Updated: Novel respiratory coronavirus identified in travelers to Middle Eastern countries #travelmedicine

Public Health Agency of Canada: February 15, 2013
US Centers for Disease Control: March 7, 2013

Update: A total of 14 confirmed cases of novel coronavirus infection have been identified, with 8 deaths. There seems to be an association with recent travel to the Arabian Peninsula (Saudi Arabia, Qatar, Jordan) and influenza A (H1N1) co-infection. Patients presented with lower respiratory infections. Cases have been reported in the UK but not the US. Testing of specimens in the US is being done by the CDC via local health departments.

Q: How many people have been infected?
A: From April 2012 to March 2013, a total of 14 people from Jordan, Saudi Arabia, Qatar, and the United Kingdom were confirmed to have an infection caused by the novel coronavirus.

Saudi Arabia: 7 people; 5 of them died
Qatar: 2 people; both survived
Jordan: 2 people; both died
UK: 3 people; 1 died, 1 receiving treatment, 1 recovered

Original Post: In fall 2012, a novel (new) coronavirus was identified in a small number of cases of persons who went to or came from Saudi Arabia, Qatar and Jordan. A new case has recently been identified in the United Kingdom. This individual had no prior travel history, but is a relative of one of the earlier cases and has an underlying medical condition, increasing the risk for respiratory infections. This suggests that the recently identified person may have acquired the infection through human-to-human contact with the relative; however, the risk of contracting this infection is still considered to be very low.

Coronaviruses are the cause of the common cold but can also be the cause of more severe illnesses including Severe Acute Respiratory Syndrome (SARS). At this time, there is still more to learn about this novel coronavirus. All cases have experienced influenza-like illness including signs and symptoms of pneumonia which may include coughing, mucous, shortness of breath, malaise, chest pain and/or fever.

The World Health Organization continues to work with relevant ministries of health and other international partners to support investigations to gain a better understanding of the disease and its risks. There continues to be no travel restrictions as the risk to travellers remains very low.

Reference: CDC MMWR early release March 7, 2013.

Recommendations

Consult a travel health clinic at least six weeks before you travel.

Protect yourself and others from the spread of germs and influenza-like illness

If you are sick with influenza-like symptoms , delay travel or stay home:

Travelers should recognize signs and symptoms of influenza-like illness, and delay travel or stay home if not feeling well.
Travelers should note that they may be subject to quarantine measures in some countries if showing flu-like symptoms.

Wash your hands frequently:

Avoid touching your eyes, nose and mouth with your hands as germs can be spread this way. For example, if you touch a doorknob that has germs on it then touch your mouth, you can get sick.
By washing your hands with soap under warm running water for at least 20 seconds, you will reduce your chance of getting sick.
Use alcohol-based hand sanitizer if soap and water are not readily available. It's a good idea to keep some with you in your pocket or purse when you travel.

Practise proper cough and sneeze etiquette:

Cover your mouth and nose with your arm to reduce the spread of germs. Remember if you use a tissue, dispose of it as soon as possible and wash your hands afterward
Try to avoid close contact with people who are sick.

Stay up-to-date with your vaccinations

There is no vaccine for this novel coronavirus, however, it is important to be up-to-date on all of your routine and recommended vaccinations, including this year's seasonal flu vaccine, prior to travel.

Monitor your health

If you develop symptoms that cause difficulty breathing upon your return from travel:

Seek medical attention immediately.
Tell your health care provider which countries you have visited while traveling.

How much will a sprained ankle cost me in the ER? Somewhere between $4 and $24110. #costsofcare

You sprain your ankle badly, and aren't sure if it's broken or not. It's 6pm on a Friday evening, so you head to the ER to have it x-rayed. At triage you ask “how much might this cost me?” Typically, nobody working in the hospital at that moment will be able to even take a guess.

A new study out of UCSF, to be published in the upcoming issue of the open-source jornal PLoS ONE, looked at the bills for over 8000 emergency department visits for the ten most common ER diagnoses for patients between 18 and 64

years of age. The results, while not surprising to me, highlight how much financial risk you take walking into a hospital in the United States.

The prices for common conditions ranged widely. While this might reflect severity of illness and necessary diagnostics, the range of prices far exceeds the range of potential complexity:

Sprains and strains: $4 to $24,110.
Headache: $15 to $17,797.
Kidney stone, $128 to $39,408.
Urinary tract infection? $50 to $73.002.

These are “charge master” charges (list prices), the prices that cash-paying patients are asked to pay, and that for the basis of discounts given to insurance companies. These results are consistent with the recent treatise in Time magazine by Stephen Brill on billing practices in the insurance industry (a must-read article).

Link to source article in PLOS One

What can we do given the unpredictability of prices at most hospitals?

Cultivate a relationship with a medical doctor who can help you navigate the hospital in the unlikely event that you need to use one.
Have a doctor who is available enough to take care of things that don't require a hospital, outside of the hospital, in a timely fashion.
Have some kind of catastrophic insurance that will keep you from bankruptcy in the event of a sprained ankle. A policy without a low maximum payout amount.

Here in San Francisco you can always choose My Doctor Medical Group as your medical home and advocate, to help avoid some of the avoidable uncertainty and lack of transparency in the larger health care system.

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

Required reading for everyone who lives in the United States, or who is thinking about doing so: Stephen Brill delivered an amazing piece of investigative journalism last week 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.

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

Stephen Brill on the Daily Show with Jon Stewart

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.

And watch the Entire Interview by Jon Stewart on the Daily Show.

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.

The Daily Show with Jon Stewart
Get More: Daily Show Full Episodes,Political Humor & Satire Blog,The Daily Show on Facebook

How can I find out if I have celiac disease?

I often see patients who are concerned about gluten sensitivity or celiac disease. Indeed, that is a common problem and many people do feel better if they removed processed foods, and gluten in particular, from their diet.

The problem is that it matters how you go about investigating your body's response to gluten.

What is celiac disease?

Celiac disease is an auto-immune response to gluten ingested in food. In other words, your own immune system attacks your body because it inappropriately reacts to gluten (contained in grains like wheat, rye and spelt) that you eat. Celiac disease can have all sorts of harmful effects on the body, ranging from diarrhea to anemia to nerve damage to increased rates of certain cancers.

For more information on celiac disease, you can check out this article on UpToDate.com.

How can celiac disease be best diagnosed?

There is an important difference between gluten sensitivity and true celiac disease. Gluten sensitivity is more common, and can potentially be improved or reversed by improving the overall health of the intestinal mucosa and immune system. Celiac disease, however, tends to be a life-long problem and requires very strict removal of all gluten from the diet, forever. The consequences of not removing gluten strictly, if you have true celiac disease, can be increased risk of heart disease, cancer, and other serious illnesses down the line.

So I strongly recommend that everyone get properly tested, by a standard reference lab, for celiac disease before they remove gluten from their diet. If you do the tests after eliminating gluten, they often falsely come up normal, and you won't know. Again, you must be consuming some amount of gluten to get an accurate test result.

If you just have gluten sensitivity (diagnosed by an elimination-rechallenge experiment), there's hope that you can fix your intestinal permeability and no longer have to be perfect about gluten avoidance. However, if you have true celiac disease based on these tests, you must eliminate all gluten, strictly, for the rest of your life.

It's an important distinction.

What tests are most appropriate?

I usually recommend checking only a serum tissue transglutaminase IgA antibody (anti-tTG IgA) and a serum total immunoglobulin A (IgA) level. There are certain circumstances when other blood tests, and even endoscopic biopsies, are required, but most people can rely on these two simple tests. However, if the total IgA level is low, one must get further consultation to figure out how best to get an accurate test result.

How much do these tests cost?

Typically you will spend around $80-120 for the lab tests themselves, depending on where you go. Insurance may cover them if you have them done at a standard reference laboratory, ordered by a medical doctor, and have symptoms that “medically justify” the tests.

What if I've already eliminated gluten?

You have two choices. Continue off gluten very strictly, forever (i.e. assume you have true celiac disease). Or, you can restart eating some gluten daily for 4-6 weeks and then do the blood tests. It really can take that long to start making the antibodies again after you've eliminated gluten.

Where can I get these tests done?

Here in California, labs must be ordered by a licensed health care provider. So you'll need to visit a doctor who's willing to do this for you. Even better, one (like a doctor here at My Doctor Medical Group) who knows what things costs and who can get you fair and transparent pricing on the lab tests. You can also order these tests online from out-of-state companies, often at somewhat higher cost, without seeing a doctor.

What if I'm not sure what to do?

By all means, see a doctor who knows about these things, who can help explain your options and make sure you figure things out correctly. Like us, if you can come see us in San Francisco.

Why the #QuantifiedSelf Movement Will Continue to Make Inroads in Medicine

Excerpt from an article on The Medtech Pulse blog:

“Many of the people who come to my office…have come because modern medicine has failed them in some way, or they have used up its power to help them and they know not what else to do.” —Rachel Naomi Remen, MD

A couple of weeks ago, at Stanford Medicine X, Paul Abramson MD used that quotation to kick off a presentation on how the Quantified Self movement is intersecting with medicine. Abramson, originally an electrical engineer by training, discovered he was more motivated by listening to people’s stories and trying to help them than doing research in engineering. He then enrolled in medical school, and eventually began practicing family medicine. Later on, he began to dabble in self tracking to find out why he had been experiencing recurrent headaches. He later used data garnered from the experiments to link the headaches to a sleep problem and had an epiphany: “Why can’t we do [something similar] for a lot of people?”

Among the biggest problems in medicine, as Abramson sees it, is a lack of patient empowerment and poor customer service. The Quantified Self movement can be harnessed to help address such problems, he explained. In many ways, what health trackers are doing is an extension of a long medical tradition. “Doctors have been prescribing headache logs for people with migraines and dietary logs [for a long time.]” While the Quantified self movement gives adherents new power to monitor their health, most people, however, have limited success with self tracking unless they are highly motivated, he acknowledged. To deal with that issue, Abramson has come up with a paradigm in his medical practice to put the patient in touch with a data-tracking coach as well as the doctor. “It is a team based approach but it is really based on this self-exploratory model.” The quant coach works with a patient as a peer to help motivate them and interpret their health data.

You may find the original article here: http://www.qmed.com/mpmn/medtechpulse/why-quantified-self-movement-will-continue-make-inroads-medicine

And Dr. Abramson's Quantified Doctor blog here

Dr. Abramson’s Talk at Medicine X 2012 on Self Tracking in Medical Care

I gave a talk on implementing self tracking in my medical practice at the Medicine X 2012 Conference at Stanford on September 28, 2012. A bit of perspective on the health care system and its shortcomings provided an introduction to a new model of care involving a Quant Coach as an integral member of a medical team, with the patient at the center.

A direct link is here: Quantified Doctor Talk: Slides on SlideShare

You may visit Dr. Abramson's “Quantified Doctor” blog here: The Quantified Doctor

Are you taking vitamin D supplements? Some suggestions.

Many patients come to me on vitamin D supplements, and there have been a lot of opinion pieces for and against vitamin D supplementation lately. Without getting into the data too deeply, it seems likely that vitamin D3 supplemention is probably going to turn out to be beneficial up to a point, but that over-supplementing is probably harmful even before you get to frank vitamin D toxicity (which is rare).

Three simple suggestions:

If you've got chronic medical conditions, talk to a doctor about vitamin D testing and dosing to avoid any unintended consequences;
Take vitamin D3 supplements with the meal of the day that contains the most fat/oils. It's a fat-soluble vitamin and this will increase absorption;
If you are an adult and taking more than 2000 I.U. of vitamin D3 per day, it's important to have a 25-OH-vitamin D blood test checked to make sure you're in a reasonable range (in my view, 30-60 ng/mL). It takes up to 6 weeks for levels to equilibrate after a dose change.

Of course, if you have specific questions about your health, please talk to your doctor, or come see us as a patient in San Francisco.

Study: Statin use leads to fatigue

What has long been observed by physicians, statin-induced fatigue, is now being demonstrated in proper randomized controlled studies.

Researchers took 1016 adults with elevated LDL cholesterol, and gave them simvastatin, pravastatin or placebo. At 6 months, those taking the statin medications were more likely to be fatigued both at rest and with exertion.

It makes sense to only use statin medication in those patients where the medications are likely to provide a net benefit, such as those who have demonstrated cardiovascular or cerebrovascular disease or diabetes. Routine use to treat elevated cholesterol in lower risk populations is a bad idea, despite extensive historical drug company marketing to the contrary.

In cases where it's not clear what to do, sometimes more advanced testing can be helpful to stratify risk and make an education decision about statin use.

Reference:
Archives of Internal Medicine: http://archinte.jamanetwork.com/article.aspx?articleid=1183454

How Psychedelic Drugs Can Help Patients Face Death via @nytimes

Can psychedelics ease the suffering of those with terminal illness? A growing number of medical studies, and a recent article in the New York Times, say “yes.”

Research into the use of psychedelic and entheogenic drugs, such as psilocybin-containing mushrooms, LSD and MDMA, to treat medical and psychiatric problems was actively pursued in the 1950s and 1960s. Recently, after a decades-long hiatus due to government reaction to cultural factors in the 1960s, research has begun again. The initial focus has been on mental health issues such as anxiety in terminally-ill patients and PTSD in military veterans. But using these substances to treat medical conditions, such as LSD for cluster headaches, has also shown promise.

Pam Sakuda was 55 when she found out she was dying. Shortly after having a tumor removed from her colon, she heard the doctor’s dreaded words: Stage 4; metastatic. Sakuda was given 6 to 14 months to live. Determined to slow her disease’s insidious course, she ran several miles every day, even during her grueling treatment regimens. By nature upbeat, articulate and dignified, Sakuda — who died in November 2006, outlasting everyone’s expectations by living for four years — was alarmed when anxiety and depression came to claim her after she passed the 14-month mark, her days darkening as she grew closer to her biological demise. […]
Norbert Litzinger remembers picking up his wife from the medical center after her first [psychedelic] session and seeing that this deeply distressed woman was now “glowing from the inside out.” […] under the influence of the psilocybin, she came to a very visceral understanding that there was a present, a now, and that it was hers to have.

The latest study out of UCLA, published in the Archives of General Psychiatry in 2011 and conducted by Charles Grob MD, administered psilocybin — an active component of magic mushrooms — to end-stage cancer patients to see if it could reduce their fear of death.

The results showed that administering psilocybin to terminally ill subjects could be done safely while reducing the subjects’ anxiety and depression about their impending deaths.

Surely more research is needed. And these drugs are currently all still in Schedule 2 of the Controlled Substances Act in the United States. So any use outside of a DEA-approved research protocol is illegal.

You can find the entire NYT article here.

Study Shows Shocking Disparities in Hospital Bills for Appendicitis Treatment #costsofcare

“Mommy, my tummy hurts.”

It's 4am. Your 8-year-old son is shaking you awake. After you confirm that in fact, he is having abdominal pain and not just a bad dream, you head down to the local hospital emergency department to have him checked out.

Little did you suspect, a variety of factors beyond your control in the next 2 hours, having little to do with your son's medical condition, will determine whether your family has to declare bankruptcy or not.
Read More

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