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According to a new study in the latest issue of the Archives of Otolaryngology — Head & Neck Surgery, saline irrigation treatments show greater efficacy versus saline spray for providing short-term relief of chronic nasal and sinus symptoms.

In the United States, 29.5 million people 18 years of age and older are affected by sinusitis [1]. Millions more are affected by other types of allergic and non-allergic rhinitis (meaning irritation and inflammation of the mucosal membrane of the nose). Some people can reduce symptom severity using medication, including antihistamines and anti-inflammatory drugs. Antibiotics are frequently prescribed for acute and chronic sinusitis. However, their use far outweighs the predicted incidence of bacterial infection, suggesting that antibiotics are overprescribed for sinus infections. Regardless of the medication used however, for many patients, symptoms persist.

Nasal irrigation - the flooding of the sinus cavity with warm saline solution - can help to reduce sinus congestion and is often recommended by otolaryngologists (ear, nose and throat physicians) for a variety of sinus conditions. The goal of nasal irrigation is to clear excess mucus and foreign debris out of the sinuses, and to moisturize the mucosal membrane. The practice has been subjected to clinical testing and has been found to be safe and beneficial with no apparent side effects (for reviews of clinical evidence, see [2-3]). The practice is simple and inexpensive, and has been shown to decrease the symptoms of a variety of nasal and sinus conditions. As an alternative to irrigation, saline spray is often used because it is thought to be similar to and better tolerated than irrigation. However, the effectiveness of nasal saline spray has not been proven in clinical trials.

A new study from researchers at the University of Michigan Health System concludes that nasal irrigation is more effective that commonly used saline sprays for treating chronic nasal and sinus symptoms. Participants in the study, 127 adults with chronic nasal and sinus symptoms, were randomly assigned to irrigation or spray for 8 weeks. Those using nasal irrigation showed a statistically significant change in symptom severity as early as 2 weeks into the study. After 8 weeks, only 40% of participants in the irrigation group reported frequent (defined as “often or always”) nasal and sinus symptoms compared with 61% in the spray group [4].

Both groups experienced adverse effects. More were reported in the irrigation group. However, most adverse effects were minor and none required that treatment be stopped. The most commonly reported adverse effect was post-irrigation drainage, which occurs when saline in the upper sinuses isn’t expelled and later drains.

The study is the first of it’s kind to show greater efficacy of saline irrigation treatments versus saline spray for providing short-term relief of chronic nasal symptoms. According to lead author Melissa A. Pynnonen, M.D., clinical assistant professor in the University of Michigan Department of Otolaryngology [5]:

The irrigation group achieved a clinically significant improvement in quality of life in terms of the severity of their symptoms, whereas the spray group did not. Strikingly, they also experienced 50 percent lower odds of frequent nasal symptoms compared with the spray group.

An interview-based study assessing the attitudes regarding use of nasal irrigation for frequent rhinosinusitis as well as chronic sinus and nasal symptoms published last year found that [6]:

• Nasal irrigation produced rapid and long-term improvement in the quality of life.
• Users felt empowered.
• Barriers to use included discomfort, time and mild side effects.
• Instruction and at-home use can overcome the fore-mentioned barriers.

The take-home message? If you’re using saline spray to treat chronic sinus symptoms, you will experience a much greater benefit in terms of both symptom severity and frequency with saline nasal irrigation.

Do you use nasal irrigation? Why or why not?

References

1. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2005. U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. National Center for Health Statistics. 2006 Dec.
2. Papsin and McTavish. Saline nasal irrigation: Its role as an adjunct treatment. Can Fam Physician. 2003 Feb;49:168-73.
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3. Harvey et al. Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD006394.
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4. Pynnonen et al. Nasal saline for chronic sinonasal symptoms: a randomized controlled trial. Arch Otolaryngol Head Neck Surg. 2007 Nov;133(11):1115-20.
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5. Sinus problems are treated well with safe, inexpensive treatment, UMHS study finds. Department of Public Relations and Marketing Communications Newsroom. University of Michigan Health System. 2007 Nov 19.
6. Rabago et al. Qualitative aspects of nasal irrigation use by patients with chronic sinus disease in a multimethod study. Ann Fam Med. 2006 Jul-Aug;4(4):295-301.
   View abstract

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Last week, the Centers for Disease Control and Prevention (CDC) reported that a new virulent strain of the common cold virus, adenovirus, has caused 10 deaths over the last 18 months [1]. The virus, identified as adenovirus serotype 14 (Ad14), is a rarely reported strain of adenovirus that can cause severe and even fatal respiratory illness. It’s unusual since adenoviruses typically cause non-lethal infections. According the the CDC report:

The cases described in this report are unusual because they suggest the emergence of a new and virulent Ad14 variant that has spread within the United States.

Indeed, between the months of March-June 2007, Ad14 caused at least 140 respiratory illnesses in three states; Oregon, Texas and Washington [1]. More than 50 of those patients were hospitalized, including 24 who were admitted to intensive care units. Nine of those patients died, most from severe pneumonia. People of all ages have been affected, including healthy young adults, typically the group least susceptible.

Adenovirus

Adenoviruses are a group of viruses, specifically non-enveloped icosahedral DNA viruses, that infect various tissues, including respiratory, gastrointestinal and urinary tracts as well as the eye. Adenoviruses get their name as they were originally isolated from human adenoid tissue (tonsils) in the 1950’s [2-3]. Adenoviruses comprise more than 50 serotypes (meaning a group of organisms that can be distinguished based on molecules present on their cell surface that are able to stimulate an immune response), clustered in 6 species designated A through F.

Adenoviruses display a certain degree of tissue specificity and several clinical symptoms are associated with particular groups of virus. For example, adenovirus serotypes Ad2 and Ad5 from species C are associated with approximately 7% of respiratory illnesses in children [4]. In contrast, Ad40 and Ad41 from species F are typically associated with gastrointestinal infection. Adenovirus serotypes 8, 19 and 37 are associated with a relatively severe contagious form of epidemic keratoconjunctivitis (inflammation of the cornea and conjunctiva, the outermost layer of the eye and inner surface of the eyelids).

Ad14 infection was first described in 1955 [5] and was associated with epidemic acute respiratory disease in military recruits in Europe in 1969 [6] but has since been detected infrequently.

Transmission and symptoms

Adenoviruses are typically transmitted via aerosolized secretions from the respiratory tract. Infection can also occur from contact with infectious material on inanimate objects, such as doorknobs and drinking fountains. The gastrointestinal strain is usually transmitted by fecal-oral contact, occurring from poor hand washing or ingestion of contaminated food or water.

Most adenovirus infections affect the upper respiratory tract, often presenting as tonsillitis, conjunctivitis, ear infection and croup (a respiratory disease causing inflammation of the larynx and upper airway in infants and young children). Children may develop bronchiolitis (an inflammation of the bronchioles, the smallest air passages of the lungs) or pneumonia. Pneumonia results in the alveoli (tiny air-filled sacs in the lung that are responsible for absorbing oxygen) becoming inflamed and filled with fluid. Adenoviruses can also cause stomach flu (gastroenteritis).

Adenoviral respiratory infections are most common in the late winter, spring and early summer, while intestinal tract infections occur throughout the year. In most people, adenovirus infection is asymptomatic. For people who do experience symptoms, there are no specific antiviral treatments and symptoms often gradually disappear on their own.

Some of the most common symptoms of adenoviral infections include:

Respiratory infections, with symptoms developing 2 to 14 days after exposure
• runny nose
• sore throat
• fever
• severe cough
• swollen lymph nodes
• headache

Intestinal tract infections, with symptoms developing 3 to 10 days after exposure and lasting 1 to 2 weeks (usually occurring in children < 4 years)

• abrupt onset of watery diarrhea
• fever
• abdominal tenderness
• vomiting

Treatment

There is no cure for adenovirus infection and, because the infection is caused by a virus, antibiotics are not effective. Treatment is focused on relieving symptoms associated with infection and include increased fluid intake, pain relievers and plenty of rest.

In the case of Ad14, a number of antiviral drugs have been used to treat infection, including ribavirin, vibarabine and cidofovir, but none have been shown to be effective [7]. Patients have been treated with liquids, pain relievers and bed rest. Retrospective examination of laboratory reports showed that the virus has been responsible for a number of respiratory diseases, including pneumonia, febrile respiratory infection and conjunctivitis. Although scientists have not determined the prevalence of Ad14 in the population, they emphasize that the virus is not widespread.

Clinicians with questions related to testing of patients for adenovirus or Ad14 infection have been advised to contact their state health departments. CDC officials don’t consider the Ad14 outbreak to be a cause for alarm and are not recommending any new precautions for the the general public.

Remember that coughing and sneezing can spread cold and flu germs. One of the most effective ways to fight adenovirus infection is to simply wash your hands.

References

1. Acute Respiratory Disease Associated with Adenovirus Serotype 14 — Four States, 2006–2007. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2007 Nov 16;56(45):1181-1184.
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2. Rowe et al. Isolation of a cytopathogenic agent from human adenoids undergoing spontaneous degeneration in tissue culture. Proc Soc Exp Biol Med. 1953 Dec;84(3):570-3.
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3. Hilleman and Werner. Recovery of new agent from patients with acute respiratory illness. Proc Soc Exp Biol Med. 1954 Jan;85(1):183-8.
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4. Sinaniotis CA. Viral pneumoniae in children: incidence and aetiology. Paediatr Respir Rev. 2004;5 Suppl A:S197-200.
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5. Van der Veen et al. Isolation and typing of adenoviruses recovered from military recruits with acute respiratory disease in The Netherlands. Am J Hyg. 1957 Mar;65(2):119-29.
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6. Hierholzer and Pumarola. Antigenic characterization of intermediate adenovirus 14-11 strains associated with upper respiratory illness in a military camp. Infect Immun. 1976 Feb;13(2):354-9.
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7. Adenovirus. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of infectious disease. 6th edition. Philadelphia, PA: Churchill Livingstone; 2004.

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After feasting on your Thanksgiving dinner today, a specific word may come to mind: tryptophan. Tryptophan is an amino acid found in high levels in turkey. The main reason for the association between tryptophan and drowsiness is that tryptophan is a chemical precursor to melatonin, a neurotransmitter that plays a role in regulating the circadian cycle, the regular changes in mental and physical characteristics that occur over the course of 24 hours. Indeed, purified tryptophan is a mild sleep-inducing agent [1].

Tryptophan breaks down into at least three metabolites. The first is melatonin, which can lead to sleepiness. The second is niacin, a form of vitamin B. Tryptophan also breaks down into serotonin, a neurotransmitter that regulates agression, body temperature, appetite and mood. In a recent study presented at the Society for Neurosciences, Robert Rodgers, Ph.D. and his colleagues at Oxford University used game theory to study serotonin’s role in social interactions [2].

The study asked volunteers to play a two-person game called Prisoner’s Dilemma. In the game, people make choices that affect each other, either choosing to make a move that wins them money from the other player or a move that wins both players money. Under normal circumstances, players were found to cooperate about 75% of the time. However, by depleting levels of l-tryptophan, which in turn reduced levels of serotonin, researchers found a significantly decreased level of cooperation among players. The lowered levels of serotonin also effected players judgment of the social characteristics of others and they rated fellow players as less trustworthy.

According to Rogers, serotonin may [2]:

… play a role in modulating the cognitions that underpin dependable relationships with our social partners.

The research findings suggest that serotonin deficiency may impair continual cooperation and diminish the reward value of cooperative behavior.

Does all this mean we’re more trusting after a Thanksgiving day meal? Likely not. Scientists haven’t yet determined how increased levels of tryptophan affect trust. However, after a large meal of turkey, stuffing, gravy, cranberries, sweet potatoes and pumpkin pie, brain levels of tryptophan may actually decrease.

The transport system that’s used to take tryptophan to the brain is shared by a number of other amino acids and there’s competition between them. Thus, after a large meal, less tryptophan will reach the brain than on an empty stomach. In addition, this means that, contrary to popular belief, the tryptophan in turkey does not cause drowsiness.

So why are we so sleepy after a Thanksgiving meal?

It’s not unusual to feel sleepy after eating a lot, especially after consuming large amounts of high-carbohydrate foods. Indeed, consumption of high glycemic index foods has been shown to decrease the time it takes to fall asleep [3]. Additionally, it’s not unusual to feel sedated after a high-calorie meal. The best way to reduce drowsiness this Thanksgiving? Simple … eat less.

Resources

1. Hartmann et al. L-Tryptophane and sleep. Psychopharmacologia. 1971;19(2):114-27.
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2. Research reveals brain areas for types of decision-making, shows how a brain chemical underpins social interaction. Society for Neuroscience. 2007 Nov 4.
3. Afaghi et al. High-glycemic-index carbohydrate meals shorten sleep onset. Am J Clin Nutr. 2007 Feb;85(2):426-30.
   View abstract

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