Durban-based journalist, Adrian Rorvik, has suffered from knee problems for most of his life. “I was told by doctors that my knee cartilage stopped developing at ‘fish’ stage in the womb,” he says. Diagnosed with a degenerative condition and discoid meniscus, he has since the age of 24 undergone three arthroscopy surgeries, two to his left knee and one to his right. The last took place 10 years ago when Rorvik was 38; the surgeon said he had never seen knees in such bad shape in someone of that age.

Anatomy

Cartilage is the body’s shock-absorber, a connective tissue that cushions the ends of bones in the joints. When it is damaged and the synovial fluid that lubricates joints is reduced, bone-ends begin to rub together and thereby cause friction, pain and stiffness. This is sometimes caused by a specific condition, or it may simply be the result of wear and tear over the years leading to cartilage thinning. Millions of people around the world live with joint-pain and there is currently no medical treatment that can cure the condition.

Treatment

Typical allopathic treatment is designed to alleviate symptoms and manage the pain: it includes non-steroidal anti-inflammatory drugs (NSAID), COX-2 inhibitors and analgesics. While these do provide pain relief they can, with regular chronic use, cause serious side-effects such as kidney and liver damage plus cardiovascular and intestinal problems. They must therefore be used with caution.

Supplements

There is a safer option in the form of two nutritional supplements – glucosamine and chondroitin sulphate. Among the most popular dietary supplements in the United States, glucosamine and chondroitin are naturally occurring substances found in the body’s connective tissue. These two substances are molecules that make up the type of cartilage found in joints, and the theory is that oral consumption of glucosamine and chondroitin may assist in managing cartilage-related problems.

After Rorvik’s last arthroscopy, his surgeon recommended a glucosamine and chondroitin combination supplement as he himself had found them beneficial for his own joint problems. Ten years on, Rorvik says his knees are “holding up well” and he would not consider giving up his nutritional supplements. “In the past I stopped taking them on a few occasions,” he reveals, “but within a couple of days my knees felt less lubricated and they began to creak and grind and become painful.”

The Dynamic Duo
Glucosamine
A basic building-block of cartilage, glucosamine sulphate is naturally synthesised in the human body. It is an amino sugar protein – a precursor to the molecule glycosaminoglycan – that is believed to help form, develop, repair, renew and lubricate cartilage. Naturally present in the shells of crustaceans, animal bones and bone marrow, it is usually extracted from crab, lobster or shrimp shells, but can also be found in some fungi such as Aspergillus niger.

Chondroitin
Chondroitin sulfate is also a major component of connective tissue. A naturally occurring substance formed of sugar-chains, chondroitin is believed to help the body maintain fluid and flexibility in the joints. It is a complex carbohydrate that aids cartilage in the process of retaining water and maintaining resilience plus elasticity. The theory is that chondroitin has an anti-inflammatory action that may help alleviate painful joint swelling. Most chondroitin sulfate used in supplements is extracted from animal cartilage and can be of shark, porcine or bovine origin – for example shark cartilage, cow trachea and pig ear and nose.

Glucosamine and chondroitin work together synergistically and are reputed to help alleviate joint pain and may even inhibit joint cartilage degeneration. Although they may not work for everyone, millions of people around the world – from surgeons and housewives to athletes and the elderly – have found that they can offer relief from joint-pain.

Research Controversy

Much of the research conducted into these two nutritional supplements is controversial, contradictory and inconclusive. Some study results are positive, while others claim that glucosamine and chondroitin function no better in joint-pain relief than a placebo.

A 2004 article entitled “Alternative Therapies: glucosamine and chondroitin” published by the Arthritis Foundation revealed that some studies established that certain patients with mild to moderate osteoarthritis who take the supplements may have pain relief at a similar level to patients who take NSAID.

One of the most publicised studies – the Glucosamine/chondroitin Arthritis Intervention Trial (GAIT) – was a multi-million dollar, randomised, placebo-controlled exercise conducted at several sites across the United States and funded by two components of the National Institutes of Health, the National Centre for Complementary and Alternative Medicine (NCCAM) and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. The trial set out to study the effects of chondroitin sulfate, glucosamine hydrochloride, chondroitin/glucosamine in combination and celecoxib as a treatment for knee-pain among 1 583 people suffering from osteoarthritis of the knee. The subjects were divided into two groups – those enduring mild pain and those enduring moderate to severe pain. The University of Utah School of Medicine coordinated the study which was conducted at 16 rheumatology research centres across the United States: it was the first large-scale clinical trial of the supplements and the first study to be funded by the American federal government and not private industry.

The results, published on 22 February 2006 in the highly respected New England Journal of Medicine, showed that the combination of glucosamine and chondroitin sulfate did not provide significant relief from osteoarthritis pain among all participants. A smaller subgroup of study participants with moderate-to-severe pain did however report significant relief with use of the combined supplements.

In November 2005 on the Natural Health News website, editor Mike Adams wrote that research confirming the effectiveness of glucosamine and chondroitin had been presented at the Annual Scientific Meeting of the American College of Rheumatology in San Diego.

On the NCCAM website, the two-year GAIT study results from June 2010 states: “New data from a long-term study of the dietary supplements glucosamine and chondroitin for knee osteoarthritis pain reveal that patients who took the supplements (alone or in combination) had outcomes similar to those experienced by patients who took celecoxib or placebo pills. Previous studies have examined the effects of glucosamine and chondroitin on pain associated with osteoarthritis of the knee over a short duration – 24 weeks. This study, published in the Annals of Rheumatic Diseases, is the first to assess the safety and effectiveness of the supplements over two years.”

While more scientific research is obviously necessary, glucosamine and chondroitin nutritional supplements could be considered a viable treatment for knee-pain in certain people. In the United States, glucosamine is not approved by the Food and Drug Administration for medical use in humans, but is sold as a dietary supplement, while in Europe, glucosamine is approved as a medical drug and sold in the form of glucosamine sulfate.

Dose

The typical daily therapeutic dose is 1500 mg of glucosamine and 1200 mg of chondroitin – divided into three doses. The combined substances are available in numerous brands, but quality and content may vary between brands so it is always best to choose high quality, GMP-compliant, reputable products. Always use chondroitin and glucosamine as directed on the package or by a healthcare provider. Never use higher quantities than recommended on the label or by a healthcare provider.

Side-Effects

Glucosamine and chondroitin sulfate nutritional supplements appear to be quite safe and have a low incidence of side-effects. To date, no significant side- effects have been reported, although long-term studies on the safety of glucosamine and chondroitin sulfate supplements still need to be conducted. The most common side-effects that do occur are usually minor and include upset stomach, nausea, heartburn, constipation, diarrhoea, headache and rash: most of these can however be reduced if the supplements are taken with food.

Contraindications

While generally considered safe, it is advisable for certain people to consult with a doctor, pharmacist or natural healthcare practitioner before taking glucosamine and chondroitin. Most glucosamine is derived from shellfish, so people with any seafood allergies should check with a healthcare practitioner – even though the fish allergen is usually in the flesh and not the shell, so it may be safe for those with shellfish allergies. Diabetics, people on blood-thinning medication such as warfarin, haemophiliacs, the obese, those with any drug allergies, children and pregnant or lactating women should only take these supplements under medical supervision. Do not substitute chondroitin and glucosamine for prescription medications unless this has been approved by your physician.

Although women are more likely to develop osteoporosis, men can become osteoporotic as well. A good foundation of sufficient calcium during childhood will result in adequate prevention in later years. Statistics released by various world authorities state that women have a one in three chance of developing osteoporosis in later life, which makes it even more important that bone health should be considered with preventative measures taken throughout.

Osteoporosis

Osteoporosis is a disease of the skeletal system which means that the bone is not dense enough and appears ‘porous’, making the entire skeleton weaker and more prone to fractures.  The high risk areas are the wrists, the hips and the spine.

Causes of Osteoporosis

Most people would have achieved most of their skeletal mass by age 20, but a large decline in this density occurs in older adults and this can lead to osteoporosis.

Women, especially from menopause onwards, are at an increased risk of developing osteoporosis which is why it is important for girls during their teenage growth spurt to ensure they achieve peak bone mass. This could reduce their risk later in life, as inadequate calcium intake and a lack of physical activity can prevent optimal skeletal development, hence a calcium rich diet and calcium supplementation should be considered from a young age.

Other risks for developing osteoporosis include Caucasians, post-menopausal women, older adults, a petite body structure, certain medications, a diet low in calcium and physical inactivity.

Bones are continuously being broken down and renewed by the body’s metabolism,  for younger people the development of new bone is faster than the breaking down of old bone which ensures optimal bone mass. This happens until around 30-35 years, after which it slows down. The higher the bone density at this time, the less likelihood of developing osteoporosis, but at any age, bone density can be increased or at least remain fairly constant with good diet, supplementation and exercise. There are no symptoms or early warning systems to alert a person to this potential disease. Osteoporosis can have devastating consequences as one grows older, so people should be made aware of the importance of good bone health.

Treatment and Prevention

Once a person has been diagnosed with osteoporosis, the healthcare professional should decide on the best course of action and treatment. A person suffering from this disorder can also aid in their own recovery by following their treatment regime as well as following a healthier, calcium rich diet and adding exercise. Calcium can boost the effects of the osteoporosis drugs that are taken to reduce bone loss, such as estrogens and bisphosphonates.

Diet

Fortunately a lot of foods in the supermarkets are now fortified with extra calcium and vitamins. The knowledge of how to read the labels will help a person choose better and more calcium rich foods.

Milk, eggs, cheese, salmon, green vegetables are all calcium rich foods. Tinned sardines and salmon are a good source of calcium as well as having many other benefits.

To read and understand the labels on food packaging, it is necessary to know that the RDA (recommended daily allowance) is an average of how much calcium would be needed by an adult daily, which in South Africa is 1000mg. If the labels states 20% of RDA per 100g serving, it will contain 200mg of the daily amount of calcium needed. From this it would be fairly simple to ensure adequate intake from the various food sources.

Vitamin D facilitates the absorption of calcium and is hence an important component of calcium rich foods. Alternatively consider a calcium supplement to ensure that there is enough calcium in the diet.

For people who are lactose intolerant, there are many lactose- free foods available that are high in calcium.

Calcium Supplements

Caltrate Plus^® (600mg calcium) is a popular calcium supplement that can be taken from a young age. It is available in chewable and tablet form. The same is true for Sandoz Calcium Forte^® (500mg and other minerals), which is an effervescent tablet and Calcium Optima^® in tablet form.  B-Cal-D^® (500mg) is available in a chewable and a tablet form.

Exercise

While exercise is important for all people of all ages to ensure good health, it is especially important for those suffering from osteoporosis as it improves bone health and also increases muscle strength, coordination and balance. This naturally decreases the possibility of an older person falling and suffering a fracture. Although obesity could ‘cushion’ the bones somewhat, it would still be a lot healthier to prevent an overweight situation which could put more strain on the skeleton and especially the joints. That is besides all the other problems associated with obesity such as diabetes, heart disease, high cholesterol and many others.

The best bone- building exercise would be weight- bearing exercise. Training against gravity would include weight training, walking, hiking, jogging, climbing stairs, dancing etc.

In many weight loss programs a minimum of 10,000 steps a day is advised, and nowadays the i-Phone has an app that can be used by buying a small object that goes into a person’s shoe and they can then monitor their daily progress.

Some Tips for Healthy Bones

Most of these tips have already been discussed above, but as a handy guide the following can help prevent osteoporosis:

• Eat calcium-rich foods such as dairy products, choose fish with bones (salmon and sardines) and include dark green vegetables. For the lactose intolerant people, alternatives to dairy products are available, namely tofu and soy milk. If a person would like a snack, they can consider almonds or dried figs.
• Take a calcium supplement. This is true for teenagers to achieve peak bone mass during the growth spurt of the teenage years as well as being mandatory for women from menopause onwards. It is recommended that women during menopause would need 1000-1500mg per day unless they are taking hormone therapy. The body only absorbs about 500mg of calcium at a time, so taking a dose in the morning and one in the evening would be of benefit. If they are taking a multivitamin, there is probably calcium in those tablets as well.
• A good calcium supplement will contain vitamin D as well. Recent research has shown that the sunshine vitamin is even more important than previously thought and if a person is not getting at least 20 minutes of full sunshine per day, it should be supplemented to meet daily needs.
• Weight bearing exercise should be included in a person’s daily routine. Clear any exercise plan with a doctor or healthcare professional if the person is osteopenic, arthritic or has osteoporosis.
• Avoid smoking and drinking excessively as loss of bone mineral density is associated with tobacco use and excessive alcohol intake.
• Especially for women of forty plus,  a test measuring bone mineral density (BMD) can help determine whether a person is at risk or not. Women who tend to skip periods or suffer unexplained fractures should test sooner.
• Consider medication if necessary,  peri-menopausal women are at high risk of osteoporosis. They should consider hormone therapy to boost low levels of oestrogen or their doctors may consider a bisphosphonate necessary. However, the doctor or gynaecologist would consider the overall health of a patient before deciding on therapy.

The stresses and strains of daily living, combined with an inadequate diet and lack of exercise, all increase a person’s overall chances of acquiring a disorder unnecessarily. Whether it is to promote one’s bone health or one’s health in general, preventing disease with a healthy diet and adequate exercise is a lot less expensive than treating a disease.

Sometimes the fashion of the season is straight, sometimes it is curly but whatever the style a person eventually chooses, it is best to ensure that it matches a person’s facial shape is manageable. African hair has a tendency to be dry, the structure makes it more difficult for oil to properly penetrate both the scalp and the ends of the hair. This means that a person must have a regular routine to keep it looking its best. The experts do not always agree on how often hair should be shampooed, but at least every seven to ten days is generally recommended to avoid unhealthy bacterial growth on the scalp. Washing hair too often will strip the moisture of the hair, so a fine balance must be maintained.

To properly maintain curly hair, it is necessary for the customer to understand which kind of shampoo, conditioner and oil will give them the best results, especially if the hair has been chemically treated.

Choosing a Shampoo

It is important to understand the pH levels to help customers select a suitable shampoo. The amount of hydrogen in a solution determines whether it is more alkaline or acid and this is measured on a pH scale from 0 – 14. A more acid shampoo will have a pH rating anywhere between 0 – 6.9 and more alkaline from 7 upwards. The higher the pH rating the stronger and harsher the shampoo, this can leave hair dry and porous.

An acid-balanced or everyday shampoo is one that is balanced to the pH of skin and hair (4.5 – 5.5).  Acid-balanced shampoo helps to close the hair cuticle and is recommended for hair that has been chemically treated.

Conditioning

Conditioners are special chemical agents applied to the hair to deposit protein or moisturizer, to help restore its strength or to protect it against possible breakage.  Conditioners are a temporary remedy for hair that feels dry, appears damaged, or is damaged.  It can only repair to a certain extent and cannot “heal” damaged hair.

There are three basic types of conditioners and these are:

• Rinse-through – which is rinsed out after working it through the hair, and is the conditioner most people use.
• Treatment conditioner should be left on the hair for about 10-20 minutes as it restores protein and moisture in the hair
• Leave-in conditioners are applied to the hair and not rinsed off which would be a deep conditioning treatment.

A concentrated protein treatment conditioner is usually not applied immediately after a chemical treatment as it can alter the desired effect of either relaxing or colouring of the hair and it is designed to slightly increase the hair diameter with a coating action. It passes through the cuticle, penetrate into the cortex and replace the keratin that has been lost from the hair to improve appearance and equalize porosity.

A moisturising conditioner is similar to a rinse through conditioner, but tends to be more penetrating and have better staying power, and these are recommended for use after chemical treatments.

Products to use for African Hair conditioning

An oil spray is needed to give each strand of hair a natural healthy sheen. Olive oil has been used as a healing elixir to restore new life and it is rich in essential fatty acids that infuse moisture directly into the scalp and hair shaft. It is good for thin hair as it doesn’t weigh the hair down. Olive oil has historically been known to improve elasticity and hydration of hair when used regularly. Grape seed oil or shea butter is a popular choice as well as various other combinations of moisturising products and oils.

Hair activators work with naturally curly hair and these are available in either liquid or gel form to define natural curls while giving it hold. These products spray onto hair as a curl activator or moisturiser for natural curls and permed hair.

When selecting a liquid activator it is better to select a ‘no drip’ formula so that the product can be sprayed into a curl, but there’s no run off. These products generally contain glycerin to help eliminate breakage and keep hair soft and shiny.

Relaxing

Relaxing the natural curl permanently will alter the natural wave pattern of the hair and these would include permanent waving (perm), soft permanent curl as well as chemical hair relaxing for straightening the hair.

Chemical hair relaxing is the process of rearranging the basic structure of extremely curly hair into a straight form. Thus a perm will curl straight hair and relaxer will straighten curly hair and apart from the final outcome, the two procedures are the same. The chemistry may be different, but both procedures reshape the hair by breaking disulfide bonds.

The relaxers are characterised by high alkalinity and can ‘melt’ or dissolve hair if used incorrectly, in fact many of them contain the same ingredients as products used for temporary hair removal. Be certain to stress to customers that they should follow the instructions rigorously!

Most products are available in mild, regular or super and the difference is the strength of the hydroxide relaxers. Mild products should be used for fine, colour treated or damaged hair, and the regular of normal hair texture with a medium natural curl. The super strength should only be used for maximum straightening on coarse hair that is extremely curly.

Home or Salon?

Whether a person decides to go to a salon or do it at home, one of the golden rules for successful hair relaxing would be not to over process hair. All that is needed is to relax the curl enough to break up the wave, and leaving any chemical on longer than necessary that will lead to damage. The second golden rule is to rinse, rinse and rinse again to ensure that all chemicals are removed from the hair.

Hair that Breaks

Dry hair will lose its suppleness and will be more likely to break. Additional moisturiser or oil must be used to help with healthy looking hair and styling. Chemicals and heat used on the hair will dry hair out and to avoid this, look for heat-shielding and hydrating products that contain silicone. They coat the hair and help seal in moisture.

Even wrapping hair in a satin scarf or bonnet before bed will help hair retain moisture.

Useful Tips

1. Healthy living and eating habits will result in healthier hair.
2. Massage scalp regularly to stimulate oil production and reduce hair dryness. This is best done while hair is still damp and then brush out the ends of the hair.
3. Do not shampoo every day – every 3-7 days is recommended
4. If a person perspires a lot or exercises often, it is recommended that hair is rinsed with water and not to use a shampoo daily. If shampoo must be used every day, use a moisturising one with a low pH level.
5. Use a separate shampoo and conditioner. The 2-in-1 products are not suitable for dry hair.
6. Avoid tangling when washing hair by rubbing in one direction only.
7. Try a leave-in conditioner to hydrate and protect the hair. It is also easier to comb.
8. When drying hair, do not rub, instead blot the hair as rubbing will cause tangles which can break the hair when being combed out.
9. Always use a pick or wide-toothed comb and comb when hair is slightly moist to detangle and comb hair. Do not comb very wet hair as it is most fragile and likely to break when wet.
10. Customers must experiment with various products to find the ones that work best for their hair. What works well on African hair may not work at all on very curly Caucasian hair.

There are so many products on the market and choosing the correct product will be a balance between tried and tested as well as what a person’s pocket can afford. There are well-known brands such as Sunsilk, Black Chic, Dark & Lovely, Restore Plus, Sof’nFree and many others, but it is best to get as much professional advice for each person’s problem which that will make choosing the correct product a bit easier. Whether it is olive oil, grape seed oil, shea butter or a mixture of ingredients, curly hair needs to be well moisturised and taken care of regularly.

Despite these deaths in our midst, the awareness of pneumococcal disease is largely absent in South Africa. WHO has estimated that more than 1.6 million people, including more than 800,000 children under 5 years old, die every year from pneumococcal infections.

In South Africa, pneumococcal disease is estimated to occur in 100 – 200 per 100 000 of the population and is the leading cause of vaccine-preventable death in children under five years of age.

A South African study monitored children in Soweto over a decade and assessed the influence of HIV infection and any changes in infections that may occur. These children had a high incidence of pneumococcal bacteraemia which doubled during the study period mainly as a result of the impact of the HIV epidemic.

Serious pneumococcal infections can occur throughout life, but children under two years old and the elderly are at highest risk. HIV infection and other conditions associated with immune deficiency greatly increase the likelihood of contracting pneumococcal disease. The rate of invasive pneumococcal disease is 37-42 times greater in HIV+ children.

During the recent AfME Paediatric Pneumococcal Disease Summit in Cape Town, Prof Shabir Madhi, CEO of the National Institute for Communicable Diseases (NICD), said in an interview that the role of pharmacy staff in promoting vaccination cannot be emphasized enough. Not only can they promote early vaccination and ensure easy access to the vaccines, but they are also the gate keepers in ensuring that the penicillin dosages prescribed by doctors are high enough once a child has contracted the disease.  The required dosage is 90mg/kg and doctors often prescribe lower dosages that can lead to antibiotic resistance.  Dr Anne von Gottberg, who coordinates various surveillance programmes at the NICD said that by being well informed about available vaccines, pharmacy personnel will be able to assist parents properly by providing the correct information.

Cause

Pneumococcal disease is a leading cause of serious illness throughout the world. It describes a group of illnesses caused by the bacterium Streptococcus pneumoniae (pneumococcus). It can cause meningitis, pneumonia, bacteraemia (blood infection), sinusitis as well as otitis media. Pneumococci are transmitted by direct contact with respiratory secretions from patients and healthy carriers.

Otitis media is the most common, occurring approximately ten times more frequently than pneumonia and a hundred times more than meningitis. Pneumococcal meningitis is the most severe form of pneumococcal disease and one of the most fatal childhood illnesses. In developing countries, it kills or disables 40-70% of children who get it. Bacteraemia and meningitis are responsible for the highest rates of death among the elderly and patients who have underlying medical conditions.

The primary causes of death from pneumococcus are:

• pneumonia, in which fluid fills the lungs, hindering oxygen from reaching the bloodstream
• meningitis, an infection of the fluid surrounding the spinal cord and brain
• sepsis, an overwhelming infection of the bloodstream by toxin-producing bacteria.

In about 30% of people with pneumococcal pneumonia, the bacteria invade the bloodstream from the lungs. This causes bacteraemia, a very serious complication of pneumococcal pneumonia that also can cause other lung problems and certain heart problems.

Prevention

Since most pneumococcal diseases are treated with antibiotics, growing resistance of pneumococcus to conventional antibiotics is seen and underlines the urgent need for vaccines to be used to control and prevent the disease.

In 2007, WHO recommended the use of pneumococcal conjugate vaccines in all countries, urging that the highest priority for introduction be given to countries with high pneumonia and under-five mortality rates. South Africa was identified as one of a few countries in which the under-five mortality rates have increased since 1990, largely attributable to the HIV/AIDS epidemic.

Therefore, the World Health Organisation made a decision to support the inclusion of pneumococcal conjugate vaccine (PCV) in national immunisation programmes worldwide. In view of the demonstrated vaccine efficacy and high disease burden, PCV can help to substantially reduce mortality and morbidity. Vaccines are also recommended for adults 65 years of age and older as well as persons at high risk of contracting the disease.

Prevention of pneumococcal infections by immunisation therefore remains the most rational approach to disease management.

In South Africa, according to the Expanded Programme for Immnunisation (EPI), the PCV (pneumococcal conjugated vaccines) Prevenar® (six weeks to five years) and Synflorix® (six weeks to two years) are recommended. The South African immunisation program adopted a two-dose primary series at six and fourteen weeks with a booster dose at nine months of age.

The use of pneumococcal conjugate vaccine has had a significant impact in reducing the incidence of pneumococcal disease, the associated morbidity and mortality. Following the introduction of PCV in 2009 in South Africa, preliminary data indicates a reduction in pneumococcal disease burden, which is in keeping with the impact of the vaccine seen in other countries.

Considering the challenge of high child mortality in South Africa, PCV not only protects those who are vaccinated but it also provides herd immunity i.e. protecting many people who are not vaccinated – including HIV+ adults and the elderly, who are at high risk of invasive pneumococcal disease (IPD). Furthermore, 65% of all IPD in children under-five years was associated with underlying HIV infection.

Most S. pneumoniae serotypes have been shown to cause serious disease, but only a few serotypes produce the majority of pneumococcal infections. The ten most common serotypes are estimated to account for about 62% of invasive disease worldwide.

Prevenar® 13 is produced by Pfizer. It is a triskaivalent vaccine with  broad coverage for the prevention of invasive pneumococcal disease, pneumonia and otitis media caused by Streptococcus pneumoniae. Prevenar® 13 includes the same seven serotypes contained in the pneumococcal seven-valent conjugate vaccine but also includes coverage of an additional six serotypes. The thirteen serotypes of pneumococcus are conjugated (linked to) to a carrier protein.

None of the pneumococcal vaccines are   100% effective and will only help protect against the  pneumococcal  serotypes included in the specific vaccine.

In infants and toddlers, the most common side-effects are tenderness, redness or swelling at the injection site, irritability, decreased appetite, decreased or increased sleep and fever.

In adults, immune responses to Prevenar® 13 were reduced when given with injected seasonal flu vaccine. The common side effects were pain, redness, or swelling at the injection site, limitation of arm movement, fatigue, headache, muscle pain, joint pain, decreased appetite, chills or rash. Prevenar® 13 is not registered for adults in South Africa.

Synflorix® is produced by GlaxoSmithKline. It is a decavalent vaccine, meaning that it contains ten serotypes of pneumococcus which are conjugated to a carrier protein.

Imovax pneumo 23®, a polysaccharide Streptococcus pneumonia vaccine registered for use in children and adults older than two years is marketed by Sanofi Pasteur and provides immunity against 23 strains of S.pneumoniae.

Why vaccinate adults against pneumococcal disease?

In adults the fatality rate of pneumococcal bacteraemia is 15-20% and five to seven percent for pneumococcal pneumonia. For pneumococcal meningitis in adults the fatality rate is 16-37%. Pneumococcal meningitis can cause hearing loss, seizures, blindness and paralysis. Concurrent cardiac events are common among patients hospitalised with pneumococcal pneumonia.

According to several international guidelines, the following risk groups should consider vaccination:

• All adults age 65 and older
• Adults with lung, heart, liver or kidney disease; asthma; diabetes; alcoholism; immune-compromising conditions such as cancer; a damaged or missing spleen; cochlear implants; or cerebrospinal fluid (CSF) leaks
• Adults living in nursing homes or other long-term care facilities
• All adults who smoke cigarettes.

Prevenar® 13 is not registered for adults in South Africa.

It is fortunate that medical research has delivered such an excellent tool to prevent against pneumococcal disease. Conjugate pneumococcal vaccination is safe and effective for preventing severe childhood and adult pneumococcal disease caused by serotypes included in the vaccines.  These vaccines are expected to prevent 50-80% of all serious childhood pneumococcal disease worldwide and are an effective tool to prevent antibiotic-resistant infections.

Blocked “stuffy” nose in infants

Colds (upper respiratory tract infections) are very common in infants and young children as they have not yet built up their immunity against the numerous different cold viruses. It can occur any time of year, although more commonly in winter. The virus usually takes a few days to incubate, and the cold can last for anything from three to ten days.

Typical symptoms are:

• A runny nose – it may start off as a watery clear discharge, but often becomes thicker and yellow;
• Sneezing;
• Nasal congestion.

Treatment:

• Humidify the air: a humidifier is the simplest method, otherwise boil a kettle in the room – but always ensure it is out of reach of children to avoid the danger of burns. The moist air helps to reduce nasal congestion, making it easier for the child to breathe;
• Elevate the head of the cot/bed by placing a rolled up towel or a pillow under the mattress;
• Saline nose drops soften nasal secretions so the mother can gently remove them (a suction bulb can be used for this) or the baby can sneeze them out. This often helps the infant to feed and sleep better;
• Decongestant nose drops (e.g. Iliadin® Paediatric nose drops) should only be used in infants if recommended by a doctor, and then for not longer than a few days, to avoid rebound congestion.

Adenoids

The adenoids are thick frond-like projections of lymphoid tissue, situated at the junction of the ear, nose and throat. When the adenoids are diseased, they can cause clinical symptoms in the ears, nose and throat in two ways:

• The enlarged adenoids can cause obstruction;
• The adenoids can act as a reservoir of infective micro-organisms, resulting in persistent or recurrent ear, nose and throat infections.

The child with chronically infected/ inflamed adenoids presents with a blocked, snotty nose, breathing through his/her mouth and talking with a hyponasal tone of voice (as though there is a peg on the nose). However, as there is a normal incidence of  6 – 8 upper respiratory tract infections (URTIs) a year in children, causing a similar kind of picture, one must ascertain whether this is an intermittent occurrence or a constant state of affairs. In an acute infective episode, symptoms may be typical of adenoiditis, but will resolve spontaneously.

Similarly, if there is an underlying allergic rhinitis, an adenoidal picture can present. If an allergic picture is suspected – sneezing, sniffing, fluctuating runny nose and blocked nose, itchy nose, palate and eyes, and family/ personal history of atopy (eczema, asthma, “hay fever”) -  then a trial of inhaled nasal corticosteroids (e.g. Flixonase ®) is indicated.

If the nasal obstruction (blocked nose) is one-sided, think of a foreign body in the nose, especially if there is an associated purulent/ foul-smelling nasal discharge, and the history is of a short duration.

Sleep Apnea in Children

One of the common causes of sleep apnoea in children is upper airway obstruction from enlarged tonsils and/or adenoids. Children with sleep apnoea syndrome typically present with constant snoring. Other associated symptoms are:

• Excessive daytime mouth-breathing;
• Morning headaches and irritability;
• Failure to thrive.

They are usually in the pre-school and junior school age group, as this is the age when tonsils and adenoids reach their maximal size. Even though the tonsils may not appear overly enlarged, the decrease in muscle tone and change in posture during sleep, result in a functional obstruction.

Asthma

During an asthma attack, the child will cough and wheeze (noisy, whistling expiration), with a tight chest and shortness of breath. This can last anything from a couple of hours to a couple of days. Symptoms may also be brought on by exercise, cold and aspirin. Symptoms usually worsen at night. There is usually a family history of atopy (asthma, eczema or hay fever).

Treatment:

Refer the child to a doctor if these are new symptoms, or if there is difficulty breathing. Nebulisation is often required to relieve the acute episode. In known asthmatics, the doctor will usually have discussed with the patient’s parents how to step up treatment when the symptoms start to worsen.

Asthma attacks are usually triggered by a viral respiratory tract infection, so antibiotics are not routinely given.

Pneumonia

The typical symptoms of pneumonia are:

• High fever and rigors (shaking chills);
• Coughing – green sputum, which is often scanty at first;
• Haemoptysis – the sputum may become blood-stained;
• Pleuritic chest pain – sharp stabbing pain, worsened with coughing or deep inspiration;
• Breathlessness and dyspnoea (shortness of breath on exertion)

However, in babies and children the signs and symptoms of pneumonia may be less clear-cut. They may just have fever and lethargy, appearing unwell but with no obvious cause. Have a high index of suspicion, and refer to their doctor for a thorough examination and investigations.

Treatment:

If the patient is young and in general good health, s/he can be treated at home with bed rest, plenty of fluids and an oral antibiotic. In some cases, ceftriaxone (Rocephin®) may be given in the doctor’s rooms to avoid a hospital admission – one or more doses – followed up with oral antibiotics once the patient is responding.

• Infants often require admission to hospital for intravenous antibiotics, oxygen if required, and physiotherapy. They need careful monitoring as they can tire easily and become hypoxic with the effort of breathing.

Epiglottitis

Although epiglottitis is not commonly seen it can be a life-threatening condition, so it is important to be aware of it and to recognise the warning signs. It is a bacterial disease seen in older children and young adults, presenting with:

• An extremely sore throat.
• Dysphagia (difficulty swallowing).
• Toxaemia (the patient is ill, with a high temperature).
• Airway obstruction that is rapidly progressive – if there is stridor (noise on inhalation) then total airway obstruction is imminent: this is a medical emergency.

The child may not immediately appear to be in danger because he uses various manoeuvres to keep the airway open – these manoeuvres are what should alert you to the condition:

• The child sits with the head kept still and the jaw pushed forwards.
• He does not want to open his mouth wide.
• He breathes shallowly and slowly.
• He does not want to speak and if he does it sounds muffled (“hot potato” voice).
• Because swallowing is painful, he may drool.

Do not try to change the way the child is sitting or do anything that would make the child cry as this could cause acute closure of the airways. Refer the child IMMEDIATELY for emergency care.

There is now evidence to show that the urogenital flora (the bacteria that live in the vagina and bladder) play a role in our health.Probiotics or “good bacteria” are receiving recognition for helping to maintain and restore healthy normal flora.

Bacterial Vaginosis

Bacterial vaginosis (BV) is the most common cause of vaginal infection and affects women usually between the ages of 17 – 30 years as well as older women.

BV is the name of the condition where the normal balance of bacteria in the vagina is disrupted and replaced by an overgrowth of certain “bad” or “harmful” bacteria.

Symptoms

There may be no symptoms at all, or a thin, white or grey vaginal discharge with an unpleasant, “fish-like” odour may be present. There may also be burning during urination or itching.

It is not fully understood how BV is caused, but it occurs when there is an imbalance in the bacteria that are normally found in the vagina.Douching, having a new sex partner or having multiple sex partners may increase the risk of developing BV.

BV is treated with antibiotics, such as metronidazole or clindamycin. However, it may recur after treatmentand the following steps may be required to prevent upsetting the natural balance of bacteria in the vagina:

• Abstinence or limit the number of sex partners
• Do not douche
• Use all of the medicine prescribed to treat BV (finish your course of antibiotics)
• Consider using a probiotic that will help restore and maintain a healthy vaginal flora

Candidiasis

Yeast vaginitis or candidiasis is a fungal infection that occurs when there is an overgrowth of the fungus, Candida albicans. Candida is usually present in the body in small amounts. However, when an imbalance in the normal flora occurs, Candida can multiply and the symptoms of candidiasis appear.

Symptoms: There may be a “cottage cheese-like” discharge, with genital itching and burning as well as pain during sexual intercourse.

The overgrowth of candida, that causes the symptoms of an infection, may be caused by a weakened immune system, or occur during pregnancy, when using medication such as corticosteroids or broad-spectrum antibiotics, or in someone with another illness such as diabetes mellitus.

Candidiasis is treated with antifungal creams or medication, such as fluconazole.However, like BV, it may recur after treatment.

In terms of probiotics, very few are actually able to kill or inhibit adhesion of the yeast to vaginal cells, although the strains L. rhamnosus GR-1 and L. fermentum RC-14 do have some such activity. There is little evidence that probiotics can effectively cure a symptomatic yeast vaginitis, but a reliable probiotic product might be a worthwhile addition to drug therapy (antifungal medicines) as a means to help reduce the risk of recurrence.

The Immune System: The immune system is an effective network of cells, tissues and organs that work together to defend the body against harmful invaders. This amazing system can remember and recognize (immunologic memory) different enemies that derive from body tissue and render the invader harmless. Any particle capable of being recognized by the immune system is called an antigen (Ag). The secret to the immune system’s success lies in the communication between the various role-players. The immune system consists of cells (cellular) and chemicals (molecular) components that work together to destroy the antigens. These include:

• Antibodies: Antibodies are produced by the B-cells in response to antigens.
• Lymphocytes:
  • B-cells: About 5 to 15% of lymphocytes in the blood are B-cells. B-cells mature in bone marrow and are also present in the spleen, lymph nodes and tonsils. Their primary function is to manufacture and secrete special antibodies. Some B-cells can undergo changes and differentiate into memory cells. Once in the blood, the B-cells are on patrol looking for invaders and waiting to get signals from the T-cells. B-cells work together to smother the invader.
  • T-cells: T-cells develop from bone marrow stem cells that have travel to the thymus gland. In the thymus they go through rigorous selection and only T-cells that can recognize non-self (foreign) antigens from self (internal) antigens survive. Killer T-cells multiply when they find an invader. They will attach themselves to the invader and release chemicals to kill the invader. Helper T-cells send messages to the B-cells, telling them to start multiplying to attack the invader. Suppressor T-cells tell the B-cells when the fight is over. When the number of T-cells in an HIV/AIDS patient drops below a certain level, the patient gets sick because the T-cells cannot prevent the infection.
  • Natural killer cells: About 5 to 15% of blood lymphocytes are natural killer cells. They are natural lymphocytes that do not belong to B-cells or T-cells. Natural killer cells have the same killing mechanism as T-cells but they lack immunologic memory.
  • Lymphokine activated killers: Some lympokines develop into vicious lymphokine activated killers. These killers are capable of killing a wide spectrum of tumor target cells, abnormal lymphocytes and lymphocytes containing certain viruses.

It is clear that all these cells are blood cells.

The Barriers: The body has external defences in place. These must be overcome before the immune system is activated to destroy the foreign intruder. The barriers include:

• The skin with its keratinized outer layer and acid mantle. The sweat glands also play an important role in this defence
• The mucous of the respiratory, gastro intestinal and urogenital tracts
• The cilia on the respiratory epithelial cells which help expel particles or organisms trapped by the mucous.
  

Benefits of an effective immune system: The immune system does a remarkable job of defending one against disease-causing micro-organisms. A germ invades successfully and makes one sick! What can we do to make the immune system and barriers stronger?

The immune system is a system consisting of different components working together. To function optimally, it requires balance and harmony.

Immune boosting lifestyle:  The first step towards a healthier and stronger immune system is to choose a healthy lifestyle. Here are some guidelines:

• Stop smoking: Smoking is detrimental to good health and has negative effects on the body and well-being. Kick the habit to preserve your health. The following can assist those that want to quit smoking:
  • Nicorette Chewing Gum^®: The Nicorette chewing gum provides a flexible dosing of nicotine. The smoker can control cravings when they feel the urge to smoke. It is available in 2mg and 4mg strengths. The nicotine contained in the gum is absorbed into the bloodstream through the mucosa of the mouth. It is important to advise smokers not to chew Nicorette gums continuously.
  • Quit^®: Quit contains 4 different concentrations of nicotine in a convenient spray form. Start with the strongest concentration and gradually wean off to the weakest concentration.
• Diet: Dietary changes: We are what we eat! The following guidelines can assist in changing over to a healthy lifestyle:
  • Breakfast is the most important meal of the day and should never be skipped. Try eating three meals a day at fairly regular intervals.
  • Read labels and know the ingredients of all products. Make wise decisions. Look for products that contain the least amount of processed ingredients.
  • Seek satisfaction in genuine flavours obtained from herbs rather than from fat, sugar, salt and chemical additives.
  • Avoid beige! Bring colour on your plate and try to combine at least five different colours of food at each meal. Rainbow coloured fruits and vegetables will assist in achieving this.
  • Be knowledgeable on the different types of fats. We get good fats and bad fats. Always try to grill and not to fry food.
• Physical activity: Exercise and physical activity form the foundation of a healthy lifestyle. It is important for maintaining physical fitness and can contribute to healthy weight, muscle strength, physical well-being and a robust immune system. Exercise as part of the lifestyle can take different forms from brisk walking to gardening! To reap the full benefit, one should “exercise” three to five times a week for at least 30minutes per interval. The main goal is to enjoy the activity and to have fun!
• Maintain healthy weight: Overweight is a burden to the body and the immune system. Strive to achieve and maintain the ideal healthy weight.
• Rest: Sleep is characterized by reduced consciousness and increased anabolic (restoring / building up) activity. Research has revealed that lack of sleep can increase the risk to certain chronic diseases. The following steps can be implemented to restore a proper sleep routine:
  • Melatonin: Melatonin is produced by the pineal gland which is located in the mid brain. The production of melatonin is regulated by the SCN (supra-chiasmatic nucleus). The SCN will delay the production of melatonin until darkness arrives and the release of melatonin is associated with sleep onset. Supplements containing melatonin Solal Melatonin^® can be recommended to supplement the melatonin levels in the body.
  • Valerian root: Valerian is a well-known herb in the treatment of anxiety and as a sleep aid. Calmette’s Night^® contains valerian and is most effective when taken shortly before bedtime. Valerian does not interfere with sleep cycles or with REM (restful) sleep.
  • Redormin^® contains standardised natural extracts of Valeriana officinalis (valerian) and Humulus lupulus to restore the body’s natural sleeping pattern and circadian rhythm.

Bedtime routine is also important. Use the bed for sleep and sex only and not as a work station! Keep the room dark to enhance the production of melatonin. It is also advisable to ensure adequate ventilation.

• Avoid infection: Take active steps to avoid infection. These include:
  • Washing hands frequently and thoroughly
  • Cooking meats thoroughly
  • Be mindful of what one touches. Bathroom door handles and escalator hand supports are oragism reservoirs.
• The stress connection: We live in stressful times and are constantly exposed to barely-tolerable pressures and stressors. Stress brings unhappiness and diseases! The following tips can assist to escape the claws of stress:
  • Keep a sense of humour! Laughter is most contagious, binds people together and increases happiness. The other benefits of humour and laughter include:
    • Boosting of immune system
    • Boosting energy
    • Fighting pain and stress
    • It relaxes the whole body
    • It triggers the release of endorphins which promote an overall sense of well-being
    • Laughter improves the function of blood vessels and increases blood circulation.

Schedule time to relax: Relaxation can take various forms. Apply lavender oil to the temples and focus on deep breathing.

• Calmettes^® contains valerian root and can be recommended to those who need a boost to overcome the devastating effects of stress. In the recommended dose it can be taken up to three times daily without causing drowsiness. Biral^® tablets contain ingredients (valerian and passiflora) from plant origin. These herbs act on the central nervous system to bring about a mild tranquilizing action. Biral can be used during the day since it should not cause drowsiness or impair mental alertness and concentration. Remotive^® contains standardised natural extract of Hypericum perforatum (St John’s Wort) and can be recommended to relieve the symptoms of stress, anxiety and mild to moderate depression.

Immune Boosting supplements: Boosting the immune system is actually a grey area. There are so many different kinds of cells in the immune system that respond to so many different antigens in so many ways. The question is which cells should one boost and to what extent? Providing the body with sufficient nutrients can assist the body to equip itself for fighting the foreign invaders. The following products may have a positive effect on the immune system:

• Airmune^®: Airmune has a combination of herbal extracts, beet root extract, amino acids (L-glutamine & L-lysine), vitamins (vit A, C and E) and minerals (zinc and selenium) to boost the immune system and to help attack viruses. Airmune Junior can be recommended for children and the Airmune for adults.
• Vital maxi C^® 1000mg: It is an antioxidant and immune booster that contains all the nutrients needed to maintain healthy cells and support the immune function. Maxi C has added bioflavonoids (rutin, hesperidin and alpha lipoic acid) to prevent free radical damage.
• Ginsana^®: Ginsana contains standardized panax ginseng which is well-known tonic. Ginsana increases perceived physical capacities and boost immunity. It can be recommended to multi-tasking, over-worked adults, sportspeople and those who are immunodeficient.
• Natrix Immune Support for Everyday^®: This product contains a comprehensive and active blend of immuno-supportive botanicals (olive leave extract), vitamins (vit A, C, D3 and E), and minerals (zinc and selenium) to maintain a strong immune system.
• ViralChoice^®: Viralchoice (syrup of capsules) has a combination of nutritional supplements specifically formulated to support and boost the immune system. It can be recommended during times of viral infection (flu season), to boost recovery after illness and as a general immune booster. Immunochoice^® contains antioxidants, minerals, nutrients and phytosterols. These ingredients work together to assist the body with the following functions:
  • Fighting free radicals
  • Maintains a balanced immune system
  • Provide cardiovascular protection and improve circulation
  • Normalise cholesterol levels
  • Retard the signs of ageing
• A Vogel Echinacea^®: This is a natural remedy with supportive therapy for the prevention and treatment of colds, influenza infections and other upper respiratory tract infections. Can be used to modulate the immune response to infections.
• Biobalance Immunova+ Immunomodulator Tablets^®: Contains CHD-FA (carbohydrate derived fucidic acid) and can be recommended to HIV/AIDS patients, diabetics, elderly and those suffering recurrent infections. It is conveniently packed in 90 tablets and the recommended dosage is one tablet three times a day.
• Cal-C-Vita Immune Protector^®: This product contains all the essential vitamins and minerals to keep the immune system in excellent condition. One tablet daily can be recommended throughout the year.
• Multivitamin and minerals: Emvit M^® is a complete multivitamin that contains 20 essential vitamins and minerals. Emvit M has added iron and folic acid and can also be recommended during pregnancy and breastfeeding. Centrum A-Z^® or Centrum 50+^® can also be recommended to provide all essential nutrients for a healthy body.
• Colban^®: Colban provides a proven mechanism of action by attacking infections at the onset and destroying the ability of the infectious organisms to build momentum. Colban has declared war against colds and has an easy to remember contingent:
  • Foot soldiers: Colban increases the production of natural killer cells. The foot soldiers are alarmed and activated at the first sight of enemy (invading organism) attack. They focus on eradicating the enemy as soon as possible.
  • Armoured tanks: Colban increases the production of phagocytic white blood cells. The armoured tanks attack and engulf the enemy (particles and viruses) and limit their ability to populate.
  • Counter-intelligence agents: Colban increases memory cells. The counter-intelligence agents protect the body against the nasty repeat of infections which are common during winter. The CI-agents enable the body to deal with infections more quickly if it arises in the future.
  • Medical soldiers: Colban decreases the number of B-lymphocytes and thus reducing the inflammation commonly associated with infections.

Colban is available in a pleasant tasting chewable tablet and should be taken daily.

Boosting the immune system can keep our immune system functioning efficiently, minimize the frequency and severity of all illnesses, and shorten recovery time. Remember that laughter is the best medicine for our bodies. With all these in place we are more likely to enjoy a healthy quality of life.

Causes of Coughs

There are many causes of coughing. They are classified into two categories, acute and chronic. An acute cough is one that been present for less than three weeks. Chronic coughs are those present for more than three weeks.

Acute coughs can be divided into infectious and non-infectious causes.

• Infectious causes of acute cough include viral upper respiratory infections, sinus infections, acute bronchitis, pneumonia, and whooping cough.
• Non-infectious causes of cough include flare-ups of chronic conditions such as chronic bronchitis, emphysema, asthma, and environmental allergies.

To classify the causes of chronic cough they can be divided into their locations with respect to the lungs.

• Any environmental substance that irritates the air passages or the lungs is capable of producing a chronic cough with continued exposure. Cigarette smoke is the most common cause of chronic cough. Other cough-producing irritants include dusts, pollens, pet dander, particulate matter, industrial chemicals and pollution, cigar and pipe smoke and low environmental humidity.
• Conditions within the lungs cause chronic cough. Common causes include asthma, emphysema and chronic bronchitis. Less common causes of lung-induced chronic cough include cancer, sarcoidosis, diseases of the lung tissue, and congestive heart failure with chronic fluid build-up in the lungs.
• Chronic sinus infections, chronic postnasal drip, diseases of the external ear, infections of the throat.
• ACE inhibitor medication for high blood pressure is implicated in chronic cough.
• Gastro Oesophageal Reflux Disease (GORD) is an often-overlooked cause of the chronic cough. GORD occurs when acid from the stomach travels up the oesophagus. This abnormal condition can cause irritation of the oesophagus and larynx resulting in the reflex production of a cough.

Cough Symptoms

The causes of cough can be differentiated by the associated signs and symptoms. Acute coughs have been divided into infectious and non-infectious causes.

• Signs and symptoms that indicate an infection include fever, chills, body aches, sore throat, nausea, vomiting, headache, sinus pressure, runny nose, night sweats, and postnasal drip. Sputum, or phlegm, sometimes indicates an infection is present, but it is also seen in non-infectious causes.
• Signs and symptoms that indicate a non-infectious cause include coughs that occur when a person is exposed to certain chemicals or irritants in the environment, coughs with wheezing, coughs that routinely worsen when an individual goes to certain locations or does certain activities, or coughs that improve with inhalers or allergy medications.

The signs and symptoms of the chronic coughs can be hard to assess, because many causes of chronic cough have overlapping signs and symptoms.

• If a cough is related to environmental irritants, it will worsen when exposed to the offending agent. If a person has an environmental allergy, the cough may improve when using allergy medications. If a person has a smoker’s cough, it may improve if they stop smoking.

• If a person has a chronic lung disease such as asthma, emphysema, or chronic bronchitis, they may have a persistent cough or a cough that worsens with certain locations or activities.
• If a cough is caused by chronic sinus infections, chronic runny nose, or chronic postnasal drip, the person will often have the signs and symptoms associated with these conditions.

• If a cough is associated with medications, such as angiotensin converting enzyme (ACE) inhibitors, the cough often begins after starting the medication in question, but can come on at any point during the use of the medication. The cough is often dry and improves when the medication is stopped.
• A cough associated with GORD is often associated with a sensation of heartburn. This type of cough worsens during the day or when lying flat on the back. Some people with a cough caused by GORD will have no symptoms of reflux, but most people will report improvement in their cough when GORD is treated properly.
• If a cough is a warning sign of an underlying cancer, the person may have a group of symptoms. If lung cancer or a cancer of the air passages is present, the person may cough up blood. Other signs and symptoms that may warn of a cancer include worsening fatigue, loss of appetite, unexplained loss of weight, or decreased ability to swallow solid or liquid foods.

Cough Treatment

The treatment of a cough will depend largely on its severity and underlying cause.

If a bacterial infection is suspected, antibiotics need to be prescribed. People suspected of having a viral infection will not benefit from antibiotics.

Although there is no evidence to show that cough preparations help a cough, some people may find them useful. There various kinds of cough medicines:

• Expectorants may make it easier to cough up mucus when you have a productive cough. Expectorant include guaphenisin e.g. Benylin^® Wet, Dilinct^® Junior, are used if the cough produces thick mucus which is difficult to cough up. Recommend the drinking plenty of fluids. Liquids help thin the mucus in the throat and make it easier to cough it up.
• Suppressants or anti-tussive agents may control or suppress the cough reflex and work best for a dry, hacking cough that keeps the patient awake. Cough suppressants include Codeine (e.g. Benylin with Codeine), or Dextromethorphan (e.g. Dilinct^® Dry Cough Syrup or Benylin^® Syrup DM)

A productive cough should not be suppressed too much, unless it is keeping the patient from getting enough rest. Coughing is useful because it brings up mucus from the lungs and helps to prevent bacterial infections.

• Mucolytics are agents that dissolve and breakdown thick mucus in order to make it easier to be coughed up. N-acytylcysteine (e.g. ACC 200, Solmucol^® or Amucol^®) or Carbocysteine (Muscospect^® , Flemex^®) have mucolytic actions.
• Bronchodilators cause the widening of air passages by relaxing bronchial smooth muscle and relieving the cough. Theophyllin and etophyllin in Solphyllin^® and Alcophyllin^® are bronchodilators, Other bronchodilators can be administered as aerosols to give rapid relief. Salbutamol-containing aerosols include Ventolin^® Inhaler, Venteze^® and Asthavent^® Inhalers.
• Mucolytic/Bronchodilator combination: Many products currently available on the market have combined the benefits of breaking down the mucous and widening the air passages e.g. Bisolvon Linctus^®, Adco-Linctopent^® and Bronkese^® Sollphyllex^®, Alcophyllex^®.
• Decongestants and antihistamines prevent the allergies and postnasal drip that cause coughing. These are usually found in combination products over the counter. E.g. Actifed^® Cold, Demazine^® Syrup, Dimetapp^®, Rinex^®.

Refer the patients to a medical practitioner when

• There is a  history of heart disease, swelling in the legs, or a cough that gets worse when they patient lies down (may be signs of congestive heart failure)
• Been exposed to someone with tuberculosis
• Cough in an infant younger than 3 months old
• Cough that lasts longer than 10-14 days
• Cough that produces blood
• Fever (may be a sign of a bacterial infection that requires antibiotics)
• High-pitched sound (called stridor) when breathing in
• Thick, foul-smelling, yellowish-green phlegm (could be a bacterial infection)
• Unintentional weight loss or night sweats (could be tuberculosis)
• Violent cough that begins suddenly

In conclusion

Highlight that patients cover their mouth when they cough as many tiny droplets are produced in a standard cough which could carry viruses or bacteria. It is essential for public health to prevent the spread of disease.

Gout is a painful condition that occurs when uric acid is deposited as needle-like crystals in the joints and/or soft tissues. In the joints, these uric acid crystals cause inflammatory arthritis, which in turn leads to swelling, redness, heat, pain and stiffness in the joints.

Men are more likely to get gout, but women become increasingly susceptible to gout after menopause. Scientists estimate that 6 million adults report having had gout at some time in their lives. It is rare in children and young adults. People who have had an organ transplant are more susceptible to gout.

Causes

Gout usually develops after a number of years of buildup of uric acid crystals in the joints and surrounding tissues.

The body produces uric acid when it breaks down purines — substances that are found naturally in the body, as well as in certain foods, such as organ meats, anchovies, asparagus and mushrooms.

Normally, uric acid dissolves in the blood and passes through the kidneys into the urine. But sometimes the body either produces too much uric acid or the kidneys excrete too little uric acid. When this happens, uric acid can build up, forming the sharp, needle-like urate crystals in a joint or surrounding tissue that cause pain, inflammation and swelling.

A number of risk factors are associated with hyperuricemia and gout. They include:

• Genetics

Many people with gout have a family history of the disease.

• Gender and age

It is more common in men than in women and more common in adults than in children.

• Weight

Being overweight increases the risk of developing hyperuricemia and gout because there is more tissue available for turnover or breakdown, which leads to excess uric acid production.

• Alcohol consumption

Drinking too much alcohol can lead to hyperuricemia, because alcohol interferes with the removal of uric acid from the body.  Generally more than two drinks a day for men and more than one for women, increases the risk of gout.

• Diet

Eating too many foods that are rich in purines can cause or aggravate gout in some people.

• Medications

A number of medications may put people at risk for developing hyperuricemia and gout. The use of thiazide diuretics — commonly used to treat hypertension — and low-dose aspirin can increase uric acid levels. This is also true during the use of anti-rejection drugs e.g. cyclosporine.

Symptoms

The signs and symptoms of gout are almost always acute, occurring suddenly — often at night — and without warning. A gout attack typically causes pain, swelling, redness and warmth (inflammation) in a single joint, most often the big toe.

The pain is likely to be most severe within the first 12 to 24 hours after it begins. Most gout attacks stop after about a week. Mild attacks may stop after several hours or last for one to two days. Severe attacks may last up to several weeks, with soreness lasting for up to one month.

Many people have a second attack of gout within six months to two years after their first attack, but there may be intervals of many years between attacks. Later attacks are likely to last longer and affect more joints. If untreated, the frequency of attacks usually increases with time.

Treatment

Gout medications can be used to treat acute attacks and prevent future attacks as well as reduce the risk of complications from gout, such as the development of tophi from urate crystal deposits.

Tophi are deposits of crystallised uric acid normally found just under the skin. Commonly, they occur on the ear, fingers and toes and around the ankle and elbow. When small they are not always obvious, but appear as movable lumps.

Medicines to lower uric acid levels are not given until a gout attack is over. Starting these medicines during a gout attack can cause release of uric acid stored elsewhere in the body, which can make the gout attack worse.

Medicines used to treat acute attacks

To ease the pain during a gout attack, rest the joint that hurts.

NSAIDs may control inflammation and pain e.g. ibuprofen (Advil) and naproxen (Napflam). NSAIDs reduce the inflammation caused by deposits of uric acid crystals, but have no effect on the amount of uric acid in the body.

Do not use aspirin as it may change uric acid levels in the blood and may make the attack worse.

Colchicine (Lennon-colchicine) is a type of pain reliever that effectively reduces gout pain. This drug is most effective when taken within the first 12 hours of an acute attack. A low daily dose of colchicines can prevent future attacks.

Corticosteroid medications, such as prednisone, may control gout inflammation and pain. It can also be injected into the joint and is usually used for cases of gout that do not respond to NSAIDs or colchicine.

Medications to prevent gout complications

To people that experience several gout attacks each year or if the gout attacks are less frequent but particularly painful, the doctor may recommend medication to reduce the risk of gout-related complications.

Medications that block uric acid production

Drugs called xanthine oxidase inhibitors, including allopurinol ( Zyloprim), limit the amount of uric acid the body produces. This may lower the blood’s uric acid level and reduce the risk of gout.

Xanthine oxidase inhibitors may trigger a new, acute attack if taken before a recent attack has totally resolved. Taking a short course of low-dose colchicine before starting a xanthine oxidase inhibitor has been found to significantly reduce this risk.

Medication that improves uric acid removal

Probenecid (Proben) improves the kidneys’ ability to remove uric acid from the body. This may lower the uric acid levels and reduce the risk of gout, but the level of uric acid in the urine is increased.

Prevention

During symptom-free periods, careful eating may help protect against future gout attacks:

• Limit the daily intake of meat, fish and poultry to 113 to 170 grams.

• Low-fat dairy products may actually have a protective effect against gout, so these are the protein sources of choice.
• Drink plenty of non-alcoholic fluids, especially water to help remove uric acid from the body.
• Avoid alcohol as it can raise the levels of uric acid in the blood.

• Exercise regularly and maintain a healthy body weight. Avoid fasting or rapid weight loss, since it may temporarily raise uric acid levels.

• Avoid foods that are high in purines e.g. anchovies, asparagus, dried beans and peas, game meats, gravy, liver, mushrooms and sardines.

Fortunately, gout symptoms can be controlled and patients can lead productive lives. Successful treatment can reduce discomfort caused by the symptoms of gout, as well as long-term damage to the affected joints.

And if you are unlucky several of these small blisters may even come together and form one large blister.  Therefore you will have an ugly, painful blister for at least 8-12 days. At least you can count on some sympathy!

The worst news is that unlike most viral infections, the cold sore virus is not completely eliminated by the body’s  defences. For this reason, cold sores often recur. With recurring cold sores, it can take seven to ten days before the blisters completely disappear and the skin appears normal again.

What causes cold sores?

There are two types of Herpes simplex virus (HSV), type I and type II. In general, type I, also known as Herpes labialis, causes infections above the waist, most commonly known as cold sores. Type II infections occur mainly below the waist, leading to genital herpes. This article will focus only on cold sores.

What causes a cold sore recurrence?

Herpes infections, no matter where they occur first, have a tendency to recur in more or less the same place.

After the first infection, the virus enters the nerve cells and travels up the nerve until it comes to a ganglion. There, it lies dormant for a period. At times, the virus can start multiplying again and travel down the nerve to the skin, causing new cold sores.

There are many factors that can trigger a cold sore outbreak, however, it seems to be related to times when the immune system is compromised or run down.

Some conditions seem to be associated with recurrences, including

• fever, colds or flu
• exposure to the sun
• stress
• hormonal changes, such as menstruation
• trauma to the skin
• pregnancy
• drinking a lot of alcohol
• fatigue
• diet and certain foods
• temperature extremes
• steroid medication (e.g. asthma medication)

In immunocompromised people, such as those receiving chemotherapy, severe outbreaks of herpes may occur. Colds sores may spread to large parts of the lower face or invade organs.

How is the cold sore virus spread?

Cold sores are generally spread after skin-to-skin contact with an infected area.

The herpes simplex virus usually enters the body through a break in the skin around or inside the mouth. The virus is spread from person to person by kissing or other close contact with sores or even from contact with apparently normal skin that is shedding the virus. Furthermore, infected saliva can be a means of transmitting the virus.

It is also possible to transmit virus particles to another person through intermediate objects such as a drinking glass, eating utensil, lipstick, lip gloss, toothbrush or even a face cloth.

When are cold sores most contagious?

It is important to know that the virus is considered to be contagious from the very first sign of an outbreak (including the tingling, itching stage) until the area is completely healed again.

Cold sores are considered to be most contagious when the blisters have burst open and have begun to weep fluid. There is a much smaller amount of virus particles present when the sore is healing and when a scab has formed. The infected area is still considered to be contagious until the skin has completely healed.

What can I do to prevent cold sores?

To help reduce cold sore outbreaks, try the following steps:

• Avoid sunlight

Exposure to sunlight and ultraviolet rays can trigger a breakout of cold sores. For protection wear a hat and use a lip balm that contains sunscreen.

• Moisturise

Damage to lips can bring on an episode of cold sores, so keep the lips protected from chapping and wind burn with a moisturising balm.

• Choose an effective treatment

An effective cold sore treatment should shorten the duration of outbreaks, as well reduce the possibility of a recurrence.

• Healthy living

Adequate rest, moderate exercise and fresh fruit and vegetables will assist in boosting the immune system. An active immune system can defend against the virus, reducing the possibility of an occurrence.

• Avoid coming into contact with infected body fluids, such as kissing an infected person.
• Avoid sharing eating utensils, drinking cups or other items that a person with a cold sore may have used.

What is the best cold sore treatment?

Cold sores will usually start to heal on their own within a few days.

Some home remedies can temporarily help to relieve the symptoms:

• Ice can be applied to the sores to both numb and soothe the area.
• Cold tea bags applied to the infected area every hour may be beneficial. This is because tea bags contain tannic acid which is thought to have antiviral properties, best used at the first sign of an outbreak.
• Lip moisturisers can soothe and moisten the lips, helping to prevent the cold sore scabs from cracking and bleeding.

Certain dietary supplements such as vitamin C, vitamin A, vitamin E and zinc are believed to be beneficial in the treatment of herpes, either alone, or in conjunction with prescribed antiviral therapy. Aloe vera, available as a cream or gel, makes an affected area heal faster and may prevent recurrences.

Topical treatment is limited in its effectiveness because it has poor penetration into the site of replication of the virus and therefore is restricted in its healing ability. Treatment may get rid of the cold sores one to two days faster, but it can also help ease painful blisters or other uncomfortable symptoms.

Using topical anaesthetics such as benzocaine will help relieve burning, itching and pain of cold sores.

Other topical medications include acyclovir (Activir® cream) and should be applied five times per day for four days, and penciclovir (Fenivir®) cream should be applied every two hours while awake for four days.

Antiviral oral medications used against herpes viruses work by interfering with viral replication, effectively slowing the replication rate of the virus and providing a greater opportunity for the immune response to intervene.

Currently available in South Africa is acyclovir (Zovirax®) which is indicated for initial and recurrent Herpes simplex infections and valacyclovir  (Zelitrex®) and famciclovir (Famvir®) which are indicated for the treatment of recurrent Herpes simplex infections. These oral medications have been shown to decrease the duration of the outbreak, especially when started during early onset symptoms. The medications are generally well tolerated with few side-effects. Headache, nausea and diarrhoea may occur in some people. Pregnant women and nursing mothers should contact their physicians or pharmacists prior to using any medication.

Patients who have more than two outbreaks in four months, which significantly affect their daily lives, should consider chronic suppressive therapy.