Health updates on CPR, peptic ulcers, and shingles

Medicine marches on — and at a pace much faster than anytime in history. Somehow, there seems to be a continuing flow of new discoveries, new techniques, new drugs, and new dimensions in the treatment of diseases. Today’s column demonstrates this. It deals with the new guidelines in cardiopulmonary resuscitation, an improved technique in wiping out the bacteria that cause peptic ulcer, and the latest advisory on the use of the shingles vaccine.

New CPR Guidelines May Help You Save A Life

When a person is seized by cardiac arrest and collapses, unconscious, with no pulse, immediate cardiopulmonary resuscitation (CPR) may be the only thing that keeps him/her alive until medical help arrives. But if you saw someone in that state, would you know what to do? Would you feel confident enough to try and re-start the heart of a friend or a loved one? The American Heart Association (AHA) is hoping that new guidelines released in March 2008, which include a focus on chest compressions only and not the traditional mouth-to-mouth breathing, will help bystanders take quick decisive action.

Bruce J. Darrow, MD, assistant professor of cardiology at the Mount Sinai School of Medicine in New York, says the average adult can survive about four minutes without blood circulating and oxygenating through the lungs before permanent organ damage and even sudden cardiac death begin. He says many rapid compressions are especially critical for getting blood to the brain, since the brain uses more of the oxygen in the blood than any other organ. “What the compression does is take some of the blood that still has oxygen in it and pushes it up to the brain where the blood is being depleted of oxygen,” Darrow explains.

While doctors agree that CPR training is valuable for everyone, they also say that even untrained bystanders should try to save a life whenever possible. In fact, the AHA was prompted to begin its “Hands Only” campaign last year in recognition that more bystanders need to take action, but were unsure about traditional CPR — as well as recent evidence noting the essentially equal effectiveness of the two methods. “There is little danger to performing CPR, especially now that rescue breathing is not always necessary,” says Mount Sinai cardiologist Eric Adler, MD. “Performing CPR for a long period of time can be strenuous, however, so if you are with others who are trained, it is recommended that you switch off to avoid being fatigued.”

Dr. Darrow stresses that CPR should only be performed on someone who is unresponsive, with no pulse or no heartbeat. He also notes that CPR, even done by a trained bystander or emergency worker, does not guarantee resuscitation. “In movies and television, it seems like a person who receives CPR magically comes back to life almost every time,” Dr. Darrow says. “In reality, under 10 percent of people survive cardiac arrest outside the hospital, and a good CPR is essential for those who do survive.”

Here’s how to do compression-only CPR:

• Check to see if the person is breathing and has a pulse. If not, begin CPR.

• Place the heel of one hand in the middle of the person’s chest and put your other hand on top of the first, with fingers interlaced (see photo on Page D-1).

• Push down on the chest between one and two inches at a rate that would equal 100 compressions per minute.

• Pause after 30 compressions and check again for a pulse.

• If there is no pulse, continue doing more sets of 30 compressions until a pulse resumes or the paramedics arrive.

New Strategy For Peptic Ulcers

Ulcers are often blamed on stress and spicy food, but the reality is that bacteria called Helicobacter pylori (H. pylori) cause most of these painful erosions in the stomach and small intestines. The goal of ulcer treatment is to prevent stomach acid from continuing to erode the lesion and to eradicate H. pylori. New research shows ways to fight even the most recalcitrant H. pylori infection.

Peptic ulcers are deep, non-healing sores — holes — in the lining of the stomach (gastric ulcers) and in the first part of the small intestine, called duodenum (duodenal ulcers). Between 70 percent and 80 percent of gastric ulcers and nearly all duodenal ulcers result from H. pylori bacteria that infect the lining of the stomach and cause inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs), like aspirin and ibuprofen, can erode the stomach lining and are the second most common cause of ulcers. H. pylori may also be present in people who develop ulcers from NSAIDs. Painless ulcers may not be found until they cause bleeding. Symptoms such as anemia or blood in the stool may suggest bleeding due to a blood vessel ruptured by an ulcer. An upper endoscopy is often needed to check for ulcers. During endoscopy, a biopsy sample can be taken to be tested for H. pylori. (Breath tests can detect H. pylori, but an endoscopy allows your doctor to gauge the extent of damage to the stomach and duodenum at the same time.)

Medications called H2-blockers and proton pump inhibitors (PPIs) suppress the production of stomach acid and let ulcers heal. (PPIs are usually more effective than H2-blockers, so they are tried first.) Antibiotics are taken simultaneously to treat the H. pylori infection. To ensure that H. pylori are eliminated, doctors typically prescribe 10- to 14-day “triple therapy,” which includes a PPI plus two antibiotics. Bismuth subsalicylate (Pepto-Bismol and other brands) may also be recommended. In 2007, a study in the Annals of Internal Medicine offered another solution to H. pylori: sequential therapy, which starts patients on a PPI and five days of a mild antibiotic — then two stronger antibiotics added to the proton pump inhibitor for five days. The study compared triple therapy with sequential therapy in 300 people. Patients received the PPI pantoprazole plus the antibiotics clarithromycin and amoxicillin, and placebo followed by five days of pantoprazole, clarithromycin, and the antibiotic tinidazole. Eight weeks later, breath tests revealed that H pylori were eradicated in 93 percent of the sequential-therapy patients versus 79 percent of the triple therapy patients. More recently, an analysis of data from 10 clinical trials revealed similar results. H pylori were eradicated in 93.4 percent of 1,363 patients who underwent sequential therapy vs. 76.9 percent of 1,385 patients who took triple therapy. Sequential therapy may help combat H. pylori that have become resistant to frequently used antibiotics. The first stage of sequential therapy might eradicate enough H pylori to make mutations against the second wave of antibiotics more difficult.

Antibiotics may not cure ulcers that are caused by NSAIDs, and continued use of NSAIDs lowers the chances that ulcers will heal. However, people who take NSAIDs and then develop ulcers should still be tested and treated for H. pylori infection. Proton pump inhibitors might help reduce the risk of subsequent ulcers in patients who must continue taking NSAIDs to treat other medical conditions.

Shingles Vaccine Advised For 60-Plus

People aged 60 and older should be vaccinated against shingles, or herpes zoster, a condition marked by debilitating chronic pain, according to a new recommendation by the US Centers for Disease Control (CDC). The CDC suggests a single dose of the zoster vaccine even if they had a prior episode of shingles. The new recommendation replaces a provisional recommendation that the CDC made in 2006, after the vaccine was licensed by the FDA. Researchers found that, overall, in those aged 60 and above, the vaccine reduced the occurrence of shingles by about 50 percent. For individuals aged 60-69, it reduced occurrence by 64 percent. According to CDC statistics, about a third of people will get shingles, including half of those who reach age 85.

When a person is infected with chicken pox as a child, it remains inactive (dormant) in the nerves. As one gets older, the virus can reactivate and travel along nerve endings to your skin. It usually appears as a blistering rash along one side of the trunk, chest, back or face. Shingles is particularly dangerous when it’s on the face because it can affect the eye and lead to temporary or permanent blindness. But the most common complication is postherpetic neuralgia, a chronic pain that can be so severe people are willing to do anything to get rid of it. The vaccine prevents about 70 percent of cases of postherpetic neuralgia. It consists of a live virus, however, so one shouldn’t get it if you have a weakened immune system for any reason. One shouldn’t also get a vaccine if she is pregnant or has ever had life-threatening allergic reaction to gelatin, the antibiotic neomycin or any other component of the shingles vaccine.

One problem with the vaccine is its cost. The price in the US ranges from $150 to $300 for the shot, which can be expensive for many people. On the other hand, if you have a 20 to 30 percent chance of having shingles after age 60 and, maybe, another 20 percent chance of experiencing chronic pain following the rash, the vaccine is a good investment.