tag:blogger.com,1999:blog-88372768594287195212024-03-12T20:01:38.427-07:00for prescription use onlyanything from medications, new trials and disease states to my experiences traveling in East Africa, India, and around the United States is for prescription use onlyRxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.comBlogger53125tag:blogger.com,1999:blog-8837276859428719521.post-56890425013597627642013-09-19T23:43:00.000-07:002013-09-19T23:43:13.174-07:00Buying Turkish Carpets<div dir="ltr" style="text-align: left;" trbidi="on">
Turkey, how the hell do I even start? Everything about the country was so intense, especially to my innocent little American senses, right down to the simple act of buying a floor covering.<br />
<br />
After over 24 hours of travel and an 8 hour time difference, I had arrived in Turkey miraculously with my luggage and ready to throw all of myself into seeing the city. This was my first time traveling with someone that I had not met along the journey since I was 19 years old and went to Mexico with my crazy roommate. I was nervous about it, but she didn't kill me, so I think it went ok.<br />
<br />
After walking around in a daze wandering old town, we ended up on a cobblestone street leading up a hill, not far from our ghetto-fab Turkish guesthouse. So many great things to see from windows! Gorgeous ceramics and whole shops filled floor to ceiling with lanterns... or jewelry, tiles, hookahs or rugs!<br />
<br />
I managed to convince my friend to go into a rug shop, I just want a little look, I said, afterwards I promised we could go to the jewelry shop next door that I could see she was eyeing.<br />
<br />
A good-looking Turkish man, just slightly shorter than myself, dark hair and a figure that any gay man would kill for swiftly jaunted over and led us over to a sofa in the corner of the shop<br />
<br />
Make yourself at home! Make yourself at home!<br />
<br />
He yelled in between ordering for a few idlers to bring tea! bring tea! you like tea, yes?<br />
<br />
Somehow after a brief introduction and establishing that I was vaguely interested in seeing some carpets, Sahin, as I learned the man was named, was able to convince us to move to another room in the basement of the building filled with piles upon piles and rolls of carpet wall to wall where we sat drinking cup after cup of tea as he yelled to four different helpers to unroll this! Take away that! Get this! As I was dazzled as carpet after carpet was unrolled before me, Sahin of course refusing to share the price until the end.<br />
<br />
The carpet is for the home! Only gets more valuable with time! A piece that I would be able to have that was beautiful and would last me a long time. Feel the carpet! Look at it from here! Look at it from there! If you buy carpet, I will send you Christmas card!<br />
<br />
We established a little pile of carpets that were my favorite, of course all of them were enormous, hand dyed, hand knotted carpets that I knew long before hearing the price would be far beyond my price range- which they were and the larger carpets were removed within a blink of an eye. Now let the haggling begin.<br />
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Haggling has to be one of my least favorite activities. Most of the time I just wish that someone would offer me a reasonable price when traveling, I'd gladly take it over arguing over a price for extensive periods of time. In this case, I was honestly not so keen on buying a carpet when I had been in Turkey for less than 6 hours and especially when I heard that Istanbul is one of the most expensive places to buy a Turkish rug. I was unsure of what the fair price for the carpets would be, but regardless, I was sure that the prices were outlandish.<br />
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I was torn between truly not wanting to purchase a carpet on my first day in Turkey (holy crap, how will I survive the next two weeks if I get suckered in this easily?) and being totally completely buttered up by Sahin and pampered by cups on cups of apple tea (elma cay) and fingers deep in a vegetarian casserole he had brought for me from his family owned restaurant.<br />
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For anyone that has known me for any period of time, I think the fact that I am a major sucker shines through. I may have resisted officially purchasing the carpet that time, but I did agree upon turning in a $100 deposit on it with a written agreement that I could have my $100 deposit on my return at the end of our two week trip if I no longer wanted the carpet. I think even at that point 75% of myself knew that I would never come back for that deposit after the end of two weeks, but I was truly at the mercy of the tea.<br />
<br />
Sahin seemed to be pleased enough with this agreement and we again were whisked off to the top of a rooftop bar where white wine was ordered, and despite the 90 degree F heat during the day, the air was chilled and breezy as we watched the sunset over the Bosphorous and creating dramatic silhoettes of Hagia Sofia and the many mosques dotting the hillside. <br />
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Next we were whisked off to a new section of town with his friend and his cousin. To be honest, I have no idea where we were but it vaguely reminded me of Chelsea in New York. Narrow cobblestone alleyways with restaurants and bars open to the street, while people and music overflowed making it difficult to make our way through the street. I had been promised a night of jazz music by the Sahin, what I got was an all male Turkish band playing some Turkish music but mostly covers of American music that ranged from U2 to Adele. I had my first and only drink of raki, the traditional Turkish alcohol. It was infused with anise and tasted like dark licorice despite its white smokey look, the first taste was interesting the second disgusting and I next opted for what became my official drink of Turkey, Efes beer. Named for the city of Ephesus, refreshing, always cold, and tasted like Miller Highlife (champagne of beers). We ate mussels bought from a street vender, served cold on a paper plate with lemon and as more Efes' were emptied, danced, sang along and I was crowned with ridiculous light up Minnie Mouse ears.<br />
<br />
I liked that bar just fine but was somehow convinced to try another, without realizing it would entail another cab ride. Getting into a cab with three strange men in a foreign country where you don't speak the language on the very first night is generally frowned upon. In general, when traveling on my own I am the most boring least daring person ever, but give me a travel buddy and I will make poor decisions left and right until the other member of the party throws in the towel. Together the two of us agreed that we would take the cab, but ditch the guys at the next place and head back to out ghetto-fab Turkish guesthouse to call it a night.<br />
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My travel buddy tried to help box me into the cab in a way so that Sahin could not sit next to me, but instead he went around to the other side of the cab and squeezed in next to me. I kept looking at my travel buddy who had gotten stuck next to Sahin's cousin who was fairly mild mannered, but had also been drinking. The cab ride carried us along a highway outside the main area of the city and in the opposite direction as old town. Again I glanced at my friend and saw Sahin's cousin try to hold her hand as moments later we pulled up to another club in a somewhat more residential area.<br />
<br />
Get out! my travel buddy yelled, we are staying here, you are getting out of the cab, we are going BACK. Sahin who had been quite the sweet talker to this point, attempted to get back in to escort us back the way we came but was essentially booted out of the cab.<br />
<br />
YOU are staying HERE.<br />
<br />
The hand had been held, the line crossed. It was the end of party time.<br />
<br />
Thankfully Sahin told the cab driver how to get back to his carpet shop as the cab driver only spoke Turkish and despite months of listening to my Pimsleur's Learning Turkish CDs on my three hour drives to visit my boyfriend, my Turkish was still sub par, to put it mildly.<br />
<br />
I think it was 3 or 4 am by the time we got back to our guesthouse, with bright red glossy bed covers and beige wallpaper that must have been put up by someone either blind or missing a few fingers, possibly both. Although I set my alarm for 8am, I rolled over in bed at 1pm only to be informed that I had promptly turned off my alarm in my sleep and went back to bed as it awoke my travel buddy and left her staring at the ceiling for hours before I allowed myself to wake up on my own sweet time.<br />
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We saw the rest of the main sights in old town and as the day was wearing to a close, it became clear that it was now or never if I was interested in ever getting my carpet deposit back. Again, likely against my better judgement we went back over to the shop and of course are greeted once again at the door by Sahin.<br />
<br />
As I explained that I simply could not afford the carpet, he was surprisingly silent, thoughtful. He rolled it out in front of me.<br />
<br />
I ask you something, how much you pay for this carpet? I will not be offended.<br />
<br />
Well, $400. That's it. That's my carpet budget.<br />
<br />
My carpet was taken away and again more carpet rolled out in front of me. Some of them antique, all of them smaller than the one I had chosen, then I laid eyes on MY carpet. After some haggling we agreed on a price. I got my hand dyed hand knotted Turkish carpet that I would have the privilage of lugging around in my travel backpack for the remaining two weeks, Sahin got to keep his deposit plus some, and best of all, in four months I will get my promised Christmas card from the rug shop in Istanbul signed, Sahin.</div>
Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com1tag:blogger.com,1999:blog-8837276859428719521.post-23954519958881435212013-02-21T20:37:00.001-08:002013-02-21T20:45:11.939-08:00Reservation Rescue<div dir="ltr" style="text-align: left;" trbidi="on">
About a month ago, I was very excited to hear that a friend of mine, whom I had met at Officer Basic Course in Gaithersberg, MD was going to apply for the pharmacy residency position at my hospital and needed a place to stay. I have always admired the art of being a good host, and jumped on the opportunity. <br />
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It was the end of January in the southwest, and while Gallup had clear skies, she told me that it had been snowing out in Kayenta, AZ where she was working. At around 8:45 p.m. she texted me that she would be arriving in Gallup in an hour and a half.<br />
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No worries, but I'll probably be going to bed shortly after you arrive. Work at 6:45 am... ugh... I'm not THAT much of a morning person...<br />
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Only about a half hour later, her name popped up on my phone. I answered and she was crying on the other line. Her car had started spinning out of control, hit a rock, and rolled over.<br />
<br />
Are you ok?<br />
<br />
Physically yes, mentally... very shaken up<br />
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Is anyone with you?<br />
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She had the "good luck" to get into an accident near someone's home on the reservation. They helped her out, gave her blankets, and called the Navajo police. The Navajo people live spread out from each other across the reservation. When driving across, you'll see houses here and there but for the most part, the reservation looks vast and empty.<br />
<br />
Where are you and do you need me to come get you?<br />
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I'm on Indian Route 12 at mile marker 80<br />
<br />
... O Jesus Christ<br />
<br />
I'll wait for the Navajo cops, then call you.<br />
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Alright. I started going through my head what I needed to do... ok tell someone I'm leaving, bring water, food, a sleeping bag, warm clothes...<br />
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Sure enough 15 minutes later she said that she would need a ride into Gallup. How else would she get here? Her car was clearly not drivable. I threw my stuff in the car and set off. In retrospect, I'm really thankful that I did bring supplies and that I texted my coworker what was going on. She offered me to switch for her 10am shift, but I was sure I would be back in time. Tired, but back. <br />
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As soon as I passed into Arizona, it started snowing. There was very little snow sticking to the ground, but it made me uneasy and decreased visibility. There were some other drivers on the road, the majority of which having only one working headlight so as I drove through the night I kept seeing lone headlights approaching, pretty ridiculous as I couldn't tell exactly where the car would be. <br />
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After missing a turn (no street signs) I found Indian Route 12 and tried to pay close attention to the mile markers, which would be my only indication of how close I was to finding my friend. Naturally, all of them were graffitied and with the snow, were damn near impossible to read. I finally was able to make out mile marker 50 and decided to text my friend. <br />
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No cell service. Naturally, this is the reservation, what was I expecting? I had texted her when I left my house, but aside from that, she had no idea where I was. Fantastic.<br />
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I kept glancing down at my phone but service not found. <br />
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At about mile marker 60, I came over a small hill, I was going at 30-40 miles per hour which had been fine for most of the trip, but on the other side of the hill, there was suddenly a couple inches of snow on the ground. As I came down the hill I could feel my little Hyundai accent, Regina, slipping from side to side. 90 degrees to the left, then 90 degrees to the right, and so on. It was obvious that I was spinning more and more out of control, I finally turned the wheel in the the turn, spun around a few times and landed neatly just off the road.<br />
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After my futile efforts of trying to drive out of the ditch, then push Regina out, my first thought was that the night pharmacist would kill me when I didn't show up in the morning, then of course of sting of thoughts on what I could have done better... text my friend sooner, bring a friend with me, not have been hasty in setting out in this weather when I know for a damn fact that I can't drive in snow... I can barely drive under optimal driving conditions so knew this would be a disaster from the start.<br />
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Yet I also knew that I had had to try. What was I supposed to do? Say good luck and hop into bed while my friend was stranded and shaken up in the middle of the reservation?<br />
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And of course, I still had no cell service. There was no one in sight, no sign of civilization, the last houses I'd seen were just before mile marker 50 and I wasn't about to leave my car and walk back to them in the snow at 11:30 at night. I flipped on my hazard lights and crawled into my sleeping bag. My hope was my friend would eventually come this way with the Navajo cops when I didn't arrive.<br />
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While I am able to sleep in almost any conditions (a blessing, really), nearly everything woke me up. At 1am, I woke up thinking I had seen headlights approaching. At this point, Regina was completely covered in snow, I could barely make out lights in the distance. Sure enough, I could see a truck coming over the peak moving at about 10 miles per hour. I jumped outside and waved my hands frantically. As they approached, they almost seemed to stop, then kept going. I kept waiting for them to stop and when they didn't, I chased after the car;<br />
<br />
You assholes ASSHOLES!!! I yelled<br />
<br />
but they didn't seem to care, just kept driving away at about 10 miles an hour with a crazy white girl screaming and running behind their truck.<br />
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The good thing about this situation was 1. I realized that it had stopped snowing and 2. I found cell services. A string of worried texts came through from my friend who knew it shouldn't have taken me that long to get to her. I gave her my location, and she immediately left to come save me with the Navajo cops. I also texted my coworker and asked... actually... on second thought, can I switch you for that 10 am shift? In retrospect it was a bit of an asshole move on my part to be texting anyone at 1 am on a work night, but she replied and agreed right away.<br />
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The Navajo cops helped pull my car out of the ditch, my friend and I jumped in and set off towards home. We didn't make it back until 4:30 am, but we made it back. Neither of us were hurt. At the end of the day, I have to say, things could have gone better, things could have gone worse. A reminder of how quickly you can be humbled before nature. Without the protection of my car, my sleeping bag, and my water I would have been helpless on the reservation in temperatures dropping well below freezing. While I will always feel a connection to all of the Public Health Service officers who went through Officer Basic Course with me, this friend and I will always share the bond of having survived the blizzard. The extraordinary is not so distant from the ordinary.<br />
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At the end of the day, I live for this shit.</div>
Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-15269172293855715692013-01-11T00:56:00.003-08:002013-01-11T01:00:36.615-08:00El Mirador<div dir="ltr" style="text-align: left;" trbidi="on">
Now that I am a responsible working adult my trips have been cut dramatically short. I got back a week ago from a 10 day Guatemalan adventure. I'll take what I can get when it comes to vacation, but it still felt painfully short #whitegirlproblems<br />
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I've taken so little time to reflect on ? anything this past year, but if 2012 was the year of ambition, I hereby declare 2013 to be the year of adventure. By the end of a chaotic and accomplished year, I still had (have) no idea what I'm doing with my life as I plunged forward. I was certain that my only salvation from myself would be adventure tourism in Latin America. Guatemala was chosen by flight price, and I proceeded to review my options. I consulted a friend who had worked at a hostel in Livingston, Guatemala for 8 months, and he mentioned El Mirador.<br />
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The Mayan empire preceeded that of the Incas or Aztecs. The height of their civilization had fallen long before the arrival of the Spanish, hypothesized to be secondary to drought, but Mayan culture is still very much alive in many central American countries, like Guatemala. El Mirador is not the best known Mayan site in Guatemala, that title goes to Tikal, yet it is the location of the tallest known Mayan pyramid, La Danta. <br />
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My rough guide stated that per any year, the number of archaeologists visiting the site far outnumbers that of tourists, although per my guide on the hike, El Mirador hosted 300-400 travelers for the 13th Baktun, or the "Mayan end of the world" on December 21, 2012, a great exception to the usual numbers. There are no roads to El Mirador, it must be done on foot or by helicopter. Mel Gibson opted for the latter during the shooting of Apocalypto, which was shot on top of La Danta. I make an active commitment to avoid Mel Gibson films, but I'm a little curious about it after completion of the hike. Our guide, Juan Carlos, found it very entertaining that the movie portrayed Mayan human sacrifices on top of the pyramids when there is no evidence that this was conducted at the top of the pyramid at any of the sites. The Mayans did not begin the practice of human sacrifice until the later years of the empire, it was not discussed by our guide in the context of El Mirador. As El Mirador was one of the earlier Mayan sites, it may not have played a major part in that society.<br />
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I was sold. El Mirador or bust. I arrived in Flores on my 3rd day and got a spot on a hike with 11 other travelers to El Mirador.<br />
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This tour was pretty "cushie" for a five day backpacking trip. I was told the only think that I needed to bring was extra clothing, "las mulas" the mules would carry all of the food, tents and ended up carrying all of our extra stuff as well. By the time we reached each camping site, the food had already been prepared and the tents ready. <br />
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The first day we hiked 12 km (7 miles) and reached Tintal. The jungles of Mayan lands are covered in small uncovered ruins. Tintal was essentially a suburb of El Mirador. Although much smaller, the people of Tintal had built their own pyramids and the city was surrounded by a moat which served primarily as water storage. By the time we reached Tintal, we had already been walking on a path of limestone, now overgrown with jungle, that had been built by the Mayans thousands of years ago. The path went all the way to El Mirador, the parts that were still recognizable as an ancient highway looked to be about 10 meters in width though I believe that our guide, Juan Carlos, said (in Spanish) that it was up to 30 meters across. The Mayans did not use domesticated animals, so the "highway" was exclusively for foot traffic. This region of Peten is now densely covered with jungle<br />
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The second day I believe was a 26 km (16 miles... I have decided to add a list of conversion factors to my list of travel essentials) arriving on December 31st. My diverse group included 2 Guatemalan guides, 3 Germans, 2 Israelis, 1 Norwegian, 2 Brits, 1 member from Japan, 1 member from Hong Kong, 1 from the Netherlands, and the token American (myself). None of us actually made it to midnight that night, but we spent the day celebrating New Years for every country represented by each of us in the group, starting with Japan at 10am. I watched the sunset on December 31, 2012 from the top of El Tigre, the second highest pyramid in El Mirador. <br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSVRhd3zXnYobp4riTIGP1JBzcNdfhYx110udIXFEkATHZ8CMGp-thIqMQxw2QVi8k3eKIrtWznjSW_ME7pEUIVaILhH5d6Mbe0Bn4hGZrTSdmmtHQ6Wc6Rn67InP2X4DMis9UHCAKjl8Z/s1600/Tapir.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSVRhd3zXnYobp4riTIGP1JBzcNdfhYx110udIXFEkATHZ8CMGp-thIqMQxw2QVi8k3eKIrtWznjSW_ME7pEUIVaILhH5d6Mbe0Bn4hGZrTSdmmtHQ6Wc6Rn67InP2X4DMis9UHCAKjl8Z/s200/Tapir.jpg" width="200" /></a></div>
Each of the buildings in El Mirador was named for an animal: la danta, el tigre, el jaguar are the largest constructions. "La Danta" is a daunting title, but directly translates to "the tapir" which was the largest- and oddest looking- animal that the Spanish could think of. <br />
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We sat around the table in candlelight, high on life and Jesus as the Brits were the only ones with enough sense to bring rum. Naturally we came up with the brilliant idea of going back into the jungle to watch the stars from on top of El Tigre. Our group member from the Netherlands was working on his PhD in physics and would explain to us the workings of the universe from pyramid top.<br />
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Yeah! We're the adventurous and daring group! Coolest group of people to EVER visit El Mirador.<br />
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Juan Carlos was waiting for us at the trail head.<br />
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I'm sorry, you can't go tonight.<br />
<br />
He explained that it was particularly an issue this night because some of the people who were in charge of the El Mirador national park were also camping there this night. We can go to see the sunrise tomorrow he offered in exchange.<br />
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I have a sneaking feeling that we are more predictable than we believe...<br />
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La Danta was incredible. It was built on top of 2 platforms built during different time periods. The first platform was large enough to fit multiple football fields. After climbing the steps to the top, it was unrecognizable as a man-made platform. Jungle had completely taken over and we hiked onward to reach the next set of steps. The next platform was taller, but significantly smaller in area. On top of this was La Danta which was adjacent to several smaller pyramids. <br />
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Each of the platforms was built during different time periods. It is incredible to think that each of the stones was unearthed and carried to this location to build it to what it is today. The total construction spanned a few hundred years, a total of 15 million days of labor and built up to a height of 78 meters. The United States as a nation is just past its 200th anniversary, El Mirador existed starting in 500 BC and fell around 150 AD - existing three times as long as the United States has and La Danta alone took longer to build that my country has been in existence. What is most difficult for me to imagine regarding its construction, it the continued dedication of the society to place resources into its construction, and the agreement that its construction was justified, over hundreds of years. <br />
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El Mirador was the most powerful Mayan site of its time, reaching the height of its civilization by 100 BC. Tikal was just emerging as a society by 1 AD. Even after El Mirador was past its prime, it was still far more powerful than Tikal. The people of Tikal made alliances with surrounding Mayan societies and led a successful attack on El Mirador. Per Juan Carlos, after that many people fled El Mirador and eventually, it was abandoned.<br />
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We stared at this structure, the tallest Mayan pyramid built 2000 years ago. Archaeologists have uncovered parts of El Mirador enough to discover their hidden secrets, but still leaving it looking quite raw. La Danta, this intimidating pile of limestone is now covered in trees and appearing as a small hill in the depths of the jungle. This area of Peten was once heavily populated, likely heavily deforested to made way for homes, markets, and farm land given time has returned to jungle.<br />
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We spent January 1st in the midst of what once was the greatest civilization in central America and watching the clouds pass by. I'm not really sure what I want to accomplish with my life, but for now, I can be ok with the way things are take things day by day.</div>
Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-78542805763613247052012-09-23T20:46:00.001-07:002012-09-24T12:05:51.253-07:00Disco-dosing and PrEP<div dir="ltr" style="text-align: left;" trbidi="on">
Status-post residency, I decided to subscribe to The New England Journal of Medicine in an attempt to look awesome and scholarly in front of my neighbors. Since I began receiving the journal at the beginning of July, the weekly issues have remained stacked on top of my "hope chest", aka ottoman next to the sofa, accumulating dust for the most part and serving as the occasional coffee rest.<br />
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Volume 367 Number 5 happened to attract my attention today; it focused on articles pertaining to pre-exposure prophylaxis for HIV. To give some background, POST exposure prophylaxis (for HIV) has been around for a long time. If a person is exposed to HIV or at high risk of having been exposed, ie unprotected sex, rape, needle stick, the same medications used to treat HIV infection, antiretrovirals, can be used to reduce the risk of transmission or seroconversion to an active infection in the exposed person. Post-exposure prophylaxis is well established in medicine, but recently there has been an increase in studies looking at use of antiretrovirals, ARVs, BEFORE a person engages in an activity that increases risk of HIV infection; I'm talking about sex.<br />
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The iPrEX study opened the flood gates; it found reduced risk of HIV infection when men-who-have-sex-with-men, or MSM, took tenofovir-emtricitabine before engaging in high risk behavior. The aptly named "disco-dosing" was done hand in hand with education on transmission and condom use. The CAPRISA study released shortly after found a 39% reduction in HIV transmission when women in South Africa used a tenofovir vaginal gel before sexual intercourse. The medicated vaginal gel allowed women to take their health into their own hands especially in a culture that gave women little right to demand that their partners or husband wear a condom. Strangely, tenofovir vaginal gel failed to show any benefit in the VOICE study.<br />
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Three studies were published together in the August 2nd issue of NEJM comparing Truvada (emtricitabine-tenofovir) and placebo used daily for pre-exposure prophylaxis in heterosexual persons in Africa. The Partners PrEP study compared the use of emtricitabine-tenofovir or tenofovir alone to placebo in serodiscordant couples in East Africa, where one partner had a positive HIV status while the other was negative, and followed patients for a year. Relative to placebo, daily tenofovir decreased the risk of HIV transmission by 67% while daily use of emtricitabine-tenofovir reduced risk 75%. Patients taking emtricitabine-tenofovir had an increased risk of neutropenia, GI upset, and fatigue but no difference was seen in death or worsening kidney function (tenofovir can cause kidney toxicity). I was surprised that the majority of seronegative patients at baseline were men (62%).<br />
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The FEM-PrEP study evaluated the use of daily Truvada in HIV-negative, higher-risk women in Kenya, Tanzania, and South Africa. High risk was defined as woman whom had had at least one vaginal sex act in the past two weeks or more than one sex partner in the past month. All women were given access to condoms and other medications for contraception. While the study was stopped early due to futility, the investigators saw high pregnancy rates in both groups, including in women who were "taking" oral contraceptives. In addition, adherence rates were self reported as "high" and pill counts showed study drug adherence of 88%, while random drug-level testing showed less than 1/3 of patients were actually taking the study medication. Failure to show benefit may have been secondary to low adherence rates. <br />
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The TDF2 study, also published in the August 2, 2012 edition of The New England Journal of Medicine, compared the use of daily Truvada to placebo in sexually active, heterosexual adults in Botswana, which has the second highest HIV prevalence in the world. All patients were given condoms and counseling on HIV in addition to other HIV prevention services and all women enrolled also had to agree to use effective contraception during the course of the study. There was a 62.2% risk reduction for patients taking Truvada. It is interesting to note that while the FEM-PrEP study only enrolled "high risk" sexually active females, this study had no inclusion criteria for behavioral risk but <i>did</i> show a significant risk reduction of HIV infection.<br />
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Breakdown:<br />
These studies will be instrumental in developing guidelines on populations where pre-exposure prophylaxis, or "disco-dosing" will be most beneficial in preventing infection. While the iPrEX and CAPRISA studies showed benefit to chemoprophylaxis of HIV, many questions remain. In my opinion, starting a daily antiretroviral in an otherwise healthy person puts them at risks of drug toxicities and is an additional burden on the health-care budget. The TDF2 study showed that heterosexual sexually active adults in Botswana could significantly reduce their risk of HIV with daily Truvada, yet it does not seem economically feasible to place all adults aged 18-39 in Botswana on the drug and furthermore encourages the formation of resistant strains to what is the first line NRTI combination for the treatment of HIV. <br />
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While these studies are beneficial in establishing cohorts that may benefit most from chemoprophylaxis, the results are conflicting, as seen in comparing the TDF2 study to the FEM-PrEP study and the CAPRISA study to the VOICE study. In addition to balancing risk of drug-induced toxicity to risk of contracting HIV, no studies as of yet have established the length of time a person needs to stay on PrEP. While emtricitabine and tenofovir are two of the better tolerated ARVs, all studies showed increased nausea, vomiting, dizziness, and drowsiness in patients taking the study medications. It may be difficult to convince otherwise healthy adults to add an additional medication to their daily routine that may come with a side effect burden.<br />
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To conclude, pre-exposure prophylaxis is undoubtably an exciting advance in HIV world, but despite growing numbers of studies, I just haven't been able to buy in quite yet.<br />
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References:<br />
Grant RM et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. NEJM 2010; 363(27):2787-99. (iPrEX)<br />
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Baeten JM et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. NEJM 2012; 367(5):399-410. (Partners PrEP)<br />
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Van Damme L et al. Preexposure prophylaxis for HIV infection among African women. NEJM 2012; 367(5):411-22. (FEM-PrEP)<br />
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Thigpen MC et al. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. NEJM 2012; 367(5):423-34. (TDF2)<br />
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Cohen MS, Baden LR. Preexposure prophylaxis for HIV- where do we go from here? NEJM 2012; 367(5):459-61.<br />
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Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-57681466080507722102012-08-01T22:40:00.002-07:002012-08-02T07:38:26.044-07:00Wisdom from Farmer<div dir="ltr" style="text-align: left;" trbidi="on">
It is very expensive to deliver poor quality health care to poor people in a rich country<br />
-the man, the myth, the legend: Dr. Paul Farmer<br />
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After jumbling times at the International AIDS conference and realizing after the fact that I had missed a presentation by both Paul Farmer, a physician that co-founded Partners in Healthcare, AND Elton John, I was relieved to know that Paul Farmer was coming to Gallup, New Mexico to present.<br />
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Paul Farmer has written extensively on inequalities on a global scale in health care, as I have only read one of his books (now signed!) "Infections and Inequalities" I will be primarily drawing from this, his talk, and personal experience. What I found fascinating about "Infections and Inequalities" is that it provided data to support truths that I had already experienced. At the risk of sounding like a cliche 20-something year old American girl (which I am), it took a trip to a third world country for me to see that the problems of Africa are not so distant from the problems at home. I saw the same disease states in the homeless population of Boston as I did in Tanzania, namely tuberculosis and HIV. <br />
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Paul Farmer remarks in his book that an analysis of the cause of death for the worlds wealthiest fifth is dramatically different than that of the world's poorest fifth, where the leading cause of death is not heart disease or cancer, but rather infectious disease. Shocking still is that likelihood of contracting an infection (or dying from infectious disease) is not determined by the country of origin, but rather from a person's socioeconomic status.<br />
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To return with my opening quote from today's lecture, I believe that Dr. Farmer intended to weigh quality of care with budget, an issue that I am confronted with daily, if not hourly, at an Indian Health Service hospital. When funds are limited, how can we ensure that we are delivering the high quality care that every patient has a right to while staying within budget restrictions?<br />
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Dr. Farmer explained that currently, much of the money going into HIV/AIDS programs is being funneled into establishing primary care programs, which benefit not only HIV positive patients, but the other members of their communities of well. When chronic disease states are well managed, the cost of care decreases as a result of decreased complications. The issue with weighing finances with quality of care is that large funds are not typically allotted to establishing good primary care. Dr. Farmer emphasized the importance of establishing structures, like the hospital or clinic itself, training caregivers, and providing community health reps as vital in improving care quality. Community health reps are people that go on home visits to ensure not only that the patient is taking medications, but also that everything else in the patient's environment is not contributing to worse health outcomes.<br />
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Providing poor quality care increases health expenditures as it does not decrease complications of chronic and acute disease states. A dear friend of mine in Tanzania became ill, was hospitalized for two weeks, and subsequently died. I returned to Tanzania to see her family and to pay back the hospital bill.<br />
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My friend's mother, Bibi (KiSwahili word for grandmother) had already sold her cow in order to make the payment. I agreed to pay her back, only to discover that the cost of a two week hospitalization at a rural hospital was ~$275 USD. The difference in cost between this and a 2 week hospitalization in the U.S. is astounding. When tourists fall ill, they are most often airlifted to the Nairobi hospital, which seems to be considered to provide the highest quality of health care within Eastern Africa. The cost of care at this facility, in addition to transport to this hospital, would have undoubtedly exceeded $275, but would my friend have lived? In healthcare, as in most things, you get what you pay for.<br />
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Paul Farmer emphasized that many things comprise the health of a patient. He believes that poverty, political unrest, and unemployment among other things are disease states. Changing a patient's situation in life has dramatic effects on their health. Many interventions we can make, such as sending out community health reps or CHR, can make an impact through helping the patient to find a more stable living situation or even help to repair things in the patient's home (the example he gave was of a CHR sent out to provide education on diabetes but instead helped to repair a patient's roof). Ensuring a patient's nutrition status can dramatically change their health status as well, to paraphrase Dr. Farmer:<br />
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I am excited to say that I will soon be receiving a nobel prize for discovering that the cure for malnutrition is something called "food".<br />
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Simple, but stable, interventions can go a long way.</div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-15245937893697592022012-07-31T23:07:00.000-07:002012-08-01T22:50:43.040-07:00AIDS 2012<div dir="ltr" style="text-align: left;" trbidi="on">
The first time that I remember hearing about HIV/AIDS was the day the principal of my elementary school retired in 1993. We were at an assembly and the principal was speaking, giving a resignation speech. I was paying more attention to my feet than anything else but as he finished, I looked up and saw that all of the adults in the room, including my mother, were crying. I asked her what was wrong and she told me he had AIDS. It would be a long time before I really understood what this meant. (correction: my mother informs me she does not remember this happening).<br />
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Flash forward: I am a college graduate working in a multidisciplinary clinic caring for HIV positive patients and I have been given the opportunity to attend the International AIDS Society conference in Washington DC. It is absolutely incredible how far medicine has progressed in less than 10 years.<br />
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In remembrance of 1993: there was only one drug available for treatment. Zidovudine, which was first marketed in 1987, is a nucleoside reverse transcriptase inhibitor or "NRTI". It is the only anti-retroviral drug currently available in intravenous formulation and is still used in patients today. However, in light of the most current guidelines, it is shocking to think of using a single medication in treatment of HIV, which mutates rapidly. Current drug regimens typically include two NRTIs and a third medication from a different medication class. The first protease inhibitor did not become available until 1995. In 1993, there were already multiple case reports of drug resistant strains of HIV to the only available drug, zidovudine, developing after the patient had been on the medication for six months or longer.<br />
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Aside from the vast medical advances we have made in the treatment of HIV, it is also worth reflecting how global society has changed since the CDC first recognized HIV in 1981 to the day my principal retired in 1993 to today. In the 1980s, a diagnosis of HIV, a virus well known but not well understood, was a death sentence. The introduction of antiretrovirals provided hope but fear continued to run deep in 1993 and today.<br />
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A week ago at the AIDS 2012 conference Hillary Clinton called for an AIDS free generation, an incredibly bold statement that may in fact be feasible if governments, societies, and health-care professionals continue to fight. I think that making a distinction between an "HIV free generation" and "AIDS free generation" is important to make at this moment. Hillary's plan outlined in her speech focused primarily on increasing efforts at prevention of new infection, but separating the idea of an AIDS free generation from that of an HIV free one would indicate that improving the quality of care for our HIV positive patients could prevent AIDS and allow all patients with a positive status the right to a long and healthy life. <br />
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AIDS, or Aquired Immune Deficiency Syndrome, occurs when the human immunodeficiency virus has destroyed enough of the immune system that it is no longer able to prevent the patient from contracting infections that healthy individuals would not be subject to. Preventing AIDS would include:<br />
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- Test more people: many patients receive a diagnosis of AIDS along with a HIV diagnosis upon initial presentation. The CDC recommends that all individuals between 13 and 64 years of age receive at least one HIV test in their lifetime and more frequently if they engage in high risk behavior, ie unprotected anal sex and sharing needles.<br />
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- Improve follow up. Many patients receiving a diagnosis of HIV/AIDS never follow up and therefore are unable to receive treatment which would likely result in the progression of their disease to AIDS.<br />
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- Get more patients on treatment: medications are expensive but there are a number of assistance programs available. From a global perspective, many countries reserve treatment for when patients develop AIDS because limited treatment options in certain countries increase the risk of developing resistance or losing control of the epidemic if resistant strains are widespread. The type of intervention for improvement would depend on the country.<br />
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- Get more patients to an undetectable viral load on treatment: This means that the medication is working and the patient is taking it like they are supposed to. Unfortunately, HIV hides in certain cells and there is no cure for HIV currently, but having an undetectable viral load allows for the immune system to recover. In a presentation at the conference, it was estimated that about 50% of HIV positive patients (including those not yet tested) had an undetectable viral load versus about 25% of HIV positive patients in the United States. <br />
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I was also fortunate enough to attend a profound session moderated by Laurie Garrett, the author of "The Coming Plague", the book that sparked my interest in epidemiology and public health. She began with a quote from the World Health Organization:<br />
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"The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries." In other words, how do government, health care structure, social norms and culture influence a person's health?<br />
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Also on the panel was Dr. Nono Simelela who ran (runs?) the South Africa AIDS counsel and continues to work closely with the current president. Ms. Garrett set the stage discussing that in a society where 1/3 of the population is HIV positive, people in the society became fatalistic. They saw HIV as unavoidable with death at its heels, and as a result, this fatalism contributed to increased unemployment and further reduced morale. <br />
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Dr. Simelela responded saying that it truly is an epidemic of depravation. Aside from looking for funding for HIV programs, South Africa analyzed the gains already made and uses allotted funds to not only move forward, but to ensure that the gains made are not lost. On striving for an AIDS free generation, she discussed the need to get more people involved. It will not work if it is only government officials changing laws, everyone will need to be an educator. Patients may spend a few hours with a health care professional per year if they choose to access the health system, but that does not account for the 5000+ hours spent doing everything else. HIV is an issue that needs to be discussed from different angles. If people are not talking about it in terms of helping things progress, then little will be gained by society.<br />
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I could go on for pages over what I saw at the conference and what was said in this session, but I will end with a quote from a member of that panel, Michaela Clayton, who works in Namibia:<br />
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<span class="Apple-style-span" style="font-size: large;">We don't defend human rights because people have HIV, we defend human rights because people have human rights.</span><br />
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References:<br />
http://www.kff.org/hivaids/timeline/hivtimeline.cfm<br />
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Erice A et al. Primary infection with zidovudine-resistant human immunodeficiency virus type-1. The New England Journal of Medicine 1993; 328:1163-5.<br />
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http://www.who.int/social_determinants/en/<br />
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Asch DA et al. Automated hovering in health care - watching over the 5000 hours. The New England Journal of Medicine 2012; 367(1):1-3. </div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-1493498198189395272012-06-09T15:15:00.000-07:002012-08-02T07:37:43.302-07:00Statins in Low Risk Patients<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="letter-spacing: 0.0px;"><span class="Apple-style-span" style="font-family: inherit; font-size: small;">Although data supporting the use of statins to reduce cardiovascular risk are extensive, questions remain. Currently experts in cardiovascular health are in disagreement over the use of statins in low-risk patients, particularly patients with high cholesterol but no other cardiovascular risk factors.</span></span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-style-span" style="font-family: inherit; font-size: small;">While statin benefits are well established, real-world cohort studies have shown higher risks of complications and side-effects than seen in randomized-controlled trials. For every 100 otherwise healthy men men who take a statin for five years, one or two myocardial infarctions will be prevented but at least one patient will develop diabetes, and 20% or more will experience significant side effects. </span></span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-style-span" style="font-family: inherit; font-size: small;">One side of the argument states that in low-risk patients, clinicians should focus on lifestyle changes such as diet, exercise and smoking cessation. The use of statins in primary prevention is not a standard of care and the decision to initiate therapy should be based off a careful assessment of risk versus benefit.</span></span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-style-span" style="font-family: inherit; font-size: small;">Although previous meta-analyses have stressed that there is no mortality benefit with statins for primary prevention, a recent meta-analysis published in <i>The Lancet</i> showed that proportional reduction in major vascular events was as great in low risk patients as in high risk patients. Despite the author’s conclusion that statins are beneficial in low risk patients, clinicians remain divided over this issue.</span></span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-style-span" style="font-family: inherit; font-size: small;">References: </span></span></div>
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<span class="Apple-style-span" style="font-family: inherit; font-size: small;"><span style="letter-spacing: 0.0px;">Redberg RF, Katz MH. Healthy men should not take statins. Journal of the American Medical Association 2012; 307(14):1491-3.</span></span></div>
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<span style="letter-spacing: 0.0px;">Mihaylova B, Emberson J, Blackwell L et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: a meta-analysis of individual data from 27 randomised trials. The Lancet 2012; DOI:10.1016/S0140-6736(12)60367-5</span></div>
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</div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-42249872170950103962012-06-08T11:30:00.004-07:002012-08-02T07:37:43.333-07:00Renin, angiotensin, aldosterone and you<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-family: inherit; font-size: small;">There’s no escaping the kidneys in pharmacy. Their significance in drug elimination, blood pressure and salt and fluid balance is undeniable. </span></span><br />
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-family: inherit; font-size: small;">Renin is produced by juxtaglomerular cells in the afferent arteriole in response to decreased pressure in the kidney. Renin is also responsible for the initial rate limiting step in the production of angiotensin. Angiotensin-converting enzyme (ACE) facilitates the final step in the production of the active angiotensin II and is also responsible for the metabolism of certain peptides, such as bradykinin.</span></span><br />
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-family: inherit; font-size: small;">ACE-inhibitors (ACE-i) and angiotensin receptor blockers (ARB) reduce the effects of angiotensin II, which is responsible for vasoconstriction and aldosterone and sodium retention, to decrease the blood pressure and pressure within the kidney through different mechanisms. ACE-i block ACE; however there are other pathways for the production of angiotensin leading to “ACE escape”. ARBs would block angiotensin at its site of action, thereby bypassing the risk of “ACE escape”. Both classes of medications can lead to increases in renin due to sustained lower pressures within the glomerulus.</span></span><br />
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-family: inherit; font-size: small;">Though increased bradykinin is the cause of the notorious ACE-i induced dry cough, it also provides added vasodilation. A recent meta-analysis looking at mortality data from 20 trials utilizing an ACE-i or an ARB compared with a control showed that ACE-i offered a 10% mortality decrease compared with ARBs and the control drug or placebo. The meta-analysis excluded patients who had heart disease or kidney disease, where RAAS inhibition has already been shown to have significant added benefits. </span></span><br />
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-family: inherit; font-size: small;">The analysis shows that there is a clear mortality benefit to using an ACE-i in patients with hypertension without other comorbidities that would indicate RAAS inhibition. If a patient is unable to take an ACE-i, there is no added mortality benefit to using an ARB over another antihypertensive.</span></span><br />
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-family: inherit; font-size: small;">Aliskiren, or Tekturna, is a direct renin inhibitor, the newest class of RAAS inhibitors. Researchers hypothesized that using aliskiren in combination with an ACE-i or an ARB would improve outcomes by targeting RAAS through two mechanisms. The “Aliskiren trial in type 2 diabetes using cardio-renal endpoints” studying aliskiren with an ACE-i or and ARB in diabetics was stopped early in December due to futility as well as increased risk of renal impairment, hypotension, and hypokalemia. Prior to this in 2008, the TARGET study had also shown lack of benefit with combining an ACE-i and an ARB in patients with vascular disease or diabetes with organ damage.</span></span><br />
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-family: inherit; font-size: small;">The Food and Drug Administration, FDA, has recently placed a warning on aliskiren against its use in combination with an ACE-i or an ARB in patients with diabetes or moderate to severe renal impairment. </span></span><br />
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-family: inherit; font-size: small;">While both an ACE-i or an ARB has clear benefit in patients with kidney disease or heart failure, ACE-i are superior to ARBs in mortality benefit in patients with hypertension alone. Combining an ACE-i with an ARB or aliskiren should be avoided.</span></span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-family: inherit; font-size: small;">References:</span></span></div>
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<span class="Apple-style-span" style="font-family: inherit; font-size: small;"><span style="letter-spacing: 0px;">Atlas SA. The renin-angiotensin aldosterone system: pathophysiological role and pharmacologic inhibition. Journal of Managed Care Pharmacy 2007; 13(8): S9-S20.</span></span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">van Vark LC, Bertrand M, Akkerhuis KM et al. Angiotensin-converting enzyme inhibitors reduce mortality in hypertension: a meta-analysis of randomized clinical trials of renin-angiotensin-aldosterone system inhibitors involving 158 998 patients. European Heart Journal 2012; DOI:10.1093/eurheartj/ehs075. Available at: <a href="http://www.theheart.org/viewDocument.do?document=http%3A%2F%2Feurheartj.oxfordjournals.org"><span style="text-decoration: underline;"><b>http://eurheartj.oxfordjournals.org</b></span></a></span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">Lowes R. No aliskiren with ACE inhibitors, ARBs in some patients: FDA. theheart.org April 20, 2012. Available at http://www.theheart.org/article/1388139.do</span></div>
</span></div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-63339465014706827922012-06-07T21:02:00.000-07:002012-06-09T15:24:17.026-07:00Understanding Love and Loss<div dir="ltr" style="text-align: left;" trbidi="on">
It has been about a month since I went back to Tanzania to visit the grave of my sister. As the pharmacy resident, I am not granted much time off during the year, I was unsure of the possibility of returning until after residency but thankfully my supervisor granted me 10 days off to go, as ~3 days were travel days, I had seven days in Tanzania.<br />
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<tr><td class="tr-caption" style="text-align: center;">Memu's home in 2008</td></tr>
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In 2008 I saw Memu's unfinished house in Maji ya Chai and she told me the things she had hoped for; of having a home to herself, now becoming a reality, and how much she wanted a baby. "Like Mama Gladness," she told me of her sister who had raised two sons by herself without accepting a man in her life. Returning in 2010 to see all these dreams become a reality, speeding up the hill on a piki piki to see her again, I hardly even recognized the house. It was beautiful. It was surrounded by a fence and garden and saw her coming down the road her hair in braids followed by her boyfriend. Not long after I left she told me<br />
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Nakupenda dada yangu nakumiss the nest time you came you see my baby<br />
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Images now came to mind of returning this third time after her death and seeing the garden overgrown as well as wondering what would happen to her baby, who is not even a year old.<br />
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The day before I came, her American boyfriend told me that he was leaving for Dar to try to get a visa for the baby. I knew that already I was burdening Mama Gladness by staying with her and now I would not get to see Memu's baby, I had my doubts about going.<br />
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I took a cab from the airport in Kilimanjaro to Tengeru, where Mama lives. I loved the stillness of everything, driving down the highway at night, seeing familiar sights of jungle and shambas, or farms. Past Maji ya Chai, past Usa and we arrived at Mama's house. I collapsed into Mama's arms and finally allowed myself to cry for the first time this trip.<br />
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I allowed Mama to spoil me. We took tea together in the mornings and always ate supper together, talking as long as we could stay awake. It rained most mornings until about noon which made for a good excuse to sleep in and take tea for extended hours.<br />
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The second evening I was there she asked me if I would like to see Lema's grave, her eldest son who was killed in a car accident March 20, four days before Memu.<br />
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<tr><td class="tr-caption" style="text-align: center;">Tengeru, Mt Meru hidden behind clouds</td></tr>
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I couldn't without anything to offer. I made a point of buying flowers in Arusha the next day. Lema is buried behind Mama's house, I spent a moment over his grave. I was not particularly close to Lema despite living with him for four months in 2008. He was only 4 years older than I am. I was never very sure if he liked me while I was living with him, but I remembered the last time I saw him I was walking with Memu down the highway and we saw him.<br />
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So you have come back to buy a house on the hill?<br />
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Maybe next time I told him. It is a little too easy to fall in love with Tanzania. I had always pictured myself someday living in a home near Memu on the hill in Maji ya Chai.<br />
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Even when he was little he liked cars, Mama Gladness told me. She told me that when he was six years old he stole a car to drive to the field at Patandi College to go play.<br />
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I was disappointed that I could not go that same day to see Memu, but Mama and I went together the next day. We took a bus from the market in Tengeru packed so full of people that I was halfway out of the dalla dalla, or bus, for most of the ride. The air was sticky from the rain and hot.<br />
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We then walked past a school and down a hill that was spotted with grave sites. Mama finally stopped at one and laid her flowers down at the base of a cross at it's head. I cried out and dropped down, as soon as I did it felt like a lightning bolt ripped through my skull. My tears stopped and I knelt on the ground next to my sister as my head pounded and Mama stood clutching the cross and wailing in Swahili telling Memu of her sorrows. Her grave was covered with flowers, now blackened and dead and what now stood out more than the flowers were their cellophane wrappers.<br />
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When Mama was finished she went around the grave pulling weeds as if their presence itself was an insult aimed directly at her. I placed my flowers at the head of the grave, pink and purple roses on a bed of blackened flowers. We stood a moment in silence then began the walk back arm in arm in a daze. We walked all the way back to Tengeru. We talked the whole way back but only of good things.<br />
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My flight from Tanzania was set for Thursday evening. That morning, I went to Maji ya Chai to see Memu's home. I had planned to see the hospital where she had died, to try to understand the cause of death, to wonder if I could have changed anything if I had been there, but when I finally got to Tanzania, it somehow didn't seem as important.<br />
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I had pictured the house to be in decline. I remembered this walk in better times. Maji ya Chai seemed unaware of the great tragedy that had befallen it, healthy stocks of corn grew in shambas, trees towered over head, I remember the day as being very clear out. Flowers grew along the drainage ditch and the creek for which Maji ya Chai, meaning "tea water" was named was flooded with the clear brown water that had become its namesake.<br />
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I was surprised to see someone working in the garden when I arrived at the house. I explained who I was and he invited me in. In 2010, Memu and I worked to plant beans together behind the house. She had had a small garden with some vegetables, now her yard was now bursting with corn and a variety of other vegetables. The house was locked and gated but exactly as I had remembered it.<br />
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<tr><td class="tr-caption" style="text-align: center;">Memu 2008</td></tr>
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The day I left in 2010, I left my towel and shower shoes with Memu for the next time I came to stay with her. My shower shoes were now neatly placed at the back door exactly where I had left them a year and a half before; I felt that maybe if I had waited long enough, Memu would walk through the gate and we would start to prepare dinner together. A planter had been built in the behind the house, the top of the rock wall covered in cement with the words<br />
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In memory of MEMU 24MAR2012<br />
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Before leaving for this trip, all I could do was cry and feel a terrible heaviness every time that I thought of her. I sat in the garden of her home that had represented everything she had hoped and worked for, her independence. I thought of all the wonderful times we had together and I smiled.</div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-57793163269915257132012-03-24T22:12:00.003-07:002012-03-25T12:20:32.757-07:00My Sister<div dir="ltr" style="text-align: left;" trbidi="on">
My sister died of pneumonia today. Who knows what was really going on. All I knew was that she was sick. Then she was at the hospital. Then home. Then the hospital again. <br />
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My sister. A 34 year old Tanzanian woman. Calling Memu my sister usually sets off eye rolls or exasperated comments from my friends. I am not related by blood to Memu. I have not even spent very much time together with this woman. <br />
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Maybe because of the intensity of the experience, arriving in Tanzania the day before my 21st birthday, traveling alone by myself for the first time, then managing to make a home for myself in another culture. Maybe because the African sense of family is much broader, any woman of similar age to myself would be greeted as "my sister" in Tanzania. Or maybe because of the intimacy of the conversations I had with this woman my sister. For all these reasons and more, Memu became my sister.<br />
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Her boyfriend, an American, called and told me that she was sick again this week, and back in the hospital. He had informed me the first time, which worried me, but my sister is strong. I was not worried. Hearing she was back in the hospital was concerning.<br />
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I met Memu in the fall of 2008. I came to Tanzania to volunteer. Her nephew, son of her oldest sister (Mama Gladness), ran a volunteer house where I was staying. She would stop by to visit. Eager to make friends with locals, I would greet her and ask her how her day was<br />
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I cook. I feed the animals. I wash the clothes.<br />
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I felt I had nothing in common with this woman. <br />
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A month into my stay, all the other volunteers left which was the best thing that ever happened to me. I started spending more time at Memu's home which she shared with her mother. I would watch her do chores, helping where I could, though I probably slowed her down more so than anything else. Some of my best memories are in her kitchen, a shed attached to the cow pen. With a pot propped above a small fire, the room would fill with smoke till I could barely see and my eyes watered as we chopped vegetables and talked about anything and everything. <br />
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English was difficult for my sister, but this did not deter her from asking me the most complex questions about America and the philosophy of life. I was like a child. She taught me how to carry water, to pick coffee, to cook like an African, and helped me learn to speak kiSwahili and kiMeru, the language of her tribe.<br />
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Every day I would finish volunteering and I could not wait to see my sister, tell her about my day and discuss differences between life in Tanzania and life in America.<br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIhp3HwR5dTuDYhS9MBj0v2rp-gVDA7S80NRaG5lu4aTfTzeaEZfVPnOjZJS46T0xoI2mZs9WL6x62IYvatwsSA5wlaNi3HXjv1QhxJLboT2U-58SxxM20s0EzvjS6rfcXgHCzpHSlrPtI/s1600/1978_609815402899_1816543_38370801_4600_n.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIhp3HwR5dTuDYhS9MBj0v2rp-gVDA7S80NRaG5lu4aTfTzeaEZfVPnOjZJS46T0xoI2mZs9WL6x62IYvatwsSA5wlaNi3HXjv1QhxJLboT2U-58SxxM20s0EzvjS6rfcXgHCzpHSlrPtI/s320/1978_609815402899_1816543_38370801_4600_n.jpg" width="213" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">My sister helps me with my suitcase</td></tr>
</tbody></table>
I learned that she was building a house in Maji ya Chai, water like tea. In the month before I left, she took me to see the house. Maji ya Chai is a small town between Arusha and Moshi. While wazungu, or white people, have flooded into Arusha and surrounding suburbs for safari and volunteer work, Maji ya Chai was untouched by tourism. <br />
<br />
We walked past shops and stands selling vegetables and began a long trek uphill. We walked past empty fields of mahindi, corn and migomba, banana trees. We walked across a small brown creek, for which Maji ya Chai received its name. We walked through fields and past goats and past the water tower and finally as we seemed to near the end of civilization and I felt I could walk no further, there her house was at the top of the hill like a little oasis. <br />
<br />
At the time Memu was living in the home of her mother; she had painstakingly saved money from selling the milk of her cow and piece by piece, bought land and built a house. She had just finished the roof and had yet to add furniture and a few other finishing touches.<br />
<br />
The only thing present in the house was a rug, so we laid out the rug on the floor, Memu bought sodas for us and we laid down on the mat drinking soda pop talking about boys and giggling like school girls. It was one of the best days of my life, I can still remember pieces of that day so vividly, and fondly.<br />
<br />
I came back in 2010, although my trip was cut dramatically shorter. I stayed in her, now finished home, in Maji ya Chai for 3 weeks. I almost didn't recognize it. Fully furnished with a beautiful garden and even electricity, most prized of all was a water spigot in the back yard. Even in Memu's mother's house, Memu would have to walk a half mile to the stream or to her friend's home that had a pump and carry water back every day in order to take care of animals, wash clothes, cook. This home was a little piece of paradise that she had dreamed up and built up herself.<br />
<br />
When I dream of Africa I dream of lying in her garden facing the sky and watching lizards and people pass by. I dream of having a house on the hill in Maji ya Chai next to hers where I could visit often and laugh talk and learn. <br />
<br />
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I made the choice to stay and live in America and help people of my own country that do not have good access to health care. I thought about coming back after classes were over, but I was busy with studying for the pharmacy boards and made the decision to wait until after my residency year. I've been talking to my boss and making plans to come back in November.<br />
<br />
Although I don't think that Memu would see these decisions as a failure on my part to be a true friend, let alone a true sister to her it has been difficult not to look back with regret if I had known! if I had known. But I didn't know. The Memu I know is a healthy woman, and stubborn to the point that even if she had hired help with her work, would probably do it herself anyway. I felt so distanced from what was going on and so confident that she would get better.<br />
<br />
I think of her fierce independence, her thought provoking questions in broken English, and her smile. I think of her incredible patience with me and my complete lack of knowledge of Meru language and culture then her impatience watching her fiercely argue in Swahili to get the best deal on vegetables or bus fare.<br />
<br />
It seems just too ironic that I decided to work with an underserved population in America then to hear that my sister died of pneumonia today. No matter what the cause I know I would feel her loss but aside from that I cannot help but feel anger that her death today seemed to be so preventable. <br />
<br />
In the end it didn't matter that she was well off by African standards. That she had worked hard her entire life. That despite not having a high school education I consider her one of the most intelligent persons I have ever met. She died today because she was a woman living in Tanzania, without access to the same kinds of facilities medications and equipment that would be available in other countries.<br />
<br />
People die preventable deaths in Africa everyday but Memu's strength had always made her seem untouchable to me. I feel cliche writing this, I really don't know how to express what I feel. If I just close my eyes everything will be alright.<br />
<br />
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She will be buried in her garden in Maji ya Chai on Tuesday.<br />
<br />
Nakupenda dada yangu, I love you my sister.<br />
<br />
<br />
<br />
http://www.youtube.com/watch?v=SyJzaPUbmEg</div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com1tag:blogger.com,1999:blog-8837276859428719521.post-51124407704473559092012-03-16T17:37:00.004-07:002012-04-22T17:56:48.036-07:00Genocide in the Age of Globalization<div dir="ltr" style="text-align: left;" trbidi="on">
The road to hell is paved with good intentions.<br />
<br />
It doesn't get more disheartening than that. <br />
<br />
I've decided to use my coveted day off curled up on my sofa reading "The Blue Sweater" by Jacqueline Novogratz, about her experiences educating and lending to micro-finance groups in East Africa, focusing on Rwanda. Its incredible trying to grasp just how interconnected the world is today. I recently finished reading "Black Hawk Down" by Mark Bowden, which had nothing and everything to do with the 1994 events in Rwanda.<br />
<br />
Black hawk down was a disaster and, with 20/20 hindsight, the book reviews where mistakes were made and where things could have gone better in the planning process, yet in the final chapter, the author reviews the events and despite setbacks, the Somalis took a higher toll during the mission than the rangers did. Despite this, Clinton withdrew troops following the "failed" mission and the United States is no longer directly involved in Somalia. Horrifying images of American soldiers' bodies being dishonored in the streets of Mogadishu appeared in the media. With this fresh in the minds of politicians and the American public, there was a sense of reluctancy to involve ourselves in international affairs, especially those in Africa.<br />
<br />
Only months later, on April 6, 1994 a plane carrying the Hutu president of Rwanda and president of Burundi back from peace talks in Arusha was shot down as it flew into Kigali, killing both men. That night, the genocide began to unfold. In 100 days, roughly 800,000 people were murdered by people whom may have been their neighbors, relatives, or coworkers.<br />
<br />
To this day it seems that Rwanda serves as a guilty conscience upon the international community, especially the United States. Because of the delay in labeling the conflict as "genocide" and delay in international involvement, thousands of people were slaughtered.<br />
<br />
It is now eighteen years later and, unfortunately, its seems that history has a cruel way of repeating itself. The United States is now working to finally withdraw troops from Afghanistan and have only recently officially "ended" our involvement in Iraq, after roughly a decade of heavy military presence in both countries. Our reasons as a nation for entering each nation were very different.<br />
<br />
My knowledge of Iraq and its history are fairly limited, but I can say confidently that Saddam Hussain was not a good man and hundreds of his own people were killed under his watch. Post 9/11 the Bush administration played to our sentiments and even Democrats authorized the start of a new war in yet another Middle Eastern country. It took almost a decade before we officially withdrew troops and left; Americans had long growth tired of hearing of our involvement in a country that had initially posed little threat to ours and there had been a growing opinion that we should not have entered to begin with.<br />
<br />
Not all international interventions have been this disastrous; in comparison, our involvement in Libya seems to have gone relatively smoothly, although I am gauging this on the fact that our involvement was short-lived and that I have not seen much about Libya in the news recently.<br />
<br />
Libya aside, my question is, when is it right for the United States to involve itself in the domestic conflicts of other nations? <br />
<br />
More recently has been the plight of the Sudanese. Sudan is (was) an astonishing large and diverse country. The north has an Arab majority which the south is predominantly tribal. In Julie Flint and Alex de Waals book "Darfur: a new history of a long war" the authors criticize the international community for labeling the conflict in this region "genocide" because, they argue, it is far more complex. Although Omar al-Bashir was most certainly aware of, and likely supported, the Janjaweed's atrocities, tribal conflict as well as conflict with neighboring Chad contributed to the suffering of the innocent. Again, the United States involvement was limited, if not non-existant, in this conflict. <br />
<br />
In July 2011, South Sudan gained its independence (http://www.goss.org/). Tensions in Darfur have calmed and people are finally returning home and trying to rebuild (Darfur is located in Sudan, not southern). However there has been recent blasts from the media over a "new" conflict erupting in the Nuba mountains, just north of the South Sudan border. Unlike the ruling power in Khartoum, the Nubians are tribal and are targeted by the government for ethnic and religious reasons. <br />
<br />
Today George Clooney was arrested for protesting outside of the U.S. Embassy for Sudan following the release of a youtube video made by Clooney and the ENOUGH project on March 13 http://www.youtube.com/watch?feature=player_embedded&v=p89OuPODBMM. Op-Ed reporter for the New York Times, Nicholas Kristof, has also written a number of recent pieces on conflict in this area.<br />
<br />
In the final shot of the Clooney video, Clooney stands over a dead body decaying in the sand and words appear on the screen: How many more bodies until the Nuba Mountains become the next Darfur?<br />
<br />
Do I care? One-hundred percent. I think that the world is too connected to allow these kinds of atrocities to take place unnoticed by the global community and, as an American, I believe that every person on earth deserves the basic rights of food, health-care and free speech. However as the international community demands that Omar al-Bashir be overthrown and taken to international court for atrocities he committed, I can't help but think that if we did get involved, could this be another Iraq? Also, I think that there are more cultural complexities to the Sudan than even I can fathom, it may take more than removing Omar al-Bashir to establish peace.<br />
<br />
The only thing I feel I know for certain is that I don't know what the solution would be.</div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com1tag:blogger.com,1999:blog-8837276859428719521.post-31777574753236442382012-03-03T11:13:00.000-08:002012-08-02T07:37:43.324-07:00CHEST 2012 is blowing my mind.<div dir="ltr" style="text-align: left;" trbidi="on">
After committing the 2008 guidelines to heart and four years of reverence as my holy book, the time has come to toss out the old and move onto the new; CHEST 2012 is here.<br />
<br />
Its absolutely amazing how much additional evidence has become available in four years and to see just how much has changed. Although my work cut out for me, in reviewing the guidelines, it makes it easier to review what the experts recommend, rather than trying to go through all the trials and piece together recommendations myself. When guidelines wait too long to provide updates, in the end, they end up discrediting themselves *cough* JNC7 *cough*<br />
<br />
Less than a year out a pharmacy school, I still have trouble wrapping my head around some of these recommendations. Have I become this set in my ways?<br />
<br />
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Let's look at CHEST.<br />
<br />
Warfarin:<br />
Warfarin can be initiated the same day that LMWH/fondaparinux/UFH is started for the treatment of VTE . Pharmacy school hammered into my head the mantra "no loading dose, no loading dose, no loading dose" however new recommendations suggest that patients should be given 10mg of warfarin for the first two days, then dosing after that should be based off the change seen in the INR. This recommendation seems to apply for any indication for warfarin start. This will push the patient into range faster, examples given showed patients more likely to get to range a day ahead of patients dosed conventionally.<br />
<br />
Rebuttal: First and foremost, I would have to review the individual trials to see if patients were dichotomized by age, but it is unclear if the guidelines are recommending 10mg for two days across the board, including our 80 year old grandmas. I would like to see data specific to the elderly before following along.<br />
Secondly, irregular dosing makes it more difficult to establish a starting weekly dose outpatient. From my brief experiences in managing patients in an outpatient warfarin clinic, I have had the most difficulty dosing patients who received highly variable dosing in the hospital, which can end up meaning overshooting or undershooting their INR.<br />
<br />
Despite this recommendation by the consensus guideline, I doubt that many of the anticoagulation pharmacists at my facility will buy into it. The Navajo tend to be slower to respond to warfarin but much more sensitive. For anticoagulation pharmacists across the Navajo Nation, it is hypothesized that there may be a gene that contributes to this, but we have no way of knowing which patients will be more likely to respond in certain ways. Despite how slowly the INR budges in the first few days, some of the patients end up shooting up to incredibly high INRs in the second week. Very little medical research is done on Native Americans (it doesn't take a rocket scientist to figure out why they may be adverse to the idea considering the history with white America) so again, I have no data to support this, but using a loading dose in this population may be more dangerous than using it in other populations.<br />
<br />
Dabigatran.<br />
Dabigatran 150mg twice daily is recommended over warfarin for patients with atrial fibrillation with a CHADS score of one or higher.<br />
<br />
Dabigatran was approved for atrial fibrillation based off the results from the RE-LY trial, which only looked at 110mg twice daily or 150mg twice daily and excluded patients with a creatinine clearance less than 30mL/min. <br />
<br />
I am so excited about the new anticoagulants, and if you understand warfarin, its not difficult to understand why. Warfarin is a difficult drug. But the fact of the matter is, these new drugs are relatively unknown. It is difficult for me to consider recommending an expensive, new drug that has been studied limitedly over the gold standard of anti-coagulation that has been proven effective time and again in clinical trials. Am I afraid of the unknown? To be honest, yes. I know what to expect from warfarin, but I'm not entirely sure of all the risks I bestow on a patient by recommending dabigatran. <br />
<br />
Furthermore, it is interesting that the guidelines specifically recommend only the 150mg twice daily dosing for patients with "good" renal function. The 75mg twice daily dose was never studied in clinical trials and many of the new precautions with bleeding are specific to patients with impaired renal function, despite being on the lower dose. A New Zealand study published in the New England Journal examined a series of case reports regarding bleeding with dabigatran showed that patients with low body weight, low renal function, and older age were at greater risk. Furthermore, the makers of dabigatran recommend that the INR fall below 2.0 for patients previously on warfarin before starting, which may not always be adhered to.<br />
<br />
<span class="Apple-style-span" style="font-family: 'Lucida Grande', arial, helvetica, sans-serif; font-size: 13px; line-height: 16px;">"But dabigatran did not have that caveat; I think the government wanted it be used. They saw it as a good replacement for<b>warfarin</b> and wanted as many people as possible to switch. The uptake was very quick—too quick. Doctors were very keen to prescribe it, and everyone got carried away." </span>Dr. Harper, the primary investigator, tells HeartWire (www.theheart.org).<br />
<br />
To my knowledge, only two patients are taking dabigatran at my facility but are taking the 75mg twice daily dose (not according to my recommendation). One of the patients was switched as a result of variable INR due to non-compliance. This patient is not going to be anti-coagulated if she is non-compliant with her dabigatran, the difference is that we may not know the difference until she strokes out.<br />
<br />
To summarize, I disagree with CHEST's "blanket-statement" recommendation and think that dabigatran should be recommended on a case-to-case basis and the greatest folly I see in the recommendation of the switch to dabigatran is to recommend it in patients who are non-compliant with warfarin. Patients that refuse to take their anticoagulants will not be anti-coagulated.<br />
<br />
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Aspirin.<br />
I have a couple of beefs with recommendations regarding aspirin in the new guidelines.<br />
<br />
For patients that have undergone hip fracture surgery, there is a strong recommendation for clot prevention therapy for at least 10-14 days, out to 30 days. Patients can use LMWH, UFH, fondaparinux, warfarin or... aspirin? really? aspirin? It almost seems hypocritical especially because aspirin has not been recommended as sufficient clot prophylaxis in other scenarios. LMWH is still recommended first line, and honestly I would need to see the full length VTE prophylaxis guideline to fully file my complaint on this one, but... really? aspirin?<br />
<br />
Aspirin is recommended for anyone over the age of 50 WITHOUT symptomatic cardiovascular disease. Aspirin is cheap and prevents clots. In the early years of pharmacy school, I was told to give aspirin to anyone over the age of 50 AND to anyone with diabetes, regardless of age. However, after presenting on the ADA/AHA/ACCF 2010 and U.S. Preventive Service Task Force 2009 guidelines, I began to change my mind.<br />
<br />
The majority of trials looking at aspirin for primary prevention did not reach statistical significance additionally, practitioners are beginning to think twice about using aspirin because there absolutely is an increased risk of bleed associated with its use. Both guidelines focus on weighing the risk of bleed against the risk of having an event. The Task Forces break down the recommendation by age, and recommend aspirin for age cohorts based on the man's risk of CHD and the woman's risk of stroke. Check the document for the specific recommendation, but to ball-park it, use aspirin in patients ages 60-79 when man's risk of CHD is greater or equal to 10% or woman's risk of stroke is greater of equal to 10% (recommendation for use in patients ages 50-59 starts at a lower risk level ~5%). The Task Forces do not make a specific recommendation for ages of either gender above the age of 80 due to significantly increased risk of bleed. <br />
<br />
ADA is easier to follow but can only apply to patients with diabetes. For men over 50 and women over 60 with an additional risk factor (smoking, hypertension, hyperlipidemia, family history premature CVD, or albuminuria) low dose aspirin is recommended. Controlled risk factors are not counted.<br />
<br />
The CHEST 2012 recommendation to use aspirin in any patient over 50 almost seems archaic in light of recommendations made recently by other major medical organizations. The ADA and Task Force guidelines are fairly similar; the CHEST recommendation creates a major discrepancy among other major guidelines.<br />
<br />
So<br />
<br />
I may not agree with everything in the new guidelines, I may be wary to change my ways, but the great thing about the medical field is that is always changing. A professor told me that she had been taught NEVER to use a beta-blocker in any patient with heart failure, now it is the standard of care. These discoveries that completely change clinical practice occur on a year to year basis. I think the best we can do is educate ourselves, read the literature, and keep an open mind. Despite my complaints/rebuttals, I love my new CHEST which if filled with a plethora of fabulous recommendations and will help us to guide therapy to improve patient care.<br />
<br />
References:<br />
pending (please excuse my unprofessionalism), CHEST exec summary, Chest Anticoagulants, CHEST therapy for VTE disease, USPSTF 2009, ADA/AHA/ACCF 2010, http://www.theheart.org/article/1363757.do</div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-1393871187665470552012-02-24T23:20:00.001-08:002012-08-02T07:37:43.298-07:00The girl and the peach<div dir="ltr" style="text-align: left;" trbidi="on">
I wrote this some time ago, back in September, a lot has been going on. I feel much more settled in my new home and work environment, but I still need to set aside time to collect my thoughts.<br />
<br />
The girl and the peach.<br />
<br />
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<span style="letter-spacing: 0.0px;"><span class="Apple-style-span" style="font-size: small;">I was also talking to the ER pharmacist today. We went out to breakfast at Denny’s then tried on boots. She had worked there during her residency for three months. The docs and nurses didn’t always like having a pharmacist there. The ER is small and cramped. It is often overflowing and beds are set up in the walk ways as needed. Less critical patients are often moved out of beds and into chairs. Space is limited.</span></span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-style-span" style="font-size: small;">Besides the trial of becoming accepted as a useful resource in an already crowded area came the emotional toll of seeing good people or children coming in hurt and sometimes permanently damaged from preventable circumstances. The story that has been told to me repeatedly by ER pharmacist is the story of the girl and the peach.</span></span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-style-span" style="font-size: small;">A young girl (2 years old? 6 years old?) was being watched by her grandmother. Her parents had gone out for the day. She was eating a peach. A slice of the peach slid down her throat. She was choking. Grandma called the parents. They were still in town shopping. They would be home later. Grandma knew no first aid. She didn’t even know enough to try to hit the girl on the back to help her to get it back up. As the little girl slowly lost oxygen, she became tired. Grandma told her to go lie down and get some sleep.</span></span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-style-span" style="font-size: small;">When the parents came home hours later, the girl was still sleeping and now, unresponsive. They moved her into the truck and drove the the ER. By the time she had gotten there, she had had the peach lodged in her throat for hours already. She was blue and unresponsive. As the doctors pounded on her tiny chest and struggled to get breathing tubes down into her throat, they saw a tiny heart rate come back.</span></span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-style-span" style="font-size: small;">A child’s heart is very resilient, the pharmacist told me. It will keep beating even after they’re gone.</span></span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-style-span" style="font-size: small;">The little girl was probably already gone long before she came into the ER, but they continued to struggle to save her life.</span></span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-style-span" style="font-size: small;">Eventually, the heart monitor showed only a flat line. She was gone. She died because she had choked on the soft flesh of a peach and her family was so uneducated about basic first aid that the only recommendation her grandmother had given her was to go lie down in her room.</span></span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-style-span" style="font-size: small;">We all cried that day, she told me.</span></span></div>
</div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-59336140443923712382012-01-15T19:05:00.000-08:002012-08-02T07:37:43.345-07:00Emerging vaccines & Latent TB<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="letter-spacing: 0px;"><b><span class="Apple-style-span" style="font-size: small;">Human Immunodeficiency Virus (HIV)</span></b></span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">In the past 20 years since the development of the first antiretroviral medication, science has made great progress in combating the human immunodeficiency virus, or HIV. Research on vaccines has not been promising as of yet, but starting this month, a new vaccine made from killed virus will begin its phase 1 trials. Stay up to date with the Vaccine Trials Network: <a href="http://www.hvtn.org/"><span style="font: normal normal normal 9px/normal Baskerville; text-decoration: underline;">www.hvtn.org</span></a></span></span></div>
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<span style="letter-spacing: 0px;"><b><span class="Apple-style-span" style="font-size: small;">Malaria</span></b></span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><i>Plasmodium falciparum</i>, the parasitic cause of severe malaria, relies on the anopheles mosquito and the human for its lifecycle. Eradication of this disease is potentially feasible, if this cycle can be broken. Interim results for a vaccine showed a 55% protection in infants given the vaccine. Hope seems to be on the horizon, despite major setbacks in the development of multi-drug resistant strains.</span></span></div>
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<span style="letter-spacing: 0px;"><b><span class="Apple-style-span" style="font-size: small;">Ebola</span></b></span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">This hemorrhagic virus kills 90% of patients it infects. Currently the only treatment available is supportive care. Great strides were made in creation of a vaccine when a recent trial showed disease prevention in 80% of mice vaccinated. The vaccine was created through genetically engineering bacteria to grow the viral surface proteins.</span></span></div>
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<span class="Apple-style-span" style="font-size: small;"><span style="letter-spacing: 0px;"><b>New Treatment Option for Latent Tuberculosis</b></span> </span></div>
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<span class="Apple-style-span" style="font-size: small;"><span style="letter-spacing: 0px;">In 2010, nine million people around the world were diagnosed with tuberculosis, TB. Over 11,000 cases were reported in the United States, where prevalence among Native Americans and Pacific Islanders was three times that of caucasian Americans.</span></span></div>
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<span style="font-size: small; letter-spacing: 0px;">Previous options for the treatment of latent TB consisted of either six to nine months of isoniazid or four months of rifampin therapy. Long treatment durations are difficult for patients to adhere to until completion.</span></div>
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<span style="font-size: small; letter-spacing: 0px;">A multicenter randomized trial compared three months of rifapentine with isoniazid to nine months of isoniazid treatment for latent TB. A total of 7731 patients were followed for 30 months. </span></div>
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<span style="font-size: small; letter-spacing: 0px;">Combination therapy was found to be non-inferior with a trend toward superiority. Patients taking combination therapy were significantly more likely to finish the treatment regimen, though were more likely to discontinue therapy due to an adverse event. However, there was significantly less hepatotoxicity with combination therapy.</span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">References:</span></span></div>
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<span class="Apple-style-span" style="font-size: small;"><b>HIV. </b><span style="letter-spacing: 0px;">CBC News: HIV vaccine trial approved by FDA: Canadian-developed vaccine to start human clinical trials in January 2012. CBC News 12/20/11. Available at <a href="http://www.cbc.ca/news/health/story/2011/12/20/hiv-vaccine-western.html"><span style="text-decoration: underline;">http://www.cbc.ca/news/health/story/2011/12/20/hiv-vaccine-western.html</span></a> </span></span></div>
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<span class="Apple-style-span" style="font-size: small;"><span style="letter-spacing: 0px;">Johnston MI. HIV vaccine development- improving on natural immunity. The New England Journal of Medicine 2011;365(10):873-875.</span><b> </b></span></div>
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<span class="Apple-style-span" style="font-size: small;"><b>Malaria. </b><span style="letter-spacing: 0px;">Schweitzer A, Todagbe S, Lell B, Soulanoudjingar SS, Fernandes J, Abossolo BP, et al. Results of phase 3 trial of RTS,S/AS01 malaria vaccine in African children. The New England Journal of Medicine 2011;365(20):1863-75. </span></span></div>
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<span style="font-size: small; letter-spacing: 0px;">White NM. A vaccine for malaria. The New England Journal of Medicine 2011;365:1926-1927. </span></div>
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<span class="Apple-style-span" style="font-size: small;"><b>Ebola. </b><span style="letter-spacing: 0px;">Carpenter J. Vaccine developed against ebola. BBC 12/6/11. Available at <span style="text-decoration: underline;"><a href="http://www.bbc.co.uk/news/science-environment-16011748">http://www.bbc.co.uk/news/science-environment-16011748</a></span></span></span></div>
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<span class="Apple-style-span" style="font-size: small;"><b>New treatment option for latent tuberculosis. </b><span style="letter-spacing: 0px;">Morbidity and Mortality Weekly Report (MMWR). Decrease in reported tuberculosis cases --- United States, 2009. Centers for Disease Control and Prevention 2010;59(10):289-294. </span></span></div>
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<span style="font-size: small; letter-spacing: 0px;">Sterling TR, Villarino ME, Borisov AS, Shang N, Gordin F, Bilven-Sizemore E et al. Three months of rifapentine and isoniazid for latent tuberculosis infection. The New England Journal of Medicine 2011; 365(23):2155-66.</span></div>
</span></div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-30912504571501313372012-01-15T19:01:00.000-08:002012-08-02T07:37:43.320-07:00Bleeding & Dabigatran<div dir="ltr" style="text-align: left;" trbidi="on">
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<span class="Apple-style-span" style="font-size: small;">I could not be more thrilled to see all the new oral anticoagulation options emerge. Warfarin can be difficult to manage due to its many drug interactions and need for frequent monitoring. One of the questions that seems to have arisen with some of the new oral anticoagulants if our patients are being placed in additional risk of a thromboembolic event or a bleed due to our inability to monitor levels and predict drug effect in certain patient populations.</span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-style-span" style="font-size: small;">Dabigatran is a direct thrombin inhibitor marketed in 2010 for prevention of stroke in atrial fibrillation. While no difference in bleeding was seen with the 150mg twice daily dose compared to warfarin, the medication is not risk free.</span></span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-style-span" style="font-size: small;">The Food and Drug Administration (FDA) is currently reviewing case reports of bleeding with the manufacturer, Boehringer Ingelheim, to develop better monitoring and risk assessment strategies.</span></span></div>
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<span class="Apple-style-span" style="font-size: small;"><span style="letter-spacing: 0.0px;">Unlike warfarin, there is currently no reversal method for the effects of dabigatran save for emergency dialysis. The author of an editorial published in </span><span style="letter-spacing: 0.0px; text-decoration: underline;">The New England Journal of Medicine</span><span style="letter-spacing: 0.0px;"> expresses concern over the poor outcomes of patients taking dabigatran admitted for trauma. While warfarin is far from perfect, we are able to reverse some of its effects with the administration of vitamin K.</span></span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-style-span" style="font-size: small;">Patients are at a greater risk of bleeding if they are 75 years old or greater, have kidney problems, or have a history of stomach bleeding. In patients with renal dysfunction, the risk of bleeding is greater even with the reduced dose. Renal function should be monitored frequently in these patients.</span></span></div>
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<span style="letter-spacing: 0.0px color: #346236;"><b>Bleeding with dabigatran. </b></span><span style="letter-spacing: 0.0px;">Cotton BA, McCarthy JJ, Holcomb JB. Acutely injured patients on dabigatran. The New England Journal of Medicine 2011;365(21):2039-40.</span></div>
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</div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com1tag:blogger.com,1999:blog-8837276859428719521.post-21811589793779271102012-01-15T18:53:00.000-08:002012-08-02T07:37:43.306-07:00The American Heart: 2011 in review<div dir="ltr" style="text-align: left;" trbidi="on">
<span class="Apple-style-span" style="font-family: Baskerville;">Despite increasing health care costs and American waist-lines, the mortality rate for cardiovascular disease declined in the past year, according to a recent report from the American Heart Association, AHA. </span><br />
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">From 1998 to 2008, cardiovascular mortality fell 30% but the AHA document illustrates we have a long ways to go. Data from 2008 showed that an average of one American will die of cardiovascular disease every 39 seconds, coronary heart disease is responsible for one of every six deaths in the United States, and that one of nine death certificates mentioned heart failure.</span></span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">The trends are looking good, but cardiovascular disease continues to be the cause of significant morbidity and mortality in the United States.</span></span></div>
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<span style="font: normal normal normal 10px/normal Baskerville; letter-spacing: 0px;"><b><span class="Apple-style-span" style="font-size: small;">children & cardiovascular disease</span></b></span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">In the past 30 years, the incidence of childhood obesity has risen from 4% to 20% and over half of children 12 to 19 have multiple risk factors for developing cardiovascular disease. </span></span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">Among children aged 12 to 19, the prevalence of dyslipidemia is a shocking 20%. Currently, screening this age group for dyslipidemia has not been universally recommended, though statins can be used in children as young as 8 years of age.</span></span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">American Indian youths had the third highest prevalence of childhood diabetes, with 2.28 cases per 1000 patients. </span></span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">While mortality data decreases, let’s continue to encourage patients to eat healthy and exercise; come on Gallup, let’s move!</span></span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">References:</span></span></div>
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<span class="Apple-style-span" style="font-size: small;"><b>The American heart. </b><span style="letter-spacing: 0px;">Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB et al. Heart disease and stroke statistics-- 1012 update: a report from the American Heart Association. Circulation 2012; 125:e2-e220. </span></span></div>
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<span class="Apple-style-span" style="font-size: small;"><span style="letter-spacing: 0px;">Let’s Move Campaign, accessed at <a href="http://www.letsmove.gov/"><span style="text-decoration: underline;">www.letsmove.gov</span></a> on 01/04/12.</span></span></div>
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</span></div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-41290792366731578462012-01-15T18:51:00.000-08:002012-08-02T07:37:43.329-07:00Cholesterol Conundrum<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">Statins have time and again proven their worth in prevention of cardiovascular events. To add to the evidence is the “Effect of two intensive statin regimens on progression of coronary disease” (SATURN) trial which looked at atorvastatin and rosuvastatin therapy in patients with at least 20% occlusion in one or more vessels. </span></span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">Patients who’s cholesterol reached less than 116mg/dL with either atorvastatin 40mg or rosuvastatin 20mg were again randomized 1:1 to maintain the dosage or to increase. </span></span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">There was a statistically significant reduction in percent atheroma volume in patients taking rosuvastatin, but the clinical benefit remains unknown.</span></span></div>
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<span style="letter-spacing: 0px;"><b><span class="Apple-style-span" style="font-size: small;">Treat the patient, not the number</span></b></span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">“Treat the patient, not the numbers” is one of the many mantras of medicine, yet clinical decisions regarding lipid management are far from simplistic.</span></span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">Undisputed, dyslipidemia is a major risk factor for cardiovascular events, and while statins continue to show benefit, there is a dearth of evidence supporting clinical benefit with other antilipid therapies.</span></span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">The AIM-HIGH trial was stopped early due to lack of benefit seen in adding niacin to simvastatin in patients with low HDL and high triglycerides. The 2008 ENHANCE trial failed to show clinical benefit to adding ezetimibe to simvastatin, although the SHARP trial published earlier this year showed that ezetimibe with simvastatin in patients with chronic kidney injury decreased stroke and re-vascularization compared with a non-study statin. The ACCORD-lipid trial failed to show clinical benefit to adding fenofibrate to simvastatin.</span></span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">What these trials all have in common is that they examine non-statin anti-lipid therapy in addition to a statin. Currently there is a lack of evidence of the benefits of these therapies in patients whom are unable to tolerate a statin. </span></span></div>
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;">Patients who are not at goal but tolerating a statin may receive more benefit being switched to a more potent statin than to add a medication. Fibrates, niacin, and ezetimbe should still be recommended for patients unable to tolerate a statin.</span></span></div>
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<span style="letter-spacing: 0px;">References:</span></div>
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<span style="letter-spacing: 0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: x-small;">Nicholls SJ, Ballantyne CM, Barter PJ, Chapman MJ, Erbel RM, Libby P et al. Effect of </span><span class="Apple-style-span" style="font-size: small;">two intensive statin regimens on progression of cornoary disease. The New England Journal of Medicine 2011;365:2078-87.</span></span></span></div>
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<span style="font-size: small; letter-spacing: 0px;">Boden WE, Probstfield JL, Anderson T, Chaitman BR, Koprowicz K, McBride R et al. Niacin in patients with low HDL cholesterol levles receiving intensive statin therapy. The New England Journal of Medicine 2011;365:2255-67.</span></div>
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<span style="font-size: small; letter-spacing: 0px;">Kastelein JJP, Akdim F, Stroes ESG, Zwinderman AH, Bots ML, Stalenhoef AFH et al. Simvastatin with or without ezetimibe in familial hypercholesterolesmia. The New England Journal of Medicine 2008;358:1431-43.</span></div>
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<span style="font-size: small; letter-spacing: 0px;">Baigent C, Landray MJ, Reith C, Emberson J, Wheeler DC, Tomson C et al. The effects of lowering LDL cholesterol with simvastin plus ezetimibe in patients with chronic kidney disease (Study of Heart and Renal Protection): a randomised placebo-controlled trial The Lancet 2011;377:2181-92.</span></div>
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<span style="font-size: small; letter-spacing: 0px;">Ginsberg HN, Elam MB, Lovato LC, Crouse JR, Leiter LA, Linz P et al. Effects of combination lipid therapy in type 2 diabetes mellitus. The New England Journal of Medicine 2010;362(17): 1563-74.</span></div>
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</div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-552856913004111342011-12-03T10:33:00.001-08:002012-08-02T07:38:26.041-07:00Highway Karma<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">I haven’t been home for a major holiday in years. I really dislike traveling around Thanksgiving and Christmas, and, if given enough time off I generally opt for traveling to a new place rather than going to a familiar one.</span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">I had been planning to spend Thanksgiving in Gallup then was invited by a friend to spend it with him in Solana Beach, CA. True, Solana Beach is nearly equidistant to Gallup as the Bay Area is BUT this particular friend happens to live a block away from the beach. My heart was set on it.</span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">Wednesday after work I climbed into my Hyundai with my Bossypants book on tape and an assortment of caffinated beverages. I was so engrossed in Tina Fey’s stories when I noticed that gas was on empty and I had to pee like a racehorse. I’m usually really good about stopping regularly for gas (so I tell myself), but I’ve also noticed that anytime I am running on empty, it is always somewhere miles and miles away from a gas station. Yes, I was officially in the Middle of Nowhere, Arizona.</span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">Exit exit exit exit...</span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">In Montezuma, AZ, I finally found a gas station. Off the exit, all I could see was a gas station and a Mexican food restaurant- nothing else for as far as the eye could see.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8JkLkzfR_J2kTjmBIChCyIycKMNsPLd3ku3KJz9itWYBpsnHAQgSQyHFRYiA7KQ1x03ob5x3cG2c9Z4Qv20DrnrBeekeDFBAfXBYfdAf1uXmfSMEtuKUD8qvtlKY9c3GgiwWc_0Neu5t0/s1600/IMG_8377.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><span class="Apple-style-span" style="font-size: small;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8JkLkzfR_J2kTjmBIChCyIycKMNsPLd3ku3KJz9itWYBpsnHAQgSQyHFRYiA7KQ1x03ob5x3cG2c9Z4Qv20DrnrBeekeDFBAfXBYfdAf1uXmfSMEtuKUD8qvtlKY9c3GgiwWc_0Neu5t0/s320/IMG_8377.jpg" width="213" /></span></a></div>
<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">I ran in and used the restroom at the Mexican restaurant without purchasing anything (an action I generally try to exclusively reserve for Starbucks, aka the public restroom of New York). I left and drove over to the gas station, as I was about to fill up my tank, I saw with horror that my rear driver side tire was COMPLETELY flat. </span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">O jeez... how long has that been there?</span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">Was I really going 80 completely oblivious of a flat?</span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">Can I just put air in my tire and go?</span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">O my god I’m going to be stuck in Montezuma for the rest of my life... am I going to die here?</span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">I went back into the Mexican restaurant trying to keep my cool but dying inside. I explained the situation. No problem, we’ll help you get your spare on. They even refused any compensation for the help. </span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">Have I been completely lucky or unlucky tonight? </span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">I made it to Phoenix. It was past 8; nothing would be open now... and the next day was Thanksgiving. I pulled into a mall trying to find internet and ended up talking to some people in the parking lot. </span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">O yeah, Walmart is open on Thanksgiving and they’re right across the parking lot.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDzDiUkC6N8b9dR6FSwYQJ5NBbkqAZLuu2ea6c6DfVJcLd4TGJmQX5Ktm8T1TRX3T5VcKOS3PZTOcSTEJ_GHavNlfkHKUxzhMs1TKNoiNrjrOpOHvhonybnHyQF8oLYZDbuKOigXkprBHa/s1600/IMG_8443.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDzDiUkC6N8b9dR6FSwYQJ5NBbkqAZLuu2ea6c6DfVJcLd4TGJmQX5Ktm8T1TRX3T5VcKOS3PZTOcSTEJ_GHavNlfkHKUxzhMs1TKNoiNrjrOpOHvhonybnHyQF8oLYZDbuKOigXkprBHa/s320/IMG_8443.jpg" width="212" /></a><span style="font-family: inherit; font-size: small; letter-spacing: 0px;">I spent the night in Phoenix, got my tire fixed and made it to Solana Beach without any trouble. The fiasco was relatively uneventful, but if I hadn’t had help I would never have figured out how to get my spare on etc.</span></div>
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<span class="Apple-style-span" style="font-size: small;">Flash forward to the drive back to Gallup 3 days later. I was about two hours away from getting back to Gallup and pulled off to get gas. I went to park my car to use the restroom (seeing a pattern? I unfortunately was born with a tiny bladder. It's on account of my uterus) and saw a man standing on the curb with all his belongings around him. O god. I don’t want to deal with this. I parked as far away as possible. I tried to look down and hurry past him but there it was...</span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">Going East? </span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">He asked. I mumbled something about being a poor helpless female traveling alone NO HITCH-HIKERS He nodded.</span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">In the restroom I saw a mother and little girl talking.</span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">Are we ever going to get home mama?</span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">Don’t worry sweetheart, we’ll get home. Daddy will find someone nice enough to give us a ride.</span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">O god. I couldn’t leave them. I would be the world’s worst person, especially since it was Thanksgiving which is supposed to be about helping people out in need and eating until you vomit.</span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">They piled into my car and we were off. </span></div>
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">I couldn’t have picked a better ending to the trip. It had an eerie karma feeling to it and left me with a sense of order in the universe (or at least order on the roads of the Southwest). I have passed the right of passage and am, officially, New Mexican.</span><br />
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<span style="font-family: inherit; font-size: small; letter-spacing: 0px;">Images were taken by me at El Morro National Monument in New Mexico.</span></div>
</div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com1tag:blogger.com,1999:blog-8837276859428719521.post-39847320132207344142011-08-17T22:28:00.000-07:002012-08-02T07:38:26.037-07:00Yah'ah'teh'ah'bin'eh!<div dir="ltr" style="text-align: left;" trbidi="on">Good morning!<br />
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I officially know four words in Navajo. It has now been almost a month since I have been back and settled in Gallup from Maryland. And I am preparing again to make another trip. I have been so caught up in trying to figure out how to be a pharmacist that sometimes (actually, most times) I have been overlooking the beauty of the people and landscape around me.<br />
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The Navajo revere things in fours, which is represented in the New Mexico state flag. North, South, East and West seem to guide all aspects of life, with each direction associated with a different time of life, a different stone, a different temperament. The Navajo Nation is surrounded by four sacred mountain peaks, one for each direction. The Long Walk, when the Navajo were forced to go to Oklahoma, was particularly devastating because their land is not only their home; it is their religion.<br />
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An (incomplete) guide to all things in four.<br />
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<span class="Apple-style-span" style="color: #990000;">Ha'a'aah</span>. East Dawn Spirit.<br />
<br />
I was told by an older Navajo woman working at the hospital that as a child, she was woken up by her mother before dawn and taught to run toward the east, to the rising sun. Good things come from the East and as children, they were taught to run out to greet it with arms outstretched.<br />
<br />
Mount Blanca is the eastern mountain.<br />
<br />
<span class="Apple-style-span" style="color: #990000;">Shadi'aah</span>. The South.<br />
<br />
Gallup is closest to the Southern mountain, Mt. Taylor. The South is "nahata", planning, knowledge, competence. Turquoise is the stone.<br />
<br />
<span class="Apple-style-span" style="color: #990000;">E'e'aah</span>. West.<br />
<br />
Represented by yellow and "iina": inspiration, life. <br />
<br />
The San Francisco peaks near Flagstaff, AZ represent the west of the Navajo Nation. These mountains also have special significance for the Hopi. A nurse who had worked in Tuba City for a long time, and was one of less than 30 non-Hopis to speak the Hopi language, informed me that the Hopi believe their gods to live on top of the San Francisco peaks. This land is disputed territory between the Navajo and Hopi people.<br />
<br />
There is quite a bit of tension between the ski resorts on the San Francisco peaks and the Navajo Nation. The ski resorts generate snow atop the mountains to extend the ski period, this snow is made from waste water. In juxtaposition, only the most revered elders are allowed to climb to the top of these peaks. It is a sacred place, the mother, that is sprayed with waste water so that tourists are able to come and ski.<br />
<br />
<span class="Apple-style-span" style="color: #990000;">Nahookos</span>. North. Folding Darkness Spirit.<br />
<br />
North is old age. Si ha sine integrity and hope.<br />
<br />
Hope is one of the most important values to the Navajo. When speaking of bad things, such as possible complications to a procedure or disease state, it is important to speak in the third person, otherwise you may be wishing harm on the patient and taking away their hope.<br />
<br />
<br />
<br />
I have so much to learn.</div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-22299723819187891062011-07-29T23:47:00.000-07:002012-08-02T07:38:26.026-07:00The Rubix Cube<div dir="ltr" style="text-align: left;" trbidi="on"><br />
<div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0.0px;">It was 110 in DC and humid on the day that I left. As I stood in line outside to check my luggage, I felt as though I were on the border of life and death. I would have passed out if the thickness of the air hadn’t been holding me up. </span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 14.0px;"><span style="letter-spacing: 0.0px;"></span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0.0px;">Inside, the airport was packed. The majority of terminals where I was waiting were also waiting for planes to Dallas. It was so hot out that the planes were not able to take off with full passenger loads, leaving many, including some of my friends from training who had left for the airport over an hour before I had, struggling to get standby on flights. My plane luckily boarded me but needed to make an emergency landing in Nashville for fuel. Delayed taking off and delayed again in Tennessee when a leak in the hydraulics was discovered, I was starting to accept that I would probably be spending the night in the Dallas airport. </span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 14.0px;"><span style="letter-spacing: 0.0px;"></span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0.0px;">In Dallas, I was booked on standby for a full flight. I remained hopeful until I saw an entire high school boarding. There was no way I would make it on this flight.</span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 14.0px;"><span style="letter-spacing: 0.0px;"></span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0.0px;">Somehow, I made it. I was the last person allowed to board. I breathed a sigh of relief as I sat down next to an attractive young man about my age deftly flipping the colors of a rubix cube into disarray then back to solids and again into checkered patterns.</span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 14.0px;"><span style="letter-spacing: 0.0px;"></span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0.0px;">You just have to know the algorithms. he said. I don’t even look at the cube anymore, you just know it in your fingers.</span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 14.0px;"><span style="letter-spacing: 0.0px;"></span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0.0px;">He was going to a naval academy in Annapolis, MD. Both his parents were musicians and he grew up on the road. His friends were shocked when he announced that he was joining the military after growing up in a family of musicians. He did it for the travel, the education, and to serve his country.</span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 14.0px;"><span style="letter-spacing: 0.0px;"></span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0.0px;">I watched him play with the rubix cube some more. Making order out of chaos then watching the colors spin out of control again with a few quick turns.</span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 14.0px;"><span style="letter-spacing: 0.0px;"></span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0.0px;">It’s hardest at the end. You get so close to what you need it to be, then you have to mess it up almost completely to fix it.</span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 14.0px;"><span style="letter-spacing: 0.0px;"></span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0.0px;">I think that its the same in life. Sometimes you just have to give into chaos, let it overtake you in order to restructure yourself and come out finding more meaning and order in your surroundings than ever before. As I begin my career, part of me wonders what I am doing by completely uprooting myself and finding work in a place that may as well be a foreign country compared to Boston. I just have to find the algorithm.</span></div></div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-80579781273850980922011-07-29T23:35:00.000-07:002012-08-02T07:38:26.048-07:00The Accident<div dir="ltr" style="text-align: left;" trbidi="on"><br />
<div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;">Some of the people you meet on the road are really amazing. I want to tell the story of one woman I met.</span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><br />
</span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4hqKnb9egC2itFr0FP6Uv_ApE_D48zOgfO7koMD3RiGmm-umjk65ynnARB1EnVfGNUi1AxiqKUuiFKK3oFKUGicG4L2CJRgii4s0420K29N8K7oIjkIjdxO9tq1jFPY6d5r9tH5BFXqMh/s1600/IMG_7603.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4hqKnb9egC2itFr0FP6Uv_ApE_D48zOgfO7koMD3RiGmm-umjk65ynnARB1EnVfGNUi1AxiqKUuiFKK3oFKUGicG4L2CJRgii4s0420K29N8K7oIjkIjdxO9tq1jFPY6d5r9tH5BFXqMh/s320/IMG_7603.JPG" width="320" /></a></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;">She is a White Mountain Apache woman living in Wisconsin/Minnesota. She seems so motherly and gives off warmth and protection. Her dark eyes under blond eyebrows show that her mind is whirling and part of her is off in some other world, she seems to be seeing something else, beyond what I am able to see around me. She is difficult to follow because she seems to be lost in another realm and speaks almost painfully slowly and quietly. </span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 14.0px;"><span style="letter-spacing: 0px;"></span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;">I sat with her at dinner and she was talking about her work and getting commissioned.</span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 14.0px;"><span style="letter-spacing: 0px;"></span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;">She mentions she was in a terrible motorcycle accident 2 summers ago. She was biking with friends, some of whom had children serving overseas, and they were going to a memorial site to mourn those lost. Her front tire lost 25 lbs of pressure rapidly, her cycle began veering side to side and she went down in a ditch, smashing her head against the pavement. </span><br />
<span style="letter-spacing: 0px;"><br />
</span><br />
<span style="letter-spacing: 0px;">She was not wearing a helmet. </span><br />
<span style="letter-spacing: 0px;"><br />
</span><br />
<span style="letter-spacing: 0px;">She smashed her cheekbone, split open the side of her face and cracked her skull, suffered a brain hemorrhage.</span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 14.0px;"><span style="letter-spacing: 0px;"></span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;">She lay in the hospital about to die. Surrounded by the surgeon and her family. One of the tribal counsel members came. He laid eagle feathers across her body and called her back from the dead. He told her that it was not her time to die, the Chippewa tribe needed her. He called on her to live. He called on her to open her eyes. She opened her eyes.</span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 14.0px;"><span style="letter-spacing: 0px;"></span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;">Her face bore no scars as she calmly recounted the story. The tribe needed her. She is getting commissioned. She has a duty and mission to serve for her tribe and country. </span></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 14.0px;"><span style="letter-spacing: 0px;"></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBMVYCGazO1D6wyN-JSdiB_4axOHM5MB1VXeBvRFbMT0pfLekovkuyKmu4tXf6TpAMQCQbbYKCGoUYX-vRifnS3FrMltJsMYgIC9CN88eHF2M1wGXhD-zWQPdg4nFjdphvndRWY4uh1Psr/s1600/IMG_7620.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBMVYCGazO1D6wyN-JSdiB_4axOHM5MB1VXeBvRFbMT0pfLekovkuyKmu4tXf6TpAMQCQbbYKCGoUYX-vRifnS3FrMltJsMYgIC9CN88eHF2M1wGXhD-zWQPdg4nFjdphvndRWY4uh1Psr/s320/IMG_7620.jpg" width="213" /></a></div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 14.0px;">So you wear a helmet now, right? I asked wide-eyed</div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 14.0px;"><br />
</div><div style="font: 12.0px 'Gill Sans Light'; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 14.0px;">Her dark eyes under blond eye-brows stared back at me and she laughed.</div></div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-30961942971582918162011-07-09T19:23:00.000-07:002012-08-02T07:38:26.033-07:00Disparity and the American Dream<div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">The highest attainable standard of health is one of the fundamental rights of every human being.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-tab-span" style="white-space: pre;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"> </span></span></span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">-WHO</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBwkJ3KyLfH6eRcSk98fqHVPK_6YdEbzIyKEIy434K31h2ZWCZ7mnhrwm56qej-ts-lyJW5vtG6Jq2SWwJM5Jh3FEtsw9-wrWBsBmI7BA9Ir_FxPEAaWtCP-cqDwvsLco9UK8pctahGUvv/s1600/IMG_7177.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><img border="0" height="133" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBwkJ3KyLfH6eRcSk98fqHVPK_6YdEbzIyKEIy434K31h2ZWCZ7mnhrwm56qej-ts-lyJW5vtG6Jq2SWwJM5Jh3FEtsw9-wrWBsBmI7BA9Ir_FxPEAaWtCP-cqDwvsLco9UK8pctahGUvv/s200/IMG_7177.JPG" width="200" /></span></span></a></div><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">I have come full circle. I left Boston, arrived in California, drove to Gallup, and have now flown back to Maryland for training.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">After an 10+ hour drive from Los Angeles to Gallup, I rushed to the grocery store before closing for essentials like diet Coke and toilet paper. I gushed to the clerk about my excitement in moving to Gallup from Boston and I am ready for new adventures!</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">You won't have any adventures here.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">I'm sorry, I misunderstood you, could you repeat?</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">I said, you won't have any adventures here.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">Oh....</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">I think that has been the meanest thing anyone has said to me.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgHqo0u7NHPp6Z3HtVonRgEaKXtiBYBy3vTQocVijOrdECsJZktFMVFgHPaEPY77I_mR7hUvW93Dtz85r9CbknsL2Xxg83jXHSKRprBQ_WZEEjsZO7jzLgB_Rv9FxkjZ_y-L1TqVOrhND-w/s1600/IMG_7198.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgHqo0u7NHPp6Z3HtVonRgEaKXtiBYBy3vTQocVijOrdECsJZktFMVFgHPaEPY77I_mR7hUvW93Dtz85r9CbknsL2Xxg83jXHSKRprBQ_WZEEjsZO7jzLgB_Rv9FxkjZ_y-L1TqVOrhND-w/s320/IMG_7198.jpg" width="213" /></span></span></a></div><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">The week and a half spent in Gallup flew by, but as I boarded my flight to Washington-Reagan, I felt as if I had already been there for months. My coworkers welcomed me with arms outstretched and my transition to work and new living has been relatively smooth.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">I had hoped to sleep on the plane, my first flight was only an hour and I ended up in Dallas, walking around in a daze. Just as I had settled into my seat, I had to get up again to let by a bulky man with dark slicked back hair, smooth skin, and a long braid. His friend, who had leopard print dyed hair settled in to the window seat behind him.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">"Excuse me, miss?" he asked the stewardess.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">"Are animals allowed on the plane?" giving a nod to his friend and laughing as the stewardess tried to suppress a smile and shook her head.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">We soon struck up a conversation on travel. This man seemed to have been everywhere in Europe, the US, and central/south America. I jotted down notes on places I needed to visit in the future as he announced that he had been receiving pilot lessons and had been giving talks to inner city kids about the high investment-returns on becoming a pilot.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiK5p4RBxG_53I_4i_IswjJVz6YrZbttrRHnRvRQvTrN2GNww0bppmuQjkn6nW31QmEpnn1MLePoTIH-t3n-6Y_NchZFjX07HzpQxMRLgFoOdQ4tRbmYoHjaFauMM9NNpR-Uxm4EDrseuhc/s1600/IMG_7203.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiK5p4RBxG_53I_4i_IswjJVz6YrZbttrRHnRvRQvTrN2GNww0bppmuQjkn6nW31QmEpnn1MLePoTIH-t3n-6Y_NchZFjX07HzpQxMRLgFoOdQ4tRbmYoHjaFauMM9NNpR-Uxm4EDrseuhc/s320/IMG_7203.jpg" width="212" /></span></span></a><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">You don't have to be a rocket scientist. Some of the best people to be pilots are people who are creative, or people who are good a video-games. You have to be able to multi-task, to get creative if something goes wrong. But you don't need to be book smart. </span></span></span><br />
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<span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">These kids, they don't want to work for something. They want to make money quick. The pimps and drug dealers, they become role models in the inner cities. The kids see people like me or you with good jobs, but they don't see all the work and struggle we went through to get what we have. They don't want to do the work. They want the money quick.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">I added that many inner city kids are less likely to be encouraged by their parents to do school work or go to school. They end up so far behind that catching up becomes impossible. Even community college may be out of reach for someone who never graduated from high school and barely made it through grade-school.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJsUa5THx6mWw-xYto0EiQ3t8a0RQYq1OpB_6iZNcVp1CqCh_lt9l-yQ_DNVhZ3eyIyMtiHeU3GYVnlQe_mtzYwEqYrIRAr2kVrOJwtuFc2DMs500L9nRL4foJBoww2M81a7VClweV_dvX/s1600/IMG_7183.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJsUa5THx6mWw-xYto0EiQ3t8a0RQYq1OpB_6iZNcVp1CqCh_lt9l-yQ_DNVhZ3eyIyMtiHeU3GYVnlQe_mtzYwEqYrIRAr2kVrOJwtuFc2DMs500L9nRL4foJBoww2M81a7VClweV_dvX/s320/IMG_7183.jpg" width="212" /></span></span></a><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">Inner city kids are also more likely to be raised by a single parent working multiple jobs. As a result, the parent is unable to be at home enough to enforce school attendance. Even if the parent recognizes the value of education, if they are always working and unable to be home, their ability to encourage school attendance is low.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">An unexpected lesson on humility.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">In the glare of the American dream lie inequality and disparity. Poverty, lack of education, and poor health always seem to appear together. </span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">While theoretically a microbe should be just as able to infect one person as the next, Paul Farmer outlines in his book, "Infections and Inequalities" that while the first world designates funds for research into preventative medicine, the threat of bioterrorism, and getting patients the best and newest treatments, the global South struggles to provide treatment for curable or treatable diseases to its patients. In 1990, only 8% of the world’s wealthiest fifth died of infectious disease, in comparison to 56% of the poorest fifth. Poverty is directly related to increased susceptibility to infectious diseases in addition to worse outcomes.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><div class="separator" style="clear: both; text-align: auto;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><br />
</span></span> </div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjatweD9-4fz3xbenXqABWvtavgUttVpRzOHck_PJTCs0tAY3wGoWkfH-BesbdaL4q55ty-dWyKarOvim6t5QenTOVaikQL3YM3db0vEZs5XHOL-BK2Bz__93Fh186BNScTD-sC0pxBAhSG/s1600/IMG_2257.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjatweD9-4fz3xbenXqABWvtavgUttVpRzOHck_PJTCs0tAY3wGoWkfH-BesbdaL4q55ty-dWyKarOvim6t5QenTOVaikQL3YM3db0vEZs5XHOL-BK2Bz__93Fh186BNScTD-sC0pxBAhSG/s320/IMG_2257.jpg" width="213" /></span></span></a></div><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">In Tanzania, cancer, hypertension, hyperlipidemia, diabetes, and other chronic diseases are all present but are overshadowed by malaria, tuberculosis, HIV and other infectious diseases. I saw the same infectious diseases, save malaria, present in the homeless population in Boston. Although I do not have prevalence data, it is unreal to me that such high incidences of tuberculosis were present in a population living practically within my neighborhood while, to my knowledge, I know of no college friends who have been afflicted.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">The poor are less likely to have access to proper sanitation facilities and more likely to live in cramped crowded spaces. The poor are less likely to have a means to pay for health care, such as health insurance. </span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi2oIlPSfV3rulRzz60QAHP8oqoBq1ezIL735nOPFTrQ70-un-wUXHck2-f4oI-4fnqSQ4E0NjXQeoT5ZCELxf_jPlsZVBrGxm7_hY4B0HZdmYXGjflJohx8MC7HVnhAbB6_FzeQ_kHaJcs/s1600/IMG_4035.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><img border="0" height="133" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi2oIlPSfV3rulRzz60QAHP8oqoBq1ezIL735nOPFTrQ70-un-wUXHck2-f4oI-4fnqSQ4E0NjXQeoT5ZCELxf_jPlsZVBrGxm7_hY4B0HZdmYXGjflJohx8MC7HVnhAbB6_FzeQ_kHaJcs/s200/IMG_4035.JPG" width="200" /></span></span></a></div><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">In 2008, extra funding allowed Oregon to insure more of its residents. 90,000 Oregonians enrolled, far exceeding the amount of people that could be covered by the funding. The result: a computer randomized Oregonians to receive or not receive a health plan. Due to ethical reasons, this was the first experiment of its kind and showed that residents with insurance were more likely to access health care, have less medical debt (and more medical bills paid), and have better self-reported health. There was no difference in emergency room visits.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><div class="separator" style="clear: both; text-align: auto;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><br />
</span></span> </div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirAIRYzlVCVkO-8ZQ5f_iF0-CdBKTiD0_aJhI_5avRKrf6DIyhBTvx-LE-6PYm3yerQI-juMUqvmNH3pH4sV6uAkghumbQk6WNgRik009OsvzlK8fsudhC5Wc4PZiVbZ72dhcKVb6je_2Q/s1600/IMG_7201.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><img border="0" height="133" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirAIRYzlVCVkO-8ZQ5f_iF0-CdBKTiD0_aJhI_5avRKrf6DIyhBTvx-LE-6PYm3yerQI-juMUqvmNH3pH4sV6uAkghumbQk6WNgRik009OsvzlK8fsudhC5Wc4PZiVbZ72dhcKVb6je_2Q/s200/IMG_7201.JPG" width="200" /></span></span></a></div><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">Under looming threats of increasing cuts to Medicaid, the nation would likely be affected if less people are insured or as plan coverage worsens by decreased productivity and the possibility of increased strain on other assistance programs. The Oregon study showed that medical debts are less likely to be paid by patients that do not have insurance, which would also place a strain on the budgets of hospitals and clinics.</span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px; min-height: 21.0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><span style="letter-spacing: 0px;"></span></span></span></div><div style="font: 16.0px Geneva; margin: 0.0px 0.0px 0.0px 0.0px;"><span style="letter-spacing: 0px;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">Available treatment options are far from flawless. While I highly admire scientists struggling to innovate panaceas and better methods for testing and treating patients, the real challenge in health care lies in distribution of resources ensuring that those in our communities, states and nation are not dying of preventable and curable diseases.</span></span></span><br />
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<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgznf2J_BvM8Qg-n3i0CZcMPL7lQOW2gWQGuwJEXmLel3pkGEMJn1N8dnmR7AYzeNnBKxxDAl9IFW_Z3VnqSdn8bU3eybXifJm8loOpbCs2xT7rdya8XD24_HNuQZN_kehifbeTMDasakuG/s1600/IMG_7353.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><img border="0" height="266" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgznf2J_BvM8Qg-n3i0CZcMPL7lQOW2gWQGuwJEXmLel3pkGEMJn1N8dnmR7AYzeNnBKxxDAl9IFW_Z3VnqSdn8bU3eybXifJm8loOpbCs2xT7rdya8XD24_HNuQZN_kehifbeTMDasakuG/s400/IMG_7353.JPG" width="400" /></span></span></a></div><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><br />
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<span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">References:</span></span><br />
<span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">Farmer P. Infections and Inequalities: the modern plagues. University of California Press 2001.</span></span><br />
<span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;"><br />
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<span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">Allen H et al. What the Oregon Health Study can tell us about expanding Medicaid. Health Affairs 2010:29(8)1498-1506.</span></span><br />
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<span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: inherit;">Finkelstein A et al. The Oregon health insurance experiment: evidence from the first year. National Bureau of Economic Research 2011.</span></span></div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-85512244396128181912011-04-22T08:14:00.000-07:002011-04-24T16:58:10.647-07:00Atlas Shrugged<div dir="ltr" style="text-align: left;" trbidi="on">I am a member of the Massachusetts Green-Rainbow party and I like Ayn Rand.<br />
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<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZ2WB6jtWrsBAgOuO930-ebuCziOZHlNfszhiJ9gsGWaJ3MxOVtruoksF4wMVvi8kAn_TL63xhUtzYEBVzcwpXULTBMr5-TiYUHPyOqKM89A7KTT0ZQV01aq4AkSSeUYJU_NjS5uEocJYN/s1600/IMAG0066.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZ2WB6jtWrsBAgOuO930-ebuCziOZHlNfszhiJ9gsGWaJ3MxOVtruoksF4wMVvi8kAn_TL63xhUtzYEBVzcwpXULTBMr5-TiYUHPyOqKM89A7KTT0ZQV01aq4AkSSeUYJU_NjS5uEocJYN/s320/IMAG0066.jpg" width="191" /></a></div>I feel like I should join a support group. I found out just yesterday that a movie had been made based on her novel, Atlas Shrugged, and 10 minutes later was out the door and on my way to the theater.<br />
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I thought that Francisco was too fat and Dagny was too vulnerable, the overly-dramatic background music grated on my nerves and some of my favorite moments or lines were distorted from the novel. The movie also cut the book into two parts but the first part was only 90 minutes long. Other than that it was alright.<br />
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Ironically, I read Atlas Shrugged while I was volunteering in India. I had read The Fountain and We the Living previously. Although Ayn Rand is known as a champion for the Red (I'm much more of a rainbow), I don't think that her ideals go against mine and in fact, I perceive her ideals as being critical of the current state of the Republican party.<br />
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Although the author would disagree, the philosophy Atlas Shrugged is not anti-altruism but rather seeks to expose the irony of persons using a shield of selfless-ness to further their career or to profit from the hard work of others. You can call is altruism. You can call it selfless-ness. You can call it utopia. But selfish destructive acts can easily be perpetrated under the guise of morality. The looters of Atlas Shrugged construct a morality that will keep them in power and keep wealth within their circle of cronies and call it in the best interest of society. Those with the intelligence to see through the bullshit and the audacity to succeed in spite of open distain for the administration are black-listed.<br />
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<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEihzaPw-8TUD6dL3JSARsl5P2FZr2pYsym_dy9MjE8LG3LPyOLrXCpdg5Fm3XhuvoFGXf8F0n7smS_dfTUuOT2uBwrRBTGjQbD1oaiBlxezZEuLCUfpUHncKbFxtYPlOHx9tyO8VzXiyEQz/s1600/andy-warhol--money-icon.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEihzaPw-8TUD6dL3JSARsl5P2FZr2pYsym_dy9MjE8LG3LPyOLrXCpdg5Fm3XhuvoFGXf8F0n7smS_dfTUuOT2uBwrRBTGjQbD1oaiBlxezZEuLCUfpUHncKbFxtYPlOHx9tyO8VzXiyEQz/s1600/andy-warhol--money-icon.png" /></a></div>Ayn Rand also questions motives in her novels. I don't like suffering. I like sleeping in a bed. I like having heat in my house. I like being able to take hot showers. I do like volunteering and reading Ayn Rand did not take any of the enjoyment out of that for me. In volunteering, I am given a unique experience to expose myself to different work environments for a short period of time. In international volunteering, I came to a new place, a new culture, and was able to make friends in a new place and to gain exposure to different systems. I like meeting people and being able to teach them things about my culture and ways to better improve their health. It is fulfilling to come to a new place for a short time and leave knowing that you will be remembered.<br />
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<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhHNkd-jr2IFd7uEYPIUel7SfCilr9A9CztGmDYMj4ksvt2IKH2iWANvDNW2SW-V7qbCHovrh9IZHBatoImRQLT7DJ0kG_nRmePE6Gko0D6F2f_B7ITv9R22nFzkBmB6lXNR41HtXf_j2Xj/s1600/IMG_3137.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhHNkd-jr2IFd7uEYPIUel7SfCilr9A9CztGmDYMj4ksvt2IKH2iWANvDNW2SW-V7qbCHovrh9IZHBatoImRQLT7DJ0kG_nRmePE6Gko0D6F2f_B7ITv9R22nFzkBmB6lXNR41HtXf_j2Xj/s320/IMG_3137.jpg" width="213" /></a></div>I do not volunteer because I feel that forcing my opinions and ideals on other people will save their lives. I have gone away from my volunteer experiences with so much more knowledge than I could have ever hoped to give to anyone else. I would not expect that everyone would want to spend their money on the same things that I have spent my money on. Ultimately, it makes me happy and my selfish motives do not change anything objectively that I have done.<br />
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Someone who truly suffers for the sake of others without hope of anything in return is bound to burn themselves out. I strongly believe that no one is truly able to help others or contribute to society unless they put themselves first, for obvious reasons: a sick or mentally unwell person would be incapable of delivering a high quality of work and eventually would become a burden on the people around them and on their society.<br />
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Rather than putting it in terms of selflessness and altruism, it is human nature to trade. In Howard Bloom's The Global Brain, he shows that human civilizations through all ages have relied on trade for survival. Even babies will trade with each other. A person will be more likely to share or give to a stranger in whom they can identify qualities that they associate with themself, unconsciously in hopes that a stranger would give to them if they were in a similar situation. I don't give money to homeless people but I gave money to a pregnant middle class girl at South Station who was trying to get home to New Jersey, and I have met much more pleasant homeless people. Altruism is not selfless, it is human to expect something in return.<br />
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Although Atlas Shrugged depicts "the looters" profiting from the hard work of others, ultimately, it is the workers who profit in the end. Although Ayn Rand starkly defends wealthy businessmen who have profited from a lifetime of competence and hard work, her Atlantis is also filled with everyone who is hard working and good at the jobs that they do, no matter what the job. The workers, in the end, take over the bourgeoisie policy makers. Atlas Shrugged stands against the lazy and inactive who profit off the hard work of others.<br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhao4ZnmSKCWQM9olLieYuMgUdfZFQGL6tmIW26yDZppFmuRL2aidxCsWklKUpNS-E_AHRl0ArVWdbshW57AshMfnHWDxKT2sCPa1ROoi5VsAvF31VUvBenkfE9AMYFP61QL2r5SrRn2zYV/s1600/ayn-rand.gif" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="245" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhao4ZnmSKCWQM9olLieYuMgUdfZFQGL6tmIW26yDZppFmuRL2aidxCsWklKUpNS-E_AHRl0ArVWdbshW57AshMfnHWDxKT2sCPa1ROoi5VsAvF31VUvBenkfE9AMYFP61QL2r5SrRn2zYV/s320/ayn-rand.gif" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">www.toothpastefordinner.com</td></tr>
</tbody></table>In that, the ideals behind Atlas Shrugged are shockingly similar to Marx in that, as society tumbles and falls, it is the workers who will prevail. Any idea can be distorted. Communist societies have more parallels to dictatorships than to the ideals of the Democratic party. It all comes down to semantics in my opinion.</div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-68139560799856421732011-04-19T15:19:00.000-07:002011-04-19T15:30:49.529-07:00Biking through the history of Plymouth<div dir="ltr" style="text-align: left;" trbidi="on">I'm finally done with school! It really seems unreal. I was getting so anxious about what I would do with all this time off- I haven't been able to pick up very many shifts at work and I am lacking funds for extravagant vacations. I suppose this is Vishnu's way of telling me to go on amazing biking adventures.<br />
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<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0okWTteB-9_mVgVI2Bjs9PHCPgrd-zfyV7Jc8kO_NriRTDuOqWcRKvOou2f6U7CVYCSsKWZL4eytI3mUVYjg2CFXdPoQskI2Go2xY9U5V6pXcxeZU3WUM7kXplyt5NJ2p9j2kk3NyuBaj/s1600/P5270013.JPG" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0okWTteB-9_mVgVI2Bjs9PHCPgrd-zfyV7Jc8kO_NriRTDuOqWcRKvOou2f6U7CVYCSsKWZL4eytI3mUVYjg2CFXdPoQskI2Go2xY9U5V6pXcxeZU3WUM7kXplyt5NJ2p9j2kk3NyuBaj/s200/P5270013.JPG" width="200" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Provincetown 2007</td></tr>
</tbody></table>Yesterday I convinced my good friend, Dunk, to bike with me from Boston to Plymouth on Marathon Monday. I've lived in Boston for six years and have gone out of my way not to see Plymouth rock; it was finally time. I was secretly making extravagant plans to try to bike all the way out to Provincetown, or P-town which is 125 miles away. I didn't quite make it.<br />
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Dunk was a little more realistic. He agreed only to accompany me if we would take the T to Braintree then take the commuter rail back. I grudgingly accepted.<br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRnvanSPQb4MxG0A1zmA5XSlE0O9wmfSVgDkae9yhNW-g8UMgeroqkpN4X_CHUyWuLrFa6KhO07qvyw6rjDrhAoJGX0MNhmGlFxrPuHlVzkZQJS4kkM_aNwXvRqDUOJDR5iMZa-ESalh0w/s1600/IMG_0030.JPG" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRnvanSPQb4MxG0A1zmA5XSlE0O9wmfSVgDkae9yhNW-g8UMgeroqkpN4X_CHUyWuLrFa6KhO07qvyw6rjDrhAoJGX0MNhmGlFxrPuHlVzkZQJS4kkM_aNwXvRqDUOJDR5iMZa-ESalh0w/s200/IMG_0030.JPG" width="133" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">JFK, Hyannis</td></tr>
</tbody></table>Besides living in Hyannis for four months, I hadn't really seen the south shore. It was beautiful. We tossed the route that I had mapped out and Dunk took me through back roads and along the ocean. There's something about seeing the ocean that is just so freeing, the smell always brings over a wave of nostalgia whether I am on the west coast, east coast, or watching hundreds of crabs scuttle along the shore of the Indian ocean, making the sand appear as a moving living entity.<br />
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After biking though Hingham, or (not so) fondly known as Chi-ching-em, we cut through Jerusalem street in Cohasset and as I came over the final hill, the ocean lay sprawling in front of me as blue as tanzanite and crashing against yellow rocks. I'm so sad I have no pictures. We biked on through Marshfield and Duxbury, or "Deluxe-bury", finally reached Plymouth, and collapsed on the ground.<br />
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Plymouth actually wasn't the first place that the pilgrims landed. They first landed in P-town, decided it was too gay for their taste, and moved onto Plymouth.<br />
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They tried to escape the king and all they found was queens, Dunk told me.<br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgZGpuVQo2Nju9pT3KzaKKBWlCdUvnRSJxe1gHLWZNzGUrpm2-NaOe3F7DeGZQAOE95rSIJYx_ujxJGJU6jU_2tkNwjnb2d3cSbKkLsQOR63NYe9tEv0X1s_KVmlFP4DO3fG_TWBIAoVzQv/s1600/IMAG0995.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="191" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgZGpuVQo2Nju9pT3KzaKKBWlCdUvnRSJxe1gHLWZNzGUrpm2-NaOe3F7DeGZQAOE95rSIJYx_ujxJGJU6jU_2tkNwjnb2d3cSbKkLsQOR63NYe9tEv0X1s_KVmlFP4DO3fG_TWBIAoVzQv/s320/IMAG0995.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Plymouth Harbor 2011</td></tr>
</tbody></table>When the Pilgrims landed in Plymouth in 1620 they first met the Wampanoags. The Wampanoags had been trading with Europeans since the 1500s. In the early 1600s, they had been depopulated by a series of epidemics. Massasoit, Squanto, and Hobomah extended a welcoming hand to the Pilgrims, who would not have survived the first year without aid. Soon more settlers came. In only five years, the Pilgrims requested more land from the Pemaquid tribe, whose leader signed a treaty to humor them. In 1630, Boston was founded. By the time Massasoit died in 1662, the Wampanoags were being pushed further back.<br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0NKQQ05BXA2ttqe9zXRgogAWyY5xPeW-Wd63Hdmf7fCAHI75f50NroZfd7N2svgO2h2MxgEHnpH2oIGHQmOlzHygzoygzVo6L2PKQ9C_x0h5LfOZccrzgG-uPf3KF66SAE4sGmgpi2DIs/s1600/IMG_9996.JPG" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0NKQQ05BXA2ttqe9zXRgogAWyY5xPeW-Wd63Hdmf7fCAHI75f50NroZfd7N2svgO2h2MxgEHnpH2oIGHQmOlzHygzoygzVo6L2PKQ9C_x0h5LfOZccrzgG-uPf3KF66SAE4sGmgpi2DIs/s320/IMG_9996.JPG" width="213" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Peace pipe, Hyannis</td></tr>
</tbody></table>Metacom, son of Massasoit and dubbed "King Philip" by the settlers, began to form alliances with neighboring tribes in anticipation of more settlers to arrive. In 1675, Metacom with the Wampanoags and Narragansetts launched a war on the settlers. The settlers responded to the violence with violence, and as their battle technology far surpassed that of the Narragansett and Wampanoag, the American Indians suffered a great defeat. Metacom was killed and his head was displayed on a pike in Plymouth for twenty years.<br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhCC8Xj91gvKMuZGMEiHpkAVlQAQRdj51Cgfgnu_3hVDDmV5njd7FZc30Mm2bt4CUobwckseD0UVFIPc_fg9oAjp_dPMRpo_FlUe3KwapBMAGbjWRdhX70mGRCRlhnpTQ5XI6xxaTE4TPqm/s1600/IMAG0998.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="119" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhCC8Xj91gvKMuZGMEiHpkAVlQAQRdj51Cgfgnu_3hVDDmV5njd7FZc30Mm2bt4CUobwckseD0UVFIPc_fg9oAjp_dPMRpo_FlUe3KwapBMAGbjWRdhX70mGRCRlhnpTQ5XI6xxaTE4TPqm/s200/IMAG0998.jpg" width="200" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Mayflower II</td></tr>
</tbody></table><br />
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I found out after I already got back to my home in mission hill that there were wigwams on display at the Plymouth Plantation as well as some information about the local native tribes. <br />
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<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg9D-Zmn3hwfAGaFNjOvFMet4-DQzr2OMWXZ40LhJ4xdxhXNxNEtL79mzl9RB3AWGF-FZ0NTeDUfcpoRbMp5cSETphrZ2cF-SSNkLBFURcag_3I4t4dE5SMG9C_cXw_z76SWFGFvgcv_ZqO/s1600/IMAG1002.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="190" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg9D-Zmn3hwfAGaFNjOvFMet4-DQzr2OMWXZ40LhJ4xdxhXNxNEtL79mzl9RB3AWGF-FZ0NTeDUfcpoRbMp5cSETphrZ2cF-SSNkLBFURcag_3I4t4dE5SMG9C_cXw_z76SWFGFvgcv_ZqO/s320/IMAG1002.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">the rock</td></tr>
</tbody></table>I got to see the Mayflower II and caught a glimpse of Plymouth rock. Dunk informed me that the real rock is out in the bay and the rock on display is just symbolic of the Pilgrims landing. <br />
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In the end, I was thankful to be taking the commuter rail back. My legs felt like butter. We gazed out the window, counting cranberry bogs until we fell asleep.<br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsLwkhDnE_qgz3i9cKzlgrOAJznvET7wpatb6tvwmCuihyphenhyphenPKejuPeSVqAR9Fx6AHpUOYBnNGMTNnFp9FgHdfEPI3EjvPvA43XTN7a5DiVPFhuHd-sIy5n8VVMHn5eIRr0M2TQmeV-rObGc/s1600/IMG_0011.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="266" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsLwkhDnE_qgz3i9cKzlgrOAJznvET7wpatb6tvwmCuihyphenhyphenPKejuPeSVqAR9Fx6AHpUOYBnNGMTNnFp9FgHdfEPI3EjvPvA43XTN7a5DiVPFhuHd-sIy5n8VVMHn5eIRr0M2TQmeV-rObGc/s400/IMG_0011.JPG" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Cranberry bog in Hyannis</td></tr>
</tbody></table><br />
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References:<br />
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Brown D. Bury my heart at wounded knee: an Indian history of the American west. Henry Holt and Company, NY. copyright 1970.</div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0tag:blogger.com,1999:blog-8837276859428719521.post-9829746923390364022011-04-07T15:12:00.000-07:002012-08-02T07:37:43.348-07:00Statins and Diabetes<div dir="ltr" style="text-align: left;" trbidi="on">Baby I'm afraid of a lot of things but I ain't scared of loving you.<br />
- Karen O<br />
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<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhmHArf4puufeZFXyuwqMA4yNMblZrnw2aDaAXM4lbvQertq_BACpsytpYROv5R0SQCoZFpAI8GD9wxB-xQRe9IYBsxqZ1skmBwgIquafxEDSlMukQEnL0gKUWXrNURH9qOLG4Fe74Jfa-k/s1600/KnolCandyMain.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhmHArf4puufeZFXyuwqMA4yNMblZrnw2aDaAXM4lbvQertq_BACpsytpYROv5R0SQCoZFpAI8GD9wxB-xQRe9IYBsxqZ1skmBwgIquafxEDSlMukQEnL0gKUWXrNURH9qOLG4Fe74Jfa-k/s320/KnolCandyMain.jpg" width="213" /></a></div>Diabetes scares me probably more than any other disease state. Diabetes puts patients at risk of slow healing wounds, peripheral neuropathy, increased infections, kidney failure, cardiovascular events, and is the number one cause of blindness.<br />
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My roommate has the best definition of diabetes that I've ever heard:<br />
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If you eat too much candy, your foot is going to fall off.<br />
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She has a point.<br />
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There is no way to prevent type 1 diabetes, but research into preventing type 2 diabetes is endless. Most recently there has been evidence showing that statins increase the risk of developing diabetes. An inquisitive NP at my rotation was asking me about a Huffington Post article in regards to the topic, so in the past few days I have attempted to dissect the evidence and assess the risk.<br />
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<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcVi122zE-FNRT5AKsY6rrwducK9ZrXLdjiTf97gxbCN5QS2Jqre28_AA3j_sS0oOVtFqwkXXS66IHjslQKhyvvLhRJWzkBGBkK7_6ah44ipTWh5evHddkCcrMlriPscYeQM-vetdJezfa/s1600/voyager-jupiter.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="296" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcVi122zE-FNRT5AKsY6rrwducK9ZrXLdjiTf97gxbCN5QS2Jqre28_AA3j_sS0oOVtFqwkXXS66IHjslQKhyvvLhRJWzkBGBkK7_6ah44ipTWh5evHddkCcrMlriPscYeQM-vetdJezfa/s320/voyager-jupiter.jpg" width="320" /></a></div>Attention was first called to incident diabetes with statin use when the JUPITER trial was published in NEJM in 2008. Despite screening for cardiovascular risk factors, an estimated half of all myocardial infarctions occur in patients that are at their target LDL goal. C-reactive protein, a marker of vascular inflammation, has been shown to be a risk factor for CV events independent of cholesterol levels. Statins have been shown to reduce C-reactive protein levels in addition to reducing LDL.<br />
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The JUPITER trial looked at patients at a LOW risk of CV events but high C-reactive protein levels: men over 50 and women over 60 who had no history of cardiovascular disease, and LDL less than 130mg/dL, and a C-reactive protein level greater than 2.0mg/L. Patients with diabetes, blood pressure above 190/100, low renal function, or use of anti-lipid therapy were excluded. 17,802 patients randomized to 20mg rosuvastatin or placebo were followed for a median of 1.9 years to the occurrence of the first event: MI, nonfatal stroke, hospitalization for unstable angina, arterial revascularization, or cardiovascular death.<br />
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Patients taking rosuvastatin 20mg had a decreased risk of cardiovascular events; one event prevented for every 95 patients treated over two years or 31 patients treated over four years. However, the study also showed a statistically significant increase in the onset of diabetes in patients taking rosuvastatin.<br />
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<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiS8AJYbYWOytvfgY2_EXoyVC7FsR3VI_0-aE9UVW1qjJRiYrNsm46FU257ZPfhLdinIKY5QPYDBTn27E1VEKKQm5GZCeePn-2nwpC8RATQM6UBbu9JOa0HL0ZhxMrJA4ohbAUgaF9DURLe/s1600/cupcake.png" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiS8AJYbYWOytvfgY2_EXoyVC7FsR3VI_0-aE9UVW1qjJRiYrNsm46FU257ZPfhLdinIKY5QPYDBTn27E1VEKKQm5GZCeePn-2nwpC8RATQM6UBbu9JOa0HL0ZhxMrJA4ohbAUgaF9DURLe/s1600/cupcake.png" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">The Buttery</td></tr>
</tbody></table>The PROSPER study published in 2002 also showed a significant increase in diabetes in patients taking pravastatin.<br />
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In response, Sattar et al. conducted a meta-analysis of trials containing over 1000 patients treated with a statin for at least a year. The analysis included 13 trials and 91,140 patients. The statins used were atorvastatin, lovastatin, rosuvastatin, simvastatin, and pravastatin; where six of 13 trials utilized pravastatin. <br />
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Sattar et al. found a 9% increase in new onset diabetes in patients taking a statin, or one more new case of diabetes in a patient on a statin for every 225 patients treated for four years. Increase in diabetes was seen even without the inclusion of the JUPITER trial. The only other correlation to the development of diabetes was increasing age.<br />
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The analysis by Sattar et al. only included one trial, ASCOT-LLA, that utilized atorvastatin. The stir in the medical community lately has been over an analysis by Waters et al. published in 2011 looking at the incidence of diabetes in IDEAL, TNT, and SPARCL which all utilized atorvastatin.<br />
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<tr><td class="tr-caption" style="text-align: center;">New York</td></tr>
</tbody></table>I am disappointed that Waters et al. did not conduct a meta-analysis, but they found a trend to new-onset diabetes in the TNT and IDEAL trials and an increase in new-onset diabetes in SPARCL. Patients that developed diabetes were more likely at baseline to have higher fasting glucose, BMI, white blood cell count, blood pressure total cholesterol/HDL ratio, and triglycerides. 80mg of atorvastatin was more likely to worsen glycemic control than 10 or 20mg atorvastatin. Age differences, sex, and smoking were not associated with incident diabetes.<br />
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The real question is how this will change the way we treat patients. Despite a slight increase in diabetes, statins have been shown to decrease the risk of cardiovascular events and mortality. Waters tells heartwire, "Compared with their risk of a cardiovascular event, their risk of developing diabetes is paltry" and advises patients not to stop taking their statins. Dr. Blumenthal of John Hopkins Medical Institute also comments to theheart.org that this analysis will not change his use of statins. ALLHAT similarly showed an increase in diabetes in patients taking chlorthalidone, but these patients had improved mortality outcomes. <br />
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</div>The available evidence shows that the benefit that patients receive from statins outweighs the risk of diabetes. To me, these analyses show that no medication comes without risk. Its a reminder to those that believe or believed that statins should be in our drinking water that this is a prescription medication. There is a risk of liver dysfunction, rhabdomyolysis, and now, a risk of diabetes associated with their use. Patients should be monitored accordingly.<br />
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I would attempt to make lame parallels between the JUPITER trial and the planet, but I know that I cannot do the planet justice. I think I have failed my parents. My mother builds satellites and my dad builds video servers by day, and charts the sky by night. Check out his amazing nebula photos at:<br />
http://astrospotter.zenfolio.com/<br />
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<tr><td class="tr-caption" style="text-align: center;">Hyannis 2008</td></tr>
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References:<br />
Ridker PM et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. The New England Journal of Medicine 2008;359(21):2195-207.<br />
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Shepherd J et al. Pravastatin in elderly individuals at risk of vascular disease: a randomised controlled trial. Lancet 2002;360:1623-30.<br />
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Sattar N et al. Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. Lancet 2010;375:735-42.<br />
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Waters DD et al. Predictors of new-onset diabetes in patients treated with atorvastatin. Journal of the American College of Cardiology 2011;57(14):1535-45.<br />
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Hughes S. More data on diabetes risk with statins. March 30, 2011; http://www.theheart.org/article/1203383.do </div>Rxxxhttp://www.blogger.com/profile/13829173569627275582noreply@blogger.com0