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Spring Is In The Air — And So Are The Pollens

Allergy season is here again, evidenced by the waves of patients coming in to see me complaining of sneezing, nasal congestion, chronic cough, and watery, itchy eyes. Most people have accepted the fact that allergies are one the rise, and that it’s a normal part of living life in the 21st century. Numerous clinical studies confirming this remind us of this fact every day.

But it doesn’t have to this way. Listed below are simple tips to help you lessen the severity of your allergy symptoms, or even prevent it altogether. The more tips you follow, the better your results will be. Not all the tips will apply to everyone, so use common sense in choosing which options to choose from.

Also, before you whole heartedly invest your time and money with these allergy prevention tips, it’s a good idea to make sure you’re actually allergic to seasonal pollens. If you’re not sure, consider seeing an allergist to get tested.

10 Tips For An Allergy Free Season

1. Stay indoors during allergy season or high pollution days, minimizing time spent outdoors. Use air conditioning when indoors.

2. Don’t wear shoes indoors. Allergies, dust, molds and dirt can be brought into your living space. (See my article, An Allergist’s Nightmare: The Micro-Poop Theory).

3. Keep pets out of the bedroom. They can track in dirt, dust, and allergens.

4. Wash your hair or take a shower after you come home or before bedtime. Pollens can settle on your head, which rubs off on your pillow, which you then inhale while sleeping.

5. Try to spend more time at the beach, where there are less pollens.

6. Invest in a HEPA filter for your bedroom (and other rooms as well if you can afford it).

7. When traveling, ask for an allergy-free room. Click here to search for allergy-free rooms.

8. Use saline nasal sprays regularly. Saline flushes out pollens and contaminants, and acts as a mild nasal decongestant. A Neti-pot is one variation. Do this once before bedtime and once in the morning.

9. Consider investing in allergy-free bed sheets (if you’re allergic to dust).

10. Follow the 10 Solutions for Better Sleep I’ve mentioned in this month’s newsletter. Good quality sleep can lower your immune system’s overactivity to allergens.

Deciphering Your OTC (Over the Counter) Meds

If you’ve followed the above and are still suffering, here are some helpful hints regarding over the counter (OTC) and prescription medications. For those of you who are more visual, you can get a print out of an OTC chart organized by symptoms by clicking here.

For simple sneezing, watery, itchy eyes and a runny nose, an antihistamine is your best bet. Three of the newer OTC antihistamines are loratadine (Claritin), fexofenadine (Allegra), and ceftirizine (Zyrtec). In general, ceftirizine is the most potent, as well as having the most potential for drowsiness (about 10% chance). In general, the drowsiness effects wears off after a few doses. It probably safer taken at night. Different people have different rates of effectiveness as well as side effects, so you may have to try all three to see which one works the best for you.

If you have any nasal congestion or sinus pressure, taking one of the above medications that includes the letter "D" can help. The "D" stands for decongestant, which is actually a stimulant that constricts your blood vessels. For some people who are sensitive to oral decongestants (usually stimuoation), it’s not a good idea to take them. If you have high blood pressure or an enlarged prostate, decongestants can sometimes worsen these conditions. Diphenhydramine (Benadryl) is an older antihistamine that’s relatively strong, but has a much higher chance that it can make you drowsy. It’s also the main ingredient in many OTC sleep aids.

If the above OTC medications are not effective, then prescription medications are available. There are a number of topical nasal allergy sprays that contain an anti-inflamatory steroid. These nasal sprays are designed not to enter the bloodstream in significant amounts. The more common brand names are Flonase, Nasonex, Veramyst, Rhinocort, and Nasacort. They’re all essentially the same, but different people with have different reactions, whether it’s how well the allergy symptoms are controlled, to what kind of side effects are seen. Irritation or nosebleeds are two of the most common side effects, but overall, most people tolerate these sprays very well. Your choice is usually made by what’s on your prescription plan’s formulary, and the prescribing doctor’s preferences.

These sprays are meant to be used on a regular basis, which prevents allergy attacks from happening. For example, if you know you have severe spring allergies, then you can start using this on a daily basis a few weeks before the season starts and continue on throughout the season.

Aselastine (Astelin) is a topical nasal antihistamine spray that’s good for acute nasal allergy symptoms. Ipratropium (Atrovent) is also a nasal spray that acts by blocking your nasal nervous system’s signal to cause your nose to produce mucous and congestion. It’s more often given for chronic rhinitis or non-allergic rhinitis, where your nose is overly sensitive to weather changes, chemicals, scents or odors.

If you have severe watery, itchy eyes, and if over the counter eye drops don’t help, then olopatadine (Patanol) eye drops are useful. These are antihistamine eye drops. Studies have also shown that regular use of nasal steroid sprays are almost as effective as topical antihistamine eye drops, but in addition, addresses your nasal symptoms.

Oral steroids are sometimes given for severe allergies or life-threatening allergy attacks. These medications are similar to what your body makes when you’re under stress, and side-effects like weight gain and stomach problems occur more commonly with long-term, high-dose use (such as for asthma or rheumatoid arthritis). A convenient way of taking this is found in a Medrol Dose Pack, which is a moderate dose of steroids that tapers down quickly over 6 days.

If your allergy symptoms are very severe, or you suffer for much longer periods than you desire, then a formal allergy evaluation with testing may be a good option. It’s a good idea to know exactly what you’re allergic to. Your allergist can discuss with you various treatment options, from conservative measures like what I already discussed, to immunotherapy (sublingual or traditional shots).

Some Unconventional Allergy Solutions

If you’re interested in natural options, stinging nettle is a well-known herb that has been shown to help with common allergies. Butterbur is another herbal antihistamine. Both can be found in most health food stores.

Needless to say, a healthy diet rich in fruits, vegetables, omega-3 oils (found in fish), and fiber will help your immune system to function more optimally.

Lastly, eating locally produced honey has been suggested to help with allergies. It’s thought that the honey contains the local pollens that can cause your allergy symptoms. Being exposed to small amounts of pollen on a regular basis is similar to what the allergist does through shots. Use honey as a sweetener on a daily basis before the onset of the allergy season.

If you follow some of the conservative steps I’ve outlined earlier, most of you won’t need to take any medications. However, if you feel the need to take something, hopefully this article can guide you towards making the right choices. You should always talk to your doctor before trying new OTC or prescription medications, as there can be interactions with certain prescription medications.

10 Solutions for Better Sleep

 

During my residency, there was a kind of unstated competition, to see who went the longest without sleep, or who worked the most number of hours per week. It was routine practice to go over 140 hours per week on some surgical rotations, and sometimes we had to work through two straight nights, without any sleep. These days are long gone, now with new residency work hour mandates requiring no more than 80 hours per week.

Chronic sleep deprivation is known to significantly increase errors in judgment, focus and memory capacities. You don’t need any studies to prove this, when most of us can attest to this first hand (Read about pregnancy and sleep deprivation in this month’s Ask Dr. Park by clicking here) Yet, sleep is still given low priority and the first thing to be sacrificed when someone is short on time.

The Importance of Sleep

Studies come out daily about the benefits of good, quality sleep, as well as the health consequences of not getting enough good sleep. I can’t emphasize enough how important sleep is, in terms of both quality as well as quantity. I’ll even go as far as to say the you should center your life around good quality sleep.

You may be asking by now, with all of life’s stresses and distractions, how can one sleep better? The answer to this simple. Don’t try to accomplish everything all at once-take it one step at a time.

Take Mini Steps

Below a list of 10 steps you can take to improve the quality of your sleep. To be successful, begin with implementing only one or two strategies at most into your nightly routine. Moreover, do this consistently for 30 days before trying anything else.

Some options need only one action step, whereas others are daily habits. Since habits are not something that’s formed overnight, I emphasize again the importance of implementing one strategy at a time and repeating it over 30 days. If you can master these sleep disciplines, I guarantee you’ll not only sleep better, but also feels better during the day, with much more energy, productivity, and increased quality of life.

                                 The 10 Easy Steps for a “Do It Yourself” Sleep Makeover

1. Try not to eat anything within 3-4 hours of going to bed. There are many good explanations for why this helps you sleep better, but one simple explanation is that any lingering stomach juices can regurgitate up into your throat, causing inflammation and swelling. Since most modern humans are susceptible to intermittent breathing obstruction while sleeping, eating just before bedtime can aggravate this process, causing you to keep waking up.

2. Avoid alcohol close to bedtime. Drinking a nightcap may help you to fall asleep after a stressful day, but because alcohol is a muscle relaxant, it can aggravate obstruction and arousals, worsening your quality of sleep even more. It’s OK to have 1-2 servings of wine or beer with an early dinner.

3. Don’t watch TV, use the computer, or play video games within 1-2 hours of bedtime. Stimulation of the brain and information overload will definitely prevent you from getting a good night’s sleep.

4. Don’t read, eat, watch TV, surf the internet, or talk on the phone while in bed. Leave your bed exclusively for sleep and sex.

5. Set your room temperature slightly cooler than normal. Colder temperatures promote sleep.

6. Avoid eating or drinking anything that’s stimulating close to bedtime. This includes anything caffeinated (coffee, tea, sodas), chocolates, or ginseng. Certain cold medications that contain decongestants can keep you awake.

7. Exercise regularly outdoors in the sunlight. Your eyes need natural bright sunlight to stimulate the sleep-wake cycles. If you can’t exercise in the mornings, make every excuse to go outdoors in the middle of the day.

8. Make your room as dark as possible. Many of the newer LED lights on electronic devices are super bright. Cover them with black electrical tape. Get light-blocking curtains or shades.

9. If your nose is stuffy for any reason, take measures to start breathing through your nose again. If you have a simple cold, or even allergies, nasal saline can act as a mild decongestant. This also works for people who have chronic nasal congestion. A Neti-pot or any other device that vigorously sprays nasal saline into your nose on a regular basis will help you to sleep better.

10. If you snore, or feel tired and unrefreshed no matter how long you sleep, see your doctor and get it taken care of. If your bedpartner snores and it bothers you, get that taken care of as well, so that you can sleep better (click here for a complete list of medical and non medical snoring solutions)

Bonus tip: Learn proper deep breathing techniques as taught in yoga or tai chi. Do it for 5-10 minutes just before bedtime, and especially every few hours during the day for a minute or two. This helps to calm your nervous system, which helps you not only to sleep better, but will also help you to remain calm, focused and more productive in whatever activities you engage in throughout the day. (Click here if you’d like to sign up for a FREE audio download (worth $45) of my live workshop on how to breathe better with Yoga expert, Deborah Quilter)

If you’re thinking that many of those steps are just impossible to implement given your hectic life and work schedule, think again.  If you’re not putting sleep at the top of your list of priorities, it won’t be too long before your body functions will start shutting down making you incapable of doing much of anything.  If it’s deemed risky for medical residents (who are used to being on call) to go without sleep, think how much more risk you’re taking by doing so yourself. Just something for you to sleep on.
 

Q: Can Sleep Deprivation Be Harmful For Pregnancy During Medical Residency?

Q: 
Dear Dr. Park,

I will be starting internship in a few months, and will be doing q4 30 hour call for the entire first year. I am worried about the possible detrimental effects to my health (cardiovascular, metabolic, chronic pro-inflammatory state) from not sleeping AT ALL every 4th night for one year. More importantly, do you know of any studies that have been done with pregnant women and sleep deprivation? If I were to become pregnant sometime during residency, is it dangerous for the baby to be on a 30 hour q4 call cycle? Any insight you could provide would be greatly appreciated!
Sincerely,
D, med student

A:  You bring up an interesting question, in light of the fact that new recommendations were released by the Institute of medicine regarding resident work hours (click here to read.) It sounds like you’ll definitely get more sleep than in years past: One of the recommendations is a 5 hour protected sleep shift during overnight shifts. Gone are the days when residents worked 120 to 140 hours every week. I won’t get into the pros and cons of this debate, but it’s safe to say that any degree of long-term sleep deprivation is not good for anyone, male or female. I’m not aware of any studies of intentional sleep deprivation and pregnancy, for obvious reasons.

Depending on the type of residency, some programs or specialties are more conducive to pregnancies than others. Internship is probably not a good time to have a baby, but in the latter years of residency, many women do go through pregnancies with creative scheduling and cooperation with other residents.

Soundbite Medicine

During lunch the other day in my hospital’s cafeteria, I mentioned to my colleagues that in my recent poll of multiple sclerosis (MS) patients, the vast majority seemed to have symptoms of obstructive sleep apnea or upper airway resistance syndrome: Severe parental snoring, cold hands or feet, never being able to sleep on their backs, and frequent trips to the bathroom at night. Immediately they reflexively dismissed a possible association and attributed the symptoms to neurologic reasons. 

The same situation occurs with patients as well, especially if they already have one (test) confirmed diagnosis. Any other or unusual signs or symptoms are attributed to their original medical diagnosis and a search for other possible causes is never perused. 

 

Many people will develop obstructive sleep apnea as they age. It’s estimated that about 1/4 of all men and 1/10th of all women have obstructive sleep apnea in this country. Eighty to ninety percent are thought not to be diagnosed. After age 60, a majority of people probably have some degree of sleep apnea. If that person already has another diagnosis (such as MS), then symptoms such as fatigue, insomnia, and headaches will automatically be blamed on MS, no matter how unusual. 

 

In the classic book, Influence: The Science of Persuasion, by Dr. Robert Cialdini, he brings up the concept of commitment and consistency. Once you’re committed to something, how you behave and think has to be consistent with your original commitment. The same process applies with medical diagnoses, to a certain degree.

 

In this era of information overload for both patients and physicians, it’s no wonder that alternative or additional possible explanations are not looked into once you already have another diagnosis. Not only are you bringing into doubt the original diagnosis, but it also just takes too much time and energy.

Provent: A New Way of Treating Sleep Apnea

I’ve been waiting a long time for Provent to be available to the general public. I saw a pilot study about this device in one of my sleep medicine journals 6 months ago, and was intrigued by how this device works. Essentially, it’s two nasal plugs that attach to your nostrils using adhesives. During inspiration, you can breathe normally, but during exhalation, it limits the amount of air that can pass through the device. The theory is that when there’s more resistance when you exhale, at the end of exhalation, a slight positive pressure effect is created in the throat, keeping your relaxed muscles more open.

 

Looking at the raw data, it does seem to make a difference, but it doesn’t really "cure" the problem. On average, it lowered the AHI by about 50%. In some people, the results were much better, and in others, it was actually worse. 

 

Since it’s so new, insurance doesn’t cover it. A 30 day supply is about $135, but for a limited time, they’re offering a 50% discount. It must be ordered through a prescribing physician and will be mailed to your house.

 

I got some samples and will offer it to select patients to test it out. I’ll keep you posted on the results.

EMRs to the Rescue

On a routine office visit, a patient asked why, despite our office being technologically advanced in many ways, doesn’t use an electronic medical record (EMR). Good question. 

 

Being somewhat of a gadget and computer geek, I’ve dabbled with EMRs for over 20 years. More recently, in private practice, I’ve looked seriously into a few dozen options, but nothing seemed attractive, and the features and functionality of current EMRs didn’t justify investing thousands, or even tens of thousands of dollars, not to mention probably dozens, if not hundreds of hours of time learning the new system, and years before we get a return on investment. Plus, since these programs are designed mainly for primary care providers, I’d only be using about 10% of the features that I’m paying for. Not one colleague that I’ve spoken to is ecstatic about their experience with EMRs. 

 

Another major reason is that expect for being able to go paperless, and becoming more efficient with patient information in-house, with the lack of a national standard where doctors and hospitals can communicate with each other (like banks), there won’t be any advantage to going electronic.

 

One common buzzword in the EMR field is "point-of-care" documentation. This means that you’re inputing information while you’re interviewing the patient, saving time. If you’re taking copious notes while interviewing someone, notice that more than half your time is spent jotting down notes, with your eyes on your notebook (or tablet PC). You’re not focused on the person you’re interviewing. This is what I found so frustrating. I’m getting the facts down, but I’m missing the message and story that the patient is telling me. 

 

There’s a study that’s often quoted that looked at the relative impact of facial expressions and spoken words. What the study author concluded was that only 7% of real communications happens with words, another 38% through vocal tone and pitch, and the remaining 55% is through facial expressions and body language. What this study implies is that without seeing or hearing any nonverbal cues, it’s easier to misunderstand what the person is trying to convey. 

 

When I tried to take notes while seeing a patient, I found that I wasn’t able to determine the true wants and needs of the patient, despite "hearing" their main problems. There was ultimately a disconnect between what I perceived and what the patient ultimately wanted. There’s always another story behind the obvious reasons why they come to me. When I went back to giving my undivided attention to the patient without being distracted, patient encounters were much more rewarding and satisfying. Unfortunately, with more EMRs being used and doctors’ focus on the computer tablet rather than the patient, the doctor-patient relationship will deteriorate even more. 

Can Sleepwalking Be Cured With CPAP?

I came across this older article by Dr. Guilleminault, published in 2005, which showed that most sleepwalkers have sleep-breathing problems. All sleepwalkers who were compliant with CPAP were cured. Non-compliant patients did not improve. Those that underwent successful surgery also had complete resolution of their sleepwalking. Another study that supports my sleep-breathing paradigm.

Have You Checked Your GABA Levels Lately?

GABA is a neurotransmitter that shows up once in a while that’s linked to a number of various medical and psychiatric disorders. One of the more recent studies was published in the 11/08 issue of Sleep (a summary can be seen here). Chronic insomniacs were found to have 30% less GABA activity in their brains. This finding could be misinterpreted to imply that because of low GABA levels, people can have insomnia. Let me explain.

GABA is one of numerous neurotransmitters in the brain that sends messages from one part of the brain to another. High GABA levels are associated with a calming, relaxing effect, whereas low levels are associated with anxiety and stress. Conventional wisdom says that if this is true, let’s increase GABA levels with supplements. The same can be said for various other neurotransmitters, hormones or vitamins that we use as supplements. In many cases, replacing what’s missing can certainly help, but you’re still not addressing what’s actually causing the lowering of these substances. 

If you look in the research literature (and on the internet), you’ll see many studies linking stress and low GABA levels. Another study showed that practicing yoga increases GABA. This is why any method or discipline that is calming or relaxing can raise your GABA levels. So it’s not a lack of GABA that gives you insomnia, per se, but there’s something else that is causing insomnia and low GABA levels.

This is a problem that we see with almost every area of modern medicine, where we’re great at finding associations, but not very good at solving the root of the problem. 

The common thread with all these studies goes back to stress. Yes, we have many different types of stress in our lives that can lead to insomnia (financial, work, family, poor diets, toxins, etc.), but what I’m suggesting is the possibility that due to our unique upper airway anatomy, all of us are somewhat susceptible to physiologic stress due to an inability to breathe properly at night. External stresses (psychologic, emotional and physical) can also aggravate this internal, physiologic stress.

The extreme end of this spectrum that I describe is called obstructive sleep apnea. But even if you’re "normal," having a narrowed upper airway anatomy can predispose you to microbstructions and arousals, leading to a physiologic state of hyperarousal. These people won’t officially meet the criteria for sleep apnea. Many of these people will also not be able to sleep on their backs, since that’s when the tongue falls back the most, due to gravity.

If you measure neurotransmitter levels in these patients, of course they’ll have abnormalities. This is why chronic insomnia is linked later in life to so many other medical conditions such as depression, diabetes, hypertension, and heart disease. Notice that these are all complications of obstructive sleep apnea. 

This is not to say that we should stop everything we do to treat insomnia. Cognitive Behavioral Therapy (CBT) is a great way to calm the mind and develop good sleep habits. It’s even been found to work better than sleeping pills. My only concern is what happens to these people many decades later, even if their insomnia is initially cured.

Does Sleep Apnea Cause Kidney Disease?

Kidney disease is not something that I’ve written about so far, but a recent study published in the March issue of Chest revealed that having chronic kidney disease is associated with a much higher chance of having obstructive sleep apnea. Knowing what we know about all the various physiologic effects caused by sleep apnea, this new finding is not surprising.

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