Lumbar Disc Herniation in Military Helicopter Pilots vs. Matched Controls.

INTRODUCTION: Lumbar disc herniation (LDH) is a common injury among active duty service members resulting in missed duty hours and limited duty status. Little is known about the current burden of disease and risk factors for LDH among military rotary wing aviators. METHODS: A query was made using the Defense Medical Epidemiology Database (DMED), including patient encounters for the U.S. Military from 2006-2015 using the ICD-9 code for LDH. Incidence rates were calculated for patients with the occupation of helicopter pilot and stratified by age, gender, and branch of service, then compared to matched controls using a Poisson regression analysis. Then, data from a 17-yr period were examined for long term trends. RESULTS: We identified 1218 cases of LDH among 141,383 person-years among helicopter pilots, yielding a 1.22-fold higher incidence rate compared to controls. Significant risk factors identified after Poisson regression analysis were age greater than 30 yr old and Army service branch affiliation. Male gender was not found to be a significant risk factor. Long term data revealed a 2.6-fold increased incidence of LDH among helicopter pilots since 1997. DISCUSSION: We identified significant increased risk of LDH in rotary wing pilots as compared to their nonpilot peers. Among rotary wing pilots, the incidence of this condition has increased, with both increasing pilot age and Army branch affiliation identified as risk factors. This information will allow targeted prevention strategies and further investigation to potential aircraft-specific causes of increased risk in Army pilots.Knox JB, Deal JB Jr, Knox JA. Lumbar disc herniation in military helicopter pilots vs. matched controls. Aerosp Med Hum Perform. 2018; 89(5):442-445.

Epidemiology of spinal cord injury without radiographic abnormality in children: a nationwide perspective.

PURPOSE: To characterize the epidemiology and costs associated with spinal cord injury without radiographic abnormality (SCIWORA) based on patient age. METHODS: An analysis of data complied for 2012 in the Healthcare Utilization Project KID database (HCUP-KID), which represents a nationwide database of pediatric admissions, was performed. An initial search identified all children diagnosed with SCIWORA based on International Classification of Diseases, 9th edition (ICD-9) codes. Only data on patients aged <18 years were included in the analysis. The associated codes were then searched to identify the cause of injury. Pertinent epidemiologic data were collected from the database, including age, gender, and racial group. Injury level and pattern were determined from the associated ICD-9 codes, as were associated injuries. Hospital data included length of stay, in-hospital mortality, total hospital charges, and primary payer. All data were compiled and stratified based on patient age into three groups: group 1, age 0-3 years; group 2, age 4-10 years; group 3, age 11-17 years. These data were compared using Student's t test and Chi-squared analyses. RESULTS: A total of 297 patients were identified who met the inclusion criteria. There was a slight predominance of females among the youngest patients (53 %) with a significant dominance of males in the oldest group (72 %) (p < 0.001). The most common race among the patients studied was white (50 %) followed by Hispanic (14 %), Black (12 %), Asian/Pacific Islander (4 %), and Native American (1 %). Overall, the most common cause of injury was sports injuries, which were responsible for 122/297 (41 %) injuries, followed by motor vehicle collisions (26 %). Mechanisms of injury were significantly varied based on age group, with motor vehicle collisions the most common cause in the youngest two age groups and sports injuries the most common in the oldest age group (p < 0.05). The most common location injured was the cervical spine (46 %), with the upper cervical spine most commonly injured, particularly in the younger age groups. Additional injuries were found in 158/297 (53 %) of patients, and these were more common among younger patients. Head trauma was the most common associated injury in all age groups, but the highest rate was found the youngest age groups (p < 0.0001). The average hospital stay for all patients was 13 days, with longer stays seen in younger age groups (p < 0.05). In-hospital mortality was uncommon among these patients and occurred in only 6/297 (2 %) of patients. Hospital charges were highest in the younger age groups, with an average charge of $210,772 for those in the youngest age group, decreasing to $72,178 for those in group 3 (p < 0.0005). The most common payer was public insurance/medicaid in the youngest age group and private insurance in groups 2 and 3 (p < 0.0001). CONCLUSIONS: SCIWORA is an uncommon but potentially devastating injury in children. As with many pediatric injuries, this injury is heterogeneous between children of differing ages. This analysis of a nationwide series of children with such injuries identified significant differences in injury location, causes of injury, associated injuries, and hospital charges associated with this diagnosis.

The Effects of Restraint Type on Pattern of Spine Injury in Children.

INTRODUCTION: While the use of vehicular restraints has reduced the morbidity and mortality of children involved in motor vehicle collisions (MVC), to our knowledge, no study has examined the relationship between restraint type and patterns of pediatric spinal injuries. The purpose of this study is to evaluate this association and review the spinal injuries sustained in children involved in MVC. METHODS: We completed an IRB-approved, retrospective chart review of all patients below 10 years of age presenting to a level 1 pediatric trauma hospital with spine injuries sustained in MVC from 2003 to 2011. We reviewed prehospital data, medical records, and radiographs to establish the restraint type and characterize the spinal injuries sustained. RESULTS: A total of 97 patients were identified with spinal trauma secondary to MVC with appropriate and documentation of restraint type. Results are reported regardless of whether the restraint employed was properly used per established guidelines. Car seat/booster seat (C/B) patients sustained significantly higher rates of cervical spine (62%) and ligamentous (62%) injuries than the 2-point (2P) (10%) and 3-point (3P) restraint (24%) groups (P<0.001). Two-point and 3P restraint use was associated with significantly higher rates of thoracolumbar injuries (67% and 62%, respectively) than the C/B (14%) and unrestrained (0%) groups (P<0.001). Two-point and 3P passengers also had a higher rate of flexion-distraction injuries (P<0.001). Patients in the unrestrained group sustained a significantly higher rate of cervical spine (80%) and ligamentous (40%) injuries than the 2P and 3P groups (P<0.001). No differences were found in the type or location of injury between the 2P and 3P groups. Significant differences in proper restraint use were identified between age groups with younger children demonstrating higher rates of proper restraint use (P<0.01). CONCLUSIONS: Two-point or 3P seatbelt use is associated with lower rates of cervical spine trauma but higher rates of thoracic and lumbar trauma, particularly flexion-distraction injuries, when compared with car or booster seats. Children in C/B and those who are unrestrained sustain high rates of cervical spine injury. LEVEL OF EVIDENCE: Level III-prognostic study.

Complications Associated With High-dose Corticosteroid Administration in Children With Spinal Cord Injury.

BACKGROUND: Complications with high-dose steroid administration for spinal cord injury are documented in adult patients. Our purpose was to determine the incidence of early complications of this therapy in pediatric patients with spinal cord injuries. METHODS: An IRB-approved retrospective review was performed for patients treated for spinal cord injury at a level 1 pediatric trauma center between 2003 and 2011. Demographic data, injury characteristics, and surgical interventions were documented. Complications were divided into 4 categories: infectious, gastrointestinal (GI), hyperglycemia/endocrine, and wound healing problems. Complication rates were compared using a Student's t test and Fischer's exact test. RESULTS: Thirty-four spinal cord injury patients were identified. Twenty-three patients (mean age 6.6 y) in the treatment group received high-dose steroid treatment and 11 patients (mean age 8.4 y) did not and comprised the control group. No statistical difference was detected between the 2 groups regarding age, mechanism of injury, rate of surgical intervention, level of injury, and injury severity. Hyperglycemia was the most common complication and was present in all patients in both the treatment and control groups. The overall infection rate was 64% in the control group compared with 26% in the treatment (P<0.05). The control group demonstrated a significantly increased rate of respiratory tract infections [45% control vs. 9% treatment (P<0.05)]. No surgical patients developed a wound infection. One treatment group patient experienced a GI bleed. CONCLUSIONS: This is the largest study evaluating the complications associated with high-dose steroid administration for spinal trauma in a pediatric population. Hyperglycemia was found in all spinal cord injury patients, regardless of steroid treatment. Paradoxically, infection rates were noted to be higher in the control group. GI and wound problems were not significantly different. Larger, multicenter prospective studies are needed to better understand the risks in pediatric SCI patients.

Spine trauma in very young children: a retrospective study of 206 patients presenting to a level 1 pediatric trauma center.

BACKGROUND: The immature spine has anatomic and biomechanical properties that differ from the adult spine and result in unique characteristics of pediatric spinal trauma. Although distinct patterns of spinal injury have been identified in children younger than 10 years of age, little research has explored the differing characteristics of spinal trauma within this age group, particularly in the very young. The purpose of this study is to identify differences in the epidemiology and characteristics of spinal trauma between children under the age of 4 years and those between 4 and 9 years of age. METHODS: A review of all patients treated for spinal injury at a single large level I pediatric trauma center between 2003 and 2011 was conducted. Demographic data, injury mechanism, neurologic status, and details of any associated injuries were compiled. Radiographic studies were used to determine injury location and fracture classification. The patient population was divided into 2 groups: the infantile/toddler (IT) group (ages 0 to 3 y) and the young (Y) group (ages 4 to 9 y). Data were compared between these groups using the χ2 test and the Student t test to identify differences in injury characteristics. RESULTS: A total of 206 patients were identified. Fifty-seven patients were between 0 and 3 years of age and 149 were between 4 and 9 years old. Although motor vehicle collision was the most common cause of injury in both the groups, nonaccidental trauma was responsible for 19% of spine trauma among patients aged 0 to 3 years. Cervical spine injuries were much more common in the youngest patients (P<0.05) with injuries primarily in the upper cervical spine. Children in the IT group were more likely to sustain ligamentous injuries, whereas Y patients had more compression fractures (P<0.05). Neurologic injury was common in both the groups with IT patients more often presenting with complete loss of function or hemiplegia and Y patients sustaining more spinal cord injuries (P<0.05). IT patients had a 25% mortality rate, which was significantly higher than that of the Y group (P=0.005). CONCLUSIONS: This study shows many significant differences in characteristics of spinal injury in infants/toddlers when compared with older children. These differences can help guide diagnostic evaluation and initial management, as well as future prevention efforts. LEVEL OF EVIDENCE: Level III.

Characteristics of spinal injuries secondary to nonaccidental trauma.

BACKGROUND: Nonaccidental trauma (NAT) is considered an uncommon cause of spine trauma in the pediatric population. Little has been published on such injuries and no large series is available in the literature. The purpose of this study is to describe the incidence and characteristics of spine trauma secondary to NAT. METHODS: An IRB-approved retrospective review of all patients presenting to a single level 1 pediatric trauma center with a spinal injury between 2003 and 2011 was performed. Patients were identified using our institution's trauma registry. Medical records were reviewed to identify all spine injuries that occurred as a result of NAT. These cases were reviewed for details regarding injury mechanism, type and location of injury, associated injuries, and the treatment. Our institution's NAT database was also queried to identify the total number of patients formally determined to have sustained any injury as a result of NAT during the same period. RESULTS: NAT was the cause of 11/342 (3.2%) spine injuries diagnosed during the study period. A total of 726 cases of NAT were identified, with spine injury present in 1.5%. All patients with spine trauma secondary to NAT were under the age of 2 years with an average age of 7 months. Among patients below 2 years with spinal trauma, NAT was tied as the most common mechanism, resulting in 38% of injuries. Eight of the 11 patients' spine injuries were cervical and 7 of these injuries were in the atlanto-occipital and atlantoaxial regions. Multilevel spine trauma was present in 64% of patients. Associated head and thoracic trauma was present in 73% and 36% of patients, respectively. Neurological injury was found in 54% of patients. The majority of injuries were treated nonoperatively and 1 patient required surgical management. CONCLUSIONS: NAT represents a very common yet often overlooked cause of spinal trauma in children under the age of 2 years. Because of its frequency in this age group, clinicians should consider including an assessment of the spine in all young NAT patients. Patients with spinal trauma sustained as a result of NAT must undergo a thorough evaluation for associated injuries remote to the spine, neurological deficit, and multilevel spine injury. SUMMARY: NAT is a common mechanism of spinal injury in patients below 2 years of age.

Occupational driving as a risk factor for low back pain in active-duty military service members.

BACKGROUND CONTEXT: Although occupational driving has been associated with low back pain, little has been reported on the incidence rates for this disorder. PURPOSE: To determine the incidence rate and demographic risk factors of low back pain in an ethnically diverse and physically active population of US military vehicle operators. STUDY DESIGN/SETTING: Retrospective database analysis. PATIENT SAMPLE: All active-duty military service members between 1998 and 2006. OUTCOME MEASURES: Low back pain requiring visit to a health-care provider. METHODS: A query was performed using the US Defense Medical Epidemiology Database for the International Classification of Diseases, Ninth Revision, Clinical Modification code for low back pain (724.20). Multivariate Poisson regression analysis was used to estimate the rate of low back pain among military vehicle operators and control subjects per 1,000 person-years, while controlling for sex, race, rank, service, age, and marital status. RESULTS: A total of 8,447,167 person-years of data were investigated. The overall unadjusted low back pain incidence rate for military members whose occupation is vehicle operator was 54.2 per 1,000 person-years. Compared with service members with other occupations, motor vehicle operators had a significantly increased adjusted incidence rate ratio (IRR) for low back pain of 1.15 (95% confidence interval [CI] 1.13-1.17). Female motor vehicle operators, compared with males, had a significantly increased adjusted IRR for low back pain of 1.45 (95% CI 1.39-1.52). With senior enlisted as the referent category, the junior enlisted rank group of motor vehicle operators had a significantly increased adjusted IRR for low back pain: 1.60 (95% CI 1.52-1.70). Compared with Marine service members, those motor vehicle operators in both the Army, 2.74 (95% CI 2.60-2.89), and the Air Force, 1.98 (95% CI 1.84-2.14), had a significantly increased adjusted IRR for low back pain. The adjusted IRRs for the less than 20-year and more than 40-year age groups, compared with the 30- to 39-year age group, were 1.24 (1.15-1.36) and 1.23 (1.10-1.38), respectively. CONCLUSIONS: Motor vehicle operators have a small but statistically significantly increased rate of low back pain compared with matched control population.

Pediatric lateral distraction injury of the lumbar spine: a case report.

BACKGROUND CONTEXT: Lateral distraction injuries represent a very rare pattern of injury with only five cases reported in the literature. Such injuries are a result of high-energy trauma and have a high association with severe concomitant injuries. All previous reports of this injury are in skeletally mature individuals, and this has not been previously described in young children. PURPOSE: To report a case of a lateral distraction injury in a young child secondary to improper seat belt use. STUDY DESIGN: Case report and review of the literature. PATIENT SAMPLE: Case report of an 8-year-old girl involved in a highway speed head-on collision. METHODS: We report here on an 8-year-old girl who was lying supine in the backseat of a motor vehicle while wearing a lap belt when the vehicle was involved in a high-speed motor vehicle crash. She presented with focal back pain, abdominal pain, and a seat belt sign. Imaging demonstrated focal coronal plane deformity with unilateral ligamentous disruption. The patient was diagnosed with a ligamentous lateral distraction injury of the lumbar spine. This injury was treated with open reduction and posterior spinal fusion with pedicle screw fixation. RESULTS: The patient tolerated the procedure well and had an uneventful postoperative course. CONCLUSIONS: In this case, we describe a lateral distraction injury in a young child secondary to improper seat belt use. This represents the first description of such an injury in this age group, and this case highlights the spectrum of injury caused by improper seat belt use in the pediatric population.

Flexion-distraction injuries in children and adolescents.

Flexion-distraction injuries represent an uncommon pattern of injury in the pediatric population. Although this is a well-studied topic in adults, the literature on such injuries in children and adolescents is relatively sparse, with only low levels of evidence available to guide treatment. These injuries carry a high rate of concomitant injuries and a high morbidity and mortality in this population. Proper understanding of these complex injuries is important to ensure proper management and avoid complications.

Incidence and risk factors for acute low back pain in active duty infantry.

Although much research has been performed on occupational risk factors for low back pain, little has been published on low back pain among infantrymen. This purpose of this study is to evaluate the incidence of acute low back pain amongst active duty infantrymen as compared to a matched control population. The Defense Medical Epidemiology Database was searched and incidence rates were calculated and compared between infantry and noninfantry soldiers. Data was stratified and controlled for age, race, marital status, rank, and branch of service using the Poisson multivariate regression analysis. Significantly lower rates of acute low back pain were discovered in active duty infantrymen when compared to matched controls (32.9 versus 49.5 cases per 1,000 person-years). Additionally, significantly lower rates were identified in the Marines versus the Army, and among junior enlisted compared to senior enlisted service members.

Racial differences in the incidence of acute low back pain in United States military service members.

STUDY DESIGN: An epidemiological study. OBJECTIVE: To determine the effect of race on the incidence of acute low back pain, resulting in a health care encounter in active duty military service members. SUMMARY OF BACKGROUND DATA: Although racial differences in the incidence of low back pain have been documented in previous studies, currently no consensus exists on the relative risk between these groups. METHODS: A query was performed using the Armed Forces Health Surveillance Center database for the International Classification of Diseases, Ninth Revision code for low back pain (724.20). A total of 12,399,276 person-years of data were analyzed and stratified by age, race, and sex. Incidence rates were calculated and compared using the multivariate Poisson regression analysis. RESULTS: A total of 467,950 cases of low back pain resulted in a visit to a health care provider in our population, with an overall incidence rate of 37.74 per 1000 person-years. Asians/Pacific Islanders had the lowest incidence rate of 30.7 and blacks had the highest with 43.7. Female sex and older age were also significant risk factors but with significantly different effect sizes between racial groups. Native Americans/Alaskan Natives demonstrated the greatest effect of age on low back pain incidence rates, with a 126% increase between the youngest and oldest age groups compared with a 36% difference in whites. CONCLUSION: Race, sex, and age were all found to be significant risk factors for acute low back pain. The highest rates were identified in blacks followed by whites, Hispanics, and American Indian/Alaskan Native, and the lowest rates were identified in Asians/Pacific Islanders. Significant differences in the effect of sex and age were identified between the different racial groups.

Superior segment facet joint violation and cortical violation after minimally invasive pedicle screw placement.

BACKGROUND CONTEXT: Minimally invasive approaches to the lumbar spine allow for pedicle screw placement through a muscle-splitting paraspinal approach. These techniques are highly dependent on fluoroscopy and do not allow for direct visualization of anatomic landmarks. The effect of this on the accuracy of pedicle screw placement is not well described. The purpose of this study was to evaluate the rate of violation of the superior segment facet joint and rates of cortical violation after minimally invasive pedicle screw placement. PURPOSE: To evaluate the rate of cortical violation and involvement of the superior segment facet after minimally invasive pedicle screw placement. STUDY DESIGN/SETTING: Retrospective chart review. PATIENT SAMPLE: Patients who underwent minimally invasive pedicle screw placement by a single surgeon between January 2004 and July 2009. OUTCOME MEASURES: Violation of the superior segment facet joint or cortical violation identified on computed tomography (CT). METHODS: This study consisted of a consecutive series of adult patients undergoing minimally invasive pedicle screw placement by a single surgeon for degenerative lumbar spinal conditions. Routine postoperative CT was obtained and evaluated for involvement of the superior segment facet joint and for cortical violation. RESULTS: Sixty-one consecutive patients (282 pedicle screws) met the study criteria and were included in the study, including 42 single-level fusions and 19 two-level fusions. Seven cortical breaches were identified for a rate of 2.48%. Seven patients had involvement of the superior-level facet for an incidence of 11.48%. One patient required revision for a malpositioned pedicle screw. CONCLUSIONS: This study revealed a low rate of superior segment facet violation and cortical violation after minimally invasive pedicle screw placement. This rate of superior-level facet involvement is significantly lower than previously reported after open procedures. The rate of cortical violation is similar to previous reports in the literature with a low revision rate.

The incidence of low back pain in active duty United States military service members.

STUDY DESIGN: Epidemiological study. OBJECTIVE: To investigate the incidence and risk factors for developing low back pain in active duty military population to include age, sex, race, and rank, and military service. SUMMARY OF BACKGROUND DATA: Low back pain is among the most common musculoskeletal conditions worldwide and is estimated to affect nearly two-thirds of the US population at some point in their lives. Low back pain is a multifactorial disease and many risk factors have been implicated including age, race, sex, and marital status. METHODS: A query was performed using the US Defense Medical Epidemiology Database (DMED) for the International Classification of Diseases, Ninth Revision, Clinical Modification code for low back pain (724.20). 13,754,261 person-years of data were investigated. Multivariate Poisson regression analysis was used to estimate the rate of low back pain per 1000 person-years, whereas controlling for sex, race, rank, service, age, and marital status. RESULTS: The overall unadjusted incidence rate of low back pain was 40.5 per 1000 person-years. Women, compared with men, had a significantly increased incidence rate ratio for low back pain of 1.45. The incidence rate ratio for the 40+ age group compared with the 20 to 29 years of age group was 1.28. With junior officers as the referent category, junior- and senior-enlisted rank groups had increased incidence rate ratio for low back pain, 1.95 and 1.35, respectively. Each service, when compared with the Marines as the referent category, had a significantly increased incidence rate ratio of low back pain: Army: 2.19, Navy: 1.02, and Air Force: 1.54. Compared with single service members, significantly increased incidence rate ratio for low back pain were seen in married service members: 1.21. CONCLUSION: Female sex, enlisted rank groups, service in the Army, Navy, or Air Force, age greater than 40 years, and a marital status of married were all risk factors for low back pain.

Osteolysis in transforaminal lumbar interbody fusion with bone morphogenetic protein-2.

STUDY DESIGN.: Retrospective radiographic review. OBJECTIVE.: To determine the incidence of osteolysis, graft subsidence, and cage migration after recombinant human bone morphogenetic protein-2 (rhBMP-2) use with transforaminal lumbar interbody fusion (TLIF). SUMMARY OF BACKGROUND DATA.: Osteolysis after TLIF is a recently described phenomenon associated with rhBMP-2 use. Although this is typically a self-limiting condition, complications such as graft subsidence and cage migration have been described. The incidence of this is not well defined and most studies use plain radiographs for diagnosis rather than more advanced imaging. This study serves to quantify the risk of osteolysis and its associated graft complications with routine use of computed tomography. METHODS.: A total of 58 patients who underwent primary TLIF from a single surgeon between 2004 and 2007 underwent routine postoperative computed tomographic scan. Seventy-seven levels of fusion were evaluated for osteolysis. All patients received the same dose of rhBMP-2 of 5 mg per level. Imaging was performed immediately postoperative and again at an average of 4.3 months postoperative (range = 2.4-9.0 months). These images were evaluated for the presence of osteolysis, graft subsidence, and cage migration. These changes were then graded according to their severity. RESULTS.: Osteolysis was found in 16 of the 58 (27.6%) patients and 19 of the 77 (24.7%) levels treated. No significant difference was found between single and two-level fusions. The degree of osteolysis ranged from 3 to 20 mm with an average of 12.5 mm. The osteolysis was characterized as severe (>1 cm) in 12 of the 19 levels. Of the patients with osteolysis, 31.6% demonstrated graft subsidence all of which occurred with severe osteolytic defects. Migration of the intervertebral cage was found in 8.8% of patients. CONCLUSION.: rhBMP-2 use with TLIF is associated with a significant risk of postoperative osteolysis. Patients who demonstrated postoperative osteolysis were associated with significant risk of subsidence or migration of the intervertebral cage. The clinical implications of these changes are not currently known.

Percutaneous pins versus volar plates for unstable distal radius fractures: a biomechanic study using a cadaver model.

PURPOSE: A biomechanic study using a cadaver model of a dorsally unstable distal radius fracture was used to compare the stability of percutaneous pinning and volar fixed-angle plating. Among the many surgical options for treating distal radius fractures are percutaneous pinning and internal plate fixation. Although percutaneous pin fixation requires less soft-tissue trauma and has low complication rates, plate fixation allows for early active movement with good clinical results. The biomechanic stability of these 2 methods was studied by using a cadaver model of a dorsally unstable intra-articular distal radius fracture. METHODS: This study was performed on 7 fresh-frozen cadaver arms, in each of which an unstable intra-articular fracture with dorsal comminution was created. The fracture was first fixed with 0.062-mm K-wires inserted in standard crossed fashion and was tested in a pneumatic loading device that indirectly loaded the wrists through the 5 motor tendons 3 times at each level of force in flexion and extension. Testing was then repeated after removal of the pins and fixation with a fixed-angle DVR distal volar radius plate system (Hand Innovations, Inc., Miami, FL). Testing was performed in flexion up to 68 N and in extension up to 100 N, and the distance across the fracture site was measured. RESULTS: Volar plating was significantly more stable than pinning, with an average movement across the fracture site of 2.51 mm for pin fixation and 1.07 mm for plate fixation. The pins also showed a substantial degree of slipping after repeated stressing, but the plates remained stable. CONCLUSIONS: These results show the superior biomechanic stability of internal fixation using plates for dorsally comminuted intra-articular distal radius fractures in this cadaver model. Further clinical correlations are needed.

Dietary supplements for the prevention and treatment of coronary artery disease.

PURPOSE: With the recent growth in the use of dietary supplements, it is increasingly important for clinicians to be familiar with the evidence for and against their efficacy. We set out to systematically review the dietary supplements available for the prevention and treatment of coronary artery disease. METHODS: Between May 2004 and May 2006, we searched MEDLINE, the Cochrane Library, and Pro-Quest using the MeSH terms hypertension, hypercholesterolemia, myocardial infarction, dietary supplements, and herb-drug interactions. The MeSH terms of individual supplements identified were then added to the search. Reference lists of pertinent papers were also searched to find appropriate papers for inclusion. We included randomized controlled trials published in English of at least 1 week's duration that studied the efficacy of supplements in the treatment of hypercholesterolemia, or hypertension, or in the prevention of cardiac events. Qualifying papers were identified and assigned a Jadad quality score. In areas of uncertainty, a second investigator independently scored the trial. RESULTS: Fifteen (15) supplements were identified. Of these, most had little data available and most of the data were of poor quality. The supplements with the most supporting data were policosanol and garlic, both for hyperlipidemia. CONCLUSIONS: A growing body of literature exists for numerous supplements in the prevention of coronary artery disease, but much of these data are inconclusive. Clinicians should become familiar with the extent and limitations of this literature so that they may counsel their patients better.