Alternative Medicine Los Angeles

Background  While the role of hydroxymethyl glutaryl coenzyme A reductase inhibitors (statins) in secondary prevention of cardiovascular (CV) events and mortality is established, their value for primary prevention is less clear. To clarify the role of statins for patients without CV disease, we performed a meta-analysis of randomized controlled trials (RCTs).

Methods  MEDLINE, EMBASE, Cochrane Collaboration, and American College of Physicians Journal Club databases were searched for RCTs published between 1966 and June 2005. We included RCTs with follow-up of 1 year or longer, more than 100 major CV events, and 80% or more of the population without CV disease. From each trial, demographic data, lipid profile, CV outcomes, mortality, and adverse outcomes were recorded. Summary relative risk (RR) ratios with 95% confidence intervals (CIs) were calculated using a random effects model.

Results  Seven trials with 42 848 patients were included. Ninety percent had no history of CV disease. Mean follow-up was 4.3 years. Statin therapy reduced the RR of major coronary events, major cerebrovascular events, and revascularizations by 29.2% (95% CI, 16.7%-39.8%) (P<.001), 14.4% (95% CI, 2.8%-24.6%) (P = .02), and 33.8% (95% CI, 19.6%-45.5%) (P<.001), respectively. Statins produced a nonsignificant 22.6% RR reduction in coronary heart disease mortality (95% CI, 0.56-1.08) (P = .13). No significant reduction in overall mortality (RR, 0.92 [95% CI, 0.84-1.01]) (P = .09) or increases in cancer or levels of liver enzymes or creatine kinase were observed.

Conclusion  In patients without CV disease, statin therapy decreases the incidence of major coronary and cerebrovascular events and revascularizations but not coronary heart disease or overall mortality.

Background  Depression is common in primary care but is suboptimally managed. Collaborative care, that is, structured care involving a greater role of nonmedical specialists to augment primary care, has emerged as a potentially effective candidate intervention to improve quality of primary care and patient outcomes.

Methods  To quantify the short-term and longer-term effectiveness of collaborative care compared with standard care and to understand mechanisms of action by exploring between-study heterogeneity, we conducted a systematic review of randomized controlled trials that compared collaborative care with usual primary care in patients with depression. We searched MEDLINE (from the beginning of 1966), EMBASE (from the beginning of 1980), CINAHL (from the beginning of 1980), PsycINFO (from the beginning of 1980), the Cochrane Library (from the beginning of 1966), and DARE (Database of Abstracts of Reviews of Effectiveness) (from the beginning of 1985) databases from study inception to February 6, 2006.

Results  We found 37 randomized studies including 12 355 patients with depression receiving primary care. Random effects meta-analysis showed that depression outcomes were improved at 6 months (standardized mean difference, 0.25; 95% confidence interval, 0.18-0.32), and evidence of longer-term benefit was found for up to 5 years (standardized mean difference, 0.15; 95% confidence interval, 0.001-0.31). When exploring determinants of effectiveness, effect size was directly related to medication compliance and to the professional background and method of supervision of case managers. The addition of brief psychotherapy did not substantially improve outcome, nor did increased numbers of sessions. Cumulative meta-analysis showed that sufficient evidence had emerged by 2000 to demonstrate the statistically significant benefit of collaborative care.

Conclusions  Collaborative care is more effective than standard care in improving depression outcomes in the short and longer terms. Future research needs to address the implementation of collaborative care, particularly in settings other than the United States.

Background  Obesity is associated with increased risk of atrial fibrillation (AF), but it is unknown whether the association differs by duration or persistence of AF. It is also unknown to what extent cardiovascular risk factors may mediate this association.

Methods  This population-based case-control study included 425 subjects with new-onset AF and 707 controls. The AF cases were identified through International Classification of Diseases, Ninth Revision codes for inpatient and outpatient visits and verified by medical record review. Medical records provided data on height, weight, and cardiovascular risk factors.

Results  On average, AF risk was 3% higher (95% confidence interval [CI], 1%-5%) per unit increment in body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared). For sustained AF (duration ≥6 months), risk was higher by 7% (95% CI, 3%-11%) per unit BMI increment; for intermittent AF (duration ≥8 days or recurrent), 4% (95% CI, 1%-6%); and for transitory AF (duration <8 days), 1% (95% CI, –1% to +4%). Compared with those with normal BMI, the odds ratios for overweight and obese subjects were as follows: overweight, 0.97 (95% CI, 0.68-1.38); obese class 1, 1.18 (95% CI, 0.80-1.73); obese class 2, 1.34 (95% CI, 0.82-2.18); and obese class 3, 2.31 (95% CI, 1.36-3.91) (P = .002 for trend). When diabetes mellitus, a possible mediator, was added to the model, the odds ratio per unit increment of BMI decreased from 1.034 to 1.028. Adjustment for other cardiovascular risk factors including hyperlipidemia and blood pressure did not attenuate the BMI-AF association.

Conclusions  The association with BMI was stronger for sustained AF than for transitory or intermittent AF. The obesity-AF association appears to be partially mediated by diabetes mellitus but minimally through other cardiovascular risk factors.

Background  Cardiac rehabilitation is widely recognized as a medical management procedure that reduces mortality, but the cardiovascular safety of exercise training has not been clearly established. Published data are retrospective or outdated, as patient management has substantially progressed in recent years. The aim of this prospective registry was to determine the current complication rate during exercise performed in the course of cardiac rehabilitation.

Methods  This study was conducted by the Functional Evaluation and Cardiac Rehabilitation Working Group of the French Society of Cardiology. During a 1-year period, 65 cardiac rehabilitation centers reported that serious events had occurred during or 1 hour after an exercise stress test or a training session. Severe cardiovascular events were validated by a scientific committee.

Results  A total of 25 420 patients (78% men; mean age, 61.3 years) were included in the study. Initial indications for cardiac rehabilitation were post–cardiac surgery (coronary bypass, 34.3%; valvular surgery, 18.4%); recent percutaneous coronary intervention (21.6%); and other coronary (13.2%) and noncoronary (12.5%) conditions. The study population underwent 42 419 exercise stress tests and 743 471 patient-hours of exercise training. Twenty severe cardiac events were reported: 5 were related to exercise testing and 15 were related to exercise training. The event rate was 1 per 8484 exercise stress tests and 1 per 49 565 patient-hours of exercise training; the cardiac arrest rate was 1.3 per million patient-hours of exercise. Neither fatal complications nor emergency defibrillations were reported.

Conclusion  The frequency of major cardiovascular complications during supervised exercise training in France is quite low.

Background  The role of nutritional status in the disablement process is still unclear. The objective of this study was to assess whether low concentrations of nutrients predict the development and course of disability.

Methods  Longitudinal study including community-dwelling women 65 years or older enrolled in the Women's Health and Aging Study I. In total, 643 women were assessed prospectively at 6-month intervals from 1992 to 1995.

Results  Incidence rates of disability in activities of daily living (ADLs) during 3 years of follow-up. Incidence rates in the lowest quartile of each selected nutrient were compared with those in the upper quartiles. The hazard ratios were estimated from Cox models adjusted for potential confounders. Women in the lowest quartile of serum concentrations of vitamin B₆ (hazard ratio [HR], 1.31; 95% confidence interval [CI], 1.03-1.67), vitamin B₁₂ (HR, 1.40; 95% CI, 1.12-1.74), and selenium (HR, 1.38; 95% CI, 1.12-1.71) had significantly higher risk of disability in ADLs during 3 years of follow-up compared with women in the upper 3 quartiles.

Conclusions  Low serum concentrations of vitamins B₆ and B₁₂ and selenium predict subsequent disability in ADLs in older women living in the community. Nutritional status is one of the key factors to be considered in the development of strategies aimed at preventing or delaying the disablement process.

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