The Ever-elusive Prescription for the Optimum Diet

SOURCE: Dehghan M, Mente A, Zhang X, et al. Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): A prospective cohort study. Lancet 2017;390:2050-2062.

Opinions about how to best structure optimum dietary constituents have gone through multiple dramatic changes in the last three decades, with little consistency. Remember when eggs were bad because of cholesterol, and margarine was preferred to butter because of calories and fat, and fat, generally, was regarded as an anathema?

The Prospective Urban Rural Epidemiology study was an observational cohort (n = 135,335) of adults aged 35-70 years, followed for 7.4 years, representing 18 different countries, selected to represent the three tiers of low-, middle-, and high-income nations.

During the follow-up interval, 5,796 deaths and 4,784 nonfatal cardiovascular events occurred. Overall for carbohydrates, comparing the highest quintile of intake to the lowest (quintile 5 vs. quintile 1), the hazard ratio for mortality was 1.28. Perhaps surprisingly, carbohydrate levels were not associated with mortality from cardiovascular disease or with cardiovascular events. Additionally, somewhat contrary to the prevailing wisdom, intake of total fat was inversely associated with total mortality (hazard ratio, 0.77). Even the much-maligned saturated fat in the diet was associated with a reduced hazard ratio for total mortality (0.86). Each of these outcomes was statistically significant.

The authors’ interpretation of their results, as quoted, is appropriate: “Global dietary guidelines should be reconsidered in light of these findings.”

Dealing With Severe Acute Pain in the ED

SOURCE: Chang AK, Bijur PE, Esses D, et al. Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: A randomized clinical trial. JAMA 2017;318:1661-1667.

The desire to provide meaningful pain relief for patients with acute severe pain is complicated by concerns about potential overuse of opioids, sometimes leading to misuse, diversion, dependency, and addiction. Despite the commonplace nature of acute pain syndromes (e.g., acute fracture), the literature base comparing different analgesic strategies is modest.

Chang et al performed a randomized, controlled trial among adults (n = 411) presenting with severe acute pain to EDs in the Bronx. The authors compared four different pain regimens, with the specific outcome of change in pain at two hours post-analgesic as measured on a 10-point (0-10) numeric pain rating scale. At baseline, the mean pain scale score was 8.7, indicative of moderately severe to severe pain.

The four regimens (each given as a single dose) were ibuprofen 400 mg/acetaminophen 1,000 mg, oxycodone 325 mg/acetaminophen 325 mg, hydrocodone 5 mg/acetaminophen 300 mg, and codeine 30 mg/acetaminophen 300 mg. At two hours, there was no statistically significant difference in pain reduction between the four different treatment arms. The success of a non-opioid treatment arm in direct comparison with three opioid treatment arms should justify greater consideration of non-opioid treatment for acute severe pain.

Reducing Falls Among Older Adults

SOURCE: Tricco AC, Thomas SM, Veroniki AA, et al. Comparisons of interventions for preventing falls in older adults: A systematic review and meta-analysis. JAMA 2017;318:1687-1699.

Most clinicians recognize the serious burden resulting from falls in senior citizens. Even when falls do not result in serious injury, fear of falls may be quite compromising. Seniors may be reluctant to report postural instability to their families, caregivers, or clinicians, lest their disclosure result in loss of autonomy, nursing home placement, or other restrictions.

Fortunately, as reported in this systematic review, a substantial number of randomized, controlled trials (n = 283 trials, which included 159,910 participants) provide convincing evidence that interventions are remarkably beneficial. Exercise, correction of impaired vision, supplemental calcium/vitamin D, and environmental interventions reduce falls. The interventions that were multimodal appear to produce additive benefits.

Although these results are encouraging, it is noted that there is some signal for an increase in falls when patients become more mobile subsequent to strength and exercise training. Clinicians are advised to caution patients to be cognizant of the risks of greater levels of activity while enjoying greater mobility.