This month marks the start of my 20^th year both in medical practice and on the faculty at New York Medical College. The changes in medicine in these years have been striking, and mostly to the good:

• lower rates of heart attack and stroke
• lowering of cancer rates
• better ways to manage diabetes
• ubiquitous CT & MRI scans
• better tools for diagnosis & therapy of many other diseases
• minimally invasive surgery, angioplasty ("plaque squashing") and stenting
• the rise of AIDS and the beginning of its conquest
• the dawn of genetic medicine

But, we still need to:

• make this care available to all
• use all of what we know for every patient every time.
• manage "managed care" (which is really just "managed cost")

Prescription Reminder: Our 24 hr prescription line 914 962-3182 serves best if you are specific about your needs! Please include:

Another Winner: Joseph Hvisc is our debut winner of 2 Hollywood Video rentals for getting his colon cancer (guaiac) screening cards in promptly. Everyone who does this test is a winner in the fight to reduce this preventable cancer!

Tetanus Shots on Hold: due to a nationwide shortage of tetanus toxoid, we will not be able to give "routine" booster shots until 2002. Shots are still advised for deep wounds (if you’ve not had one in 5 years) and foreign travel and pregnancy. If we can’t get it, you may need to make alternate arrangements. There were only 2 manufacturers - 1 pulled out; Aventis Pasteur is working to meet the need, but production time is 11 months!

Breast Self-Exams Challenged: A Canadian task force, writing in the Canadian Medical Association Journal says women 40-69 find "too many" lumps that are benign, but cause a lot of worry. They recommend that doctors stop teaching women to do the exam, and base this on ongoing large studies in Russia and China. But in the Journal two Harvard researchers say they may not even apply to American and Canadian women. We will continue to teach self-exam to those who want to know how to do it properly, and we’ll continue to recommend annual mammograms.

Pills for Tick Bites? New York Medical College’s own Dr. Robert Nadelman and colleagues have found a single 200 mg dose of doxycycline (Doryx, others) can prevent 87% of Lyme disease. In an article in the upcoming July 12 New England Journal of Medicine, only 1 of 235 tick bite patients treated within 72 hrs got the Lyme rash. So, should every tick bite be treated? No, in the opinion of Yale’s Dr. Eugene Shapiro. In an editorial, he says only when it’s the tiny nymphal form of the deer tick and only if it’s at least partially full of blood.

In the same NEJM, our old friend Dr. Arthur Weinstein and colleagues report trying 90 days’ antibiotics for previously treated Lyme patients with persistent symptoms; the symptoms did not improve.

The first partial success in transfer of genes to make the missing clotting factor VIII is reported in the June 6 New England Journal of Medicine. Harvard’s Dr. David Roth and colleagues biopsied skin in 6 patients and then "transfected" some of the cells, called fibroblasts, with a piece of DNA containing the code for factor VIII in a plasmid. The engineered cells were grown up and injected into the abdominal fat pad with a laparoscope. Factor levels rose in 4/6 patients, who had decreased bleeding or needed less factor infusion

Cough is one of the most common complaints we hear. In fact, it’s estimated to account for 4% of adult visits to doctors, of 25 million visits a year. The annual cost of treating cough in the U.S. is estimated to exceed $1 billion!

Acute cough is any cough that lasts less than 3 weeks. It’s usually caused by a viral illness, such as a cold. Lots of other things can be responsible:

sinusitis

allergy (post-nasal drip)

asthma

acute bronchitis

pertussis (whooping cough)

More rarely:

pneumonia

congestive heart failure (see April 2001 newsletter)

pulmonary embolus (a clot that travels to lung arteries)

Chronic cough lasts 3 weeks or more. Major causes include:

post-nasal drip (40-50%)

asthma (25-30%)

GERD - GastroEsophageal Reflux Disease - or heartburn (20-25%)

And there are less frequent causes:

chronic bronchitis

                    bronchiectasis (thinning and consolidation of air sacs such as from cystic fibrosis or smoking)

                    post-infectious cough - such as the one that lingers from whooping ("100 day") cough, more common now due to waning immunity from the childhood vaccine.

                    tumors: lung & other cancers

                    medications, such as angio-tensin converting enzyme inhibitors (ACEI’s): captopril (Capoten), enalopril (Vasotec) and others.

Post-Nasal Drip is far and away the most common cause of cough. There are 3 major issues:

                Allergic drip: profuse watery discharge can be seen with seasonal (acute) allergy - and can lead to "choke cough" when lying down. It can also be seen with perennial allergy - which is frequently obscure because there’s no itch, sneeze or runny nose.

                Non-allergic drip can come from chronic extra blood flow in the nose and sinuses; these patients also are more likely to have upper airway and bronchial spasm.

                Chronic sinusitis will also cause cough: such patients will have excess sputum with their cough.

Rare causes include:

                Chronic Interstitial Lung Diseases which are often tough to diagnose.

                Habit (nervous) cough

Asthma is frequently due to allergy, and is often triggered by mouth breathing (which is seen in those who can’t nose breathe). Cough can be the only symptom (cough variant or "hidden" asthma). Post-nasal drip can trigger asthma; but some patients seem susceptible to both.

GERD (Heartburn) is due to acid "leaking" up form the stomach, which is protected from it, into the esophagus, which is not. 10-20% of GERD patients have respiratory symptoms including cough. These occur due to a nerve reflex from the esophagus to the airway or due to "microaspiration" of acid into the lung. Most patients with GERD cough do not have heartburn symptoms!

Diagnosis and Treatment are directed at the cause (or causes!) of the cough, sometimes treating the major causes simultaneously: sprays and antihistamines (and perhaps antibiotics) for the nose, inhalers and other drugs for asthma, allergy avoidance (or allergy shots), and acid blockers for the GERD. If therapy is unsuccessful, other tests, such as X-rays and CT scans, are done.

For Cough History Questionnaire, Please Look at Cough in the Guides Section