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Omega-3 Polyunsaturated Fatty Acids and Cardiovascular Health: A Comprehensive Review.
Elagizi, A, Lavie, CJ, Marshall, K, DiNicolantonio, JJ, O'Keefe, JH, Milani, RV
Progress in cardiovascular diseases. 2018;(1):76-85
Abstract
The potential cardiovascular (CV) disease (CVD) benefits of Omega-3 Polyunsaturated Fatty Acids (OM3) have been intensely studied and debated for decades. Initial trials were performed in patients with low use of maximal medical therapy for CVD, and reported significant mortality benefits with the use of 1 g/day OM3 intervention following myocardial infarction (MI). More recent studies, including cohorts of patients receiving modern guideline directed medical therapy for CVD, have often not shown similar benefits with OM3 use. We conducted a literature review using PubMed, professional society guidelines, specific journal databases including New England Journal of Medicine and Journal of the American College of Cardiology from January 1, 2007 to December 31, 2017. References from selected articles were also reviewed, as well as key articles outside of the selected time-frame for their important findings or historical perspectives. Currently, there are no Class I recommendations from the American Heart Association (AHA) for the use of OM3, however, considering the safety of this therapy and beneficial findings of some modern studies (including patients with current maximal medical therapy for CVD), the AHA has recently expanded their list of Class II recommendations, in which treatment with OM3 for CVD benefit is reasonable. This review discusses the current state of the evidence, summarizes current professional recommendations, and provides recommendations for future research.
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Engaging primary care professionals in collaborative processes for optimising type 2 diabetes prevention practice: the PREDIAPS cluster randomised type II hybrid implementation trial.
Sanchez, A, Grandes, G, Pablo, S, Espinosa, M, Torres, A, García-Alvarez, A, ,
Implementation science : IS. 2018;(1):94
Abstract
BACKGROUND There is a lack of evidence concerning the effectiveness of different strategies to engage healthcare professionals in collaborative processes that seek to optimise clinical practice. The PREDIAPS project aims to assess the effect of different primary health care (PHC) providers' engagement procedures in the creation and execution of a facilitated interprofessional collaborative process to optimise the integration of the recommended clinical practice for the prevention of type-2 diabetes (T2D) in routine PHC. METHODS This will be a randomised cluster type II hybrid implementation trial. Nine PHC centres from the Basque Health Service (Osakidetza) will be allocated to two different procedures to engage family doctors and nurses and create an interprofessional collaborative practice to optimise the integration of a T2D primary prevention programme. All centres and PHC professionals will receive training on current guidelines in primary prevention of T2D and effective interventions to promote healthy lifestyles. Headed by a local leader and an external facilitator, centres will conduct a collaborative structured process to model and adapt the intervention and its implementation to the specific context of professionals and centres. One of the groups will apply this strategy globally, promoting the cooperation of all health professionals from the beginning. The other will perform it sequentially, centred first on nurses, who will then seek the pragmatic cooperation of doctors. All patients without diabetes aged ≥ 30 years old who attend collaborating centres at least once during the study period and found to be at high risk of developing T2D will be eligible for programme inclusion. The main outcome measures focus on changes observed in indicators of T2D prevention clinical practice at centre level after 12 and 24 months, associated with the application of one or other engagement procedure. Secondary outcomes will compare their clinical effectiveness in changing eligible exposed patients' main lifestyle behaviours and risk factors (physical activity and diet, weight, etc.) after 12 months. DISCUSSION The PREDIAPS project will generate scientific knowledge on procedures for engaging PHC professional to facilitate feasible and effective adoption of proven interventions for the prevention of T2D in routine clinical practice through the application of implementation strategies. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT03254979 . Registered 16 August 2017.
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Mobile phone-based interventions for improving adherence to medication prescribed for the primary prevention of cardiovascular disease in adults.
Palmer, MJ, Barnard, S, Perel, P, Free, C
The Cochrane database of systematic reviews. 2018;(6):CD012675
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Abstract
BACKGROUND Cardiovascular disease (CVD) is a major cause of disability and mortality globally. Premature fatal and non-fatal CVD is considered to be largely preventable through the control of risk factors via lifestyle modifications and preventive medication. Lipid-lowering and antihypertensive drug therapies for primary prevention are cost-effective in reducing CVD morbidity and mortality among high-risk people and are recommended by international guidelines. However, adherence to medication prescribed for the prevention of CVD can be poor. Approximately 9% of CVD cases in the EU are attributed to poor adherence to vascular medications. Low-cost, scalable interventions to improve adherence to medications for the primary prevention of CVD have potential to reduce morbidity, mortality and healthcare costs associated with CVD. OBJECTIVES To establish the effectiveness of interventions delivered by mobile phone to improve adherence to medication prescribed for the primary prevention of CVD in adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and two other databases on 21 June 2017 and two clinical trial registries on 14 July 2017. We searched reference lists of relevant papers. We applied no language or date restrictions. SELECTION CRITERIA We included randomised controlled trials investigating interventions delivered wholly or partly by mobile phones to improve adherence to cardiovascular medications prescribed for the primary prevention of CVD. We only included trials with a minimum of one-year follow-up in order that the outcome measures related to longer-term, sustained medication adherence behaviours and outcomes. Eligible comparators were usual care or control groups receiving no mobile phone-delivered component of the intervention. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. We contacted study authors for disaggregated data when trials included a subset of eligible participants. MAIN RESULTS We included four trials with 2429 randomised participants. Participants were recruited from community-based primary care or outpatient clinics in high-income (Canada, Spain) and upper- to middle-income countries (South Africa, China). The interventions received varied widely; one trial evaluated an intervention focused on blood pressure medication adherence delivered solely through short messaging service (SMS), and one intervention involved blood pressure monitoring combined with feedback delivered via smartphone. Two trials involved interventions which targeted a combination of lifestyle modifications, alongside CVD medication adherence, one of which was delivered through text messages, written information pamphlets and self-completion cards for participants, and the other through a multi-component intervention comprising of text messages, a computerised CVD risk evaluation and face-to-face counselling. Due to heterogeneity in the nature and delivery of the interventions, we did not conduct a meta-analysis, and therefore reported results narratively.We judged the body of evidence for the effect of mobile phone-based interventions on objective outcomes (blood pressure and cholesterol) of low quality due to all included trials being at high risk of bias, and inconsistency in outcome effects. Of two trials targeting medication adherence alongside other lifestyle modifications, one reported a small beneficial intervention effect in reducing low-density lipoprotein cholesterol (mean difference (MD) -9.2 mg/dL, 95% confidence interval (CI) -17.70 to -0.70; 304 participants), and the other found no benefit (MD 0.77 mg/dL, 95% CI -4.64 to 6.18; 589 participants). One trial (1372 participants) of a text messaging-based intervention targeting adherence showed a small reduction in systolic blood pressure (SBP) for the intervention arm which delivered information-only text messages (MD -2.2 mmHg, 95% CI -4.4 to -0.04), but uncertain evidence of benefit for the second intervention arm that provided additional interactivity (MD -1.6 mmHg, 95% CI -3.7 to 0.5). One study examined the effect of blood pressure monitoring combined with smartphone messaging, and reported moderate intervention benefits on SBP and diastolic blood pressure (DBP) (SBP: MD -7.10 mmHg, 95% CI -11.61 to -2.59; DBP: -3.90 mmHg, 95% CI -6.45 to -1.35; 105 participants). There was mixed evidence from trials targeting medication adherence alongside lifestyle advice using multi-component interventions. One trial found large benefits for SBP and DBP (SBP: MD -12.45 mmHg, 95% CI -15.02 to -9.88; DBP: MD -12.23 mmHg, 95% CI -14.03 to -10.43; 589 participants), whereas the other trial demonstrated no beneficial effects on SBP or DBP (SBP: MD 0.83 mmHg, 95% CI -2.67 to 4.33; DBP: MD 1.64 mmHg, 95% CI -0.55 to 3.83; 304 participants).Two trials reported on adverse events and provided low-quality evidence that the interventions did not cause harm. One study provided low-quality evidence that there was no intervention effect on reported satisfaction with treatment.Two trials were conducted in high-income countries, and two in upper- to middle-income countries. The interventions evaluated employed between three and 16 behaviour change techniques according to coding using Michie's taxonomic method. Two trials evaluated interventions that involved potential users in their development. AUTHORS' CONCLUSIONS There is low-quality evidence relating to the effects of mobile phone-delivered interventions to increase adherence to medication prescribed for the primary prevention of CVD; some trials reported small benefits while others found no effect. There is low-quality evidence that these interventions do not result in harm. On the basis of this review, there is currently uncertainty around the effectiveness of these interventions. We identified six ongoing trials being conducted in a range of contexts including low-income settings with potential to generate more precise estimates of the effect of primary prevention medication adherence interventions delivered by mobile phone.
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Primary prevention of Clostridium difficile infections with a specific probiotic combining Lactobacillus acidophilus, L. casei, and L. rhamnosus strains: assessing the evidence.
McFarland, LV, Ship, N, Auclair, J, Millette, M
The Journal of hospital infection. 2018;(4):443-452
Abstract
Clostridium difficile infection (CDI) has become the leading healthcare-associated infection and cause of outbreaks around the world. Although various innovative treatments have been developed, preventive strategies using multi-faceted infection control programmes have not been successful in reducing CDI rates. The major risk factor for CDI is the disruption of the normally protective gastrointestinal microbiota, typically by antibiotic use. Supplementation with specific probiotics has been effective in preventing various negative outcomes, including antibiotic-associated diarrhoea and CDI. However, a consensus of which probiotic strains might prevent CDI has not been reached and meta-analyses report high degrees of heterogeneity when studies of different probiotic products are pooled together. We searched the literature for probiotics with sufficient evidence to assess clinical efficacy for the prevention of CDI and focused on one specific probiotic formulation comprised of three lactobacilli strains (Lactobacillus acidophilus CL1285, Lactobacillus casei LBC80R, Lactobacillus rhamnosus CLR2, Bio-K+) for its ability to prevent CDI in healthcare settings. A literature search on this probiotic formulation was conducted using electronic databases (PubMed, Google Scholar), abstracts from infectious disease and infection control meetings, and communications from the probiotic company. Supporting evidence was found for its mechanisms of action against CDI and that it has an excellent safety and tolerability profile. Evidence from randomized controlled trials and facility-level interventions that administer Bio-K+ show reduced incidence rates of CDI. This probiotic formulation may have a role in primary prevention of healthcare-associated CDI when administered to patients who receive antibiotics.
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Primary prevention of coronary artery disease: let's start with calcium score.
Gatto, L, Prati, F
Journal of cardiovascular medicine (Hagerstown, Md.). 2018;:e103-e106
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Stratified prevention: opportunities and limitations. Report on the 1st interdisciplinary cardiovascular workshop in Augsburg.
Kirchhof, G, Lindner, JF, Achenbach, S, Berger, K, Blankenberg, S, Fangerau, H, Gimpel, H, Gassner, UM, Kersten, J, Magnus, D, et al
Clinical research in cardiology : official journal of the German Cardiac Society. 2018;(3):193-200
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Abstract
Sufficient exercise and sleep, a balanced diet, moderate alcohol consumption and a good approach to handle stress have been known as lifestyles that protect health and longevity since the Middle Age. This traditional prevention quintet, turned into a sextet by smoking cessation, has been the basis of the "preventive personality" that formed in the twentieth century. Recent analyses of big data sets including genomic and physiological measurements have unleashed novel opportunities to estimate individual health risks with unprecedented accuracy, allowing to target preventive interventions to persons at high risk and at the same time to spare those in whom preventive measures may not be needed or even be harmful. To fully grasp these opportunities for modern preventive medicine, the established healthy life styles require supplementation by stratified prevention. The opportunities of these developments for life and health contrast with justified concerns: A "surveillance society", able to predict individual behaviour based on big data, threatens individual freedom and jeopardises equality. Social insurance law and the new German Disease Prevention Act (Präventionsgesetz) rightly stress the need for research to underpin stratified prevention which is accessible to all, ethical, effective, and evidence based. An ethical and acceptable development of stratified prevention needs to start with autonomous individuals who control and understand all information pertaining to their health. This creates a mandate for lifelong health education, enabled in an individualised form by digital technology. Stratified prevention furthermore requires the evidence-based development of a new taxonomy of cardiovascular diseases that reflects disease mechanisms. Such interdisciplinary research needs broad support from society and a better use of biosamples and data sets within an updated research governance framework.
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Interdisciplinary Perspectives on Sun Safety.
Geller, AC, Jablonski, NG, Pagoto, SL, Hay, JL, Hillhouse, J, Buller, DB, Kenney, WL, Robinson, JK, Weller, RB, Moreno, MA, et al
JAMA dermatology. 2018;(1):88-92
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Abstract
Overexposure to the sun is associated with an increased risk of melanoma and nonmelanoma skin cancer, but indications of improvements in sun protection behavior are poor. Attempts to identify emerging themes in skin cancer control have largely been driven by groups of experts from a single field. In December 2016, 19 experts from various disciplines convened for Interdisciplinary Perspectives on Skin Cancer, a 2-day meeting hosted by the National Academy of Sciences. The group discussed knowledge gaps, perspectives on sun exposure, implications for skin cancer risk and other health outcomes, and new directions. Five themes emerged from the discussion: (1) The definition of risk must be expanded, and categories for skin physiology must be refined to incorporate population diversities. (2) Risky sun exposure often co-occurs with other health-related behaviors. (3) Messages must be nuanced to target at-risk populations. (4) Persons at risk for tanning disorder must be recognized and treated. (5) Sun safety interventions must be scalable. Efficient use of technologies will be required to sharpen messages to specific populations and to integrate them within multilevel interventions. Further interdisciplinary research should address these emerging themes to build effective and sustainable approaches to large-scale behavior change.
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The Mediterranean Diet: Lost in Translation.
Kuritzky, L, Lang, S
Current hypertension reports. 2018;(12):104
Abstract
PURPOSE OF REVIEW Despite substantive evidence documenting the efficacy of the Mediterranean diet to reduce cardiovascular events, underutilization is common. An overview of the data set supporting the role of the Mediterranean diet as confirmed in both observational and interventional trials should stimulate greater clinician interest in the diet. Additionally, the availability of patient-friendly tools that enable prompt and easy adoption of the Mediterranean diet, that are able to be used by clinicians who claim no special expertise in diet knowledge, should simplify the path to successful dietary change. RECENT FINDINGS A large recently published (2018) prospective study of the Mediterranean diet for primary prevention of cardiovascular events confirmed that compared to control, Mediterranean diet is associated with reduced risk for cardiovascular events in high risk patients. Of the tools available to clinicians that might reduce cardiovascular risk, dietary intervention is the one least utilized. The evidence supports the value of dietary intervention with the Mediterranean diet, and methods to effectively employ it within the confines of typical office practice are readily at hand.
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Lactobacillus rhamnosus GG in the Primary Prevention of Eczema in Children: A Systematic Review and Meta-Analysis.
Szajewska, H, Horvath, A
Nutrients. 2018;(9)
Abstract
Current guidelines recommend the use of probiotics to reduce the risk of eczema. It remains unclear which strain(s) to use. We systematically evaluated data on the efficacy of Lactobacillus rhamnosus GG (LGG) supplementation prenatally and/or postnatally for the primary prevention of eczema. The Cochrane Library, MEDLINE, and EMBASE databases were searched up to August 2018, with no language restrictions, for systematic reviews of randomized controlled trials (RCTs) and RCTs published afterwards. The primary outcome was eczema. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (CI). A random-effects model was used to pool data. Heterogeneity was explored using the I² statistics. The GRADE criteria were used to assess the overall quality of evidence supporting the primary outcome. Seven publications reporting 5 RCTs (889 participants) were included. High to moderate certainty in the body of evidence suggests that LGG supplementation (regardless of the timing of administration) did not reduce the risk of eczema. There was also no consistent effect on other allergic outcomes. This meta-analysis shows that LGG was ineffective in reducing eczema. It does not support the general recommendation to use probiotics for preventing eczema, unless specific strains would be indicated.
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Pharmacologic Prevention of Migraine: A Narrative Review of the State of the Art in 2018.
Loder, E, Rizzoli, P
Headache. 2018;:218-229
Abstract
This paper describes current non-antibody pharmacologic approaches to the prevention of migraine in adults. Preventive therapy should be considered for patients with migraine who routinely have more than 6 headache days per month or in other special circumstances. Choices for preventive therapy are based on patient preferences about side effects and evidence of efficacy. The evidence level and commonly used doses for selected categories of migraine preventive medication are reviewed, including antiepileptic drugs, antihypertensive drugs, and antidepressants. Propranolol, timolol, topiramate, and divalproex sodium are approved for migraine prevention by the US FDA. OnabotulinumtoxinA is approved for prevention of chronic migraine. Several off-label drugs, especially lisinopril, candesartan, and amitriptyline also have good evidence of benefit. The spectrum of response to preventive therapy varies; in general, complete cessation of headaches is uncommon, although there are "super-responders" to every therapy, as illustrated by patient reports of dramatic responses to treatment. Preventive treatment should be started at a low dose and doses increased slowly until therapeutic benefit is achieved or side effects preclude continued use.