Mayo Clinic proceedings. Innovations, quality & outcomes最新文献

Objective

To provide a synthesis of randomized controlled trials (RCTs) investigating statin-associated muscle symptoms (SAMS) in adults who underwent exercise training intervention.

Patients and Methods

We systematically searched 5 electronic databases for placebo-controlled RCTs through January 31, 2023. We included short-term and long-term exercise interventions that compared the efficacy and safety of exercise+statin vs exercise+placebo in healthy adults and reported SAMS preintervention and postintervention. Publication bias and methodological study quality assessments were performed.

Results

Five of 454 potentially qualifying RCTs met the inclusion criteria, all short-term exercise RCTs. Participants were predominantly physically inactive young to middle-aged (M=37.2 y) men (57%), 252 (49%) who were on statin therapy, and 271 (53%) on placebo. Of the 3 RCTs providing qualitative SAMS results, 19 (9%) out of 220 participants reported SAMS on exercise+statin and 10 (4%) out of 234 reported SAMS on exercise+placebo. There was no difference between exercise+statin vs exercise+placebo for maximal oxygen consumption (d=−0.18; 95% CI, −0.37 to 0.00; P=.06) or creatine kinase after short-term exercise (d=0.59; 95% CI, −0.06 to 1.25; P=.08). Participants in the exercise+statin group reduced low-density lipoprotein cholesterol vs exercise+placebo (d=−1.84; 95% CI, −2.28 to −1.39; P<.001). Most of the RCTs exhibited low levels of risk of bias (k=4, 80%) and achieved moderate methodological study quality (75.0%±5.2%).

Conclusion

Self-reported SAMs tended to be 5% greater after short-term exercise in statin users compared with placebo, although this difference did not achieve statistical significance. There remains an important need for placebo-controlled RCTs investigating the prevalence of statin-induced SAMS during exercise training.

Objective

To determine the risk of morbidity and mortality in patients receiving dental extractions before planned cardiovascular surgery (CVS) and examine factors that may affect the chance of oral health clearance.

Patients and Methods

A retrospective medical record review was performed of patients who underwent dental screening before CVS from January 1, 2015, to December 31, 2021, at a major medical institution. A total of 496 patients met the inclusion criteria and were divided into 2 groups. Group 1 patients were cleared to advance to planned CVS (n=390). Group 2 patients were not cleared for surgery and subsequently underwent dental extractions before planned CVS (n=106).

Results

Six patients (5.7%) experienced postoperative complications after dental extraction that resulted in an emergency room visit. No deaths occurred after dental extraction before CVS. However, 4 patients died within 30 days of CVS, 3 from Group 1 (0.77%) and 1 from Group 2 (0.94%). Dental extraction before planned CVS showed a borderline significant association with death based on unadjusted (P=.06) and age-adjusted analysis (P=.05). Patients who reported seeing a dentist routinely had a significantly higher chance of oral health clearance (P <.001). No differences were noted between the 2 groups with regard to age, sex, or 30-day hospital readmission rate.

Conclusion

Patients who had dental extractions completed before planned CVS may be at an increased risk of mortality. Further studies are needed to examine this relationship. Emphasis should be on prioritization of routine dental visits before planned CVS.

Lifestyle Medicine (LM) is a rapidly growing discipline that focuses on the role of lifestyle factors in preventing, managing, and reversing chronic disease. At this point in the field’s evolution, there is strong evidence that the 6 pillars of LM—a whole-food, plant-predominant eating pattern, physical activity, restorative sleep, stress management, avoidance of risky substances, and positive social connections—are central in the creation and maintenance of health. Previous publications, many of them randomized controlled studies and meta-analyses, have solidified the evidence base for the use of the 6 pillars within the field of LM. As data emerged, so did its governing body, the American College of Lifestyle Medicine (ACLM), and with it a rich history began to unfold. Several articles have been written on the early history of the ACLM and the growth of the field; however, this review article explores the history and foundation of LM, aiming to provide a comprehensive understanding of its relevance and impact on health care. It underscores landmark studies that have defined the field and provides a road map detailing national and global barriers and areas of potential future growth.

Chronic diseases like diabetes, heart disease, stroke, and cancer have been and continue to be some of the major causes of worldwide morbidity and mortality. A transition between infectious and noncommunicable diseases occurred in the early 1900s as a result of improved public health and has persisted ever since. Now, as individuals live longer, the prevalence and cost of chronic disease continue to grow. The estimated cost of chronic disease is expected to reach $47 trillion worldwide by 2030. Individual lifestyle and behaviors and community factors play important roles in the development and management of chronic diseases. Many of these conditions (diabetes, heart disease, and respiratory diseases) are preventable, and their leading risk factors are physical inactivity, poor nutrition, tobacco use, and excessive alcohol. Unfortunately, the investment in prevention remains small compared with treatment, both from a lifestyle perspective and a social determinants of health perspective. Given the future trajectory of chronic disease, innovation in technology and pharmaceuticals with a concomitant investment in prevention will be required. Our future depends on it.

Ninety percent of people with chronic kidney disease (CKD) remain undiagnosed, most people at risk do not receive guideline-concordant testing, and disparities of care and outcomes exist across all stages of the disease. To improve CKD diagnosis and management across primary care, the National Kidney Foundation launched a collective impact (CI) initiative known as Show Me CKDintercept. The initiative was implemented in Missouri, USA from January 2021 to June 2022, using a data strategy, stakeholder engagement and relationship mapping, learning in action working groups (LAWG), and a virtual leadership summit. The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework was used to evaluate success. The initiative united 159 stakeholders from 81 organizations (Reach) to create an urgency for change and engage new CKD champions (Effectiveness). The adoption resulted in 53% of participants committed to advancing the roadmap (Adoption). Short-term results reported success in laying a foundation for CI across Missouri. The long-term success of the CI initiative in addressing the public health burden of kidney disease remains to be determined. The project reported the potential use of a CI initiative to build leadership consensus to drive measurable public health improvements nationwide.

Multifocal motor neuropathy (MMN) is a rare immune-mediated motor neuropathy characterized by asymmetric weakness that preferentially affects distal upper limb muscles. The clinical features of MMN may be difficult to differentiate from motor neuron disease. Other conditions that may be mistaken for MMN include inclusion body myositis, chronic inflammatory demyelinating polyradiculoneuropathy, hereditary neuropathy with liability to pressure palsy, focal neuropathies, and radiculopathies. A key distinguishing electrophysiologic feature of MMN is the motor nerve conduction block located at noncompressible sites. MMN is a treatable neuropathy; therefore it is important that primary care physicians are aware of the features of the disease to identify potential patients and make referrals to a neuromuscular specialist in a timely manner. This review provides an overview of the disease, highlights key differential diagnoses, and describes available treatment options for patients with MMN.

Giant cell arteritis is an autoimmune disease that affects large and medium blood vessels of the head and neck. Its prompt treatment is mandatory to avoid severe and permanent complications, such as blindness. Temporal artery biopsy is an important part of the diagnostic work-up, especially in those patients with cranial symptoms or in the elderly with a fever of unknown origin. Most patients have signs and symptoms matching the distribution of their arterial involvement. In the case scenario of occipital headache or nuchal pain, a biopsy of the occipital artery may be preferred to a temporal artery biopsy. This article provides important anatomical details of the course of the occipital artery and explains, in a stepwise fashion, how to perform an occipital artery biopsy.

Objective

To examine the dose-response association between estimated cardiorespiratory fitness (eCRF) and risk of myocardial infarction (MI).

Patients and Methods

Adults who attended Tromsø Study surveys 4-6 (Janurary 1,1994-December 20, 2008) with no previous cardiovascular disease were followed up through December 31, 2014 for incident MI. Associations were examined using restricted cubic splines Fine and Gray regressions, adjusted for education, smoking, alcohol, diet, sex, adiposity, physical activity, study survey, and age (timescale) in the total cohort and subsamples with hyperlipidemia (n=2956), hypertension (n=8290), obesity (n=5784), metabolic syndrome (n=1410), smokers (n=3823), and poor diet (n=3463) and in those who were physically inactive (n=6255).

Results

Of 14,285 participants (mean age ± SD, 53.7±11.4 years), 979 (6.9%) experienced MI during follow-up (median, 7.2 years; 25th-75th, 5.3-14.6 years). Females with median eCRF (32 mL/kg/min) had 43% lower MI risk (subdistributed hazard ratio [SHR], 0.57; 95% CI, 0.48-0.68) than those at the 10th percentile (25 mL/kg/min) as reference. The lowest MI risk was observed at 47 mL/kg/min (SHR, 0.02; 95% CI, 0.01-0.11). Males had 26% lower MI risk at median eCRF (40 mL/kg/min; SHR, 0.74; 95% CI, 0.63-0.86) than those at the 10th percentile (32 mL/kg/min), and the lowest risk was 69% (SHR, 0.31; 95% CI, 0.14-0.71) at 60 mL/kg/min. The associations were similar in subsamples with cardiovascular disease risk factors.

Conclusion

Higher eCRF associated with lower MI risk in females and males, but associations were more pronounced among females than those in males. This suggest eCRF as a vital estimate to implement in medical care to identify individuals at high risk of future MI, especially for females.

We investigated the association of daylight saving time (DST) transitions with the rates of adverse cardiovascular events in a large, US-based nationwide study. The study cohort included 36,116,951 unique individuals from deidentified administrative claims data of the OptumLabs Data Warehouse. There were 74,722 total adverse cardiovascular events during DST transition and the control weeks (2 weeks before and after) in spring and autumn of 2015-2019. We used Bayesian hierarchical Poisson regression models to estimate event rate ratios representing the ratio of composite adverse cardiovascular event rates between DST transition and control weeks. There was an average increase of 3% (95% uncertainty interval, −3% to −10%) and 4% (95% uncertainty interval, −2% to −12%) in adverse cardiovascular event rates during Monday and Friday of the spring DST transition, respectively. The probability of this being associated with a moderate-to-large increase in the event rates (estimate event rate ratio, >1.10) was estimated to be less than 6% for Monday and Friday, and less than 1% for the remaining days. During autumn DST transition, the probability of any decrease in adverse cardiovascular event rates was estimated to be less than 46% and a moderate-to-large decrease in the event rates to be less than 4% across all days. Results were similar when adjusted by age. In conclusion, spring DST transition had a suggestive association with a minor increase in adverse cardiovascular event rates but with a very low estimated probability to be of clinical importance. Our findings suggest that DST transitions are unlikely to meaningfully impact the rate of cardiovascular events.