Highway Karma

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.

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.

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.

Exit exit exit exit...

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.

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.  

O jeez... how long has that been there?

Was I really going 80 completely oblivious of a flat?

Can I just put air in my tire and go?

O my god I’m going to be stuck in Montezuma for the rest of my life... am I going to die here?

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.  

Have I been completely lucky or unlucky tonight? 

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.  

O yeah, Walmart is open on Thanksgiving and they’re right across the parking lot.

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.

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...

Going East? 

He asked.  I mumbled something about being a poor helpless female traveling alone NO HITCH-HIKERS He nodded.

In the restroom I saw a mother and little girl talking.

Are we ever going to get home mama?

Don’t worry sweetheart, we’ll get home.  Daddy will find someone nice enough to give us a ride.

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.

They piled into my car and we were off.  

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.












Images were taken by me at El Morro National Monument in New Mexico.

Yah'ah'teh'ah'bin'eh!

Good morning!

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.

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.

An (incomplete) guide to all things in four.

Ha'a'aah.  East Dawn Spirit.

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.

Mount Blanca is the eastern mountain.

Shadi'aah.  The South.

Gallup is closest to the Southern mountain, Mt. Taylor.  The South is "nahata", planning, knowledge, competence.  Turquoise is the stone.

E'e'aah.  West.

Represented by yellow and "iina": inspiration, life.

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.

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.

Nahookos.  North.  Folding Darkness Spirit.

North is old age.  Si ha sine integrity and hope.

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.



I have so much to learn.

The Rubix Cube

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.  

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.  

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.

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.

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.

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.

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.

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.

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.

The Accident

Some of the people you meet on the road are really amazing.  I want to tell the story of one woman I met.

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. 

I sat with her at dinner and she was talking about her work and getting commissioned.

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.  


She was not wearing a helmet.  


She smashed her cheekbone, split open the side of her face and cracked her skull, suffered a brain hemorrhage.

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.

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.  

So you wear a helmet now, right? I asked wide-eyed

Her dark eyes under blond eye-brows stared back at me and she laughed.

Disparity and the American Dream

The highest attainable standard of health is one of the fundamental rights of every human being.

-WHO

I have come full circle.  I left Boston, arrived in California, drove to Gallup, and have now flown back to Maryland for training.

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!

You won't have any adventures here.

I'm sorry, I misunderstood you, could you repeat?

I said, you won't have any adventures here.

Oh....

I think that has been the meanest thing anyone has said to me.

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.

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.

"Excuse me, miss?" he asked the stewardess.

"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.

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.

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.  


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.

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.

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.

An unexpected lesson on humility.

In the glare of the American dream lie inequality and disparity.  Poverty, lack of education, and poor health always seem to appear together.  

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.

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.

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.  

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.

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.

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.

References:
Farmer P.  Infections and Inequalities: the modern plagues.  University of California Press 2001.


Allen H et al.  What the Oregon Health Study can tell us about expanding Medicaid.  Health Affairs 2010:29(8)1498-1506.


Finkelstein A et al.  The Oregon health insurance experiment: evidence from the first year.  National Bureau of Economic Research 2011.

Atlas Shrugged

I am a member of the Massachusetts Green-Rainbow party and I like Ayn Rand.

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.

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.

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.

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.

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.

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.

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.

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.

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.

www.toothpastefordinner.com

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.

Biking through the history of Plymouth

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.

Provincetown 2007

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.

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.

JFK, Hyannis

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.

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.

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.

They tried to escape the king and all they found was queens, Dunk told me.

Plymouth Harbor 2011

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.

Peace pipe, Hyannis

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.

Mayflower II

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.

the rock

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.

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.

Cranberry bog in Hyannis

References:

Brown D.  Bury my heart at wounded knee: an Indian history of the American west.  Henry Holt and Company, NY.  copyright 1970.

Statins and Diabetes

Baby I'm afraid of a lot of things but I ain't scared of loving you.
- Karen O

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.

My roommate has the best definition of diabetes that I've ever heard:

If you eat too much candy, your foot is going to fall off.

She has a point.

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.

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.

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.

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.

The Buttery

The PROSPER study published in 2002 also showed a significant increase in diabetes in patients taking pravastatin.

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.

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.

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.

New York

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.

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.

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.

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:
http://astrospotter.zenfolio.com/

Hyannis 2008

References:
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.

Shepherd J et al. Pravastatin in elderly individuals at risk of vascular disease: a randomised controlled trial.  Lancet 2002;360:1623-30.

Sattar N et al.  Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials.  Lancet 2010;375:735-42.

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.

Hughes S.  More data on diabetes risk with statins.  March 30, 2011; http://www.theheart.org/article/1203383.do 

Nitrate use in Heart Failure

Isosorbide dinitrate can be used with hydralazine in heart failure as an alternative to ACE-inhibitors or ARBs.  The medications act complementary to dilate the blood vessels.  Hydralazine reduces afterload by decreasing both pulmonary and systemic vascular resistance.  Its effects on vasodilation are not completely understood.  It also has some moderate inotropic effects.  It reduces renal vascular resistance, though not by as much as ACE-inhibitors.¹ 

Nitrates like isosorbide dinitrate relax blood vessels by releasing NO.  Isosorbide dinitrate improves exercise capacity in patients with heart failure^1,2.  Nitrates can inhibit vascular and myocardial remodeling³.  Nitrates must be dosed so that there is a six to eight hour period of negligible drug levels or tolerance may develop.  Hydralazine may decrease nitrate tolerance. ^1,3

The V-HeFT trial in 1986 showed decreased mortality with the use of hydralazine and isosorbide dinitrate compared to prazosin ².  The V-HeFT II trial compared isosorbide dinitrate to enalapril in patients with moderate heart failure and found decreased survival due to a higher incidence of sudden death in the isosorbide dinitrate-hydralazine arm.  There was no difference in mortality rate in African Americans taking isosorbide dinitrate-hydralazine compared to enalapril. ²   

The A-HeFT trail in 2004 compared the addition of isosorbide dinitrate with hydralazine or placebo to standard heart failure treatment in patients of African descent in NYHA stage III or IV heart failure.  The trial was terminated early due to increased survival in patients taking hydralazine with isosorbide dinitrate.  The target dosing used in this trial was 75mg hydralazine and 40mg isosorbide dinitrate three times daily for a total daily dose of 225mg hydralazine and 120mg isosorbide dinitrate.⁴

Compliance is more difficult with a regimen containing isosorbide dinitrate and hydralazine because these medications are dosed three to four times a day.  The new product, BiDil, contains both medications but is about twice as expensive and must also be taken multiple times per day.  There is also a high discontinuation rate due to incidence of headache and GI upset.³

There is a lack of trials evaluating the use of isosorbide dinitrate without hydralazine in heart failure; these medications should be used together³.   The ACC/AHA guidelines recommend to consider the addition of hydralazine with isosorbide dinitrate in African Americans.  However, hydralazine with isosorbide should not be considered before an ACE-inhibitor if the patient has no history or ACE-inhibitor intolerance or if they are tolerating ACE-inhibitor therapy.³  The HFSA guidelines recommend to consider the use of hydralazine and isosorbide dinitrate in African Americans in standard therapy, as they do not respond as well to ACE-inhibitors as white patients.  The HFSA also recommends to consider the addition of hydralazine with isosorbide dinitrate in African Americans with stage II or III heart failure and LV dysfunction even if their regimen includes an ACE-inhibitor or beta-blocker.⁵

*Note: images are not of heart failure but are of the beach

References:

1. Brunton LL, Lazo JS, Parker KL, editors.  Goodman & Gilman’s: the pharmacological basis of therapeutics.  11th ed.  New York: McGraw-Hill Companies, Inc.; 2006.
2. Elkayam U, Bitar F.  Effects of nitrates and hydralazine in heart failure: clinical evidence before the African American heart failure trial.  American Journal of Cardiology 2005;96(suppl):37i-43i.
3. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.  ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult.  Circulation 2005;112:e154-e235.
4. Taylor AL, Ziesche S, Yancy C, Carson P,  D’Agostino R, Ferdinand K et al.  Combination of isosorbide dinitrate and hydralazine in blacks with heart failure.  The New England Journal of Medicine 2004;351(20):2049-2057.
5. Adams KF, Lindenfeld J, Arnold JMO, Baker DW, Barnard DH, Baughman KL et al.  Executive summary: HFSA 2006 comprehensive heart failure practice guideline.  Journal of Cardiac Failure 2006; 12(1):10-38.