Zafren K.,Alaska Native Medical Center |
Zafren K.,Stanford University |
Zafren K.,International Commission for Mountain Emergency Medicine ICAR MEDCOM
Travel Medicine and Infectious Disease | Year: 2014
High altitude illness - Acute Mountain Sickness (AMS), High Altitude Cerebral Edema (HACE) and High Altitude Pulmonary Edema (HAPE) - can be prevented or limited in severity by gradual ascent and by pharmacologic methods. The decision whether to use pharmacologic prophylaxis depends on the ascent rate and an individual's previous history of altitude illness. This review discusses risk stratification to determine whether to use pharmacologic prophylaxis and recommends specific drugs, especially acetazolamide, dexamethasone and nifedipine. This review also evaluates non-recommended drugs. In addition, this review suggests non-pharmacologic methods of decreasing the risk of severe altitude illness. There are also brief sections on how to decrease sleep disturbance at high altitude, travel to high altitude for patients with pre-existing illness and advice for travelers ascending to high altitude. © 2013 Published by Elsevier Ltd.
Zhu A.Z.X.,University of Toronto |
Renner C.C.,Alaska Native Medical Center |
Hatsukami D.K.,University of Minnesota |
Benowitz N.L.,University of California at San Francisco |
Tyndale R.F.,University of Toronto
Addiction | Year: 2013
Background and aims: Gene variants in CHRNA5-A3-B4, which encode for the α5, α3 and β4 nicotinic receptor subunits, are associated with altered smoking behaviors in European Americans. Little is known about CHRNA5-A3-B4 and its association with smoking behaviors and weight in Alaska Native people, which is a population with high prevalence but low levels of tobacco consumption, extensive smokeless tobacco use and high rates of obesity. We investigated CHRNA5-A3-B4 haplotype structure and its association with nicotine intake and obesity in Alaska Native people. Design, setting and participants: A cross-sectional study of 400 Alaska Native individuals, including 290 tobacco users. Measurements: CHRNA5-A3-B4 genotype, body weight and tobacco consumption biomarkers such as plasma cotinine and urinary total nicotine equivalents (TNE). Findings: Alaska Native people have a distinct CHRNA5-A3-B4 haplotype structure compared with European/African Americans. In 290 Alaska Native tobacco users the 'G' allele of rs578776, which tagged a 30kb haplotype in CHRNA5-A3-B4, was prevalent (16%) and associated significantly with nicotine intake (20% higher plasma cotinine, P<0.001, 16% higher TNE, P=0.076), while rs16969968 was not associated with nicotine intake. Rs578776 acted in combination with CYP2A6, the main nicotine-metabolizing enzyme, to increase nicotine intake by 1.8-fold compared with the low-risk group (P<0.001). Furthermore, rs2869950, a single nucleotide polymorphism 5′ to CHRNB4, was associated significantly with increased body mass index (P<0.01) in the tobacco users even after controlling for differences in nicotine intake (P<0.01). Conclusions: Genetic variants in CHRNA5-A3-B4 alter nicotine intake and body mass index in a population of Alaska Native people, who have a distinct haplotype structure, smoking behaviors and prevalence of obesity. © 2013 Society for the Study of Addiction.
Jonas M.M.,Childrens Hospital Boston |
Block J.M.,Hepatitis B Foundation |
Haber B.A.,Children's Hospital of Philadelphia |
Karpen S.J.,Baylor College of Medicine |
And 6 more authors.
Hepatology | Year: 2010
Chronic hepatitis B virus (HBV) infection in children presents a therapeutic challenge for the practitioner. Decisions regarding selection of patients who may benefit from treatment, appropriate timing of treatment, and the choice of antiviral therapy are complex and are compounded by the limited number of drugs that have been studied in children. An expert panel of nationally recognized pediatric liver specialists was convened by the Hepatitis B Foundation on August 11, 2009, to consider clinical practice relative to the therapeutic options available for children. A detailed account of these discussions is provided, and the opinions expressed are based on consensus of the experts, as well as on published evidence when available. The panel concludes that, at this time, there is no established benefit of treatment of children in the immune tolerant phase, and there is a very high risk of development of drug resistance. In addition, there is no indication for treatment of children in the inactive carrier state. For children in the immune active or reactivation phases, liver histology can help guide treatment decisions, and family history of liver disease, especially hepatocellular carcinoma, may argue for early treatment in some cases. Outside of clinical trials, interferon is the agent of choice in most cases. Nucleos(t)ide analogues are secondary therapies, and children who receive these agents require careful monitoring for development of resistance. There are a few situations when treatment is indicated regardless of HBV DNA or alanine aminotransferase levels. There is still much to be elucidated about the appropriate use of HBV therapy in children. Until more clinical data and therapeutic options are available, a conservative approach is warranted. Copyright © 2010 American Association for the Study of Liver Diseases.
Bruce M.G.,Centers for Disease Control and Prevention |
Zulz T.,Centers for Disease Control and Prevention |
DeByle C.,Centers for Disease Control and Prevention |
Singleton R.,Alaska Native Medical Center |
And 6 more authors.
Emerging Infectious Diseases | Year: 2013
Before introduction of Haemophilus influenzae type b (Hib) vaccines, rates of Hib disease in Alaska's indigenous people were among the highest in the world. Vaccination reduced rates dramatically; however, invasive H. influenzae type a (Hia) disease has emerged. Cases of invasive disease were identified through Alaska statewide surveillance during1983-2011. Of 866 isolates analyzed for serotype, 32 (4%) were Hia. No Hia disease was identified before 2002; 32 cases occurred during 2002-2011 (p<0.001). Median age of case-patients was 0.7 years; 3 infants died. Incidence of Hia infection (2002-2011) among children <5 years was 5.4/100,000; 27 cases occurred in Alaska Native children (18/100,000) versus 2 cases in non-Native children (0.5/100,000) (risk ratio = 36, p<0.001). From 12/2009 to 12/2011, 15 cases of Hia disease occurred in southwestern Alaska (in children <5 years, rate = 204/100,000). Since introduction of the Hib conjugate vaccine, Hia infection has become a major invasive bacterial disease in Alaska Native children.
Zhu A.Z.X.,King's College |
Renner C.C.,Alaska Native Medical Center |
Hatsukami D.K.,University of Minnesota |
Swan G.E.,SRI International |
And 4 more authors.
Cancer Epidemiology Biomarkers and Prevention | Year: 2013
Background: Cotinine, a nicotine metabolite, is a biomarker of tobacco, nicotine, and carcinogen exposure. However, a given cotinine level may not represent the same tobacco exposure; for example, African-Americans have higher cotinine levels than Caucasians after controlling for exposure. Methods: Cotinine levels are determined by the amount of cotinine formation and the rate of cotinine removal, which are both mediated by the enzyme CYP2A6. Because CYP2A6 activity differs by sex (estrogen induces CYP2A6) and genotype, their effect on cotinine formation and removal was measured in nonsmoking Caucasians (Study 1, n 181) infused with labeled nicotine and cotinine. The findings were then extended to ad libitum smokers (Study 2, n 163). Results: Study 1: Reduced CYP2A6 activity altered cotinine formation less than cotinine removal resulting in ratios of formation to removal of 1.31 and 1.12 in CYP2A6 reduced and normal metabolizers (P 0.01), or 1.39 and 1.12 in males and females (P 0.001), suggesting an overestimation of tobacco exposure in slower metabolizers. Study 2: Cotinine again overestimated tobacco and carcinogen exposure by 25% or more in CYP2A6 reduced metabolizers (2-fold between some genotypes) and in males. Conclusions: In people with slower relative to faster CYP2A6 activity, cotinine accumulates resulting in substantial differences in cotinine levels for a given tobacco exposure. Impact: Cotinine levels may be misleading when comparing those with differing CYP2A6 genotypes within a race, between races with differing frequencies of CYP2A6 gene variants (i.e., African-Americans have higher frequencies of reduced function variants contributing to their higher cotinine levels), or between the sexes. © 2013 American Association for Cancer Research.
Kelly H.W.,University of New Mexico |
Sternberg A.L.,Johns Hopkins University |
Lescher R.,Washington University in St. Louis |
Lescher R.,Alaska Native Medical Center |
And 7 more authors.
New England Journal of Medicine | Year: 2012
BACKGROUND: The use of inhaled glucocorticoids for persistent asthma causes a temporary reduction in growth velocity in prepubertal children. The resulting decrease in attained height 1 to 4 years after the initiation of inhaled glucocorticoids is thought not to decrease attained adult height. METHODS:We measured adult height in 943 of 1041 participants (90.6%) in the Childhood Asthma Management Program; adult height was determined at a mean (±SD) age of 24.9±2.7 years. Starting at the age of 5 to 13 years, the participants had been randomly assigned to receive 400 μg of budesonide, 16 mg of nedocromil, or placebo daily for 4 to 6 years. We calculated differences in adult height for each active treatment group, as compared with placebo, using multiple linear regression with adjustment for demographic characteristics, asthma features, and height at trial entry. RESULTS: Mean adult height was 1.2 cm lower (95% confidence interval [CI], -1.9 to -0.5) in the budesonide group than in the placebo group (P = 0.001) and was 0.2 cm lower (95% CI, -0.9 to 0.5) in the nedocromil group than in the placebo group (P = 0.61). A larger daily dose of inhaled glucocorticoid in the first 2 years was associated with a lower adult height (-0.1 cm for each microgram per kilogram of body weight) (P = 0.007). The reduction in adult height in the budesonide group as compared with the placebo group was similar to that seen after 2 years of treatment (-1.3 cm; 95% CI, -1.7 to -0.9). During the first 2 years, decreased growth velocity in the budesonide group occurred primarily in prepubertal participants. CONCLUSIONS: The initial decrease in attained height associated with the use of inhaled glucocorticoids in prepubertal children persisted as a reduction in adult height, although the decrease was not progressive or cumulative. (Funded by the National Heart, Lung, and Blood Institute and the National Center for Research Resources; CAMP ClinicalTrials.gov number, NCT00000575.) Copyright © 2012 Massachusetts Medical Society. All rights reserved.
Locke M.R.,Alaska Native Medical Center |
Shiyanbola O.O.,University of Wisconsin - Madison |
Gripentrog E.,University of Nebraska Medical Center
Journal of the American Pharmacists Association | Year: 2014
Objectives: To develop new, easy-to-understand prescription auxiliary labels, assess patient understanding of both new and existing labels, and compare the effectiveness of existing labels with the newly developed ones. Design: Cross-sectional study. Setting: Semistructured interviews. Participants: Convenience sample of adults from minority populations who were currently taking or had previously taken a prescription medication and could understand English. Intervention: Easy-to-understand prescription auxiliary labels were developed. Both these newly created labels and existing labels were shown to participants. Participants' health literacy levels and understanding of the information provided on the labels were determined. The reading difficulty of the auxiliary labels was determined using a Lexile Score. Main outcome measures: Interpretation and understanding of prescription auxiliary labels. Results: The study included 120 participants with a mean age of 40 years (SD = 14). All existing prescription auxiliary labels yielded less than 50% "excellent" interpretations except for those indicating "Take with food" and "Do not chew or crush." The newly designed labels were better understood compared with existing labels. Some existing labels yielded Lexile scores above the sixth-grade reading level. There was an association between higher levels of education (χ2 = 20.86, P = 0.02) or higher REALM-R (Rapid Estimate of Adult Literacy in Medicine, Revised) scores (χ2 = 26.79, P = 0.02) and better interpretation of auxiliary labels. Conclusion: Simpler auxiliary labels with improved patient comprehension can be developed. Auxiliary label understanding and interpretation is low for commonly used labels. Pharmacies should consider using existing manufacturer auxiliary labels that meet the criteria for patients with low literacy.
Zafren K.,Stanford University |
Zafren K.,Alaska Native Medical Center
High Altitude Medicine and Biology | Year: 2013
Zafren, Ken. Frostbite: Prevention and initial management. High Alt. Med. Biol. 14:9-12, 2013. - Frostbite is a local freezing injury that can cause tissue loss. Historically, it has been a disease of wars, but it is a hazard for anyone who ventures outdoors in cold weather. Frozen tissue is damaged both during freezing and rewarming. Frozen tissue is numb. Rewarming causes hyperemia and is often painful. Blisters and edema develop after rewarming. Hard eschar may form with healthy tissue deep to the eschar. Frostbite can be classified as superficial, without permanent tissue loss, or deep, with varying degrees of permanent tissue loss, often less than appearances suggest. It can be difficult to predict the amount of tissue loss at the time of presentation and early in the subsequent course. Prevention is better than treatment. It may be advisable not to rewarm frozen extremities in the field, but spontaneous thawing is often unavoidable. Extremities that have thawed should be protected from refreezing at all costs. Once in a protected environment, extremities that are still frozen should be rapidly thawed in warm water. Therapy with aspirin or ibuprofen may be helpful, but evidence is limited. Thrombolytic treatment within the first 24 hours after rewarming seems to be beneficial in some cases of severe frostbite. Prostacyclin therapy is very promising. Copyright © 2013, Mary Ann Liebert, Inc. 2013.
Kokesh J.,Alaska Native Medical Center |
Ferguson A.S.,Alaska Native Tribal Health Consortium |
Patricoski C.,Alaska Native Tribal Health Consortium
Otolaryngologic Clinics of North America | Year: 2011
This article discusses the development, evaluation, and growth of telemedicine in Alaska. Store-and-forward telemedicine has been used to deliver ear, nose, and throat (ENT) care to rural Alaska since 2002. It has proved valuable in the treatment of many conditions of the head and neck, and it is particularly well suited for the diagnosis and treatment of ear disease. Usage has grown steadily as telemedicine has become widely accepted. Store-and-forward telemedicine has been shown within the Alaska Native Health System to improve access for care and reduce wait times, as well as decrease travel-associated costs for patients. © 2011.
Gray J.M.,Aurora University |
Gray J.M.,Alaska Native Medical Center |
Cohn D.L.,Aurora University |
Cohn D.L.,Denver Health and Hospital Authority
Seminars in Respiratory and Critical Care Medicine | Year: 2013
The human immunodeficiency virus (HIV) pandemic has amplified the global burden of tuberculosis (TB), particularly in sub-Saharan Africa, where 82% of the world's TB/HIV coinfection exists. HIV infection significantly increases the risk of developing and dying from TB and was associated with 350,000 TB deaths in 2010. The diagnosis of HIV-associated TB is often challenging due to atypical clinical and radiographic manifestations, more frequent extrapulmonary disease, and higher rates of smear-negative pulmonary TB. Nucleic acid amplification tests, including the Xpert MTB/RIF assay (Cepheid, Sunnyvale, CA), improve our ability to rapidly diagnose both smear-negative and extrapulmonary TB. The standard 6-month anti-TB regimen is usually adequate for HIV coinfected persons, but intermittent dosing in the intensive phase should be avoided because of an increased risk of relapse with acquired rifamycin resistance. The comanagement of HIV and TB is challenging due to drug-drug interactions, overlapping drug toxicities, concerns about adherence, and the immune reconstitution inflammatory syndrome. However, the initiation of antiretroviral therapy (ART) during the course of TB treatment is necessary to improve survival, and the appropriate timing of ART is dependent on the level of immune suppression. Therefore, the management of TB must be well coordinated with HIV resources, prepared to rapidly diagnose HIV, assess immune status, and correctly treat both infections. © 2013 by Thieme Medical Publishers, Inc.