Search

Background Cardiovascular disease (CVD) is a global burden and varies between regions. This regional variation has been linked in part to dietary factors and low fruit and vegetable intake has been associated with higher rates of CVD. Objectives: To determine the effectiveness of advice to increase fruit and vegetable consumption and the provision of fruit and vegetables to increase consumption, for the primary prevention of CVD. Methods The following electronic databases were searched with no language restrictions from their inception to October 2012: MEDLINE, EMBASE, CINAHL, Web of Science, the Cochrane Library and trial registers. Included studies fulfilled the following criteria: study design – RCT’s, participants - free of CVD (includes those at high risk of CVD), intervention - advice to increase fruit and vegetable consumption or the provision of fruit and vegetables to increase consumption, comparator - no intervention or minimal intervention (e.g. no face to face advice), outcomes - diagnosis of CVD or change in the risk factor profile for CVD (blood pressure, lipids). Two reviewers independently screened titles and abstracts, assessed shortlisted studies for formal inclusion/exclusion, abstracted data and assessed methodological quality. Results Database searching resulted in 7222 of which 298 went forward for informal inclusion and exclusion. Nine RCT’s met the inclusion criteria. Five trials investigated the provision of fruit and vegetables, and four trials examined advice to increase fruit and vegetable consumption. The intervention components, and the dietary advice provided differed between trials. None of the trials reported clinical events. There was no strong evidence for effects of individual trials of provision of fruit and vegetables on cardiovascular risk factors, but trials were heterogeneous and short term. Dietary advice showed favourable effects on blood pressure (SBP: mean difference -3.0 mmHg [95% CI -4.91, -1.08], DBP: mean difference -0.85 mmHg [-1.96, 0.26]) and to a lesser extent total cholesterol levels over six months (mean difference -0.13 mmol/l [-0.33, 0.08]), but few trials contributed to each analysis. Conclusion There are very few studies to date examining provision of, or advice to increase the consumption of, fruit and vegetables in the absence of additional dietary interventions or other lifestyle interventions for the primary prevention of CVD. The limited evidence suggests advice to increase fruit and vegetables as a single intervention has favourable effects on CVD risk factors but more trials are needed to confirm this.

The unfolding of bovine brain myo-inositol monophosphatase by guanidine. HCl (Gdn. HCl) has been investigated. The recovery of circular dichroism, emission spectra, and catalytic activity after dilution of Gdn.HCl-treated samples indicate that the overall process is reversible. The steepness of the spectroscopic changes between 3 M and 5 M Gdn.HCl, and the lack of any discernible plateau suggest that unfolding of the protein is a cooperative process. The sensitized luminescence of bound Tb(III) was used as a probe of conformational changes of the metal-binding loop. Denaturation of the enzyme by Gdn.HCl does not abolish sensitized luminescence. A 50% decrease in sensitized luminescence was observed in 5 M Gdn.HCl. Under this set of experimental conditions, the protein binds terbium with an association constant of 1 x 10(6)M-1. It is suggested that a residual structure of denatured myo-inositol monophosphatase is responsible for the binding of terbium ions. The kinetics of unfolding and refolding as a function of Gdn.HCl concentration were monitored by protein fluorescence in a stopped-flow instrument. The monophosphatase unfolded in a single kinetic phase with rate constants in the range 80-65 s-1 at 25 degrees C. The refolding kinetics fit monoexponential functions with rate constants in the range 120-65 s-1 depending on the Gdn.HCl concentration. Substantial refolding of the protein occurs within the dead time of mixing.

Patients with obstructive sleep apnea (OSA) experience severe sleep disruption and consequent daytime sleepiness. Current arousal scoring criteria show that some obstructive apneic events do not end in a recognizable cortical electroencephalographic (EEG) arousal. It is not known whether events that end in an obvious EEG arousal differ from those that do not, in terms of EEG frequency changes during the apneic event, the respiratory effort developed prior to apnea termination, the degree of the postapneic increase in blood pressure, or changes in CO2 tensions. We studied 15 patients with OSA in early Stage 2 sleep and analyzed obstructive apneic events with and without typical EEG arousals, defining an arousal as a frequency shift to waking alpha rhythm of 1 s or longer. EEG signals were digitized and analyzed by fast Fourier transform during and immediately after each apnea. The median EEG frequency and mean pleural pressure of the first and second halves of the apneic episode were compared with that of the first breath. Peak pleural pressure was measured just before the end of the apneic episode. Systolic and diastolic blood pressures and CO2 tensions were measured at the onset and termination of apnea. For each patient, 10 events that ended in EEG arousal were compared with 10 events that did not. Mean apnea duration did not differ for the two groups of events. Median EEG frequency and pleural pressure increased significantly from 8.14 to 9.25 Hz and 15.4 to 22.1 cm H2O, respectively, as the apnea progressed, but there was no difference between the groups nor any difference in the peak pleural pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Background Selenium is a key component of a number of selenoproteins which protect against oxidative stress and have the potential to prevent chronic diseases including CVD. However, observational studies have shown inconsistent associations between selenium intake and CVD risk; in addition there is concern around an increased risk of type 2 diabetes with high selenium exposure. Objective To determine the effectiveness of selenium only supplementation for the primary prevention of CVD and examine potential adverse effects on type 2 diabetes. Methods The following electronic databases were searched with no language restrictions from their inception to July 2011: MEDLINE, EMBASE, CINAHL, Web of Science, the Cochrane Library and trial registers. Studies were included if they fulfilled the following criteria: study design - RCTs, participants - free of CVD (includes those at high risk), intervention - selenium only supplementation, comparator – no intervention or placebo, outcomes – diagnosis of CVD or change in the risk factor profile for CVD (blood pressure, lipids) or adverse effects (type 2 diabetes). Two reviewers independently screened titles and abstracts, assessed shortlisted studies for formal inclusion/exclusion, abstracted data and assessed methodological quality. Data were analysed using RevMan 5.1 software. Results Database searching resulted in 1310 hits of which 43 went forward for formal inclusion/exclusion; 9 RCTs met the inclusion criteria. Included trials were heterogeneous in the participants recruited, dose of selenium, intervention and follow-up periods, outcomes reported, country of recruitment and baseline selenium status. Meta-analysis was possible for 2 trials reporting clinical events, but the analysis was dominated by the SELECT trial which carried over 80% of the weight. There were no statistically significant effects of selenium supplementation on total mortality (RR 0.97, 95% CI 0.88, 1.08), CVD mortality (RR 0.97, 95% CI 0.79, 1.2) or non-fatal CVD events (RR 0.97, 95% CI 0.9, 1.05). Similarly, the SELECT trial dominated the findings from 3 trials reporting type 2 diabetes, where selenium supplementation increased the risk of type 2 diabetes (RR 1.06, 95%CI 0.97, 1.16) although this did not reach statistical significance. There were no statistically significant effects of selenium on total or HDL cholesterol (measured in 2 trials (5 intervention arms) with varying doses of selenium supplementation). Conclusion There is still a lack of evidence of the effects of selenium supplementation in the primary prevention of CVD. More trial evidence is needed especially to clarify the potential adverse effect of selenium supplementation on type 2 diabetes.

Background Both vitamin D deficiency/insufficiency and depression are major global public health concerns. An estimated 1 billion people worldwide have low vitamin D levels and the WHO reports that depression is the third largest burden of disease worldwide. In the last 10 years animal, genetic and cross-sectional studies have shown an association between low vitamin D levels and increased depressive symptoms. Objectives (1) To examine the association between vitamin D status (using serum levels) and depressive symptoms. (2) To determine the effectiveness of vitamin D supplementation for the primary and secondary prevention of depressive symptoms. Methods MEDLINE, EMBASE, Web of Science and Knowledge, PsychInfo, the Cochrane Library and trial registers were searched with no language restrictions from inception to October 2010. Studies were included if they fulfilled the following criteria: (1) prospective observational studies (cohort/nested case control studies), with participants free of depressive disorder at baseline, 25 hydroxy-vitamin D3 serum levels measured, and outcomes relevant to depressive symptoms (clinically diagnosed depressive disorder or a change in depressive symptoms measured by validated mood/depression scales. (2) Randomised controlled trials (RCTs), with participants free of depressive disorder at baseline for primary prevention trials, or a diagnosis of depressive disorder for secondary prevention trials, where the intervention was vitamin D supplementation (as a single micronutrient or multivitamin preparations), the comparison groups were no intervention or placebo, and outcomes were: clinical diagnosis of depression or change in validated mood/depression scale score for primary prevention, and for secondary prevention a change in disease progression measured by validated mood/depression scales or clinically using the Mental State Examination. Results Following initial screening of the titles and abstracts 47 potentially relevant studies were assessed for inclusion by 2 reviewers independently. 12 separate studies met the inclusion criteria, 2 addressing objective 1 and 10 addressing objective 2. Studies reported a wide range of different populations, interventions and outcomes which preclude an overall synthetic meta-analysis. Preliminary data from prospective studies show an association between low vitamin D levels and subsequent depressive symptoms. Data from trials are mixed, with the largest RCT showing no beneficial effect of supplementation on depressive symptoms, while most smaller studies (6/9) show a positive effect of vitamin D supplementation on depressive symptoms, indicating likely publication bias. Conclusions There is limited research on the role of vitamin D to reduce depressive symptoms and it currently provides a mixed picture – it is likely that more research will be needed.

The inositol monophosphatase from bovine brain is inactivated by the histidine-specific reagent diethylpyrocarbonate. Using 4 mM reagent at pH 6.5, the reaction results in the modification of 3 equivalents of histidine per polypeptide chain. The loss of activity occurs at the same rate as the slowest reacting of these residues. Site directed mutagenesis studies have been used to generate a mutated enzyme species bearing a His-217→Gln replacement and have shown that it is the modification of histidine 217 which results in the inactivation of the enzyme.

Cold air may worsen asthmatic bronchoconstriction but can lessen breathlessness in normal individuals. Patients with COPD sometimes report improvement in their dyspnea in cold weather. We examined the effect of breathing cold air on exercise tolerance and the perception of breathlessness in 19 patients with stable COPD (age [+/- SD], 63 +/- 6 years; FEV1, 0.99 +/- 0.28 L) in a randomized open study. Patients exercised on a cycle ergometer breathing either room or cold air (-13 degrees C), breathlessness being assessed by Borg scaling. Peak exercise performance improved when breathing cold air (mean +/- SE), 46 +/- 6 W compared with 37 +/- 7 W (p0.05) while end-exercise breathlessness fell from 4.6 +/- 0.4 compared with 4.1 +/- 0.5 (p0.05) when breathing cold air. End-exercise ETCO2 was higher breathing cold air (6.1 +/- 0.3 kPa compared with 5.5 +/- 0.3 kPa) (p0.005). There was no difference in breathlessness at equivalent levels of ventilation. Cold air reduces breathlessness in COPD, probably by inducing relative hypoventilation.

Accessible online at: www.karger.com/journals/hed The number of clinical trials published in the area of cardiology is huge. Each year, over 1,000 trials of health care interventions within cardiology are identified for inclusion in the specialist trials register of the Cochrane Library (links via www.cochrane.org). Clearly, keeping up to date with new information is extremely difficult. With the advent of systematic reviews, where similar trials are grouped to provide a summary effect estimate, the accessibility of information for busy clinicians has improved. Whilst the potential benefits of this approach are many, the methodological quality of systematic reviews published in conventional journals and their relevance to clinical practice have been raised as potential problems. This is the subject of the report by Dr. Kleist [1] in this issue of Heart Drug. Cochrane systematic reviews differ from systematic reviews published in paper-based journals in several respects. The fundamental distinction is that authors are expected to update and amend them in light of relevant new data. There are also strict methodological guidelines to follow. Cochrane reviews are more likely to include a description of the inclusion and exclusion criteria, assess the methodological quality of individual trials and include non-English-language articles than systematic reviews published in paper-based journals [2]. These issues, particularly relating to the methodological quality of individual trials and potential sources of bias, have been highlighted in the report by Kleist [1]. Many of the problems associated with the interpretation and critical appraisal of systematic reviews are due to inadequate reporting. In an attempt to make interpretation more transparent, guidelines have recently been developed to improve the quality of reporting of systematic reviews (the QUOROM statement) [3]. Systematic reviews are certainly an advance compared to traditional ‘opinion’ reviews that cite evidence selectively to support a viewpoint. Another concern is the external validity (i.e. generalisability) of findings from systematic reviews, and hence their relevance to clinical practice. Clearly, the external validity of systematic reviews is dependent on the external validity of the trials included within them. There are two main concerns. First, patients who are recruited into clinical trials are not necessarily representative. There are often age restrictions and exclusions associated with comorbidity. Findings from such trials may not be applicable to the patient population as a whole. Secondly, trials may ask questions of little relevance to clinical practice. A study by the Cochrane Heart Group [4] examined the clinical relevance of 1,008 trials of health care interventions in cardiology published in 1998. The setting where the trials were conducted was reported in only 45% of studies, and of these, only 7% were community rather than hospital based. The majority of trials were of pharmacological interventions (61.5%). Most trials were of short duration and of relatively small size (recruiting less than 100 patients). Perhaps the most striking finding was that only half of the trials reported clinical events, and less than 4% reported quality of life as an outcome. Trials of

The cause of the sudden infant death syndrome is unclear. Polygraphic recordings of 30 infants who subsequently died of the syndrome showed a significant increase in mixed and obstructive apnoeas compared with well matched controls.1 Postmortem examination suggests upper airway narrowing in victims of the syndrome. The decreased number of cases of sudden infant death syndrome after advice to put infants to sleep supine suggests a posture dependent cause, and recent evidence suggests that upper airways of sleeping infants are more widely patent supine than prone.2 Thus sleeping supine might decrease obstructive apnoeas. An increased frequency of sudden infant death syndrome and apparent life threatening events in infants has been found in the families of patients with the obstructive sleep apnoea/hypopnoea syndrome. 3 4 We found that retroposition of the maxilla was a common feature in families who had both the obstructive sleep apnoea/hypopnoea and sudden infant death syndromes.3 …

Objective: Coronary artery bypass grafting (CABG) in overweight patients carries significant morbidity. We compare the effectiveness of off-pump coronary artery bypass (OPCAB) surgery versus conventional CABG using cardiopulmonary bypass and cardioplegic arrest, in a consecutive series of overweight patients. Methods: From April 1996 to April 2001, data from 4321 patients undergoing coronary revascularisation (mortality 1.4%) were prospectively entered into the Patients Analysis and Tracking System. Data were extracted for all patients with a body mass index (BMI) ≥ 25. In hospital mortality and early morbidity were compared between patients undergoing on- and off-pump coronary surgery. A risk-adjusted analysis was also carried out to assess the influence of surgery on outcomes. Results: 2844 overweight patients with BMI ≥ 25 were identified, and of these 674 (23.7%) were operated on with off-pump surgery. On-pump patients were less likely to have unstable angina, hypercholesterolaemia, to have coronary disease involving the left main stem, or to have a BMI ≥ 30. However, they had more extensive coronary disease, were more likely to have suffered previous myocardial infarction, and received more grafts than those undergoing off-pump surgery. Intra- and post-operative arrhythmias, inotropic use, and post-operative low cardiac output, use of IABP, blood loss, transfusion requirement, chest infections, neurological complications including permanent stroke, ICU and hospital stay all were significantly reduced in the off-pump group (all p < 0.05). After adjustment for age, gender, ejection fraction, extent of coronary disease, and degree of urgency, odd ratios (ORs) for most of the adverse outcomes investigated, confirmed significant benefit of off-pump surgery (table). The point estimate of the adjusted effect size for in-hospital mortality also indicated benefit from off-pump surgery (table). Variable On-Pump (2169) Off-Pump (674) OR/Mean Difference 95% CI p Death 20 (0.92%) 2 (0.29%) 0.37 0.08, 1.59 0.18 Postoperative MI 35 (1.6%) 14 (2.0%) 1.37 0.72, 2.62 0.337 New Inotropes 879 (40.5%) 219 (32.5%) 0.8 0.66, 0.97 0.02 New IABP 54 (2.5%) 5 (0.7%) 0.32 0.12, 0.8 0.015 Ward arrhythmia 320 (14.8%) 65 (9.6%) 0.63 0.47, 0.84 0.002 Chest Infection 106 (4.9%) 14 (2.1%) 0.43 0.24, 0.76 0.004 Neurolog. Complic. 59 (2.7%) 6 (0.9%) 0.36 0.15, 0.85 0.02 Blood Loss (ml) 939.9 (512.3) 856.2 (582.1) −60.8 −111.7, −9.87 0.019 Total RBCs (unit) 1.05 (1.51) 0.436 (1.52) −0.51 −0.65, −0.37 0.0001 Total Platelets (unit) 0.24 (0.81) 0.08 (0.455) −0.157 −0.23, −0.08 0.0001 Total FFP (unit) 0.49 (1.48) 0.126 (0.72) −0.38 −0.5, −0.25 0.0001 Sternal rewiring 17 (0.78%) 1 (0.14%) −0.22 0.03, 1.7 0.15 Renal complications 98 (4.5%) 24 (3.56%) −0.74 0.44, 1.25 0.265 Hospital stay (day) 7.76 (4.26) 6.64 (3.04) −0.94 −1.39, −0.49 0.0001 Conclusions: These results suggest that off-pump surgery is safe, effective and associated with reduced morbidity in overweight patients.

This Cochrane Review has been superseded by a review entitled Vegan dietary pattern for the primary and secondary prevention of cardiovascular diseases (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013501.pub2/full) https://pubmed.ncbi.nlm.nih.gov/33629376/There is increasing evidence that high consumption of fruit and vegetables is beneficial for cardiovascular disease (CVD) prevention.The primary objective is to determine the effectiveness of i) advice to increase fruit and vegetable consumption ii) the provision of fruit and vegetables to increase consumption, for the primary prevention of CVD.We searched the following electronic databases: The Cochrane Library (2012, issue 9-CENTRAL, HTA, DARE, NEED), MEDLINE (1946 to week 3 September 2012); EMBASE (1980 to 2012 week 39) and the Conference Proceedings Citation Index - Science on ISI Web of Science (5 October 2012). We searched trial registers, screened reference lists and contacted authors for additional information where necessary. No language restrictions were applied.Randomised controlled trials with at least three months follow-up (follow-up was considered to be the time elapsed since the start of the intervention) involving healthy adults or those at high risk of CVD. Trials investigated either advice to increase fruit and vegetable intake (via any source or modality) or the provision of fruit and vegetables to increase intake. The comparison group was no intervention or minimal intervention. Outcomes of interest were CVD clinical events (mortality (CVD and all-cause), myocardial infarction (MI), coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA), angiographically-defined angina pectoris, stroke, carotid endarterectomy, peripheral arterial disease (PAD)) and major CVD risk factors (blood pressure, blood lipids, type 2 diabetes). Trials involving multifactorial lifestyle interventions (including different dietary patterns, exercise) or where the focus was weight loss were excluded to avoid confounding.Two review authors independently selected trials for inclusion, extracted data and assessed the risk of bias. Trials of provision of fruit and vegetables were analysed separately from trials of dietary advice.We identified 10 trials with a total of 1730 participants randomised, and one ongoing trial. Six trials investigated the provision of fruit and vegetables, and four trials examined advice to increase fruit and vegetable consumption.The ongoing trial is examining the provision of an avocado-rich diet.The number and type of intervention components for provision, and the dietary advice provided differed between trials.None of the trials reported clinical events as they were all relatively short term. There was no strong evidence for effects of individual trials of provision of fruit and vegetables on cardiovascular risk factors, but trials were heterogeneous and short term. Furthermore, five of the six trials only provided one fruit or vegetable. Dietary advice showed some favourable effects on blood pressure (systolic blood pressure (SBP): mean difference (MD) -3.0 mmHg (95% confidence interval (CI) -4.92 to -1.09), diastolic blood pressure (DBP): MD -0.90 mmHg (95% CI -2.03 to 0.24)) and low-density lipoprotein (LDL) cholesterol but analyses were based on only two trials. Three of the 10 included trials examined adverse effects, which included increased bowel movements, bad breath and body odour.There are very few studies to date examining provision of, or advice to increase the consumption of, fruit and vegetables in the absence of additional dietary interventions or other lifestyle interventions for the primary prevention of CVD. The limited evidence suggests advice to increase fruit and vegetables as a single intervention has favourable effects on CVD risk factors but more trials are needed to confirm this.

BACKGROUND: The burden of cardiovascular disease world-wide is one of great concern to patients and health care agencies alike. Cardiac rehabilitation aims to restore patients with heart disease to health through exercise only based rehabilitation or comprehensive cardiac rehabilitation. OBJECTIVES: To determine the effectiveness of exercise only or exercise as part of a comprehensive cardiac rehabilitation programme on the mortality, morbidity, health-related quality of life (HRQoL) and modifiable cardiac risk factors of patients with coronary heart disease. SEARCH STRATEGY: Electronic databases were searched for randomised controlled trials, using standardised trial filters, from the earliest date available to December 31st 1998. SELECTION CRITERIA: Men and women of all ages, in hospital or community settings, who have had myocardial infarction, coronary artery bypass graft or percutaneous transluminal coronary angioplasty, or who have angina pectoris or coronary artery disease defined by angiography. DATA COLLECTION AND ANALYSIS: Studies were selected independently by two reviewers, and data extracted independently. Authors were contacted where possible to obtain missing information. MAIN RESULTS: This systematic review has allowed analysis of an increased number of patients from approximately 4500 in earlier meta-analyses to 8440 (7683 contributing to the total mortality outcome). The pooled effect estimate for total mortality for the exercise only intervention shows a 27% reduction in all cause mortality (random effects model OR 0.73 (0.54, 0.98)). Comprehensive cardiac rehabilitation reduced all cause mortality, but to a lesser degree (OR 0.87 (0.71, 1.05)). Total cardiac mortality was reduced by 31% (random effects model OR 0.69 (0.51, 0.94)) and 26% (random effects model OR 0.74 (0.57, 0.96)) in the exercise only and comprehensive cardiac rehabilitation groups respectively. Neither intervention had any effect on the occurrence of non-fatal myocardial infarction. There was a significant net reduction in total cholesterol (pooled WMD random effects model -0.57 mmol/l (-0.83, -0.31)) and LDL (pooled WMD random effects model -0.51 mmol/l (-0.82, -0.19) in the comprehensive cardiac rehabilitation group. REVIEWER'S CONCLUSIONS: Exercise-based cardiac rehabilitation is effective in reducing cardiac deaths. It is not clear from this review whether exercise only or a comprehensive cardiac rehabilitation intervention is more beneficial. The population studied in this review is still predominantly male, middle aged and low risk. Identification of the ethnic origin of the participants was seldom reported. It is possible that patients who would have benefited most from the intervention were excluded from the trials on the grounds of age, sex or co-morbidity.

Background Adolescent overweight and obesity has increased globally, and can be associated with short- and long-term health consequences. Modifying known dietary and behavioural risk factors through behaviour changing interventions (BCI) may help to reduce childhood overweight and obesity. This is an update of a review published in 2009. Objectives To assess the effects of diet, physical activity and behavioural interventions for the treatment of overweight or obese adolescents aged 12 to 17 years. Search methods We performed a systematic literature search in: CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, and the trial registers ClinicalTrials.gov and ICTRP Search Portal. We checked references of identified studies and systematic reviews. There were no language restrictions. The date of the last search was July 2016 for all databases. Selection criteria We selected randomised controlled trials (RCTs) of diet, physical activity and behavioural interventions for treating overweight or obesity in adolescents aged 12 to 17 years. Data collection and analysis Two review authors independently assessed risk of bias, evaluated the overall quality of the evidence using the GRADE instrument and extracted data following the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. We contacted trial authors for additional information. Main results We included 44 completed RCTs (4781 participants) and 50 ongoing studies. The number of participants in each trial varied (10 to 521) as did the length of follow-up (6 to 24 months). Participants ages ranged from 12 to 17.5 years in all trials that reported mean age at baseline. Most of the trials used a multidisciplinary intervention with a combination of diet, physical activity and behavioural components. The content and duration of the intervention, its delivery and the comparators varied across trials. The studies contributing most information to outcomes of weight and body mass index (BMI) were from studies at a low risk of bias, but studies with a high risk of bias provided data on adverse events and quality of life. The mean difference (MD) of the change in BMI at the longest follow-up period in favour of BCI was -1.18 kg/m2 (95% confidence interval (CI) -1.67 to -0.69); 2774 participants; 28 trials; low quality evidence. BCI lowered the change in BMI z score by -0.13 units (95% CI -0.21 to -0.05); 2399 participants; 20 trials; low quality evidence. BCI lowered body weight by -3.67 kg (95% CI -5.21 to -2.13); 1993 participants; 20 trials; moderate quality evidence. The effect on weight measures persisted in trials with 18 to 24 months' follow-up for both BMI (MD -1.49 kg/m2 (95% CI -2.56 to -0.41); 760 participants; 6 trials and BMI z score MD -0.34 (95% CI -0.66 to -0.02); 602 participants; 5 trials). There were subgroup differences showing larger effects for both BMI and BMI z score in studies comparing interventions with no intervention/wait list control or usual care, compared with those testing concomitant interventions delivered to both the intervention and control group. There were no subgroup differences between interventions with and without parental involvement or by intervention type or setting (health care, community, school) or mode of delivery (individual versus group). The rate of adverse events in intervention and control groups was unclear with only five trials reporting harms, and of these, details were provided in only one (low quality evidence). None of the included studies reported on all-cause mortality, morbidity or socioeconomic effects. BCIs at the longest follow-up moderately improved adolescent's health-related quality of life (standardised mean difference 0.44 ((95% CI 0.09 to 0.79); P = 0.01; 972 participants; 7 trials; 8 comparisons; low quality of evidence) but not self-esteem. Trials were inconsistent in how they measured dietary intake, dietary behaviours, physical activity and behaviour. Authors' conclusions We found low quality evidence that multidisciplinary interventions involving a combination of diet, physical activity and behavioural components reduce measures of BMI and moderate quality evidence that they reduce weight in overweight or obese adolescents, mainly when compared with no treatment or waiting list controls. Inconsistent results, risk of bias or indirectness of outcome measures used mean that the evidence should be interpreted with caution. We have identified a large number of ongoing trials (50) which we will include in future updates of this review.

Neuroinflammation may play a key role in the neurodegeneration associated with Parkinson's disease (PD). Non-steroidal anti-inflammatory drugs (NSAIDs) may be beneficial in the primary and secondary prevention of PD.1) Do NSAIDs prevent the onset of PD?2) Are NSAIDs neuroprotective in PD - do they slow the progression of disease once PD is established?3) What are the adverse effects of taking NSAIDs in PD?We searched electronic databases, including trial registers, complemented with handsearching of conference proceedings and citation searching on key articles. All searching was updated in May 2011. We contacted authors to provide additional information where necessary.For the primary prevention review, we sought primary prevention trials and observational studies (cohort and case-control studies). Participants were free of PD when exposure to NSAIDs was assessed. For the secondary prevention review, we sought clinical trials in patients with a well-defined definition of PD. Two people independently selected studies for inclusion using predetermined criteria.Two review authors abstracted data from the source papers and assessed methodological quality independently. No studies met the inclusion criteria for the secondary prevention review. For the primary prevention review only observational studies were found. We combined data where appropriate using the inverse variance method. We assessed methodological quality using the Newcastle Ottawa Scales and by examining the period of exposure assessed prior to PD onset (or the index date in controls).Fourteen observational studies met the inclusion criteria for the primary prevention review (five cohort, nine case-control studies). Exposure to any NSAIDs or aspirin had no effect on the risk of developing PD. Exposure to non-aspirin NSAIDs reduced the risk of developing PD by 13% (effect estimate 0.87 (95% CI 0.73 to 1.04 - random-effects model), but this did not reach statistical significance. We found similar results for the most robust studies. Ibuprofen in isolation was examined in four studies and was associated with a 27% reduction in risk (effect estimate 0.73, 95% CI 0.63 to 0.85). There was a lack of information on adverse effects.There is currently no evidence for the use of NSAIDs in the secondary prevention of PD. Non-aspirin NSAIDs, particularly ibuprofen, may reduce the risk of developing PD. However, little is known of the effects of other individual drugs and at present no recommendations can be made regarding their use in primary prevention.

Background Coronary artery bypass surgery (CABG) may be life saving, but known side effects include neurological damage and cognitive impairment. The temperature used during cardiopulmonary bypass (CPB) may be important with regard to these adverse outcomes, where hypothermia is used as a means of neuroprotection. Objectives To assess the effectiveness of hypothermia during CABG in reducing neurological damage and subsequent cognitive deficits. Search methods The Cochrane Controlled Trials Register was searched for randomised controlled trials (RCT) and this was updated by searching MEDLINE and EMBASE to December 1999 using database specific RCT filters. Reference lists of retrieved articles were searched and experts in the field were contacted. Selection criteria Only RCTs were considered. All patients undergoing CABG, either first time or revisions, elective or emergency procedures, were included. Any hypothermia protocol was considered. Only trials reporting neurological outcomes were included. Data collection and analysis Studies were selected independently and data were extracted from the source papers independently by two reviewers. Authors were contacted for further information. Studies were combined with meta-analysis where appropriate, and meta-regression was used to explore heterogeneity. Main results There was a trend towards a reduction in the incidence of non fatal strokes in the hypothermic group (OR 0.68 (0.43, 1.05)). Conversely, there was a trend for the number of non stroke related perioperative deaths to be higher in the hypothermic group (OR 1.46 (0.9, 2.37)). There was no evidence to suggest that hypothermia had an effect on the incidence of non fatal myocardial infarction (OR 1.05 (0.81, 1.37)), but the incidence of another marker of myocardial damage, low output syndrome, was higher in the hypothermic group (OR 1.21 (0.99, 1.48). When pooling all "bad" outcomes (stroke, perioperative death, myocardial infarction, low output syndrome, intra aortic balloon pump use) there was no significant advantage of either hypothermia or normothermia (OR 1.07 (0.92, 1.24)). Only 4 of 17 trials reported neuropsychological function as an outcome. Authors' conclusions This review could find no definite advantage of hypothermia over normothermia in the incidence of clinical events. Hypothermia was associated with a reduced stroke rate, but this is off set by a trend towards an increase in non stroke related perioperative mortality and myocardial damage. There is insufficient data to date to draw any conclusions about the use of mild hypothermia. Similarly, there is insufficient data to date to comment on the effect of temperature during CPB on subtle neurological deficits, and further trials are needed in these areas.

Levodopa is the mainstay of treatment for alleviating the motor symptoms associated with Parkinson's disease. However, patients often experience fluctuations in their symptoms over time and 'wearing off' which may be partly related to variable absorption of the drug. There is some evidence that treatment of the common gastrointestinal infection Helicobacter pylori (H pylori) with antibiotics may improve levodopa absorption in the gut and hence improve symptoms.1) What is the prevalence of H pylori in Parkinson's disease patients? 2) Does treatment of H pylori infection with antibiotics improve symptoms in Parkinson's disease patients? Is this effect dependent on improvements in the absorption of levodopa?We searched electronic databases (including CENTRAL, MEDLINE, EMBASE, PsycINFO and CINAHL) and trial registers, handsearched conference proceedings and carried out citation searching on key articles. All searching was updated in August 2009. We contacted authors to provide additional information where necessary.Clinical trials in patients with a well-defined definition of Parkinson's disease and who were H pylori-positive. Two people independently selected studies for inclusion using predetermined criteria. We used recruitment figures from clinical trials and other studies identified from the searching to determine the prevalence of H pylori in Parkinson's disease.Two authors abstracted data from the source papers and assessed methodological quality independently. We presented results descriptively.Two completed and one ongoing clinical trial met the inclusion criteria. One trial (34 patients randomised) examined the effects of H pylori eradication on levodopa absorption and motor symptoms and found significant improvements in both. The ongoing trial has similar objectives and aims to recruit 100 patients. The other completed trial (20 patients analysed) sought to find a causal link between infection with H pylori and Parkinsonism and was non-contributory. A worsening of symptoms was noted with eradication failure.The prevalence of H pylori in Parkinson's disease was reported in four studies and ranged from 37% to 59% which is similar to that of the general population.There is currently a lack of evidence on the effects of screening and treating H pylori in patients with Parkinson's disease. There is limited evidence to suggest that H Pylori eradication improves the absorption of levodopa and improves motor symptoms. Results from an ongoing trial will inform the evidence base and will be incorporated in an update of this review. There is a need for well-conducted randomised controlled trials with standard outcome measures for motor symptoms and incorporating the costs of screening and treatment.

OBJECTIVES: To estimate UK need for outpatient cardiac rehabilitation, current provision and identification of patient groups not receiving services. To conduct a systematic review of literature on methods to improve uptake and adherence to cardiac rehabilitation. To estimate cost implications of increasing uptake of cardiac rehabilitation. DATA SOURCES: Hospital Episode Statistics (England). Hospital Inpatient Systems (Northern Ireland). Patients Episode Database for Wales. British Association for Cardiac Rehabilitation/British Heart Foundation surveys. Cardiac rehabilitation centres. Patients from general hospitals. Electronic databases. REVIEW METHODS: The study analysed hospital discharge statistics to ascertain the population need for outpatient cardiac rehabilitation in the UK. Surveys of cardiac rehabilitation programmes were conducted to determine UK provision, uptake and audit activity, and to identify local interventions to improve uptake. Data were also examined from a trial estimating eligibility for cardiac rehabilitation and non-attendance. A systematic review of interventions to improve patient uptake, adherence and professional compliance in cardiac rehabilitation was conducted. Estimated costs of improving uptake were identified from national survey, systematic review and sampled cardiac rehabilitation programmes. RESULTS: In England, Wales and Northern Ireland nearly 146,000 patients discharged from hospital with primary diagnosis of acute myocardial infarction, unstable angina or following revascularisation were potentially eligible for cardiac rehabilitation. In England in 2000, 45-67% of these patients were referred, with 27-41% attending outpatient cardiac rehabilitation. If all discharge diagnoses of ischaemic heart disease were considered, nearly 299,000 patients would be potentially eligible and in England rates of attendance and referral would be 22-33% and 13-20% respectively. Rates of referral and attendance were similar in Wales, but somewhat lower in Northern Ireland. It was found that referral and attendance of older people and women at cardiac rehabilitation tended to be low. It was also suggested that patients from ethnic minorities and those with angina or heart failure were less likely to be referred to or join programmes. A wide range of local interventions suggested awareness of the problem of uptake. In an NHS-funded randomised controlled trial, possibly representing more optimal protocol-led care, medical and nursing staff identified 73-81% of patients with acute myocardial infarction as eligible for cardiac rehabilitation. Excluded patients tended to be older with more severe presentation of cardiac disease. Experiences of patients suggested that uptake may be improved by addressing issues of motivation and relevance of rehabilitation to future well-being, co-morbidities, site and time of programme, transport and care for dependents. Systematic review of studies supported the use of letters, pamphlets or home visits to motivate patients and the use of trained lay visitors. Self-management techniques showed some value in promoting adherence to lifestyle changes. Studies examining professional compliance found that professional support for practice nurses may have value in the coordination of postdischarge care. Average costs in 2001 of cardiac rehabilitation to the health service per patient completing a cardiac rehabilitation programme were about GBP350 (staff only) and GBP490 (total). If services were modelled on an intermediate multidisciplinary configuration with three to five key staff, approximately 13% more patients could be treated with the same budget. Depending on staffing configuration an approximate 200-790% budget increase would be required to provide cardiac rehabilitation to all potentially eligible patients. CONCLUSIONS: Provision of outpatient cardiac rehabilitation in the UK is low and little is known about the capacity of cardiac rehabilitation centres to increase this provision. There is an uncoordinated approach to audit data collection and few interventions aimed at improving the situation have been formally evaluated. Motivational communications and trained lay volunteers may improve uptake of cardiac rehabilitation, as may self-management techniques. Experience of low-cost interventions and good practice exists within rehabilitation centres, although cost information frequently is not reported. Increased provision of outpatient cardiac rehabilitation will require extra resources. Further trials are required to compare the cost-effectiveness of comprehensive multidisciplinary rehabilitation with simpler outpatient programmes, also research is needed into economic and patient preference studies of the effects of different methods of using increased funding for cardiac rehabilitation. An evaluation of a range of interventions to promote attendance in all patients and under-represented groups would also be useful. The development of standards is suggested for audit methods and for eligibility criteria, as well as regular and comprehensive data collection to estimate the need for and provision of cardiac rehabilitation. Further areas for intervention could be identified through qualitative studies, and the extension of low-cost interventions and good practice within rehabilitation centres. Regularly updated systematic reviews of relevant literature would also be useful.

Objective: To investigate the influence of age and modern techniques of coronary artery bypass grafting with or without cardiopulmonary bypass on early and mid-term mortality and morbidity in a consecutive series of elderly patients. Methods: From April 1996 to December 2000, data of 3842 patients undergoing coronary revascularisation were prospectively entered into a database. Data were extracted for 990 patients older than 70 years: (A) 70‐74 years, (n ¼ 659); (B) 75 or more years, (n ¼ 331). Results: A total of 990 elderly patients ($70 years) underwent coronary revascularisation, 219 (22.1%) with off-pump surgery. Elderly patients were more likely to have higher CCS, NYHA and EuroScores, history of previous MI, unstable angina, renal dysfunction, left main stem disease $50%, and to be urgent. However, they were less likely to be overweight. In-hospital mortality, occurrence of re-intubation, renal dysfunction, and hospital stay were significantly higher in this elderly group. Overall, the distribution of mortality was doubled in the female gender although this was not statistically significant. Patients undergoing on-pump surgery had lower EuroScore, were less likely to be .75 years of age, likely to have obesity or hypercholesterolaemia, or to have suffered a previous cerebro-vascular accident. However, they had more extensive coronary disease, were more likely to have unstable angina, and received more grafts than those undergoing off-pump surgery. After adjustment for prognostic variables, off-pump surgery was found to be associated with reduced inotropic use, intra-operative arrhythmias, blood loss and transfusion requirement when compared to on-pump coronary surgery (point estimates of odd ratios, 0.26‐0.87) (all P , 0:05). Mid-term mortality or cardiac-related events were similar in the two groups. Conclusions: Early but not mid-term mortality is higher in patients aged 75 or more years when compared with those aged 70‐74 years. Off-pump coronary artery bypass surgery is safe and effective in the elderly population. q 2002 Elsevier Science B.V. All rights reserved.

Background This is an update of the original review published in 2008. The risk of adverse cardiovascular outcomes is increased with influenza-like infection, and vaccination against influenza may improve cardiovascular outcomes. Objectives To assess the potential benefits of influenza vaccination for primary and secondary prevention of cardiovascular disease. Search methods We searched the following electronic databases on 18 October 2013: The Cochrane Library (including Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Economic Evaluation Database (EED) and Health Technology Assessment database (HTA)), MEDLINE, EMBASE, Science Citation Index Expanded, Conference Proceedings Citation Index – Science and ongoing trials registers (www.controlled-trials.com/ and www.clinicaltrials.gov). We examined reference lists of relevant primary studies and systematic reviews. We performed a limited PubMed search on 20 February 2015, just before publication. Selection criteria Randomised controlled trials (RCTs) of influenza vaccination compared with placebo or no treatment in participants with or without cardiovascular disease, assessing cardiovascular death or non-fatal cardiovascular events. Data collection and analysis We used standard methodological procedures as expected by The Cochrane Collaboration. We carried out meta-analyses only for cardiovascular death, as other outcomes were reported too infrequently. We expressed effect sizes as risk ratios (RRs), and we used random-effects models. Main results We included eight trials of influenza vaccination compared with placebo or no vaccination, with 12,029 participants receiving at least one vaccination or control treatment. We included six new studies (n = 11,251), in addition to the two included in the previous version of the review. Four of these trials (n = 10,347) focused on prevention of influenza in the general or elderly population and reported cardiovascular outcomes among their safety analyses; four trials (n = 1682) focused on prevention of cardiovascular events in patients with established coronary heart disease. These populations were analysed separately. Follow-up continued between 42 days and one year. Five RCTs showed deficits in at least three of the risk of bias criteria assessed. When reported (seven studies), vaccination provided adequate immunogenicity or protection against influenza. Cardiovascular mortality was reported by four secondary prevention trials and was significantly reduced by influenza vaccination overall (risk ratio (RR) 0.45, 95% confidence interval (CI) 0.26 to 0.76; P value 0.003) with no significant heterogeneity between studies, and by three trials reporting cardiovascular mortality as part of their safety analyses when the numbers of events were too small to permit conclusions. In studies of patients with coronary heart disease, composite outcomes of cardiovascular events tended to be decreased with influenza vaccination compared with placebo. Generally no significant difference was found between comparison groups regarding individual outcomes such as myocardial infarction. Authors' conclusions In patients with cardiovascular disease, influenza vaccination may reduce cardiovascular mortality and combined cardiovascular events. However, studies had some risk of bias, and results were not always consistent, so additional higher-quality evidence is necessary to confirm these findings. Not enough evidence was available to establish whether influenza vaccination has a role to play in the primary prevention of cardiovascular disease.