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Retirement, eh?

December 2nd, 2017 · Comments Off on Retirement, eh? · Uncategorized

Dear Travel Patients,

After 30 years of practicing travel medicine (as well as Family Practice), nearly 200,000 vaccinations,  125,000 prescriptions for antimalarials, a few fainting spells and almost a quarter million scripts for Imodium and Cipro, as well as lots of other sound advice,  I have decided to retire from my family and travel medicine practices. My office at 3292 Bayview Avenue, Toronto, will close February 28, 2018. I plan to stop seeing travel patients as of January 31.

I hope to fill my coming years with some rest, time at the cottage, jazz piano, yoga, squash, reading, teaching, volunteering and spending time with my lovely family. I have several destinations on my travel bucket list, including Vietnam and Cambodia, Manitoulin Island, Petra, and hopefully retracing some of my steps to places I have been before.

174Over the past 30 years, I have had the honour and the pleasure of seeing thousands of travelers before their trips (and sometimes after), to almost every destination and for every imaginable reason. I have learned so much about so many things from you. Though I have been fortunate to travel widely on my own, I consider myself one of the world’s most successful vicarious travelers.

Perhaps my greatest joy is having looked after the medical needs of so many international volunteers, with tremendous organizations such as VSO, CUSO, Right To Play. Engineers Without Borders, The Aga Khan Foundation, Canadian Feed The Children, Journalists For Human Rights, Free The Children, the RCMP and many more.

I plan to stay involved in travel and international medicine, so please keep in touch with my website in the future, as I may turn up elsewhere! I hope to post a YouTube video telling most of you almost everything you need to know.

From a practical point of view, I hope and assume you have written records of the vaccines you have received in my clinic. When I began in travel medicine many years ago, there were less than a handful of “travel clinics” in the GTA. They are now as ubiquitous as Tim Hortons! Quality may vary, in my humble opinion. For a list of local travel clinics, click here.

I would like to thank my staff, Indi Lochan, Lilliana Gallego, Dolly Travaranjah and Karon Rautianen, for looking after me, and you, so well over many years.

I wish you all good health, happiness, exciting travels, and I hope our paths will cross in the future.

Mark Wise MD, DTM&H

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Tick Flick

November 5th, 2017 · Comments Off on Tick Flick · Uncategorized

For those who wonder what a tick looks like, you can obviously go on the internet, or watch this video on my daughter Carrie’s arm in Kingston!

tick flick

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Flu vaccine 2017-2018 … for those 65 and over

October 10th, 2017 · Comments Off on Flu vaccine 2017-2018 … for those 65 and over · Uncategorized

Dear Patients,

Please read the guidelines below. If you are 65 or over, you have a choice between the government provided vaccine, Fluviral, or a “high-dose” vaccine(Fluzone High-Dose) made by Sanofi (not government funded). The latter is slightly more effective (see diagram below). If you are under 65, you should be receiving the usual vaccine.

2017-2018 NACI GUIDELINES FOR FLU VACCINATION

Adults ≥65 years of age

Four types of vaccine are available for use in adults ≥65 years of age: standard dose TIV, high dose TIV, MF59-adjuvanted TIV, and QIV.

Choice of vaccine product for adults ≥65 years of age

In choosing a vaccine product, it is important to consider the relative burden of influenza disease caused by the various influenza subtypes (i.e., influenza A(H1N1), influenza A(H3N2) and influenza B) in this age group, as well as the efficacy, immunogenicity and safety profile of the available vaccines.

A study focusing on estimates of deaths associated with influenza in the USA has established that the average annual rate of influenza-associated deaths for adults aged ≥65 years was 17.0 deaths per 100,000 (range: 2.4–36.7) . The study also states that deaths among persons aged ≥65 years accounted for 87.9% of the overall estimated average annual influenza-associated deaths with underlying pneumonia and influenza causes. When influenza-related deaths were estimated using underlying respiratory and circulatory causes, these estimates increased to 66.1 deaths per 100,000 (range: 8.0–121.1) and 89.4%, respectively.

Canadian surveillance data shows that hospitalization rates among individuals ≥65 years of age were higher during the 2014–2015 season, a season in which A(H3N2) circulation predominated and there was a vaccine mismatch with the circulating A(H3N2) strain, compared to the previous five influenza seasons and also compared to the 2012–2013 season when A(H3N2) also predominated. Similar to the hospitalization rates, death rates among seniors were highest in the 2014–2015 season compared to the previous five seasons and compared to the previous A(H3N2) season in 2012–2013. Deaths rates among other age groups were similar to or lower than the previous five influenza seasons. Laboratory detections over this same time period showed that influenza seasons predominated by Influenza subtype A(H3N2) disproportionally affected adults ≥65 years of age while seasons with greater A(H1N1) detections  resulted in a higher prevalence of positive cases in younger age groups.

Based on the available evidence, NACI concludes that there is evidence that high dose TIV should provide superior protection compared with standard dose TIV for adults ≥65 years of age.

flu

Considering the burden of disease associated with influenza A(H3N2) and the evidence of superior efficacy of high dose TIV compared to standard dose TIV, it appears that high dose TIV would provide the greatest benefit to the ≥65 years age group.

This high dose flu vaccine is not provided by our Ontario government. It can be purchased from the pharmacy or at my office for $80.

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Potpourri

October 1st, 2017 · Comments Off on Potpourri · Uncategorized

I was 14 years old when JEOPARDY! first appeared on TV. I was a regular, and my favourite category, aside from Sports, was Potpourri. Today’s blog, after another sabbatical, is some potpourri.

Travel medicine continues to be plagued by vaccine shortages… not just for yellow fever, but also typhoid, Twinrix (hepatitis A and B) and rabies. Yellow fever vaccine is being doled out in fractions, according to my past blogs. Organizing travelers who need, or might want, or might not want, the yellow fever vaccine is no easy matter.

The world isn’t growing any more countries or mountains or ancient ruins. So people continue to be off to the usual destinations, Peru and Machu Picchu with a dip in the Amazon, southern Africa including Kruger National Park, Botswana, Namibia and Zimbabwe (someone brought be the lovely gift of a tick, which he had found on his ….), and Southeast Asia including Thailand, Cambodia, Lao and Vietnam.

Many of the same issues popup every day, including:

  • do I really need that typhoid shot
  • I hear the antimalarials make you psychotic
  • I can’t remember whether I got the booster
  • my brother-in-law had the shot downtown
  • isn’t it better just to let the diarrhea run its course
  • is there anything other than DEET

…. and much more.

Some people have called enquiring about a new “super-resistant” malaria in Southeast Asia. To read more about, read this. To clarify, the strain of P. falciparum malaria in the Mekong region is resistant to certain treatments, but not to prophylaxis with either Malarone or doxycycline. The majority of travelers to this region are at very low risk of contracting malaria.

We may not be out of the woods yet with Zika in the Caribbean and Latin America, but it seems to have declined. The 2/6 rules continue to be in place (see CDC), that is, if you are travelling there, do not plan to become pregnant for 2 months (for women), and don’t plan to impregnate someone for 6 months (for men).

On a personal note, I continue to study jazz piano. If you would like to hear my teacher, Brian Rudolf, plan Tuesday night dinner at Santo’s Restaurant in Thornhill.

Once again, I made a whirlwind trip to Ottawa with my children, this time Benjamin, who his 35, and his son Jonah, who is 4. After a lovely train ride from Kingston to Ottawa, we quickly got ensconced in The Chateau Laurier Hotel (paid for with Aeroplan points), and in 24 short hours, visited Parliament Hill where we tossed the baseball, The Pirate Adventure at Mooney’s Bay, Byward Market for a pizza and a Beavertail, the piano bar at The Chateau, and The Museum of Natural History. That is Karsh’s magnificent portrait of Churchill in the background. I highly recommend this trip for everyone. No shots needed!

churchill

I will stop there for now. Happy Thanksgiving to everyone.

Mark

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So what’s new?

May 6th, 2017 · Comments Off on So what’s new? · Uncategorized

Firstly, we survived Cuba – no sunburns, diarrhea, abrasions or muggings. We were at the Pestana Resort in Cayo Coco. Great pool, lovely beach and ocean, a baby grand piano, red wine and the food was good enough for us! Great pizza! We will go back one more time with our children and grandchildren. sails

We are still experiencing a shortage of yellow fever vaccine. Not all travel clinics are able to provide the vaccine, and those who are like me are trying to use fractional doses as recommended by WHO and PHAC. Shortages of vaccines, and other medications, are nothing new in the medical field. Rabies vaccine for high risk travelers is no longer available, for now. Stay away from dogs and monkeys!

The incidence of Zika seems to have declined in Latin America and the Caribbean. However we are still “stuck” with the “2/6” guidelines. Women, don’t become pregnant for two months after being in a Zika area. Men, don’t impregnate anyone for 6 months after possible exposure. Use your insect repellent, containing DEET, or a new option, Picaridin, if you can find it. MEC has it!

My wonderful receptionist, Indi, is off to Peru this week. Hopefully she will dodge diarrhea, dog bites and altitude sickness. (see Nov. 2016 blog). While my short term memory seems to be on the wane (I can’t remember from which side I served in squash), my memories of that trip remain clear as a bell. The infectious, healing springs at Aguas Calientes seem like yesterday. The juice blended by the ladies in the market. We didn’t have to pay for a hotel at Machu Picchu. We camped illegally on the terraces. The sunrise was spectacular. I bought a helluva lot of alpaca stuff! mp

A Canadian lady and her American companion were murdered in Belize last week. Does that now make Belize a dangerous destination to avoid? Not quite. Our government advises us to exercise a “high degree of caution” in most countries in the world, besides Canada and Switzerland. As one who notices these gruesome headlines, I find that they can pop up anywhere. Personal safety is probably the most important issue for travelers, with diarrhea and Zika interesting, and not fun, but perhaps less of a concern.

My next trip is to Ottawa with my grandson Jonah, to stay at the castle-like Chateau Laurier Hotel with its lovely piano bar, to wander around the Byward Market, and hopefully get on the pirate ship at Mooney’s Bay.

May is devoted to lots of squash, singles and doubles, and a plethora of family birthdays and Mothers’ Day. Pharmacies are now able to give travel advice and administer travel vaccines. We will see where that goes!

I realize that the ability to travel is a bonus.

Mark

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Off to Cuba

March 17th, 2017 · Comments Off on Off to Cuba · Uncategorized

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Tomorrow I am off to Cuba with my wife Gayle, my children Benjamin and Ros, and their two lovely kids, Jonah, 4, and Noah, 2. We will be in Cayo Coco at the same Pestana resort we visited last year with a different set of kids.

So, from the travel medicine perspective, we are all protected against hepatitis A, the kids not yet B. No Dukoral for the family – just don’t feel that it is that effective or worthwhile or pleasant to take or cheap! I think Health Canada feels the same way.

I have packed some oral rehydration salts in case the kids get diarrhea, and a short course of Zithromax, powder and pills, in case someone gets a really bad case of the runs. In my mind, that might mean going to the washroom every 20 minutes all day, diarrhea associated with fever and chills, and diarrhea just not getting better after a day or two. On a very brief trip, I might be more prone to use the antibiotic, even just for a day, as there isn’t much time built into a seven day holiday for rest and rehab. You are welcome to unlimited probiotics! Small amounts of Imodium are also an option for mild diarrhea.

What else? Tylenol, sunscreen, insect repellent, Gravol, Polysporin, books, cashews, baby powder, puzzles, a hat, sunglasses and a passport.

Zika, dengue fever, chikungunya and even malaria are likely all a threat in Cuba. We will apply our DEET containing repellent, probably less than religiously. No more children or grandchildren on the horizon from this group, so the precautions regarding future pregnancy are not an issue. There is a new non-DEET based repellent called Icardin, or Picardin. It is now available at Mountain Equipment Coop, in Canada, for the less DEET-inclined.

These days, I tend to worry more about accidents and injuries in my patients than exotic infectious diseases. We will watch our steps, as I would advise you to do as well.

I have outgrown the need to shop for others on my vacations. My closet is full of colorful clothing from Burkina Faso and pillow covers from Rajasthan that have gone unwanted. But I do have a friend in need of some Cuban cigars. Nothing better than a trip with a mission!

BOATdadpiano

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a musical interlude

February 19th, 2017 · Comments Off on a musical interlude · Uncategorized

When not talking about diarrhea and yellow fever vaccine shortages, I enjoy playing squash (singles and doubles) and piano. They have much in common with each other, and life. Here is a sample of my piano… Blue in Green, by Miles Davis, or perhaps Bill Evans.

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Yellow fever vaccine shortage … again!!!!

February 1st, 2017 · Comments Off on Yellow fever vaccine shortage … again!!!! · Uncategorized

February 1, 2017

 

Dear Travel Patients,

 

There is currently a shortage of YELLOW FEVER vaccine, across Toronto, Canada and the world. This also occurred recently in the summer of 2016, due to production problems and outbreaks in Africa. There is a new outbreak in Brasil. At that time, WHO (World Health Organization), along with CDC (USA) and PHAC (Canada) developed the following regulations and recommendations:

 

  1. Doses of 0.1 cc, rather than the usual .5 cc, have been shown to be perfectly effective in preventing yellow fever.
  2. In the event of a shortage of YF vaccine, the smaller dose should be used in order to conserve supplies and to vaccinate and protect the maximum number of travellers.
  3. In view of a lack of longer term studies, this smaller dosage, for the time being, should be considered protective for at least 1 year, rather than the lifetime duration of the full dose of vaccine.
  4. Everyone receiving either dose of vaccine will receive the YELLOW CARD showing that you have been immunized.
  5. Because of logistical reasons, it may be necessary to “clump” people receiving the YF vaccine together.
  6. People who are not at risk of YF, or those with additional medical conditions or those over 60, should discuss with their provider as to whether YF vaccine is warranted.
  7. Recall that it is now felt (by WHO) that previous yellow fever vaccine confers lifetime immunity.

Further information regarding this issue can be found on my website/blog (www.drwisetravel.com – May 2016), at CDC, WHO and PHAC.

Mark Wise MD DTM&H (London)

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My family practice

January 29th, 2017 · Comments Off on My family practice · Uncategorized

Travel medicine aside, here is what I have written to my family practice patients this new year.

 

Dear Patients,

I hope this letter finds you rested from the holidays and in good health. I realize, being your doctor, that this unfortunately might not be the case. My family is well, including my four wonderful grandchildren, now aged two to eight. When I am not in the office, I can usually be found at Tim Horton’s, the library, at a piano, playing squash or asleep in bed.

I hope you appreciate my staff as much as I do – Indi, Lilliana, Karon and Dolly. I think they are the kindest and best at what they do.

I wasn’t sure what to write this year. I also wasn’t sure if anyone reads these letters, as I get very little in the way of feedback. In any case, let me list for you the most commonly heard comments and questions that I get in my office. Next year I will provide the commentary on each one!

  1. But I never had this before.
  2. Why is it just on one side?
  3. Is it my age?
  4. Is it contagious?
  5. I saw this on the Internet!
  6. So you’re saying there’s nothing wrong?
  7. My naturopath / chiropractor / massage therapist says I need all of this blood work / an MRI.
  8. Shouldn’t I be on an antibiotic?
  9. Do I really need all of these pills?
  10. You know …the little green ones!
  11. But I got the flu after the flu shot.
  12. But I can’t afford it (physiotherapy, counselling, medications …).
  13. What do you mean my appointment isn’t until May?
  14. Are there any side effects?
  15. Do I need to take all of these vitamins?
  16. When are you planning to retire?
  17. Can I e-mail you? (preferably not)

A reminder – please keep up to date, with my help, with your vaccinations (including shingles and pneumonia), and age (and sex) appropriate screening for colon cancer (FOBT or colonoscopy), osteoporosis (BDM), cervical cancer (Pap smear), and breast cancer (mammogram). There is no shortage of controversy regarding screening for prostate cancer (PSA) and everything else in medicine. I am happy to discuss these issues with you.

I look forward to a good year for us all.

Mark Wise MD, DTM&H (London)

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Year End

December 25th, 2016 · Comments Off on Year End · Uncategorized

It is time to wax eloquently over the past year, with respect to travel medicine and otherwise.
It has been a good year.

While my travels are no longer far flung, I have visited Cayo Coco in Cuba, Apsley and Silent Lake Provincial Park, the Rideau Canal and Ottawa, St. Johns, Newfoundland, Kingston, and Paris. I am glad that I waited sixty-six years to see Paris. It made it that much more stunning. Playing the grand piano at the Gare du Nord stands as one of the highlights of my life. I plan to return to Cuba in March with my children and grandchildren, “before the Americans get there”, as so many of my patients say.

Travel medicine has not changed that much. We have run out of destinations and diseases, with the exception of new arrivals like Zika. Vaccine shortages have become a way of life. Mefloquine or Lariam has had a resurgence of bad publicity. No destination is immune to natural disaster or terrorism. Vaccine costs in North America continue to present a barrier for many travelers. The next meeting of The International Society of Travel Medicine is next May in Barcelona. I look forward to seeing that beautiful city, renewing old acquaintances  and finding out what is new.

In Ontario, pharmacists have now been granted the right to provide travel medicine advice and vaccines. Needless to say, in spite of my obvious bias or conflict of interest, I don’t feel that this is in the best interest of the traveler. More to say about that in the new year.

I am also a busy family doctor. My aging practice, along with its aging doctor, is overwhelmed with high cholesterol, diabetes, heart disease, addiction, aches and pains, leaky valves, cognitive impairment, depression and cancer. Wait times for diagnostic testing and specialist consultations are usually, though not always, longer than I and my patient would hope for. Guidelines, drug interactions, side effects, natural remedies and patient demands are part of my daily life. I am blessed to lie geographically halfway between Sunnybrook and North York General Hospital. I am also fortunate to have a caring and superb staff, who look after and care for me as much as my patients. That would be Indi, Karon, Lilliana and Dolly. Lesson for young doctors – surround yourself with excellent colleagues (or work alone like I have for the past 15 years), but more importantly, staff.

We are in constant conflict with the Ontario government, with only imposed solutions rather than negotiated settlements. Our health minister, himself a physician, seems to despise us. The future will likely bring more bureaucracy, more scrutiny and less freedom. No surprise that the thought of retirement marinates in my mind.

I have lost many people this year, as we have all. Family, friends, colleagues and patients. Christy Afuwape, my Nigerian travel nurse and treasured friend, passed away unexpectedly this year. I subscribe to The Globe and Mail. While I wouldn’t call it my favourite section, the Obituaries is where I turn to first, to learn about the accomplished and loving lives that people have led.

I feel fortunate to have a wonderful family, with children and grandchildren that make me proud, thankful and happy. My spare time, or perhaps my primary time, is filled with squash (the racquet sport), piano, sample here,  (jazz), coffee (double cream and sweetener), reading and dear friends. I dislike Toronto traffic and endless passwords.

I wish you a happy and health New Year, and hope some of that pleasure comes from travel.

Mark

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