Moderate alcohol consumption is associated with a reduced risk of coronary heart disease, but whether any specific type of alcoholic drink has particular benefit has not been systematically addressed. Rimm et al (p 731) examined the relation between specific alcoholic drinks and the reduction of risk of coronary heart disease by summarising published reports from ecological, case-control, and cohort studies. Most of the ecological studies suggested that wine was more effective in reducing risk of mortality than beer or spirits. Taken together, the three case-control studies did not suggest that one type of drink was more cardioprotective than others. Of the 10 prospective cohort studies, four found a significant inverse association between risk of heart disease and moderate wine drinking, four found the association for beer, and four found it for spirits. The authors conclude that all alcoholic drinks are linked with lower risk, so that much of the benefit is from alcohol rather than other components of each type of drink.
Drinkers' lower risk of heart disease depends on low density lipoprotein cholesterol
On p 736 Hein et al report the six year follow up of 2826 middle aged and elderly men without heart disease according to their lipid profile, alcohol consumption, and development of ischaemic heart disease. In the 558 men with a low concentration of serum low density lipoprotein cholesterol they found a low risk of ischaemic heart disease that was not modified by use of alcohol. With increasing concentration of low density lipoprotein cholesterol, however, the beneficial effect of drinking increased as well. Among the 564 men generally regarded as being at high risk of developing the disease because they had a high concentration (5.3 mmol/l or more) those who did not drink alcohol had five times the risk of those who drank three or more alcoholic drinks a day. Intake of saturated fat is associated with an increase in concentration of low density lipoprotein cholesterol and should theoretically be consistent with an increased risk of ischaemic heart disease. In some parts of France the incidence of ischaemic heart disease is quite low, although the consumption of saturated fat is high. These results from Copenhagen suggest that drinking partly explains the French paradox.
Double blinding and exclusions need more attention in reported randomised trials
Double blinding and avoiding the exclusion of patients after they have entered a trial are critical methodological elements in randomised controlled trials, yet the scientific community knows little about investigators' compliance with these elements in published articles. On p 742 Schulz et al report some disturbing findings from their survey of a group of specialist journals. Investigators could have double blinded more often in their trials than they did. Those who did double blind poorly reported it, which suggests ineffective blinding in some cases. Schulz et a' also found that some investigators who did not report exclusions may in fact have excluded patients during the trial but ignored this in their report. Thus readers may interpret some faulty trials as good trials and vice versa. Flawed reporting of exclusions seems to mislead readers about the quality of a trial.
Guided self management controls asthmatic symptoms better than traditional care
Although many guidelines on asthma suggest self management practices, conflicting results exist concerning the effectiveness of this treatment. In a 12 month prospective randomised trial in 115 patients Lahdensuo et al (p 748) compared the efficacy of guided self management with that of traditional asthma treatment in patients with mild to moderately severe disease. They found that supervised self management consisting of patient education and teaching patients to adjust their anti-inflammatory treatment in line with peak expiratory flow measurements reduced the number of unscheduled visits for ambulatory care, days off work, and courses of antibiotics and prednisolone when compared with conventional asthma care. Guided self management also had a better effect on quality of life.