Freedom isn’t free is a lesson for protesting South African students

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By Hilton Kolbe *

Student protests currently gripping capital cities in South Africa have been a catalyst for change since the mid 1970s. Cape Town and the University of the Western Cape have been no strangers to political unrest, campus shut downs and police brutality.

In 1973, students were boycotting classes and taking to the streets to protest against the Afrikaner government and its insistence on mandatory teaching of Afrikaans. Twenty years later monumental changes occurred and the student uprisings could be seen as the beginning of the end for apartheid.

Now in 2015, students are again taking to the streets in protest.

They are not boycotting classes because universities have shut the doors in a growing climate of violence and hostility. This time the protests are against the Zuma government and free university education for all. Will these events also signal the start of the end for the current political structures just as it did in 1973? That is hard to say. Probably unlikely given the current state of the Opposition parties, but the seeds of dissent have been scattered.

The national push for no fee increases for university education has been a thorn in the side for the government. Already President Jacob Zuma has backed down with angry students clamouring at the doors of Parliament in Cape Town. It was a time for strong men to stand erect but they all went limp.  Government should impose higher taxes on the rich to fund free higher education for the poor, Higher Education Minister Blade Nzimande said. “My own considered view is that government must have the political will to tax the rich and the wealthy to fund higher education. None of us must develop cold feet about the necessity of taxing the rich to fund our children.”

Instead, they agreed to halt any fee increases for this year. Wits University agreed not to increase 2016 tuition and residence fees, with an undertaking that the upfront payment of R9 340 for 2016 would be discussed further. But this was a dark day for the government who capitulated to student demands. It was a cowardly gesture of a government in denial to concede and bow to pressure from those barging at the doors of the lawmakers.

No matter what the circumstances, never concede to thugs and protesters who come knocking at the doors of Parliament seeking gifts. The system does not work this way. It only encourages every other group with a gripe or demand to take similar disruptive action. And to add further insult to fiscal injury, the Finance Minister Nhlanhla Nene was forced to delay his mini Budget briefing and MPs had to wait as police struggled to keep an angry mob at bay.

In a country where one in four people are without jobs, the cost of free university education is expected to knock a R2.6 billion blowout in capital expenditure; it is not easy to see where the funds will come from. South Africa is beset by a multitude of developmental problems and embezzlement of public funds. And, what is it that makes these Born Free students feel it is their entitlement.

If there is something that sticks in the craw about the so-called Born Frees, and by extension the rabidly obtuse Gen Exers with their sense of entitlement and ability to transform the slightest bit of adversity into an opportunity for grand reward, then it is the bold self-righteous way in way in which these vociferous young people go about staking out their claims.

The student protests have been marred by ugly scenes, police clashes and more sinister in many cases the momentum has been driven by participants armed with clubs and weapons. At the University of Limpopo at least 13 students were arrested as police clamped down on students accused of burning and looting at the campus. Students went on rampage and vandalised six cafeterias and a national outlet restaurant after the institution said it could not commit to their demands for free education.

At Wits students and security guards pelted each other with stones and   burly men in black suits throttled and wrestled students to stop them from disrupting classes. A bookshop and two vehicles were also set on fire in the early hours and access control mechanisms on turnstiles were ripped off.


The University of the Western Cape was also shut down until further notice after a group of students started rallying support for ongoing protest action across campus buildings and offices and demanding that staff leave the campus. Students preparing for exams were also disrupted.

 A statement  from UWC said the intensity of the action led to many staff and students feeling vulnerable and intimidated as some in the protest group wore balaclavas and had sticks and crowbars.

Meanwhile on campus, hundreds of students occupied the university’s Life Science centre where some of the demands, read out by student Busiswa Ngqamani. Demands included that all student debts be scrapped, that no students be prevented from graduating because of outstanding fees and that students should not pay any registration fees. 

Other demands included that students be able to register for the entire year in January instead of every semester, and that the university starts a process of buying houses in the surrounding community and make them UWC communes.  (Quoting IoL news reports)

Student leader Kamva Rubulana said that the president’s announcement of the zero percent fee increment meant nothing to the students as they were not fighting for the zero percent increment but for the fall of all fees.  “The only way we can stop this shut down is if the debt problem of UWC students can be resolved, he added. 

 Ngqamani, included that all student debts be scrapped, that no students be prevented from graduating because of outstanding fees and that students should not pay any registration fees. (Quoting IoL news reports)

These demands come from a privileged few who in the main have had a solid private education in some of the best schools that have enabled them to obtain a matric exemption and to enter university with the poshest of English accents. There is nothing wrong about that. But to demand free university education from a system that you have not contributed a single cent in tax is very wrong. 

So who has to subsidize these free loaders? A father of four children who makes his way by taxi van to his labouring job some 50km away and who earns subsistence wages and pays taxes will not be feeling too happy about the prospective doctors, lawyers, teachers and engineers demanding free education.

There was a time when the student protest movement sang revolutionary songs about freedom isn’t free, it is about time the Gen Exers realised this. Tertiary education is a privilege, not a right. 

 A much fairer and more equitable system would be a user pays scheme perhaps based on the Australian model of the higher education contribution scheme. Students wishing to study can accept State funding and have to repay the money when they start working and paying tax. By using the student’s Identity Number, they are hooked into a system that will allow them to study and pass or fail at their own cost. 

By the time they start out on their career path, the taxman will collect what is owed. This would be a much fairer scheme for all concerned.

It is difficult to locate any country in the world that affords students the luxury of free tertiary studies. Tuition fees at universities in Cuba vary between $US20, 000 and $US40, 000 depending on the university and the course of study. The good news is that this is the tuition fee for the whole course, not just for one year.

 Dr Kolbe is a writer and media commentator.

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Tanzania global health education and research program an eye opener for WCMC-Q students

Ahmed Saleh and Lama Obeid knew what they were in for even before they left for Tanzania on a WCMC-Q global health program but they were still shocked by the lack of proper health care and limited access to medication, not to mention the constant threat of tuberculosis or malaria infection.

Both quickly learned that life in a largely impoverished developing country in Africa was very different to life in Qatar. But, despite the difference in quality of lifestyle, health care and culture, it was still an exciting learning experience they both enjoyed and they encourage other students to also participate in this rewarding exercise.

The two students from Weill Cornell Medical College in Qatar returned from a challenging global health education and research program in Tanzania determined to do more for the sick and poor in under-resourced developing nations.

Second-year medical students Ahmed Saleh and Lama Obeid spent eight weeks of their summer break in Mwanza, the second biggest city in Tanzania, where they worked at the Weill Bugando Medical Center. WCMC-Q’s Department of Global and Public Health sponsors two medical students every year during the summer break for a global health education and research experience.  This is the third group of WCMC-Q medical students to participate in the program.

Lama said the program offered exciting opportunities for medical students both in health care training and research opportunities as well as personal development. “You are very quickly exposed to a variety of issues and experiences and you are challenged in many ways not only with regard to medicine but also in the way that you live your own life. Most people in Tanzania are not as fortunate as we are and life can be difficult for them,” Lama said.

“I would suggest everyone, not just first-year medical students should make it a point to gain some form of a global health experience. It will completely change their perspective on medicine and how it is practiced. On top of the immense personal development, you will experience, you will also realize that no matter what your goals or interests are, there are lots of opportunities within global health to develop those interests and benefit a lot of people at the same time.”

Ahmed found significant health issues in Tanzania, as in most developing countries. “There is a lot that can be done to enhance the limited medical services that are provided in Tanzania and elsewhere. Health education is a key element. I believe it is our duty as medical professionals to limit the spread of infectious diseases by spreading awareness among the public,” Ahmed said.

“Being in an environment where resources are very limited challenges you in a way by limiting your options. This was a great learning opportunity as it teaches you how to look at things in different ways.  You have to come up with a diagnosis based on history and physical examination without having any modern testing modalities and this helps you to move a step higher in rationalizing your decisions and diagnoses,” Ahmed said.

For Lama, it was both an opportunity to observe at close range the treatment and effects of infectious diseases such as malaria and TB and other rare infectious diseases and a chance to experience the African traditions and lifestyle.

“Mostly we attended morning reports and then went around the wards with the doctors and the medical students, checking on patients and discussing their cases. We were exposed to a wide range of procedures, and we learned a lot of medical practice. Often it would be the sort of things you wouldn’t ever get to see because we come from a different part of the world,” Lama said.

“Tropical diseases were very prevalent and mostly in late stage because people cannot afford to visit the hospital often. The patients are manly poor and unable to buy medication. They rely mostly on traditional healers and herbal medicine, which is a big challenge modern medicine faces in such communities. Resources are very limited,” Lama said.

Weill Bugando Medical Centre is a large medical complex with more than 900 beds and four referral hospitals that serve the community needs of people living on the fringes of Lake Victoria and the western regions of Tanzania. It also serves as a consultant and teaching hospital for the region and draws on a catchment area of more than 13 million people.

The hospital is a partnership with the Catholic Church, the Tanzania Government through the Ministry of Health, the Touch Foundation and other partners in making sure that services at BMC are of good quality and that they are training competent health professionals.

Both students agreed that the global health program and the challenges that they faced have had a profound impact on them.  “It has definitely helped me a lot in terms of studies,” Lama said. “I learned about diseases that I would probably only be able to read about in text books here and I also got to see the debilitating symptoms of serious infectious diseases first hand. It also highlighted for me the differences between how medicine is practiced in more developed countries as compared to low-resource settings.

“I never imagined diseases like diabetes and hypertension would be as widespread and prevalent as they are in Tanzania. A lot of the patients on the medical wards had very advanced forms of these diseases, mostly due to the lack of primary care,” Lama said.

After his relatively brief global health experience in Tanzania, Ahmed said it has changed his perspectives on how medicine should be practiced and it has sparked a desire to become more involved with global health issues in his future career.

“This experience has definitely taught me a lot and has added to my understanding of many concepts. I have studied about many infectious diseases, but have never seen real cases with such illnesses, and I believe I would never see such cases in Doha or any other developed country. Being in Tanzania has exposed me to such conditions.

“This experience has changed my whole view of medicine and it has even changed my future career plans. Before I went to Tanzania, my main thought was to travel to a new country and to see how things are done in a somewhat different health system. But after being there for just two months, I became very interested in pursuing a career in global health as I realize now that there is a lot of work waiting to be done in developing countries.”

WCMC-Q Associate Dean for Admissions and head of the Global Public Health team Professor Ravi Mamtani said the program provided participants with an excellent foundation in global health treatment and clinical research in a part of the world where health care resources are limited and treatment options are challenging.

“These are experiences that you can only gain when you have been put in those situations. This kind of experience is not a substitute and it confirms that the WCMC-Q Global and Public Health department is succeeding in what it is supposed to do,” Professor Mamtani said

“You will not be able to gain that experience in Tanzania by sitting in Qatar or in the United States. It is an amazing experience for our students even though it is recognized that they are operating with limited resources. It all adds to a great experience in the practice of medicine and it sharpens their clinical skills.”

International experts focus on spina bifida prevention and treatment

 

 

Doha, September 27. The prevention and treatment of spina bifida was the focus of a major three-day international medical conference that got underway today with the latest research data and innovative new treatment options available.

Spina bifida is a serious birth defect that occurs when the bones of the spine do not form properly around part of a baby’s spinal cord. There is no definitive cure for spina bifida.

Most children who have spina bifida do not have problems from it but it can affect how the skin on the back looks. And in severe cases, it can make walking or daily activities difficult.

Hosted by Weill Cornell Medical College in Qatar in association with Hamad Medical Corporation and Sidra, the International Conference on Spina Bifida: Genetic-Environmental Causes, Prevention and Treatment meeting attracted acclaimed international leaders in epidemiology, genetics, fetal surgery, metabolomics and epigenetics. Guest faculty from WCMC-Q, Hamad and Sidra who are all leading geneticists, practitioners in neurology, maternal fetal medicine and nephrology working in Qatar and the region also attended.

Representing WCMC-Q on the public forum panel was Assistant Research Professor of Neurology Alice Abdel Aleem who was also a session moderator.

In his opening address, WCMC-Q Dean Dr. Javaid Sheikh welcomed the distinguished group of experts and praised the work of researchers and the developments that have been made in advancing treatment of spina bifida.

“Weill Cornell Medical College in Qatar remains committed to innovative and high quality research not only for the benefit or the development of Qatar but also for international advancement and for the benefit of all those who are in need.  So it is indeed a special honor for WCMC-Q to be associated with this international spina bifida conference. It shows our commitment to the international community and points to our rapidly growing legacy in promoting quality medical research and a leader of medical education in the Gulf region,” Dean Sheikh said.

Organizers said the meeting was designed to be highly interactive, geared toward regional physicians, geneticists and healthcare providers practicing in the GCC community. Participants had ample opportunity to discuss clinical experiences, therapeutic challenges and practical solutions in the near term as well as long-term prospects to accelerate advances in the field of spina bifida treatment and prevention.

Neural Tube Defects (NTDs), primarily spina bifida and anencephaly, are major developmental disorders with prevalence worldwide of one in 1,000 live births. Infants with spina bifida often survive and face a life challenged by paralysis and a variety of urological and neurological complications.

The exact cause of this birth defect is not known. Experts think that genes and the environment are part of the cause. Children with a severe defect are sometimes born with fluid buildup in the brain. They may also have this problem after birth. It can cause seizures, intellectual disability, or sight problems. Some children also develop a curve in the spine, such as scoliosis.

The conference programs presented the latest information regarding the genetic and environmental factors contributing to the development of NTDs. It also provided a forum for overview and discussion of NTDs encountered in Qatar and the MENA region. In addition, an evening public forum provided an opportunity for the Doha non-medical community to hear about the latest research into prevention and treatment of spina bifida and other NTDs from experts in the field.

WCMC-Q study finds Arab women at higher risk of aggressive breast cancer

Doha, September 13. The clinical features of breast cancer among Arab women are quite different from other populations and Middle East women often present with more aggressive forms of breast cancer than Western women, a research report by Weill Cornell Medical College in Qatar has found.

Breast cancer is a major health problem in both developed and developing countries. The report finds that the incidence of breast cancer is lower in Arabic countries than in Europe and the United States but is rising fast. The report also finds breast cancers in women from Arab populations have different characteristics to those reported in women from the United States and Europe.  At 48, the average age of presentation of breast cancer in Arab women is 10 years younger than patients in the US and Europe.

WCMC-Q Assistant Dean for Basic Science Curriculum Professor Lotfi Chouchane said Arab populations have some particularities in terms of cancer, especially breast cancer, and also the clinical features of breast cancer among Arab women are different from other populations.

“Inflammatory breast cancer is the most lethal form of the disease and constitutes 1-2 per cent of all breast cancer tumors in the United States. But a higher proportion of cases are reported in Arab populations. For example in Tunisia, seven to 10 per cent of all breast cancer is inflammatory. Similarly, in a population-based study in the Gharbiah region of Egypt, inflammatory breast cancer was confirmed as more prevalent than in the United States, constituting up to 11 per cent as opposed to 1-2 per cent in the United States. ”

Professor Chouchane was lead author of the report published in the latest edition of The Lancet Oncology, an internationally respected medical journal. Co-authors were WCMC-Q research associate in microbiology and immunology Dr. Konduru Sastry and Dr. Hammouda Boussen from Tunisia.

The Lancet Oncology is a peer-reviewed and edited journal that is recognized for providing a global, authoritative, and independent forum for the highest quality clinical oncology research and opinion. With an impact factor of 25.12, the journal ranks among the top 3 oncology journals worldwide, is the leading clinical research journal in oncology, and is in the top 0.5% of all scientific journals, of any discipline, in the world.

 “This report is going to be the reference for anybody who wan to undertake studies about breast cancer in Arab populations and researchers will refer to it because here we describe all the characteristics of breast cancer in Arab populations based on our own findings and based also on the literature what is found,” Professor Chouchane said.

The reduction of the incidence in breast cancer and its mortality can be achieved with major efforts in screening and early detection, Professor Chouchane said. “Although several awareness campaigns have been undertaken, no structured national programs exist for population mammography screening in Arab countries.

“The cultural value of modesty and misconceptions about cancer, coupled with insufficient levels of education about breast cancer and difficulties in accessing healthcare facilities can often prohibit women from participating in breast screening. And this can lead to delayed detection,” Professor Chouchane said.

He said breast cancer mortality could be reduced if the disease was detected at an early stage by the implementation of proper   awareness and screening programs that would be possible in countries with sufficient resources. Further research on cancer should also be given priority in Arab countries, Professor Chouchane said.

This study was supported by the Biomedical Research Program fund at Weill Cornell Medical College in Qatar and by grants from the Qatar National Research Fund. The rapidly expanding Research Department at WCMC-Q seeks to establish a state of the art biomedical research program focused on tackling the most pressing health needs in Qatar and the region.

Cancer accounts for 10 percent of all deaths in Qatar and the leadership of Qatar has moved to improve the healthcare of patients  with the Supreme Council of Health establishing the National Cancer Strategy. WCMC-Q supports the mission of Qatar’s National Cancer strategy that was launched in 2011 by Her Highness Sheikha Moza bint Nasser, Vice Chairperson of the Supreme Council of Health.

 It was the first-ever initiative of its kind in the region to combat a disease. The cancer strategy is closely linked to the National Health Strategy (NHS).  With an investment of more than QR2,204m, the strategy also includes a plan for refurbishment of Al Amal Hospital to establish National Center for Cancer Care and Research, and a new cancer hospital, over the next five years.

http://www.healthcanal.com/cancers/breast-cancer/43163-wcmc-q-study-finds-arab-women-at-higher-risk-of-aggressive-breast-cancer.html

http://www.bi-me.com/main.php?id=63334&t=1&c=35&cg=4

http://www.menafn.com/1093701340/WCMC-Q-study-finds-Arab-women-at-higher-risk-of-aggressive-breast-cancer

WCMC-Q graduates impress with international cardiac research

By Hilton Kolbe and agencies

Weill Cornell Medical College in Qatar Class of 2010 graduate Dr. Mohamed Badreldin Elshazly and Dr. Mohammed Al-Hijji, WCMC-Q graduate in the Class of 2011 have stepped into the spotlight of international cardiac research as co-authors of a major clinical investigation of lipids that has been published in the prestigious Journal of the American College of Cardiology.

Dr. Elshazly is currently working in the Osler Internal Medicine Residency program at Johns Hopkins Hospital in Baltimore, Maryland and has also taken up Cardiology Fellowship at Cleveland Clinic, in Ohio.  Dr. Al-Hijji, is currently doing his final year of internal medicine residency at Johns Hopkins Hospital.

The title of the study is: Non-HDL Cholesterol, Guideline Targets, and Population Percentiles for Secondary Prevention in a Clinical Sample of 1.3 Million Adults The Very Large Database of Lipids (VLDL-2 Study).

The study presents a new analysis of 1.3 million individuals that highlights the magnitude of patient-level discordance between LDL and non-HDL percentiles.

According to the report, there is significant discordance between LDL and non-HDL percentiles at lower LDL and higher triglyceride levels.

In the study, Dr. Elshazly and colleagues wrote: “Current non-HDL cutpoints for high-risk patients may need to be lowered to match percentiles of LDL cutpoints. Relatively small absolute reductions in non-HDL cutpoints result in substantial reclassification of patients to higher treatment categories with potential implications for risk assessment and treatment.”

The researchers investigated whether non-HDL goals should be used at the same population percentiles as LDL goals, as suggested by previous research. They examined lipid profiles of 1,310,440 US adults (mean age, 59 years; 52% women) included in the Very Large Database of Lipids. Participants had triglyceride levels of less than 400 mg/dL and underwent lipid testing by vertical spin density gradient ultracentrifugation (Atherotech) from 2009 to 2011.

“Low-density lipoprotein cholesterol (LDL-C) has always been referred to as the “bad” cholesterol and high-density lipoprotein (HDL-C) as the “good” cholesterol. However, as the prevalence of obesity, diabetes mellitus and metabolic syndrome increased over the past few decades, we have witnessed an increase in other types of “bad” cholesterol such as Very Low-density lipoprotein, Intermediate density lipoprotein, cholesterol remnants and Lipoprotein[a],” Dr. Elshazly said.

“All these atherogenic lipoproteins in addition to LDL-C are included in non-HDL cholesterol, which is simply calculated by subtracting HDL-C (good cholesterol) from total cholesterol and available in the standard lipid profile at no additional cost or inconvenience. “

Dr. Elshazly said over the past two decades, numerous studies have suggested that non-HDL-C is a better marker of cardiovascular disease risk and a better target for lipid-lowering therapy than LDL-C but this has not been reflected in the most recent cholesterol guidelines. The current worldwide guidelines recommend using non-HDL-C only as a secondary treatment target in patients with triglyceride levels of at least 200 mg/dl.  Therefore, we are potentially treating some patients only to their optimal LDL-C goal while their non-HDL-C value remains above goal.

“Our research group at the Johns Hopkins Ciccarone Center for prevention acquired a database of 1.3 million patients who underwent lipid profiling by direct ultracentrifugation (Vertical Autoprofile test by Atherotech, Birmingham, Alabama, USA) from 2009 to 2011. Their age, sex and lipid parameter distributions closely matched those of the National Health and Nutrition Examination survey, a nationally representative sample of the USA population.,” he said.

“It is registered on clinicaltrials.gov as the Very Large Database of Lipids (NCT01698489). We aimed to use this gigantic database to highlight the amount of patient-level discordance between non-HDL-C and LDL-C percentiles and the potential for inadequate treatment in the structure of current guidelines.

“We found that a significant proportion of individuals are reclassified to higher ATP III (Adult Treatment Panel III) treatment categories when non-HDL-C is used to classify them rather than LDL-C. In addition, there is significant discordance between population percentiles of LDL-C and non-HDL-C particularly when accuracy is most crucial; at LDL-C in the treatment range of high-risk patients and at high triglycerides.

“For example, in patients with LDL-C levels less than 70 mg/dl, 15% had a non-HDL-C value of at least 100 mg/dl, the cutpoint recommended by guidelines, while 25% had a non-HDL-C level of at least 93 mg/dl, the cutpoint based on percentile equivalence. The percentages increased to 22% and 50%, respectively, if triglycerides were 150 mg/dl to 199 mg/dl concurrently.

“We concluded that lowering conventional non–HDL-C cutpoints for high-risk patients to match percentiles of LDL-C cutpoints as well as wider adoption of non–HDL-C in clinical practice might potentially improve secondary prevention outcomes and residual risk assessment and treatment. Therefore, clinicians should be more aggressive about treating their high-risk patients to LDL-C as well as non-HDL-C goals. They should consider using lower non-HDL-C goals for secondary prevention as highlighted in our study.”

Dr. Elshazly first got involve in the project in 2011 when he I started working with the Ciccarone Center of Prevention of the Johns Hopkins Department of Cardiology.  

“We started working on this 1.3 million patients database called the Very Large Database of Lipids and published our first paper in the Journal of the American College of Cardiology (Martin SS. Blaha MJ, Elshazly MB. Friedewald) of estimated versus directly measured low-density lipoprotein cholesterol and treatment implications.

“We presented several abstracts from this database in the American College of Cardiology meetings in 2012 and 2013, American Heart Association meetings in 2012 and 2013 and Arteriosclerosis, Thrombosis and Vascular Biology Scientific Sessions in 2013. And I also participated in an interview on Yahoo Health with Dr. Blaha,” Dr. Elshazly said.

Later he moved on to work on his non-HDL-C study with his mentors Dr. Steven Jones and Dr. Seth Martin at Johns Hopkins Hospital, who are experts in the fields of lipids and atherosclerosis.

 Dr. Elshazly was lavish in praise of his medical and research training in Doha. “WCMC-Q had a great impact on what I am doing today. There were tremendous opportunities to do research in medical school such as summer research scholarships to WCMC-NY as well as state supported funds to do research in Qatar such as UREP and QNRF and I participated in both.

“In addition, WCMC-Q was my road to joining internal medicine residency at Johns Hopkins followed by cardiology fellowship at the Cleveland Clinic. Therefore, I will always be grateful to Qatar Foundation, WCMC-Q and Qatar’s leadership for their investment in research and the human potential and I hope I will be able to use my research expertise to help advance medicine and cardiovascular research in the Middle East,” Dr. Elshazly said.

The study population included 1,310,440 U.S. adults who had triglyceride levels below 400 mg/dL. Their mean age was 59 years, and 52% were women. The authors found that LDL-C cutpoints of 70 mg/dL, 100 mg/dL, 130 mg/dL, 160 mg/dL and 190 mg/dL corresponded to the same population percentiles as non-HDL-C levels of 93 mg/dL, 125 mg/dL, 157 mg/dL, 190 mg/dL and 223 mg/dL, respectively.

When patients were reclassified by non-HDL-C, a significant proportion moved to a higher treatment category compared with LDL-C, especially high-risk patients and patients with a triglyceride level of 150 mg/dL or greater.

Fifteen percent of patients with an LDL-C level below 70 mg/dL had a non-HDL-C level of 100 mg/dL, the guideline-based cutpoint, while 25% had a non-HDL-C of 93 mg/dL or greater, the percentile-based cutpoint. When triglyceride levels between 150 and 199 mg/dL were also considered, 22% of patients with an LDL-C level below 70 mg/dL had a non-HDL-C level of 100 mg/dL and 50% had a non-HDL-C of 93 mg/dL or greater.

The authors acknowledged that clinical and demographic data were limited and that they could not determine the effect of reclassification on clinical outcomes, among other limitations. However, they concluded that patient-level discordance exists between non-HDL-C and LDL-C percentiles, especially at lower LDL-C and higher triglyceride levels, when they said accuracy is most critical.

"Lowering conventional non-HDL-C cutpoints for high-risk patients to match percentiles of LDL-C cutpoints as well as wider adoption of non-HDL-C in clinical practice may potentially improve secondary prevention outcomes and residual risk assessment and treatment," the authors wrote.

The study results were first published online August 21, 2013 by the Journal of the American College of Cardiology.

PANEL BOX plus photos for illustration

Study: Non-HDL Cholesterol, Guideline Targets, and Population Percentiles for Secondary Prevention in a Clinical Sample of 1.3 Million Adults The Very Large Database of Lipids (VLDL-2 Study).

Mohamed B. Elshazly, MD; Seth S. Martin, MD; Michael J. Blaha, MD, MPH; Parag H. Joshi, MD; Peter P. Toth, MD, PhD, FACC; John W. McEvoy, MB BCh; Mohammed A. Al-Hijji, MD; Krishnaji R. Kulkarni, PhD; Peter O. Kwiterovich, MD; Roger S. Blumenthal, MD, FACC; Steven R. Jones, MD, FACC

J Am Coll Cardiol.  

Link: http://content.onlinejacc.org/article.aspx?articleid=1731125

Abstract

Objectives 

To examine patient-level discordance between population percentiles of non-HDL cholesterol (non-HDL-C) and LDL cholesterol (LDL-C).

Background 

Non-HDL-C is an alternative to LDL-C for risk stratification and lipid-lowering therapy. The justification for the present guideline-based non-HDL-C cutpoints of 30 mg/dL higher than LDL-C cutpoints remains largely untested.

Methods 

We assigned population percentiles to non-HDL-C and Friedewald-estimated LDL-C values of 1,310,440 U.S. adults with triglycerides < 400 mg/dL who underwent lipid testing by vertical spin density gradient ultracentrifugation (Atherotech, Birmingham, Alabama) from 2009 to 2011.

Results 

LDL-C cutpoints of 70, 100, 130, 160, and 190 mg/dL were in the same population percentiles as non-HDL-C values of 93, 125, 157, 190, and 223 mg/dL, respectively. Non-HDL-C reclassified a significant proportion of patients within a higher treatment category compared with Friedewald LDL-C, especially at LDL-C levels in the treatment range of high-risk patients and at triglyceride levels ≥ 150 mg/dL. Of patients with LDL-C < 70 mg/dL, 15% had a non-HDL-C ≥ 100 mg/dL (guideline-based cutpoint) and 25% had a non-HDL-C ≥ 93 mg/dL (percentile-based cutpoint); 22% and 50% respectively if triglycerides concurrently 150-199 mg/dL.

Conclusions 

There is significant patient-level discordance between non-HDL-C and LDL-C percentiles at lower LDL-C and higher triglycerides; a finding with implications for treatment of high-risk patients. Current non-HDL-C cutpoints for high-risk patients may need to be lowered to match percentiles of LDL-C cutpoints. Relatively small absolute reductions in non-HDL-C cutpoints result in substantial reclassification of patients to higher treatment categories with potential implications for risk assessment and treatment.

Clinical trial info VLDL-2; NCT01698489