Plague in Madagascar

World Health Organization Advisory: Plague in Madagascar: October 2017

As of October 4th, the Ministry of Public Health of Madagascar reports 194 cases of plague, including pneumonic, bubonic and once case of septicemia, with 30 deaths in 20 districts and cities across the country.

Implications for travelers:

The risk of infection with Yersinia pestis for international travelers to Madagascar is generally low. Plague is endemic in Madagascar where cases are reported every year. Due to current cases reported in several cities (including the capital Antananarivo) and the start of epidemic season (September to April) further spread is likely.

Madagascar is well linked by air both regionally and internationally. One visitor from the Seychelles who was participating in a basketball tournament was infected and died. Travelers to rural areas of plague-endemic regions may be at risk, particularly if camping or hunting or if contact with rodents takes place. In addition, travelers to previously non-endemic regions from where cases of pneumonic plague have been recently reported should avoid crowded areas, avoid contact with dead animals, infected tissues or materials, and avoid close contact with patients with pneumonic plague.

Travelers can protect against flea bites using repellent products for personal protection against mosquitoes, fleas and other blood-sucking arthropods. Travelers returning from Madagascar should seek immediate medical attention if they experience symptoms of fever, chills, painful and inflamed lymph nodes, or shortness of breath with coughing and/or blood-tinged sputum.

Based on the available information to date, the risk of international spread of plague appears very low. WHO advises against any restriction on travel or trade based on the available information about the plague in Madagascar.

Reference (NPR): http://www.npr.org/sections/goatsandsoda/2017/10/04/555338600/why-plague-season-is-a-big-worry-in-madagascar-this-year

Source: WHO: Plague in Madagascar: Disease outbreak news

KQED Science: Dr. Abramson Interviewed on NPR About Health Technology

Dr. Abramson was interviewed on NPR Morning Edition by Amy Standen yesterday about the role of wearable technology and health apps in the doctor's office.

Take, for example, Dr. Paul Abramson, a primary care doctor in San Francisco’s financial district.

Abramson is no techno-phobe. He sees patients in a sleek white office with a hydraulic standing desk from Denmark and listens to their hearts with a digital stethoscope.

“I like gadgets,” Abramson explains.

Abramson sees many patients from the tech industry. More and more, he says, people are coming in with data collected from consumer medical devices. One recent patient took this to an extreme.

Listen to the show or read a transcript here:

Do Wearables and Health Apps Belong in the Doctor’s Office?

Giardia: Not a Traveler’s Best Friend

Giardiasis is a fairly common infection of the small intestines caused by the organism Giardia intestinalis (also known as Giardia lamblia). Giardia is a protozoan parasite that thrives in the intestinal tract of mammals and that reproduces by forming cysts, which are transmitted from host to host through the feces of an infected person or animal being ingested by another. The cysts are very resistant and can survive for long periods of time in fresh water, such as lakes, streams and reservoirs.

While Giardia is a common issue in backpackers in the United States (it is present ubiquitously in all states), it is also an under-recognized issue in travelers to developing countries where the water supply can be contaminated.

You can acquire Giardia by:

Eating contaminated food or drinking contaminated water;
Taking in water while swimming in contaminated lakes, ponds, and other fresh water;
Ingesting contaminated feces, including via sexual contact.

Infection is only symptomatic 50% of the time, and it may take up to three weeks or longer for symptoms to occur. However, symptoms are often severe when they arise:

Diarrhea
Gas
Greasy stools that float
Stomach pain and cramping
Nausea
Dehydration
Weight loss of ~10 pounds

Symptoms may last 2-6 weeks before resolving, or can be longer-lasting. Once diagnosed, treatment is always a good idea. To properly diagnose Giardiasis, a doctor or other licensed health care provider must order a stool test for specific Giardia antigen testing, since regular ova and parasite microscopic exams often miss this organism. But it's important to do the microscopic exam for other ova and parasites as well, since multiple microorganisms are sometimes contributing to symptoms.

The complications of Giardia can be frustrating. Some people find that they are lactose intolerant or have developed irritable bowel syndrome (IBS) after Giardia intestinalis infection.

To avoid Giardia, take the following steps:

Practice good hygiene and hand washing
Avoid possibly contaminated water
Use a UV water purifier, halogenation, or a filtration device small enough for parasites
Boil water long enough to kill cysts (one minute, or 3 minutes at elevations of 6500 feet)
Avoid contact with feces
Avoid uncooked foods while traveling

If you suspect that you do have Giardia, seek medical attention and get a specific stool test, since usual antibiotics for travelers diarrhea (ciprofloxacin or azithromycin) will not cure this infection. If you have more than one type of infecting organism, you may need multiple medications to treat them all.

If you have after-effects of Giardia infection, medical attention may also be of help in remedying persistent symptoms.

And before you travel to developing countries (including Mexico), consider having a professional travel medicine consultation.

References:

Giardia Treatment and Diagnosis (Stanford)
Patient Information: Giardia (Beyond the Basics), UpToDate.com
Giardiasis, Mayo Clinic
Giardiasis, Clinical Key
Giardia Infections, Medline Plus
Giardia infection, National Library of Medicine

Paul Abramson MD Interviewed On Doctors Who Accept Bitcoin

Health IT News ran a piece this week about physicians who accept payment in the virtual currency Bitcoin. Dr. Paul Abramson was interviewed on his experiences taking Bitcoin at My Doctor Medical Group in San Francisco.

Abramson, founder of My Doctor Medical Group, is a former software programmer and trained electrical engineer with a significant personal interest in privacy.

It was privacy that drew him to learn more about bitcoins. Early assessments of the technology suggested the bitcoin exchange system had significant anonymity protections that could augment existing medical privacy laws and allow patients who sought the ultimate discretion a nearly invisible form of payment.

“It's important for people to be able to maintain their privacy” about all things, but particularly medical issues, Abramson said.

However, as bitcoin use has expanded, further exploration of its privacy protections has shown that, while it does take some effort to uncover a bitcoin user's identity, it is possible.

You can read the whole article here:

Healthcare IT News Interview

For Reddit r/bitcoin commentary: Reddit commentary on interview

For more information on Bitcoin at My Doctor Medical Group: A Doctor Who Accepts Bitcoin

SF Chronicle Interview: Paul Abramson MD on Medically-Supervised Self Tracking

My Doctor Medical Group founder Paul Abramson MD was interviewed this week in the San Francisco Chronicle about his use of self tracking technologies, in collaboration with “Quant Coach” Lauren DeDecker, to collaboratively help his patients in San Francisco solve vexing health challenges, taking the do-it-yourself Quantified Self approach to a professionally-supervised level.

Most importantly, Dr. Abramson emphasized that self tracking in a medical context has “..made me focus on the fact that medical care is more of a process .. It's more than just a result.” Far beyond simply using the “medical gadget of the day,” his practice offers a highly-supported environment for patients to gain self knowledge while conducting safe and effective physician-supervised personal health experiments.

An excerpt from the article:

When Dr. Paul Abramson treats patients, he has the usual assortment of medical tools, tests and protocols. And then there's the patient-gathered data he reserves for his most confounding cases.

Using an iPhone app, Abramson will have a patient with, say, mystifying migraines or seemingly inexplicable stomachaches self-track data such as how much sleep they're getting or what they're eating.

That information is eventually fed back to Abramson as potential clues to whatever medical mystery he's trying to solve. The result is a more complete picture of his patients that in turn makes it much easier for him to figure out what's going on. […]

Click here for the entire article at SFGate.com

For more information about medically supervised self tracking and the Quant Coach program at My Doctor Medical Group: Click Here.

Irritable Bowel Syndrome (IBS), When the Mind-Body Connection Short Circuits

So many diseases and conditions in America are automatically treated with a prescription pad. But what if pills won’t help?

“The mind and the body are linked, physically, neurologically, as well as emotionally, and that things that affect the mind can affect the gut and vice versa. If you do something to alleviate mind stressors, you can improve body functions.”

Truer words have not been spoken, by Dr. Arnold Wald in a recent Reuters Health article on the mind-body connection and Irritable Bowel Syndrome (IBS). IBS is characterized by abdominal pain and constipation, diarrhea, or both. The abdominal pain is typically due to gas and bloating. While the cause is unknown, many factors appear to play a role in the development and treatment of IBS.

Infection. The risk of developing IBS is elevated after a bacterial, protozoan, helminth, or viral gastrointestinal infection, including travelers diarrhea.
Inflammation. The immune system is activated in some IBS patients, particularly those with diarrhea (though inflammatory blood markers will appear normal). Increased intestinal permeability may also be present.
Gut flora. Emerging data suggest that the microbiota of those with IBS differs from healthy individuals and varies with the predominant symptom (constipation versus diarrhea). Gut flora is often disrupted after taking antibiotics, especially repeatedly.
Food sensitivities. Some IBS sufferers have sensitivities to carbohydrates (like FODMAPs), fructose, gluten, and/or dairy.
Genetics. There may be gene polymorphisms that increase the risk of IBS. One study on twins did indicate that familial nature of IBS may be due to social learning as well as genetics.
Stress and mental health. Patients with IBS symptoms report more stress in life and day to day. They tend to have more anxiety, depression, phobias, somatization, and sleep problems. This isn’t surprising, as 90% of the neurotransmitters in the body are located in the intestinal nervous system. A problem in the mind can transmit to a problem in the gut, and vice versa.

Because of the many contributory elements to IBS, treatment is a multi-faceted approach. Because it is likely unclear what is causing your IBS, it is best to treat each possibility, one at at time. A first line of treatment will consist of dietary modifications like eliminating lactose, starting a no-FODMAPs diet, very low carb diet, or gluten free diet.

Diet and Supplements. An evolutionary, or “Paleo” diet plan combines several of these approaches and can be easier to implement. Fiber, probiotics, or anti-inflammatory supplements may be a next step if symptoms continue.

Mind-Body Medicine. Because of the apparent mind-body connection with IBS, psychotherapy may be very helpful in alleviating symptoms. A randomized controlled trial of 431 adults showed that cognitive-behavioral therapy (CBT) was effective at treating severe IBS, and probably more effective than medication. Other studied mind-body techniques include meditation and acupuncture. Medications can be effective, but the best long-term strategy often involves a multi-modal approach.

Physical activity is another natural option that may help alleviate stress and improve gut comfort and motility.

With so many options for treatment, it is important to try one thing at a time to see what helps your symptoms and what does not. Tracking the symptoms and changes is important for differentiating between what works and what doesn’t. Medically-supervised self tracking, using our model of a Quant Coach and Quant-Friendly Doctor, can guide you in your experiments and ensure that they are done in the most efficient and safe manner, as well as provide support on your journey, and keep an eye on your medical status.

Bitter Pill: Why Medical Bills are Crushing Us. Investigative reporting at its best from Steven Brill. #costsofcare

Required reading for everyone who lives in the United States, or who is thinking about doing so: Steven Brill delivered an amazing piece of investigative journalism in February 2013 on the U.S. health care system in Time Magazine. Hopefully everyone will read it before they develop a serious illness, but regardless it lays bare some of the reasons why the health care economy makes absolutely no sense. That in itself wouldn't be a problem, but it's also bankrupting individuals and the entire country, which is really a shame.

[We have updated this post to correct the spelling of Steven Brill's name, but also to republish it to keep this important topic in the public eye on an ongoing basis –Ed.]

If you have ever consumed health care at a hospital and looked at the bills that resulted, you will instantly relate to his 36-page analysis of six hospital bills. But he documents in no uncertain terms the sheer brazenness of a health industry that sets prices arbitrarily, applies them unevenly, and often collects on ridiculous charges unmercifully.

I am hoping that this piece sets into motion a sea change where Americans demand in the health care economy basic things that are required in every other economy. But in a market where

the consumers (people with sudden severe illness) are really not free to shop around, I think hospitals should be held to a standard of transparency and ethics that are higher than, for example, the grocery store industry.

The article is here: Bitter Pill Why Medical Bills are Crushing Us, in Time Magazine.

YouTube: Video from Time Magazine on his article.

Brill's conclusion that we should simply expand Medicare to fix this problem is probably wrong. But he exposes some very fundamental flaws that every consumer should be aware of before they head to any hospital for anything, inpatient, outpatient, lab, imaging, surgical, or emergency.

He talks about billing advocates that helped people cut their bills after the fact. But it's also critical to have a doctor who's aware of the cost issue and can help you navigate before and during a health crisis. We are experts of this at My Doctor Medical Group in San Francisco, and it's one of the reasons our patients go out of network to choose us for primary care. After all, the costs of outpatient care are tiny compared to hospital care, and it's often a worthwhile investment to have a doctor on your team who works for you, not your insurance company, when the chips are down.

Sodium Butyrate: An Overlooked Supplement for #Crohn’s Disease #ibd

Sodium butyrate is a short chain fatty acid by-product of gut microbes and the primary energy source for cells lining the colon. Since it is sold as a dietary supplement in the United States, it is not regulated by the FDA as a medication. Sodium butyrate may be a beneficial supplement for those suffering from mild-to-moderate Crohn’s disease, especially since it seems generally safe and has few potential side effects.

Crohn’s disease is an autoimmune inflammatory bowel disease whose underlying cause is not yet known. Various etiologies have been proposed, ranging from immune responses to pathogenic parasites or bacteria, to the effects of certain foods, to imbalances in the normal intestinal flora. Unlike the other main form of inflammatory bowel disease, Crohn’s disease can affect any part of the gastrointestinal system, from the mouth to the anus. Symptoms can include abdominal pain, fevers, diarrhea, and rectal bleeding. Over time complications can include scarring and strictures, nutritional deficiencies, abscesses, fistulas and bowel obstructions.

A study. Di Sabatino, et al (2005) investigated the effect of sodium butyrate supplementation on a group of Crohn’s patients. The group was given enteric-coated sodium butyrate supplements for 8 weeks. An impressive 69% responded to treatment, with the majority of those people achieving full remission. Those who had a clinical response also had decreased mucosal levels of inflammatory markers NF-κB and IL-1β after treatment.¹

It appears that sodium butyrate may exert its positive effects by down-regulating inflammatory cytokines, thereby decreasing mucosal inflammation that is a core mechanism of Crohn's disease. Because it is an energy source to colonocytes, it is also thought to aid in the healing of the lining of the colon after injury.

Due to the lack of large controlled studies, sodium butyrate is not yet being used as a conventional treatment for IBD. But data from small studies appears promising. We have successfully added it to the regimens of some of our patients with Crohn's, and early “N of 1” experiments appear promising.

Medically-supervised Quant Coaching. Since people often respond differently to medications and supplements, we have found it very beneficial at My Doctor Medical Group to help our patients with Crohn's conduct carefully controlled experiments of dietary, supplement and medication interventions by using self-tracking technology. These experiments are usually conducted under the supervision of a Quant Coach (me) and licensed health professionals like our medical director Paul Abramson MD, and a registered dietitian like Denise Garbinski RD.

Please contact us if you would like more information on the ways we help patients with inflammatory bowel disease in our practice in San Francisco. And please talk to your treating physician before adding any dietary supplements to your regimen.

¹Di Sabatino et al., Alimentary Pharmacology & Therapeutics, Volume 22, Issue 9, pages 789–794, November 2005

Can eating processed carbs thwart attempts to treat other addictions?

A recent article in the New York Times: “How Carbs Can Trigger Food Cravings” discussed the mechanisms by which high-glycemic index foods based on processed carbs trigger similar brain reward responses as highly addictive drugs like cocaine.

While the author mainly concluded that people wanting to lose weight should avoid processed carbs and sugar, which is obvious, I think the next logical implication is that people trying to detox from addiction to opiates, alcohol, stimulants and other substances should also avoid flaring up their nucleus accumbens reward pathway by simultaneously avoiding processed and refined carbohydrates.

Another interesting research study in the journal Obesity, June 2013 edition, measured retinal responses to specific light stimuli with a technique called electroretinography which had been found to have a specific pattern when a person was given a dopamine-releasing, rewarding stimulus like the amphetamine-like drug methylphenidate (Ritalin). They then showed that a chocolate brownie, a highly potent source of processed carbs and sugar, created a very similar reward pattern on electroretinography to the amphetamine, and was also associated with increased binge eating behavior.

Ultimately, I think brains need to have a more stable, less quickly fluctuating, and therefore more “boring” neurochemical balance to achieve better function and performance over time.

The irony of Alcoholic Anonymous meetings is that often the attendees gather outside to, yes, binge on cigarettes, coffee and pastries. In other words, maximally stimulating their deprived reward pathways with “acceptable” rewarding substances (nicotine, caffeine and processed carbs/sugars) to compensate for the absence of alcohol or other drugs of abuse. Since nicotine, caffeine and high-glycemic-index foods are very short-acting agents, producing a rapid rise and then fall in blood levels of the rewarding substance, this behavior just keeps the neurochemical roller coaster going, and I believe makes achieving lasting brain stability more difficult.

The NYT article is here: http://well.blogs.nytimes.com/2013/06/27/how-carbs-can-trigger-food-cravings/

The abstract of the June 2013 article in Obesity is here: http://www.ncbi.nlm.nih.gov/pubmed/23784899

Food is indeed medicine, acting just like a prescription drug, and we should respect it as such.

Do you or a loved one have the Female Athlete Triad?

How often does a doctor say “you need to gain weight?” We’re all used to medical professionals (and the media) focusing on weight loss and other ways to prevent diabetes and cardiovascular disease. What’s often overlooked is that a surprising number of otherwise healthy people actually suffer from being underweight, sometimes with devastating consequences.
One group of such people is those with the Female Athlete Triad, with a combination of three elements:

Too few calories available. This can be due to not eating enough, exercising too much, or both.
Menstrual irregularities. Menstrual periods can be irregular or absent.
Bone loss.

This develops into osteopenia and snowballs into osteoporosis. Stress fractures are a key early warning sign. The diagnosis requires a bone density (DEXA) scan and sometimes an MRI to detect early stress fractures.

Why does it matter?

Amenorrhea is a key part of infertility;
Osteoporosis can lead to broken bones at any age. The older you are, the more serious the consequences of a break can be. With severe osteoporosis, even normal activities like lifting a box can lead to a fracture;
Osteoporosis can result in compression of the spine, causing decreased height and deformities like a dowager’s hump (kyphosis);
Depression, anxiety, and mood disturbances are often related to the hormonal imbalances caused by too much exercise and/or insufficient nutrition;
Electrolyte imbalances and anemia can both lead to fatigue, cramping, fainting, and under-performance in sport and daily activities;
Heart arrhythmias and low blood pressure can be life threatening in serious cases of disordered eating and malnutrition.

How does it happen?

Essentially, the Triad is caused by stress on the body. Stress can come in many forms:

Not eating enough calories;
Intermittent fasting;
Cutting out carbohydrates or fat;
Exercising too much;
Not having enough body fat;
Not sleeping enough;
Taking certain drugs, dietary supplements or medications.

Ongoing stress shuts down the GnRH signal from the hypothalamus, which will stop the production of the hormones FSH and LH. Without FSH and LH, estrogen and progesterone levels will plummet. Estrogen is necessary for bone formation and preservation, so inadequate estrogen guarantees bone loss.

What can I do?

If you (or someone you know) identify with any element of the triad, go see your primary care doctor as soon as possible. The doctor can measure your body fat, order blood work, and request a DEXA scan. The two of you can check your body composition and hormonal status and devise a plan to bring you back to a healthy, bone building state. Alterations in diet, exercise, supplements, and overall lifestyle will likely be necessary. Medically supervised “self tracking” is a useful tool for keeping track of dietary intake, exercise, sleep, body pH levels, and correlating these with changes in bone density. Having a Quant Coach and Quant-friendly Doctor on your team can give you the support and guidance you need to stay on your route to recovery and health.

If you need a doctor who understands these issues, and has a team ready to help, just give us a call here at My Doctor Medical Group.

Page 1 of 4
1
2
3
...
4
→