Mark W. Steffen

The effect of coffee consumption on blood pressure and the development of hypertension: a systematic review and meta-analysis.

Context: Coffee is one of the most widely consumed beverages worldwide and is known to acutely raise blood pressure (BP), but the effects of chronic consumption on BP is unclear. Objectives: To conduct a systematic review and meta-analysis of available randomized controlled trials (RCTs) and cohort studies to assess the effect of chronic coffee consumption on BP and the development of hypertension. Data sources: Ovid, MEDLINE (from 1948), EMBASE (from 1988), and all of Web of Science and Scopus. Study selection: RCTs and cohort studies of at least 1-week duration that assessed BP and/or the incidence of hypertension in coffee consumers compared with a control group that consumed less or no coffee. Data extraction: Two authors independently reviewed abstracts and full-text articles for inclusion. Data were abstracted using standardized forms. Risk of bias in the RCTs was examined using the method described in the Cochrane Handbook for Systematic Reviews of Interventions. Quality of the cohort studies were assessed using the Newcastle–Ottawa quality assessment scale for cohort studies. Data synthesis: Six hundred and ten articles were retrieved and a total of 15 (10 RCTs and five cohort studies) met inclusion criteria. Meta-analysis of RCTs demonstrated a pooled weighted difference in mean change in SBP of −0.55 mmHg [95% confidence interval (CI) −2.46 to 1.36) and DBP −0.45 mmHg (95% CI −1.52 to 0.61). Meta-analysis of the cohort studies demonstrated a pooled risk ratio for developing hypertension of 1.03 (95% CI 0.98–1.08). Conclusion: Low-quality evidence did not show any statistically significant effect of coffee consumption on BP or the risk of hypertension. Given the quality of the currently available evidence, no recommendation can be made for or against coffee consumption as it relates to BP and hypertension.

The natural history of untreated severe or critical limb ischemia

OBJECTIVE Critical limb ischemia (CLI) is associated with high morbidity and mortality. Because most patients with CLI will eventually undergo some type of revascularization, the natural history of CLI is not well defined, although it is important to know when patients decide to pursue treatment. METHODS We systematically searched multiple databases for controlled and uncontrolled studies of patients with CLI who did not receive revascularization with a minimum follow-up of ≥1 year. Predefined outcomes of interest were mortality, major amputation, and wound healing. Random-effects meta-analysis was used to pool cumulative incidence across studies. RESULTS We identified 13 studies enrolling 1527 patients. During a median follow-up of 12 months, all-cause mortality rate was 22% (confidence interval [CI], 12%-33%) and major amputation rate was 22% (CI, 2%-42%). Worsened wound or ulcer was found at 35% (CI, 10%-62%). There was a trend toward improvement in mortality and amputation rate in studies done after 1997. The quality of evidence was low because of increased risk of bias and inconsistency. CONCLUSIONS Mortality and major amputations are common in patients who have untreated CLI during a median follow-up of 1 year, although these outcomes have improved in recent times.

Bypass surgery versus endovascular interventions in severe or critical limb ischemia

OBJECTIVE Critical limb ischemia is associated with a significant morbidity and mortality. We systematically reviewed the evidence to compare bypass surgery with endovascular revascularization in patients with critical limb ischemia. METHODS We systematically searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and Scopus through October 2014 for comparative studies (randomized and nonrandomized). Predefined outcomes of interest were mortality, major amputation, patency, and wound healing. We pooled odds ratios (ORs) of the outcomes of interest using the random-effects model. RESULTS Nine studies that enrolled 3071 subjects were included. There was no significant difference in mortality (OR, 0.72; 95% confidence interval [CI], 0.44-1.16) or amputation (OR, 1.2; 95% CI, 0.87-1.65). Bypass surgery was associated with higher primary patency (OR, 2.50; 95% CI, 1.25-4.99) and assisted primary patency (OR, 3.39; 95% CI, 1.53-7.51). The quality of evidence was low for mortality and amputation outcomes and moderate for patency outcomes. CONCLUSIONS Low quality of evidence due to imprecision and heterogeneity suggests that bypass surgery and endovascular approaches may have similar effect on mortality and major amputations. However, better primary and primary assisted patency can be expected with surgery.

Improving sleep: outcomes from a worksite healthy sleep program.

Objective: Unhealthy and inadequate sleep is a common and significant problem impacting absenteeism, presenteeism, health, and productivity. This study aimed at analyzing the effect of a worksite-based healthy sleep program. Methods: Retrospective analysis of 53 adult members of a worksite wellness center who participated in an 8-week healthy sleep program and completed pre- and postintervention health behavior questionnaires. Results: Following the intervention participants felt significantly more rested, more confident in their ability to deal with sleep problems, and more knowledgeable about sleep. In addition, they reported a reduction in their stress level, improved quality of life, and increase energy level. Conclusions: These results support the effectiveness of worksite programs designed to promote healthy sleep. Future randomized studies are needed to further investigate the effectiveness and optimal delivery of healthy sleep promotion.

The association of 9p21-3 locus with coronary atherosclerosis: a systematic review and meta-analysis

BackgroundStudies suggest that the 9p21-3 locus may influence susceptibility to myocardial infarction. We performed a systematic review and meta-analysis to assess whether this locus is associated with severity of coronary atherosclerosis and adverse clinical outcomes in those with known coronary disease.MethodsMultiple electronic databases were searched from inception through August 2012. Studies examining 9p21-3 genotype in patients with known coronary artery disease were included. We extracted the association of the 9p21-3 locus with measures of severity of coronary atherosclerosis [number of diseased vessels, Gensini Score, Duke CAD Prognostic Index (DPI)], angiographic outcomes [change in minimum lumen diameter (∆MLD) and number of new lesions at follow-up], and key clinical outcomes (all-cause mortality, recurrent myocardial infarction and the need for coronary revascularization). Relative risks (RR) and weighted mean difference (WMD) were pooled using the random effects models.Results23 cohorts enrolling 16,860 participants were analyzed. There was no significant difference between HR and LR genotypes in terms of all-cause mortality, recurrent myocardial infarction or the frequency of coronary revascularization. HR genotype was associated with increased risk of triple vessel disease (RR = 1.34; 95% CI 1.08-1.65; P = 0.01) and increased baseline Gensini Score (WMD = 5.30; 95% CI 0.66-9.93; P = 0.03). However there was no association with DPI (WMD = 4.00; 95% CI 2.94-10.94; P = 0.26). HR genotype did not predict ∆MLD or number of new lesions at follow-up.ConclusionsPatients of coronary atherosclerosis who carry the high risk genotype of the 9p21-3 allele may be more likely to have multi-vessel CAD. However the effect of this allele on CAD progression and disease specific clinical outcomes are not observed possibly due to diminishing genetic risk following dietary modification and therapy.

Nonrevascularization-based treatments in patients with severe or critical limb ischemia

OBJECTIVE The aim of this systematic review was to synthesize the existing evidence about various nonrevascularization-based therapies used to treat patients with severe or critical limb ischemia (CLI) who are not candidates for surgical revascularization. METHODS We systematically searched multiple databases through November 2014 for controlled randomized and nonrandomized studies comparing the effect of medical therapies (prostaglandin E1 and angiogenic growth factors) and devices (pumps and spinal cord stimulators). We report odds ratios (ORs) and 95% confidence intervals (CIs) of the outcomes of interest pooling data across studies using the random effects model. RESULTS We included 19 studies that enrolled 2779 patients. None of the nonrevascularization-based treatments were associated with a significant effect on mortality. Intermittent pneumatic compression (OR, 0.14; 95% CI, 0.04-0.55) and spinal cord stimulators (OR, 0.53; 95% CI, 0.36-0.79) were associated with reduced risk of amputation. A priori established subgroup analyses (combined vs single therapy; randomized vs nonrandomized) were not statistically significant. CONCLUSIONS Very low-quality evidence, mainly due to imprecision and increased risk of bias, suggests that intermittent pneumatic compression and spinal cord stimulators may reduce the risk of amputations. Evidence supporting other medical therapies is insufficient.

Self-report of tobacco use status: comparison of paper-based questionnaire, online questionnaire, and direct face-to-face interview--implications for meaningful use.

Identifying tobacco use status is essential to address use and provide resources to help patients quit. Being able to collect this information in an electronic format will become increasingly important, as the Centers for Medicare and Medicaid Services has included the assessment of tobacco use as part of its Stage 1 Meaningful Use criteria. The objective was to compare the accuracy of online vs. paper assessment methods to ascertain cigarette smoking status using a face-to-face structured interview as the gold standard. This was a retrospective analysis of a stratified opportunity sample of consecutive patients, reporting in 2010 for a periodic health evaluation, who completed either a scannable paper-based form or an online questionnaire and underwent a standardized rooming interview. Compared with face-to-face structured interview, the overall observed agreement and kappa coefficient for both methods combined (paper and online) were 97.7% and 0.69 (95% confidence interval (CI) 0.51-0.86) . For the online form they were 97.4% and 0.61 (95% CI 0.33-0.90), and for the paper form they were 97.9% and 0.75 (95% CI 0.54-0.96). There was no statistically significant difference in agreement between the online and paper-based methods (P=0.76) compared with a face-to-face structured interview. Online assessment of tobacco use status is as accurate as a paper questionnaire, and both methods have greater than 97% observed agreement with a face-to-face structured interview. The use of online assessment of tobacco use status has several advantages and more widespread use should be explored.

Effect of exercise on anthropometric measures and serum lipids in older individuals: a systematic review and meta-analysis

Objectives Overweight and obesity are increasing in individuals over age 60 years. This systematic review quantifies the effect of exercise on body mass index (BMI), waist circumference (WC) and lipids in overweight and obese individuals over the age of 60 years. Settings Nine randomised controlled trials conducted in Brazil, Great Britain, Iceland, Japan and the USA compared aerobic and/or resistance exercise with a control group. Participants Final analysis reviewed 1166 participants over the age of 60 years for 3–9 months. Primary outcome measures This study reviewed the effects of exercise on BMI, WC and low-density lipoprotein (LDL). Results Exercise produced a significant reduction in BMI (−1.01 kg/m2, 95% CI −2.00 to −0.01) and WC (−3.09 cm, 95% CI −4.14 to −2.04) but not LDL cholesterol (−0.31 mg/dL, 95% CI −0.81 to 0.19). Analyses revealed substantial heterogeneity likely due to the type and intensity of exercise. Data on adverse effects were minimal. The overall level of evidence is moderate due to imprecision and heterogeneity. Conclusions Exercise in overweight and obese older individuals improves anthropometric measures such as BMI and WC. The effect of exercise on serum lipids is unclear.

Improving patient-centered care: Agenda-setting in occupational medicine

Objective: To improve patient satisfaction with care at an occupational medicine clinic by promoting agenda-setting before the visit. Methods: We distributed agenda-setting form to 77 randomly selected patients attending an occupational health clinic and used another randomly selected sample of 36 patients as control group. Patients completed a survey regarding the acceptability of this procedure and whether they felt clinicians addressed their important concerns. Results: Most patients found the form helpful (73%) and wanted it offered in future visits (74%). There was no statistically significant difference in terms of the proportion of patients expressing greatest satisfaction by answering, “strongly agree” (intervention [86%], control [97%]; odds ratio, 0.17; 95% confidence interval, 0.02 to 1.38; P = 0.06). Conclusion: Agenda-setting can improve patient experience before occupational visits but does not improve postvisit satisfaction.

Screening for depression in the occupational health setting

BACKGROUND The cost of workplace absenteeism and presenteeism due to depression in the USA is substantial. AIMS To assess the frequency of depression and its impact at the point of care in an occupational health (OH) practice. METHODS Patients presenting to an OH practice completed a standardized depression screening tool and were compared to an unscreened group in the same clinic. Respondents with a nine-item Patient Health Questionnaire (PHQ-9) score >15 and untreated for depression were referred for further evaluation per usual practice. A comparison group of unscreened patients were selected from the same clinic from 1 year prior and records were reviewed for evidence of prior depression, treatment and outcomes. After 1 year, frequency of depression, PHQ-9 scoring for screened patients, days absent from work, days on restricted duties and permanent restrictions were recorded for both groups. RESULTS Two hundred and five patients were screened for depression. Screening was associated with increased frequency of a diagnosis of current depression (30 versus 4%; P < 0.05). Screening was associated with similar rates of absenteeism but lower number of days on restricted duties (97 versus 159 days; P < 0.001). After adjusting for age, sex, history of and treatment for depression, screening was associated with lower odds of being on work restrictions [odds ratio (OR) 0.55; 95% confidence interval (CI) 0.38-0.78] or permanent restrictions (OR 0.35; 95% CI 0.23-0.52). CONCLUSIONS Depression was common in this OH practice. Screening for depression, with appropriate recognition and referral, may reduce time for employed patients on restricted duties and permanent restrictions.