The Medical Director's Desk

Topics of Interest:

  Preventing Colds and Flu

  Flu Vaccine Season is Here

   I resolve to… (Part 1 of 3) - Exercise

  I resolve to... (Part 2 of 3) - Lose Weight

   I resolve to... (Part 3 of 3) - Quit Smoking

  Seasonal Allergy Update

Preventing Colds and Flu

“What can I do to avoid getting sick?”

This question is on everyone’s mind as we approach the winter cold and flu season.

Very few popular preventive strategies like Echinacea, zinc lozenges or nasal gel have shown consistent, significant benefits; though, there has been some evidence to support the benefit of taking higher doses of Vitamin C (200mg – 500mg per day) for reducing the frequency of viral upper respiratory infections.

Unfortunately, none of the above has proven effective in shortening the duration or severity of a cold once it begins. So the best strategy to prevent illness is to reduce your direct exposure to the viruses that cause infection.

Unlike common colds, influenza can be treated if caught early, ideally within 48 hours of symptom onset. Specific anti-viral medicines can be prescribed by your doctor. These same medicines can also be used to reduce your risk of catching influenza from a close contact or family member. And remember: getting vaccinated every year against influenza remains one the most effective ways of avoiding this serious and potentially deadly viral illness.

Perhaps the simplest and least expensive way to reduce the risk of contracting colds and flu is to develop an understanding and commitment to hand washing and hygiene.

People with colds and flu carry the virus on their hands. The virus remains alive on the skin and is capable of infecting another person for at least two hours. It can then be transmitted if the person touches their eye, nose or mouth. Some cold viruses can live on surfaces (such as a counter top, door handle, or phone) for several hours. Droplets containing viral particles can be exhaled (blown out) into the air by a person with a cold as the person breathes, coughs, or sneezes.

Hand washing is an essential and highly effective way to prevent the spread of infection. Hands should be wet with water and plain soap, and rubbed together for 15 to 30 seconds, then dried with a single use, clean towel. Alcohol-based hand rubs are an excellent alternative for disinfecting hands if a sink is not available. They also cause less drying and irritation of the skin than soap and water with frequent hand cleansing. Carrying an alcohol-based hand gel allows you to disinfect your hands frequently, especially after touching shared objects like phones, pens or door handles.

In addition, always carry tissues and cover your mouth when you cough or sneeze. Then discard the tissue and wash or sanitize your hands right away. If no tissue is available, sneeze or cough into the crease of your elbow so that you won’t spread the virus to your hands. If you are caring for a loved one who is sick, be extra careful to wash or sanitize your hands whenever handling their clothing, bedding or any objects they touch.

While there is no guaranteed way to avoid colds and flu, the best defense truly can be in your own hands – or on them!

For additional information on the topics of “Common cold “and “hand hygiene” from which some of the above information was drawn, follow or paste the following web link:

Flu Vaccine Season is Here

As the seasons change and the colder weather approaches, it’s time to prepare for the annual return of one of the most preventable illnesses we face: influenza. Unlike the many respiratory viruses for which there is no effective vaccine or drug treatment, those which cause the common cold, bronchitis and sinus infections, influenza is both preventable and treatable.

Unfortunately, just as we are seeing with many bacterial infections, some influenza virus strains are becoming resistant to the few anti-viral medications available to treat the illness. Fortunately, during the years when the vaccine is well-matched to the active strains, its effectiveness in preventing infection can be as high as 70-90 percent.

Flu season typically does not reach its peak until January or February; but it can begin as early as October and run as late as May. It usually takes about two weeks for the vaccine to begin to protect you; so waiting until close contacts are sick may be waiting too long.

Flu vaccine for the 2008-2009 season is now available and no shortage is predicted. Important changes and updates have been made to the 2008 recommendations including

o     Annual vaccination of all children ages 5-18 is now recommended.

o     Children age 6-months – 59-months with health conditions which place them at increased risk from influenza complications should be vaccinated.

o     Children age 6-months – 8 years should receive 2 doses of vaccine (separated by 4 or more weeks) if they have not had a 2-dose vaccination series in any prior year.

o     Either influenza vaccine injection or live attenuated (nasal spray) vaccine can be used when vaccinating healthy persons aged 2-49.

o     Children age 6-23 months, children with possible reactive airway disease (asthma, recurrent wheezing or recent wheezing episodes), and adults older than 49 or persons at higher risk for complications from influenza should receive the influenza vaccine injection not the nasal spray vaccine.

 Many misconceptions still exist about flu vaccine.

• The most common misconception is that the vaccine will cause influenza.

- While the effect of stimulating your immune system to make antibodies which will protect you may cause low grade fever, soreness or redness at the vaccine site or mild achiness, these are not symptoms of the flu but are signs that your immune system is responding to the vaccine.

•  The vaccine doesn’t work.

- The effectiveness of the vaccine does vary with the match of the strains chosen; however, in 16 of the last 20 U.S. flu seasons, the viruses in the vaccine have been well matched to the predominant circulating strains. Further, even in years when the circulating strains do not match the vaccine, cross-reacting protection may still provide  enough protection to lessen the severity of the illness and prevent flu-related complications.

•  I don’t need to be vaccinated as long as other people around me do.

 - While it’s true that populations can develop a certain degree of “herd” immunity when a enough people become immune that the virus cannot spread easily across the community, that protection only works if the majority of vulnerable individuals are vaccinated before the illness emerges in the area. Further, there is a real moral hazard in counting on others to be responsible for protecting you and your family. Obviously, if everyone opted for the free ride, no one would be protected.

Influenza remains a major cause of severe illness, hospitalization and death, especially in the most vulnerable among us: the very young, the very old and those with serious medical conditions.

Much of that could be avoided if everyone were to take responsibility for their own health and for the health of their family and community by getting their flu shot every year.

For more information, see the Center for Disease Control and Prevention (CDC) website at:

I resolve to… (Part 1 of 3) - Exercise

So it’s no wonder that the tradition of New Year’s resolutions also stirs an equal mixture of hope and disappointment. Setting your sights on improving yourself and your life is a worthwhile goal; but setting unrealistic expectations is a recipe for failure.

During the course of this first month of 2009 I’d like to highlight three of the most common New Year’s resolutions: exercising more; losing weight; and quitting smoking.

I.                    “In 2009, I Resolve to Exercise More”

Many Americans have little or no physical activity in their daily lives. Only about half get the recommended minimum amount of physical activity. Numerous medical studies have shown the risk of the sedentary lifestyle and the benefit of regular moderate exercise. These benefits include:

• weight reduction;
• decreased triglyceride and increased HDL (good cholesterol) levels 
• blood pressure reduction; 
• prevention or delay of Type II diabetes
• stress and anxiety reduction;
• preventing osteoporosis;
• helping to quit smoking.

The American Heart Association (AHA) recommends that all adults get at least 30 minutes of physical activity on most days. That should be 60 minutes if you’re trying to lose weight. The activity does not have to be all at once but can be broken up into 15 minute intervals that better fit your schedule or your exercise tolerance.

People who don’t normally get much exercise should begin by moderate exercising (like walking) for a few minutes at a time. As fitness improves, the duration, intensity and frequency should be slowly increased. Develop a routine, like choosing the same time of day each day, so it becomes a regular part of your lifestyle. Exercise with a friend or family member; you’ll both be more likely to stick with it. Most of all don’t be discouraged if you stop. Life’s demands have a way of derailing the best intentions. Gradually start again and work back up to your old pace.

You don’t need expensive gym memberships or home fitness equipment to get the exercise you need. Once you make exercise a regular part of your lifestyle, you may want to challenge or motivate yourself even further by adding machines or fitness programs. Best of all, once you’ve gotten into the routine and begin to feel the benefits, the chances will be even better that you will stick with the gym or continue to use the equipment.

By setting realistic goals you’re more likely to succeed. Studies show that the greatest health benefit is seen among people who change from a sedentary life to a lifestyle including modest amounts of regular exercise. Start small and work your way up. The benefits will last a lifetime so they’re worth the effort.

Remember: individuals with a history of heart disease or heart disease risk equivalents like diabetes, peripheral or central vascular disease, should discuss any planned exercise program with their doctors before beginning.

For further information on starting a Physical Activity Program, check the following link:

I resolve to... (Part 2 of 3) - Lose Weight

Losing Weight

The goal of any weight loss program should be to achieve a sustainable, healthy weight not to be as thin as possible. The former has lifelong health and medical consequences; the latter is a harmful, unattainable myth created by the entertainment and fashion industry.

Unfortunately, true obesity has become a worldwide epidemic, with Americans leading the way. Rates of obesity in the U.S. have increased from 14 percent in the late 1970’s to 33.5% by the year 2000; and they are still climbing. Obesity is associated with many medical problems including: diabetes, high blood pressure, heart disease, stroke, cancer, arthritis, gallstones, sleep apnea and reduced life expectancy.

Currently, obesity-associated risks are determined by calculating your BMI (Body Mass Index = body weight [kilograms] / height [meters] squared) and estimating your body fat distribution by measuring your waist circumference. A BMI between 25 and 30 is considered overweight. A BMI over 30 is considered to be obese. In addition, a waist circumference greater than 35 inches in woman or 40 inches in men indicates that there may be excessive abdominal fat, which is also associated with a greater risk for heart disease, diabetes and other associated illnesses.

So, how do you start on the path toward a sustainable, healthier weight? The key word to remember is “sustainable”.  If something seems too good to be true, it probably is. That is especially true for rapid weight loss “fad” diets. Often their severe carbohydrate restriction leads to rapid water loss, and apparent weight loss, which inevitably will return as your body adjusts. Likewise anything that promises to reduce your weight without restricting your eating will not lead you to your goal. In the end, there are no secret formulas or shortcuts; weight loss simply requires that you take in fewer calories than you burn.

One pound of fat contains about 3500 calories. Losing that pound in a week requires taking in 3500 fewer calories, or about 500 fewer calories per day.  Starvation is not the answer since the lowest recommended daily intake for woman and men are 1200 and 1500 calories respectively, though lower caloric intake can be a part of a medically supervised program for limited times. The key is striking the balance between your caloric intake and your daily energy use.

Aerobic physical activity will increase your muscle mass which will help you burn more calories every day. Gradual changes in eating habits are more likely to lead to a permanent lifestyle change. You should aim for a slow weight loss of 1-2 pounds per week. Setting a realistic goal is critical to achieving long term success. Progress that is gradual but sustained can be self-reinforcing. Further, many of the health benefits of weight loss begin with as little as 5% initial boy weight loss, just 15 pounds for a 300 pound individual.

Numerous types of treatment are available including: behavioral modification; diet therapy, including portion controlled diets, low-fat diets, balanced low-calorie diets; and weight loss medications. Naturally, any medication use, whether prescription or over the counter, should be supervised by a health care professional for your safety. In addition, dietary consultation with a nutritionist can help you design a calorie reduced diet that is well-balanced, safe and sustainable in order to produce and maintain the desired results.

And, of course, since your weight depends on the balance of the calories eaten with the calories burned, incorporating a continuous exercise program most days of the week will allow you to maintain your healthier weight with less diet restriction as your increased muscle uses the calories you eat more efficiently.

For more information about this topic, including additional links to related resources, click on UpToDate.com link below." 

I resolve to... (Part 3 of 3) - Quit Smoking

Knowing When It’s Time to Quit

In the United States, cigarette smoking is the leading preventable cause of disease. It is responsible for more than 400,000 deaths annually from: cardiovascular disease like heart attack and stroke; lung cancer; and chronic obstructive pulmonary disease (COPD). It also contributes to many other diseases such as asthma, peripheral vascular disease and cancers of the: head and neck, larynx (voice box), esophagus, kidney, bladder, pancreas and stomach. In addition, children who grow up in households with smokers are at greater risk for asthma and other respiratory diseases and, worse yet, of becoming smokers themselves.

These days, almost everybody knows the why; the problem remains the how. The good news is that today there are more effective ways than ever to help you quit smoking. No one strategy works for everyone and most people need several tries to finally quit. The most important component of any successful plan is the desire and commitment to quit.

Whether you slowly cut down, choose a nicotine substitute, work with your doctor using medications or just quit “cold turkey”, planning ahead and adjusting your lifestyle to change your “smoking” routines and enlisting the support of family, friends, community health resources like www.NJ.quitnet.com (866-NJStops) and your doctor will increase your chances of successfully quitting.

Some of the more successful approaches include:

o      Behavioral therapy with individual or group counseling. Some employers and  health insurance companies provide or subsidize these programs; and some online and telephone support services, like NJQuit.net, are free.

o        Nicotine replacement with patches, gum, sprays and inhalers. Patches and gum do not require a prescription and recent studies show that using a combination of the two, under your doctor’s supervision, can increase your success rate. This allows a steady release of nicotine from the patch to reduce the desire and the added quick nicotine dose from the gum for moments of greater craving.

o        Bupropion (Wellbutrin) is an antidepressant medication used in the U.S. since 1989 and also available as a sustained release medication called Zyban, which has been shown to double the likelihood of quitting in multiple patient studies. It requires a doctor’s prescription and medical evaluation and does have some risks and side effects that need to be considered. It remains one of the most effective approaches and can be even more effective if used along with nicotine replacement.

o        Varenicline (Chantrix) is a chemical that binds to some nicotine receptors and has been shown to be more effective than bupropion in aiding smoking cessation in several studies. However recent FDA warnings about reports of suicidal thoughts and aggressive behavior and of increased road accidents and falls have emerged. As with all newer medications, it is important that patients work closely with their physician to report any unusual or unexpected side effects. Further, the Federal Highway Safety Administration and the Federal Airline Administration have prohibited the use of varenicline by commercial drivers and pilots at this time pending further understanding of the potential accident related side effects.

In addition to these options, new medications are being developed and studies examining the benefits of older well established medications are on-going. With the personal and financial costs associated with smoking-related diseases being so great, many resources are being applied to easing the challenge and increasing the ranks of ex-smokers.

As with any difficult task, it’s important to plan ahead. Learn what to expect in terms of physical and psychological withdrawal symptoms and how to manage them. Remember, they will pass. Think through the barriers to quitting: the lifestyle cues and social cues that you associate with smoking; and plan around them for a while. Set a quit date and stick with it. Seek the support of those close to you and your doctor as well the numerous state and health system support websites and phone lines. And don’t be discouraged if you relapse – most people do; but most smokers who want to quit do eventually succeed. There are few lifestyle changes that can provide so many returns throughout the rest of your life; so it’s worth every effort, however long it takes.

 For more information about this topic click on the following website link or look on our Informational Links page and search the Center for Disease Control and Prevention (C.D.C) or American Heart Association (A.H.A) websites.

Seasonal Allergy Update

As winter finally fades away the warmer weather also heralds the beginning of the spring allergy season. Small airborne pollen particles that reach the nose, lungs and eyes can activate inflammatory cells producing histamines and other inflammatory chemicals that cause nasal congestion, itching, sneezing and even asthma.

Twenty percent of people of all ages have allergic rhinitis, sometimes known as hay fever. Symptoms can begin at any age but ususally occur in childhood or in the 30's or 40's; and the severity can vary throughout life. For some, seasonal pollens such as trees or grass in the spring or ragweed in the fall are the main trigger; that's why they are called seasonal allergies. For others, triggers like dust mites, mold and animal dander are present all year and cause perennial (year round) allergy symptoms.

Most often, the exact allergy triggers are unknown but can be suspected based on timing. For instance, tree pollens peak before grasses in the spring. Or, in some cases, specific foliage blooming around your home may signal the onset of your symptoms. In most cases, for seasonal allergies, knowing the when is more important than the what; because the treatment will be the same.

In the case of perennial allergies, diagnosing the exact cause may be an important first step toward reducing the symptoms through immunotherapy, often known as "allergy shots". These can also be used in some cases of seasonal allergies, especially when they are severe or when the seasons tend to merge and the symptoms are present more often than not.

Though avoidance of allergy triggers is desirable, it is easier to accomplish for some perenniel allergy sufferers, such as those who react to animal dander, dust mites or mold. Certainly, remaining indoors and using air conditioning can help, especially during peak pollen counts. And, wearing a filtering mask when exposed to extremely high levels such as when mowing the lawn, will have some benefit. But, in the end, seasonal allegens are so widespread and all methods of filtration, including high efficiency particulate air (HEPA)filters are limited in their proven efficacy; so avoidance is rarely sufficient.

Nasal irrigation with saline (salt-water) solutions is gaining popularity, especially among those who wish to avoid or minimize their use of medication. Though saline nose sprays can help, they are generally less effective than using larger volumes. Nasal irrigation (also called lavage) can be performed using a variety of kits purchased over-the counter including bulb syringes, Neti pots and bottle sprayers. Saline solutions can be purchase pre-made or prepared at home.

The treatment helps both to rinse out allergen particles and to clean out the nasal passages from excess mucous. That may be especially useful in preparation for some nasal spray medications. One such method can be found at the following WebMD site: www.webmd.com/allergies/sinus-pain-pressure-9/neti-pots (just copy and paste the web address into your browser).

For most seasonal allergy sufferers though, medications, both over the counter and prescribed, remain the mainstay of treatment. There are several medication types that can help with different symptoms and, often, they complement each other in their benefit. Many effective medications that once required a prescription are now available over-the-counter. Unfortunately, there is no one perfect solution and the most effective choices still require a doctor's prescription.

The current recommended first-line treatment for allergic rhinitis is nasal steroids. These prescription medicines have fewer side effects and are thought to be more effective than oral antihistamines. Most can be taken once daily. Unlike oral or inhaled steroids (used for asthma) the dose of nasal steroids is so low that studies have shown them to be safe after years of use. The most common side effects include local irritation and, rarely, nasal infection; and therefore periodic nasal examination is recommended.

It is important to know that nasal steroids do not work immediately; they usually take several days or even a week to reach maximum benefit. Therefore, it is best to begin them before allergy season starts or, at least, at the first sign of allergy symptoms.  Multiple formulations exist, all with comparable efficacy. In general aqueous (water-based) solutions are less drying and irritating. Combined with oral antihistamines, these two medication classes represent the most common approach to seasonal allergies.

Antihistamine pills have been available for decades. Though the newer generation medications tend to have fewer side effects (especially less drowsiness) and offer more convenient, once-daily dosing, they are usually no more effective than the older choices like diphenhydramine (Benadryl) or chlorpheniramine (Chlor-Trimeton). Still, medications like loratadine (Claritin, Alavert) or cetirizine (Zyrtec) can offer some relief. Prescription alternatives like fexofenadine (Allegra), desloratidine (Clarinex) or levocetrizine (Xyzal) are also available.

Newer nasal spray antihistamines like Astelin, Astepro and Patanase are also effective at relieving post-nasal drip, congestion and sneezing but can have some side effects including nsasl irritation, bad taste and still can cause some drowsiness.

Decongestants like pseudoephedrine and phenylephrine were often combined with antihistamines in allergy drugs. Though they help with the mucous menbrane swelling and pressure, they have many side effects, including elevating blood pressure and heart rate (which can be especially problematic for people with high blood pressure or heart disease). Further, pseudoephedrine, the most effective oral decongestant, was removed from most medications due to its diversion and misuse in manufacturing illegal drugs.

Topical decongestants like oxymetazoline (Afrin) or phenylephrine (Neo-synephrine) can be very effective at relieving nasal congestion quickly; but extended use (more than three days) can lead to rebound congestion that is very hard to relieve. Still, they can be very useful during the first few days of symptoms, especially when first starting nasal steroid use, as they allow better delivery of the steroid medication. In addition, they can be extremely helpful during air travel to reduce the ear pain and pressure-related ear injury caused by cabin pressure changes. Remember though, use them for a maximum of three days .

There is also a newer type of oral medicine called Singulair, a leukotriene modifiers.  This  medicine was introduced for asthma treatment and can also help allergy symptoms. However, it is generally reserved for those who cannot tolerate nasal steroids, which are more effective.

Finally, Nasalcrom (cromolyn sodium) is a nasal spray, now available over-the-counter, that stabilizes the allergy cells and reduces the inflammatory chemical they release. However, it must be used 3-4 times a day and you must start before the allergens trigger the reaction. Nevertheless, it presents a helpful alternative for those who do not wish to use nasal steroid sprays.

Though allergic rhinitis remains a common problem, recent advances in treatment provide more effective, more convenient alternatives than ever before. If the growing number of over-the-counter remedies are not helping, your doctor has several effective options for you to try. In the most severe or chronic (longstanding) cases, referral to an allergy or sinus specialist may be needed to consider additional measures such as immunotherapy or direct nasal and sinus examination or other procedures.

Though the congestion, runny nose and post nasal drip of allergies and infections can be similar, allergic rhinitis should not cause fever (temperature over 100.5), severe facial pain or thick pus-like mucous for many days. These symptoms are more typical of infections which may be coincident to or a consequence of the allegies.  They should be evaluated by your doctor if they are severe, last more than a week or are worsening rapidly.

For more information from the source of this summary and for related links, please click on the link below.