Toronto

Last week, I submitted an abstract to the XVI International AIDS Conference in Toronto, Canada. I had expected just to throw something together, but this actually took up a good bit of my time. It was really difficult to keep it under the 300 word minimum. It is the result of work I have been doing for the past several months, so its kind of a brief summary of what the heck I have been doing over here. I am actully slightly proud of it, but know that it is one of 12,000 abstract submissions to the biggest AIDS conference in the world. I belive my chances of being accepted are quite slim. Regardless here is my official submission:

Response to highly active antiretroviral therapy among patients with CD4 counts below 50 cells/mm³ in a resource-constrained setting

Background: AIDS patients in the developing world often present for HAART with lower CD4 counts and more advanced disease. This study provides data on how patients with advanced AIDS respond to HAART in a resource-constrained setting in South Africa.

Methods: Fifty HIV+ patients with CD4 counts below 50 were paired with sex and age matched controls with CD4 counts above 100. Non-ambulatory patients with complicated opportunistic infections or Karnofsky scores below 70 were referred out. All patients were initially commenced on a once daily HAART regimen of efavirenz, lamivudine, and didanosine. Patients were seen by a clinician monthly. CD4 count and viral load were measured at 6 month intervals.

Results: The mean baseline CD4 and viral load of the CD4 below 50 group was 22.5 cells/mm3 and 363,795 copies/ml respectively, while that of the CD4 greater than 100 group was 151.7 cells/mm3 and 286,577 copies/ml. During the first 10 months of therapy, 8 patients in the CD4 below 50 group and 1 patient in the CD4 greater than 100 group died from AIDS related illnesses. After 6 months of therapy, 64.8% of the CD4 below 50 group and 97.8% of the CD4 greater than 100 group achieved complete viral suppression. The 6 month CD4 count increased to 137.0 cells/mm3 in the CD4 below 50 group and to 271.6 cells/mm3 in the CD4 greater than 100 group.

Discussion: The risk of death for patients with CD4 below 50 was RR 8 (95% CI 1.5 - 42.7) compared to the CD4 greater than 100 group. Among the 8 deaths, 6 patients died within the first 2 months of therapy. It is likely that these patients presented too late for treatment and never underwent complete immune reconstitution. Among the survivors, fewer patients in the CD4 below 50 group achieved viral suppression at 6 months [RR 0.7 (0.5 - 0.8)]. These findings highlight the importance of identifying AIDS patients at an earlier stage of disease with CD4 counts greater than 100 for initiation of HAART.

Update on Lindiwe

I had written previously about a young girl named Lindiwe who came to our clinic with advanced AIDS. When I first met her, she had a CD4 count of 2 (normal is 1,000, below 200 means you have AIDS), could barely walk, and was severely dehydrated. For the past 3 months she had been too nauseous to keep food down, and anything she ate was likely not absorbed due to her chronic diarrhea. This situation also resulted in her being continually dehydrated. For months, she presented to several Durban hospitals in a dangerous dehydrated state. While these hospitals would stabilize her with IV fluids, they rarely admitted her over night, and never even mentioned the prospect of ARV (antiretroviral) medication.

Sadly, patients like Lindiwe are extremely common here. You have a whole group of AIDS patients that are dangerously ill. Patients like these need ARV medication, but it must be administered by an experienced clinician while the patient is in the hospital. These patients are so volatile, that the addition of ARV's might actually kill them. As a result, they are essentially neglected by any ARV rollout where they attempt to seek therapy. No clinic would want to start them on ARV's for fear that they might die in between visits. Thus they get refered to hospital, where they get an IV and are quickly rushed back out the door.

Lindiwe needed to be hospitalized and started on ARV's, but I knew that if I sent her to the local hospital, she would not get the care she needed. I also knew it wasnt safe for us to start her ARV medication as an outpatient. So, I cheated, and called Dr. Yunus Moosa to see if her would take her.

Dr. Moosa possess the rare combination of clinical brilliance, unyielding determination, and powerful dedication to his patient's health and well being. I truly think there are very few like him in South Africa. He somehow manages to practice quality medicine in a place where the roadblocks to doing so are many. When the lab fails to provide his patient with a result, he calls them from his cell phone while waiting on the ward. If a nurse fails to carry out his orders, he brings her over to the patient, and watches her administer medicines or start an IV. Despite all the odds against them, his patients get better.

I knew if Lindiwe was going to survive, he was her only hope. It took one well timed phone call, and we managed to get Lindiwe onto Dr. Moosa's service. Due to her immunocompormised state, Lindiwe had developed a tuberculosis infection of her abdomen, a viral infection inside her eyeball, and a seemingly unrelenting case of chronic diarrhea.

Lindiwe spent the next 3 months in the hosptial under Dr. Moosa's care. For the first month, she only recieved tuberculosis medicines and IV hydration for when her diarrhea got out of hand. Once she was a little more stable, Dr. Moosa started her on antiretroviral therapy. She also went once a week to an opthomology clinic to have her eyeball injected with antiviral medicine.

We tried to visit Lindiwe when we could but I imagine her time in the hospital was not a lot of fun. There is not much to do in the hospital and for most of her time, she was too weak to walk around. Her family came to visit, but couldnt always afford the trip into Durban. During the stay, her youngest child died of AIDS related illnesses in the pediatric ward a few stories below her floor. Needless to say this was a devastating blow to her, though somewhat expected.

Around mid-January, Lindiwe was released from the hospital and sent home with a month of antiretroviral medicine. She also had an appointment at the HIV clinic that will be managing her medicines.

I bring up this story not as some amazing success story or powerful intervention. I just think Lindiwe is an example of a tremendous problem in South Africa: the late stage AIDS patient. Her inability to access the medicines she needs to live is a recurring theme for these types of patients. I am certainly glad she is feeling better and on antiretrovirals, but I also know that she is not out of the woods yet. It will take a long time for her immune system to recover from its severly depleted state. But she at least has a much better chance of survival now that she is stable, tolerating foods, and taking her medicines.

Lindiwe is the exact type patient that I am trying to study right now. I am following a cohort of 50 very sick AIDS patients on antiretrovirals at our clinic. They are a really unstable group. 10 of them died in the first 10 months. I know a lot about the lab values and demographics, but dont know very many of them personally. So I am grateful to have known Lindiwe. To me, she is the living example of what so many South Africans go through, but with a positive outcome.

I have Lindiwe's cell phone number and will continue to follow up on her. Would be curious to see how she is doing in a few months once the antiretrovirals have had a chance to work. Hopefully, she'll have gained lots of weight, kicked her TB infection, and will have the energy and drive to raise her remaining child.

Florida Road

Florida Road is the greatest street in Durban. Its within walking distance from our house, so we frequent it often to meet friends for drinks, dinner, to rent a movie or just go for a walk. A few weeks ago, Kylie and I decided to have a "progressive" evening and moved from place to place, having a drink, appetizer, or meal at each spot. Here is the pictorial journey down Florida Rd.

First stop was Zeta Bar, a very cool place with great decor and excellent drinks. It has the style of a very trendy club, but seems to attract very down to earth, unassuming clientele. We each had a mixed drink that was consumed way to fast.Next door was a new restaurant called Villa Nova. We had this crazy appetizer that was almost too good looking to eat. We really wanted to just stay and eat dinner here. We were the only people in the restaurant, and our waitress was cool. But in the spirit of our evening, we felt the need to move on. As a compromise, we decided to have another glass of wine.

We then went for dinner at Europa where we forgot to take a picture. Dont worry, you didnt miss much. Nothing too exciting, just some pasta and more wine. At this point, we were starting to get full on drinks and food. So, we decided to move on to coffee, albeit, Irish coffee.Up next was Tribeca. This is a very stylish, very aesthetic little coffee shop that has only been in Durban about as long as we have. They have one of the most creatively designed menus I have ever had the pleasure of ordering from. The whole place is decorated with a simplistic, modern style. As you can guess, everything is also expensive (at least by South African standards, reasonable cheap by American). You can barely make out Kylie sitting all by her lonesome while I took this picture. We finished the night off at an old favorite, Johnny Foxes. At this point, it was way past our normal bedtime of 9:00 pm, and the drinks, wine, and Irish coffee were having their way with our sensibilities. We managed to finish our beers, and finally decided it was time for bed.

What did we learn from our progressive evening? First, Florida road is great. Second, dont confuse a progressive dinner with a pub crawl as we somehow did. Third, we are really lucky to live in such a great, safe part of Durban. Fourth, you would have had SO much fun had you actually decided to come visit (you know who you are...)

Earthquake in Mozambique

There was apparently an earthquake late last night around 12:15 am in Mozambique. It was a 7.5 and at least currently, there are no reports of serious damage. People reported feeling the quake in Durban, but if I was dead asleep. While I am a little disapointed, I suppose its a good thing. I'd rather sleep through a quake than wake up trapped by collapsed rubble. Still, this is like the 4th earthquake I have slept through. I do think it would be cool to feel one and watch it knock a few books off your shelf.

My dad is one of those types that reads or remembers dangerous events in the news and assumes that one is going to happen to me or my brother. Yet, he seems to overlook real dnagers like car accidents. When West Nile was all the rage, he harassed me about mosquitos in Galveston. Because of the 2004 Tsunami, he has been constantly worried about me getting swept away while surfing in Durban. I (incorrectly) told him that there was no seismologic activity near Durban. But apparently, the East African Rift System stretches at least as far south as the Mozambique channel. While this isnt exactly a dangerous place for earthquakes, I suppose I must now consider a tsunami generated by a quake in the Mozambique channel as a real possibility. Sometimes, those dads are actually right about a few things.

New Stuff!

There is lots of new stuff on the side bar. But you'll have to scroll down and see it. I am particularly proud of the unpossible button that I stole from the South African National Parks.

Oh, and Kylie says hi to all her friends. She is doing great.

Swoptov

There is something about moving to and living in a semi-exotic location like South Africa that really makes people want to say they will come visit you. Notice I use the words say they will rather than actually visit. I can (and will) name several individuals who expressed interest, or even outright stated that they were going to visit me in South Africa. Kylie and I discussed this phenomenon, and decided that it needs a name.

We thought about the term "traker" as a combo of travel and faker. Also entertained things like "traveliar." But in the middle of a very boring lecture on the history of epidemiology, I came up with the word swoptov. Its actually an acromnym for "Someone Who Only Promises To Visit." Examples of usage are below:

"Jason really seemed excited to come visit me in April, but then he bailed just before he bought his tickets. What a swoptov!"

"Erica promised me she was going to come stay with us in December, turns out she was really just a swoptov."

Can also be used as a verb:

"David always said he wanted to come see me in Peru. But then he swoptoved his way out of it"

My own personal list of swoptovs is below:

Todd Wiseman (my brother who rarely even returns my emails)
Kristi Wiseman (who graciously stayed behind so my dad could come)
Brent Savoie (former South African travel partner busy with weddings and law school)
Chad Crim (you have a child for Christ's sake, why would you even get my hopes up!)
Jesse Holmes (motivational issues were difficult to overcome)
Blake Brickman (was my leading candidate for a while, but understandably opted for a wedding)

So who is actually coming to visit me? One person: my Dad. We have a 10 day trip planned through the Kruger and to Victoria Falls. This makes him the only pwptovad that I know.

My 10,000th Day

So I discovered this great new website that allows you to calculate the amount of time that has lapsed between to dates. I originally used it to find out how long patients in my study had been on treatment. Was very helpful, especially when the alternative is counting by hand the number of days between Septemebr 5, 2004 and April 8 2005. But, I also discovered that the same site can calculate your "alternative birthdays." Ever wanted to know when you will have lived for 15 million minutes? Here is your chance.

My next big date is my 10,000 day on earth. Quite a feat, I believe. On April 1st, 2006, I will have been alive for 27 years, 4 months, and 18 days. Which any calculator can tell you is equal to 10,000 days. Now that you know, I expect cards, presents, and even cake if you are here in Durban. Sure, you managed to forget my 27th birthday, but I will truly be insulted if I dont hear from you on my 10,000th day. Dont worry, you'll likely be getting another reminder.

So go on, waste some time and find out when your next big day, minute, or second will occur.

My medical indecision

I had written previously about the huge question that medical students face when they are forced to pick a residency. I was only a lad of 22 when I first realized that in some regard, my career choice would fall somewhere along the greed-altruism spectrum. At one end is the Paul Farmer-esque physician who fights relentlessly for the health and well being of the poor and the underserved. On the other end is the Beverly Hills plastic surgeon whose practice is largely economically driven and makes millions off of people's personal insecurities.

I have pondered endlessly on this topic. A huge part of me wants to specialize in something. I always envied the cool, collected surgical specialist who provides their unique skills and focused knowledge whenever the primary care doctor requests a consult. At the same time, I am truly inspired by people like Paul Farmer whose dedication to places like Haiti are truly making a difference in the lives of the poor.

Aside from these issues, I also found myself interested in about every medical specialty I tried. From family practice to radiology to medicine to plastic surgery, at one time, I entertained the idea of chosing most any medical field as my career (with the obvious exception of Ob/Gyn, the worst job on the planet).

But, after all this, I think I am down to something that might resemble a decision. Sort of. I am fairly certain that I want to work in some sort of emergency care setting. This limits me to a short list of fields. Emergency medicine, trauma surgery, and ortho trauma are really the only people who spend all their time in the ER. I have always had an interest in EM, but wonder if I would really want be an EM physician taking care of drunk teenagers at 4:30 am when I am 60 years old. Trauma surgery was a possibility, but I dont think I can subject myself to the world of general surgery. I have a healthy fear of colostomy bags and also would like to someday have a life outside of the OR.

In my twisted logic, this leaves me with two options. A five year, combined emergency medicine-internal medicine residency (aka EM-IM) and ortho trauma. EM-IM would give me a very diverse background but more importantly, would give me an easy out of the emergency room when I am too old to stay up all night. An EM-IM doc is just as comfortable in an emergency as they are on the wards or in a private clinic.

Ortho trauma would let me be a specialist, but would allow me to treat patients that acutely and desperately need orthopedic intervention. Ortho trauma surgeons assess, manage, and operate on victims of major trauma. They would set your 8 year old's broken arm but also spend 10 hours in the OR repairing a trauma patients shattered pelvis. I think being a specialist like this would help me get past the whole depending on consult problem I see with fields like medicine or pediatrics.

In a sense, I am down to the same argument as before, whether I want to know a little about a wide variety of topics or know a lot about one topic. But for the first time I have some direction and some idea of where I might end up in 5-6 years.

More importantly, this small step toward a decision has allowed me to think about how I would set up my 4th year rotations. Currently, I am planning on doing away rotations in EM and ortho trauma early on to help me make up my mind.

Well, thats where I am. Would appreciate any comments!

Big day

Every once in a while, I notice real improvement in my surfing. Trust me when I say this with a lot of humility. I have been thoroughly embarassed several times in the water here in Durban. Its bad enough to lost your balance and crash head first into a wave while a group of young girls giggle at you. But the most awful moments occur when you unintentionally drop in on someone (i.e. cut them off and/or steal their wave) and they make the point of telling you what a dumbass you are. This is even worse when they are 11 and you are 27. Needless to say, I went through this a lot as I was first starting, probably more often than I would like to admit. Its truly humiliating, but one of the unfortunate consequences of learning to surf in your 20's.

But on one early morning in February, I surfed like I had never surfed before. The conditions were calm and glass with 4-6 foot waves rolling through the piers (see the aerial photo taken from the Surf Conditions website on February 6). I found a spot where they were breaking consistently and kept paddling over to it to wait for a good wave to come through. I got several good rights (which means you move to the left if you are standing on the beach watching the surfer) and rode them out until I reached the shoulder. A couple nearly broke on top of me, but I managed to barely escape and turn the corner back behind the wave. As I paddled back, two guys said "Nice wave." For the first time in my short surfing career, people were actually congratulating me instead of threatening me like they usually did.

At one point, I did have a pretty nasty wipeout that dragged me toward the beach for a few meters. As I was paddling back to my spot, I made eye contact with an older surfer who looked to be in his 40's. "You've had a lot of bombs today, you should be embarassed!" he said to me with a strange smile. Oh no, I thought. Just as I thought I was getting better, this guy has to comment on my awful wipeouts and make remind me that I still totally suck.

I was a little defensive at first, and replied with some remark of disregard. Oddly, he seemed to be smiling when he made this insulting comment. I kept surfing, though with a bit more caution and certainly a lot less bravado. The more I thought about it, the more I was confused by what this guy had said to me. Why was he smiling when he insulted me so? In all honesty, I am not too caught up on my South African surfer lingo, and didnt really know what he meant by "bombs." I just assumed he meant my awful wipe outs.

So I refered to my Surfikan Slang Dictionary and loked up the term "Bomb." As it turns out, a bomb is a good or choice wave. This guy was complimenting me, saying I had caught several good waves. I suppose he said I should be embarassed because I wasnt sharing? Dont really know.

In a matter of seconds, my ego was restored and I was pleased. I found it funny that my poor knowledge of surfing slang resulted in such miscommunication. Regardless, I was happy to have made some modest improvement in my surfing and to have had some positive feedback for a change. So beware giggling girls and 11 year old punks, I have finally earned a shred of respect from my fellow North Beach surfers. Though, I think we all know I have a long way to go before I can brag with any sincerity.

Our new Jetta

We sold our old, brokedown Ford Sapphire the day we left to go home for Christmas. Thus, upon returning to South Africa, we had no wheels. Luckily we found this 1996 VW Jetta for a reasonable price. This car has been a pleasure to drive. It has power steering, an alarm, gets good gas mileage, and you can acutally use the AC while driving up hills! (This was not the case with the previous car.) More importantly, she has proven reliable thus far (knock on wood). Note the totally dope surf rack that has gotten a lot of use lately!

When you show up in a foreign country for a few months and need to buy a car, one would think that it makes sense to buy a cheap piece of crap since you'll only use it for a short while. THIS IS NOT THE CASE! Buy a good car that is reliable and safe. You dont need a Porche or a Land Rover (though that would be cool...) but pay whatever you must pay to have a car that won't break down to often. That is the lesson we learned the hard way.

Paris

Kylie and I had a mere 12 hours in Paris on the way back to South Africa. But it was enough for me to remember what an amazing place it is. We were exhausted and decided to splurge on a nice hotel called Hotel Bourg Tibourg in Marais. It was not cheap, but the hotel was truly amazing. Plus it was so worth it, if nothing else, to take a nap in a comfortable bed. Here is some experimental photography we tried just before heading out for the evening.

I'm Back...

Have been quite busy lately, but am back and will be posting everyday now. Lots too to write about, but we'll get to it all tomorrow. Just a heads up that we're back and ready to start posting again. Check back tomorrow and there should be a lot of new changes.