Episode 37 - Honey - a podcast by Rio Bravo Family Medicine Residency Program

Episode 37: Honey in Medicine. 

Smoking cessation update. Honey in medicine. Uses, precautions, honey-related terms. Macroglossia and presbycusis are defined. Jokes about honey. 

Today is January 15, 2021. 

The American Thoracic Society approved a clinical practice guideline regarding pharmacologic treatment of tobacco dependence in adults. This guideline was published in May 2020 in the American Journal of Respiratory and Clinical Care Medicine. Seven recommendations about initial medications used in smoking cessation were given, five are STRONG recommendations and two are CONDITIONAL recommendations.

Let’s start with the STRONG recommendations for tobacco-dependent adults in whom treatment is being initiated:

Varenicline over a nicotine patch is recommended. Remarks: Be prepared to counsel your patients about the relative safety and efficacy of varenicline compared with a nicotine patch.

Varenicline over bupropion is recommended.

In patients who are not ready to quit smoking, treatment with varenicline rather than waiting until patients are ready to stop tobacco use is recommended.

In patients with comorbid psychiatric conditions, including substance-use disorder, depression, anxiety, schizophrenia, and/or bipolar disorder, varenicline over a nicotine patch is recommended.

For tobacco-dependent adults for whom treatment is being initiated with a controller, extended-duration (>12 weeks) over standard-duration (6–12 weeks) therapy is recommended. A controller is a medication with a delayed onset of effect that reduces the frequency and intensity of smoking (i.e. varenicline), whereas a reliever is a medication with acute effect to reduce cravings (i.e. nicotine gum). 

CONDITIONAL recommendations:

Varenicline plus a nicotine patch over varenicline alone is suggested (conditional recommendation, low certainty in the estimated effects).

Varenicline over electronic cigarettes is recommended. Remarks: serious adverse effects of e-cigarettes have been reported. The recommendation will be reevaluated if these reports continue. 

 

 

Quotes about honey: 

You catch more flies with honey than with vinegar.

No bees, no honey; no work, no money.

Honey is sweet but bees sting.

Be like the honey bee, anything it eats is clean, anything it drops is sweet, and the branch it sits upon does not break (Iman Ali, Pakistani actress)

When you go in search of honey you must expect to be stung by bees (Joseph Joubert, French moralist)

Life is the flower for which love is the honey (Victor Hugo, French poet)

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Claudia: Today we have a special episode to honor those with a sweet tooth. We will talk about the ultimate nature candy: honey. Yes, we will talk anything related to honey in medicine.

But... what is honey? It is a sticky, sweet, clear yellowish-brown fluid made by bees. How? you might wonder; well they collect nectar in their honey stomach or what they call the “crop” and as you might be guessing they create honey by vomiting this digested nectar. 

Hector: Let’s start with honeycomb lung. 

Claudia: Honeycomb lung — This is something many medical students and residents might hear for the first time and think huh? Unfortunately hearing a patient has honeycomb lungs is not at all “sweet news.” Honeycomb lung is indicative of end-stage pulmonary fibrosis, and many disorders such as Idiopathic Pulmonary Fibrosis, sarcoidosis, hypersensitivity pneumonia, and eosinophilic granuloma can progress to end-stage fibrosis, but cannot be detected by pathologists at this stage of the disease. For that reason, biopsy of extensive honeycomb lung is not helpful and should be avoided.

This Honey-comb appearance of lungs in CT scan has been found to be common in COVID-19.

Hector: Yes, honeycombing fibrosis seems to follow ground-glass opacities(1) in COVID 19 patients. Honeycombing are small cystic spaces with irregular thickened walls made out of fibrous tissue. A friend told me this bold statement: “A CT scan is more sensitive than PCR to detect COVID-19”. That puzzled me, and I had to look it up. The American College of Radiology issued a statement saying that “viral testing remains the only specific method of diagnosis. Confirmation with the viral test is required, even if radiologic findings are suggestive of COVID-19 on CXR or CT. CT is reserved for hospitalized, symptomatic patients with specific clinical indications for CT.”(2) Do not use CT for COVID-19 diagnosis.

Claudia: Next term is Honeymoon cystitis — Now why would you ruin a honeymoon which is supposed to be fun with the not so fun word cystitis.? Well because this uncomfortable infection is common in sexually active women and it makes sense that it can occur more often in newly-weds during a much-anticipated vacation. 

Hector: Recurrent urinary tract infections are a common problem in sexually active women. Anatomy is to blame of this problem. Sexual intercourse may cause local irritation of the urethral meatus and lead to cystitis ("honeymoon cystitis"). 

Claudia: Honey-colored crusts are present in Impetigo — This one is not as pretty as it sounds. Think of honey equals pus for this “honey colored crust”. Impetigo occurs most commonly on the face and can present with bullae, honey-colored crusts, erythema, edema, and exudate.

Hector: A very very important topic is Honey in infants— Because it must not be given to them! And here is why.  Infant botulism occurs when C. Botulinum spores, which can live in honey, are ingested, colonize the GI tract, and release a wicked toxin. In the US, most cases are thought to result from ingestion of environmental dust and soil containing C. botulinum spores. 

 

Claudia: The incidence of reported cases of infant botulism is highest in Utah, Pennsylvania, and California, states in which soil botulinum spore counts are high. 

 

Hector: Did you know Utah is called the beehive state? Infant botulism has been associated with the ingestion of raw honey, but telling people “Don’t give honey to your babies” has not changed the incidence of infant botulism in the United States.

[Insert joke here: Hey, a patient was admitted to the ICU because of botulism. Dr Saito: Did it take care of his wrinkles?

Claudia: Honey has a high fructose content, and it is part of the FODMAPs (fermentable oligo-, di-, mono-saccharides and polyols). A diet low in FODMAPs is recommended in patients with IBS. So, if you have IBS, honey is likely not the best sweetener for you. 

Now, let’s talk about Honeymoon phase of type 1 diabetes — A few weeks after the diagnosis and initiation of insulin therapy, a period of decreasing exogenous insulin (such as lispro or lantus) requirement occurs, commonly referred to as the "honeymoon" or remission phase of diabetes. During this period, the remaining functional beta cells in your pancreas secrete some endogenous insulin resulting in reduced exogenous requirement, so you give yourself less of the injectable insulin. 

Hector: I had a real case with this condition. He is a male patient on his mid 20s. He was diagnosed with diabetes let’s say in October 2019. He was admitted to the ICU because of DKA. His A1C was >11. He was sent home on insulin and then in January 2020 he decided to stop insulin “to see if he really needed it”. He came to me in July 2020, and I freaked out, I thought, “this guy’s sugar is going to be 500 and A1C will be in the double digits”. My surprise was that his insulin was 5.3! 

Claudia: Close monitoring of blood glucose is critical as hypoglycemic episodes are likely if the insulin is not adjusted appropriately. Some clues that the honeymoon phase in type 1 diabetes may be ending are: rising blood glucose levels, higher A1C, and increasing exogenous insulin need, that’s why monitoring is very important. The duration of this phase is variable and may last several months to several years. 

Hector: Let’s talk about folk medicine. This treatment has been known for centuries: Use of Honey in common cold – honey is an option for treating cough in children who are older than 1 year old with common cold symptoms. Honey can be given straight in 0.5 to 1 teaspoon or diluted in liquid like tea or juice. Corn syrup may be substituted if honey is not available. Honey has a modest beneficial effect on nocturnal cough and is unlikely to be harmful in children older than one year of age. Just as a reminder of what we covered earlier: Honey should be avoided in children younger than one year because of the risk of botulism.

Claudia:  In a randomized trial, 300 children (one to five years of age) with upper respiratory infection and nocturnal cough were assigned to receive a single dose (10 g) of honey (eucalyptus, citrus, or labiatae) or placebo (a date extract similar to honey in appearance and taste) before bedtime; caregivers completed a symptom survey on the days before and after the intervention; 270 children completed the study. Symptoms improved in all children after the intervention. However, children who received honey had greater mean improvement in cough frequency (1.85 versus 1.00 points), severity (1.94 versus 0.99 points) and bothersomeness (2.16 versus 1.25 points) than those who received placebo. 

Hector: Adverse effects such as abdominal pain, nausea, vomiting occurred in five patients, approximately evenly distributed among each of the honey and the placebo groups. The findings of this trial were confirmed in a 2018 systematic review and meta-analysis of randomized trials (mean difference in cough frequency -1.62, 95% CI -3.02 to -0.22)[3]. Honey also reduced cough frequency compared with no treatment and diphenhydramine.

Claudia: Given the relative safety and low cost of honey, the World Health Organization (WHO) and American Academy of Pediatrics (AAP) suggest it as a potential treatment for URI in young children who are older than one year. The American College of Chest Physicians suggests that honey is more effective than placebo for cough due to the common cold.

 

Hector: Now we can talk about one of the favorite topics of Dr Tu (listen to our episode 6 about wound care), let’s talk about the use of Honey in wound care — Did you guys know that honey has been used since ancient times for the management of wounds? Honey has broad-spectrum antimicrobial activity due to its high osmolarity and high concentration of hydrogen peroxide. 

 

Claudia: Medical-grade honey products are now available as a gel, paste, and impregnated into adhesive, alginate, and colloid dressings. Based upon the results of systematic reviews evaluating honey to aid healing in a variety of wounds, there are insufficient data to provide any recommendations for the routine use of honey for all wound types; specific wound types, such as burns, may benefit, whereas others, such as chronic venous ulcers and ingrown toenails after surgery, may not.

 

Hector: Honey in chemoprophylaxis in partial-thickness burns — so this is an interesting one; as we mentioned a couple of minutes ago honey has a broad spectrum antimicrobial activity, remember? High osmolarity and hydrogen peroxide content. Partial thickness burns are prone to rapid bacterial colonization which can potentially become an invasive infection. It makes sense that we can use honey for partial thickness burns.

Claudia: Anything more significant than sunburn or superficial burn since those do not need topical antimicrobials, normally, non-perfumed moisturizing cream is all that is needed. Silver Sulfadiazine can also be used but tends to delay healing. Modern hydrocolloid and silver impregnated dressings can be superior but surprise → honey “the ancient wound medicine” is still an effective treatment.

Hector: Great, we talked about honeycomb lung, honeymoon cystitis, honey-colored crusts in impetigo, honey in infants, honeymoon phase of type 1 diabetes, honey in common cold, wound care and burns. Fun fact: Honey can be stored indefinitely.

 

Jokes about Honey
by Katherine Schlaerth, Manuel Tu, Claudia Carranza, Gloria Villegas, and Gracie

Why do bees have sticky hair? --> because they use honey combs.

How do bees get to school? --> on the school buZZZ

What kind of bees make milk? --> BOO bees

What do you call a bee that lives in America? --> a USBee

What does a bee sit on? --> it’s Bee-hind 

What kind of bees live in graveyards? --> zom-bees

And remember, a bee that will not stop eating will eventually become a little Chuh-Bee!

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[Music] 

Speaking Medical: Macroglossia
by Xeng Xiong, MS4

Your tongue can say a lot about your health. Today, I will go over the medical term macroglossia which means enlargement of the tongue. Symptoms associated with macroglossia may include drooling, speech impairment, difficulty eating, snoring and airway obstruction. 

Macroglossia is an uncommon anatomical abnormality and is usually a sign of an underlying condition. Some of the diseases associated with macroglossia are Down syndrome, hypothyroidism, tuberculosis, sarcoidosis, and angioedema. 

Examination often reveals an enlarged appearance on the lateral margins of the tongue caused by crowding against the teeth.  It is important to consider macroglossia as a sign of an underlying disorder and proceed with focused diagnostic testing, including possible biopsy. 

Treatment should be directed at the underlying disorder. 

Thanks for listening to macroglossia and have a Tongue-tastic day!

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Speaking Medical: Presbycusis

Hi, I’m Dr Rodriguez and I am presenting the Medical Word of the week. 

If you remember, in episode 28, we talked about presbyopia, so today I will teach you about presbycusis. Presbycusis is just one form of hearing loss that happens as you age. Presbycusis affects more than half of all adults by the time they reach the age of 75. Presbycusis is a progressive sensorineural hearing loss that mostly affects hearing of high-pitched sounds. That means that a person with presbycusis might have trouble hearing a bird chirping, phone ringing, crowded places but still be able to hear a truck rumbling.

Multiple factors can influence the onset and severity of presbycusis, including white race, loud noise exposure, ototoxins (such as aminoglycosides), ear infections, smoking, hypertension, diabetes. 

In a patient with presbycusis, an audiogram will show decreased pure tone thresholds with relative preservation of word recognition. Even though hearing aids may offer some help, only a small percentage of patients actually receive effective treatment with amplification. Auditory rehabilitation, when available, is usually practiced in combination with hearing devices in presbycusis. For patients with severe presbycusis with poor response to conventional amplification, cochlear implantation offers hope to restore hearing.

So, remember the medical word of the week: presbycusis

Alyssa: Before you go, let me ask you a serious question. Many people told Beethoven that he would not make good music because he was deaf, but did he listen?

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[Music] 

Question of the week: Diabetes management

by Claudia Carranza, MD

 

Q: What is the first treatment approach for type 2 DM? For example, for a patient who had polydipsia, polyuria for a few weeks and at your office had a random BG of 210.

 

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Now we conclude our episode number 37: “Honey in Medicine.” We started with an update on medications used for smoking cessation. Then, Dr Carranza and Dr Arreaza presented medical conditions related to the word “honey”, and they explained evidence-based uses of honey in medicine. Dr Rodriguez defined presbycusis, and future Dr Xiong explained macroglossia. You may ask, “what does smoking, honey, deafness, and big tongues have in common?” The answer is: Family Medicine. Remember, the question of the week is: What is the first treatment approach for type 2 diabetes? The listener with the best answer will receive a prize! Send you answer to our email: rbresidency@clinicasierravista.org.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Claudia Carranza, Steven Saito, Alyssa Der Mugrdechian, Yodaisy Rodriguez, Xeng Xiong, Katherine Schlaerth, Gloria Villegas, Manuel Tu, and Gracie Pena. Audio edition: Suraj Amrutia. See you next week!

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References:

Leone, Frank T.; Zhang, Yuqing; Evers-Casey, Sarah, and col., Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline,  American Journal of Respiratory and Critical Care Medicine, American Thoracic Society,  https://doi.org/10.1164/rccm.202005-1982ST

 

Combet M, Pavot A, Savale L, Humbert M, Monnet X. Rapid onset honeycombing fibrosis in spontaneously breathing patient with COVID-19. Eur Respir J. 2020;56(2):2001808. Published 2020 Aug 27. doi:10.1183/13993003.01808-2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7338404/

 

ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection, American College of Radiology, https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Recommendations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection, accessed on Jan 13, 2021. 

 

Oduwole O, Udoh EE, Oyo-Ita A, Meremikwu MM. Honey for acute cough in children. Cochrane Database Syst Rev. 2018 Apr 10;4(4):CD007094. doi: 10.1002/14651858.CD007094.pub5. PMID: 29633783; PMCID: PMC6513626. https://pubmed.ncbi.nlm.nih.gov/29633783/

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