Eric B Rimm, Arthur Klatsky, Diederick Grobbee, Meir J Stampfer
Abstract
Objectives - To review the effect of specific types of alcoholic drink on coronary risk.
Design - Systematic review of ecological, case control, and cohort studies in which specific associations were available for consumption of beer, wine, and spirits and risk of coronary heart disease.
Subjects - 12 ecological, three case-control, and 10 separate prospective cohort studies.
Main outcome measures - Alcohol consumption and relative risk of morbidity and mortality from coronary heart disease.
Results - Most ecological studies suggested that wine was more effective in reducing risk of mortality from heart disease than beer or spirits. Taken together, the three case-control studies did not suggest that one type of drink was more cardioprotective than the others. Of the 10 prospective cohort studies, four found a significant inverse association between risk of heart disease and moderate wine drinking, four found such an association for beer, and four for spirits.
Conclusions - Results from observational studies, where alcohol consumption can be linked directly to an individual's risk of coronary heart disease, provide strong evidence that all alcoholic drinks are linked with lower risk. Thus, a substantial portion of the benefit is from alcohol rather than other components of each type of drink.
Department of Nutrition Harvard School of Public Health Boston MA 02115 USA Eric B Rimm assistant professor of epidemiology and nutrition Meir J Stampfer professor of epidemiology and nutrition
Kaiser Permanente Medical Center and the Division of Research Group Oakland CA USA Arthur Klatsky senior consultant in cardiology
Department of Epidemiology and Biostatistics Erasmus University Medical School Rotterdam Netherlands Diederick Grobbee professor of epidemiology
Correspondence to: Dr Rimm.
Hans Ole Hem, Poul Suadicani, Finn Gyntelberg
Abstract
Objectives - To investigate the interplay between use of alcohol, concentration of low density lipoprotein cholesterol, and risk of ischaemic heart disease.
Design - Prospective study with controlling for several relevant confounders, including concentrations of other lipid fractions.
Setting - Copenhagen male study, Denmark.
Subjects - 2,826 men aged 53-74 years without overt ischaemic heart disease.
Main outcome measure - Incidence of ischaemic heart disease during a six year follow up period.
Results - 172 men (6.1%) had a first ischaemic heart disease event. There was an overall inverse association between alcohol intake and risk of ischaemic heart disease. The association was highly dependent on concentration of low density lipoprotein cholesterol. In men with a high concentration (greater than or equal to 5.25 mmol/l) cumulative incidence rates of ischaemic heart disease were 16.4% for abstainers, 8.7% for those who drank 1-21 beverages a week, and 4.4% for those who drank 22 or more beverages a week. With abstainers as reference and after adjustment for confounders, corresponding relative risks (95% confidence interval) were 0.4 (0.2 to 1.0; P is less than 0.05) and 0.2 (0.1 to 0.8; P is less than 0.01). In men with a concentration less than 3.63 mmoI/l use of alcohol was not associated with risk. The attributable risk (95% confidence interval) of ischaemic heart disease among men with concentrations greater than 3.63 mmol/l who abstained from drinking alcohol was 43% (10% to 64%).
Conclusions - In middle aged and elderly men the inverse association between alcohol consumption and risk of ischaemic heart disease is highly dependent on the concentration of low density lipoprotein cholesterol. These results support the suggestion that use of alcohol may in part explain the French paradox.
Copenhagen Male Study Epidemiological Research Unit 7122 Rigshospitalet State University Hospital DK-2200 Copenhagen N Denmark Hans Ole Hein associate professor Poul Suadicani senior researcher Finn Gyntelberg professor
Correspondence to: Dr Hein.
Kenneth F Schulz, David A Grimes, Douglas G Altman, Richard I Hayes
Abstract
Objective - To assess the methodological quality of approaches to blinding and to handling of exclusions as reported In randomised trials from one medical specialty.
Design - Survey of published, parallel group randomised controlled trials.
Data sources - A random sample of 110 reports in which allocation was described as randomised from the 1990 and 1991 volumes of four journals of obstetrics and gynaecology.
Main outcome measures - The adequacy of the descriptions of double blinding and exclusions after randomisation.
Results - Though 31 trials reported being double blind, about twice as many could have been. Of the 31 trials only eight (26%) provided information on the protection of the allocation schedule and only five (16%) provided some written assurance of successful implemention of double blinding. Of 38 trials in which the authors provided sufficient information for readers to infer that no exclusions after randomisation had occurred, six (16%) reported adequate allocation concealment and none stated that an intention to treat analysis had been performed. That compared with 14 (27%) and six (12%), respectively, for the 52 trials that reported exclusions.
Conclusions - Investigators could have double blinded more often. When they did double blind, they reported poorly and rarely evaluated it. Paradoxically, trials that reported exclusions seemed generally of a higher methodological standard than those that had no apparent exclusions. Exclusions from analysis may have been made in some of the trials in which no exclusions were reported. Editors and readers of reports of randomised trials should understand that flawed reporting of exclusions may often provide a misleading impression of the quality of the trial.
Division of Sexually Transmitted Diseases Prevention Centers for Disease Control and Prevention Atlanta GA 30333 USA Kenneth F Schulz assistant director
Department of Obstetrics, Gynecology, and Reproductive Sciences University of California San Francisco CA 94110 USA David A Grimes professor
Medical Statistics Laboratory Imperial Cancer Research Fund Medical Statistics Group Centre for Statistics in Medicine Oxford 0X3 7LF Douglas G Altman head
Tropical Health Epidemiology Unit London School of Hygiene and Tropical Medicine London WC1E 9HT Richard I Hayes head
Correspondence to: Dr Schulz.
Randomised comparison of guided self management and traditional treatment of asthma over one year
Aarne Lahdensuo, Tan Haahtela, Jaakko Herrala, Tuomo Kava, Kirsti Kiviranta, Paula Kuusisto, Erkki Peramaki, Tuija Poussa, Seppo Saarelainen, Thore Svahn
Abstract
Objective - To compare the efficacy of self management of asthma with traditional treatment.
Design - 12 month prospective randomised trial.
Setting - Outpatient clinics in Finland.
Subjects - 115 patients with mild to moderately severe asthma. Interventions - Patient education and adjustment of anti-inflammatory therapy guided by peak flow measurements.
Main outcome measures - Unscheduled admissions to hospital and outpatient visits, days off work, courses of antibiotics and prednisolone, lung function, and quality of life.
Results - The mean number of unscheduled visits to ambulatory care facilities (0.5 v 1.0), days off work (2.8 v 4.8), and courses of antibiotics (0.4 v 0.9) and prednisolone (0.4 v 1.0) per patient were lower and the quality of life score (16.6 v 8.4 at 12 months) higher in the self management group than in the traditionally treated group. In both groups admissions for asthma were rare.
Conclusions - Self management reduces incidents caused by asthma and improves quality of life.
Department of Pulmonary Diseases Tampere University Hospital 36280 Pikonlinna Finland Aarne Lahdensuo head Jaakko Herrala consultant physician Paula Kuusisto consultant physician Seppo Saarelainen consultant physician
Skin and Allergy Hospital Helsinki University Central Hospital 00250 Helsinki Tari Haahtela director Kirsti Kiviranta consultant physician
Department of Pulmonary Diseases Central Hospital of Northern Karelia 80780 Kontioniemi Tuomo Kava head Erkki Peramaki consultant physician STAT-Consulting 33300 Tampere Tuija Poussa statistician
Suomen Astra Oy 02430 Masala Thore Svahn clinical research scientist
Correspondence to: Dr Lahdensuo.