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Whooping cough is surging in Australia. Why, and how can we protect ourselves?

<p><em><a href="https://theconversation.com/profiles/laurence-don-wai-luu-1415508">Laurence Don Wai Luu</a>, <a href="https://theconversation.com/institutions/university-of-technology-sydney-936">University of Technology Sydney</a></em></p> <p>Australia is facing a whooping cough outbreak. Some <a href="https://nindss.health.gov.au/pbi-dashboard/">2,799 cases</a> were recorded in the first three months of 2024. Cases are highest in Queensland and New South Wales, with more than 1,000 recorded in each state.</p> <p>The last time Queensland recorded more than 1,000 cases in three months was <a href="https://nindss.health.gov.au/pbi-dashboard/">the first quarter of 2013</a>. This was at the tail end of a significant outbreak that spanned 2008 until 2012 – Australia’s largest reported outbreak since the <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/cda-cdi2205-pdf-cnt.htm/$FILE/cdi2205c.pdf">widespread introduction</a> of whooping cough vaccines <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/cda-pubs-annlrpt-oz_dis19_91.htm/$FILE/ozdis1917_91.pdf">in the 1950s</a>. More than 140,000 cases were recorded during this period, with the number peaking at 38,748 in 2011.</p> <p>There was a smaller outbreak between <a href="https://nindss.health.gov.au/pbi-dashboard/">2014 and 2017</a>, with more than 60,000 cases in these years.</p> <p>So what is whooping cough, why are cases rising now, and how can you protect yourself?</p> <h2>It’s most dangerous for babies</h2> <p>Whooping cough is a serious and <a href="https://www.healthdirect.gov.au/whooping-cough">highly contagious</a> respiratory disease. Also called pertussis, it’s caused by the bacteria <em>Bordetella pertussis</em>.</p> <p>The initial symptoms of whooping cough resemble other cold and flu-like symptoms. These include runny nose, sneezing, mild cough and fever. However, as the disease progresses into the second week, the coughing fits become worse and more frequent. After or between bouts of coughing, patients may gasp for air and produce the characteristic “whoop” noise.</p> <p>The disease is also sometimes called the “100-day cough” as it can last for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7150027/">6–12 weeks</a>. It’s especially serious and can be life-threatening in newborns who are yet to receive their vaccinations. In older children who are fully vaccinated, as well as adolescents and adults, the disease is normally less severe. However, even in adults, the coughing can lead to <a href="https://www.nejm.org/doi/full/10.1056/NEJMicm1701940">fractured ribs</a>.</p> <p>Antibiotics are used to <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/ebch.1845">treat whooping cough</a> but are most effective when given during the initial stages of the illness. The best protection in the first instance is <a href="https://www.healthdirect.gov.au/whooping-cough">vaccination</a>, which prevents most cases of serious illness, and reduces the spread of whooping cough in the community.</p> <p>It’s recommended children are given six doses of a whooping cough vaccine (which is combined with vaccines for other diseases) between the ages of roughly two months and 13 years. Vaccination is free under the <a href="https://www.health.gov.au/topics/immunisation/vaccines/whooping-cough-pertussis-immunisation-service">National Immunisation Program</a> for children and pregnant women. Vaccinating women against whooping cough during pregnancy protects newborns in their first months of life.</p> <p>Immunity from these vaccines wanes over time, so it’s also recommended adults receive a booster, particularly those who may come into frequent contact with babies.</p> <h2>Why are cases rising now?</h2> <p>Whooping cough outbreaks generally occur <a href="https://www.healthdirect.gov.au/whooping-cough">every 3–4 years</a>. Due to COVID measures such as border closures, social isolation and masks, the number of cases declined dramatically during 2020–23. If trends had followed the usual outbreak cycle, this might have been around the time we’d have seen another outbreak.</p> <p>Missed <a href="https://ncirs.org.au/ncirs-study-confirms-decline-childhood-vaccination-coverage-throughout-covid-19-pandemic">routine whooping cough vaccinations</a> at the height of the pandemic may mean Australia is more vulnerable now. Reduced immunity in the population could be one of the reasons we’re seeing a rise in whooping cough cases in Australia and other countries including the <a href="https://www.gov.uk/government/publications/pertussis-epidemiology-in-england-2024/confirmed-cases-of-pertussis-in-england-by-month">United Kingdom</a> and the <a href="https://www.nyc.gov/assets/doh/downloads/pdf/han/advisory/2024/han-advisory-5.pdf">United States</a>.</p> <p>In Australia, cases have been particularly high during this outbreak in children aged 10–14.</p> <h2>A potential superbug</h2> <p>Over the past two decades, whooping cough has been getting better at evading vaccines and antibiotics. Most vaccines used in Australia and other developed countries stimulate your immune system to recognise and target <a href="https://immunisationhandbook.health.gov.au/contents/vaccine-preventable-diseases/pertussis-whooping-cough">three to five components</a> of the bacteria.</p> <p>Over time, the bacteria that causes whooping cough has been slowly acquiring mutations in these genes. These mutations make the bacteria look slightly different to the one used in the vaccine, helping it better hide from the immune system.</p> <p>Most of these changes were small. But in 2008, a new strain appeared in Australia that no longer produced <a href="https://wwwnc.cdc.gov/eid/article/20/4/13-1478_article">pertactin</a>, one of the components targeted by the vaccine. This means your immune system, like a detective, has one less clue to recognise the bacteria.</p> <p>This new strain rapidly increased from <a href="https://wwwnc.cdc.gov/eid/article/25/6/18-0240_article">5% of strains found in 2008</a>, to become the dominant strain in less than ten years, making up <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6537726/">90% of strains</a> by 2017. This pertactin-negative strain was shown to survive better in <a href="https://pubmed.ncbi.nlm.nih.gov/26432908/">vaccinated mice</a> and may have contributed to the high number of cases in the 2008–12 outbreak.</p> <p>Worryingly, since 2013, <a href="https://www.cdc.gov/drugresistance/biggest-threats.html">antibiotic-resistant strains</a> of whooping cough have become <a href="https://www.tandfonline.com/doi/full/10.1080/22221751.2019.1587315">widespread in China</a>. While there are other antibiotics available, these are not recommended for infants <a href="https://www.health.nsw.gov.au/Infectious/whoopingcough/Pages/workers-managing-cases.aspx">younger than two months</a> (the age group at most risk of serious disease). These resistant strains are increasingly <a href="https://wwwnc.cdc.gov/eid/article/26/10/20-1035_article">spreading through Asia</a> but are not yet in Australia.</p> <h2>What next?</h2> <p>It’s too early to know how big this outbreak will be or what strains are responsible for it. Greater tracking of whooping cough strains, like we do with COVID, is needed to inform future vaccine design and treatments.</p> <p>Importantly, although the bacteria is evolving, current vaccines are still very effective at preventing serious disease and reducing transmission. They remain our best tool to limit this outbreak.</p> <p>To protect oneself, vulnerable newborns, and the wider community, everyone should ensure they are up-to-date with their <a href="https://immunisationhandbook.health.gov.au/contents/vaccine-preventable-diseases/pertussis-whooping-cough">whooping cough vaccinations</a>. You can check this with your GP if you’re not sure. And anyone with cold or flu-like symptoms should <a href="https://ncirs.org.au/ncirs-fact-sheets-faqs/pertussis">stay away</a> from infants.<!-- Below is The Conversation's page counter tag. Please DO NOT REMOVE. --><img style="border: none !important; box-shadow: none !important; margin: 0 !important; max-height: 1px !important; max-width: 1px !important; min-height: 1px !important; min-width: 1px !important; opacity: 0 !important; outline: none !important; padding: 0 !important;" src="https://counter.theconversation.com/content/226918/count.gif?distributor=republish-lightbox-basic" alt="The Conversation" width="1" height="1" /><!-- End of code. If you don't see any code above, please get new code from the Advanced tab after you click the republish button. The page counter does not collect any personal data. More info: https://theconversation.com/republishing-guidelines --></p> <p><a href="https://theconversation.com/profiles/laurence-don-wai-luu-1415508"><em>Laurence Don Wai Luu</em></a><em>, Lecturer and Chancellor's Research Fellow, School of Life Sciences, <a href="https://theconversation.com/institutions/university-of-technology-sydney-936">University of Technology Sydney</a></em></p> <p><em>Image credits: Getty Images </em></p> <p><em>This article is republished from <a href="https://theconversation.com">The Conversation</a> under a Creative Commons license. Read the <a href="https://theconversation.com/whooping-cough-is-surging-in-australia-why-and-how-can-we-protect-ourselves-226918">original article</a>.</em></p>

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URGENT RECALL of 44 different cough medicines

<p>Numerous cough medicines containing pholcodine are being stripped from pharmacy shelves after a safety investigation was undertaken by the Therapeutic Goods Administration (TGA).</p> <p>55 products are being cancelled from the Australian Register of Therapeutic Goods.</p> <p>Of the 55 products containing pholcodine that were registered in Australia, 44 products are currently stocked on shelves in pharmacies and are subject to the recall, a spokesperson from the TGA told 7News.</p> <p>The discovery of a new link between pholcodine-containing medicines and an increased risk of anaphylactic reactions to certain medicines used as muscle relaxants during general anaesthesia prompted the action.</p> <p>Pholcodine has been used in a wide range of over-the-counter medicines to treat dry coughs, particularly present in syrups and lozenges. It is also used in combination with other medicines in products that treat the symptoms of cold and flu.</p> <p>“It is difficult to reliably predict who may be at risk of anaphylaxis during anaesthesia and some patients may not know if they have taken pholcodine medicines recently,” TGA Head Adjunct Professor John Skerritt said.</p> <p>“Some patients undergoing emergency surgery may not be in a position to talk to their anaesthetist at all. In addition, while surgical facilities may ask about which prescription medicines a patient is taking, they may not ask about over-the-counter products.</p> <p>“Fortunately, safer alternatives to treat a dry cough are available and consumers should ask their doctor or pharmacist for advice. I urge consumers to check if any of your over-the-counter cold and flu medicines contain pholcodine and, if they do, ask your doctor or pharmacist to suggest an alternative treatment.</p> <p>“If you will need general anaesthesia and have taken pholcodine in the past 12 months, I advise you to tell your health professional. Health professionals should also check whether patients scheduled to undergo general anaesthesia have used pholcodine in the previous 12 months.”</p> <p>The European Medicines Agency (EMA) had recently recommended the withdrawal of marketing authorisations for these products in Europe, prompting the review in Australia.</p> <p>Supported by a Western Australia study, the European findings showed that pholcodine was a risk factor.</p> <p>The TGA has received 50 reports of Australian cases of suspected pholcodine-related anaphylactic reactions to neuromuscular blockers, including one fatality earlier this year.</p> <p>Find the full list of recalled products <a href="https://www.tga.gov.au/safety/information-about-specific-safety-alerts-and-recalls/about-pholcodine-cough-medicines-cancelled-tga-and-recalled-pharmacies-safety-reasons" target="_blank" rel="noopener">here</a>.</p> <p><em>Image credit: Getty</em></p>

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Airlines to cough up millions in refunds and fines over delays and cancellations

<p dir="ltr">Frustrated travellers subject to major delays or cancellations to their US flights could be entitled to a portion of $US 600 million ($AU 896 million) in refunds from six airlines forced to refund their customers.</p> <p dir="ltr">The airlines have been ordered to pay back customers by the US Department of Transport as part of “historic enforcement actions”.</p> <p dir="ltr">Under US law, customers must be refunded by airlines or ticket agents if the airline cancels or significantly changes a flight to, from or within the US and they don’t want to accept the alternate offer.</p> <p dir="ltr">The department also ordered the airlines to pay a total of $US 7.25 million ($AU 10.84 millIon) in fines for “extreme delays in providing refunds”.</p> <p dir="ltr">“When a flight gets cancelled, passengers seeking refunds should be paid back promptly. Whenever that doesn’t happen, we will act to hold airlines accountable on behalf of American travellers and get passengers their money back.” said U.S. Transportation Secretary Pete Buttigieg in <a href="https://www.transportation.gov/briefing-room/more-600-million-refunds-returned-airline-passengers-under-dot-rules-backed-new" target="_blank" rel="noopener">a press release</a> shared on Monday.</p> <p dir="ltr">“A flight cancellation is frustrating enough, and you shouldn’t also have to haggle or wait months to get your refund.”</p> <p dir="ltr">According to 7News.com.au, the refunds apply to both US and international travellers.</p> <p dir="ltr">The fines and refunds vary from airline to airline, with the affected airlines including: </p> <ul> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Frontier Airlines - ordered to refund $US 222 million ($AU 331.9 million) and pay $US 2.2 million ($AU 3.2 million) in fines</p> </li> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Air India - to pay back $US 121.5 million ($AU 181.6 million) and fined $US 1.4 ($AU 2.1 million)</p> </li> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">TAP Portugal - with refunds totalling $US 126.5 million ($AU 189.1 million) and fines of $US 1.1 million ($AU 1.6 million)</p> </li> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Aeromexico - to refund $US 13.6 million ($AU 20.3 million) and pay $900,000 ($AU 1.3 million) in fines</p> </li> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">El Al - due to pay $US 61.9 million ($AU 92.5 million) in refunds and $900,000 ($AU 1.3 million) in fines</p> </li> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Avianca - with total refunds of $US 76.8 million ($AU 114.8 million) and a fine of $US 750,000 ($AU 1.1 million)</p> </li> </ul> <p dir="ltr">Most of the fines will be paid to the Treasury Department, with the remainder to be credited based on airlines paying customers beyond the legal requirement.</p> <p dir="ltr">According to Blane Workie, the assistant general counsel for the Office of Aviation Consumer Protection DOT, the refunds have either already been made or customers should have been informed of them.</p> <p><span id="docs-internal-guid-fdbaa05c-7fff-7d0d-8da4-81e90c75a489"></span></p> <p dir="ltr"><em>Image: Getty Images</em></p>

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Why has my cold dragged on so long, and how do I know when it’s morphed into something more serious?

<p>Common colds are caused by viruses. There are no effective cures, and antibiotics do not work on viruses, so treatment is targeted at managing the symptoms until your immune system has cleared the cold.</p> <p>So why might someone go to a doctor at all for a cold?</p> <p>Well, occasionally a cold might turn into something more serious requiring assessment and specific treatment, and a GP visit could be warranted. Or you may just want reassurance and advice.</p> <h2>Don’t rush to the GP for something totally normal</h2> <p>Problems arise when there too many unwarranted visits to GPs for cold symptoms.</p> <p>Studies have shown <a href="https://www.annfammed.org/content/11/1/5" target="_blank" rel="noopener">antibiotics</a> are <a href="https://onlinelibrary.wiley.com/doi/abs/10.5694/mja16.01042" target="_blank" rel="noopener">still prescribed widely</a> for viral colds, even though they don’t help, and this contributes to antibiotic resistance. It hastens the arrival of an era when many antibiotics simply don’t work at all.</p> <p>On average, children have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152362/" target="_blank" rel="noopener">four to six colds</a> per year, while in adults the average is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152362/" target="_blank" rel="noopener">two to three</a>.</p> <p>Some people are more <a href="https://www.sciencedirect.com/science/article/abs/pii/S1530156705601189?via%3Dihub" target="_blank" rel="noopener">prone</a> to colds, but we don’t know exactly why.</p> <p>The usual cold persists about one week, although 25% last two weeks. In one <a href="https://journals.asm.org/doi/10.1128/jcm.35.11.2864-2868.1997" target="_blank" rel="noopener">study</a> with 346 adults, the infection lasted 9.5 to 11 days.</p> <p>Cold symptoms may last longer in younger children. One <a href="https://publications.aap.org/pediatrics/article-abstract/87/2/129/56810/Upper-Respiratory-Tract-Infections-in-Young?redirectedFrom=fulltext" target="_blank" rel="noopener">study</a> showed an average duration of colds ranged from 6.6 to 9 days. But symptoms lasted more than 15 days in 6.5% of 1-3 year old children in home care, and 13.1% of 2-3 year old children in day care.</p> <p>A cough tends to last longer than other symptoms, and often beyond the actual viral infection. The average <a href="https://www.annfammed.org/content/11/1/5" target="_blank" rel="noopener">duration</a> of a cough is about 17.8 days.</p> <h2>Discoloured sputum, cough or snot</h2> <p>Discoloured mucus in snot or cough is a common trigger for requesting antibiotics from a GP. But as we know, antibiotics are useless against a virus. They only work against bacterial infection.</p> <p>In fact, thick or coloured nasal mucus secretion is common following colds. Only a tiny proportion <a href="https://europepmc.org/article/pmc/pmc7151789" target="_blank" rel="noopener">involve</a> bacterial infection.</p> <p>When it happens, this is termed <a href="https://www.nps.org.au/australian-prescriber/articles/treating-acute-sinusitis-3" target="_blank" rel="noopener">acute rhinosinusitis</a>. But antibiotics are not recommended unless it lasts more than ten to 14 days and there are <a href="https://europepmc.org/article/pmc/pmc7151789" target="_blank" rel="noopener">signs</a> of bacterial sinusitis infection, such as:</p> <ul> <li>symptoms worsening after improvement in the original cold</li> <li>return of fever and</li> <li>strong facial pain.</li> </ul> <p>A prolonged cough after colds is usually caused by an irritated throat or the clearing of sticky mucus coming down from the nose. The cough may sound moist (so wrongly called “chesty”) due to the phlegm, but only small amounts of phlegm are coughed up.</p> <p>Yellow or green coloured mucus is often interpreted as a <a href="http://theconversation.com/health-check-what-you-need-to-know-about-mucus-and-phlegm-33192" target="_blank" rel="noopener">sign</a> of bacterial infection.</p> <p>But yellow or green sputum alone <a href="https://www.tandfonline.com/doi/full/10.1080/02813430902759663" target="_blank" rel="noopener">does not</a> mean you have a serious bacterial infection. One study found being prescribed antibiotics under these circumstances <a href="https://erj.ersjournals.com/content/38/1/119" target="_blank" rel="noopener">failed</a> to shorten recovery time.</p> <p>Nasal saline sprays and washes can be used to rinse out the nose and sinuses and possibly <a href="https://dtb.bmj.com/content/57/4/56" target="_blank" rel="noopener">shorten</a> rhinosinusitis and cough after colds.</p> <h2>Could it just be hayfever, or another underlying issue?</h2> <p>Hayfever or allergic rhinitis is a common cause for prolonged symptoms after a cold, especially cough and nasal congestion and maybe also sneezing.</p> <p>The damage in the upper airways following a viral infection may allow airborne allergens to trigger hayfever. Self-medicating with antihistamines, nasal saline spray or intranasal steroids is worthwhile if <a href="https://theconversation.com/health-check-why-do-i-have-a-cough-and-what-can-i-do-about-it-119172" target="_blank" rel="noopener">allergic rhinitis</a> is suspected.</p> <p>There may be other reasons for persistence of cough, such as exacerbation of underlying asthma or chronic lung disease. If so, this may require a visit to your GP.</p> <h2>What about bronchitis or pneumonia?</h2> <p>Many people worry about developing a chest infection after a cold.</p> <p>Acute bronchitis is a self-limiting infectious disease characterised by acute cough with or without sputum but without <a href="https://www.nhs.uk/conditions/pneumonia/" target="_blank" rel="noopener">signs of pneumonia</a> (such as high temperatures and feeling breathless). Most acute bronchitis cases are caused by viruses. Antibiotics are often prescribed, but produce <a href="https://www.tandfonline.com/doi/full/10.1080/14787210.2016.1193435" target="_blank" rel="noopener">no significant clinical improvement</a> compared with placebo, so are not recommended.</p> <p>Pneumonia is a potentially serious secondary disease that <a href="https://pubmed.ncbi.nlm.nih.gov/28159155/" target="_blank" rel="noopener">may follow</a> an episode of flu in a small number of cases, but is <a href="https://www.ncbi.nlm.nih.gov/books/NBK532961/" target="_blank" rel="noopener">relatively rare</a> following a cold. Symptoms and signs of pneumonia feature heavily in the list of warning signs that signal the need for a medical assessment.</p> <h2>When should I seek medical help for a cough or a cold?</h2> <p>Contact a GP if you experience:</p> <ul> <li>shortness of breath or trouble breathing</li> <li>feeling faint or dizzy</li> <li>chest pain</li> <li>dehydration</li> <li>fever or cough symptoms that improve but then return or worsen</li> <li>worsening of chronic medical conditions such as asthma.</li> </ul> <p>This is not a complete list, but may guide you on what to expect and what to watch out for.</p> <p>You might also contact your GP (perhaps for a telehealth consult) if you are finding your symptoms very unpleasant, or are concerned your condition is more serious or prolonged than expected. You might just need reassurance and education about self care options.</p> <p><strong>This article originally appeared on <a href="https://theconversation.com/why-has-my-cold-dragged-on-so-long-and-how-do-i-know-when-its-morphed-into-something-more-serious-190429" target="_blank" rel="noopener">The Conversation</a>.</strong></p> <p><em>Image: Shutterstock</em></p>

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Man charged after "coughing" on co-workers and giving them COVID-19

<div class="post_body_wrapper"> <div class="post_body"> <div class="body_text redactor-styles redactor-in"> <p>A 40-year-old man from Majorca has been arrested on assault charges after allegedly infecting more than 22 people with coronavirus.</p> <p>The man refused to isolate himself at the requests of his colleagues and continued to work out at the gym while displaying COVID-19 symptoms.</p> <p>An investigation by police into the man's behaviour began at the end of January.</p> <p>"Days before the outbreak was revealed, the worker began to present symptoms compatible with the disease, so his colleagues began to worry as they observed that he was not well," a police statement said.</p> <p>Police allege that the man was "coughing loudly all over the place" and lowering his mask at work.</p> <p>"I'm going to give you all the coronavirus," the man allegedly said to his colleagues.</p> <p>The man was tested for coronavirus but decided to go to his gym and workplace instead of isolating, resulting in the infection of eight people.</p> <p>The people directly infected from the man, which were five at his workplace and three at the gym, then passed the disease onto their loved ones.</p> <p>This includes three babies being infected with COVID-19.</p> <p>"The worker was arrested as the alleged perpetrator of a crime of injuries and yesterday he was placed at the disposal of the Judicial Authority," the police said.</p> <p>None of the people infected by the man have been admitted to hospital.</p> </div> </div> </div>

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Coughs on film and the fine but deadly art of foreshadowing

<p>Movie characters – like Greek heroes – are typically faster, stronger, braver and better looking than those of us in the audience who stare on in admiration. We watch as obstacles are overcome and goals achieved, attracted by the <a href="https://libres.uncg.edu/ir/asu/f/Bazzini_Doris_1999_Are_the_Beautiful_Good_in_Hollywood.pdf">beauty and goodness</a> in the cinematic story world.</p> <p>But, should movie characters cough as they go about their extraordinary business, you can just about guarantee they will be dead before the end of the film. The screen cough, it seems, is fatal.</p> <p>In the time of COVID-19, the screen cough takes on new significance. A low budget Canadian film <a href="https://www.bbc.com/news/av/world-us-canada-52232382/coronavirus-seven-people-stuck-in-a-lift-then-one-coughs">made early this year</a> is thought to be the first movie about coronavirus. It features a woman getting into a lift with others and the confrontations that ensue when she starts coughing.</p> <p><strong>More than a tickle</strong></p> <p>From Marguerite Gauthier (played by Greta Garbo) in the 1936 movie <a href="https://www.imdb.com/title/tt0028683/?ref_=fn_al_tt_1">Camille</a>, to Boris Shcherbina (Stellan Skarsgard) in the HBO series <a href="https://www.imdb.com/title/tt7366338/?ref_=nv_sr_srsg_0">Chernobyl</a> (2019), coughing on screen has deadly significance.</p> <p>In the dramatic opening moments of the first episode of <a href="https://www.imdb.com/title/tt4786824/?ref_=fn_al_tt_1">The Crown</a> (2016), there is only darkness and silence … until we hear the sound of a dreadful hacking cough. Fade in to reveal King George V (Jared Harris, who also coughed in Chernobyl) in his bathroom, looking concerned. He coughs some more. Terribly sorry, your Majesty, but you’ll be dead before the end of Episode 2.</p> <p>Satine (Nicole Kidman) coughs in Moulin Rouge (2000)</p> <p>Nicole Kidman, as Satine in Baz Luhrmann’s <a href="https://www.imdb.com/title/tt0203009/?ref_=fn_al_tt_1">Moulin Rouge</a> (2001) coughs on page 35 of the screenplay. Well, she has been singing and dancing vigorously in front of Christian (Ewen McGregor) in a steamy Parisian nightclub, so perhaps it’s just a question of fitness.</p> <p>“Oh, these silly costumes” she says to those gathered around her, in an attempt to explain her breathlessness. But it’s neither the clothes nor the exertion: the screen cough means she is doomed to die 83 pages later, in her lover’s arms, afflicted like Garbo’s Marguerite with tuberculosis.</p> <p>The <a href="https://www.youtube.com/watch?v=mijaVWfKhKU">sound of a cough opens</a> Steven Soderbergh’s 2011 film <a href="https://www.imdb.com/title/tt1598778/?ref_=fn_al_tt_1">Contagion</a>, currently one of the world’s <a href="https://www.washingtonpost.com/technology/2020/03/06/contagion-streaming/">top streaming titles</a>.</p> <p>That cough belongs to Beth Emhoff (Gwyneth Paltrow) and, sure enough, she doesn’t make it very far into the movie. The virus that takes her to an early screen grave also infects Erin Mears (Kate Winslet) who coughs while on the phone to her boss (Laurence Fishbourne). His look is enough to confirm our fears and within a few scenes her lifeless form is being zipped into a body bag.</p> <p>Erin Mears (Kate Winslet) coughs in Contagion (2011).</p> <p>Many others have succumbed to the <a href="https://tvtropes.org/pmwiki/pmwiki.php/Main/IncurableCoughOfDeath">incurable screen cough of death</a>, including even Yoda in <a href="https://www.imdb.com/title/tt0086190/?ref_=fn_al_tt_1">Return of the Jedi</a> (1983). To be fair, Yoda is 900 years old and knows he’s about to die. “Soon,” he splutters to Luke Skywalker, “I will rest. Yes, forever sleep” and promptly becomes one with the Force.</p> <p><strong>Selling it</strong></p> <p>The screen cough is a phenomenon so well known by screenwriters that it’s become the subject of parody. Mitchell &amp; Webb played with the trope in a BBC sketch named The Man Who Has A Cough And It’s Just A Cough And He’s Fine in 2008.</p> <p>Alec Baldwin went one step further on Saturday Night Live in 2009 with an actors studio-style breakdown on how to sell your impending death effectively, starting with the fateful cough. The <a href="https://snltranscripts.jt.org/08/08pcoughs.phtml">sketch</a> – First Coughs: Mastering the Art of Foreshadowing Your Character’s Death – starts with step one: say “it’s only a cold”. Sometime later, the actor should emphatically state, “I don’t need any damn doctors!”. The final step is complex but mightily effective: “cough into a handkerchief, notice that there’s blood on it, look around nervously, then quickly shove it back in your pocket and hurry on your way”.</p> <p>When I see these send-ups, of course I laugh, but with a tinge of resentment: parody is both celebration and humiliation. I can’t help but think that I’ll never again be able to see the beautiful &amp; dramatic subtlety of a well placed screen cough without a snigger.</p> <p>The Man Who Has A Cough And It’s Just A Cough And He’s Fine (2008)</p> <p><strong>Smoke signals</strong></p> <p>The art of signalling a future event in narration is a literary device apparent in the earliest ancient stories. It comes in many forms, from prophesy, dreams and omens to portents and apprehensions.</p> <p>In the 4000-year-old poetic work, <a href="https://theconversation.com/guide-to-the-classics-the-epic-of-gilgamesh-73444">Epic of Gilgamesh</a>, dreams predict the hero’s victorious battle with a great bull as well as his friend’s tragic death. Early in Sophocles’s play <a href="https://www.britannica.com/topic/Oedipus-Rex-play-by-Sophocles">Oedipus Rex</a>, a blind prophet riddles the truth of the story to come. The Bible is full of prophecy, none more memorable than Jesus’s prediction in The Gospel of John that one of his disciples would betray him.</p> <p>Driven by our need for certainty, we value knowing what may lie ahead. Facing open time, with all its possibilities, takes courage and – from budgets to prayers – we seek to gain a sense of control over our future. It’s unsurprising that we find pleasure in stories where foreshadowing signals what will happen, from storytellers who sneak the future into the present.</p> <p>The ability to manipulate the direction of time is fundamental to sophisticated narration. Merely explaining what happens next – the way time works in real life – is not enough when it comes to entertainment. There’s nothing more tedious than a story that proceeds along the lines of “this happens, then this, then this” and so on. Novelist E. M. Forster – who wrote A Room with a View, Howard’s End and A Passage to India – famously <a href="http://publications.anveshanaindia.com/wp-content/uploads/2016/11/NARRATIVE-TECHNIQUE-IN-LITERATURE-WITH-REFERENCE-TO-E-M-FORSTER%E2%80%99S-WORKS.pdf">decreed</a> that this kind of primitive narration causes listeners to fall asleep or rise up to kill the storyteller.</p> <p>To avoid such a fate, skilled narrators use foreshadowing to create tension, build anticipation and hook the audience into a belief that there’s something of interest to follow. We instinctively know that everything in a story has been planned and the author has determined the destiny of each character, so we intuitively look for the signs and the structures that will take us towards closure, including moments of foreshadowing.</p> <p>They can be subtle and poetic (a storm or a shooting star), psychological (a character worrying about something that has yet to be revealed) or concrete, like the appearance of a deadly weapon. But common to all these forms of foreshadowing is that we see them as the future pointing backwards. The grief to come has caused the present storm; bad news the anxiety; the body at the end of the film requires the gun at the start.</p> <p><a href="https://www.youtube.com/watch?v=DPFsuc_M_3E">Alfred Hitchcock</a> knew only too well the importance of being able to play with time. Imagine four people seated at a table having a conversation about football for five minutes, when suddenly a bomb goes off. That’s five minutes of boredom followed by a surprise. What’s in it for the audience, says Hitchcock, is only “ten seconds of shock”. But take the same scene and show the audience the bomb at the beginning, and the conversation about football becomes an exercise in suspense and high anxiety.</p> <p>Orson Welles plays out this idea in the famous opening scene of Touch of Evil (1958), showing us a bomb set to go off in three minutes. It’s then hidden in the boot of a car that moves erratically through a busy crowd. We hold our breath wondering where the car will be when the time is up.</p> <p>Opening Scene of Touch of Evil (1958)</p> <p><strong>The cough is a timebomb</strong></p> <p>The screen cough is also the ticking of a bomb, leaving both character and audience unsure when it will go off. One of the most dramatic screen coughs occurs in <a href="https://www.imdb.com/title/tt5027774/?ref_=fn_al_tt_1">Three Billboards Outside Ebbing, Missouri</a> (2017). It’s revealed early in the movie that police chief Willoughby (Woody Harrelson) has terminal pancreatic cancer, but it’s a brutal shock when he violently coughs blood over Mildred Hayes (Francis McDormand).</p> <p>In a strangely poignant sequence, writer/director Martin McDonagh opts for Willoughby to take his own life rather than let the disease run its course: he knows what lies ahead after that dreadful coughing incident.</p> <p>Storytellers have a delicate balancing act to maintain when it comes to foreshadowing. Too oblique or poetic and the audience struggles to see the connection between the signalling moment and the signalled event, or perhaps only recognises it retrospectively. Because the screen cough is linked to both a specific individual (the sufferer) and a specific outcome (death), it’s necessary to be subtle when using it as a narrative device.</p> <p>Perhaps we are now beyond subtlety. The combination of our current hyper-vigilance of respiratory symptoms and the increasing awareness of the function of the screen cough, risks it becoming a dreadful cliche, a trope in need of a innovative makeover. Like the good guys wearing white hats in Westerns, and detectives smoking excessively in <em>film noir</em>, it may just be time to give the screen cough a breather.</p> <p><em>Written by Simon Weaving. Republished with permission of <a href="https://theconversation.com/friday-essay-coughs-on-film-and-the-fine-but-deadly-art-of-foreshadowing-135697">The Conversation.</a> </em></p>

Movies

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Dry, wet, barking, hacking: A guide to coughs in the time of coronavirus

<p>For centuries, doctors and care givers have listened to the different types of cough in search of clues to help <a href="https://doi.org/10.1016/j.imu.2020.100319">diagnose</a> underlying disease.</p> <p>Coughs are a valuable diagnostic tool, but how do you know if you’ve got a relatively harmless cough, a coronavirus cough – or something else altogether?</p> <p>An occasional cough is healthy, but one that persists for weeks, produces bloody mucus, causes changes in phlegm colour or comes with fever, dizziness or fatigue may be a sign you need to see a doctor.</p> <p><strong>Cough questions</strong></p> <p>If you’ve gone to see a doctor about a cough, he or she will want to know:</p> <ul> <li>how long has the cough lasted? Days, weeks, months?</li> <li>when is the cough most intense? Night, morning, intermittently throughout the day?</li> <li>how does the cough sound? Dry, wet, barking, hacking, loud, soft?</li> <li>does the cough produce symptoms such as vomiting, dizziness, sleeplessness or something else?</li> <li>how bad is your cough? Does it interfere with daily activities, is it debilitating, annoying, persistent, intermittent?</li> </ul> <p><strong>COVID-19 cough: dry, persistent and leaves you short of breath</strong></p> <p>The most prominent symptoms of COVID-19 are fever and fatigue, and you may feel like you have a cold or flu. Cough is present in about half of infected patients.</p> <p>Considering that COVID-19 irritates lung tissue, the cough is dry and persistent. It is accompanied with shortness of breath and muscle pain.</p> <p>As disease progresses, the lung tissue is filled with fluid and you may feel even more short of breath as your body struggles to get enough oxygen.</p> <p><strong>Wet and phlegmy or dry and hacking?</strong></p> <p>A wet cough brings up phlegm from the lower respiratory tract (the lungs and lower airways, as opposed to your nose and throat) into the mouth.</p> <p>The “wet” sound is caused by the fluid in the airways and can be accompanied by a wheezing sound when breathing in. The lower airways have more secretory glands than your throat, which is why lower respiratory tract infections cause a wet cough.</p> <p>A dry cough doesn’t produce phlegm. It usually starts at the back of the throat and produces a barking or coarse sound. A dry cough does not clear your airways so sufferers often describe it as an unsatisfactory cough.</p> <p>Nose and throat infections cause irritation to those areas and produce a hacking dry cough with sore throat. These types of cough are often seen in flu or cold.</p> <p>Sometimes a cough can start off dry but eventually turn wet.</p> <p>For example, the lung infection pneumonia often begins with a dry cough that’s sometimes painful and can cause progressive shortness of breath. As infection progresses, the lung air sacs (alveoli) can fill up with inflammatory secretions such as lung tissue fluid and blood, and then the cough will become wet. At this stage, sputum becomes frothy and blood-tinged.</p> <p><strong>What about whooping cough?</strong></p> <p>Whooping cough is caused by bacterial infection that affects cells in the airways and causes irritation and secretion.</p> <p>Symptoms include coughing fits that end in a loud, “breathing in” noise that often sounds like a long “whoop” and leaves you gasping for air. Mucus is often expelled.</p> <p>Prolonged, forceful coughing can damage your airways, or cause rib fractures or muscle tears – so it’s important to know when medical help is required.</p> <p>So whatever your cough sounds like, keep an eye on it and see a doctor (either in person or via a <a href="https://theconversation.com/what-can-you-use-a-telehealth-consult-for-and-when-should-you-physically-visit-your-gp-135046">telehealth</a> appointment) if it doesn’t go away or gets worse.<!-- Below is The Conversation's page counter tag. Please DO NOT REMOVE. --><img style="border: none !important; box-shadow: none !important; margin: 0 !important; max-height: 1px !important; max-width: 1px !important; min-height: 1px !important; min-width: 1px !important; opacity: 0 !important; outline: none !important; padding: 0 !important; text-shadow: none !important;" src="https://counter.theconversation.com/content/136048/count.gif?distributor=republish-lightbox-basic" alt="The Conversation" width="1" height="1" /><!-- End of code. If you don't see any code above, please get new code from the Advanced tab after you click the republish button. The page counter does not collect any personal data. More info: https://theconversation.com/republishing-guidelines --></p> <p><span><a href="https://theconversation.com/profiles/maja-husaric-1025997"><em>Maja Husaric</em></a><em>, Lecturer, <a href="https://theconversation.com/institutions/victoria-university-1175">Victoria University</a> and <a href="https://theconversation.com/profiles/vasso-apostolopoulos-105605">Vasso Apostolopoulos</a>, Pro Vice-Chancellor, Research Partnerships, <a href="https://theconversation.com/institutions/victoria-university-1175">Victoria University</a></em></span></p> <p><em>This article is republished from <a href="https://theconversation.com">The Conversation</a> under a Creative Commons license. Read the <a href="https://theconversation.com/dry-wet-barking-hacking-a-guide-to-coughs-in-the-time-of-coronavirus-136048">original article</a>.</em></p>

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The shocking reason Sam Armytage has been absent from Sunrise for four weeks

<p>Fan favourite Sam Armytage hasn’t been seen on the set of<span> </span><em>Sunrise</em><span> </span>for over a month as she continues to recover from a “respiratory illness”.</p> <p>Armytage, 43, was first absent from the show seven weeks ago on February 26, claiming she was “at home, sick as a dog”.</p> <p>Fans first learned of her absence from the show via an Instagram story posted on March 17th.</p> <p>'Hi all... I'm taking a few weeks off work as I've had a respiratory infection (for three months) since the bushfires and it just won't heal,' she wrote.</p> <p>'I don't have coronavirus, but I'm worried I'll get it if I don't get better. Thought it was a good time to lie low.' </p> <p>She provided an update on March 23rd, praising Natalie Barr for filling in for her so she can “rest and recover as quickly as possible”.</p> <p>Armytage also slammed newspaper gossip writer Annette Sharp, saying that she was “setting the record straight after almost 10 years of her obsessive (and mostly wrong!) writing about me.”</p> <p>The two Instagram posts appear to be screenshots of text messages to Sharp, debunking Sharp’s latest accusations and addresses her absence on<span> </span>Sunrise.</p> <p>“I’m not sure where you get your information from, but it’s consistently wrong. I gave up my Christmas holiday to cover the bushfires and the consistent exposure to the smoke has left me with a respiratory infection, which is impossible to shake when you get up at 3 am each day”.</p> <p>“I’m very fortunate to have Nat to back me up, so that I can rest and recover as quickly as possible (&amp; she’s doing a wonderful job).</p> <p>“I’m NOT off contract at the end of 2020, no social media posts have been deleted (insta stories delete themselves after 24 hours) and I have NEVER asked 7 for a 4 day week).”</p> <blockquote style="background: #FFF; border: 0; border-radius: 3px; box-shadow: 0 0 1px 0 rgba(0,0,0,0.5),0 1px 10px 0 rgba(0,0,0,0.15); margin: 1px; max-width: 540px; min-width: 326px; padding: 0; width: calc(100% - 2px);" class="instagram-media" data-instgrm-captioned="" data-instgrm-permalink="https://www.instagram.com/p/B-DIpiqH5L4/?utm_source=ig_embed&amp;utm_campaign=loading" data-instgrm-version="12"> <div style="padding: 16px;"> <div style="display: flex; flex-direction: row; align-items: center;"> <div style="background-color: #f4f4f4; border-radius: 50%; flex-grow: 0; height: 40px; margin-right: 14px; width: 40px;"></div> <div style="display: flex; flex-direction: column; flex-grow: 1; justify-content: center;"> <div style="background-color: #f4f4f4; border-radius: 4px; flex-grow: 0; height: 14px; margin-bottom: 6px; width: 100px;"></div> <div style="background-color: #f4f4f4; border-radius: 4px; flex-grow: 0; height: 14px; width: 60px;"></div> </div> </div> <div style="padding: 19% 0;"></div> <div style="display: block; height: 50px; margin: 0 auto 12px; width: 50px;"></div> <div style="padding-top: 8px;"> <div style="color: #3897f0; font-family: Arial,sans-serif; font-size: 14px; font-style: normal; font-weight: 550; line-height: 18px;">View this post on Instagram</div> </div> <p style="margin: 8px 0 0 0; padding: 0 4px;"><a style="color: #000; font-family: Arial,sans-serif; font-size: 14px; font-style: normal; font-weight: normal; line-height: 17px; text-decoration: none; word-wrap: break-word;" rel="noopener" href="https://www.instagram.com/p/B-DIpiqH5L4/?utm_source=ig_embed&amp;utm_campaign=loading" target="_blank">My text to newspaper gossip writer Annette Sharp. Setting the record straight, after almost ten years of her obsessive (&amp; mostly wrong!) writing about me... You’d think right now there’d be more important (or perhaps positive?) things to write about in the world?!? 1/2 cont...</a></p> <p style="color: #c9c8cd; font-family: Arial,sans-serif; font-size: 14px; line-height: 17px; margin-bottom: 0; margin-top: 8px; overflow: hidden; padding: 8px 0 7px; text-align: center; text-overflow: ellipsis; white-space: nowrap;">A post shared by <a style="color: #c9c8cd; font-family: Arial,sans-serif; font-size: 14px; font-style: normal; font-weight: normal; line-height: 17px;" rel="noopener" href="https://www.instagram.com/sam_armytage/?utm_source=ig_embed&amp;utm_campaign=loading" target="_blank"> Samantha Armytage ⭐️</a> (@sam_armytage) on Mar 22, 2020 at 1:15pm PDT</p> </div> </blockquote> <p>There has been no update since, although recent posts on Instagram seem to indicate she may have made a full recovery after a sweet post with her boyfriend Richard Lavender on the couch watching the races.</p> <p>“Ready for Randwick” she wrote in the caption, and then joked that the best part about watching it from home was “no queue for the loo”.</p> <blockquote style="background: #FFF; border: 0; border-radius: 3px; box-shadow: 0 0 1px 0 rgba(0,0,0,0.5),0 1px 10px 0 rgba(0,0,0,0.15); margin: 1px; max-width: 540px; min-width: 326px; padding: 0; width: calc(100% - 2px);" class="instagram-media" data-instgrm-captioned="" data-instgrm-permalink="https://www.instagram.com/p/B-i6tInHXzS/?utm_source=ig_embed&amp;utm_campaign=loading" data-instgrm-version="12"> <div style="padding: 16px;"> <div style="display: flex; flex-direction: row; align-items: center;"> <div style="background-color: #f4f4f4; border-radius: 50%; flex-grow: 0; height: 40px; margin-right: 14px; width: 40px;"></div> <div style="display: flex; flex-direction: column; flex-grow: 1; justify-content: center;"> <div style="background-color: #f4f4f4; border-radius: 4px; flex-grow: 0; height: 14px; margin-bottom: 6px; width: 100px;"></div> <div style="background-color: #f4f4f4; border-radius: 4px; flex-grow: 0; height: 14px; width: 60px;"></div> </div> </div> <div style="padding: 19% 0;"></div> <div style="display: block; height: 50px; margin: 0 auto 12px; width: 50px;"></div> <div style="padding-top: 8px;"> <div style="color: #3897f0; font-family: Arial,sans-serif; font-size: 14px; font-style: normal; font-weight: 550; line-height: 18px;">View this post on Instagram</div> </div> <p style="margin: 8px 0 0 0; padding: 0 4px;"><a style="color: #000; font-family: Arial,sans-serif; font-size: 14px; font-style: normal; font-weight: normal; line-height: 17px; text-decoration: none; word-wrap: break-word;" rel="noopener" href="https://www.instagram.com/p/B-i6tInHXzS/?utm_source=ig_embed&amp;utm_campaign=loading" target="_blank">Ready for Randwick. Trackside styling by........ me. 😂📺🤷‍♀️🦠❌🐎 (where are you @natshehatastyling ?!?) The best bits: no queue for the loo. No heels. 🎉</a></p> <p style="color: #c9c8cd; font-family: Arial,sans-serif; font-size: 14px; line-height: 17px; margin-bottom: 0; margin-top: 8px; overflow: hidden; padding: 8px 0 7px; text-align: center; text-overflow: ellipsis; white-space: nowrap;">A post shared by <a style="color: #c9c8cd; font-family: Arial,sans-serif; font-size: 14px; font-style: normal; font-weight: normal; line-height: 17px;" rel="noopener" href="https://www.instagram.com/sam_armytage/?utm_source=ig_embed&amp;utm_campaign=loading" target="_blank"> Samantha Armytage ⭐️</a> (@sam_armytage) on Apr 3, 2020 at 9:29pm PDT</p> </div> </blockquote> <p>Fans are wishing Armytage a speedy recovery in the comments.</p> <p>“Where have you been we miss you on the morning show,” one fan wrote.</p> <p>“Wishing you a speedy recovery! You are missed on<span> </span><em>Sunrise</em>, take care,” another agreed.</p> <p>“Keep safe and well, hoping you return to<span> </span><em>Sunrise</em> soon.”</p>

TV

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Australians could face life in prison for coughing on doctors and nurses

<p>Federal Health Minister Greg Hunt has slammed reports of people abusing healthcare workers, warning those who deliberately cough on doctors or nurses could face life in prison.</p> <p>Speaking at a Wednesday press conference, Hunt said there had been “troubling” reports of assaults and threats against healthcare workers.</p> <p>“Whether it’s verbally or by coughing on them, by threatening to transmit the virus ... These cases are completely unacceptable and we will be cracking down on them across the jurisdictions,” Hunt said.</p> <p>The minister said the deliberate transmission of the coronavirus “is an offence under the general criminal laws that apply in every state and territory”, carrying penalties up to life imprisonment.</p> <p>State and territory criminal laws also made it an offence to “cause someone else to fear” they had been given the virus, “for example by coughing on them”.</p> <p>Two people in the ACT had been charged with “precisely this type of behaviour”, he said.</p> <p>Hunt thanked healthcare workers for being “on the frontline saving lives and protecting lives”.</p> <p>Reports of doctors and nurses being spat on, harassed and assaulted in public places have emerged across Australia in recent weeks.</p> <p>Some hospitals have also told staff not to wear their uniforms to avoid unwanted attention during their travel to and from work.</p> <p>NSW Health Minister Brad Hazzard said the “appalling” acts must end.</p> <p>“I think every right-minded member of our community would be that our doctors and nurses are being targets for these people who don’t seem to get it,” he told reporters on Sunday.</p> <p>“And I want all of us as a community to make it clear to that small minority that your behaviour is completely unacceptable. Completely.</p> <p>“It’s not Australia, it’s not the way that Aussies behave.”</p>

Legal

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Shop attendant’s horror as kids deliberately cough on them

<div class="post_body_wrapper"> <div class="post_body"> <div class="body_text "> <p>A group of children have been caught deliberately coughing on a shop attendant in Melbourne.</p> <p>The footage, which was obtained by<span> </span><a rel="noopener noreferrer" href="https://www.9news.com.au/national/coronavirus-kids-caught-coughing-on-shop-attendant-in-alleged-deliberate-attack/3b7fd1a2-1594-4c71-b183-95a98600498d?ocid=Social-9News" target="_blank">9News</a>, shows the boys and girls at a phone repair outlet and the group are ignoring social distancing as well as hygiene rules.</p> <p>The group began coughing and spluttering on the worker.</p> <p>Shop attendant Paullie said that the kids approached her last week pretending to need a phone repaired last week.</p> <p>She decided to film the group after they started to behave erratically and cough in her face.</p> <p>"I said please stop it," she said.</p> <p>"They were just laughing at me and coughing.</p> <p>"I was really scared."</p> <p>The video was shared on Facebook, which called out the dangerous behaviour.</p> <p>"I am disgusted and saddened that these kids have done this. I honestly can't believe it," Eryn Clarke said on the post.</p> <p>"This kind of behaviour needs to be stopped. It is already a highly stressful time for everyone without disgusting cruel behaviour like this.</p> <p>"I'm hoping this video reaches the parents of these children as I'm sure they won't be impressed with their kids terrorising people like this."</p> <p>Social distancing rules means that Australians must stay 1.5 metres apart and practice safe hygiene, which includes coughing or sneezing into a tissue or your elbow.</p> </div> </div> </div>

Travel Trouble

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Do you know what coronavirus cough sounds like?

<div class="post_body_wrapper"> <div class="post_body"> <div class="body_text "> <p>As cases of coronavirus continue to rise across the world, many are unsure what the respiratory condition sounds like.</p> <p>It presents with two key symptoms, which are a cough and a fever. As it’s broken out in the middle of cold and flu season, it can be difficult to tell if you’ve got the normal flu or coronavirus.</p> <p>Radio 2<span> </span>has shared audio clips of what the telltale dry cough sounds like.</p> <p>"The two main symptoms of coronavirus to look out for are a continuous dry cough and/or a fever,” said BBC’s Laura Foster.</p> <p>"If you're sneezing a lot, got a runny nose or a headache, you may be ill, but you've probably not got coronavirus.</p> <blockquote class="twitter-tweet"> <p dir="ltr">A lot of people asking for the Coronavirus explainers we're making to be put on all media platforms. Good news is they are! This is the sort of information we should be sharing regularly to take the pressure off health systems. Plus my acting is hilarious. <a href="https://twitter.com/hashtag/COVID2019?src=hash&amp;ref_src=twsrc%5Etfw">#COVID2019</a> <a href="https://twitter.com/hashtag/COVID19?src=hash&amp;ref_src=twsrc%5Etfw">#COVID19</a> <a href="https://t.co/l304j6h1A1">https://t.co/l304j6h1A1</a></p> — Laura Foster (@misslfoster) <a href="https://twitter.com/misslfoster/status/1240615821438865408?ref_src=twsrc%5Etfw">March 19, 2020</a></blockquote> <p>"So how high a fever is a coronavirus one? And what exactly is a continuous dry cough?</p> <p>"Well, it's when you cough and there's no mucous or phlegm. There's basically no gooey substance in your tissue. And this is not the odd cough here or there. It has to be coughing regularly for no other reason, such as clearing your throat or smoking."</p> <p>"So how high a fever is a coronavirus fever? Well if you have one, you will know about it. Technically it's a body temperature of more than 37.8 degrees Celsius or 100 degrees Fahrenheit. But if you've not got a thermometer, basically you will feel hot, and your chest and back would be hot if someone touched you."</p> <p>Laura added: "If you have either of these symptoms, then you and everyone you live with needs to stay at home for two weeks.”</p> </div> </div> </div>

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Why do I have a cough and what can I do about it?

<p>Dry, moist, productive, hacking, chesty, whooping, barking, throaty. These are just some of the terms people use to describe their cough.</p> <p>While we’re deep into cold and flu season, it’s one of the most common reasons people see their family doctor.</p> <p>But what is a cough anyway? And what’s the best way to get rid of it?</p> <p><strong>What is a cough?</strong></p> <p>People can <a href="http://www.mattioli1885journals.com/index.php/actabiomedica/article/view/6182">cough on purpose or spontaneously in a protective reflex action</a>. The aim is to both protect the airways from material that shouldn’t be there (like dust) or to clear the secretions that come with respiratory diseases, such as the mucus and phlegm that come with colds and flu.</p> <p>Nerve receptors throughout the lungs, and to a lesser extent in the sinuses, diaphragm and oesophagus (food pipe), detect the irritant or mucus. Then, they send messages via the vagus nerve to the brain. The brain, in turn, sends messages back through the motor nerves supplying the diaphragm, chest muscles and vocal cords.</p> <p>This results in a sudden, forceful expulsion of air.</p> <p>Your cough may be a one off. Alternatively, you can have a run of repeated coughs, especially in <a href="https://www.health.gov.au/health-topics/whooping-cough-pertussis">whooping cough</a>, which people describe as a bout, attack or episode.</p> <p><strong>Which type of cough do I have?</strong></p> <p>There are many different types of cough but no one definition that everyone agrees on. This can be confusing as patients classify their cough in descriptive terms like hacking or chesty, while doctors classify them on how long they last: acute (under three weeks), subacute (three to eight weeks) and chronic cough (more than eight weeks).</p> <p><a href="https://www.sciencedirect.com/science/article/pii/S1094553908001430?via%3Dihub">Neither of these approaches</a> tells us about the cause of the cough.</p> <p>Coughs can also be called wet or dry. <a href="http://jtd.amegroups.com/article/view/25427/19122">Officially</a>, you have a wet cough when you produce more than 10mL of phlegm a day.</p> <p>For people with chronic coughs, their cough can further be classified after an x-ray — either with lung pathology to indicate something like pneumonia or tuberculosis, or without signs of underlying disease (an x-ray negative cough).</p> <p><strong>What caused my cough?</strong></p> <p>Whether you have a <a href="https://www.ncbi.nlm.nih.gov/pubmed/29080708">wet or dry cough</a> may tell you what has caused it.</p> <p><a href="http://jtd.amegroups.com/article/view/25427/19122">A dry cough</a> indicates a non-infectious cough from conditions including <a href="https://www.nationalasthma.org.au/understanding-asthma/what-is-asthma">asthma</a>, <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/emphysema">emphysema</a>, <a href="https://www.healthdirect.gov.au/gord-reflux">oesophageal reflux</a> and <a href="https://bestpractice.bmj.com/topics/en-us/1209">upper airway cough syndrome</a>, previously called post-nasal drip.</p> <p><a href="http://jtd.amegroups.com/article/view/25427/19122">A wet cough</a> is more common in people with sinus and chest infections, including influenza, bronchitis and pneumonia, and serious infections such as <a href="https://www.health.nsw.gov.au/Infectious/factsheets/Pages/tuberculosis.aspx">tuberculosis</a>. A smoker’s cough is usually wet, as the precursor to chronic bronchitis. As it progresses, or when complicated with infection, larger amounts of mucus may be coughed up daily.</p> <p>Then there is a dry cough associated with a cold or flu that turns into a moist cough. People tend to describe this as “chesty” and it makes them worry the infection has moved to their lungs.</p> <p>Yet mostly their lungs are clear of infectious sounds when examined with a stethoscope. Even a small amount of mucus stuck around the vocal cords or back of the throat may produce a moist sounding cough. But this is not necessarily a wet or “productive” (producing lots of mucus) cough.</p> <p><a href="https://coughjournal.biomedcentral.com/articles/10.1186/1745-9974-2-1">One study</a> showed even doctors struggled to make an accurate diagnosis based only on the sound of the cough. Their diagnosis of the cough was correct only 34% of the time.</p> <p>For people with chronic “unexplained cough”, a common hypothesis is that cough receptors <a href="https://www.atsjournals.org/doi/full/10.1164/rccm.200905-0665OC">become more sensitive</a> to irritation the more they are exposed to the irritant. These cough receptors are so sensitive that even <a href="https://www.ncbi.nlm.nih.gov/pubmed/20051447">perfumes, temperature changes, talking and laughing</a>may trigger the cough.</p> <p>People with <a href="https://bestpractice.bmj.com/topics/en-us/1209">upper airway cough syndrome</a> may feel mucus secretions moving down the back of the throat, causing them to cough. New evidence suggests the cough <a href="https://journal.chestnet.org/article/S0012-3692(19)31122-5/pdf">is caused by</a> the increased thickness of the mucus and slowness of that mucus being cleared by cilia (hair like structures in lining cells whose job is to move mucus along).</p> <p>This mechanism keeps the chronic cough going through a feedback loop I call the “cough and mucus” cycle. In other words, the more the throat is irritated by the sticky mucus, the more you cough, but the cough is poor at shifting the mucus. Instead, coughing irritates the throat and fatigues the cilia, and the mucus becomes stickier and harder to shift, stimulating further coughing.</p> <p><strong>When coughing gets too much</strong></p> <p>Coughing is hard work so no wonder you can feel physically exhausted. <a href="https://www.ncbi.nlm.nih.gov/pubmed/7925902">In one study</a>, people with asthma coughed as many as 1,577 times in one 24-hour period. But for people with a chronic cough, it was up to 3,639 times.</p> <p>The high pressures generated in vigorous coughing <a href="http://jtd.amegroups.com/article/view/25427/19122">can cause</a> symptoms including chest pains, a hoarse voice, and even rib fractures and <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/hernias">hernias</a>. Other complications include vomiting, light-headedness, urinary incontinence, headaches and sleep deprivation. Chronic cough may also lead to people becoming embarrassed and avoiding others.</p> <p><strong>Is it true?</strong></p> <p>People still seemed surprised and worried when a cough persists after a cold and flu despite the fact cough outlasts other symptoms in most cases. When an <a href="https://search.informit.com.au/documentSummary;dn=380082015528918;res=IELHEA">Australian study</a> followed 131 healthy adults with an upper respiratory tract infection, 58% had a cough for at least two weeks and 35% for up to three weeks.</p> <p>Then there’s the colour of your mucus. Patients and doctors commonly interpret discoloured mucus, particularly if green, as a sign of bacterial infection. But there’s <a href="https://www.tandfonline.com/doi/full/10.1080/02813430902759663">clear evidence</a> that the colour alone is not able to differentiate between viral and bacterial infections in otherwise healthy adults.</p> <p><a href="https://erj.ersjournals.com/content/38/1/119">Another study</a> found that people with acute cough who coughed up discoloured phlegm were more likely to be prescribed antibiotics, but they did not recover any faster than those not prescribed antibiotics.</p> <p><strong>When and how should I treat my cough?</strong></p> <p>Due to the multiple causes and types of cough there is not room to cover this question adequately. A safe approach is to diagnose the disease that is causing the cough and treat it appropriately.</p> <p>For chronic dry coughs and coughs that last after acute upper respiratory tract infections, the cough is no longer serving a useful function and treatments can be targeted at breaking the cycle of irritation and further coughing. The evidence for effective treatments is patchy, but cough suppressants, steam inhalation and saline nasal irrigations, as well as prescribed anti-inflammatory sprays may help.</p> <p>A spoonful of honey <a href="https://www.ncbi.nlm.nih.gov/pubmed/22869830">reduces cough</a> in children more than placebo and some cough mixtures. It is thought that the soothing effect on the throat is the way this works.</p> <p>However, there is no good evidence for the effectiveness of commonly used over-the-counter medicine (cough medicine or syrup) to alleviate acute cough, yet they are still sold. Some contain drugs with the <a href="https://www.ncbi.nlm.nih.gov/pubmed/25420096">potential to cause harm</a> in children, such as antihistamines, and codeine-like products.</p> <p>Recent expert panel reports <a href="https://linkinghub.elsevier.com/retrieve/pii/S0012369217314083">don’t recommend the use of these cough medicines</a> for adults and children with acute cough, until they are shown to be effective.</p> <p><strong>When should I be concerned?</strong></p> <p>It is fine to try to treat yourself, but if a cough persists or is bothersome, your doctor may be able to suggest or prescribe treatments to reduce your symptoms.</p> <p>If you cough up blood or are becoming more unwell, consult a doctor, who will investigate further.</p> <p>Children who cough up phlegm for more than four weeks <a href="https://www.ncbi.nlm.nih.gov/pubmed/28143696">have been found to benefit</a> from medical investigations and antibiotics.</p> <p><em>Written by David King. Republished with permission of <a href="https://theconversation.com/health-check-why-do-i-have-a-cough-and-what-can-i-do-about-it-119172">The Conversation</a>.</em></p>

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Woman almost dies after taking cough medicine: "I flatlined completely"

<p>It’s the over-the-counter product that so many of have taken to help alleviate a cold. But for some, the combination of cough syrups and aesthetics can be potentially fatal.</p> <p>After Australian woman Narelle Campbell, 52, was given a general anaesthetic during an operation for an aneurism, she had a catastrophic allergic reaction after taking a cough medicine prior, reports <em><a rel="noopener" href="https://www.9news.com.au/national/2018/10/02/19/18/calls-for-cough-medicine-ingredient-to-be-banned-over-the-counter" target="_blank">9News</a></em>. Doctors had to break four ribs to bring her back to life.</p> <p>“I flatlined completely – I was gone,” Campbell said in an interview with <em>9News</em>.</p> <p>“The thing that surprises me is I went in there to have an operation for an aneurism and I actually died on the table because of cough medicine.”</p> <p>It happened because of the active ingredient pholcodine, an antitussive or cough-suppressing compound which <em><a rel="noopener" href="https://www.nps.org.au/australian-prescriber/articles/anaphylaxis-and-anaesthesia-can-treating-a-cough-kill" target="_blank">NPS Medicine Wise</a></em> says has been used in cough medicines since the 1950s. <span>It is banned in the US but alarmingly, it can be found in over 50 products in Australia, including household names like Benadryl, Difflam and Duro-Truss.</span></p> <p><img style="width: 500px; height: 281.25px; display: block; margin-left: auto; margin-right: auto;" src="https://oversixtydev.blob.core.windows.net/media/7821108/cough-medicine-products.jpg" alt="" data-udi="umb://media/49b2a1697fd14a3f8d56ff8c5e163ee2" /></p> <p>In 2015, Dr Michael Rose, Chairman of the Australian and New Zealand Anaesthetic Allergy Group (ANZAAG), told <a rel="noopener" href="http://www.abc.net.au/news/2015-01-29/anaesthetists-call-for-cough-medicine-restrictions/6055304" target="_blank"><em>ABC NEWS</em> </a>that the group was calling for products with the chemical to be made prescription-only.</p> <p>He said that some studies have found that pholcodine could create an antibody in a small proportion of people that causes an allergic reaction to some anaesthetics because of the muscle relaxants contained in them.</p> <p>Dr Paul McAleer of ANZAAG told <em>9News</em> that surgical anaphylaxis during anaesthesia causes over seven deaths every three years.</p> <p>“We believe pholcodine plays a part in de-sensitising some people to the effects of muscle relaxants in anaesthesia,” he said.</p> <p>Despite the deaths, the Therapeutic Goods Administration (TGA) believes there isn’t sufficient evidence to ban the chemical, after anaesthetists made the case to have cough medicines with pholcodine made prescription-only or banned altogether, in submissions in 2013 and 2015. After this latest case, they continue to lobby for tighter restrictions.</p> <p>The most compelling case for banning the drug was in Scandinavia, according to <em>ABC News</em>, with the startling contrast between surgical anaphylaxis between Norway and Sweden. Norway’s rate a decade ago was 10 times higher than Sweden’s. The use of pholcodine was high in Norway, but in Sweden it was banned.</p> <p><iframe src="https://www.facebook.com/plugins/video.php?href=https%3A%2F%2Fwww.facebook.com%2F9NewsSydney%2Fvideos%2F479965202413028%2F&amp;show_text=0&amp;width=560" width="560" height="315" style="border: none; overflow: hidden;" scrolling="no" frameborder="0" allowtransparency="true" allowfullscreen="true"></iframe></p> <p>"In 2007 the drug company that was manufacturing pholcodine in Norway voluntarily removed it from the market," explained Dr Rose.</p> <p>"And since that time the rate of allergic reactions to muscle relaxants has fallen and the rate of antibodies in the population has also fallen."</p> <p>Dr McAleer advises consumers to avoid products with pholcodine if they can.</p> <p>And if you’re having surgery, be sure to let the anaesthetist overseeing you know if you’ve had any antitussives leading up to admission to hospital.</p> <p>Do you have any of these cough syrups in your medicine cabinet at home? Tell us in the comments below.  </p>

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Perth dad pens heartbreaking letter to younger self after death of newborn son

<p>A father of three has penned a heartbreaking open letter to his former self thee years after his baby son’s death.</p> <p>Greg Hughes, from Perth, took to Facebook to write an emotional post about his son Riley, who died from whooping cough just 32 days after he was born in 2015.</p> <p>In the wake of Riley’s tragic death, Greg and his family have campaigned for all children to have a vaccination for whooping cough.</p> <p><iframe src="https://www.facebook.com/plugins/post.php?href=https%3A%2F%2Fwww.facebook.com%2Fdadminusone%2Fposts%2F1250074995122803&amp;width=500" width="500" height="682" style="border: none; overflow: hidden;" scrolling="no" frameborder="0" allowtransparency="true" allow="encrypted-media"></iframe></p> <p>The full letter is below:</p> <p><em>An Open Letter to the me of March 18th 2015</em><br /> <br /><em> Mate,</em><br /> <br /><em> I’m sorry, truly I am. It’s shallow, hollow, meaningless and empty for me to say this to you right now. I know this because I’m you and you’re a wreck at this very moment. </em><br /> <br /><em> Just a week ago you were still you - the old you. The you who was carefree, who saw no danger in the world and who truly lived the perfect and serene life. Married, middle class, pigeon pair and embarking on your journey without a concern. You had it all and you didn’t even realise it. </em><br /> <br /><em> How quickly things change.</em><br /> <br /><em> On paper it was ‘only’ your son that passed away. The reality of it is far crueller. The old you died the day his heart stopped beating and the entire foundation of your existence has been destroyed. You’ve got an enormous uphill battle on your hands that I’d equate to something like trying to scale Everest using only your pinky finger as leverage.</em><br /> <br /><em> In the weeks that come, certain people and institutions that you hold dear will fail you. Possessions you once cherished will become meaningless, locations you once frequented will become heartbreakingly painful memories and you’ll experience the emotional equivalent of being stranded on a desert island.</em><br /> <br /><em> You’ll be tested in ways you never imagined possible. You’ll have people empathise with your situation by comparing it to the beloved family pet they had put down, you’ll have others tell you that ‘you can always have another one’ and I can assure you that there’s going to be more than one occasion where you need to walk away for the safety of the person who is completely and utterly disrespectful towards the memory of your child.</em><br /> <br /><em> I’m not going to lie to you - this next three months you’ll experience will be the hardest of your life. Certain days will seem to drag on for almost an eternity. Seconds like hours, minutes like days and hours like lifetimes. </em><br /> <br /><em> Your wife will feel like a stranger (through no fault of her own), your daughter’s anguish as the crippling reality of life without a sibling hits will utterly crush you and you’ll reach a low point you never imagined possible. </em><br /> <br /><em> This is the horrible reality of grief - everyone handles it in their own way. </em><br /> <br /><em> You’re probably reading this and wondering ‘What’s the point in continuing? Why bother if it’s as bad as you say it is?’</em><br /> <br /><em> Let me tell you something - it does get easier.</em><br /> <br /><em> I wish I could navigate your journey with the knowledge I have now. I know that I would never hit the absolute rock bottom depths of despair that you have in store. For that I’m sorry, it’s not easy to tell people you’re hurting when it’s so ingrained into your psyche to keep your emotions in check.</em><br /> <br /><em> On a positive note, for every person that lets you down, there’ll be another who comes through in ways you never imagined possible. </em><br /> <br /><em> Friends will become family, acquaintances will become brothers and the help you’ll receive from certain individuals will restore your faith in humanity. You will find something so hauntingly beautiful in the occasional moments of silence you get during those brief intervals you’re not thinking about him, that hospital and that fucking disease. Of course in your fragile state, you’ll become self aware that you weren’t thinking about him and start self-loathing but that does dissipate with time.</em><br /> <br /><em> You’re on the first steps of a path that so many desperately unlucky families have trodden before and sadly so many families will follow after. You’re not unique, your pain isn’t isolated and while you wouldn’t know it there are so many others enduring their own personal versions of the heartache you’re suffering.</em><br /> <br /><em> Get a counsellor. Go with your wife, she’s done nothing wrong. She’s on the same path with the same destination as you - trouble is that both of you have totally different maps written in languages you don’t understand and you can’t help each other without the assistance of a translator. That grief counsellor is your tour guide to this awful journey and right now they’re your best friend.</em><br /> <br /><em> Those moments you want to give up? </em><br /> <br /><em> No. </em><br /> <br /><em> Step up. People need you. Your family need you. Your daughter, more than just about anyone - needs you. </em><br /> <br /><em> Don’t self medicate. There’s a time coming where you decide you want to drink away the pain. Let me tell you, the pain intensifies, the irrational thoughts start beating like jungle drums and the hangover sucks. </em><br /> <br /><em> Communication is the medication and you need to step outside your comfort zone.</em><br /> <br /><em> Once you get through this black smog of anguish, you’ll come through the other end seeing things so differently. People and relationships are the cornerstone of everything important. </em><br /> <br /><em> You’ll cherish the morning cuddles with your daughters (yes, daughters, there’s</em><br /><em> a rainbow one coming and she’s reckless, amazing, angry, loveable, hilarious and unique). </em><br /> <br /><em> Your big one will be the embodiment of compassion and will constantly astound you with her caring nature. </em><br /> <br /><em> Your little one will astound you with the distance she can throw pieces of chicken and her remarkable aim. You cherish this.</em><br /> <br /><em> Not only that, but you’ll eventually come to the same place as your wife and you’ll communicate better than you ever have before (although she refuses to admit when she’s wrong - some things never change). </em><br /> <br /><em> Lastly, and I know I don’t need to tell you this - but you need to keep going for him.</em><br /> <br /><em> 32 days. Thirty two fucking days. That’s all he got from this thing we call life and he deserved so much more. He was a victim of circumstance of which he had no choosing and you need to fight tooth and nail to honour the sacrifice that beautiful, incredible, perfect little man had to make. </em><br /> <br /><em> He is your beacon, your purpose and your motivation. </em><br /> <br /><em> Speak freely, speak openly and speak often. You’ll find yourself in a place of peace much sooner than I ever did. </em><br /> <br /><em> Yours,</em><br /> <br /><em> -D-1</em></p> <p> </p>

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Sneezed bacteria travels farther than you think – and lasts longer

<p>It’s cold and flu season and the sounds of coughs and sneezes are commonplace in the air.</p> <p>But don’t get lax on following the well-worn advice of covering your mouth and washing your hands, because Australian researchers have discovered how far sneezed and coughed bacteria spreads and how long it remains in the air – and it’s worse than you thought.</p> <p>Scientists at Queensland University of Technology found a subset of pseudomonas aeruginosa, a bacterial species associated with hospital infections, expelled from a sneeze or cough can hang around in the air for as long as 45 minutes after.</p> <p>The force of a sneeze or cough can also propel the bacteria up to four metres.</p> <p> <iframe width="560" height="315" src="https://www.youtube.com/embed/9qqHOKUXY5U" frameborder="0" allowfullscreen=""></iframe></p> <p><em>This video uses high-speed imaging to show how far some cough and sneeze droplets travel after a sneeze.</em></p> <p>"Our previous research had found that these pathogens travelled up to four metres and stayed viable for 45 minutes after being coughed into the air," Lidia Morawska, co-lead researcher and Director of the International Laboratory for Air Quality and Health,<a href="https://www.qut.edu.au/news/news?news-id=118758"> <span style="text-decoration: underline;"><strong>said in a statement</strong></span></a><span style="text-decoration: underline;"><strong>.</strong></span></p> <p>"We wanted to find out how bacteria-carrying droplets expelled by sneezes or coughs travel such distances and remain able to infect other people after such a long time."</p> <p>Professor Morawska said the research team found that the bacteria in the cough droplets decayed in two different time spans.<br /> “As soon as cough droplets hit the air they rapidly dry out, cool and become light enough to stay airborne. They also partly degrade through contact with oxygen in the air, with larger droplets taking much longer to evaporate.<br /> <br /> “We found that the concentration of active bacteria in the dried droplets showed rapid decay with a 10-second half-life for most of the bacteria but a subset of bacteria had a half-life of more than 10 minutes,” she said.<br /> <br /> “This suggests some of the pseudomonas aeruginosa bacteria are resistant to rapid biological decay and thus remain viable in room air long enough to form an airborne infection risk, especially to people with respiratory problems such as patients with cystic fibrosis.”</p> <p>So make sure next time you feel a sneezing fit coming on, full cover your mouth and wash your hands after! </p>

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Chocolate said to be effective cure for a cough

<p>Good news for chocoholics and cough-sufferers worldwide. A European study has found that chocolate can be an effective method for treating coughs, and the delicious results have been backed by a leading respiratory medicine expert.</p> <p>The study involved over-the-counter cough remedies, some of which contained cocoa.</p> <p>Patients who took the medicine that contained cocoa reported significant improvement regarding their coughs and sense of sleeplessness within two days, while those who took conventional cough syrup had to wait a little longer to report the same results.</p> <p>While this all sounds too good to be true, the findings have been backed by Professor Alyn Morice, head of cardiovascular and respiratory studies at the University of Hull.</p> <p>Professor Morice told the Daily Mail, “Chocolate can calm coughs. I know that might sound like something out of Mary Poppins, but as an independent clinician who has spent years researching the mechanism of cough, I can assure you the evidence is actually as solid a bar of Fruit and Nut.”</p> <p>We’re only a week into 2016, but this is shaping into one of the good news stories of the year.</p> <p>We can’t wait to get our next cold! </p> <p><strong>Related links:</strong></p> <p><span style="text-decoration: underline;"><em><a href="/news/news/2016/01/clever-dog-performs-a-handstand/"><strong>Watch gorgeous toy poodle perform a perfect handstand</strong></a></em></span></p> <p><span style="text-decoration: underline;"><em><a href="/news/news/2016/01/alarm-clock-rug/"><strong>You won’t believe this new rug that’s an alarm clock</strong></a></em></span></p> <p><span style="text-decoration: underline;"><em><a href="/news/news/2016/01/make-your-smartphone-battery-last-longer/"><strong>How to make your smartphone battery last longer</strong></a></em></span></p>

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