Influenza Vaccination in Adults

It is time once again to be thinking about taking your flu shot.   A recently published study by the National Foundation for Infectious Diseases (NFID) estimated that only 52% of US adults plan to take the flu shot.  Reasons for not being vaccinated include:

  • I do not believe it works (51%)
  • Concern it would cause an adverse effect (34%)
  • Concern that the vaccine would give them the flu (22%)

Health and Human Services Secretary Alex M. Azar II said, “Each season, flu vaccination prevents several million illnesses, tens of thousands of hospitalizations and thousands of deaths.  Over recent years, on average, flu vaccination has reduced the average adult’s chance of going to the doctor by between 30 – 60%.

A recent study performed by the northern California Kaiser Permanente Group, using seven years of flu season data, shows the immunity from the shot is near perfect for the first six weeks and then begins to wane. They estimate your post-vaccination chance of getting the flu, even if immunized, increases by 16% every 28 days after the shot but is near perfect for the first 42 days.

It is believed the Center for Disease Control (CDC) will recommend in future years that adults receive two flu shots each season. One will be administered at the beginning of the season and one six weeks later.  For the moment, the CDC acknowledges the flu season begins at different times in different regions of the country and suggests you receive your vaccination about two weeks before it arrives.

In South Florida, we typically see the arrival of the Influenza A virus after Thanksgiving. It peaks the last two weeks in January and first two weeks in February. For this reason, we suggest taking the shot later in the fall.

Vaccines are inactivated meaning they are not live and cannot give anyone the flu!

Heartburn, Indigestion & Protein Pump Inhibitors

I have seen multiple adult patients with intractable heartburn, reflux, indigestion and chest pressure all related to food and digestive enzymes kicking back up the esophagus from the stomach through a lax group of muscles known as the lower esophageal sphincter.  All these patients receive a fiber optic upper endoscopy (EGD) at some point and are observed and biopsied to eliminate the possibility of ulcers, cancer, gastric polyps, esophageal cancer, potential esophageal cancer and Helicobacter Pylori bacteria as the cause.

They are all treated with weight control suggestions, avoiding a host of foods, most of which are quite healthy from a cardiovascular standpoint plus limits on alcohol, elimination of tobacco and other indulgences of adults. We ask these patients to wear loose clothing at the waistline, avoid reclining for three hours after eating and take a host of medicines including proton pump inhibitors (PPI) such as Nexium, Protonix, Prilosec.  Drugs like Tagamet, Zantac (H2 Receptor Blockers), Tums, Rolaids are far less effective.

In recent years, numerous articles have appeared in medical journals stating that protein pump inhibitors, when taken regularly, can predispose to increased and early death, pneumonia and dementia.  A large review article from a prominent GI group in Boston, and published in the New England Journal of Medicine, tried to eloquently refute these claims but the doubt about long term safety lingers buoyed by numerous lay periodicals and online internet sites sensationalizing the down sides of these medicines.

To allay the patients fears, doctors and patients work together to try and stop the PPIs and substitute the older standbys like Tagamet and Zantac but they just don’t provide the symptom relief that the PPI’s do. Patient’s face the dilemma of taking the medicine that works best and incurring the potential risks or suffering.

In a recent edition of the journal Gastroenterology, Paul Moayyedi, MB ChB, PhD from McMaster University in Canada followed 17,000 patients for three years with half the group taking PPI’s. Those taking a PPI (Protonix) for three years had no more illness or adverse effects than those taking a placebo.  L. Cohen, MD, a reviewer at Mount Sinai School of Medicine in NY, concluded that the study provided strong evidence of the safety of PPIs for patients taking the drug for three consecutive years.

The controversy will continue. I am sure next week someone will produce data revealing some additional horrible consequences of taking these medications to relieve heartburn. It will ultimately come down to individual decisions about quality of life versus potential risks because the lifestyle changes necessary to control this problem are difficult for human beings to sustain over a long period of time.

Sleep Apnea and Cognitive Impairment

Convincing a patient to undergo a sleep analysis for obstructive sleep apnea is a difficult task. During our history taking session, we ask about excessive snoring, periods of not breathing while asleep, daytime sleepiness and we look at the patient’s body habitus, weight and height. Often, the patient’s spouse or partner has complained about their snoring keeping them up. Most of the time, when I ask about this the response is, “Why go for an evaluation if I am not going to wear that mask anyway?  I have a friend who has a CPAP mask and I am just not going to do that.”

Obstructive sleep apnea and periods of apnea (not breathing) results in the lung blood vessel blood pressure rising.  We call it pulmonary hypertension.  It is different from systemic arterial essential hypertension in that traditional blood pressure medicines do not lower the pulmonary pressures.

If you examine our heart and lung anatomy you realize that the very non-muscular right side of the heart, primarily the right ventricle, pumps blood a short distance to the lungs to exchange gases and removing wasteful gases in exchange for oxygen. That oxygen rich blood returns to the left side of the heart where the very muscular left ventricle pumps it out to the body.

When the body’s systemic blood pressure rises the left side of the heart has to work harder. The muscular left ventricle is much more suited for that task than the right ventricle is suited to pump against pulmonary vessel hypertension.  The result is the right heart fails much sooner than the left side and the treatment options and medications are far less successful.  This explanation to patients is often received, digested and dismissed as hypothetical and down the road.

This week the American Academy of Neurology received a presentation by a group at the Mayo Clinic in Rochester that showed that patients with untreated sleep apnea produced an increased amount of tau protein deposition in the brain. Tau protein deposition is associated with Alzheimer’s disease.  The researchers, led by Diego Z. Carvalho, MD, are not sure if more Tau protein accumulates in brains of people with untreated sleep apnea or if Tau protein accumulation actually leads to sleep apnea?  That research is ongoing.

The lesson is that sleep apnea is something that needs to be diagnosed and treated. I am a fan of referring patients’ to sleep evaluation centers where that is the primary disease state reviewed.

While sleep apnea is one of the abnormalities evaluated, there are many other disorders of sleep that can be recognized and treated to improve patient sleep. At home sleep monitors are available as well but may be limited in diagnosing sleep apnea alone.

If you are determined to have obstructive sleep apnea then treatment choices include weight loss, laser treatment of the uvula, dental appliances to open up your airways, adjustments to your sleep position and many types of facial and nasal CPAP devices.

Most of my patients who try a CPAP mask require 8-12 weeks to adjust to it. Once adjusted to it, their quality of sleep is so good that I rarely have to convince them to keep using it.

Tdap Booster Vaccinations

Several years ago an epidemic of whooping cough (pertussis) was ongoing in affluent areas of California and Arizona. Epidemiologists from the Center for Disease Control (CDC) and National Institute of Health (NIH) descended on those areas to determine the cause of the life threatening illness to very young children.

Much to their surprise, grandparents were inadvertently transmitting it to their new and not completely vaccinated grandchildren. As youngsters, these grandparents took the suggested DPT series of shots believing they were resistant to diphtheria, pertussis and tetanus for life.

Like most things, as we get older, the immune system just doesn’t work as well. The immunity to pertussis waned and adults were catching the adult version of whooping cough in the form of an upper respiratory tract infection with bronchitis. The adult version resembled a run of the mill viral upper respiratory tract infection with a prolonged barking cough. This was just the type of infection which infectious disease experts were suggesting we do not treat with antibiotics and instead let our immune systems fight off independently. Unknown to us was the fact that even after we stopped coughing, if this was in fact adult whooping cough, we could transmit the pertussis bacteria for well over a year after we stopped coughing.

The solution to the problem was to give these adults a booster shot against pertussis when they received their tetanus shot booster. It is recommended that we get a tetanus booster every seven to ten years.

Tdap, produced by Sanofli Pasteur, was the solution and an international campaign of vaccination was begun. The campaign was successful but what do you do seven to ten years later when the next tetanus shot is due? In a study sponsored by the manufacturer, adults 18- 64, were given a second dosage 8-10 years after the first Tdap shot and tolerated it very well. Blood levels for immunogenicity taken 28 days later showed the benefit of the second shot.

The data has been submitted to the CDC and its vaccination Prevention Advisory Panel for consideration for a change in the recommendations on vaccinating adults.

Marijuana, Pain Relief and the Facts

On a daily basis patients of mine come in for office visits complaining of wear and tear injuries, as well as aches and pains, and their methods of dealing with chronic pain. As we all know, aging is a part of the normal life process.

For instance, as we approach 70 years old we typically lose three quarters of our functioning kidney cells (nephrons) but do well with our limited reserve as long as we do not constantly call on that reserve. When we take nonsteroidal anti-inflammatory drugs like ibuprofen and naproxen to relieve pain we are challenging that reserve leading seniors to look for alternatives. Opioids, even when appropriate, have become taboo so alternatives are being searched for.

Medical marijuana has become a very hot topic recently.  It is being heavily marketed as a pain relief alternative in several forms.  However, what little legitimate research has been conducted indicates it is not very good at relieving non cancer related chronic pain.

Not a day goes by when several patients reveal they are using cannabis products obtained out of state for pain relief with no consideration of how it interacts with the medications they are already taking. Recently, strong public relations campaigns for legalizing medical marijuana have led to its legalization in different forms, in various states, even if it doesn’t work. A select group of investors have positioned themselves to make vast sums of money from a product with little documented upside and potentially unknown downsides.

At the same time that medical marijuana enters mainstream medicine there is a similar legislative and marketing push to legalize marijuana for recreational use. Once again, a well-financed lobby of investors is trying to sell the concept of marijuana being less troublesome than legalized tobacco or alcohol. In the last few weeks there have been several articles appearing in reputable medical journals and periodicals such as the Wall Street Journal, New York Times and New Yorker magazine all examining the known results of liberalizing marijuana use in three states.

First of all, today’s marijuana is far stronger and potent than the “love generation’s” weed of the 1960’s with a higher percentage of the hallucinogen THC. To that point, states that have legalized marijuana have seen a tripling of visits to the emergency department for psychotic behavior. Also, violent crime and murders have tripled in many jurisdictions. A growing body of evidence indicates auto accidents have increased as a direct result of marijuana’s use.

Medically speaking, there is little research evaluating marijuana as a drug. Many questions remain.  What is the minimal dosage to create an effect? What is the dosage that can cause medical illness? How does the mechanism of delivery affect the final effects such as smoking versus vaping versus eating the product? Beyond the stoners’ credo of “start low and go slow” there is little data to evaluate the product as a pharmaceutical drug and or how it can interact with other drugs prescribed for you.

I am far from an anti-marijuana critic. I’d just like to know what I’d be getting in to before I consider hallucinating. It seems to me that before we liberalize marijuana use, the product needs to be put through the type of research and scrutiny the old Food and Drug Administration (FDA) put a product through before it was approved for public use.

Chocolate as a Cough Suppressant

Well before Valentine’s Day, and conspicuously in the middle of cold and flu season, Alyn Morice of the University of Hull in Yorkshire, England published a study showing that dark chocolate derivatives may be more effective than codeine in suppressing a cough. In a small study of 163 individuals, each with a cough due to an infection, her group randomly assigned them to a group receiving a codeine based cough syrup or a chocolate cocoa based syrup called Rococo. Their results showed that within two days the chocolate based recipients felt significant improvement in their cough compared to the codeine based group. A similar study had previously been performed at the imperial College in London showing that theobromine, a product in cocoa, is superior to suppressing coughs over codeine.

Professor Morice believes the properties in cocoa are demulcent and help relieve irritation and inflammation. “This simply means it is stickier and more viscous than standard cough medicines, so it forms a coating which protects nerve endings in the throat which trigger the urge to cough. This demulcent effect explains why honey and lemon and other sugary syrups help.” They believe chocolate has additional helpful ingredients so much so that they advise sucking on a piece of dark chocolate as a mechanism of relieving a cough. We now have some science to back mom’s hot chocolate and hot cocoa for a cold and a cough.

Winter is the Season for Upper Respiratory Tract Infections and Influenza

It’s the season for winter viral upper respiratory tract system infections. It is also influenza and influenza- like illness season.

Winter brings crowds of people indoors together and holiday travel places crowds together in indoor areas as well. These viral illnesses are transmissible by hand to mouth transmission and airborne particle transmission with coughing. The viral particles can live with minimal water on surfaces for long enough periods of time to infect patients who unknowingly touch a foreign surface and bring their hands up to their mouths. Hand washing frequently is an essential part of preventing the transmission of these diseases. Common courtesy such as covering your mouth when you sneeze or cough and not coming in close contact with others when ill is essential.

Research has shown that consuming an extra 500 mg a day of Vitamin C can prevent colds and reduce the intensity of a cold if you catch one. You must take the Vitamin C all the time and in advance of exposure. Waiting until you have symptoms has no positive effect. Viral upper respiratory tract infections usually include fatigue, runny nose (coryza), sore throat (less than 90 % of adult sore throats are not a strep throat).

If you have been around a sick child age 2-7 who has a fever, swollen neck glands and an exudative sore throat your chances of having a strep throat are increased. Fever is usually low grade, less than 101, and short lived. Very often patients develop viral inflammation of the conjunctiva or conjunctivitis. While this is very contagious to others, it is self-limited and rarely requires intervention or treatment.

Caring for a cold involves listening to your body and practicing common sense solutions. Rest if tired. Don’t go to the gym and workout if you feel ill. If you insist on going, warm up slowly and thoroughly and, if you do not feel well, stop the workout.

Sore throat can be treated with lozenges. Warm fluids including tea and honey (honey is antimicrobial and anti-viral), chicken soup, saline nasal spray for congestion and acetaminophen for aches and pains or fever are mainstays of treatment. Over the counter cough medications like guaifenisin help.

Some of the viruses affect your gastrointestinal tract causing cramps and diarrhea. Nausea and vomiting are sometimes present as well. The key is to put your bowel to rest, stay hydrated and avoid contaminating or infecting others. Clear liquids, ice chips, shaved ices, Italian ices or juice pops will keep you hydrated. A whiff of an alcohol swab will relieve the nausea as well. If you are having trouble keeping food or fluids down call your doctor. If you are taking prescription medications, call your doctor and see which ones, if any, you can take a drug holiday from until you are better.

Influenza is more severe. It is almost always accompanied by fever and aches and pains. Prevention involves taking a seasonal flu shot. Flu shots are effective in keeping individuals out of the hospital from complications of influenza. They are not perfect but far better than no prevention. If you run a fever of 100.8 or higher, and ache all over, call your physician. An influenza nasal swab can confirm influenza A and B 70 % of the time.

The new molecular test which can provide results in under an hour is far more accurate but not available at most urgent care or walk in centers or physician offices. Immediate treatment with Osetamivir (Tamiflu) and the newer Peramivir are effective at reducing the duration and intensity of the infection if started early. Hydration with clear fluids, rest, acetaminophen or anti-inflammatories for fever in adults 101 or greater and rest is the mainstay of treatment. Prolonged fever or respiratory distress requires immediate medical attention. Call your doctor immediately.

I get asked frequently for a way to speed up the healing. “My children are coming down to visit. We have a cruise planned. I am flying in 48 hours on business.”  I am certainly sympathetic but these illnesses need to run their course. They are not interested in our personal or professional schedule and everyone you come in contact with is a potential new victim. If you are congested in the nose or throat, and or sinuses, then travelling by plane is putting you at risk of severe pain and damage to your ear drum. See your doctor first. Patients and pilots with nasal congestion are advised not to fly for seven to ten days for just this reason.

If you have multiple chronic illnesses including heart disease, lung disease, kidney disease and you run a fever or feel miserable then call your doctor and make arrangements to be seen. It will not necessarily speed up the healing but it will identify who actually requires antibiotics and additional follow up and tests and who can let nature take its course.