Free Answering Brief in Opposition - District Court of Delaware - Delaware

. · · Case 1:04-cv-01334-KAJ Document 34-3 Filed 03/28/2006 Page 1 of 2
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Case 1 :04—cv—01334-KAJ Document 34-3 Filed 03/28/2006 ( H; e gmoztgg 22 · M ·/·/“/ 2
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l FCM Hepatitis C Exclusion and Inclusion Treatment Criteria Sheet ( MEDICAL
g 1. Ab-solute Exclusion Criteria: YES NO
P a. Age less than 18 or greater than 60. Age: OQ
b. Failure to have a minimum of 18 months to serve, prior to V
A parole eligibility or conditional release date, from anticipated
initiation of treatment date (Note released date E E }.
c. History of documented use of illicit drugs or alco .ol in preceding
12 months. gg
· d. Failure (documented) to complete a substance abuse program once
Begun. ( ___g L
. f. History of epression •. psychosis (or prior suicide attempt) B { -· »
. g. History of m ignancy. O _;
h. Clinical signs of decompensated liver disease LZ
i. Unstable cardiac disease. lg
. j. Pregnancy or unwillingness to avoid conception up to _A_ //J
6 months after therapy. 2
lc. Uncontrolled seizures » lg
1. End stage renal disease on dialysis ___ if
. rn. Uncontrolled diabetes m__ 1/
n. Uncontrolled hypertension. l;
o. Normal ALT or ALT ·< 1.5 times normal during 12 month
observation period.
p. . History of medical non-compliance ____ { {
2. Inclusion Criteria: ·
a. Persistently elevated ALT levels as defined by ALT at least A
4 1.5 times normal limit over period of preceding 6 months.
b. Detectable HCV RNA _
c. Negative pregnancy test for female inmates. Mg ’
d. Written consent to antiviral treatment and acknowledgement i
of all side effects as below (documented on FCM HCV consent form).
. 3. Relative Exclusion Criteria:
a. Chronic steroid use.
b. Hemoglobin less than 12 mg/dl for men or ·<1 lmg/dl for women V"
c. Platelet count ·< 100,000. 1/
d. Serum Creatinine > 2.0 mg/dl. __% \/-
e. INR > 1.2. _ t F
f. Hepatitis B Surface antigen positive. ___ [/
g. White Blood Cell Count ·< 3,0-00. .
( h. Autoimmune disorders. ___ 4/
i. History of thyroid disease/hemoglobinopathies/cytopenia/anernia___ 1/
y j. Serum Albumin < 3.2 mg/dl. ___ Q
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I _ A marc Signalmc M- i - ~·- Date CQ5 { _?
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. , Providers Signature A _. , if [ lg Date ,..41 jj
MR-1087 First Correctional Medical Proprietary information June 2003