American College of Physicians: Internal Medicine — Doctors for Adults ®

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Monday, July 28, 2014

Schistosomiasis in Tanzania--a prologue

I am in the African Republic of Tanzania. This year I have again accompanied a group of medical students from University of California at Irvine who will be teaching bedside ultrasound to clinical officer students at a medical school in Mwanza, the second largest city in this East African country. We will also be looking at the utility of ultrasound in diagnosing schistosomiasis, a parasitic disease which is endemic here.

Mwanza is on the coast of Lake Victoria, a huge body of water also bordered by Kenya and Uganda. Much of the commerce here has to do with the lake, both relating to tourism and fishing. Schistosomiasis is a water-borne disease caused by a fluke that lives in the lake, harbored by snails. The snails are infected by schistosomiasis miracidia and shed cercaria capable of infecting humans in the beautiful blue water, where they penetrate the skin of mammals that swim in the lake. The flukes move through the lymphatic system, penetrate the blood vessels of the lungs and end up in the left heart and thence the blood vessels. They attach themselves to our blood vessel walls, nourish themselves on our blood, copulate constantly and produce eggs which are intensely irritating to our various internal organs. We eliminate eggs in our urine and bowels which go back into the water system to mature and complete the cycle.

Infection with Schistosoma mansoni and S. haematobium, which are the predominant species here in Tanzania, can cause fibrosis of the portal veins of the liver with chronic liver disease, scarring of the intestines and bladder with resulting kidney failure, malnutrition and anemia and chronic ulcerations of the lower genital tract. Less common and even more nightmare inspiring complications, including spinal cord and brain infection, also occur. Most people in this community are infected, though only a relatively small proportion have noticeable symptoms. The most heavily exposed people are the most severely infected, including fishermen and car washers, but also include school aged children who are weakened and perform more poorly at school. Women with schistosomiasis genital lesions may be at higher risk for contracting HIV. Patients with associated bladder or liver disease are at higher risk of developing cancer of those organs.

Schistosomiasis is one of the ”neglected tropical diseases“ which are neglected because they occur primarily in very poor areas and to very poor people. In the case of schistosomiasis, neglect is enhanced because it is debilitating and chronic but not usually fatal. Nutrition and genetics affect how sick a person gets after being infected. Tourists sometimes return with schistosomiasis, but rarely to any great harm. The treatment is simple, a big dose of an anti-parasitic medication called praziquantel given once. It will clear the fluke from the blood stream and the body can heal any damage that is not advanced enough to be irreversible. In many patients, though, treatment is delayed until long after the point of no return.

The best way to cure schistosomiasis is to completely prevent infection, and since contact with water is life to many people who live on the shores of rivers or lakes, the solution involves getting rid of the fluke. Some countries, most notably Japan, have entirely eradicated the disease using various approaches. Ideas that can work include biological control of snails, introducing predators or competing snails or infecting bacteria. Poisoning them doesn’t work very well because other mollusks and fish also die. The very successful fishing industry in Mwanza, based on introduced Nile Perch which have decimated the omnivorous cichlid species that ate, among other things, snails, has worsened the snail problem. Dams and irrigation projects move snails to previously unaffected areas, increasing the numbers of people exposed to the disease. Reducing certain plant growth along shores of ditches can reduce snails. Infected humans continue the cycle of infection by soiling water sources with urine or feces, so places with active sanitation efforts can significantly reduce their schistosomiasis burden. Large health organizations have proposed blanket treatment of school aged children with praziquantel, potentially yearly in some high risk communities, to both control human disease and reduce the reservoirs that lead to reinfection. This will be hugely expensive, but is probably necessary as part of a larger prevention effort.

I am looking forward to spending some time with the students on a large island in Lake Victoria where, we are told, 100% of the population has schistosomiasis. I expect we will see a vast array of tropical birds and fish and wide expanses of beautiful water, meet new and interesting people and see all kinds of tragic and preventable pathology. I might even go swimming. More later!

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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