A new way of looking at cold symptoms

There's no denying that the typical symptoms of the common cold---sore throat, runny nose, cough, etc. ---are miserable.  But when you realize that cold symptoms are an indication that your body's defense system is working, it gives you a different perspective on your misery.
   
Up to 50% of colds are caused by a class of viruses known as rhinoviruses. Typically the virus enters its victim's body through the nose, either by contaminated fingers or droplets produced by coughing or sneezing.  Once inside the nasal passages, the virus reproduces rapidly with cold symptoms beginning as soon as 12 hours after exposure to the virus. Symptoms usually peak after 2 to 3 days, and in most cases, resolve after a week.

When the body is infected by a cold virus, the immune system is activated to fight the infection. Initial responses of the immune system are to send white blood cells to the site of the infection and to release chemicals known as inflammatory mediators, including "kinins".   These inflammatory mediators cause tissue swelling, increased blood flow to the nasal cavities, and the production of mucus---many of the features that we identify as "cold" symptoms.  Recently, an antiviral compound known as "viperin" has been identified that also plays an important role in fighting rhinovirus infections.  These and many more responses from the immune system are essential in helping us get over a cold.

Let's look at some of the symptoms produced with a cold and what they may imply about the infection or the body's response to the infection:

• Scratchy or sore throat:  This is frequently the first manifestation of a cold.  It is thought to be caused both by damage to the mucosa from the virus as well as by inflammatory mediators that come in contact with sensitive nerve endings.
   
• Mucous drainage:  Initially, the watery drainage is thought to come about from inflammatory mediators, such as bradykinin.  The thicker, discolored drainage is related to mucocilliary clearance, an important defense mechanism in which mucous is produced to help transport infecting organisms out of the body.
   
• Cough:  This is also thought to be a component of mucociliary clearance.  Movement of hair-like structures (cilia) lining the respiratory tract and coughing help to move virus-containing mucous out of the lungs.
   
• Stuffy nose:  Blockage of nasal passages is a common feature of most colds. One of the inflammatory mediators in particular (bradykinin) is known to bring about increased blood flow and leaking of blood vessels leading to this symptom.

Some medical writers have reasoned that the more severe the cold symptoms one is experiencing, the stronger the body's immune system response.  This is perhaps a poor consolation to feeling so uncomfortable, but just remember that along with these symptoms comes the knowledge that your body is doing its best to fight the infection.

Overused and Unnecessary Medical Treatment under Scrutiny

The American Board of Internal Medicine is leading a health education campaign to inform patients and physicians about the overutilization of medical resources.  This program, known as "Choosing Wisely", includes recommendations for medical professionals as well as for the public.  It was developed "to help providers and patients engage in conversations about the overuse of tests and procedures and support efforts to help patients make smart and effective care choices."

It has been estimated that up to 30 percent of medical care delivered in this country is unnecessary and in some cases may even cause harm rather than providing benefit.  Avoiding unnecessary tests and treatments is not only in the best interest of patients but it provides cost savings to individuals and to society.
  
The campaign currently includes input from around 70 U.S. medical specialty societies and has partnered with the non-profit consumer organization, Consumer Reports, to help disseminate understandable medical information to the public.   Participating medical groups provided a list of five tests, treatments or services that are commonly overused by that specialty, with the intent that the information will be shared with other members of that specialty group as well as with patients and local community groups.  The following are just a few of the items submitted to the campaign:  

1. Removing dental fillings that contain mercury is unnecessary (American College of Medical Toxicology and the American Academy of Clinical Toxicology).

So called "silver" fillings are actually made of a material called amalgam which is an alloy of several metals including silver, mercury, tin and copper. Due to concerns regarding mercury intoxication, many people are opting to replace amalgam fillings with a non-mercury containing alternative. Replacing silver fillings is felt to be unnecessary because the fillings contain very small amounts of mercury and studies have not shown any harm from this source of mercury.  Replacing silver fillings can also be expensive and can potentially weaken the tooth requiring additional dental work, such as the placement of a crown.   Amalgam fillings should be replaced only when they are worn, broken or when there is decay beneath the filling.

2. Imaging tests, such as x-rays, CT scan or MRI, are usually not required in cases of back pain (American Academy of Family Physicians). 

Most episodes of back pain resolve within a month whether the person undergoes an imaging test or not. Furthermore, receiving an imaging does nothing to speed healing.  X-rays and CT scans expose people to radiation needlessly.  Imaging tests are expensive, ranging from around $200 for back x-rays to $1,000-1500 for a CT or MRI scan. There are, however, some clear indications for when an imagining study should be obtained in someone with back pain including unexplained weight loss, fever, loss of bladder or bowel control, and a history of cancer.

3. Try non-surgical options before considering surgery with plantar fasciitis (American Orthopaedic Foot and Ankle Society).

Plantar fasciitis is a very common cause for pain in bottom of the heel. The classic symptom is pain upon taking the first few steps after getting out of bed in the morning. The cause is inflammation of a band of tissue called the plantar fascia that runs from the heel to the ball of the foot. Surgery for plantar fasciitis should be viewed as a treatment of "last resort".  Non-surgical measures including stretching exercises, use of arch support or custom foot beds, taking an anti-inflammatory medication (e.g. ibuprofen) or wearing a splint at night to stretch the plantar fascia should be tried before surgery is considered. Surgery for plantar fasciitis can be costly (up to $10,000) and can be associated with a number of complications including nerve damage, permanent "flat feet", and more pain than was experienced prior to surgery.

4. Colonoscopy more often that once every five or ten years is rarely needed  (American Gastroenterological Association)

While there are several methods of screening for colon cancer, colonoscopy is considered to be the most accurate test available. When colonoscopy is the chosen method of screening, it is generally recommended to be initially performed at age 50 and repeated at 10 year intervals. Colon cancer usually develops slowly, stemming from a pre-malignant polyp known as an adenoma. If no polyps are seen during colonoscopy, the procedure can safely be repeated in 10 years. When adenomas are seen and removed, a follow-up colonoscopy in 5 years is often recommended.  Unless someone is at high risk of developing colon cancer, undergoing the procedure more often than this is unnecessary.  Other reasons to restrict the frequency of undergoing colonoscopy include its expense, the risk for complications, and the inconvenience of the procedure.

5. Antibiotics are usually not needed in children with respiratory infections (American College of Pediatrics).

Antibiotics are used to treat bacterial infections. They are not effective against viruses, the organism responsible for most colds, sinus infections and respiratory tract infections. Unless someone's immune system is compromised, the body's immune system will take care of these infections. Anytime antibiotics are taken there is a risk of an allergic reaction or side effect. Also, overuse of antibiotics promotes the growth of "resistant" bacteria that do not respond to commonly prescribed antibiotics.  Situations in which the use of an antibiotic may be considered include: 1) a persistent or worsening infection, 2) a confirmed bacterial infection (whooping cough, strep throat, etc.), and 3) fever (temperature at least 102 degrees) lasting for several days.

The "Choosing Wisely" site is very user-friendly and offers a wealth of information regarding rationale for performing or not performing many medical procedures, tests, and treatments. Rather than making absolute recommendations, however, a primary goal of this campaign is to promote a dialogue between patients and health care providers regarding the judicious use of medical interventions.

5 Second Rule, the “research” continues

Have you ever heard anyone invoke the "5 second rule" after dropping a piece of food on the floor?  The idea behind this rule is that food that is picked up in fewer than 5 seconds after hitting the floor has not had time to attract germs, and is safe to eat. The rule goes on to imply that food remaining on the floor longer than 5 seconds is likely to have become contaminated and should not be eaten.
   
While this rule has been tested on the Discovery Channel's MythBusters in a quasi-scientific manner (and by the way, did not pass muster), it has also been evaluated in at least three, more rigorous, scientific studies.  The first report evaluating the "5 second rule" was published by a researcher at the University of Illinois in 2003.  This study involved dropping gummy bears and fudge-striped cookies onto floor tiles that were contaminated with E. coli bacteria (a preliminary survey performed by this researcher had indicated that people were more likely to pick up candy than, say, broccoli).  In every instance, the food items became contaminated in 5 seconds or less, dispelling the notion that it is safe to eat food that has been on the floor for any length of time.
 
Claiming that this study was not representative of what actually happens in the "real world", two student-researchers at Connecticut College designed a study to test the rule in an everyday environment.  They dropped food samples (apple slices and Skittles) onto the floors of the college dining hall and snack bar. The food samples were allowed to remain on the unaltered floor for various lengths of time from 5 seconds to 5 minutes. Interestingly, no bacteria were present on the foods that had remained on the floor for 5, 10 or 30 seconds, lending support to the "5 second rule."  The apple slices did pick up bacteria after one minute, however, and the Skittles became contaminated with bacteria after remaining on the floor for 5 minutes.

The most recent study on the subject, performed at the Aston University's School of Life and Health Sciences in England, found similar results as the "Skittles" study. While the initial contact of various foods with the floor was found to transfer a small amount of bacteria, the longer that food remained on the floor the greater the contamination. Moist foods left on the floor for longer than 30 seconds picked up 10 times more bacteria than when picked up prior to the 5 second "deadline".  Interestingly, carpeted floors were less likely to transfer bacteria to a dropped piece of food.

 My take on this rule: if food lands on a contaminated surface it can pick up disease-producing bacteria almost immediately. If it lands on a clean surface, it could conceivably remain safe to eat for hours.  The problem is that without biologic testing of the surface, it is impossible to know if the surface is clean or contaminated. It is probably true; however, that the shorter the period of time that food remains on the floor the less likely it is to attract bacteria.  The next time you see someone drop some food on the floor, rather than calling out "5 second rule" it is probably best to say, "When in doubt, toss it out".