak to other providers wouldn’t necessarily know.”

HCV services offered in retail clinics have evolved over time, and there’s little reason to believe that evolution will slow any time soon.

“It’s definitely becoming more convenient,” Dr. Andres continued. “Patients can easily come in to ask questions or have insight given to them.”

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With projections of physician shortages ranging from 46,000 to 90,000 in the next decade, patients with hepatitis C virus could be left with gaps in their care.  

Retail Clinics Poised to Play Greater Role in Hep C Management

August is Psoriasis Awareness Month, making it the perfect opportunity for clinicians to brush up on the wide variety of health issues often associated with the disease.

The National Psoriasis Foundation (NPF) reports that as many as 7.5 million Americans have psoriasis, an autoimmune inflammatory disease. It can occur in all age groups, but it primarily affects adults.

As the prominence of retail clinics continues to rise, an increasing number of patients with diverse conditions are turning to convenient clinics for counseling. Psoriasis patients are no exception.

To prepare, here are some must-know facts about the condition:

Double check if patients with psoriasis are up to date with vaccines.

When a patient’s psoriasis progresses from mild to severe, the treatments that he or she needs intensify, Debra Michaud, RN, MS, ARNP, FCP-C, MBA, explained to

such as Humira (adalimumab), Remicade (infliximab), or Enbrel (etanecept).

“There are live vaccines that cannot be given to these patients,” she said. “So, we want to make sure all of their vaccinations are up to date.”

According to NPF, patients taking psoriasis therapies that suppress the immune system can receive vaccinations containing inactivated viruses because they’re less likely to progress toward infection.

Here are the routine vaccination recommendations from NPF:

Vaccinate with either live or inactivated vaccine.

Vaccinate yearly with inactivated vaccine.

Test for immunity; if negative, offer vaccine.

Not recommended in most cases. Discuss with physician.

Not recommended. However, limited data from one study suggests that it may be feasible.

Recommended for males and females up to 26 years.

Vaccinate if at high risk, and consider verifying immunization afterward.

Vaccinate if tests show no disease or immunity and if risk factors are present.

Use high-dose vaccine, and consider verifying immunization afterward.

Recommended, but precede with PPSV23 vaccination.

Vaccinate first with PCV13, then with PPSV23.

Vaccinate if there’s no history of disease and tests show no immunity.

If wounds are high risk and patient has had no pertussis vaccination, vaccinate with Tdap, provided the last Td vaccination was more than 2 years prior. Administer booster dose if it was more than 10 years prior.

2. Psoriasis can take an emotional toll on patients.

Up to 60% of psoriasis patients report that the condition negatively impacts their quality of life.

suggest that patients with psoriasis are at higher risk of developing major depression than those without the inflammatory skin condition.

Depending on where the psoriasis is located on the body, some patients might feel embarrassed about their condition. Other patients report that the condition interferes with their relationships, and women report experiencing

“The disease process can actually make them feel pretty uncomfortable because of the rashes on their arms or if it’s on their face,” Michaud said. “That can affect how they’re feeling and create stress as they think about what other people think of them.”

Given the condition’s psychological impact, clinicians can encourage patients to seek professional help if they’re feeling depressed or avoiding social events because of embarrassment. Professional guidance can assist patients with coping skills.

3. Psoriasis is often associated with comorbidities.

Hypertension, diabetes, obesity, and autoimmune diseases such as Crohn’s disease and inflammatory bowel disease are all associated with psoriasis.

has also demonstrated that psoriasis is an independent risk factor for cardiovascular disease.

Additionally, severe psoriasis is associated with early mortality of 3.5 years for men and 4.4 years for women. Women report a greater impact than men. Meanwhile, 20% to 30% of patients with psoriasis will develop psoriatic arthritis, usually within 12 years of initial onset.

For patients experiencing comorbidities due to modifiable behaviors, such as obesity or smoking, clinicians can offer nutritional and exercise counseling points to help them better manage their condition.

4. There are several distinct avenues to treat patients with psoriasis.

It’s not uncommon for patients to grow weary, impatient, or frustrated when certain treatments aren’t producing the results they want. Clinicians should be familiar with each of the treatment options so that they may suggest alternatives to patients if necessary.

·      Tumor necrosis factor antagonists

Meanwhile, phototherapy, or laser therapy, although effective, is used on treatment-resistant patches and can be time-consuming. Ultraviolet B is often combined with systemic agents, as the combination increases efficacy and allows for reduced systemic medication doses.

Clinicians should emphasize that the best outcomes are achieved with early intervention; patients should never postpone treatment. Current symptom severity isn’t predictive of future symptoms.

Up to 25% of pregnant women experience worsening of symptoms. Ask your pregnant patients about symptoms, and depending on the circumstance, discontinuing the medication during the pregnancy may be the optimal option.

5 Things Clinicians Should Know About Psoriasis

Consuming a higher percentage of protein from plants can reduce all-cause mortality risk, a recent investigation found.

Researchers from Massachusetts General Hospital and Harvard Medical School examined health data from more than 131,000 individuals included in either the Nurses’ Health Study or the Health Professionals Follow-Up Study. Both datasets had repeated measures of diet through food questionnaires and up to 32 years of follow up.

Of the participants, 64.7% were women and the average age was 49 years. Median protein intake, measured as a percentage of calories, was 14% for animal protein and 4% for plant protein.

showed that those who consume more protein from plant sources have a lower risk of death from all causes than those who eat more animal proteins.

Specifically, every 10% increment of animal protein from total calories consumed was associated with a 2% greater risk of all-cause mortality and 8% greater risk of death from cardiovascular disease, in particular. Meanwhile, eating more plant protein was associated with a 10% reduction in all-cause death for every 3% increment of total calories and a 12% lower risk of cardiovascular death.

These observations were more pronounced among adults who also had at least one unhealthy behavior, such as smoking, heavy alcohol intake, physical inactivity, and being obese/overweight.

Notably, the researchers found that individuals with similar intake with and without a healthy lifestyle demonstrated distinct profiles of protein sources. Those with unhealthy lifestyles consumed more processed and unprocessed red meats, while their healthier counterparts consumed more fish and chicken as animal protein sources.

This, they wrote, may suggest that different protein sources contributed to the observed variation in the protein-mortality associations when they controlled for lifestyle factors.

“Substitution of plant protein for animal protein, especially from processed red meat, may confer substantial health benefit. Therefore, public health recommendations should focus on improvement of protein sources,” the authors concluded.

Nurse practitioners and physician assistants can communicate these findings when counseling patients in their clinics for any reason. Discussing dietary recommendations is always appropriate and can help alleviate almost any other health ailment.

Consuming a higher percentage of protein from plants can reduce all-cause mortality risk, a recent investigation found. 

Eating More Animal Proteins Can Increase Death Risk

The US Preventive Services Task Force (USPSTF) has determined that there isn’t enough evidence to conclusively state that routine full-body skin cancer screenings by a clinician are safe or effective.

The report published in the July 26 issue of

is considered an “I statement,” which according to USPSTF means that “the evidence is insufficient to make a recommendation for or against the provision of a preventive service.”

It’s important to note that the USPSTF’s statement is based on rigorous evidence review that weighed the benefits and risks of screening. Although the potential benefits of screening are apparent, the risks may not be. Unnecessary procedures and downstream complications might be reasons to forgo screening in certain patient populations, such as the elderly.

Importantly, the USPSTF noted that no eligible trials have assessed skin cancer morbidity or all-cause mortality associated with visual skin screening.

This isn’t necessarily a vote against visual skin cancer screenings by clinicians. In light of the number of skin cancers diagnosed each year, it’s necessary to understand the importance of daily sun protection and to avoid excessive exposure to UVR in order to decrease the incidence of skin cancer, premature skin aging, and other long-term dermatologic issues.

“The USPSTF recommendations should not be misinterpreted as minimizing the importance of skin cancer,” wrote Eleni Linos, MD, DrPH, and colleagues in a related

editorial. “Instead, the report should motivate [health care providers] to improve the evidence base for identifying groups of people in whom the benefits of screening might outweigh the risks.”

The unwillingness of the USPSTF to make an official recommendation in favor of screening is the latest in a series of studies and statements weighing the importance of skin cancer safety and awareness.

, investigators from the Northwestern University Feinberg School of Medicine searched “sunscreen” on Amazon.com and selected the top 1 percentile of products as of December 2015 according to average consumer reviews (4 stars or more) and the highest number of consumer reviews.

didn’t meet American Academy of Dermatology (AAD) criteria, which include SPF of 30 or more, broad-spectrum claim, and water or sweat resistance. Particularly, a significant number of the products (30%) that didn’t meet AAD standards didn’t do so because they weren’t actually water or sweat resistant.

According to the Skin Cancer Foundation, skin cancer is the most common form of cancer in the United States. More than 3.5 million cases are diagnosed every year, and in 2012 alone, an estimated 76,250 individuals were diagnosed with malignant melanoma.

The foundation also reported that almost 90% of nonmelanoma skin cancers are associated with excessive exposure to UVR, and up to 90% of the visible dermatologic changes commonly attributed to aging are caused by the sun.

to help their patients avoid skin cancer in the first place.

For optimal sun safety, clinicians should advise patients to wear a hat and protective clothing, in addition to using sunscreen throughout the entire sun exposure period.

Some general counseling points about sunscreen include:

Use sunscreen with an SPF of at least 30.

Use sunscreen that protects against both UVA and UVB light.

Apply sunscreen to dry skin 15 to 30 minutes before sun exposure.

Reapply sunscreen every 2 to 3 hours and after sweating or swimming.

Meanwhile, there are several photosensitizing medications that can cause a healthy individual to become more sensitive to the sun, and thus more likely to burn. Patients taking doxycycline, sulfonamides, fluoroquinolones, nonsteroidal anti-inflammatory drugs, thiazide diuretics, furosemide, lamotrigine, antihistamines, or isoniazid should be aware of this risk.

The US Preventive Services Task Force has determined that there isnâ€™t enough evidence to conclusively state that routine full-body skin cancer screenings by a clinician are safe or effective.

Evidence Not Sufficient for Routine Skin Cancer Screening

Many Americans hoard antibiotics and use them without consulting a health care provider, recent survey results show.

The survey, which was published in the journal

, found that 1 in every 20 adults has held onto antibiotics and used them in the future without the supervision of a physician.

Researchers from the Baylor College of Medicine randomly selected and surveyed 400 adults treated at diverse family practice clinics across the Houston area. Of those patients, 5% admitted to using antibiotics without a prescription in the past year, while 14% said they kept a stash of leftover antibiotics in their home. Meanwhile, 1 in every 4 participants said they wouldn’t consult a physician before using any antibiotics they had on hand.

Of the antibiotics used by the participants without a prescription, 40% were purchased in a store or pharmacy, 24% were bought outside of the United States, 20% were supplied by friends and family, and 12% were leftovers. Alarmingly, in 4% of the cases, antibiotics used without a prescription were drugs intended for use in animals, not humans.

“The most common conditions patients reported self-treating with antibiotics were sore throat, runny nose or cough—conditions that typically would get better without any antibiotic treatment,” the study’s lead author, Larissa Grigoryan, MD, said in a press release from the American Society for Microbiology.

She and her co-authors found that “[p]atients from public primary care clinics, those with less education, and younger patients had a higher risk of [nonprescription] use” in the survey.

Up to half of antibiotic prescriptions in the outpatient setting are unnecessary or inappropriate, according to CDC data.  In response to this trend, the CDC and American College of Physicians (ACP) recently published recommendations on appropriate antibiotic use for clinicians to consider when treating patients with acute upper respiratory tract infections. Emphasizing the importance of antibiotic stewardship, the ACP and CDC encouraged clinicians to use their best judgment when prescribing these medications.

“Although it is everyone’s responsibility to use antibiotics appropriately, providers have the power to control prescriptions,” the organizations wrote. “Reducing inappropriate antibiotic prescribing will improve quality of care, decrease health care costs, and preserve the effectiveness of antibiotics.”

at every visit that taking antibiotics when they are

may cause them to experience unnecessary medication side effects, allergic reactions, repeat visits to health care providers, more out-of-pocket costs for co-pays and prescriptions, and more visits to the emergency department, in addition to contributing to antibiotic resistance.

Many Adults Use Old Antibiotics Without a Prescription

A bill under consideration by the Pennsylvania State Senate would allow nurse practitioners (NP) to practice independently.

Currently, NPs in Pennsylvania can practice autonomously only if they have collaborative practice agreements with 2 physicians. Notably, those physicians can end those collaborations without notice.

Under the proposed legislation (SB 717), NPs would be able to practice independently after they complete 3 years of collaboration with a physician and 3600 practice hours.

Opposition to the bill in Pennsylvania echoes opposition to similar efforts in other states. Many practicing physicians believe that NPs don’t have the requisite education to diagnose and prescribe medications for chronic and acute conditions.

“With a shortage of both nurses and physicians, increasing the responsibility of nurses is not the answer to the physician shortage,” Rebecca J. Patchin, a board member of the American Medical Association,

. “Nurses are critical to the health care team, but there is no substitute for education and training.”

Instead, the Pennsylvania Medical Society argued, patients are best served when physicians and NPs work in tandem. The group believes that SB 717 would disrupt the collaborative nature of team care that currently exists between physicians and NPs.

The results of a study conducted by the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing suggest that removing such barriers to NP authority would greatly expand access to treatment and medications to traditionally underserved patient populations, including rural communities, Medicaid recipients, and the elderly. Specifically, the study found that practices with NPs are 23% more likely to accept Medicaid patients.

“Patients in our state deserve access to the full extent of the education and training that nurse practitioner’s receive,” Lorraine Bock, DNP, FNP-C, ENP-C, FAANP, president of the Pennsylvania Coalition of Nurse Practitioners, told the

. “It is time for Pennsylvania to join the growing number of states that enable nurse practitioners to serve the healthcare needs of seniors, rural communities, and all patients.”

The proclivity of patients to turn to NP-run clinics instead of a primary care physicians (PCP) has been growing due to the rising cost of health care and shortage of PCPs. According to the Association of American Medical Colleges, the shortage of physicians is projected to exceed 46,000 within the next decade, and NPs have been called upon to help fill the void.

The requirement for NPs to collaborate with physicians has already been modified in 21 states and the District of Columbia.

A bill under consideration by the Pennsylvania State Senate would allow nurse practitioners to practice independently.