Disco-dosing and PrEP

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.

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.

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.

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%).

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.

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 did show a significant risk reduction of HIV infection.

Breakdown:
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.

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.

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.

References:
Grant RM et al.  Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. NEJM 2010; 363(27):2787-99.  (iPrEX)

Baeten JM et al.  Antiretroviral prophylaxis for HIV prevention in heterosexual men and women.  NEJM 2012; 367(5):399-410. (Partners PrEP)

Van Damme L et al.  Preexposure prophylaxis for HIV infection among African women.  NEJM 2012; 367(5):411-22. (FEM-PrEP)

Thigpen MC et al.  Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana.  NEJM 2012; 367(5):423-34.  (TDF2)

Cohen MS, Baden LR.  Preexposure prophylaxis for HIV- where do we go from here? NEJM 2012; 367(5):459-61.

Wisdom from Farmer

It is very expensive to deliver poor quality health care to poor people in a rich country
-the man, the myth, the legend: Dr. Paul Farmer

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.

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.

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.

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?

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.

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.

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.

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:

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".

Simple, but stable, interventions can go a long way.

AIDS 2012

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).

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.

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.

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.

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.

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:

- 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.

- 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.

- 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.

- 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.

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:

"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?

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.

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.

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:

We don't defend human rights because people have HIV, we defend human rights because people have human rights.

References:
http://www.kff.org/hivaids/timeline/hivtimeline.cfm

Erice A et al.  Primary infection with zidovudine-resistant human immunodeficiency virus type-1.  The New England Journal of Medicine 1993; 328:1163-5.

http://www.who.int/social_determinants/en/

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. 

Statins in Low Risk Patients

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.

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.  

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.

Although previous meta-analyses have stressed that there is no mortality benefit with statins for primary prevention, a recent meta-analysis published in The Lancet 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.

References: 

Redberg RF, Katz MH.  Healthy men should not take statins.  Journal of the American Medical Association 2012; 307(14):1491-3.

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

Renin, angiotensin, aldosterone and you

There’s no escaping the kidneys in pharmacy.  Their significance in drug elimination, blood pressure and salt and fluid balance is undeniable.  

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.

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.

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.  

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.

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.

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. 

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.

References:

Atlas SA.  The renin-angiotensin aldosterone system: pathophysiological role and pharmacologic inhibition.  Journal of Managed Care Pharmacy 2007; 13(8): S9-S20.

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: http://eurheartj.oxfordjournals.org

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

Understanding Love and Loss

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.

Memu's home in 2008

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

Nakupenda dada yangu nakumiss the nest time you came you see my baby

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.

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.

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.

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.

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.

Tengeru, Mt Meru hidden behind clouds

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.

So you have come back to buy a house on the hill?

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.

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.

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.

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.

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.

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.

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.

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.

Memu 2008

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

In memory of MEMU 24MAR2012

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.

My Sister

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.

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.

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.

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.

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

I cook.  I feed the animals.  I wash the clothes.

I felt I had nothing in common with this woman.

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.

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.

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.

My sister helps me with my suitcase

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

She will be buried in her garden in Maji ya Chai on Tuesday.

Nakupenda dada yangu, I love you my sister.



http://www.youtube.com/watch?v=SyJzaPUbmEg

Genocide in the Age of Globalization

The road to hell is paved with good intentions.

It doesn't get more disheartening than that.

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.

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.

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.

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.

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.

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.

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.

Libya aside, my question is, when is it right for the United States to involve itself in the domestic conflicts of other nations?

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.

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.

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.

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?

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.

The only thing I feel I know for certain is that I don't know what the solution would be.

CHEST 2012 is blowing my mind.

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.

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*

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?

Let's look at CHEST.

Warfarin:
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.

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.
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.

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.

Dabigatran.
Dabigatran 150mg twice daily is recommended over warfarin for patients with atrial fibrillation with a CHADS score of one or higher.

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.

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.

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.

"But dabigatran did not have that caveat; I think the government wanted it be used. They saw it as a good replacement forwarfarin 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."  Dr. Harper, the primary investigator, tells HeartWire (www.theheart.org).

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.

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.

Aspirin.
I have a couple of beefs with recommendations regarding aspirin in the new guidelines.

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?

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.

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.

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.

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.

So

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.

References:
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

The girl and the peach

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.

The girl and the peach.

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.

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.

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.

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.

A child’s heart is very resilient, the pharmacist told me.  It will keep beating even after they’re gone.

The little girl was probably already gone long before she came into the ER, but they continued to struggle to save her life.

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.

We all cried that day, she told me.

Emerging vaccines & Latent TB

Human Immunodeficiency Virus (HIV)

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: www.hvtn.org

Malaria

Plasmodium falciparum, 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.

Ebola

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.

New Treatment Option for Latent Tuberculosis 

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.

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.

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.   

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.

References:

HIV. 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 http://www.cbc.ca/news/health/story/2011/12/20/hiv-vaccine-western.html 

Johnston MI.  HIV vaccine development- improving on natural immunity. The New England Journal of Medicine 2011;365(10):873-875. 

Malaria.    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. 

White NM. A vaccine for malaria.  The New England Journal of Medicine 2011;365:1926-1927.  

Ebola. Carpenter J. Vaccine developed against ebola.  BBC 12/6/11. Available at http://www.bbc.co.uk/news/science-environment-16011748

New treatment option for latent tuberculosis. 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.  

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.

Bleeding & Dabigatran

Bleeding with Dabigatran 

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.

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.

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.

Unlike warfarin, there is currently no reversal method for the effects of dabigatran save for emergency dialysis.  The author of an editorial published in The New England Journal of Medicine 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.

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.

References:

Bleeding with dabigatran. Cotton BA, McCarthy JJ, Holcomb JB.  Acutely injured patients on dabigatran.  The New England Journal of Medicine 2011;365(21):2039-40.

The American Heart: 2011 in review

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.  

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.

The trends are looking good, but cardiovascular disease continues to be the cause of significant morbidity and mortality in the United States.

children & cardiovascular disease

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.  

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.

American Indian youths had the third highest prevalence of childhood diabetes, with 2.28 cases per 1000 patients.  

While mortality data decreases, let’s continue to encourage patients to eat healthy and exercise; come on Gallup, let’s move!

References:

The American heart. 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.  

Let’s Move Campaign, accessed at www.letsmove.gov on 01/04/12.