What that means is that, when you see someone who needs CPR and you’ve called for help, you start chest compresions first. Don’t stress out about the mouth-to-mouth and getting hepatitis and all that. Just start pushing on their chest as the video below describes — it’s a lot better than nothing, and it may save the life of a loved one.

Here’s a quick 3-minute video from the American Heart Association (with Chinese subtitles) which may save someone’s life. If you cannot see the video below, please click here.

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The AAP recommends that all infants should ride rear-facing starting with their first ride home from the hospital. All infants and toddlers should ride in a Rear-Facing Car Safety Seat until they are 2 years of age or until they reach the highest weight or height allowed by their car safety seat’s manufacturer.

Types of rear-facing car safety seats: There are 3 types of rear-facing car safety seats: infant-only seats, convertible seats, and 3-in-1 seats. When children reach the highest weight or length allowed by the manufacturer of their infant-only seat, they should continue to ride rear-facing in a convertible seat or 3-in-1 seat.

Types of Car Safety Seats at a Glance

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I said this last year because of a large meta-analysis from the esteemed Cochrane group, which found only about a 73% reduced risk of the flu — in the most ideal situation. Plus, it barely seemed effective for kids under 2 years of age. Now, just this week, an even more specific meta-analysis just published in the Lancet Infectious Diseases shows an even less effective prevention: 59%. During the recent H1N1 years, it was a bit better at 69%. Here’s a bit from their abstract:

Interpretation:Influenza vaccines can provide moderate protection against virologically confirmed influenza, but such protection is greatly reduced or absent in some seasons. Evidence for protection in adults aged 65 years or older is lacking. LAIVs consistently show highest efficacy in young children (aged 6 months to 7 years). New vaccines with improved clinical efficacy and effectiveness are needed to further reduce influenza-related morbidity and mortality

So there you have it. So the question is; do you like those odds? No, it’s not 100% but it’s still darn good, in my opinion. We all hope a better vaccine is just around the corner with new technology, but let’s just get to the point:

• I definitely plan to get the vaccine, as I am surrounded by sick adults and kids and I don’t want to give the flu to them.
• In the same vein, any person in close contact to our most vulnerable patients (kids under 2; the very old; and people with chronic diseases) should really consider getting the vaccine, again to prevent you from giving it to your vulnerable loved one.
• Pregnant women should definitely get the vaccine
• Anyone who wants it can get it.

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The FDA recently added a box warning on the packaging, discussing varenicline’s increased risk of serious psychiatric symptoms. This June, there were some new warnings from the US FDA that taking Chantix slightly increases risks for heart attacks. And just last week comes a larger study which confirms this risk. More specifically (from the NY Times article):

The new study, known as a meta-analysis, compiled data from 14 random, blinded, placebo-controlled clinical trials that tracked cardiovascular outcomes. It found 52 out of 4,908 people taking Chantix had serious cardiovascular events, a rate of 1.06 percent, compared with 27 out of 3,308 people taking a placebo, a rate of 0.82 percent. While the absolute difference is only 0.24 percent, the weighted, relative difference is 72 percent.

Here’s another way to look at it: “doctors could expect to get one extra cardiac event associated with Chantix for every 28 smokers they treated with the drug. The researchers also estimated one additional person would quit for every 10 treated with Chantix.”

What About The Side Effects of Not Stopping Smoking?

So there’s the hard data: 0.82% of the placebo group had an event, and 1.06% of the Chantix users had an event. This is the data we docs need to be telling patients. Honestly, I find the absolute difference of an increased 0.24% to be very small, and if I were a smoker I would take the chance. After all, what about the “side effects” of not stopping smoking? Smoking itself is one of the major causes of heart disease! Not to mention all the deaths from lung cancers, chronic emphysema and other cancers. Let’s compare that absolute risk of 0.24% versus the facts of smoking:

• A smoker’s cumulative risk of dying from lung cancer before age 85 years was 22.1% for a male smoker and 11.9% for a female current smoker, in the absence of competing causes of death. For nonsmokers: a 1.1% probability (men) of European descent, and 0.8% in women. (source)
• Smokers under 40 are five times more likely to have a heart attack. (source)
• Male and female smokers lose an average of 13.4 to 14.3 years of life, respectively (source)

Let’s repeat that, in a way I would say to my mostly male smokers:

“You have a 0.24% absolute risk of a cardiovascular event on this medicine. You have a 22% risk of dying from lung cancer from continuing smoking. You decide.”

Even the FDA tries to keep the risks in perspective:

Smoking is an independent and major risk factor for cardiovascular disease, and smoking cessation is of particular importance in this patient population. The known benefits of Chantix should be weighed against its potential risks when deciding to use the drug in smokers with cardiovascular disease.

If my patient were a pack-a-day smoker for 30 years and wanted to quit, I still would recommend Chantix to them if they had no major psychiatric history. But this issue is now hotly debated among doctors, many of whom indeed want this drug pulled off the market. The excellent cardiovascular blog theheart.org has a nice review of this week’s controversy, including some of these highlights:

…In an accompanying editorial, Dr Taylor Hays (Mayo Clinic, Rochester, MN), who has been involved in clinical trials of varenicline, writes: “Although these results suggest a measure of caution should be taken in prescribing varenicline for tobacco dependence treatment, the small absolute risk of cardiovascular events associated with varenicline treatment is outweighed by the enormous benefit for reducing cardiovascular morbidity and mortality that can be achieved with successful smoking abstinence.”

Independent observer Dr Robert Bonow (Northwestern University, Chicago, IL) tended to side with Hays. He commented to heartwire: “The effects of smoking are so horrific that the benefits of stopping outweigh the risks of this drug in my view.”…

…Singh notes that while 1 in 10 people on Chantix quit smoking, the number needed to harm is 28. “There is not a great difference there.” He added: “We don’t know if the cardiovascular risk with Chantix stops after the drug has been discontinued. We have only looked at one-year’s data—when the patients were actually taking the drug. And we showed a 72% increased risk of cardiovascular events. We don’t know what happens later on.” He also noted that the actual cardiovascular risk with Chantix may be even greater as more people in the Chantix arm stopped smoking and so should have had an immediate reduction in risk.

“We all know the harms of smoking, and I am not disputing the need to quit. But I would advocate using a different method to help you quit. There are lots of other aids out there that work without increasing cardiovascular risk.”

Furberg reinforces this view. He commented to heartwire: “Quitting smoking is exceedingly important. If Chantix was very effective at getting people to quit smoking, you might argue in favor of its continued use, but it is only modestly effective. With Chantix, for every 10 people who take it, 9 have relapsed after a year. And we don’t know what happens to the 10th person after a year. So the efficacy is weak. And the adverse events are piling up.”…

My bottom line: smoking is a terrible disease and worldwide killer, and I still think varenicline is a very useful tool to get people to quit — although the side effects are more serious than we previously thought, and each patient needs to make their own decision.

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Since arriving in Beijing I’ve suffered terrible insomnia. I’ve had problems before, but never like this. I’m 55. What can I do to guarantee a good night’s sleep?

Insomnia is a common problem all over the world, but there are many causes for sleeping problems, so we need to dig deeper into your history. For example, why do you think you’ve only had sleeping problems since arriving in Beijing? What is different about your lifestyle here? Smoking cigarettes certainly disrupts normal sleep, as the nicotine stays in your system for hours. Alcohol can initially make people sleepy, but then they wake up after a few hours. Caffeine is a common culprit for insomnia; many people who have caffeine in the afternoon or with dinner can develop poor sleep, even if this was routine for many years. It seems that as we get older, our bodies cannot process the caffeine as well. When I was an undergrad, I could have coffee at midnight and still sleep fine. Now if I have any caffeine after 4 pm I will have a lot of trouble falling asleep.

The most common reason I’ve seen in China for sleeping problems is overwork – people simply work too hard, late into the night. They read their laptops in bed and expect to have a normal sleep. It just doesn’t work that way. Watching a screen late at night (TV or computer) can disrupt a healthy sleep routine. Also, the stress of thinking about unfinished work keeps many people awake at night.

I suggest you first take a look at your lifestyle in Beijing and how it was before to figure out what could be causing your insomnia and fix that change. Again, major culprits are caffeine, nicotine and alcohol, as well as stress.

There are many healthy ways to get a better night’s sleep, especially regular exercise, which studies have shown can help with better sleep quality. Another technique could be to stop looking at any screen at least two hours before bedtime, while many people feel more relaxed at night after a herbal tea, such as chamomile.

As for medicines, there are a few prescriptions that can help you sleep better, but they are always a last resort and only taken as needed. It’s far healthier to work on lifestyle changes first; if you still have problems, you should discuss with your doctor.

This article was first printed on the China Daily Metro section, in my new “Ask a Health Expert“ column.

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By midday, I feel completely beat. I’m 37 and work as an English teacher in Beijing. I’m fine on mornings but by about 2 pm I just want to go home to sleep. Afternoon classes really drag. It’s been like this for a few months now. I’ve tried taking more vitamin E supplements and drinking coffee, but it’s not helping. Is there a cure for this kind of fatigue?

It’s very common for all of us to feel tired in the afternoon and only in rare cases can be a sign of more serious health problems. One major reason for afternoon fatigue is the post-lunch lethargy many people feel – it’s a mild version of that post-Thanksgiving “food coma” Americans feel after a gigantic turkey dinner. Part of this “food coma” could be the food types: heavy starches and meats always make me feel sleepier, while I always feel energized after a light Japanese or Vietnamese lunch. It’s the same with breakfast; a heavy steak-and-eggs breakfast really slows me down.

Besides assessing your lunch choices, you can also reconsider your coffee drinking, which may be making things worse. Yes, you do get an initial alertness from caffeine, but then there’s the inevitable withdrawal, which is what you may be experiencing in the afternoon. As for supplements such as vitamin E, I’m not aware of any good studies showing multivitamins helping people get more energy. As long as your diet is a rich mix of fruits and vegetables, you probably won’t find much benefit in a vitamin supplement.

In all cases above, my No 1 suggestion for improving afternoon fatigue is to take a short nap. A recent study further proved that even 10 to 20 minutes of closing your eyes in a quiet room – even at your desk – can dramatically improve your afternoon alertness and memory recall. In your case, perhaps you can take the last minutes of your lunch for a break.

There are some health issues that can cause fatigue, such as iron deficiency anemia, diabetes or thyroid problems, among others. If you change your lifestyle patterns but still feel tired, maybe it’s time to visit your family doctor.

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One trusted source is from the Harvard Health Letter, which in 2007 wrote this nice summary about barbecue’s risks:

When meat is cooked at high temperatures, amino acids react with creatine to form heterocyclic amines, which are thought to cause cancer. That’s why cooking meat by grilling, frying, or broiling is the problem. Grilling is double trouble because it also exposes meat to cancer-causing chemicals contained in the smoke that rises from burning coals and any drips of fat that cause flare-ups. How long the meat is cooked is also a factor in heterocyclic amine formation; longer cooking time means more heterocyclic amines. Depending on the temperature at which it’s cooked, meat roasted or baked in the oven may contain some heterocyclic amines, but it’s likely to be considerably less than in grilled, fried, or broiled meat.

Marinating meat is often suggested as one way to cut down on the formation of heterocyclic amines, but the evidence that marinating helps is mixed. The Harvard Health Letter suggests some other tips that may make grilled meat safer to eat:

• Cook smaller pieces: They cook more quickly and at lower temperatures.
• Choose leaner meat: Less fat should reduce flames and therefore smoke.
• Precook in the microwave: Doing so for two minutes may decrease heterocyclic amines by 90%, according to some research.
• Flip frequently: That way, neither side has time to absorb or lose too much heat.

Another good source, the USDA’s Food Safety and Inspection Service, has this to say:

Does Grilling Pose a Cancer Risk?
Some studies suggest there may be a cancer risk related to eating food cooked by high-heat cooking techniques as grilling, frying, and broiling. Based on present research findings, eating moderate amounts of grilled meats like fish, meat, and poultry cooked — without charring — to a safe temperature does not pose a problem.

To prevent charring, remove visible fat that can cause a flare-up. Precook meat in the microwave immediately before placing it on the grill to release some of the juices that can drop on coals. Cook food in the center of the grill and move coals to the side to prevent fat and juices from dripping on them. Cut charred portions off the meat.

Yet more fascinating data, backed up by studies, came from the Cancer Project website’s page on barbecue risks. Among their findings:

Cancer Project nutritionists determined that many commonly grilled foods contain alarmingly high levels of HCAs. This table lists the five foods containing the highest levels.

The Five Worst Foods to Grill
Food	HCAs ng/100g*
Chicken breast, skinless, boneless, grilled, well done	14,300 ng/100g2
Steak, grilled, well done	810 ng/100g3
Pork, barbecued	470 ng/100g4
Salmon, grilled with skin	166 ng/100g5
Hamburger, grilled, well done	130 ng/100g3
*100g portion equals about 3.5 ounces grilled

 

Safer Alternatives for Grilling
Other foods produce undetectable levels or negligible concentrations of HCAs when they are grilled. These include soy-based veggie burgers, veggie brochettes, and portabello mushroom “steaks.” These healthy vegetarian alternatives are also low in fat and cholesterol.

And yet other sites, including the New York Times, mention tantalizing research from lucky lab techs at Livermore, who reportedly found that certain marinades dramatically decreased the carcinogen production. But I’m still trying in vain to see these original studies, so I cannot comment too much on that.

The Bottom Line

I think there’s certainly enough evidence about HCA and PAC compounds to make hard-core barbecuers take note, and perhaps follow some basic changes. My major changes:

• Pre-zap more of my meats in the microwave  for 2 minutes
• Focus on less charring and less smoke
• Use more lean meats
• Use more marinade and sauces
• Barbecue more veggies (corn, roasted bell peppers, portabello, onions…awesome!)

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The simple answer is: usually not nearly as much as you may think. Let’s take the common cold for example. The common cold symptoms of a low fever, wet cough and runny nose are usually caused by a family of viruses and not bacteria. The typical course is 3-4 days of these symptoms, with the cough usually the last to resolve many days later. The commonly assumed “warning sign” of colored or greenish runny nose does not mean this infection is bacterial; it only means your body’s white cells are fighting an infection, which again most likely is viral. So in most of these cases, the antibiotic doesn’t help fight this infection at all.

Antibiotic overuse is a serious problem not only because the medicine isn’t properly treating your child; it also could cause common side effects such as diarrhea and rash, or more serious allergic reactions such as allergic shock or even death. Plus, your child’s body may become resistant to this antibiotic in the future, when they may actually need the medicine to fight a real bacterial infection.

The American Academy of Pediatrics and the American Academy of Family Medicine both agree that antibiotic overuse is a serious problem with children’s illnesses, and they are dangerously over-prescribed for simple illnesses — but especially for ear infections. Many times in this scenario, the infection again is caused by a virus, and thus a week of antibiotics is not helpful at all. Fortunately, thanks to these Academies’ public education campaigns, doctors have been much more aggressive these last few years in cutting back on prescribing antibiotics for ear infections.

So what can we all do about this? I think one major fault lies with the doctors; we really need to do a much better job convincing our patients or their parents that antibiotics are only for serious bacterial infections. Perhaps doctors should even rename “antibiotics” to “antibacterials” to help patients distinguish the difference; after all, there is a class of “antivirals” for specific viruses such as HIV, influenza or hepatitis. Another technique is to prescribe the antibiotic but to have the parents wait before buying the medicine; after 24 to 48 hours, if the child is clearly worsening, then the parents can choose to fill the prescription. This can be a nice win-win for doctor and patient, as it gives the parents a bit more control, and it also gives the child time to recover without antibiotics.

Parents and teachers can find helpful information about this important issue at http://www.dobugsneeddrugs.org/.

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Perhaps there’s a very simple answer to every doctor’s treatment plans: massage! This may seem obvious to many people, but most docs thought that massage’s effects were very short-lived. Now, I’m happy to report that perhaps massage does have long-lasting effects on people with chronic back pains. This is due to a new study, just published in the Annals of Internal Medicine, which studied three groups: a control group; one group getting relaxing massage; and a third getting more aggressive “structural massage”. The NY Times Health Section, as usual, does such a good job that I’ll just quote them:

Those who received massage scored significantly better on both symptom and function tests, and they spent less time in bed, used less medicine and were more satisfied with their current level of back pain.

At 26 weeks after treatment, those in the usual care group continued to function less well than those who had gotten massage. But there were no significant differences in the pain scores in the three groups, either at 26 or at 52 weeks.

Daniel C. Cherkin, the lead author and an epidemiologist with the Group Health Research Institute in Seattle, mentioned some of the study’s considerable strengths. It had a randomized design, a high follow-up rate, good adherence to the treatment and a large sample size. Still, he said, the study was done on a mostly white, middle-class population in otherwise good health, which may limit its applicability to other groups. The study appeared online Monday in Annals of Internal Medicine.

It is unclear how massage eases back pain, but the researchers suggest it may stimulate tissue locally or cause a more generalized central nervous system response. It is also possible that just spending time in a relaxing environment or being touched and cared for by a sympathetic therapist could have led to improvement. Also, those in the control group knew that the other groups were getting massage, and the knowledge that others were getting the treatment while they got none may have led them to underestimate their own progress.

Still, the researchers conclude that massage has few adverse effects and is a reasonable treatment for low back pain. There is no evidence, though, that it lowers the cost of health services related to back pain.

“We tested this on people who had not been getting better from the usual medical approaches, Dr. Cherkin said. “If you’ve tried other things and you’re not getting adequate relief, then massage is a reasonable thing to try.”

So there you have it; a simple massage once a week can help your overall quality of life with chronic back pain. Note how while there was no major difference in pain levels, the patient’s satisfaction rates were higher — as well as medication use.

Another good take-home message is that a more aggressive, Chinese-style massage was as effective as the more sleepy, Swedish-oil relaxation style massage. I vastly prefer the invigorating Chinese massages but actually wasn’t sure if it would make back pains worse or better — and now I know.

In my practice, I will no longer be hesitant when recommending massage to my back pain patients. Such is the power of good studies; they can quickly change medical practice.

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