The Pitt Pulse - Volume III Issue III

“If you aren’t able to play because of an injury, there will be someone else that will.” taken off the field and into the locker room. There, he undergoes more testing by team doctors and trainers. He repeats the Baseline Test to see if more serious action must be taken; this might include hospitalization or further assessment by the team’s neuropsychologist. Each concussion is different. Recovery time can vary from two to six weeks, depending on Photo courtesy of Woodbs via Wikimedia Commons

8

Photo courtesy of Keith Lovett

Before the Baseline Test can be validated, two doctors unaffiliated with the NFL must authenticate it. All together, these tests culminate in a comprehensive analysis that provides reference information for team physicians to use when diagnosing brain injuries.

When a high-impact collision like a hard tackle or a dog pile occurs, the NFL may employ a sideline concussion assessment as a follow-up safety protocol.

If injury is suspected, a sideline physician will screen players for brain trauma by following a checklist similar to the baseline examination. The results of the sideline test are then compared to the baseline evaluation. Any decrease in results regarding memory, reaction time, or other cognitive function, could be indicative of a concussion. If a player’s results indicate decreased brain function, he will be asked to recall five words and answer basic questions like location, date, and the opposing team’s name.

If a player’s sideline scores are significantly lower than his baseline scores, and the attending team physician suspects a concussion, the player is immediately

Volume III Issue III

the player and the specific nature of his brain injury.

Players fearful of temporarily losing their job, or being permanently replaced, could be inclined to withhold pertinent diagnostic information to mislead the team physician and trainers. The NFL hopes the clinical exams that are administered combat these possibilities. To gain insight into the athlete perspective on the game and related injuries, I interviewed former Pitt safety Steven Valenza.

“It’s all part of the game,” Valenza responded, when asked about sports injuries like concussions. He had suffered a concussion playing high school football.

Valenza continued to explain that injuries like concussions are considered part of the sport – a risk that players take in order to be competitive.

decisions. “It’s the coach’s final decision whether a player is fit to play or not, but they often take the advice of the trainer,” said Valenza. This implies that a player who may not be 100 percent can still play, if his coach says so. Valenza agreed that this is a dangerous imbalance of authority that allows the coach to sacrifice the health of a player for a chance at improving the team’s record.

It was not until the end of Valenza’s football career that he realized the health risks he had subjected himself to. “If you have big dreams, you’ll do what it takes to achieve them, no matter the cost.”

Although he is not taking these risks anymore, there are many high school, college, and professional athletes that are; and their safety should be valued more than their statistics.

Each concussion is different. Recovery time can vary from a couple weeks to six weeks, depending on the player and the specific nature of his brain injury.

Valenza also affirmed the reality of withholding information when being assessed for brain injury: “If you aren’t able to play because of an injury, there will be someone else that will.” Many high school athletes vie for competitive scholarships to the school of their dreams, and riding the bench for a few weeks can drastically affect their chances of securing such an award.

But what was interesting was the power the coaching staff holds in making playing

March 2013

Featured Article

AIDS in America pg. 4

With all the safety precautions and protocols aside, it is the responsibility of the player to advocate his health concerns. Withholding such information can have dire consequences, including untreated brain disease. At the end of the day, quality of life is far more important than wealth and accolades, and slowly but surely professional sports are turning to protocols that put player health first. v

Visit us online at www.thepittpulse.com

Scanning electron micrograph of human immunodeficiency virus (HIV), grown in cultured lymphocytes.

possible. Though hospital sedation is one way to provide comfort, many patients would rather interact with their loved ones at the cost of this comfort. Hospice care providers help each individual strike their preferred balance of pain management and consciousness. They are trained to aid in emotional and spiritual transitions for both patients and their loved ones, giving families the opportunity to reminisce and gain closure.

While hospice is utilized more frequently today, the shift to comfort-focused care has

In This Issue of The Pitt Pulse...

Cover Feature:

AIDS IN AMERICA p. 4-5

been tentative at best. Perhaps this is because end-of-life discussions are emotional and some physicians do not want to tread into the land of vulnerable family members.

These situations might make physicians feel uncomfortable because of insufficient training in speaking to patients and their families about end-of-life options. The stress of communicating bad news is compounded with a lack of practice. Physicians who believe strongly that care is provided to prolong life might even intentionally ignore the option

THE HARDEST HIT

Concussions and Football

Photo by Mass Communication Specialist 2nd Class D. Keith Simmons

A JOURNEY TO EL GUANTE p. 3

By Zaid Safiullah Staff Writer

IN THE END p. 6-7 THE HARDEST HIT p. 7-8

Editor in Chief: Deborah Chen

Assistant Editors: Beverly Hersh Niaz Khan

Cover Image from CDC Public Health Image Library

of hospice care. This reality is tragic, and it places many patients in end-of-life situations they would choose against if they were just given the choice.

Hospice care is a valuable option to consider when patients are at the end of life. It may not be the best fit for all patients. But educating families about hospice gives them the chance to make the best decision for the patient. v

Staff Writers:

Haadi Ali Natalie Ernecoff Prasad Kanuparthi Belinda Lao Zaid Safiullah

Jessica Craig Lauren Hasek Rashmi Kumar Yash Pandya

Layout Editor: Danielle Hu

Do you have an idea you’d like to contribute to The Pitt Pulse?

Contact our editors at thepittpulse@gmail.com Make sure to visit our website!

Scan the QR Code or visit www.thepittpulse.com

I

n the spirit of the game, their team, and the mantle of athleticism, many athletes brush off injuries, even those as serious as brain concussions. New research suggests that concussions are more detrimental than we once thought.

They may lead to Alzheimer’s disease, dementia, and even death. March is Brain Injury Awareness Month, and the perfect time to learn more about this common brain injury and how sports leagues like the National Football League are keeping their players safe.

Concussions are brain injuries caused by a high-impact collision to the head, whether from tackling, blocking, or diving. The impact force of the collision shakes the brain inside the skull, which in turn disturbs normal brain function and equilibrium. Our brain is surrounded by cerebrospinal f luid that cushions it from everyday jolts and bumps, much like a shock absorber. But when one experiences a force greater than what our brain cushion can withstand, our brain can hit the skull – a concussion.

Concussion comes from the Latin concutere, which means “to shake violently.”

If the brain is bruised, one may suffer the common symptoms of persistent headache, nausea, vomiting, lack of motor coordination, blurred vision, and ringing in the ears. Thankfully, the cure for the common concussion is simple: doctors recommend seven to 10 days of rest and relaxation. In that time, the bruised brain tissue can heal.

Case studies of 12 deceased NFL players performed by the Center for the Study of Traumatic Encephalopathy in Boston show the more severe implications of concussions. Researchers found that concussions could cause permanent brain damage and chronic traumatic encephalopathy (i.e., brain disease), which could contribute to depression.

In some cases, like that of San Diego Chargers’ Hall of Famer Junior Seau, it may even have contributed to suicide.

In January 2013, Seau’s family released the results of this study and brought the dangers of concussions into the limelight.

Visit us online at www.thepittpulse.com

Although the saga of Seau is one recent case of traumatic brain injury, it certainly is not the first. Countless football stars have fallen victim to undiagnosed brain disease. So the question remains: is the glory of an illustrious sports career worth the risk? Furthermore, what are sporting associations like the NFL doing to minimize risks for its players?

According to Dr. Stan Herring, a team physician for over 30 years with the San Francisco 49ers and the Seattle Seahawks, the Baseline Test is the first concussion assessment tool used. This test is used to routinely evaluate an athlete’s cognition, memory, balance, and reaction times, among other indicators of physical and mental health. It considers 65 points of analysis, including a recall of five previously dictated words.

The Automated Neuropsychological Assessment Metrics evaluation, originally developed by the Army as part of their baseline health profile, is also performed.

7

IN THE END

A JOURNEY TO EL GUANTE Understanding Sustainable Service

Quality of Life in the Hospice Care Setting

By Rashmi Kumar Staff Writer

By Natalie Ernecoff Staff Writer

“If you give a man a fish, you feed him for a day. If you teach a man to fish, you feed him for a lifetime.”

-Chinese Proverb

T

6

he hospital is a maze. White coats buzz everywhere. Are you invisible?

It certainly seems like it when you stop in the middle of the hallway to look for signs. Arrows? A familiar face? Anything, really.

You walk into your dad’s room. 908.

You have to look at the number because you can’t actually recognize him. He is swollen. His face is barely visible behind the breathing tubes, drips, and wires. If he were awake, would he be able to move his arms?

Probably not. He would get tangled in the wires.

It doesn’t matter, you suppose. He hasn’t been awake for two weeks. Does this seem like a lot of effort to keep someone alive, but barely? He is barely alive. Does this count as a life? That’s a question for someone above your pay grade. You just want your dad to come home; the doctors keep calling that “back to baseline.” What was his baseline?

Since your mom died he has lived alone. He cooked. He played cards. Now, his buddy Ira misses playing cards with him. He’ll never do these things again for sure. The doctors say a nursing home is the best we can hope for. The best? That’s the best? That’s terrible.

You learned a long time ago that he does not like to be told what to do. He does not want help. He’s made that clear. But this is your dad. What will you do without him?

What are you doing now? Is he already gone? And why is he on so many drugs and machines? What do they even do? We’ve already established that he’s not returning to baseline.

You walk over to the pleather recliner chair that has doubled as your bed on weeknights. Your brother stops in long enough on the weekends for you to get new clothes and a shower in your home. God forbid he took time away from his career.

That’s on you. You have vacation days, right?

Apparently this is how people die. It seems like an awfully miserable existence, but your dad is technically still alive. Is he? The doctors keep talking about what he would want. Well, he never said, “Hey, I would never want dialysis.” The doctors don’t push you for more information, so you

I Photo courtesy of Centers for DIsease Control and Prevention

assume your role now is to simply be there for your father until he is well enough to go to a nursing home. So you’re stuck here in this place, watching the man who raised you hover between life and death.

This is overwhelming, and you don’t feel like you have any other options.

What the doctors didn’t tell you is that you do have another option. When they asked what your dad’s wishes were, they were attempting to elicit what type of quality-

This may mean he dies more quickly, but he won’t be suffering like he is now.

home to die more comfortably with hospice care. You would have asked, “What is hospice?”

But that is not what happened, and here you sit in your pleather chair.

Hospice is a type of care that recognizes that the end of life may be near. It draws the focus away from aggressive measures that aren’t likely to work, and moves towards making a patient comfortable in his own home surrounded by the people who love him. This may mean he dies more quickly, but he won’t be suffering like he is now.

n May 2012, I embarked on a journey that captured the essence of this proverb.

I went to El Guante, Honduras, with Global Brigades, a volunteer global health organization. Members and I planned to set up a temporary health clinic furnished with medical supplies from the United States.

This was my first time traveling to a foreign country to offer medical aid.

We arrived in Honduras with 40 bulging suitcases full of vitamins, medication, cough syrup, and everything else necessary for a mobile pharmacy. Dragging the suitcases through the Atlanta airport, surviving customs, and sorting our supplies, all of us felt that what we had brought more than what was required. Before our trip, community-needs assessment volunteers sent us a daunting list of medications and the quantities that would be necessary to help provide health care to our community. After gathering these items, we felt more than prepared.

This all changed in a matter of hours

U

of-life he would find acceptable. But, they didn’t specifically ask if he would be okay with living an incoherent life. If he would be okay with a stranger bathing and changing him. Though you might not have chatted with your dad about these tough questions, you can infer from his lifestyle that he would not want to live that way. He would consider existence like that worse than death; that is, he would rather die.

Had the doctors tried harder to understand him, they might have provided you with information about sending him

Visit us online at www.thepittpulse.com

nfortunately, studies have suggested that hospice and related forms of comfort care are only discussed in 56 percent of physician conferences with family members when the patient approaches the end of life. If this is true, the above scenario might be common in U.S. intensive care units. Hospice care could be a relatively clear choice to make for many family members if only the option was presented to them.

Hospice care can occur in different settings for various illnesses. Since the focus of care shifts from life prolongation to comfort, patients might be transferred home, to a nursing care facility, or remain in the hospital but be withdrawn from all lifesustaining interventions.

Regardless of whether hospice care is provided in the home or hospital, the goal is to give patients the most dignified death

at the clinic. Assigned to the pharmacy, I filled out 379 plastic bags of prescriptions and dispersed them as crowds of people surrounded the entrance of the classroom that was our makeshift pharmacy. Whatever I had been expecting, nothing prepared me for the flood of patients that visited our clinic on just that first day.

With my rusty Spanish, I tried to strike up a conversation with the incredibly patient people waiting in line. I asked a local about the crowd that had gathered. He told me that he had arrived at 5 a.m. to wait in line. There had not been a medical brigade like ours in El Guante for over six months, and he lived in a neighboring community that had not seen a medical brigade for even longer. Pointing to the pharmacy, he said that he had come on the first day because he wanted to make sure he could get medication for his entire family. Confused, I naively told him that it didn’t matter what day he came on, and that he would get the medicine.

At the end of the first day, I realized we had depleted many of the medications that we had brought. Pre-natal vitamins were gone, cough syrup vanished rapidly, and those bags that had seemed impossibly heavy were now depressingly light. The man I had talked with had spoken the truth. We could not possibly provide for everyone that came. Even those that we had given medication to would run out of them a few months later.

I came to the crushing realization that the immediate relief provided by medical brigades dissipates in the months after the brigade leaves. More so, the community had realized this fact and tried their best to get as much out of each brigade as possible. They were willing to wait in line for hours, to bring

Photo courtesy of Global Brigade Volunteers

their friends and entire family from other towns, and to try their best to make our efforts last by rationing medication.

It was easy for me to become discouraged in the face of vast poverty and disease, having seen that international medical clinics only offer temporary services. But it was my upcoming realization that medical clinics are not the only way to help treat patients, in a long-term fashion, that made this trip so memorable.

On the last day of my trip, our group helped dig a water pipe as part of an educational activity facilitated by Global Brigades. We dug two football-field lengths of trench in La Concepcion, a town in a remote mountain region, for their new water system. According to the engineers on the project, the goal was to provide the entire village with clean water.

Two months after my return to the U.S., La Concepcion had clean water and pipelines to every community home. This reduced the frequency of diarrhea and parasitic infections.

By building a water system, we addressed the root of the disease - contaminated water - and the symptoms of an entire population were treated. I thought back to the clinic days when I handed out anti-diarrheal medication in packets of twenty pills. The medication we provided would have lasted a patient two or three weeks. The water system, though, might last many years.

Since my trip, the volunteers and I helped establish new Water and Public Health Brigades that will collaborate with the preexisting Medical Brigade. Now that I have gained a deeper appreciation for sustainability, I see that these services will help a community thrive long after I have packed up my bags. v

Photo courtesy of Global Brigade Volunteers

Visit us online at www.thepittpulse.com

3

Aids in America

By Lauren Hasek Staff Writer “If the nation’s capital were a nation in Africa, it would rank 23 of 54 countries in percentage of people infected with HIV.”

– PBS News Hour

O

n December 1, 2011, the University of Pittsburgh honored World AIDS Day by offering free, confidential HIV testing to its students. Few showed up. A campaign targeted at global awareness and public health was stifled largely by fear and taboo. HIV testing in a university setting can be a powerful tool for breaking down social barriers if students recognize the importance in participating. Low turnout for this program is just one of many examples of the role stigma plays as one of the greatest obstacles in the way of raising awareness, a key component to stemming the spread of HIV/AIDS in the U.S. This article offers a brief introduction into how stigma has influenced the sociopolitical and medical progression of the HIV/AIDS epidemic in America.

“If we want to be the global leader in combating HIV/ AIDS, we need to act like it.”

– President Obama

The first cases of HIV/AIDS were diagnosed in the U.S. in June 1981.

By 1987, the Department of Health and Human Services had banned any person with HIV from entering the U.S.,

4

designating it as a “dangerous contagious disease.” With this ban, the U.S. became one of only a dozen countries to make positive diagnosis a legal inadmissibility for immigration. Despite leading the world in its dedication to stemming the global AIDS pandemic, the U.S. had instituted a ban that represented a huge loss for human rights activists and a step back for global HIV policy.

In 1991, an attempt spearheaded by former President George H.W. Bush and the HHS to reverse this decision failed in Congress due to strong Republican opposition that argued severe public health risk and encouragement of homosexuality. While both the Centers for Disease Control and Prevention, and HHS, endorsed removing HIV from the list of “dangerous contagious diseases,” clinically unfounded misconceptions about transmission and its association with homosexuality allowed the ruling to stand.

In 2008, with hopes that lifting the ban would be a step towards ending the stigma against people with HIV/ AIDS, former President George W. Bush initiated the bipartisan effort that would ultimately reverse the ruling. In 2010, President Barack Obama successfully lifted the 22-year ban, stating it was “rooted in fear rather than fact.” While the legislation was a huge symbolic success against HIV stigma, disconnect between the American public and awareness of the disease meant the lifting of the ban went all but unnoticed outside the realm of health care and human rights activists.

XIX International AIDS Conference In 2012, the XIX International AIDS Conference (which has been held every two years since the onset of the global epidemic) was held in Washington, D.C., to celebrate the lifting of the ban. As the forum for the most recent developments in education, research, and policy, the conference played a key role in shaping international responses.

Holding the event in Washington, D.C., was dually significant: not only was it the site of the new legislation, but there, 3.2 percent of adults between the ages of 15 and 49 are positive for HIV. This is the highest prevalence in the U.S., and notably a higher rate than the Democratic Republic of Congo, Ghana, Rwanda, Ethiopia, and 28 other African nations.

The disease disproportionately affects men who have sex with men (who account for approximately three-fourths of male diagnosis), low-income urban populations, and African-American communities. These trends are preserved among the 1.2 million Americans currently living with HIV. By state, New York, Florida, and New Jersey have the largest number of persons living with a positive diagnosis. African Americans account for 40 percent of AIDS-related deaths. Despite decreased death rates in some ethnicities, low access to health care in Hispanic/Latino communities has caused the impact of HIV to remain constant. Prevalence in the country’s poorest urban neighborhoods is more than four times the national average.

The demographics of the epidemic further complicate treatment. On a national level, the burden of the disease continues to tax a fragile health care system. The Organization for Economic Co-operation and Development ranks the U.S. fourth in the developed world in terms of socio-economic inequality. The gap between rich and poor continues to widen due to a scarcity of jobs and rising prices, particularly of food and health care. In a country where HIV/AIDS disproportionately affects urban African

Visit us online at www.thepittpulse.com

Americans and Hispanics, who statistically are most likely to have a disadvantaged socio-economic status, the disease will continue to spread regardless of monumental advancements in treatment and prevention.

The Virus vs. The Definition Human immunodeficiency virus, or HIV, is a slowly replicating retrovirus transmitted through direct exposure to infected bodily fluids, including blood, semen, and breast milk. The virus targets helper T cells, macrophages, and dendritic cells for destruction. CD4 cells are a type of helper T cells largely responsible for cell-mediated immunity. Acquired immunodeficiency syndrome, AIDS, marks the point at which the HIV virus causes a marked reduction in CD4 (T) cells. AIDS defines notable impairment of immune system function and increased susceptibility to life-threatening opportunistic infections and viralinduced cancers. Without treatment, HIV progresses to AIDS within approximately 10 years of infection.

Just prior to the start of last summer’s conference, the Food and Drug Administration approved Truvada, a pill proven to effectively lower the risk of HIV infection by 42 percent in men who have sex with men, and 75 percent in heterosexual couples. The risk of transmission in the former is estimated to be 18 times higher than the latter, attributed largely to increased abrasions. Truvada has been used in the U.S. since 2004 to prevent HIV-positive patients from infecting their sexual partners, but the recent approval is a once-daily pill for healthy people who are at high risk of contracting HIV through sex. The mechanism of treatment involves blocking HIV-1 reverse transcriptase, the enzyme necessary for the virus to replicate, thus reducing the ability of HIV to take hold in healthy immune system cells. At nearly $14,000 a year, Truvada may become a luxury drug, out of reach for those in lowincome urban areas that need it most. With the restructuring of Medicare or Medicaid, it is uncertain if state or national programs will cover treatment.

Further reduction of discrimination is highly dependent on spreading awareness of the disease and its presence in the U.S.

FIGURES CREATED BY LAUREN HASEK. DATA FROM PREJEAN ET AL. (2011), “ESTIMATED HIV INCIDENCE IN THE UNITED STATES, 2006-2009”

Health Care and Opt-Out Testing Access to even the most basic health care remains a challenge across the U.S., particularly for HIV-positive individuals.

Only a third of those tested positive have any form of health coverage and less than one-fifth have private health insurance.

Consequently, approximately a third of patients known to have a positive status are not in care. Medicaid currently provides antiretroviral treatment free of charge, but only after an official diagnosis of AIDS. Early treatment delays disease progression by reducing viral load, which improves quality of life and reduces the likelihood of transmission. Although passage of the Affordable Care Act extends Medicaid eligibility to cover individuals with preexisting conditions or chronic illness, its passage will not abolish the existing restriction on antiretroviral treatment.

Attempts to change social acceptance of the disease and improve outcomes of those infected have come primarily through understated policies. In 2006, the CDC recommended an “opt-out”

approach to HIV testing, in hopes of reducing stigma and increasing screening.

These new guidelines suggest an HIV test should be performed for all patients 13-64 years of age unless the patient specifically declines. This places the burden of refusal on the patient and removes the process of separate, written consent to receive the test.

This was an update to previous recommendations that only encouraged testing for “at risk” populations. Studies since the updated recommendations have found that many health care facilities are not implementing the guidelines, and those that do often see more than 75 percent of patients declining to be tested.

Poor involvement in “opt-out” testing and programs such as Pitt’s free testing on World AIDS Day further highlight the power of stigma as a barrier to reducing transmission.

The face of HIV/AIDS in America is changing rapidly as new treatments are allowing patients to live longer, healthier lives. While the lifting of the travel ban marked a significant human rights victory, the HIV positive community in the U.S. remains poorly understood. The threat of HIV infection in America is often disregarded, perceived as an exotic disease, or as one restricted to select populations and the sexually promiscuous. In a country with a minute national prevalence (0.6 percent), education programs have remained basic, allowing stigma and fear to shape misconceptions. While the setting of the 2012 International AIDS Conference attracted much-needed attention to the “homegrown epidemic,” further reduction of discrimination is highly dependent on spreading awareness of the disease and its presence in the U.S. v

Visit us online at www.thepittpulse.com

5