White Coat Underground

Within 72 hours of starting kindergarten, my daughter caught a cold, and within 72 hours of that, she gave it to me.

The common cold sucks. It affects millions of people every year causing misery and lost days of school and work. It’s terribly hard to prevent, and there aren’t really any effective treatments. Vitamin C, Echinacea, zinc—all useless. Newer, more expensive antihistamines and steroid nasal sprays, both of which are great for allergies, don’t seem to help either. I find myself dispensing lots of grandmotherly advice this time of year. Thankfully, tonight is Rosh Hashanna and there’s very likely to be chicken soup, which always feels good on a sore throat. Hot tea with honey, warm saline nasal irrigation, oral decongestants, antihistamines, and ibuprofen can all help mitigate symptoms, but nothing makes a cold go away faster. A depressingly large number of patients want The Secret Cold Cure that I must be withholding from them. I remind them that if I had this secret cure, I’d be a very wealthy man. Antibiotics are also useless (and dangerous).

The loathsome National Center or Complementary and Alternative Medicine displays the usual foolishly tenacious (and wrong) thinking about some cold remedies:

What the Science Says

Study results are mixed on whether echinacea effectively treats colds or flu. For example, two NCCAM-funded studies did not find a benefit from echinacea, either as Echinacea purpurea fresh-pressed juice for treating colds in children, or as an unrefined mixture of Echinacea angustifolia root and Echinacea purpurea
root and herb in adults. However, other studies have shown that
echinacea may be beneficial in treating upper respiratory infections.

Most studies to date indicate that echinacea does not appear to prevent colds or other infections.

NCCAM is continuing to support the study of echinacea for the
treatment of upper respiratory infections. NCCAM is also studying
echinacea for its potential effects on the immune system.

In other words, the science says that Echinacea is useless for the prevention or treatment of colds, but they’ll keep looking at it until a false positive result on a study helps justify their continued drain on precious resources. After all, the people demand it (or at least Tom Harkin does).

Who can blame cold victims though. Right now, I’m feeling their pain; I’d love that secret cure. But I’m only a couple of hours away from my mother-in-law’s chicken soup, and that’ll do just fine.

Comments

#1 Donna B.
September 18, 2009

The 3 years I lived in a big city (Dallas) my family seemed to pass colds around like dinner rolls. Three different schools and two different workplaces (involving lots of contact with the public) worked like revolving doors for viruses.

I have often wondered how doctors stay well!

When we moved back to a rural area, we didn’t suffer as much. The schools and classes were smaller and my workplace was fairly isolated from the general public.

I hope you and your daughter feel better soon.

Now, here’s a political question: do you know of any of the proposed healthcare plans that would ‘delete’ NCCAM and/or stifle insurance coverage of the various CAM treatments that some (including in some cases Medicare and Medicaid)?
#2 Scicurious
September 18, 2009

I know it’s useless, but I’ll admit that echinacea tea just tastes really good when you’re sick.

Then again, Oreos do too…
#3 Dr. Free-Ride
September 18, 2009

In other words, the science says that Echinacea is useless for the prevention or treatment of colds, but they’ll keep looking at it until a false positive result on a study helps justify their continued drain on precious resources.

Oddly enough, this gave me a mental picture of the federal budget as a giant nose with a neti pot stuck in it, and then a mucousy flow of hundred dollar bills pouring out of it.

Maybe because I’m a little sleep deprived from the sneezing and coughing.

P.S. A hot mug of Cran-anything feels pretty good on a sore throat and seems to cut the mucus more effectively than herbal tea.
#4 D. C. Sessions
September 18, 2009

Shanah Tovah, Doc.
#5 Donna B.
September 18, 2009

Dr. Free-Ride… that is gross, but hilarious imagery. Now take something for that cold!

The old-fashioned remedy required a bottle of whiskey and a single object to focus on. The “cure” involved drinking enough of the whiskey to constantly see two objects.

Then, when you woke up the next day, you had a hangover instead of a cold 🙂
#6 HP
September 18, 2009

Many, many years ago I saw an episode of The Beverly Hillbillies that has stayed with me any time I hear of an “alternative” cold treatment.

It seems that Mr. Drysdale had developed an awful cold. He complained to Jed, who offered that Granny had a sure-fire cure for the common cold. Mr. Drysdale suddenly got dollar signs in his eyes, thinking of all the profit to be made off a cure. He asked Jed about it, and Jed described a hot poultice of asafoetida, wild garlic, mustardseed, possum grease, and just about every foul-smelling thing familiar to an Appalachian herbalist.

Incredulous, Mr. Drysdale asks, “And that will cure the common cold?”

“Guaranteed!,” says Jed. “You wear Granny’s poultice around your neck every day, and in a week to ten days, your cold will be gone!”

Get well soon, Pal. And if not soon, then in a week to ten days.
#7 Noadi
September 18, 2009

Regardless of what bug I pick up every cold I have always involves a sore throat so my personal favorite thing is peppermint tea over echinacea or any other. I’m sure it doesn’t help me get better any faster but that cooling mint on a sore throat is just heavenly, plus it’s got a taste and smell strong enough to penetrate even the worst stuffy nose.
#8 HP
September 18, 2009

Well, if we’re simply talking palliatives, then for a sore throat there’s slippery elm. The mucilage in slippery elm actually does something, which gives it a leg up over echinacea.

Weirdly, they started taking slippery elm tea off the store shelves a few years ago, and now it’s hard to find. But I can’t find any serious contraindications when I do a cursory googling. Does anyone know something I don’t know?

(Hmmm… Now I’m wondering if the “Throat Coat” brand of slippery elm tea I used to buy had ephedra in it.)
#9 HP
September 18, 2009

(I’m enclosing this entire comment in parentheses because I’m now so far off-topic, but following up on my previous comment, Wikipedia says that slippery elm, inserted cervically, is reputed to be an abortifacient. Is that why I can’t buy Throat Coat at the grocery store anymore? Really?)
#10 Tsu Dho Nimh
September 18, 2009

PAL –
Echinacea has two known effects on the “immune system”, neither of which makes it worth much for preventing colds, but which make it useful for other purposes:

1 – It increases phagocytic activity in vivo. This makes it useful for speeding the cleanup of the cellular debris left after the cold is over. It might also help in bacterial infections by removing them from the scene.

The stimulation toward phagocytosis becomes very evident in cases where it was impossible to find any evidence of phagocytosis before echinacea was administered, and where after the use of this drug for a period of only a few days the phagocytes were seen to contain as many as eight bacilli within the cell. (Ellingwood’s therapeutist, 1917)

http://medherb.com/Materia_Medica/Echinacea_-_Contraindications.htm has a good discussion and references.

2 – I use it because it decreases the release of histamine from MAST cells (I’ve lost the reference, it was in German from the 1990s), which reduces upper respiratory allergy symptoms, much like Zyrtec. Like Zyrtec, it takes a couple of weeks to have an effect, but unlike Zyrtec, it doesn’t knock me out for 18 hours each dose.
#11 PalMD
September 18, 2009

Two bowls of mom-in-law’s kreplach soup felt great. Now hopefully off to bed.
#12 Danimal
September 18, 2009

Welcome to the world of school, where kids spread everything and bring it home as a gift for their parents.
#13 Mara
September 18, 2009

I’m jealous! My mother-in-law didn’t make chicken soup for dinner tonight and the cold I got from *my* daughter is even worse now. Rassum frassum goshdarn preschoolitis. Hmmph.

However, shana tova u’metuka!
#14 becca
September 18, 2009

Is the mechanism for increasing phagocytosis known, and what cell types are affected? Cause I’m thinking that if you got too many of the wrong kind of DC presenting to Tregs, increasing phagocytosis could actually make it worse.
#15 military wife
September 19, 2009

hot, strong tea with equal amounts of fresh squeezed lemon juice and honey…so sweet it’s like strong, hot lemonade

it really works, and all the honey must cut the acidity in the lemon because it doesn’t sting
#16 Bob O'H
September 19, 2009

I’m not a medical doctor, but I would recommend taking a placebo, three times a day. If you can, get on a trial of experimental placebos, some of them really work (and you don’t even need to worry about which arm of the trial you’re in).
#17 Radioactive afikomen
September 19, 2009

Shanah tovah, Pal!
#18 BaldApe
September 19, 2009

When my kids were little (pre-school age) we lived in a bit of an isolated location. So we took them to a day care “nursery-school” a couple of days a week so they could play with other kids.

I just about never get sick. I had not been ill for maybe 10 years, but when my kids started going to this day care, I got the worst “stomach flu” ever. I was so sick I could not walk from one room to another without dizziness. Of course I got over it, but it was not fun.

I am intrigued by one of the claims about those zinc lozenges. They say they are effective in reducing the duration and severity of a cold, so long as you begin to use them at the very first onset of symptoms.

Is it possible that people who are more likely to treat themselves right away, rather than waiting for symptoms to get really uncomfortable, are reducing the severity of their infection? Unless the zinc lozenges work, and I am skeptical, then that is the only explanation I can come up with.

Also, tangentially related, I once asked a pharmacist I worked with why there were all those signs about whether the respiratory symptoms you have are a cold or the flu. They are both viral infections, you treat the symptoms and they go away (for most people). Who cares which virus you have?

Of course I understand that tamiflu changes that picture somewhat, but at that time it was a valid observation.
#19 KristinMH
September 19, 2009

I always drink lemon tea with fresh ginger in it. It’s soothing the throat, and the ginger helps clear out the nose, though it doesn’t do anything to reduce the length of the cold. The only side effect is that it makes you associate the taste of ginger with illness, so that Thai ginger beef will never be the same again.

Scotch toddies are also good. 😉

The only place I’ve ever seen Slippery Elm lozenges for sale is at the sheet music store I frequent. I figured they were just another bit of woo that singers fall for. Who knew they actually worked?
#20 Diane
September 19, 2009

Welcome to the world of having a school-age kid! Took our family a couple of years of having near-constant colds, but it ended eventually. Oh, except for this year, with swine flu going around and my youngest having something suspiciously flu-like.
#21 Dianne
September 19, 2009

I’ve heard of this wonderful new medication called Obecalp. If you take it regularly when you have a cold your cold will disappear in just 1-2 weeks instead of the 7-14 days it usually takes to recover from a cold.
#22 Jeff
September 19, 2009

Properly formulated echinacea does work. This 2007 Lancet meta-analysis looked at 14 studies of a specific brand of echinacea, which is widely avaliable. The researchers concluded:

1.Echinacea decreased the odds of developing the common cold by 58% and the duration of a cold by 1·4 days.

2.Published evidence supports echinacea’s benefit in decreasing the incidence and duration of the common cold.
#23 Dacks
September 19, 2009

One thing that really does help keep sinus infections from developing after colds is the steam tent. Take a large bowl of hot water, sit down in front of it with a towel over your head, and take deep breaths. The steam will temporarily clear out the mucus and ease the swelling. I used to suffer sinus infections regularly after colds, and this has helped me to avoid them in recent years. The steam from a hot shower also works wonders.
#24 Nomen Nescio
September 19, 2009

tonight is Rosh Hashanna and there’s very likely to be chicken soup, which always feels good on a sore throat.

in my native culture (Scandinavia), the traditional palliative is blueberry soup. i’ve always thought a greasy, meaty soup would be inferior to that when your throat is already aching, but perhaps it’s all culturally constructed.
#25 SimonG
September 19, 2009

I’m sure a lot of it is “nursery food”, so it’s the reassuring memories of childhood that make the difference.
For some reason my mum often gave me smoked haddock when I was ill. Not one of my favourites these days but it does retain a comforting quality.
#26 Donna B.
September 19, 2009

My Mom always gave me ginger ale when I had anything “stomach” related. Not a bad idea, it kept me hydrated when I couldn’t keep anything down.

But I don’t like it much now, as I do equate it with being ill.
#27 Patient
September 19, 2009

Feel better, PAL, and Happy New Year.
#28 Diane
September 20, 2009

My Japanese mother always made “okayu”–a thin rice gruel–for sick times. Nasty stuff.
#29 Arnold T Pants
September 20, 2009

When I lived in Manhattan, when my wife and I got sick we would get a takeout chicken dinner from this diner around the corner. A rotisserie chicken, matzoh ball soup (we’re goys, but it’s great stuff), and some other stuff. It was perfect- we’d put the chicken in the soup, and it would provide us with about a full day of perfect sickie food.
#30 Tsu Dho Nimh
September 20, 2009

@14 – Becca Is the mechanism for increasing phagocytosis known, and what cell types are affected?

It’s mostly the macrophages, and I don’t think they know exactly what the mechanism is. I would have to dredge the pre-antibiotic publications of the “Eclectics” and learn to read German.

It was a known problem for TB, because although echinacea was usually helpful, it would occasionally lead to macrophages rupturing in strange places and disseminating or unconsolidating the TB.
#31 JustaTech
September 21, 2009

When I’m just getting a cold I like chicken pho: it’s chicken soup and a steam tent in one! That, plenty of fluids, good food and a dedicated lap-cat usually limit a cold to 5-7 days.

Well, that and co-workers who think nothing of alcohol-ing your work surfaces to kill germs. But we’re in lab, so it makes sense.
#32 #1 Dinosaur
September 21, 2009

Actually, the rhinorrhea of a viral URI isn’t mediated by histamine, so the only way OTC antihistamines are going to help is by sedating you to sleep. Also, the oral decongestants are iffy in the RCT efficacy department. After all, they’re just generalized vasoconstrictors; they don’t preferentially constrict vessels in nasal mucosa, and they also raise blood pressure.

Other than that, your advice was right on, chicken soup and all.
#33 PalMD
September 21, 2009

The rhinorrhea is not helped by later-generation antihistamines, but the early ones do seem to help, probably via their anticholinergic properties.
#34 Chris
September 21, 2009

When the kids were young, we would also tend to get sick at the same time as at least one of them (the first one to get the school bug would infect a sibling and a parents at about the same time). So not only was soup often on the menu (including the hot and sour soup from our neighborhood Chinese restaurant), but so were certain videos watched while sitting in the big chair with a sick kid in your lap.

We had one ten or so hour video from a TV miniseries that had an odd take on fairy tales. So even as the kids turned into teenagers and were able spend sick days alone at home (and less likely to infect others!), I noticed more than a few times the ill adolescent would be watching that DVD on the couch surrounded by tissues and beverage containers.
#35 daedalus2u
September 22, 2009

I just saw an item in the NYT on sleep

http://www.nytimes.com/2009/09/22/health/22real.html?em

and colds referring to this article

http://archinte.ama-assn.org/cgi/content/abstract/169/1/62

Sleep is a high NO state, and high NO in the nasal passages (where it actively generated to put a few hundred ppb NO into the air that gets to your lungs) might be part of what reduces cold virus transmission during summer (warm and moist facilitates NO production).

Chicken tends to be high in arginine which is the substrate for nitric oxide synthase.

The clearing of phagocytosed bacteria (including TB) is induced by ATP, which is regulated by NO (i.e. high NO leads to high ATP via sGC)). I think the mechanism is by induction of autophagy (which requires ATP).

High NO does reduce the sensitivity of mast cells to degranulation.

What I remember about that episode of Beverly Hillbillies was that Granny’s treatment was photosensitive, so she had to make it under a blanket, and as it was sitting there, some fumes leaking from a jug burned a hole in the blanket. When it was noticed, everyone jumped and asked was that from the treatment Granny was making, she laughed and said no, that was from her jug of moonshine.
#36 BaldApe
September 22, 2009

One thing that really does help keep sinus infections from developing after colds is the steam tent.

Really, really hot peppers do the same for me. I had an awful sinus headache once, and a couple of “red-hot” burritos later, I could literally hear my sinuses draining.
#37 Kismet
September 23, 2009

Zinc useless? Are you specifically talking about zinc acetate and gluconate lozenges? I think the jury is out on the latter, isn’t it?
The last meta-analysis I remember showed rather wide CIs with a RR suggestive of a possible benefit. If new positive evidence emerges the CIs should be narrowed down (if my understanding is correct) so I am not sure how such an analysis would look today, and how it would look like if one included only gluconate/acetate lozenges.
At least one new study showed lozenges to be effective, I am wondering what your take is on quality and methodology of that paper?

J Infect Dis. 2008 Mar 15;197(6):795-802.
Duration and severity of symptoms and levels of plasma interleukin-1 receptor antagonist, soluble tumor necrosis factor receptor, and adhesion molecules in patients with common cold treated with zinc acetate.
Prasad AS, Beck FW, Bao B, Snell D, Fitzgerald JT.
#38 PalMD
September 23, 2009

A wide CI that happens to include your desired result does not argue in favor of same–it argues against it. We don’t get to look at a wide CI and say, “but hey, my hypothesis would be proved if the CI were narrower and centered about a different number.”
#39 Kismet
September 23, 2009

No, my point was that it *is* centered around the right number, it’s just the width that is off. I thought that happens even with correct results if your dataset is too small. A single study would usually show a risk ratio that corresponds to the RR of a meta-analysis just with a wider CI (e.g. as in the case of high dose vitamin E studies, most single studies have insignificant risk ratios, but if you mix ’em together in a meta-analysis you find a small, but significant increase in all-cause mortality).

So if the RR suggests a benefit, the CI is wide and we add new evidence which shows a benefit, the analysis may (or may not depending on weight of the evidence) show a significant effect as the CI narrows.

Sooner or later we need to re-assess the new evidence.
#40 Diane
September 24, 2009

Sorry, general public here..”Cl”? “RR”?
#41 StThomas
September 24, 2009

Traditional medicine from Scotland; a hot toddy. Mix honey, and lemon juice in boiling water, and add whisky to taste. Generally though, the hot water honey and lemon may be omitted without compromising the beneficial effects….
#42 catgirl
September 24, 2009

I’ve always been prone to getting sore throats, so I’ve tried everything. What works best for me is Chloraseptic spray (it also now comes in lozenges). The active ingredients is phenol, which is pretty good at numbing the throat.
#43 Patient
September 25, 2009

@39
RR- Risk ratio

Relative risk (RR) is the risk of an event (or of developing a disease) relative to exposure. Relative risk is a ratio of the probability of the event occurring in the exposed group versus a non-exposed group.

CI- Confidence Interval

Confidence intervals are used to indicate the reliability of an estimate. How likely the interval is to contain the parameter is determined by the confidence level or confidence coefficient. Increasing the desired confidence level will widen the confidence interval.

(from wikipedia)