Hay Fever and Seasonal Allergies

Hay Fever and Seasonal Allergies

Thomas Falasca, DO FACA FACPM

February 2, 2023

Hay fever, or seasonal allergic rhinitis has been estimated to affect 40 to 60 million Americans. ^a However, exposure to hay is not necessary to cause the symptoms of “hay fever” and “hay fever” typically does not produce a fever.

So, What Is Hay Fever?

Hay fever, or, more correctly, seasonal allergic rhinitis, is an allergic response to environmental substances that peak periodically and cause symptoms mostly related to the eyes, nose, and throat.

In spring, the environmental allergens producing the symptoms are typically the pollens from trees and grasses. In fall, the environmental allergens producing the symptoms are typically weed pollens and outdoor molds.

Symptoms of Hay Fever/Seasonal Allergic Rhinitis

The most common symptoms are 1

            Runny nose from excess production of mucus

            Stuffy nose from swelling of the nasal mucous membranes

            Sneezing from irritation of the nasal mucous membranes

            Itchy, red, and watery eyes from irritation of the ocular mucous membranes

            Fatigue as a generalized effect and from impaired breathing and sleep

Less common symptoms are

            Decreased decision-making capability

            Irritability in children

            Poor sleep

            Cough

Why Not a Cold?

There are many different cold viruses and individual ones tend to predominate at different times of year. Consequently, a cold may occur in the spring and target the nose and throat. However, allergies last while the allergen is in the air, which is typically somewhat longer than the cold lasts. Also, the seasonal allergens tend to produce more itching of the nose and eyes than a typical cold. ²

Allergy Capitals ^{3, 4}

Peripheral Cold-related Injury

Peripheral Cold-related Injury

Thomas Falasca, DO FACA FACPM

December 29, 2022

The danger of peripheral cold-related injuries is upon us. Although it is usual to think only of frostbite, peripheral cold-related injuries also include frostnip, chilblain, and trench foot.¹

Why Peripheral?

These cold-related injuries are peripheral because they localize to specific body parts as opposed to hypothermia which affects the entire body. Nevertheless, the regional effect does not diminish their importance because 1) they can result in amputation of the affected part, 2) their complications can result in a threat to life, and 3) the high visibility of the peripheral injury can detract attention from a co-existing life-threatening systemic hypothermia.

Frostnip

Frostnip is the mildest form of cold injury. It affects the ears, cheeks, fingers, toes, or nose and occurs when the small blood vessels of these areas contract to conserve heat in the body. The affected area may sting, burn, and feel cold. Burning may become more intense as the area rewarms. Tissues do not freeze and the skin remains soft and pliable. Frostnip may occur in skiers experiencing fast-moving, cold air.

Frostnip is reversible with no damage. It responds to gently rewarming the skin by holding the hands in the armpits or gently using warm water. Do not use hot water or heating pads as they may burn somewhat numb skin.

The main problem in frostnip is determining that it is not the much more serious frostbite. Signs of this are 1) the skin turning whiter or paler, 2) losing the sensation of cold, 3) skin becoming less soft and pliable, and 4) escalating pain. More on frostbite later. ²

Chilblains

Chilblains is more severe than frostnip. It typically occurs on the fingers, toes, and ears.

Chilblains consists of tender or itchy or burning bumps often with a red or purplish discoloration that turns white with fingertip pressure. It follows exposure to damp and cold, but non-freezing conditions; and, thus, it is more common in late winter and early spring. Chilblains lasts at least 24 hours but typically resolves spontaneously in 1-3 weeks.

While frostnip is caused by the contraction of blood vessels, chilblains is caused by an inflammation of blood vessels.

Chilblains is more common in young and middle-aged adults, especially females. Predisposing conditions are smoking, outdoor exposure, and disorders of the bone marrow and connective tissue. There seems to be a familial tendency toward chilblains.^{3, 4} 

Trench Foot

Trench foot consists of tingling pain and itching, progressing to complete numbness and leg cramps. The skin is initially red, progressing to grey and finally blue. The soles of the feet are quite tender to palpation.

Trench foot is associated with prolonged exposure to wetness and cold but non-freezing conditions especially with dependency and immobilization of lower extremities confined by tight footwear. As the name implies, it has been often seen in soldiers and shipwreck survivors. Trench foot is a disease of the nerves and blood vessels of the feet. Recovery can take months and may be complicated by bacterial or fungal infection along with moist gangrene.⁵

Frostbite

In distinction to all the above-mentioned diseases, which are associated with non-freezing cold, frostbite is associated with freezing cold.

Frostbite results from the freezing and crystalizing of fluids outside and sometimes inside the cells. The result is dehydration within the cells, cell membrane damage, and obstruction of the smallest blood vessels causing interruption of blood flow. Further damage can result from inflammation when blood flow is reestablished.

Areas most frequently involved are hands, feet, nose, and ears.

Frostbite occurs in both superficial and deep forms. Superficial frostbite involves the skin and tissues just under it. The area is numb, cold, white, and waxy. With thawing, the area becomes painful and red, then swelling ensues along with blisters fill with clear fluid.

Deep frostbite involves muscles, tendons, nerves, blood vessels, and even bone. The area is hard, wood-like and numb, with a grey color that may persist even after warming. Any blisters are filed with bloody fluid. It is often difficult to assess the depth of tissue involvement. If gangrene ensues, it is of the dry, mummified type rather than the moist gangrene of trench foot.

Frostbite risk factors are high altitude, severe wind chill, wet skin, previous cold injury, extremes of age, homelessness, and altered mental state from trauma, ethanol or drug use, or psychiatric illness.⁶

Prevention of Peripheral Cold-related Injury

Many events of peripheral cold-related injury can be prevented by following these simple steps.

•      Wear several layers of light, loose clothing to trap insulating air.
•      Use mittens instead of gloves because they reduce exposed surface area.
•      Wear at least two pair of socks.
•      Cover the face and head.
•      Avoid tight clothing.
•       Avoid getting clothing wet.
•      Avoid smoking and alcohol.
•      Avoid warming and then refreezing affected areas.

Conclusion

Cold-related injuries warrant serious attention and caution. They can result in permanent disability or even loss of a limb. Systemic hypothermia and complications such as infection may eventuate in death. Don’t become a victim. Be safe and comfortable in any cold situation.

 Thomas Falasca, DO

Sources

¹ Peters, B. (2021, October 16). Cold injuries. Practice Essentials, Overview, Systemic Hypothermia. Retrieved December 30, 2022, from https://emedicine.medscape.com/article/1278523-overview 

² Gotter, A. (2018, March 20). Frostnip: Definition, vs. Frostbite, pictures, and Recovery Time. Healthline. Retrieved December 30, 2022, from https://www.healthline.com/health/frostnip 

³ Chilblains. DermNet. (n.d.). Retrieved December 30, 2022, from https://dermnetnz.org/topics/chilblains 

⁴ Chilblains (Pernio): What is it, symptoms, causes & treatment. Cleveland Clinic. (n.d.). Retrieved December 30, 2022, from https://my.clevelandclinic.org/health/diseases/21817-chilblains-pernio 

⁵ Bush, J., Lofgran, T., & Watson, S. (2022, August 8). National Center for Biotechnology Information. Retrieved December 30, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK482364/ 

⁶ Zonnoor, B. (2021, December 15). Frostbite. Background, Pathophysiology, Etiology. Retrieved December 30, 2022, from https://emedicine.medscape.com/article/926249 

Infection-Safe Holiday Travel

Infection-Safe Holiday Travel

Thomas Falasca, DO FACA FACPM

Infection and Travel

Recently, we all have become highly aware of the infection risks that constantly surround us. Dealing with this has frequently involved restricting travel. But restrictions are difficult to observe long-term, especially when they keep us from friends and family over the holidays. In the upcoming holidays, we will be traveling more than we have in the last few years. Accordingly, here are some tips on maintaining safety from infection during holiday travel.

Riding in a Car

The safest way to travel in a car is to travel alone, as the infection risk of auto travel increases proportionally to the number of occupants in the vehicle. Nevertheless, solo travel is often not practical.

Engineers have examined the case in which a vehicle has two occupants, a driver and a rear passenger seated diagonally from the driver at the greatest possible distance in the vehicle. The engineers did computer simulations of air flow in the vehicle to examine the effect of various open-window configurations.

They examined simulations of a Toyota Prius traveling at less than 30 mph and of more than 30 mph. In all cases, ventilation was best when all windows were open. However, at greater than 30 mph, with less than four open windows, some results were a surprise.

The intuitive best configuration, with both the driver and diagonal rear seat passenger each having their windows open, was a disappointment. Instead, at these speeds, Bernoulli effects promote the inflow of air through an open rear window and the outflow through a diagonally opposed open front window.

The safest configuration for the passenger was to have the driver’s side rear window and the passenger side front window open. The safest configuration for the driver was to have the driver’s side rear window, the passenger side rear window, and the passenger side front window open.¹

Observing such window configurations continuously over a long period of time might be impractical in some types of weather. In these cases, opening the windows in these configurations confers some benefit even if done for ten seconds every 5-10 minutes.^{2, 5}

Car Cabin Air Recirculation

So, it seems that if increased ventilation is a good idea, then decreased ventilation, or cabin air recirculation is a bad idea. Certainly, this is true. Indeed, recirculation may be beneficial in protecting from outside dust or dirt and may enhance the effect of heating or air conditioning; but, when infectious agents in the cabin air are concerned, recirculation only concentrates these agents.³

Car Rental

Although car rental agencies may wipe down car surfaces between customers, and, although delayed turn-around time between customers may reduce the viability of infectious agents, it is never a bad idea to use disinfecting wipes on high-touch surfaces of any rental car.⁴

Of course, hands may become contaminated, often when the person is unaware. This is the rationale for avoiding touching the face thereby transferring infectious agents to the mucous membranes of the eyes, nose, and mouth, where they may more easily enter the body.⁴

It is also a good idea for each person in the vehicle to load their own luggage.

Also, avoid touching money or receipts. Make as many payments as possible online or with contactless apps or cards.⁸

Finally, do not let your guard down ... ever. A major risk in car rental devolves from the renter’s interactions with rental employees and other customers.⁴

In the Airport

Accept only beverages arriving in containers sealed at the factory. Then, do not defeat the purpose by adding ice from a local source.

If possible, minimize the amount of time face mask is down by drinking liquids through a straw passed under the mask.

When possible, consume only the snacks you have brought from home.⁸

Do not place excessive confidence in the screening afforded by airport temperature checks, as some studies suggest that these have a detection rate for COVID of only about 45%.⁷

On a Plane

If airplane blankets or pillows do not come to you in a package, they may well have been used previously and not processed.⁶

Some studies suggest that the safest places on an aircraft are toward the rear and in window seats.⁷

The High Efficiency Particulate Air (HEPA) Filters in most modern aircraft remove over 99.97% of particles, including those of virus size. Further, at each circulation, 50% of the air exchanges for outside air so that the entire cabin air replaces every 2-3 minutes.

Additionally, the air inlets and outlets line the entire cabin. The inlets are along the top of the cabin, not just at the over-seat air nozzles. The air outlets are along the sides of the floor. You can further increase your safety by adjusting your overhead nozzle to maximum and pointing it directly at your face to maintain air flow going away from you.

All this air flow dynamics means that exposure from fellow passe

ngers diminishes rapidly when other passengers are more than two seats   away.^{7, 10} But it is important not to defeat this safety factor.

Do not congregate around lavatories, sit in high traffic areas, or walk unnecessarily around the cabin. On long flights, make every effort to exercise in place.⁹

For boarding and disembarking, remain seated until the gate agent calls your boarding group or until disembarking reaches your row. There is obvious excitement about departing or arriving, but, really, you gain nothing by crowding around the entry to the jetway on boarding. Disembarking is even worse, whenever passengers squeeze into narrow aisles and struggle with overhead luggage when disembarking is not imminent.

Conclusion

So, unless we ourselves, those we visit, or those to whom we return are sick or immune compromised, it should not be necessary to spend another holiday at home. And, although it may be difficult to implement all these measures all the time, we can certainly do much to increase infection safety during holiday travel.

Thomas Falasca, DO

References

Should We Worry about Monkeypox?

Should We Worry about Monkeypox?

What is Monkeypox?

Monkeypox is a viral disease, usually self-limiting and resolving in 2-4 weeks. It is similar to smallpox but is less infectious and much less lethal¹. The incubation period is 4-20 days.

Like smallpox and chickenpox, the disease demonstrates a characteristic rash followed by eruptions.

The eruptions begin as macular (flat), which then become papular (raised), then vesicular (clear fluid blisters), and then pustular (pus filled). Finally, they scab and the crusts fall off. More reliably, the monkeypox rash differs from smallpox in that the monkeypox rash is accompanied by swollen lymph nodes in the neck and occasionally in the groin. These swollen nodes may sometimes measure several centimeters. Less reliably, the monkeypox rash spreads from the face and upper trunk to the rest of the body while the smallpox rash spreads from the trunk outward.

Other symptoms include fever, usually the first symptom, then chills, sweats, muscle aches, weakness, sore throat, cough, and shortness of breath.

Lastly, the evidence does not seem to suggest that monkeypox is a specifically sexually transmitted infection (STI).

Why “Monkey” pox

The name “monkeypox” is misleading since the connection with monkeys is minimal. Although first identified in laboratory monkeys in 1958¹, the disease seems endemic to rodents of central Africa and western Africa.

In 2003 an animal distributor transported prairie dogs, along with rodents from Ghana. The then-infected but pre-symptomatic prairie dogs spread the disease in the prairie dog population and a human outbreak occurred in the midwestern United States among those exposed to pet prairie dogs.

Transmission

Initial transmission from animals to humans seems to have occurred by respiratory transmission or by direct contact with skin or mucous membranes. Another possible route is by consumption of wild animals, “bush meat,” which is often undercooked.

Secondary transmission from human to human occurs by the respiratory route and by direct contact with skin or mucous membranes. Patients are considered infectious until the last scabs have fallen off.

Complications

The most common complication is pitted scars. However, there is also bronchopneumonia, blindness from corneal ulceration, septicemia, and encephalitis.

Lethality

Monkeypox is far less lethal than smallpox. Monkey pox lethality in Africa seems to have been at 1-10%, with more of these occurring in children and youth. On the other hand, the fatality rate from untreated smallpox is estimated to be 30%.²

Prevention and Treatment

Present data suggests that prior smallpox vaccination confers 85% immunity from monkeypox and that when infection does occur, it is milder. In fact, the Centers for Disease Control and Prevention (CDC) recommends smallpox vaccination even after exposure, ideally within 4 days, but also up to 2 weeks after exposure to a diseased animal or confirmed human case. The more recent discontinuation of routine smallpox vaccination may have contributed to the disproportionate frequency and severity of monkeypox in younger people.

In addition to the original smallpox vaccine, discontinued in the 1980s, and its successors, the Federal Drug Administration (FDA), in September 2019, approved a combined smallpox/monkeypox vaccine.

Finally, some antiviral drugs have shown evidence of effectiveness in the lab and in animal studies, but their effectiveness is still undocumented in human studies.

Social Implications

First, the World Health Organization (WHO) announced that it would rename monkeypox due to concerns that the name is “discriminatory and stigmatizing” because of the prevailing perception that the disease is endemic among people in some African countries. However, nearly all monkeypox outbreaks in Africa prior to 2022 have resulted from animal transmission to humans. Additionally, the Foreign Press Association of Africa has urged the global media to stop using images of black people in articles on the European outbreak.³ Finally, as of this writing, WHO has not yet determined a new name for monkeypox.

Second, several early European cases linked to a rave event in Spain and another in Belgium seem to have inspired a perception that monkeypox is a sexually transmitted infection (STI) among gay or bisexual men. However, the disease is, in fact, spread by physical contact, sexual or otherwise, with the skin eruptions of infected people.⁴

There sems to be nothing intrinsic to the monkeypox virus that would increase a proclivity for the gay or bisexual male population.

The false perception that monkeypox is an STI restricted to a circumscribed population can have both public health and clinical consequences. Regarding public health, the greater public outside the circumscribed population, feeling false security, may fail in their obligations to control the infection. Regarding the clinical arena, clinicians influenced by the false perception may be more alert to the diagnosis of monkeypox in the circumscribed population than in the greater public and so diagnose it more, resulting in a misperception becoming a self-fulfilling prophesy that narrows appropriate public health response.⁵

Monkeypox vs COVID-19 – The Good and the Bad

The appearance of monkeypox just now certainly prompts a comparison with COVID-19. Of course, comparisons must be tentative, as scientific conclusions evolve in accordance with the evolution of the evidence.

The Bad: Definitely troublesome is the fact that human-to-human spread of monkeypox has occurred in diverse locations almost simultaneously. This may result from global travel combined with a relatively long incubation period. Nevertheless, the phenomenon warrants caution.

The Good: Monkeypox seems less transmissible than COVID, with COVID spread primarily via the respiratory route and monkeypox spread primarily via direct contact.

Our experience with corona viruses spanned a few decades and with COVID-19 was nonexistent. On the other hand, our experience with pox viruses dates from the late 1700s, and with monkeypox specifically goes back 60 years.

The high transmissibility and difficulty in identifying mild cases of COVID made contact tracing difficult. However, the lower transmissibility and characteristic pox in even milder cases of monkeypox renders contact tracing easier and more effective.

Finally, in the darkest days of COVID, a vaccine was a vision. On the contrary, with monkeypox, a vaccine, and extensive experience with it, already exists.

Conclusion

We certainly do not need another epidemic. Although, currently cases are few, it is disturbing that human-to-human transmission has occurred at disparate places almost simultaneously. Additionally, scientific opinion evolves as the evidence upon which it is based develops; and this thought certainly inspires restraint in prediction.

However, we are cautiously optimistic about monkeypox not being a replay of our COVID nightmare. Monkeypox seems less transmissible, is more amenable to contact tracing, is much more familiar to us, and comes with a vaccine with which we already have extensive experience. We are in a much better position now than we were in January 2020!

Thomas Falasca, DO

References

¹ Graham, M. B. (2022, June 16). Monkeypox. eMedicine Medscape. Retrieved June 26, 2022, from https://emedicine.medscape.com/article/1134714

² Hussain, A. N. (2020, July 28). Smallpox Updated: Jul 28, 2020. Author: Aneela Naureen Hussain, MD, MBBS, FAAFM; Chief Editor: John L Brusch. eMedicine Medscape. Retrieved June 26, 2022, from https://emedicine.medscape.com/article/237229 

³ Crist, Carolyn. (2022, June 15). WHO to rename monkeypox due to stigma concerns. eMedicine Medscape. Retrieved June 26, 2022, from https///www.medscape.com/viewarticle/975681 

⁴ Heymann, D. (2022, May 24). Monkeypox spread likely "amplified" by sex at 2 raves in Europe, leading WHO adviser says. cbsnews.com. Retrieved June 26, 2022, from https://www.cbsnews.com/news/monkeypox-sex-raves-europe-world-health-organization/ 

⁵ Daskalakis, D., Mena, L., & McClung, P. (2022, June 16). Monkeypox: Avoiding the Mistakes of Past Infectious Disease Epidemics. ACPJournals.org. Retrieved June 26, 2022, from https://doi.org/10.7326/M22-1748