Evidence suggests that most nutritional supplements and dietary interventions offer no protection against cardiovascular disease or death

1. Evidence suggests that most nutritional supplements and dietary interventions offer no protection against cardiovascular disease or death

Notes: HD video soundbites of the authors discussing the paper are available to download at http://www.dssimon.com/MM/ACP-supplements

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0341

Editorial: http://annals.org/aim/article/doi/10.7326/M19-1498

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A new evidence review suggests that few nutritional supplements or dietary interventions offer any protection against cardiovascular disease or death, and some may actually cause harm. Findings from a meta-analysis are published in Annals of Internal Medicine.

Current U.S. dietary guidelines recommend several healthy eating patterns, including Mediterranean and vegetarian diets, but they do not recommend routine supplement use to reduce the risk for cardiovascular disease or other chronic diseases. Nonetheless, 1 out of 2 persons in the U.S. use some form of supplements with the reported goal of improving their overall health. With the publication of new randomized data, it was not clear if nutritional supplements and dietary interventions play a role in preventing mortality and cardiovascular disease.

Researchers from West Virginia University analyzed 277 randomized controlled trials comprising nearly 1 million people to determine the effects of 16 different nutritional supplements and 8 dietary interventions on mortality and cardiovascular outcomes in adults. The researchers found some evidence that reduced salt intake was protective for all-cause mortality in participants with normal blood pressure and that omega-3, long-chain fatty acids were protective for myocardial infarction and coronary heart disease. Folic acid showed some protective benefit for stroke. Conversely, combined calcium plus vitamin D intake increased the risk for stroke. Other supplements, such as multivitamins, selenium, vitamin A, vitamin B6, vitamin C, vitamin E, vitamin D alone, calcium alone, folic acid, and iron, or such dietary interventions as the Mediterranean diet, reduced saturated fat intake, modified fat intake, reduced dietary fat intake, and increased intake of fish oil supplements, did not seem to have significant effect on mortality or cardiovascular outcomes.

According to the authors of an accompanying editorial from Scripps Research Translational Institute, the findings are limited by the quality of the evidence. For example, geographic considerations among the studies need to be considered. The reported benefit of folate seems to be largely driven by the inclusion of one study from China, where a folate-rich diet is not routine. In addition, most studies rely on food diaries, which are based on a person's memory of what they consumed and therefore are not wholly reliable. The authors say that for now, it's reasonable to hold off on using supplements or diet modification for the purpose of cardiovascular disease prevention in all guidelines and recommendations.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Safi U. Khan, MD, please contact Cassie Thomas at cassie.thomas@hsc.wvu.edu. To speak with the author of the editorial, Eric Topol, MD (@erictopol), please contact Anna Anderson at aanders@scripps.edu or Chris Emery at cemery@scripps.edu.

2. Despite recommendations against their use, opioids often prescribed for ankle sprains

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0679

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Despite recommendations against their use, opioids are often prescribed for ankle sprains. Physicians should be aware of current prescribing guidelines and know which injuries are appropriate for opioid therapy. Findings from a brief research report are published in Annals of Internal Medicine.

Ankle sprains are a common injury, yet treatment strategies vary. Evidence-based treatment guidelines recommend ice, nonsteroidal anti-inflammatory drugs, and functional support and exercise. Opioids have never been included in treatment recommendations, but a recent study showed that approximately 25 percent of persons with ankle sprains were prescribed opioids in the emergency department.

Researchers from the University of Michigan reviewed a health insurance claims database to identify the rate of opioid prescriptions within 7 days after an ankle sprain and the rate of new, persistent opioid use among these patients. More than 590,000 patients with ankle sprains were included in the analysis. Of them, 11.9 percent filled an opioid prescription within 7 days of diagnosis, and 8.4 percent of those patients were still filling a prescription for an opioid 90 days after diagnosis. According to the researchers, these findings suggest that clinicians need to be aware that opioids are typically not indicated for ankle sprains, and other evidenced-based measures are likely underutilized.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, James R. Holmes, MD, please contact Kylie Urban at kylieo@med.umich.edu.

3. Shorter duration of antibiotics is better for pneumonia

Abstract: http://annals.org/aim/article/doi/10.7326/M18-3640

Editorial: http://annals.org/aim/article/doi/10.7326/M19-1509

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Most patients hospitalized with pneumonia are treated with antibiotics for longer than necessary and excess antibiotic treatment duration has been associated with patient-reported adverse events after discharge. Findings from a multi-hospital cohort study are published in Annals of Internal Medicine.

Pneumonia is the most common reason for inpatient antibiotic use and overuse. Recent studies, including multiple randomized controlled trials and systematic reviews, have demonstrated that shorter antibiotic therapy is safe and equally effective for most patients with pneumonia. Conversely, longer treatment places patients at risk for antibiotic-associated adverse events.

Researchers from the University of Michigan and the Michigan Hospital Medicine Safety Consortium used data from an ongoing cohort study of more than 6,000 patients hospitalized with community-acquired pneumonia or health care-associated pneumonia in 43 hospitals across Michigan to quantify excess antibiotic treatment duration, determine factors associated with it, and evaluate its relationship with outcomes. They found that two-thirds of patients received excess antibiotic therapy, mainly due to excessive prescribing at discharge. Specifically, a diagnosis of community-acquired pneumonia predicted excess treatment despite evidence that most patients can be safely treated with 5 days of antibiotics. Excess antibiotic treatment duration was associated with patient-reported adverse events after discharge.

According to the authors of an accompanying editorial, from Los Angeles County and USC Medical Center, these findings offer more proof that shorter duration is better when it comes to prescribing antibiotics for pneumonia.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Valerie M. Vaughn, MD, MSc, please contact Kara Gavin at Gavin, kegavin@med.umich.edu.

4. Pregnancy outcomes in lupus have improved over the past 2 decades

The large decline in in-hospital maternal mortality was greater for lupus pregnancies than for non-lupus pregnancies

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0120

Editorial: http://annals.org/aim/article/doi/10.7326/M19-1667

URLs go live when the embargo lifts

Pregnancy for patients with lupus has long been considered high risk and associated with both medical and obstetric complications, but outcomes have improved over the last 2 decades and continue to improve. The large decline in in-hospital maternal mortality was greater for lupus pregnancies than for non-lupus pregnancies. Findings from a retrospective cohort study are published in Annals of Internal Medicine.

Lupus is a systemic autoimmune disease that predominantly affects women of child-bearing age and required careful management during pregnancy.

Researchers from Hospital for Special Surgery, Mount Sinai, and Weill Cornell Medicine studied a national database of hospitalizations recorded for adult pregnant women with and without lupus to assess nationwide trends and disparities in maternal and fetal complications among pregnant women with lupus. They found that patients with lupus had a markedly greater improvement than those without lupus in in-hospital maternal mortality, from a rate of 34 times higher in 1998 to 2000 to less than 5 times higher in 2013 to 2015. The decrease in mortality among women with lupus was far greater than those without lupus, yet mortality rates among pregnant women with lupus are still higher than for those without lupus, suggesting a continued need for improvement. Fetal mortality rates for patients with lupus declined, but the decrease did not reach statistical significance. Outcomes in women with lupus in all measures are improving faster with those without lupus.

According to the study authors, these findings suggest that lupus pregnancy improvements are significant over the past 18 years. Lupus pregnancy risk is still higher than risk for those without lupus, which indicates more work is needed to ensure good pregnancy outcomes among women with lupus.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Bella Mehta, MBBS, please contact Tracy Hickenbottom at HickenbottomT@HSS.EDU.

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