Monday, March 28, 2016

"Achoo"--- Why We Sneeze

There is a wealth of medical mythology attached to sneezing.  One legend has it that when sneezing, the heart stops beating and the phrase "bless you" is meant to encourage the heart to resume beating.  Other sources say that offering a blessing after sneezing came in the 14th century during the bubonic plague epidemic.  At that time, sneezing was considered to be an early sign that someone had contracted the disease. The blessing "God bless you!" offered after sneezing was offered to prevent impending death due to the lethal disease.

The physiologic reality is that sneezing is your body's way of removing an irritant from your nose. During a sneeze, air is expelled forcefully from the mouth and nose in an explosive manner, hopefully removing the irritant in the process. Sneezing can be very bothersome, but is generally not a sign of a serious problem. The most common causes for sneezing include:
  • Allergies to pollen, mold, or dander, often part of the "hay fever" constellation of symptoms
  • Viral infections of the upper respiratory tract, including the common cold
  • Nasal irritants such as dust, powders, or snuff
  • Use of intranasal medications, such as corticosteroids
  • Exposure to bright light, known as "photic sneezing",  an inherited trait affecting up to a third of all people
Self-care for sneezing due to allergies
In most cases, sneezing occurs infrequently and does not require treatment. Should sneezing become more frequent, particularly if associated with an underlying problem such as allergic rhinitis, help is available. For allergic rhinitis, the first step in preventing and relieving symptoms is to avoid the allergens. Tips for reducing your exposure to allergens are:
  • In the winter, when indoor allergies caused by dust mites and pet dander emerge, wash bedding weekly in hot water and dry using a high heat setting.
  • Use an air filtration device to reduce pollen in the air.  A high-efficiency particulate air (HEPA) filter is particularly effective.
  • Change furnace filters regularly.
  • Keep windows shut during grass allergy season (usually begin in May or June and lasts most of the summer).
  • During ragweed season, avoid outdoor activities when ragweed counts are highest, between 5 a.m. and 10 a.m.
  • If you are plagued by tree pollen allergies -- which typically begin in late February or early March and continue through May -- change your clothes and wash your hair after spending time outdoors.
 If avoidance of allergens is not feasible or does not adequately control allergic symptoms, taking antihistamines may help.  Allergy symptoms are caused by the release of histamine from cells in the nasal mucous membranes. Histamine, acting on the nasal mucous membranes, causes sneezing as well as other allergy-related symptoms, like a runny nose.  Some of the antihistamines that are available over-the-counter (OTC) include the "first generation" products, diphenhydramine (Benadryl) and chlorpheniramine (Chlor-Trimeton).  Newer "second generation" products such as loratadine (Claritin) or cetirizine (Zyrtec) have the advantage of fewer typical antihistamine side effects, such as sedation.
OTC nasal sprays are also available for allergy symptoms.  Like antihistamines, cromolyn sodium nasal spray (NasalCrom) prevents the release of histamine and helps with nasal symptoms of hay fever. It is most effective when taken before symptoms start and may need to be used several times a day. Corticosteroid nasal sprays (Nasacort, Flonase, others) are highly effective at reducing inflammation and swelling in the nasal passages to improve breathing and reduce allergy symptoms.

Medical evaluation and treatment
When self-care measures and OTC medications are not effective for allergy-related sneezing, a prescription antihistamine spray or steroid nasal spray may be helpful.  Astelin and Patanase are examples of antihistamine sprays available by prescription. Beconase AQ and Vancenase AQ are the trade names for two of the "stronger" corticosteroid nasal sprays available only by prescription. With chronic or persistent symptoms, consideration could be given to allergy testing to determine which allergens are responsible for causing symptoms. Allergy testing usually involves skin testing or blood tests (RAST).  Pinpointing the specific allergen can lead to more effective avoidance measures or to desensitization with "allergy shots".

Back to sneezing mythology, sneezing does not cause the heart to stop, and as some people think, your eyeballs won't pop out if you sneeze with your eyes open.

Thursday, March 17, 2016

Women in Medicine

The fascinating on-line exhibition, "Changing the Face of Medicine" sponsored by the National Institutes of Health, provides insight into the inspiration, influences and accomplishments of many women who have had a major impact on health care in the United States.  Today's Health Tip recognizes just a small sampling of those remarkable women who literally changed the face of medicine.

Clara Barton (1821-1912) Trained as a teacher, not as a nurse, Clara Barton is one of the best known women in medicine. During the Civil War, Clara distributed medical supplies, provided nursing care, and gave emotional support to hundreds of soldiers.  Known as the "Angel of the Battlefield", she risked her life by tending to soldiers who were wounded in action.  Following the war and experience with the Red Cross in Europe, she founded the American Red Cross and later the National First Aid Association.

Elizabeth Blackwell (1821 – 1910) In 1849, Dr. Elizabeth Blackwell was the first woman to receive an M.D. degree from an American medical school. Her inspiration for entering medicine was the death of a close female friend whom she felt could have better served by a woman physician.  Along with her sister, Dr. Emily Blackwell, she started the New York Infirmary for Women and Children, providing training for women doctors and medical care for the poor. Late in her career, Dr. Blackwell wrote a book, Pioneer Work in Opening the Medical Profession to Women, encouraging women to enter the field of medicine.
Rebecca Lee Crumpler  (1831 – 1895) The first formally trained African-American physician earned her "Doctress" of Medicine degree from the New England Female Medical College in 1860.  She was married to a former fugitive slave, Arthur Crumpler, who had served in the Union army during the Civil War.  Following the war, she moved to Virginia and cared for freed slaves who did not have access to medical care.  In 1883, she wrote the book, A Book of Medical Discourses, in which she described the progression of experiences that led her to study and practice medicine.

Virginia Apgar  (1909-1974)  Best known as the developer of the Apgar score, a means of assessing the health of newborn children immediately after birth, Dr. Apgar the first woman to become a full professor at Columbia University College of Physicians and Surgeons. Never being one to be intimidated by her male colleagues in medicine she famously said, "women are liberated from the time they leave the womb."  In addition to developing the Apgar score, she was also influential in efforts to prevent birth defects and infant mortality. Late in her career she became the director of the division of congenital defects at the National Foundation for Infantile Paralysis (now the March of Dimes).

Dr. Helen Taussig (1898 – 1986) Despite disabilities including dyslexia and hearing loss, Dr. Taussig was a pioneer in pediatric heart surgery.  She and a colleague developed a procedure known as the Blalock-Taussig operation, the first real cure for "blue baby" syndrome. She was the first woman to become the president of the American Heart Association. Dr. Taussig also helped to avert a thalidomide birth defect crisis in the United States by bringing attention to the potential harmful effects of the drug.

Elisabeth Kübler-Ross  (1926 – 2004)  Born in Switzerland, Dr. Ross was a psychiatrist whose career centered on the providing psychological support to the terminally ill and their families.  After moving to the United States in 1958, Dr. Kübler-Ross was disheartened by the lack of compassion for dying patients that she observed in this country. Her book, On Death and Dying, published in 1969 described the five stages that she had observed dying patients going through----denial, anger, bargaining, depression and acceptance.  Dr. Kübler-Ross was a major advocate for humane treatment of the dying and of the concept of "death with dignity".

Rosalyn Sussman Yalow (1921-2011) Dr. Yalow was a medical physicist and Noble Prize winner for developing radioimmunoassay (RIA), a technique used to measure tiny quantities of various biological substances in human blood. Originally developed to measure insulin levels in diabetics, RIA is now widely used in medicine to measure other substances including infectious agents, enzymes and hormones.   Initially discouraged from entering the field of science, Dr. Yalow worked as a secretary in an academic physics department which provided her with the opportunity to pursue her studies in physics.

Joycelyn Elders  (b. 1933) A shout out to a former professor of mine, Dr. Elders was the first board certified pediatric endocrinologist in the state of Arkansas as well as being an outstanding lecturer, researcher and clinician at the University of Arkansas for Medical Sciences.   Dr. Elders was the first African American woman appointed Surgeon General of the United States by President Bill Clinton in 1993.  Never one to mince words, Dr. Elders was eventually fired from this position for her views on sex education and advocating for access to contraceptives in schools.
Mary-Claire King (b. 1946)   Dr. King is a medical researcher with a focus on cancer biology and heredity. She was the first to describe a gene mutation, BRCA 1, which is associated with inherited forms of breast cancer.  She is an American Cancer Society Professor at the University of Washington, Seattle where she remains actively involved in genetic research.

The Association of American Medical Colleges reports that during academic years 2013-2014, 47% of medical students and 46% of medical residents were women.  Surely Drs. Blackwell and Crumpler would be astounded to learn of the near equal inclusion of women into the medical fraternity, and pleased to learn of the impact that American women have had in medicine.

Monday, March 14, 2016

To Cough or Not to Cough---Expectorants vs suppressants

Coughing helps to clear the respiratory system of irritants and secretions associated with a cold or flu. With most minor respiratory infections it is best not to interfere with this mechanism.  When someone is unable to rest because of the cough or needs "help" in clearing secretions, they often consider taking an over-the-counter cough medicine. Two major classes of cough medicines are marketed for self-treatment--- expectorants and suppressants.
Expectorants, also known as mucolytics, are medications that thin mucus in the bronchial passages making it easier to cough up phlegm from the lungs.  The most common active ingredient in expectorants is guaifenesin which is contained in the brand name medications, Mucinex and Robitussin Chest Congestion.

Cough Suppressants, also known as antitussives, work in an entirely different manner than expectorants. Instead of helping to remove phlegm from the lungs, suppressants actually block the cough reflex. The most common suppressant in over-the counter cough medicine is the mild narcotic, dextromethorphan. Cough medicines ending in the letters, DM (Benylin DM, Robitussin DM, others) most likely contain dextromethorphan. Codeine is a more potent antitussive that is also included in many cough medicines but is only available by prescription.  The most appropriate use of a cough suppressant is for a severe cough that is keeping someone up at night or interfering with activities. Otherwise, the removal of phlegm from the lungs should be encouraged.

Combination cold medicines mix a suppressant or expectorant with other medicines to treat cold symptoms.  As with cough medicines, a combination cold medication's name followed by the letters DM indicates that it also contains a cough suppressant. The other ingredient could be an antihistamine, a decongestant and/or a pain reliever.  Robitussin Multi-Symptom Cold, Nyquil Cold and Flu, Theraflu Multi-Symptom are just a few of the available combination cold medicines available. In someone with multiple symptoms (cough, body aches, nasal congestion, etc.) this could help simplify treatment. If symptoms related to a cold or flu are more limited, you may end up taking medicine that you don't need.  In some instances, a cough suppressant and expectorant are included in the same medication. This combination seems to be more of a marketing gimmick than a useful treatment.

Alternatives to commercially available cough medicines include increasing oral fluids, breathing in humidified air, and taking a teaspoon or two of honey.  A study found that children ages 1-5 with cough due to upper respiratory tract infection had greater reduction in their cough after taking a teaspoon and a half of honey than taking dextromethorphan. This is particularly important considering that the U.S. Food and Drug Administration as well as the Academy of Pediatrics advise against giving young children over-the-counter cough or cold medicines. Honey should not be fed to children less than one year of age, however, since this has been associated with botulism infection.

Some general guidelines if considering taking an over-the-counter cough medicine with a cold or flu are to:  1) take an expectorant with a "wet" cough to help clear secretions from the lungs or 2) use a suppressant when the cough is "dry" cough and is keeping you awake or interfering with your daytime activities.

Friday, March 4, 2016

Do popular supplements work for the common cold?

The common cold is a viral infection of the upper respiratory system.  On average, children have six to eight colds per year, and adults have two to four. The common cold places a heavy burden on society, accounting for approximately 40% of time taken off work and millions of days of school missed by children each year.  While medical science has yet to develop a cure for the common cold, many people take a variety of supplements in the hopes that they will shorten the duration of the illness. The most popular of these supplements are zinc, vitamin C, and Echinacea.
Let's look at some of the scientific evidence of the effectiveness of these supplements. Much of this information comes from the Cochran Group, an international network of scientists who compile the work of several researchers into larger studies known as "meta-analyses".  By pooling data from a number of well-conducted studies, more robust and accurate conclusions can be drawn.

Zinc is commonly sold as a natural medicine for colds in tablet, lozenge, and liquid form.  It is thought to decrease the ability of cold viruses to grow on or bind to the lining of the nose. The results of studies have gone back and forth over the years regarding zinc's effectiveness in treating colds. Based on a 2011 analysis of clinical trials, The National Center for Complementary and Integrated Health reports that "oral zinc helps to reduce the length and severity of colds when taken within 24 hours after symptoms start."  After initially supporting the benefits of zinc in treating the common cold, the Cochrane Group is currently re-evaluating existing research and has not released its final opinion on its effectiveness.

Because the dosages and duration of treatment with zinc varied across the various studies evaluated, the optimal dosage for zinc supplementation has not been established.  Before taking a zinc supplement, people should be aware that it has the potential to cause nausea and other gastrointestinal side effects. In 2009, the U.S. Food and Drug Administration advised consumers to stop using intranasal zinc products) because of reports of anosmia (loss of smell).

 Echinacea is one of the most commonly used herbal supplements.  Advocates say that it is can boost the immune system and has antiviral properties, such as preventing colds.  However, two 2006 meta-analyses evaluating this natural remedy drew conflicting conclusions.  In the first analysis, extracts of Echinacea were found to be somewhat effective in preventing cold symptoms if someone had been clinically inoculated with the cold virus. The second, a Cochrane Systematic Review, found no evidence that Echinacea was any better than a placebo at treating the common cold once symptoms had begun.  Likewise, three clinical trials funded by the National Center for Complementary and Integrated Health found no benefit from Echinacea for preventing or treating colds. Echinacea products vary widely, with different preparations using different species of the plant as well a different plant parts.

 Vitamin C is an important micronutrient and antioxidant. The role of vitamin C in the prevention and treatment of the common cold has been a subject of controversy for decades. Nevertheless, it is widely used as both a preventive as well as therapeutic supplement.  A 2013 Cochrane analysis of results from 29 clinical trials involving 11,306 participants found the following related to vitamin C and prevention or treatment of colds:
  1. "The failure of vitamin C supplementation to reduce the incidence of colds in the general population indicates that routine vitamin C supplementation is not justified."
  2. "Trials of high doses of vitamin C administered after the onset of symptoms, showed no consistent effect on the duration or severity of common cold symptoms."
  3. "Given the consistent effect of vitamin C on the duration and severity of colds in the regular supplementation studies, and the low cost and safety, it may be worthwhile for common cold patients to test on an individual basis whether therapeutic vitamin C is beneficial for them."
  4. "Vitamin C supplementation may be useful for people exposed to brief periods of severe physical exercise (e.g. running a marathon) or to cold environments. In those people, taking vitamin C appeared to cut their risk of catching a cold in half."
The final word regarding these and other supplements in the prevention and treatment of the common cold awaits further research. In regard to preventing colds, the best methods currently available appear to be "behavioral" in nature, such as washing your hands regularly, getting plenty of rest, limiting exposure to people with colds, and avoiding touching your nose or eyes with potentially contaminated hands.