Favism

Favism.  G6PD deficiency.  Name derived from the hemolytic anemia a patient with G6PD deficiency will suffer after consuming fava beans.  My preceptor at my most recent rotation recently emailed me, asking if I would fill a prescription for the second generation antihistimine, meclizine, for a patient with G6PD deficiency.  Before I could answer, I had to take a few steps back and look at what exactly G6PD deficiency is.

G6PD, or glucose-6-phosphate dehydrogenase, is the rate limiting enzyme for a process that produces NADPH as a byproduct.  NADPH is a reducing agent used in the synthesis of fatty acids and cholesterol and is also utilized to protect cells from oxidative damage.

NADPH is essential to erythrocytes, which having no nucleus, during their 120 day lifecycle are unable to synthesize new proteins to repair cellular damages.  Erythrocytes rely heavily on reducing agents, like NADPH, to protect against oxidative damage.

Patients with G6PD deficiency have genetic mutations in the glucose-6-phosphate dehydrogenase enzyme.  The mutation in the enzyme determines the severity of the NADPH deficiency, and therefore the ability of erythrocytes to react to oxidative damage.  

Under conditions of oxidative stress when NADPH supplies are not sufficient to reduce the damage done to the cell, oxidized hemoglobin clumps together within the erythrocyte creating Heinz bodies, which are characteristic of G6PD deficiency.  This leads to hemolytic anemia, as the red cells burst and die.  

Symptoms of G6PD deficiency are brought on by oxidative stress; a variety of stressors can bring about hemolytic anemia.  Infections, diabetic ketoacidosis, fava beans, and some medications can bring on hemolytic anemia within days of exposure.  

Hemolytic anemia is often brought on by medications in patients with G6PD deficiency when glutathione reduces the medication in the liver during the metabolism process.  In order for the body to return glutathione to its usable state, the oxidized glutathione is reduced by NADPH.  When the mutant enzyme cannot keep up with replacing the NADPH stores, erythrocytes begin to suffer oxidative damage and anemia results, with the tell-tale Heinz bodies, dark urine, and often patients experience back-ache.

Unfortunately the medications that cause hemolytic anemia in this patient population are not structurally similar.  Additionally, many medications that are metabolized by glutathione reductase are safe, in therapeutic doses, for patients with G6PD deficiency to take, for example acetaminophen.

G6PD deficiency is genetic; prevalence varies among populations.  Persons of mediterranean, African, and middle eastern decent are more likely to have this deficiency.  A number of researchers have hypothesized that this enzyme mutation may have evolutionary survival benefits.  For example, like patients with an allele for sickle cell disease, recent studies have shown that patients with G6PD deficiency are less susceptible to malaria caused by Plasmodium falciparum.  

so...  Would I fill meclizine 25 mg for a patient with a salicylate allergy and G6PD deficiency?

Although metabolized in the liver, meclizine does not place patients with G6PD deficiency at risk of hemolytic anemia and is therefore safe to take.  Diphenhydramine, however, poses a low risk of hemolytic anemia.

Medications that put G6PD deficient patients at high risk of hemolytic anemia include: trimethoprim, dapsone, sulfa drugs like sulfamethoxazole, chloroquine, quinine, quinidine, ciprofloxacin, nitrofurantoin, primiquine, and probenecid.  This list is not all inclusive and other medications, like acetaminophen, diphenhydramine, and phenytoin pose a low risk of causing hemolytic anemia.

Patients with a G6PD deficiency can be referred to the G6PD Deficiency Favism Association’s website, available at http://www.g6pd.org for more information on their condition and for an extended list of medications to avoid.  

References:

Meisenberg G, Simmons WH, ed.  Principles of Medicinal Biochemistry.  2nd ed. Mosby-Elsevier, Philidelphia.  copyright 2006.

Beutler E.  G6PD deficiency.  Blood Journal 1994; 84: 3613-3636.

Brunton LL, Lazo JS, Parker KL, editors. Goodman and Gilman’s: The Pharmacological Basis of Therapeutics.  11th ed.  New York: The McGraw-Hil Companies, Inc.; 2006.

DRUGDEX® System (electronic version). Thomson Micromedex, Greenwood Village, Colorado, USA. Available at: http://www.thomsonhc.com (cited 11/27/2010).

G6PD Deficiency Favism Association.  Available at http://www.g6pd.org (cited 11/27/2010).

Kastrup EK, Spenard PL, Tra PN, Williams AL, Wickersham RM, Schwalm AJ, et al., editors.  Drug Facts and Comparisons.  2010 ed. St. Louis: Wolters Kluwer Health; 2009.

Dabigatran

I have never liked the sight of blood, which is why the thought of anti-coagulants at first made me uneasy.  However, blood clots can pose a significant health risk.

Symptoms of blood clots depend on where the clot is.  In hospitals or airplanes, where the patient is less able to move around to keep blood flowing through their veins, there is a serious risk of blood clotting in the legs due to venous stasis, which could result in a DVT, or deep venous thromboembolism.  A blood clot that travels to the lungs is a pulmonary embolism, a blood clot that gets lodged in a coronary artery causes a myocardial infarction, and a blood clot that blocks a cerebral artery results in a stroke.  

Clots are a serious health risk.  A person with no baseline risk of clotting has no need for daily anti-coagulant therapy.  However, there are a number of disease states and conditions that increase a patient’s risk of a blood clot.  

Anti-platelet medications such as aspirin and clopidogrel reduce risk in patients with low baseline risks of blood clots.  However, certain conditions mandate stronger anti-coagulant therapy.

Atrial fibrillation is an arrhythmia that results in blood stasis in the heart when the electrical signaling in the heart prevent the heart from beating at a normal rhythm.  Patients with atrial fibrillation are at higher risks of clots, their risk is calculated from five of risk factors (the CHADS2 score).  For years, the only available oral anti-coagulant has been warfarin (brand Coumadin) which requires patients to be closely monitored by a physician for their INR, international normalized ratio or bleeding time.  The INR is kept within a specific range, usually 2-3 but it depends on the condition, lower INRs are associated with increased risk of clot whereas a high INR could result in a life threatening bleed.

Warfarin inhibits the production of vitamin K dependent clotting factors; it inhibits numerous clotting factors in the clotting cascade but its effects can be reversed by administration of vitamin K.  It is the only medication of its class and was first developed as a rat poison. 

Warfarin tablets are very inexpensive.  However, use of this medication requires a lot of monitoring and constant dosage adjustments.  Furthermore, if the patient changes the amount of vitamin K consumed within a week, the patient’s INR will change.  Additionally, the time to reach optimal clotting time is dependent on the half life of the clotting factors, and not on the medication.  Even after steady state has been reached, clotting factors that were produced before administration of warfarin will keep the INR low.  Approximately 5 days are needed before warfarin is showing its full effects, although the INR will start to increase after a few days of therapy.

A second class of anti-coagulants are the direct thrombin inhibitors (DTIs).  This class has been restricted to injection drugs until only recently.  The first of the class, lepirudin, is derived from hirudin, an anti-coagulant released by leeches to allow the continuous sucking of blood without clotting.   While there is no antidote for DTIs, they only inhibit one clotting factor making them a “cleaner” class of drugs. 

Dabigatran etexilate is the first oral direct thrombin inhibitor to be available on the market in the United States.  There are currently only two available doses on market: one for patients will normal renal function (150 mg twice daily) and a second for patients whose creatine clearance is below 30 mL/min (75 mg twice daily).  Monitoring of INR is not necessary.

Two major ground breaking trials were published comparing warfarin and dabigatran in venous thromboembolism treatment and as clot prophylaxis in patients with atrial fibrillation at the end of 2009 in the New England Journal of Medicine.

In a non-inferiority study by the RE-LY study group, over 18,000 patients with atrial fibrillation and a CHADS score of at least 1 were randomized to three treatment arms: 110 mg dabigatran twice daily, 150 mg dabigatran twice daily, or a warfarin dose titrated to a goal INR.  The warfarin arm was not blinded.  The patients were studied for 2 years until stroke or systemic embolism and the primary secondary outcome was major hemorrhage.  

Both doses of dabigatran were shown to be non-inferior to warfarin and the higher dose of dabigatran was shown to superior to warfarin.  There was a statistically significant reduced risk of hemorrhagic stroke with both doses of dabigatran compared to warfarin and less bleeding with the 110 mg twice daily dose of dabigatran than warfarin.  The risk of a major bleed with warfarin found within the RE-LY trial was found to be higher than the risk determined in prior studies.  The risk of major bleeding with warfarin determined in this study may have biased the results in favor of dabigatran.

The RE-COVER trial published in NEJM in 2009 compared the treatment of venous thromboembolism (VTE) by dabigatran compared with warfarin.  1274 patients were randomized to receive 150 mg dabigatran twice daily or warfarin titrated to an INR of 2-3.  Dabigatran was determined to be non-inferior to warfarin for treatment of a VTE with no statistically significant difference in bleeding.  However, more patients on dabigatran therapy experienced dyspepsia and were more likely to discontinue the study drug.

Dabigatran has been shown to be a safe alternative to warfarin in the treatment of VTE and in prevention of clots in atrial fibrillation.  There is less monitoring involved, making it ideal to health care professionals but patients should be monitored for compliance due to the high incidence of dyspepsia.  Although it is more expensive, it would be interesting to see in a pharmacoeconomic analysis if the cost of the drug is offset by reduced cost of monitoring.

References:

Baetz BE et al.  Dabigatran etexilate: an oral direct thrombin inhibitor for prophylaxis and treatment of thromboembolic diseases.  Pharmacotherapy 2008; 28(11): 1254- 1373.  Accessed at http://www.medscape.com/viewarticle/583856 on 11/10/2010.

Medi C et al.  Stroke risk and antithrombotic strategies in atrial fibrillation.  Stroke 2010; 41: 2705-2713.

Ezekowitz MD et al.  The evolving field of stroke prevention in patients with atrial fibrillation.  Stroke 2010; 41(suppl 1): S17-S20.

Connolly SJ et al.  Dabigatran versus warfarin in patients with atrial fibrillation.  The New England Journal of Medicine 2009; 361(12): 1139- 1151.

Camm AJ.  The RE-LY study: randomized evaluation of long-term anticoagulant therapy: dabigatran vs. warfarin.  European Heart Journal 2009; 30: 2554- 2555.

Gericke CA.  RE-LY study (dabigatran vs. warfarin in atrial fibrillation)- a call for caution.   European Heart Journal E-letter; published November 26, 2009.  Available at http://eurheartj.oxfordjournals.org/content/30/21/2554.extract/reply#ehj_el_95

Schulman S et al.  Dabigatran versus warfarin the the treatment of acute venous thromboembolism.  The New England Journal of Medicine 2009; 361(124): 2342- 2352.

Mzungu / Mafrika

Jumapili 26 septemba

KiSwhili word of the day is wimbo. Song.

Back in Mombasa and I already have my ticket to Tanga. I didn’t really want to come back, but I don’t think Lamu to Tanga was possible, and I had a really great day anyway.

The bus ride was miserable but at least I prepared myself for it. I was in the VERY back and everytime we went over a pot hole I flew out of my seat almost over the chair in front of me. The guy next to me kept getting so angry at the bus driver and calling him lazy and all kinds of names. The reality was the road was in bad condition and we had shitty seats.

As soon as I arrived in Mombasa, I just wanted to walk around. I walked to Fort Jesus and was debating paying to go in when this guy started talking to me and he is a tour guide but wasn’t pushy and really knew the facts. He wanted to show me around... How much? He told me he would show me the city and I could decide after how much to pay him.

Sweet.

Fort Jesus is built on the highest part of Mombasa, 17 meters above sea level, on the coast. It is shaped like Jesus on the cross. The Portugese had a weird sense of humor. It was built in 1497 (?) and the walls are a meter thick. After Vasco de Gama was turned away from Mombasa the first time, the Portugese came back later and settled in here.

There is also an expensive club next to it. Only for people with big pockets. Like Brangelina. I asked if Brangelina had ever come. My guide, Harrison, said no, but they frequent Diani Beach (south of Mombasa) and are apparently very loud.

In the bedroom.

I would have been surprised if he had said otherwise.

Old town in Mombasa had similar architecture to Lamu, with large mahogany doors with shackles carved into them. I noted that it was weird the Arabs made such beautiful carvings to symbolize something so immoral and depressing, but Harrison responded that slavery to the Arabs WAS beautiful; it was a very lucrative business.

I also saw the old ferry port, a Mosque for Indian Muslims, and a Hindu temple. Mombasa is mostly Christian and Muslim with some Hindus and very few Rastafaris. Harrison is rastafari: one man, one woman, peace and love. They pray to Haile Sallassie because, one year, during a drought in Jamaica, Haile Sallassie came to Jamaica and as soon as the plane landed, it began to rain. When Harrison prays, he prays to "Ja". I asked him why he calls his god "Ja". It sounds cool when you're stoned.

When we were leaving the Hindu temple I saw this really cool looking night club so we went over to have a beer and just talked.

Of course he was very curious to know how many children I wanted.

Zero.

Little Chi Chi is enough for me. And I can only think about finishing school and starting my career.

School can wait! But you must have babies now to bring you blessings and happiness!

Which of course is the opposite of American/Western thinking. BABIES can wait. But Harrison already has 4 children by different baby-mamas. He says when he gets married he wants to have 14 children because his father had 10 and he must have more than his father. He asked me if I would like to make a little zebra with him. I politely declined.

We talked about birth control. He said a lot of women in Kenya used the shot (which does not protect against HIV) but said it is frowned upon if a woman does not have many children; it is like being selfish. Comments on condom use, "Why would you eat a banana with the peel still on? It can be done, but isn't better to remove the peel first?" Again I reminded him that eating it with the peel on is better than getting HIV, herpes, HPV, and other STIs but he replied that if you are sleeping with a boyfriend/girlfriend you do not have to worry.

I wanted to ask him how many times he'd been tested. My bets are on zero.

It was interesting. Also because of the amount of corruption in Kenya, the only thing that guarantees you a job is knowing someone at the top, so why bother with school? Family has much more significance in East African culture, so it is only natural that people would want to have large families and start earlier, even though it does not make sense from my cultural perspective.

Harrison also talked about he does not understand wazungu who come to East Africa and get stressed out. You are on vacation. Why are you stressed? He said that wazungu would not endure one day of what an African endures. From the moment a baby leaves its mother, everyday is a struggle to survive. But you know you can survive this day because look at how many days you have already survived this far.

I talked about how many people in the U.S. are depressed. I think part of it is we are told to work hard in school so we can get a good job and be able to afford the American lifestyle, but sooner or later many people just figure out its all just crap. Harrison said even the poorest person is able to laugh and enjoy himself no matter what because he knows what is important. He has life, family, friends. While I couldn't agree with Harrison that I should make a zebra with him immediately, I really value what he said about family.

We finished the Tuskers and parted. I gave him 500 KSH for the tour, but he told me the thing he appreciated most was just having the beer with me.

Beautiful.

Good Snorkeling

Jumamosi 25 septemba

KiSwahili word of the day is "baharini". The ocean.

I drank too much last night and am now preparing myself for a day in the sun on a boat with Captain Happy.

3 other girls from my hotel also paid Omar Shariff the deposit for snorkeling, but counted their losses and are going with someone else. So my American friend and I decided we would ask Omar Shariff if he could go in place of the girls.

As soon as I get to the ferry port and ask Omar Shariff, he flips out. FLIPS OUT. He's yelling about all kinds of things. I said the girls said it was ok for the other American to go in their place so he drags me across the port looking for the girls and we find them as they are getting onto their boat.

I felt awful for them! Seeing this horrible angry stinking Omar Shariff coming at them yelling about how it was rude to promice this and asks if they said what I had told him.

One of the girls nervously looks at me and says, "yes"

"OK THEN IT IS FINE!" Omar Shariff yells and turns around and we walk back to the boat. Whew!

So there are 5 wazungu on the boat: Myself, my American friend, 2 German girls, and a photographer. And 2 sailors. The photographer was great. He is originally from Australia but has lived in Fiji and California (holla) and for the past 14 months has been driving around the continent of Africa taking pictures of tribes in their traditional clothing. He is is Lamu because he is waiting for his Ethiopian visa (which is really easy to get IF you fly into Addis on Ethiopian airline which is owned by the sultan... if not, it is damn near impossible to get).

So we pull up to this spot near another island that is brown with silt from mangrove trees and the captain says "I think here we make good snorkeling". I can't even see my hand under the water. So we are given "fishing poles" which are blocks of wood with fishing line tied around and a hook and weight on the end and sit for some minutes trying to catch fish. The water is so murky the fish probably can't even see the bait.

So we move to another location. Slightly better, but still the water is really murky. "Ok I think here we make for snorkeling".

The photographer inquires about a house boat in the distance. It is a hotel. Bar? Yes.

He immediately jumps ship and starts swimming.

Is he going to the bar?

Just a few meters before he reaches it, I jump in after him, swim to the house boat and he helps pull me up onto it.

Did you bring any money? He asks.

No, did you?

No.

Well, we tried. We hung out for a while and talked then swam back to the boat. The water was warm but part of me was completely panicked about sharks and crocodiles the whole time, especially because I couldn't see under the water.

We finally ended up at the beach across from Shela and played in the waves. I watched Omar, the captain's helper, prepare the food. Then we all got back onto the boat and the captain put up a sun shade for us.

"For you, not for me" he says.

"Well, you certainly have a lot of pigment. But supposedly we are all from Africa... I guess if you don't use it you lose it..." the photographer replies.

After eating we went back to Amu port. Even though I didn't snorkel, I really enjoyed the boat ride. We passed a house or shop near the water with all these 8x10 inch windows but every single one was broken. We asked about it, and the captain said these French people lived there who hated locals walking by their house (even though the house is on the main walkway) and are always giving the locals trouble about whatever issues so one night, a bunch of people came and broke all the windows a few weeks ago. So funny!

L'amour in Lamu

Alhamisi 23 septemba

KiSwahili word of the day is salama. Peace.

I also made a YouTube video of my time in Lamu:
http://www.youtube.com/watch?v=2G90z3zLBbg

So today was a trip and a half. It begins with waking up and taking the bus to Mokowe to get the ferry. So far I have been spoiled with the Kenyan roads (so far so paved!) so I didn't mentally prepare myself for this journey and had a seat in the second to last row so was bumping all over the place on dirt roads and my bottom hurt so much every time the bus slowed down, I prayed that we were in Mokowe and it was time to stop.

ALSO there were checkpoints somewhat reminiscent of Hotel Rwanda; with armed guards and spikes in the road that had to be manually moved out of the way for buses to pass. I found out later this evening that these points were instated 3 years ago, but prior to this there were lots of bus robberies and everyone on the bus would be killed... so I am very thankful for the extra precaution.

The scenery was gorgeous though. So many ponds with lilies and monkeys! and my favorite scene was this baboon standing on top of a grass hut, with only banana trees and grasses around and a circle of baboons surrounding the hut and looking up at the first baboon... it was like nature was reclaiming civilization. or just a scene from the Lion King.

Finally at Mokowe I get onto the ferry with maybe 75 other people, all their luggage, chickens, and vegetables and the boat itself I cannot believe that it actually floats even without all the luggage and people. So the whole time I am gripping the side of the boat and trying to stay calm, but somehow we made it safely to Lamu.

I was taken to Yumbe House (GORGEOUS! even though a little more that I wanted to pay) and arranged a Dhow Tour with "Captain Happy" or Omar Shariff who would later become the bane of my existence. The whole time I was in Watamu, I felt badly for being so suspicious of everyone so placed my trusts fully in Captain Happy.

Omar Shariff took me all around Amu (the main town on Lamu), really fun, then through Kashmir (everyone is obsessed with India so many towns on the island are named after places in India) then finally we went to get tea with his friend.

His friend was building this very nice apartment complex. If you have ever seen a movie depicting a Columbian drug lord, this is kind of what the scene looked like. We met with the owner, 2 other Kenyans, and this other American was there who was just traveling after spending a year volunteering in Rwanda. We were both equally confused over what was going on, and my new friend refused to drink any of the tea or food offered.

Omar Shariff and I returned to Amu and he bought me dinner then was very eager to show me the stars from his apartment. HELLS to the NO. I appreciated his generocity in showing me around town and promising me a ride to Shela Beach on his donkey, Shakira, but the man was super sketch and had really bad body odor.

When I got to the hotel I was asking one of the guys who worked there about Omar Shariff, and a lot of what Omar Shariff had told me didn't check out, which I had already suspected. O well. Today was good anyway. Omar Shariff is a character. He is the sketchie Kenyan version of Danny Brooklyn. Maybe this is why I was so eager to trust him. He reminds me of my friend.


Ijumaa 24 septemba

KiSwahili word of the day is : rafiki. friend.

I met the American from the night before with a new guy, a Brazilian living in Italy and who had just finished working for some time in Zambia. So great. We walked to Shela Beach which was absolutely unreal. Kilometers of clear waters and white sands and no hotels in sight. We played in the waves then I turned around and the tide was already past our bags. The ground was so flat that the tide came in rapidly, I could literally see it moving across the sands. Really cool.

Then we were all desperate for a beer. Lamu is mostly Islamic, so the only beers were either really over priced at the resort or at the bar at the police station. So in Lamu, essentially, the only place you can drink or buy alcohol is at the police station.

As we were leaving the police station and going back to one of the guest houses, we were approached by Ali Hippie offering us this food and cultural experience. The Brazilian immediately starts gushing "I don't believe it! I don't believe it! THE Ali Hippie? I must get your photograph for my blog!" I am frantically flipping through Lonely Planet... "who the hell is Ali Hippie?" then finally fall back and ask the American what is going on. He explains that Ali Hippie was in some guide book in the 1970s, but recently there have been a lot of Ali Hippie imposters. My Brazilian was super excited to meet an Ali Hippie imposter finally after 6 days on Lamu and was just messing with him.

Anyway this guy was waiting outside Causarina Guest House for us for 2 hours while we hung out and learned how to chew qat. I have the final rejection on tape.

What a great day.

The three of us stayed up late talking and drinking by the main ferry port then were hanging out on top of Causarina. They have a nice porch area but too many trees to get a good view. The view from Yumbe is a lot better, but I'm paying 1000 KSH more for it.

Boat ride with Captain Happy tomorrow. Duh na na!

Sweet People

Jumatatu 20 septemba

KiSwahili word of the day is : "Tamu" for Sweet. Also can be used for "delicious!"

I have arrived in Watamu, named for "watu tamu", sweet people. I am staying at Tiki House which seems too good to be true. Its hidden off the main road, has a beautiful garden, a kitchen, hammock, and couches. The beds are Arab style and the people who work here are so helpful and friendly. I booked a snorkeling tour for tomorrow.

I have already gone to the Gede ruins and butterfly park. The Gede ruins are much larger than the ones in Mnarani and my guide, Kendi, was really cool. She was doing an unpaid internship, so we bonded over being students.

There are SO many italians here. Children in the street run up to me saying "ciao!" and speaking Italian.

I met an older American couple at an Italian restaurant; they had lived all over the U.S. so gave me great tips on American national parks.


Jumanne 21 septemba

KiSwahili word of the day is "Mikoko", Mangrove trees.

Thankfully my guy showed up to take me on the snorkeling tour, so he dropped me off at the ocean and I got on a glass bottom boat full of Kenyans and Italians. Everyone was really tan. And everything was said in either Italian or KiSwahili for the rest of the day.

We went so far out away from shore but still the water was very shallow. The reef is very large and the water was clear. There were a lot of fish, but compared to snorkeling in Maui, it was nothing spectacular. But still fun.

We stopped at a beach for lunch and were fed so much! Rice, prawns, lobster, fish, and shrimp. By the time the lobster came around I couldn't eat anymore, so I still have never eatten lobster. So good...

I paid another 500 KSH to go out in a dhow tour around the mangroves. I saw barracuda eggs and crabs. Awesome.


Jumatano 22 septemba

KiSwahili word of the day is "Msafiri". Traveler.

I'm in Malindi! (I later found out in Mombasa that Vasco de Gama was chased out of Mombasa so relanded in Malindi, where he received a warm welcome and received a wife, named Malindi, from the sultan of Malindi. The city is now named after his prize wife.)

I was sad to leave Watamu because I really liked the people that I had met. I am feeling slightly uprooted. I'm staying in Premier Guest House. I arrived an asked my took took driver to take me to one of the lonely planet recommendations and we got so horribly lost and were driving around forever on dirt roads (dying) bumping around and his gas was on empty, so any minute I was expecting it to break down and I would be stuck in the middle of no-where. Finally I was begging "Please! Just take me to any guest house! I really don't care!"

I saw the Vasco de Gama pillar and made a new friend, Muhammad. He comes from Somalia. He was really intelligent and friendly, but I think was mostly just interested in me helping him get refugee status in the U.S., which I have no idea how to help with, so eventually we parted ways. He left in 1993 and was living on Lamu for a long time. Good luck to him.

So excited to leave for Lamu tomorrow!

Pekeangu

Jumamosi 18 septemba

KiSwahili word of the day is: pekeangu. alone. As in "unasafiri pekeako?" "ndiyo, ninasafiri pekeangu." I travel alone.

Safe and sound in Berachah Guest House in Mombasa. I have a really nice room with a window and a television. When I spoke in KiSwahili to the man showing me the room, he moved me up to a better room in the front of the hotel with the TV, which I didn't watch but really appreciated his consideration.

I am listening to the call to prayer coming from the mosque accross the street. I also met another woman traveling by herself. She is from the UK and older than I am. She was telling me about hiking Mt. Kenya with her brother and we talked about porters. She specifically wanted to climb Kenya and not Kili, because Mt Kenya can be climbed without a guide and porters. BUT going up, she saw this other group with the porters carrying wheel-suit cases on their heads going up- disgusting. I can't beleive that people would make the porters do that.

I sat next to a woman with a very animated baby the whole bus ride. The baby didn't cry once. Maybe almost half of the 8 hour bus ride was spent with the woman feeding her baby. Sweet but awkward.

Really no problems with the bus ride though. All of it was paved and minimal traffic.

Jumapili 19 septemba

KiSwahili word of the day is "mnara" for minnarette (unfortuanately I cannot spell in my native language...)

Made it out of Mombasa on a matatu to Kilifi, only about an hour and a half. I finished seeing the ruins and snake park and my hotel, "Dhow's Inn" is so nice!

The snake park in itself wasn't that great, but my guide was very animated and dedicated to the care of snakes and stopping snake trafficking. He was an undercover agent essentially. 007 Kenya. His role is to catch snakes that have come into people's homes to hunt and release them again into the wild far away from homes. He also has been very involved in catching people who illegally export snakes to other countries. He goes undercover to find the people involved then notifies the government. Unfortunately, it is hard to get the government to actually take action so he has been frustrated. Most often snakes are exported to Germany, now there is also a growing demand from Japan.

I also learned that all snake antivenom in East Africa is produced in South Africa. And considering that black mambas, green mambas, and other fun poisonous snakes are endemic to this area, creating a factory in Kenya that would manufacture antivenom could be very lucrative. For a green mamba bite, you have 40 minutes to get the antivenom but for a black mamba, 15 minutes only. Crazy! My guide's dream is to open an antivenom factory with a snake-park and a clinic that specializes in treating snake bites. Hope the best for him.

I also saw the Arab ruins. My hotel was actually in Mnarani, on the other side of the river from Kilifi, and was named for the minaret at the ruins.

The Arabs caused the birth of KiSwahili and traded clothing and other goods for hides, iron ores, and slaves. They converted many Africans to Islam, so the ruins at Mnarani are of ancient mosques.

I also learned about mkilifi, the tree for which Kilifi is named. Drinking a tea made from its leaves is said to cure 40 illnesses, including malaria. The leaves taste bitter like quinine.

I learned also that before the Arabs, Africans worshiped the Baobab tree. Even today some people come to slaughter animals at the trees and place coins inside it. I got to taste the baobab fruit, which was really dry and sour. It was disgusting. He said it is good for pregnant women and tastes good on fish; its probably high in vitamin C. The shells of the fruit can be used to make drums or mouse traps. It can also be used to make soap and shampoos.

My guide was really great. He also told me a lot about the history of the area and issues today. There is a lot of malaria in Kilifi, because of the creek. The hospital there gets additional funding for this reason so my guide says the Kilifi hospital is better than the one in Malindi.

At dinner I fed feral cats and made a new friend who was very eager to show me the beach at night. Thanks, but no thanks.

Nairobi

Alhamisi 16 septemba

KiSwahili word of the day is: Karibu. Meaning is "you're welcome", but in East Africa, it really is much more generous and people saying it whole-heartedly welcome others to share in what they have.

Today I saw the elephants again! So great, and they had a new rhino named "Shida" that was adopted here when she was 2 days old, she was premature and only 25 pounds, so crazy.

We got a free ride on our way out when leaving in the back of a pick up truck. Beats getting eaten by lions. I went with 2 Americans and an older woman from Australia who came to find a long term volunteer position in hospice care here. She's really sweet and I really respect her opinion on things, especially because she has much more experience than I do. She was criticizing me for always telling the shop keepers that I would come back, which I honestly do intend to do when I say this, but she says so many people come here and make promices that they never fulfill. She said it is therefore more honerable to not make any promices at all, no matter how small.

She also criticised me again on the bus because I was asking the matatu driver if we were getting the "mzungu price". She was saying a few extra cents does not make a difference to us, to which I retorted that everybody should get the same price, its only fair. She said she believed that everyone should have the same standard of living, but clearly, do not... is that fair? She got me there... and even though for this it was only a few cents, it really is the Robin-Hood connumdrum: Is it fair for the poor to cheat or steal from the rich? Ultimately, I don't think that anyone should be able to rise above because they were cheating, but in this case, I was fine with handing over the collector the stated price.

Conversely, earlier in the market I was trying on these GORGEOUS necklaces, great craftmanship and really high quality beads. But simply could not afford them at all. The same woman was telling me essentially that this price was too high and he was somewhat cheating me, but I really felt that the necklace was worth the stated amount and in good conscience, I did not want to rob an artist of money that he really did deserve.

Ijumaa 17 septemba

KiSwahili word of the day is "Amani", meaning peace. Usually written on the back of matatus or dalla dallas.

Today was really eventful. I stayed an extra day in Nairobi to go to Hell's Gate national park and bike with the other American girls I met the day before. They are leaving for safari tomorrow, so first we went to the safari office, then Jim from the safari co. escorted us to the bus stand below Moi Ave to get the right matatu to Naivasha.

The bus area was so hectic in a really exciting way. I was just remarking how wonderful everything was, all the different people and the brightly colored shops and matatus driving everywhere. Just in front of us was a matatu that was having difficulty starting, and of course there were people absolutely everywhere.

The matatu suddenly lurched to a start. A man had been passing in front of it and we saw his arms flail upward and he went down like a rag doll. It happened so quickly then time stopped. Everything was quiet and people came out of the shops and from the sidewalks and gathered around the fallen man. I grabbed hold of one of my new friends' hand and firmly looked away as we passed.

"It happens, ya?" was pretty much the response from Jim. It just made all the dangers of bad driving suddenly real. Being in the bus area no longer was exciting because I felt like death was everywhere.

And with that, I was ready to get out of Nairobi.

We waited in the matatu for an hour and a half, waiting for it to fill up so we could leave. The three of us just wanted to get the hell out of there. The drive was gorgeous. We passed along the rim of the rift valley and during our waiting time, made friends with a guy on the matatu who was really mellow and welcoming. He enjoyed quality American shows like "Ellen", "Oprah", and "The Kardashians", so funny. Also it was nice to talk to the other girls and hear about their travel experiences.

We unfortunately didn't get to bike that long because we spent so much time waiting to leave, but we biked to the gorge and saw zebra, pumba, and a lot of different kinds of birds.

I am excited to leave for the coast tomorrow.

About the Journey...

Armed with mefloquine, ciprofloxacin and a camcorder, I travel around in circles in East Africa.

Jumatatu 13 septemba

KiSwahili word of the day is "ndege" which can mean bird or airplane.

Newark take 2. Still stuck here for another 4 hours and some guy at the bookshop just called me "sir"...

I'm a lady!


Jumanne 14 septemba

KiSwahili word of the day is "kuzunguka" meaning to go around in circles, which is where the word, "mzungu" comes from, which is a person who goes about in circle, AKA a European in East Africa.

My flight from Newark was delayed for over 2 hours for a few drops of rain. I was positive throughout the flight that I would be spending the night in Zurich, getting to Kenya just seemed unattainable at this point. Luckily, a petite Swiss woman named Sylvia met a Southern gentleman and myself at the plane and we were sprinting through the airport and going through all these shortcuts and somehow made it onto the flight.

I later found out the other passenger running with me was an ER physician from Mississippi, named Phil, who was going to do medical work in Northern Kenya... so great!


Jumatano 15 septemba

KiSwahili word of the day is "asante", or thank you. Asante sana is thank you very much.

All day quest to find phone. Staying at Wildebeest hostel in Nairobi, where I stayed 2 years ago, really beautiful and I've met some interesting characters.

I met a middle aged man at breakfast who is a lover of travel and ! biking <3 He has taught English as a second language at Harvard and got really into taking long distance bike trips. He has biked from Montana to Alaska then also cross country then fluew to Amsterdam and biked to Bulgaria. Awesome. His crazy story of the day was in Syria, some man in an American military outfit was asking to see everyone at his table in a restaurant's passports. While everyone else was handing theirs over, this man said, "No! I refuse! You will have to kill me and everyone else in this restaurant to see it! You have no authority in this place!" Fortunately, no one was killed.

My favorite person of the day was a female UN employee. She is here to get married in Kenya to her Kenyan fiance in 4 days. She has done a lot of work in Africa, so was telling me about her experiences in Somalia.

She said she went on missions into Somaliland and also into the horn of Africa. The horn of Africa is where all the Somali pirates are based, so the risk of kidnap is so high she said the security had them changing locations every 20 minutes. Also about Somalia surrounding Mogadishu, she said despite that it is a religious fight, the religious leaders all employ the different war lords to do the fighting, and these people take sides with the highest bidder.

She said that aid coming into Somaliland, she can see the benefits because at least some of it is reaching the people but putting money into trying to help people in the Mogadishu area is essentially just throwing money away because all of it is taken by the people perpetrating the crimes. She said she hopes never to work in Somalia again, which was pretty depressing. The US military is also still involved in Somalia, no surprise when are we not involved, but just to gain intelligence on Al Quaeda, then we come in and bomb the shit out of their location and leave. It would be a mistake to have a permanent presence there, which we have not had since 1994. I asked about by-standers.

"Well there's always collateral damage".

We also talked about Uganda and IDP (Internally Displaced Persons) and now there is also more investigation of IDP in Columbia. The problem is, if people leave their country due to circumstances in the parent country, they can gain aid under a refugee status. However, with the LRA in Uganda, people moved from the north into camps in the south for 25 years, but were still within Uganda. Recently, the people have been able to return to their homes in the north but while in camps, the aid was given directly to women to manage as leaders of micro-finance (which has been shown to be more effective than giving it to men). However, during the time of internment the men lost their status as leader of the household and there was a rise in domestic violence and drinking.

Also, 25 years later, there are now land disputes because people cannot remember what land was theirs in addition to third party persons coming onto the land in their absence and making use of it. Essentially an entire generation of people has been raised in refugee camps and now that they return home, of course there are going to be issues in resettling.

The issue with IDP in Columbia is, of course, drug related but has been happening slowly and steadily so that the Columbian gov has refused to acknowledge a problem. Drug lords come onto the land and either require the land owner to grow coca, or displace the land owner from their land. Right now their is a discrepancy between the Columbian gov and an NGO on the number of IDPs (3.1 million versus 4.3 million), so this has been currently under investigation.

So interesting! I would have wanted to talk more, but I felt terrible for making her talk about work while on vacation. Its amazing the people one meets while traveling.

Spinderella cut it up one time

Yo, I don't think we should talk about this
Come on, why not?
People might misunderstand what we're tryin' to say, you know?
No, but that's a part of life

Come on

Let's talk about sex, baby.

Or not.  Because 20-40% of all patients taking an SSRI, or Selective Serotonin Reuptake Inhibitor, experience sexual dysfunction in the form of decreased libido, difficulty with arousal, and/or changes in orgasm or even (gasp!) anorgasmia.

SSRIs cause sexual dysfunction to different extents.  Data from a wide variety of studies show varying percentiles, but have consistently shown that paroxitine (or Paxil) has been the greatest offender, fluoxetine (Prozac) with the lowest incidence, with sertraline (Zoloft) and citalopram (Celexa) being in between. 

The exact prevalence has not been established due to wide range of percentiles.  While some patients are able to tolerate the side effect in relation to their improvement in mood, it is intolerable to others and hinders the use of these medications.  As a result, there has been great interest in the management of sexual dysfunction in patients taking an SSRI.

Let's talk about you and me
Let's talk about all the good things
And the bad things that may be
Let's talk about sex
Let's talk about sex

All patients are created differently.  While decreasing the dose will often not alleviate the side effect, switching to another medication within the class can help.

There has also been interest in the use of ginkgo biloba for sexual dysfunction in patients taking SSRIs.

Ginkgo biloba is an herbal remedy that has recently been catching on in the U.S. after thousands of years of use in China.  Its potential uses include everything under the kitchen sink, including neuroprotection, anti-platelet effects, protection against airway hyperactivity, and sexual dysfunction. 

Let's talk about sex for now to the people at home or in the crowd
It keeps coming up anyhow
Don't decoy, avoid, or make void the topic
Cuz that ain't gonna stop it

Unfortunately there is not very much financial interest in the investigation of herbal products, but there have been a few small scale trials looking at ginkgo for sexual dysfunction.

While some small scale trials have showed increased libido or increased penile blood flow, most of the evidence does not support ginkgo as an effective treatment for sexual dysfunction.

The greatest problem with ginkgo and other herbal supplements is the lack of regulation in preparation and administration.  There is no standardization of dosing or manufacture.  Dosing used in trials for sexual dysfunction ranged from 60 mg daily to 300 mg three times daily, with no established efficacy for any of the doses. 

Additionally, the components of ginkgo have a wide range of effects, which does establish ginkgo as a remedy for a wide range of indications, but also means that the herb does not come without side effects.  Most concerning of which, is the risk of bleeding secondary to platelet inhibition.

Patients taking warfarin, aspirin, plavix or any other anti-coagulant should notify their physician before taking ginkgo.  Additionally, high doses of ginkgo may result in bleeding.  Doses above 240 mg daily have also been associated with skin reactions, vomiting, and diarrhea.

Now we talk about sex on the radio and video shows
Many will know anything goes
Let's tell it how it is, and how it could be
How it was, and of course, how it should be
Those who think it's dirty have a choice
Pick up the needle, press pause, or turn the radio off
Will that stop us, Pep? I doubt it
All right then, come on, Spin

So what’s left?  Ginkgo is not the only herbal supplement available for the potential alleviation of sexual dysfunction related to SSRIs.  A retrospective study by Keller Asher in 1997 examined the use of amantadine, yohimbine, and cyproheptadine in reversing SSRI induced sexual dysfunction in 596 patients.  While all three therapies were found to be safe and relatively effective, yohimbine was found to be significantly more effective. 

Yohimbine is an alpha-2 antagonist derived from the bark of an African tree.  Most of the data supporting the use of yohimbine has been in men and supporting erections, although there is sparse evidence to show that it may be useful for anorgasmia secondary to anti-depressant use in females as well.  Side effects include sweating, hypertension, and agitation; therefore it should not be recommended to patients with certain cardiac or psychiatric conditions.  Yohimbine doses range from 5.4 mg to 16.2 mg as needed 1 to 4 hours before intercourse.

Cyproheptadine is a serotonin receptor blocker, making it an effective treatment for serotonin syndrome and effective in reversing the side effects of SSRIs.  However, benefit in its ability to alleviate sexual dysfunction result from a reversal in the action of the antidepressant.  It should not be used daily for SSRI induced sexual dysfunction because it would negate the action of the SSRI on improving mood.

Both amantadine and bupropion, which increase dopaminergic activity, have also been shown to improved SSRI induced sexual dysfunction.  A survey by Dording et al in 2002 showed that the addition of bupropion was the most popular method in managing SSRI induced sexual dysfunction, followed by switching agents.

Ladies, all the ladies, louder now, help me out
Come on, all the ladies - let's talk about sex, all right

Yo, Pep, I don't think they're gonna play this on the radio
And why not? Everybody has sex
I mean, everybody should be makin' love
Come on, how many guys you know make love?

Let's talk about sex.

References:

Demyttenaere K et al.  Bupropion and SSRI-induced side effects.  Journal of Psychopharmacology 2008;22(7):792-804.

Uptodate online resource.  Clinical use of ginkgo biloba.  Last updated January 2010.  Available at www.uptodate.com.

Wheatley D.  Triple-blind, placebo-controlled trial of Ginkgo biloba in sexual dysfunction due to antidepressant drugs.  Human psychopharmacology 2004;19:545-8.

Rowland DL et al.  A review of plant-derived and herbal approaches to the treatment of sexual dysfunctions.  Journal of Sex & Marital Therapy 2003;29(3):185-205.

Keller Ashton A et al.  Serotonin reuptake inhibitor-induced sexual dysfunction and its treatment: a large-scale retrospective study of 596 psychiatric outpatients.  Journal of Sex & Marital Therapy 1997;23(3):165-75.

Mayo Clinic.  Erectile dysfunction herbs: a natural treatment for ED? 2008.  Available at http://www.mayoclinic.com/health/erectile-dysfunction-herbs/MC00064.

Kanaly KA et al.  Sexual side effects of SSRI medications: potential treatment strategies for SSRI-induced female sexual dysfunction.  Current Women’s Health Reports 2002;2:409-416.

Dording CM et al.  The pharmacologic management of SSRI-induced side effects: a survey of psychiatrists.  Annals of Clinical Psychiatry 2002;14(3):143-147.