Diseases Commons^™

Acute Hepatic Failure And Oral Amiodarone, Hani Alhamoud, Sivateja Mandava, Talal Alzahrani

GW Research Days 2016 - 2020

Introduction:

Amiodarone is associated with serious complications such as lung toxicity, thyroid dysfunction, and QT-prolongation. Further, hepatic failure from the intravenous (IV) formulation of amiodarone is described in numerous case reports and case series. Although there are reports of elevated liver enzymes from the oral formulation of amiodarone, to our knowledge, none have definitively identified a case of acute hepatic failure from the oral formulation alone. In this case, we report an instance of acute hepatic failure after increasing the oral amiodarone dosage as well as rapid recovery following cessation of the medication.

Case report:

A 61-year-old male with a …

Differences In Preventable Cardiovascular-Related Versus Unavoidable Occupational Causes Of Firefighter Fatalities On Duty, Amy Goad, Dnp, Ms, Np-C

Doctor of Nursing Practice Projects

Background: Firefighters across the United States face high fatality rates in the line of duty of which many are likely related to preventable cardiovascular risk factors.

Objectives: To assess differences in firefighter cardiovascular-related versus unavoidable occupational-related fatalities by career status, age, smoking, obesity, and hypertension.

Methods: We used an exploratory, comparative secondary data analysis design. We extracted data from a national database of deceased firefighters over 14 years. Variables extracted were career status, age, smoking, obesity, and hypertension as well as the reason for death while on duty (i.e., cardiovascular-related or unavoidable occupational-related death). Data were analyzed using Chi-Square to …

Changes In Coronary Plaque Volume: Comparison Of Serial Measurements On Intravascular Ultrasound And Coronary Computed Tomographic Angiography, Rine Nakanishi, Anas Alani, Suguru Matsumoto, Dong Li, Michael Fahmy, Jeby Abraham, Christopher Dailing, Alexander Broersen, Pieter H Kitslaar, Khurram Nasir, James K Min, Matthew J Budoff

The Texas Heart Institute Journal

Serial measurements of coronary plaque volume have been used to evaluate drug efficacy in atherosclerotic progression. However, the usefulness of computed tomography for this purpose is unknown. We investigated whether the change in total plaque volume on coronary computed tomographic angiography is associated with the change in segment plaque volume on intravascular ultrasound. We prospectively enrolled 11 consecutive patients (mean age, 56.3 ± 5 yr; 6 men) who were to undergo serial invasive coronary angiographic examinations with use of grayscale intravascular ultrasound and coronary computed tomography, performedvolume, nor between normalized coronary plaque volume. However, in the per-patient analysis, there were …

New Pulmonary Valvuloplasty Technique By Use Of An Hourglass-Shaped Balloon In 3 Adults With Severe Pulmonary Valve Stenosis, Teoman Kilic, Tayfun Sahin, Kurtulus Karauzum, Ertan Ural, Wesley R Pedersen

The Texas Heart Institute Journal

Percutaneous balloon pulmonary valvuloplasty is the preferred therapy for pulmonary valve stenosis. However, the designs of the cylindrical balloons historically used for valvuloplasty have limitations, especially in patients who have large pulmonary annular diameters. The hourglass-shaped V8 Aortic Valvuloplasty Balloon may prove to be an effective alternative. The balloon has 2 large bulbous segments that are separated by a narrowed waist. The geometric shape is maintained throughout inflation, improving fixation and enabling broader leaflet opening. We present our first experience with the V8 balloon in 3 adults who had severe, symptomatic pulmonary valve stenosis. In addition to describing their cases, …

Cardiac Magnetic Resonance To Evaluate Percutaneous Pulmonary Valve Implantation In Children And Young Adults, Cesar Gonzalez De Alba, Fernando Molina Berganza, John Brownlee, Muhammad Khan, Dilachew Adebo

The Texas Heart Institute Journal

Experience with cardiac magnetic resonance to evaluate coronary arteries in children and young adult patients is limited. Because noninvasive imaging has advantages over coronary angiography, we compared the effectiveness of these techniques in patients who were being considered for percutaneous pulmonary valve implantation.

We retrospectively reviewed the cases of 26 patients (mean age, 12.53 ± 4.85 yr; range, 5–25 yr), all of whom had previous right ventricular-to-pulmonary artery homografts. We studied T2-prepared whole-heart images for coronary anatomy, velocity-encoded cine images for ventricular morphology, and function- and time-resolved magnetic resonance angiographic findings. Cardiac catheterization studies included coronary angiography, balloon compression testing, …

Murmur Associated With Diastolic Paradoxical Jet Flow In A 43-Year-Old Man With Hypertrophic Cardiomyopathy, Michiyo Yamano, Tatsuya Kawasaki, Hirokazu Shiraishi, Tadaaki Kamitani, Takatomo Shima, Takashi Nakamura, Satoaki Matoba

The Texas Heart Institute Journal

A diastolic paradoxical jet flow, often seen in patients with hypertrophic cardiomyopathy, is a unique flow from the apex toward the base of the left ventricle during isovolumic relaxation. To date, this phenomenon appears to have been noninvasively detected only on echocardiograms. We report the case of a 43-year-old man with hypertrophic cardiomyopathy and a diastolic paradoxical jet flow, in whom cardiac auscultation revealed a soft S4, a systolic ejection murmur, and a low-pitched early diastolic murmur immediately after S2 at the apex. On comparing his echocardiographic findings with those on phonocardiograms and apexcardiograms, we confirmed that the unusual murmur …

Public Hospitals Matter, Herbert L Fred

The Texas Heart Institute Journal

Recent events in this country pose major concerns. Police shoot unarmed blacks, gun-wielding malcontents ambush policemen, white supremacists march, gays are murdered, gender inequality pervades our workforce, and sexual harassment and abuse are surfacing in many segments of our society. In reaction, various social movements have sprung up, including Black Lives Matter, White Lives Matter, Blue Lives (policemen) Matter, Gay Lives Matter, Girls for Gender Equity (GGE), #MeToo, and Time's Up. To that list, I add another battle cry: Public Hospitals Matter.

Prevalence Of Diabetes Mellitus, Hypertension, And Dyslipidemia In Student-Run Screening Clinics For Rural Communities In The Sierra Norte Of Puebla, Mexico, Sean Navin, Daniel M. Tomaszewski

Pharmacy Faculty Articles and Research

Background: The growing prevalence of hypertension (HTN), diabetes mellitus (DM), and in Mexico highlights the need for preventative health care services. Rural communities worldwide lack access to such services. The purpose of this study was to describe the prevalence of HTN, DM, and dyslipidemia in student-run screening clinics in rural communities of the Sierra Norte of Puebla, Mexico to better understand the role the clinics play for the patients served.

Methods: Data were collected from patients from rural, Mexican towns participating in free pharmacy student-run screening clinics. Patients consented to have their de-identified information pooled for re-search. Screenings …

Contributions Of Mean And Shape Of Blood Pressure Distribution To Worldwide Trends And Variations In Raised Blood Pressure: A Pooled Analysis Of 1018 Population-Based Measurement Studies With 88.6 Million Participants, Majid Ezzati, Bin Zhou, James Bentham, Mariachiara Di Cesare, Honor Bixby, Goodarz Danaei, Kaveh Hajifathalian, Cristina Taddei, Rodrigo M. Carrillo-Larco, Shirin Djalalinia, Shahab Khatibzadeh, Charles Lugero, Niloofar Peykari, Wan Zhu Zhang, James Bennett, Ver Bilano, Gretchen A. Stevens, Melanie J. Cowan, Leanne M. Riley, Zhengming Chen, Ian R. Hambleton, Rod T. Jackson, Andre Pascal Kengne, Young Ho Khang, Avula Laxmaiah, Jing Liu, Reza Malekzadeh, Hannelore K. Neuhauser, Maroje Sorić, Gregor Starc, Johan Sundström, Tara Coppinger, Janette Walton, Con Burns, Mark Woodward

Publications

Background: Change in the prevalence of raised blood pressure could be due to both shifts in the entire distribution of blood pressure (representing the combined effects of public health interventions and secular trends) and changes in its high-blood-pressure tail (representing successful clinical interventions to control blood pressure in the hypertensive population). Our aim was to quantify the contributions of these two phenomena to the worldwide trends in the prevalence of raised blood pressure. Methods: We pooled 1018 population-based studies with blood pressure measurements on 88.6 million participants from 1985 to 2016. We first calculated mean systolic blood pressure (SBP), mean …

Improving Canadian Indigenous Health: Diabetes & Cardiovascular Disease, Sukhmeet S. Sachal

Western Research Forum

Background:

This abstract explores improving health outcomes for Canada’s Indigenous peoples. The increased prevalence of cardiovascular diseases (CVD) and diabetes in this population makes this a public health problem because diabetes has long-term complications that affect the cardiovascular system and can result in disability and premature death.

Methods:

A literature review using specific search terms was performed to find 36 relevant articles. Search databases for the primary and secondary information were CINAHL and PubMED, respectively.

Results:

The results were classified into five groups: (1) Previous Genetic Protection; (2) Current Day Risk; (3) Diet; (4) Barriers in Developing and Maintaining …

Echocardiographic Detection Of Increased Ventricular Diastolic Stiffness In Pediatric Heart Transplant Recipients: A Pilot Study., Shahryar M. Chowdhury, Ryan J. Butts, Anthony M. Hlavacek, Carolyn L. Taylor, Karen S. Chessa, Varsha M. Bandisode, Girish S. Shirali, Arni Nutting, G Hamilton Baker

Manuscripts, Articles, Book Chapters and Other Papers

Background: Pediatric heart transplant recipients are at risk for increased left ventricular (LV) diastolic stiffness. However, the noninvasive evaluation of LV stiffness has remained elusive in this population. The objective of this study was to compare novel echocardiographic measures of LV diastolic stiffness versus gold-standard measures derived from pressure-volume loop (PVL) analysis in pediatric heart transplant recipients.

Methods: Patients undergoing left heart catheterization were prospectively enrolled. PVLs were obtained via conductance. The end-diastolic pressure-volume relationship was obtained via balloon occlusion. The stiffness constant, β, was calculated. Echocardiographic measures of diastolic function were derived from spectral and tissue Doppler and two-dimensional …

Inequalities In The Use Of Secondary Prevention Of Cardiovascular Disease By Socioeconomic Status: Evidence From The Pure Observational Study, Adrianna Murphy, Benjamin Palafox, Owen O'Donnell, David Stuckler, Pablo Perel, Khalid F. Alhabib, Alvaro Avezum, Xiulin Bai, Jephat Chifamba, Romaina Iqbal

Community Health Sciences

Background: There is little evidence on the use of secondary prevention medicines for cardiovascular disease by socioeconomic groups in countries at different levels of economic development.
Methods: We assessed use of antiplatelet, cholesterol, and blood-pressure-lowering drugs in 8492 individuals with self-reported cardiovascular disease from 21 countries enrolled in the Prospective Urban Rural Epidemiology (PURE) study. Defining one or more drugs as a minimal level of secondary prevention, wealth-related inequality was measured using the Wagstaff concentration index, scaled from -1 (pro-poor) to 1 (pro-rich), standardised by age and sex. Correlations between inequalities and national health-related indicators were estimated.
Findings: The …

Risk Factors For Major Early Adverse Events Related To Cardiac Catheterization In Children And Young Adults With Pulmonary Hypertension: An Analysis Of Data From The Impact (Improving Adult And Congenital Treatment) Registry., Michael L O'Byrne, Kevin F Kennedy, Joshua P Kanter, John T Berger, Andrew C Glatz

Pediatrics Faculty Publications

BACKGROUND: Cardiac catheterization is the gold standard for assessment and follow-up of patients with pulmonary hypertension (PH). To date, there are limited data about the factors that influence the risk of catastrophic adverse events after catheterization in this population.

METHODS AND RESULTS: A retrospective multicenter cohort study was performed to measure risk of catastrophic adverse outcomes after catheterization in children and young adults with PH and identify risk factors for these outcomes. All catheterizations in children and young adults, aged 0 to 21 years, with PH at hospitals submitting data to the IMPACT (Improving Adult and Congenital Treatment) registry between …

Adropin: An Endocrine Link Between The Biological Clock And Cholesterol Homeostasis, Sarbani Ghoshal, Joseph R. Stevens, Cyrielle Billon, Clemence Girardet, Sadichha Sitaula, Arthur S. Leon, D.C. Rao, James S. Skinner, Tuomo Rankinen, Claude Bouchard, Marinelle V. Nuñez, Kimber L. Stanhope, Deborah A. Howatt, Alan Daugherty, Jinsong Zhang, Matthew Schuelke, Edward P. Weiss, Alisha R. Coffey, Brian J. Bennett, Praveen Sethupathy, Thomas P. Burris, Peter J. Havel, Andrew A. Butler

Physiology Faculty Publications

Objective

Identify determinants of plasma adropin concentrations, a secreted peptide translated from the Energy Homeostasis Associated (ENHO) gene linked to metabolic control and vascular function.

Methods

Associations between plasma adropin concentrations, demographics (sex, age, BMI) and circulating biomarkers of lipid and glucose metabolism were assessed in plasma obtained after an overnight fast in humans. The regulation of adropin expression was then assessed in silico, in cultured human cells, and in animal models.

Results

In humans, plasma adropin concentrations are inversely related to atherogenic LDL-cholesterol (LDL-C) levels in men (n = 349), but not in women (n = …

Novel Scoring System For Prediction Of Cardiac Syndrome X In Women With Typical Angina And A Positive Exercise Tolerance Test, Farzad Masoudkabir, Ali Vasheghani-Farahani, Elham Hakki, Hamidreza Poorhosseini, Saeed Sadeghian, Seyed Hesameddin Abbasi, Shahram Bahmanyar, Seyed Ebrahim Kassaian

The Texas Heart Institute Journal

A major diagnostic challenge for cardiologists is to distinguish cardiac syndrome X (CSX) from obstructive coronary artery disease in women with typical angina and a positive exercise tolerance test (ETT). We performed this study to develop a scoring system that more accurately predicts CSX in this patient population.

Data on 976 women with typical angina and a positive ETT who underwent coronary angiography at our center were randomly divided into derivation and validation datasets. We developed a backward stepwise logistic regression model that predicted the presence of CSX, and a scoring system was derived from it.

The derivation dataset (809 …

A Great Speech From A Great Man, Herbert L Fred

The Texas Heart Institute Journal

No abstract provided.

Symptomatic Celiomesenteric Trunk: Variable Presentations And Outcomes In 2 Patients, Michael L Kueht, Darrel L Wu, Joseph L Mills, Ramyar Gilani

The Texas Heart Institute Journal

Mesenteric ischemia can be difficult to diagnose without a high degree of suspicion because it presents in a variety of ways. Visceral vascular collaterals between the fore- and midgut often provide protection against ischemia; however, the presence of anatomic variations, such as celiomesenteric trunk, can undermine the expected redundancy. Misdiagnosis can result in prolonged suffering or death, as evidenced in 2 of our patients with celiomesenteric trunk. The first patient with chronic mesenteric ischemia was diagnosed in the clinic and underwent successful surgical correction; the other had overwhelming, acute mesenteric ischemia, which resulted in death. Our cases show that successful …

Cardiac Rehabilitation Improves Cardiometabolic Health In Young Patients With Nonischemic Dilated Cardiomyopathy, Samuel G Wittekind, Yvette Gerdes, Wayne Mays, Clifford Chin, John L Jefferies

The Texas Heart Institute Journal

Nonischemic dilated cardiomyopathy is deadly and costly, and treatment options are limited. Cardiac rehabilitation has proved safe and beneficial for adults with various types of heart failure. Therefore, we retrospectively evaluated the hypothesis that rehabilitation is safe and improves cardiometabolic health in young patients with nonischemic dilated cardiomypathy. From 2011 through 2015, 8 patients (4 males) (mean age, 20.6 ± 6.6 yr; range, 10-31 yr) underwent rehabilitation at our institution. They were in American Heart Association class C or D heart failure and were on maximal medical therapy. Their mean left ventricular ejection fraction at baseline was 0.26 ± 0.15. …

Effects Of Older Donor Age And Cold Ischemic Time On Long-Term Outcomes Of Heart Transplantation, Heidi J Reich, Jon A Kobashigawa, Tamar Aintablian, Danny Ramzy, Michelle M Kittleson, Fardad Esmailian

The Texas Heart Institute Journal

Using older donor hearts in cardiac transplantation may lead to inferior outcomes: older donors have more comorbidities that reduce graft quality, including coronary artery disease, hypertension, diabetes mellitus, and dyslipidemia. Shorter cold ischemic times might overcome the detrimental effect of older donor age. We examined the relationship between donor allograft age and cold ischemic time on the long-term outcomes of heart transplant recipients. rom 1994 through 2010, surgeons at our hospital performed 745 heart transplantations. We retrospectively classified these cases by donor ages of(younger) and ≥50 years (older), then by cold ischemic times of(short), 120 to 240 min (intermediate), and …

Review Of Kawasaki Disease, Rani Shah, Hisham Hirzallah, Munes Fares, Ashwini Mallad, Gudjon Karlsson, Mehiar El-Hamdani

Marshall Journal of Medicine

Abstract

Background: Kawasaki disease is one of the leading causes of acquired heart disease in children. It is an acute self-limited vasculitis that predominantly affects infants and children younger than 5 years of age. These patients present with nonspecific symptoms, such as fever and lymphadenopathy, making the diagnosis challenging. This disease can have serious and potentially fatal outcomes, and prompt recognition of this disease is vital to the patient’s outcome. We present a complete review of the disease, including the epidemiology, pathophysiology, diagnosis and management of acute Kawasaki disease, the natural history of this disease, and follow up of …

Long-Term Exposure Of Fine Particulate Matter Causes Hypertension By Impaired Renal D1 Receptor-Mediated Sodium Excretion Via Upregulation Of G-Protein-Coupled Receptor Kinase Type 4 Expression In Sprague-Dawley Rats., Xi Lu, Zhengmeng Ye, Shuo Zheng, Hongmei Ren, Jing Zeng, Xinquan Wang, Pedro A Jose, Ken Chen, Chunyu Zeng

Medicine Faculty Publications

BACKGROUND: Epidemiological evidence supports an important association between air pollution exposure and hypertension. However, the mechanisms are not clear.

METHODS AND RESULTS: Our present study found that long-term exposure to fine particulate matter (PM2.5) causes hypertension and impairs renal sodium excretion, which might be ascribed to lower D1 receptor expression and higher D1 receptor phosphorylation, accompanied with a higher G-protein-coupled receptor kinase type 4 (GRK4) expression. The in vivo results were confirmed in in vitro studies (ie, PM2.5 increased basal and decreased D1 receptor mediated inhibitory effect on Na+-K+ ATPase activity, decreased D1 receptor expression, and increased D1 receptor phosphorylation …

The Association Between A Body Shape Index And Cardiovascular Risk In Overweight And Obese Children And Adolescents, Chiara Mameli, Nir Y. Krakauer, Jesse C. Karakauer, Alessandra Bosetti, Chiara Matilde Ferrari, Norma Moiana, Laura Schneider, Barbara Borsani, Teresa Genoni, Gianvincenzo Zuccotti

Publications and Research

A Body Shape Index (ABSI) and normalized hip circumference (Hip Index, HI) have been recently shown to be strong risk factors for mortality and for cardiovascular disease in adults. We conducted an observational cross-sectional study to evaluate the relationship between ABSI, HI and cardiometabolic risk factors and obesity-related comorbidities in overweight and obese children and adolescents aged 2±18 years. We performed multivariate linear and logistic regression analyses with BMI, ABSI, and HI age and sex normalized z scores as predictors to examine the association with cardiometabolic risk markers (systolic and diastolic blood pressure, fasting glucose and insulin, total cholesterol and …

Reduction Of Vascular Inflammation, Ldl-C, Or Both For The Protection From Cardiovascular Events?, Andromachi Reklou, Michael Doumas, Konstantinos Imprialos, Konstantinos Stavropoulos, Dimitris Patoulias, Vasilios Athyros

Medicine Faculty Publications

Background:

Low density lipoprotein cholesterol (LDL-C) and low grade arterial inflammation are key pathogenic factors for atherosclerosis and its manifestation, cardiovascular disease (CVD).

Objective:

In this narrative review we assessed if decreasing LDL-C levels or inflammation or both is more effective in reducing CVD events.

Results:

In the Scandinavian Simvastatin Survival Study (4S), all statin trials of the 90s’ and the Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) the benefit came from the LDL-C reduction. In the GREak and Atorvastatin Coronary heart disease Evaluation (GREACE), the Treating to New Targets (TNT), and the Justification …

Improving Outcomes After Pediatric Cardiac Arrest – The Icu-Resuscitation Project: Study Protocol For A Randomized Controlled Trial, Eunice Kennedy Shriver National Institute Of Child Health And Human Development Collaborative Pediatric Critical Care Research Network (Cpccrn), Murray M. Pollack

Pediatrics Faculty Publications

Background

Quality of cardiopulmonary resuscitation (CPR) is associated with survival, but recommended guidelines are often not met, and less than half the children with an in-hospital arrest will survive to discharge. A single-center before-and-after study demonstrated that outcomes may be improved with a novel training program in which all pediatric intensive care unit staff are encouraged to participate in frequent CPR refresher training and regular, structured resuscitation debriefings focused on patient-centric physiology.

Methods/design

This ongoing trial will assess whether a program of structured debriefings and point-of-care bedside practice that emphasizes physiologic resuscitation targets improves the rate of survival to hospital …

Chile: Air Pollution, Kara Eder

Global Public Health

Chile faces a constant issue of air pollution, reaping respiratory health problems for citizens in urban areas. While the many cases over the past century have increased officials to take action on the issue, the growing infrastructure and economy of the country makes it difficult to regulate harmful emissions. Wood-burning heaters within urban residential areas also contribute to the unhealthy smog. Ingestion of these forms of matter in the air causes respiratory symptoms such as bronchitis and cardiovascular disease. Bans on such heaters and taxes on vehicle emissions were placed in order to prevent the severity of pollutants in the …

Grenada: Cardiovascular Disease, Talayah Lemon

Global Public Health

Grenada has a population of 109,011 people. This public health brief encompasses cardiovascular disease and its impact in the country of Grenada. The country suffers from high level of AIDS/HIV, obesity, diabetes, etc. However, Cardiovascular disease is very prevalent in Grenada. About 34% of the population suffer from the disease. Cardiovascular disease affects the blood supply flow to the heart. Grenada’s health system has provided solutions such as providing adequate health care, but lack some healthcare services, such as cardiology and vascular surgeries. Cardiovascular disease has a huge impact on the population, but Grenada works towards ways to mitigate the …

Hungary: Cardiovascular Disease, Taylor Steger

Global Public Health

Hungary faces many public health issues. In particular, cardiovascular disease has impacted the majority of the Hungarian people with a mortality rate of 50-60%. The high consumption of fattening food, excessive alcohol drinking, smoking habits and tobacco use impact the entire population’s health status. This disease impacts blood vessels and causes them to narrow or be blocked. This blockage causes blood flow from the heart to be suppressed which can cause heart attacks, strokes etc. Hungary has the highest amount of people with cardiovascular disease out of all European countries. The most impacted people are in the urban areas. This …

Bulgaria: Brucellosis, Austin Wheeler

Global Public Health

In this brief we will discuss how a disease called Brucellosis has affected the country of Bulgaria. Bulgaria is a European country located towards the South Eastern part of Europe. A few points mentioned in the brief are what the disease can do to your body, through education of the disease we can show what a serious problem it is. The brief will also cover how you can contract the disease through animals, and how you can prevent contraction from occurring. The brief also includes a lot about the religious background of the country. This should hopefully be used to …

Bahrain: Cardiovascular Disease, Sandra Morales

Global Public Health

A beautiful island in the Arabian Gulf (Persian Gulf), east of Saudi Arabia, north of Qatar, Bahrain is home to over 1.5 million people. The diverse population consists of Muslims, Hindus, Christians, Asians, Africans, and so much more. Bahrain is a constitutional monarchy. The current commander of the Bahrain defense force is Khalifa bin Salman Al Khalifa. For the most part, Bahrainis have political freedoms. However, one major problem Bahrainis face, in particular men, is cardiovascular disease. Cardiovascular disease accounted for 34% of deaths in 2002. It is a major cause of morbidity and mortality in Bahrain. Obesity and inactivity …

Tonga: Chronic Diseases, Muhammad Taimoor

Global Public Health

Tonga is an Archipelago in the south Pacific Ocean, south of Samoa. The public health brief project is on chronic diseases in Tonga. The total population of Tonga was 107,122 in 2010. The Free Wesleyan Church of Tonga is the established religion in Tonga. Tongan’s make up the majority of the population but there are other ethnicities such as Euromericans and Europeans too. The major challenges faced by Tonga are decaying infrastructure, low economy, and political corruption. The widespread of non-communicable diseases such as cancer is a major health issue in Tonga. 74% of all adults in Tonga are the …