Fever as a Predictor of COVID-19 Outcomes in Hospitalized Patients.

INTRODUCTION: With the advent of the COVID-19 pandemic, numerous questions have arisen regarding the screening, diagnosis, treatment, and prognosis of infected patients. Among these, screening infected patients through body temperature measurement has proven ineffective. However, doubts persist regarding the role of fever as a prognostic factor in the disease. OBJECTIVE: To assess the prevalence of fever and its relevance as a marker of mortality in COVID-19. METHODOLOGY: This prospective and longitudinal cohort study was conducted between April 2020 and December 2021 and analyzed 1400 COVID-19 patients systematically admitted to the emergency department of a reference hospital during the period from April 2020 to December 2021, in the city of Curitiba, Brazil. [LG1] The study evaluated [LG2] the presence of fever (body temperature above 37,7ºC) upon admission and/or during hospitalization, patient profiles, and outcomes (in-hospital death, discharge, admission at the intensive care unit, need of mechanical ventilation). RESULTS: Fever was present in 128 participants (9.1%), with a higher prevalence in males (71%) and obese individuals (42.9%). Among the febrile patients, 39 required intubation (30.4%), with two intubated upon admission (1.5%), 104 were discharged (81.2%), and 24 deceased (18.7%). Fever was not associated with a higher mortality rate. CONCLUSION: Fever showed low prevalence, is more common in males and obese individuals, and is not related to worse clinical outcomes.

Longitudinal Relationship Between Handgrip Strength and Cognitive Function in a European Multicentric Population Older Than 50 Years.

OBJECTIVE: The aim of this study was to analyze the bidirectional association between handgrip strength (HGS) and cognitive performance in different cognitive functions in a European population and to evaluate the predictive validity of HGS for the risk of future cognitive impairment in aging individuals. METHODS: This was a prospective cohort study conducted using data on individuals over 50 years of age from the Survey of Health, Aging and Retirement in Europe (SHARE). HGS measures and scores in numeracy, recall, and verbal fluency were repeated and analyzed biannually for 4 years and were used in generalized estimating equations to test the bidirectional association, categorized by sex. RESULTS: Of the 8236 individuals included, 55.73% were women with a mean age of 67.55 (standard deviation [SD] = 8.4) years and 44.27% were men with a mean age of 68.42 (SD = 7.7) years. HGS predicted cognitive decline in both sexes, except for numeracy in men, even after adjustments. The strongest association with HGS in women was in verbal fluency (ß = .094; 95% CI = 0.039 to 0.151), whereas the strongest association with HGS in men was in delayed verbal recall (ß = .095; 95% CI = 0.039 to 0.151). Conversely, the greatest cognitive predictor of HGS decline was verbal fluency in men (ß = .796; 95% CI = 0.464 to 1.128), and in women (ß = .801; 95% CI= 0.567 to 1.109). CONCLUSION: There is a significant and bidirectional association between HGS and different cognitive functions in a European multicentric population. This bidirectional association differed between sexes. IMPACT: Both men and women who presented with cognitive decline also showed early changes in their HGS measures, and vice versa, but there still were differences between the sexes. These findings reinforce that HGS may be a simple and inexpensive method to identify early signs of cognitive decline, and that studies and rehabilitation strategies should be more sex specific.

Susceptibility of the patients infected with Sars-Cov2 to oxidative stress and possible interplay with severity of the disease.

Several recent reviews have suggested a role of oxidative stress in the pathophysiology of COVID-19, but its interplay with disease severity has not been revealed yet. In the present study, we aimed to investigate the association between the severity of COVID-19 and oxidative stress parameters. Clinical data of 77 patients with COVID-19 admitted to the hospital were analyzed and divided into moderate (n = 44) and severe (n = 33) groups based on their clinical condition. Production of oxidant (hydrogen peroxide) and defense antioxidants (total antioxidant capacity, reduced and oxidized glutathione, glutathione s-transferase), and oxidative damage (malondialdehyde, carbonyl, and sulfhydryl) were assessed using the serum samples. The results revealed that severe patients who presented high serum leukocyte count and CRP level stayed for a longer period in the hospital. However, there was no correlation observed between the oxidative stress parameters and degree of COVID-19 severity in the present study. In conclusion, these results indicate that the disease severity may not be a detrimental factor contributing to the changes in the redox profile of hospitalized patients with COVID-19.

Physical health-related quality of life at higher achieved hemoglobin levels among chronic kidney disease patients: a systematic review and meta-analysis.

BACKGROUND: The impact of anemia treatment with erythropoietin stimulating agents (ESA) on health-related quality of life (HRQOL) in chronic kidney disease (CKD) patients is controversial, particularly regarding optimal hemoglobin (Hb) target ranges. METHODS: We conducted a systematic review and meta-analysis of observational studies and randomized controlled trials (RCT) with ESA to estimate the effect of different achieved Hb values on physical HRQOL and functionality. We searched PubMed, EMBASE, CENTRAL, PEDro, PsycINFO and Web of Science databases, until May 2020. Two authors independently extracted data from studies. We included observational and RCTs that enrolled CKD patients undergoing anemia treatment with ESA with different achieved Hb levels among groups. We excluded studies with achieved Hb < 9 g/dL. For the meta-analysis, we included RCTs with control groups achieving Hb 10-11.5 g/dL and active groups with Hb > 11.5 g/dL. We analyzed the standardized mean difference (SMD) between groups for physical HRQOL. RESULTS: Among 8496 studies, fifteen RCTs and five observational studies were included for the systematic review. We performed the meta-analysis in a subset of eleven eligible RCTs. For physical role and physical function, SMDs were 0.0875 [95% CI: - 0.0025 - 0.178] and 0.08 [95% CI: - 0.03 - 0.19], respectively. For fatigue, SMD was 0.16 [95% CI: 0.09-0.24]. Subgroup analysis showed that trials with greater achieved Hb had greater pooled effects sizes - 0.21 [95% CI: 0.07-0.36] for Hb > 13 g/dL vs. 0.09 [95% CI: 0.02-0.16] for Hb 11.5-13 g/dL. Proportion of older and long-term diabetic patients across studies were associated with lower effect sizes. CONCLUSION: Achieved hemoglobin higher than currently recommended targets may be associated with small but potentially clinically significant improvement in fatigue, but not in physical role or physical function. Younger and non-diabetic patients may experience more pronounced benefits of higher Hb levels after treatment with ESAs.

Prevalence of Combined Lipid Abnormalities in Brazilian Adolescents and Its Association with Nutritional Status: Data from the Erica Study.

Background: Cardiovascular diseases are the leading cause of death in Brazil and worldwide. The growing incidence of obesity in children and adolescents and its association with lipid abnormalities may worsen this scenario, mainly in developing countries where obesity has reached epidemic levels. Dyslipidemias have several patterns, and the combination of some lipid abnormalities may have higher atherogenic potential. Objectives: To evaluate the prevalence of single or multiple combined lipid abnormalities in adolescents and its association with nutritional status assessed by body mass index. Methods: Data were obtained from the Study of Cardiovascular Risks in Adolescents (ERICA), a school-based, national representative study with Brazilian adolescents between 12 and 17 years of age. Adolescents whose lipid profiles were available were included, and lipid abnormalities were defined as LDL-C ≥ 100 mg/dL, HDL-C < 45 mg/dL, and tryglicerides (TG) ≥ 100 mg/dL. We assessed the prevalence of single or combined lipid abnormalities and correlated this nutritional status with body mass index of low weight, normal, overweight, and obesity. Results: A total of 38,069 adolescents were included, with more than 24,000 of them presenting at least one lipid abnormality (64.7%), and 3.7% showing alterations in all of them. The most prevalent combination was high TG with low HDL-C levels. The higher the BMI, the more lipid abnormalities were found. Conclusions: In this large and representative sample of Brazilian adolescents, the majority had at least one lipid abnormality. Higher BMI was associated with a higher prevalence of combined lipid abnormalities. Highlights: - There is a high prevalence of Brazilian adolescents with dyslipidemias.- BMI was associated with a higher prevalence of combined lipid abnormalities.- BMI can be considered as an indicator of the diagnosis of dyslipidemia in adolescents.

Noninvasive ventilation in acute hypoxemic respiratory failure: A systematic review and meta-analysis.

PURPOSE: Evaluate current recommendation for the use of noninvasive ventilation (Bi-level positive airway pressure- BiPAP modality) in hypoxemic acute respiratory failure, excluding chronic obstructive pulmonary disease. METHODS: Electronic searches in MEDLINE, Web of Science, Clinical Trials, and The Cochrane Central Register of Controlled Clinical Trials. We searched for randomized controlled trials comparing BiPAP to a control group in patients with hypoxemic acute respiratory failure. Endotracheal intubation and death were the assessed outcomes. RESULTS: Of the 563 studies found, nine met the inclusion criteria for this systematic review. The pooled RR (95% CI) for intubation in patients with acute pulmonary edema (APE)/community acquired pneumonia (CAP) and in immunosuppressed patients (cancer and transplants) were 0.61 (0.39-0.84) and 0.77 (0.60-0.93), respectively. For Intensive Care Units (ICU) mortality, the RR (95% CI) in patients with APE/CAP was 0.51 (0.22-0.79). The heterogeneity was low in all comparisons. CONCLUSIONS: NIV showed a significant protective effect for intubation in immunosuppressed patients (cancer and transplants) and in patients with APE/CAP. However, the benefits of NIV for other etiologies are not clear and more trials are needed to prove these effects.

Orthostatic Hypotension and Cognitive Function: Cross-sectional Results From the ELSA-Brasil Study.

BACKGROUND: The association between orthostatic hypotension (OH) and cognitive impairment is controversial, and most studies have investigated older white adults from Western Europe and the United States. Therefore, we investigated the association between OH and cognitive performance in a large and racially diverse sample of adults using cross-sectional data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). METHODS: OH was defined when systolic blood pressure decreased 20 mmHg and/or diastolic blood pressure decreased 10 mmHg from supine to standing position. We investigated the association between OH and composite global cognition, memory, verbal fluency (VF), and Trail Making Test z-scores, using multiple linear regression models. We also investigated the association of orthostatic hypertension and systolic blood pressure/diastolic blood pressure changes with cognitive performance, as well as the interaction between OH and compensatory heart rate after postural change on cognitive performance. RESULTS: We evaluated 12,826 participants (mean age = 51.5 ± 9.0 years, 46% male, 53% white). Participants with OH (4% of the sample) had poorer z-scores for VF (ß = -0.108, 95% confidence interval = -0.189; -0.025, p = .01) than participants without OH. Orthostatic hypertension was also associated with worse performance on the VF test (ß = -0.080, 95% confidence interval = -0.157; -0.003, p = .04). Systolic blood pressure orthostatic change had a nonlinear association with VF. The interaction terms between OH and compensatory increase in heart rate for the Trail Making Test z-score (p = .09) was borderline significant, suggesting that participants who lack compensatory heart rate after postural change might have poorer performance. CONCLUSION: OH and orthostatic hypertension were associated with poorer performance on the VF test in participants from Brazil.

Lifestyle factors, cardiovascular disease and all-cause mortality in middle-aged and elderly women: a systematic review and meta-analysis.

Cardiovascular disease (CVD) risk factors, incidence and death increases from around the time of menopause comparing to women in reproductive age. A healthy lifestyle can prevent CVD, but it is unclear which lifestyle factors may help maintain and improve cardiovascular health for women after menopausal transition. We conducted a systematic review and meta-analysis of prospective cohort studies to evaluate the association between modifiable lifestyle factors (specifically smoking, physical activity, alcohol intake, and obesity), with CVD and mortality in middle-aged and elderly women. Pubmed, Embase, among other databases and reference lists were searched until February 29th, 2016. Study specific relative risks (RR) were meta-analyzed using random effect models. We included 59 studies involving 5,358,902 women. Comparing current versus never smokers, pooled RR were 3.12 (95% CI 2.15-4.52) for CHD incidence, 2.09 (95% CI 1.51-2.89) for stroke incidence, 2.76 (95% CI 1.62-4.71) for CVD mortality and 2.22 (95% CI 1.92-2.57) for all-cause mortality. Physical activity was associated with a decreased risk of 0.74 (95% CI 0.67-0.80) for overall CVD, 0.71 (95% CI 0.67-0.75) for CHD, 0.77 (95% CI 0.70-0.85) for stroke, 0.70 (95% CI 0.58-0.84) for CVD mortality and 0.71 (95% CI 0.65-0.78) for all-cause mortality. Comparing moderate drinkers versus non-drinkers, the RR was 0.72 (95% CI 0.56-0.91) for CHD, 0.63 (95% CI 0.57-0.71) for CVD mortality and 0.80 (95% CI 0.76-0.84) for all-cause mortality. For women with BMI 30-35 kg/m2 the risk was 1.67 (95% CI 1.24-2.25) for CHD and 2.3 (95% CI 1.56-3.40) for CVD mortality, compared to normal weight. Each 5 kg/m2 increase in BMI was associated with 24% (95% CI 16-33%) higher risk for all-cause mortality. This meta-analysis suggests that physical activity and moderate alcohol intake were associated with a reduced risk for CVD and mortality. Smoking and higher BMI were associated with an increased risk of these endpoints. Adherence to a healthy lifestyle may substantially lower the burden of CVD and reduce the risk of mortality among middle-aged and elderly women. However, this review highlights important gaps, as lack of standardized methods in assessing lifestyle factors and lack of accurate information on menopause status, which should be addressed by future studies in order to understand the role of menopause on the association between lifestyle factors and cardiovascular events.

Prevalence of high cholesterol levels suggestive of familial hypercholesterolemia in Brazilian adolescents: Data from the study of cardiovascular risk in adolescents.

BACKGROUND: Familial hypercholesterolemia (FH) is an autosomal dominant genetic disorder with an estimated worldwide prevalence ranging from 1 in 200 individuals to 1 in 500 individuals in its heterozygous form. Individuals with FH exhibit high low-density lipoprotein cholesterol (LDLc) levels from birth, which leads to premature cardiovascular events. In Brazil, like in most countries around the world, FH is considered a public health problem but remains underdiagnosed and undertreated. OBJECTIVE: The aim of this study was to evaluate the prevalence of LDLc or non-high-density lipoprotein cholesterol (non-HDLc) levels suggestive of FH among Brazilian adolescents. METHODS: The Study of Cardiovascular Risk in Adolescents (ERICA) was a nationwide, school-based, cross-sectional study that assessed the prevalence of cardiovascular risk factors in approximately 75,000 adolescents between 12 and 17 years old. Data were analyzed according to sex, age, type of school (public or private), and geographic regions of Brazil. Adolescents with untreated fasting LDLc levels of 160 mg/dL or higher or non-HDLc levels of 190 mg/dL or higher were suspected to have FH. We also evaluated the prevalence of LDLc levels of 190 mg/dL or higher, which is highly suggestive of a diagnosis of FH in this age group. RESULTS: A total of 38,069 adolescents were evaluated; more than half (59.9%) were female and most (74%) attended public schools. The prevalence of LDLc levels of 160 mg/dL or higher or non-HDLc levels of 190 mg/dL or higher among the adolescents was 0.49% (95% confidence interval: 0.34-0.71; n = 209). Moreover, 0.12% of the adolescents (95% confidence interval: 0.04-0.34; n = 44) had LDLc levels of 190 mg/dL or higher. We estimate that approximately 100,000 (1 in 200) Brazilian adolescents aged 12 to 17 years are suspected to have FH on the basis of LDLc and non-HDLc levels. CONCLUSION: We identified a significant prevalence of cholesterol levels suggestive of FH among Brazilian adolescents. Further evaluation is needed to confirm the diagnoses among the students. Our results reinforce the importance of universal screening as a critical tool for early diagnosis and treatment of FH.

Achieved systolic blood pressure in older people: a systematic review and meta-analysis.

BACKGROUND: It remains unclear into which level the systolic blood pressure (SBP) should be lowered in order to provide the best cardiovascular protection among older people. Hypertension guidelines recommendation on attaining SBP levels <150 mmHg in this population is currently based on experts' opinion. To clarify this issue, we systematically reviewed and quantified available evidence on the impact of achieving different SBP levels <150 mmHg on various adverse outcomes in subjects aged ≥60 years old receiving antihypertensive drug treatment. METHODS: We searched 8 databases to identify randomized controlled trials (RCTs) and post-hoc analyses or subanalyses of RCTs reporting the effects of attaining different SBP levels <150 mmHg on the risk of stroke, acute myocardial infarction, heart failure, cardiovascular mortality and all-cause mortality in participants aged ≥60 years. We performed random-effects meta-analyses stratified by study design. RESULTS: Eleven studies (> 33,600 participants) were included. Compared with attaining SBP levels ≥140 mmHg, levels of 130 to <140 mmHg were not associated with lower risk of outcomes in the meta-analysis of RCTs, whereas there was an associated reduction of cardiovascular mortality (RR 0.72, 95% CI 0.59-0.88) and all-cause mortality (RR 0.86, 95% CI 0.75-0.99) in the meta-analysis of post-hoc analyses or subanalyses of RCTs. Limited and conflicting data were available for the SBP levels of <130 mmHg and 140 to <150 mmHg. CONCLUSIONS: Among older people, there is suggestive evidence that achieving SBP levels of 130 to <140 mmHg is associated with lower risks of cardiovascular and all-cause mortality. Future trials are required to confirm these findings and to provide additional evidence regarding the <130 and 140 to <150 mmHg SBP levels.

Maternal weight status, diet, and supplement use as determinants of breastfeeding and complementary feeding: a systematic review and meta-analysis.

CONTEXT: Infant feeding practices are influenced by maternal factors. OBJECTIVE: The aim of this review is to examine the associations between maternal weight status or dietary characteristics and breastfeeding or complementary feeding. DATA SOURCES: A systematic literature search of the Embase, Cochrane Library, Google Scholar, MEDLINE, PubMed, and Web of Science databases was performed. STUDY SELECTION: Interventional and cohort studies in healthy mothers and infants that reported on maternal weight status, diet, or supplement use were selected. DATA EXTRACTION: Outcomes assessed included delayed onset of lactogenesis; initiation, exclusivity, duration, and cessation of breastfeeding; and timing of complementary feeding. DATA ANALYSIS: Eighty-one studies were included. Maternal underweight, diet, and supplement use were not associated with infant feeding practices. Obese women had a relative risk of failure to initiate breastfeeding (risk ratio [RR] = 1.23; 95%CI, 1.03-1.47) and a delayed onset of lactogenesis (RR  =  2.06; 95%CI, 1.18-3.61). The RR for breastfeeding cessation was 1.11 (95%CI, 1.07-1.15) per increase in category of body mass index. CONCLUSIONS: Prevention of obesity in women of reproductive age, as well as counseling of obese women after delivery, could be targeted to improve infant feeding practices.

The effects of lutein on cardiometabolic health across the life course: a systematic review and meta-analysis.

BACKGROUND: The antioxidant lutein is suggested as being beneficial to cardiometabolic health because of its protective effect against oxidative stress, but evidence has not systematically been evaluated. OBJECTIVE: We aimed to evaluate systematically the effects of lutein (intake or concentrations) on cardiometabolic outcomes in different life stages. DESIGN: This is a systematic review with meta-analysis of literature published in MEDLINE, Embase, Cochrane Central, Web of Science, PubMed, and Google Scholar up to August 2014. Included were trials and cohort, case-control, and cross-sectional studies in which the association between lutein concentrations, dietary intake, or supplements and cardiometabolic outcomes was reported. Two independent investigators reviewed the articles. RESULTS: Seventy-one relevant articles were identified that included a total of 387,569 participants. Only 1 article investigated the effects of lutein during pregnancy, and 3 studied lutein in children. Furthermore, 31 longitudinal, 33 cross-sectional, and 3 intervention studies were conducted in adults. Meta-analysis showed a lower risk of coronary heart disease (pooled RR: 0.88; 95% CI: 0.80, 0.98) and stroke (pooled RR: 0.82; 95% CI: 0.72, 0.93) for the highest compared with the lowest tertile of lutein blood concentration or intake. There was no significant association with type 2 diabetes mellitus (pooled RR: 0.97; 95% CI: 0.77, 1.22), but higher lutein was associated with a lower risk of metabolic syndrome (pooled RR: 0.75; 95% CI: 0.60, 0.92) for the highest compared with the lowest tertile. The literature on risk factors for cardiometabolic diseases showed that lutein might be beneficial for atherosclerosis and inflammatory markers, but there were inconsistent associations with blood pressure, adiposity, insulin resistance, and blood lipids. CONCLUSIONS: Our findings suggest that higher dietary intake and higher blood concentrations of lutein are generally associated with better cardiometabolic health. However, evidence mainly comes from observational studies in adults, whereas large-scale intervention studies and studies of lutein during pregnancy and childhood are scarce.

Neck Circumference Is Independently Associated with Cardiometabolic Risk Factors: Cross-Sectional Analysis from ELSA-Brasil.

BACKGROUND: Neck circumference (NC) is a simple anthropometric measurement that may be linked with cardiometabolic risk factors. We analyzed the association between NC and a range of cardiometabolic risk factors. METHODS: In a cross-sectional and sex-specific analysis of the ELSA-Brasil study (15,105 civil servants aged 35-74 years), we excluded participants with diabetes, taking antihypertensive and/or lipid-lowering drugs. Cardiometabolic risk factors were homeostasis model assessment of insulin resistance (≥ 75th percentile), low high-density lipoprotein (HDL; <50 mg/dL for women and <40 mg/dL for men), high triglycerides ≥ 150 mg/dL, systolic blood pressure ≥ 130 mmHg, or diastolic blood pressure ≥ 85 mmHg. Logistic regression models were built to analyze the association between individual and clustered risk factors and 1-standard deviation (SD) increase in NC after adjustments for age, smoking, alcohol, body mass index, and waist circumference. RESULTS: We analyzed 8726 participants (56.3% women), with a mean age of 49.2 ± 8.0 years. Mean NC was 38.9 ± 2.6 cm for men and 33.4 ± 2.6 cm for women. Fully adjusted odds ratios (ORs) [95% confidence intervals (CIs)] per 1-SD increase in NC in men and women were, respectively, 1.32 (1.16-1.51) and 1.47 (1.31-1.64) for insulin resistance; 1.24 (1.11-1.39) and 1.25 (1.11-1.40) for raised blood pressure; 1.50 (1.33-1.70) and 1.51 (1.33-1.70) for high triglycerides; and 1.22 (0.92-1.61) and 1.54 (1.23-1.86) for low HDL. Fully adjusted ORs (95% CI) of three or more clustered risk factors per 1-SD increase in NC in men and women were 1.54 (1.34-1.79) and 1.71 (1.41-2.06). CONCLUSION: NC is significantly and independently associated with cardiometabolic risk factors in a well-defined apparently healthy population.

Serum Uric Acid and Prehypertension Among Adults Free of Cardiovascular Diseases and Diabetes: Baseline of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

The association between serum uric acid (SUA) and prehypertension was evaluated in a racially admixed sample of civil servants aged 35 to 74 years, enrolled (2008-2010) in the Brazilian Longitudinal Study of Health (ELSA-Brasil). Of the 15 105 patients who enrolled in the study, we analyzed 3412 after excluding those who reported previous cardiovascular diseases, diabetes, or hypertension; were heavy drinkers; or had a body mass index (BMI) ≥ 35 kg/m(2). Among the men, logistic regression, adjusted for age, race, income, birth weight, salt intake, insulin resistance, BMI, and renal function revealed odds ratios (ORs) and 95% confidence intervals (CIs) of prehypertension from the bottom quartile (referent) to the top quartile of SUA levels as follows: 0.84 (95% CI, 0.61-1.38), 0.97 (0.71-1.34) and 1.44 (1.04-2.0; P for trend .01). Analyzing for 1-standard deviation of change in SUA, the ORs were 1.19 (1.06-1.32). This association persisted in the subgroup analysis consisting of patients who were white, overweight, with a high salt intake but with normal renal function, and without metabolic syndrome. No association was found among women. In conclusion, SUA levels were associated with prehypertension among men.

Effects of non-pharmacological interventions on urinary citrate levels: a systematic review and meta-analysis.

BACKGROUND: Hypocitraturia is a known risk factor for nephrolithiasis, present in 20-60% of stone-forming patients. The administration of citrate or other alkali preparations has been demonstrated to benefit hypocitraturic stone formers. Dietary modifications that include citrate-containing fluids can be an alternative option to pharmacological agents. We aimed to systematically review, summarize and quantify available evidence on the effects of non-pharmacological interventions on urinary citrate and nephrolithiasis. METHODS: Manual and electronic database searches (MEDLINE/PubMed, Embase, Cochrane Library, Scopus, Scielo, LILACS) were performed for studies published up to July 2014. Two reviewers independently identified studies for inclusion and extracted data on study characteristics, outcomes and quality assessments. We included controlled studies with non-pharmacological interventions that assessed urinary citrate levels or nephrolithiasis pre- and post-intervention. Meta-analysis was performed by random effects and subgrouped by the type of intervention, and heterogeneity was analysed by I(2). RESULTS: Of the 427 studies identified, 13 studies were included (18 samples), involving 358 participants with a mean age of 43 ± 11.0 years across the studies. Interventions were grouped as commercial fruit juices, soft drinks, calcium-/magnesium-rich mineral water, high-fiber diet, low-animal-protein diet and plant extract. Almost half of the studies (6/13; 8/18 samples) reported effects in non-stone formers. Two studies included stone formers and non-stone formers. Commercial fruit juice interventions showed high I(2) (88.1%, P = 0.000) and an increase in citraturia levels ( 95% confidence interval) of 167.2 (65.4; 269) mg/day. Other types of intervention did not show important heterogeneity; however, pooled estimates were not significant. CONCLUSION: Our review indicates that further larger scale trials are required to analyze whether non-pharmacological interventions can increase urinary citrate levels and act in kidney stone prevention.

Mind-body practices for patients with cardiac disease: a systematic review and meta-analysis.

BACKGROUND: Due to new treatment modalities in the last decades, a decline in cardiovascular deaths has been observed. There is an emerging field of secondary prevention and behavioural programmes with increased interest in the use of mind-body practices. Until now, these have not been established in cardiovascular disease treatment programmes. DESIGN: We performed a systematic review and meta-analysis of the available evidence on the effectiveness of mind-body practices for patients with diagnosed cardiac disease. METHODS: We included randomized controlled trials (RCTs), published in English, reporting mind-body practices for patients with diagnosed cardiac disease. EMBASE, MEDLINE, Pubmed, Web of Science, The Cochrane Central Register of Controlled Trials and PsycINFO were searched up to July 2013. Two reviewers independently identified studies for inclusion and extracted data on study characteristics, outcomes (Quality of Life, anxiety, depression, physical parameters and exercise tolerance) and quality assessment. Standardized effect sizes (Cohen's d) were calculated comparing the outcomes between the intervention and control group and random effects meta-analysis was conducted. RESULTS: We identified 11 unique RCTs with an overall low quality. The studies evaluated mindfulness-based stress reduction, transcendental meditation, progressive muscle relaxation and stress management. Pooled analyses revealed effect sizes of 0.45 (95%CI 0.20-0.72) for physical quality of life, 0.68 (95%CI 0.10-1.26) for mental quality of life, 0.61 (95%CI 0.23-0.99) for depression, 0.52 (95%CI 0.26-0.78) for anxiety, 0.48 (95%CI 0.27-0.69) for systolic blood pressure and 0.36 (95%CI 0.15-0.57) for diastolic blood pressure. CONCLUSIONS: Mind-body practices have encouraging results for patients with cardiac disease. Our review demonstrates the need for high-quality studies in this field.

Vitamin D and risk of cause specific death: systematic review and meta-analysis of observational cohort and randomised intervention studies.

OBJECTIVE: To evaluate the extent to which circulating biomarker and supplements of vitamin D are associated with mortality from cardiovascular, cancer, or other conditions, under various circumstances. DESIGN: Systematic review and meta-analysis of observational studies and randomised controlled trials. DATA SOURCES: Medline, Embase, Cochrane Library, and reference lists of relevant studies to August 2013; correspondance with investigators. STUDY SELECTION: Observational cohort studies and randomised controlled trials in adults, which reported associations between vitamin D (measured as circulating 25-hydroxyvitamin D concentration or vitamin D supplement given singly) and cause specific mortality outcomes. DATA EXTRACTION: Data were extracted by two independent investigators, and a consensus was reached with involvement of a third. Study specific relative risks from 73 cohort studies (849,412 participants) and 22 randomised controlled trials (vitamin D given alone versus placebo or no treatment; 30,716 participants) were meta-analysed using random effects models and were grouped by study and population characteristics. RESULTS: In the primary prevention observational studies, comparing bottom versus top thirds of baseline circulating 25-hydroxyvitamin D distribution, pooled relative risks were 1.35 (95% confidence interval 1.13 to 1.61) for death from cardiovascular disease, 1.14 (1.01 to 1.29) for death from cancer, 1.30 (1.07 to 1.59) for non-vascular, non-cancer death, and 1.35 (1.22 to 1.49) for all cause mortality. Subgroup analyses in the observational studies indicated that risk of mortality was significantly higher in studies with lower baseline use of vitamin D supplements. In randomised controlled trials, relative risks for all cause mortality were 0.89 (0.80 to 0.99) for vitamin D3 supplementation and 1.04 (0.97 to 1.11) for vitamin D2 supplementation. The effects observed for vitamin D3 supplementation remained unchanged when grouped by various characteristics. However, for vitamin D2 supplementation, increased risks of mortality were observed in studies with lower intervention doses and shorter average intervention periods. CONCLUSIONS: Evidence from observational studies indicates inverse associations of circulating 25-hydroxyvitamin D with risks of death due to cardiovascular disease, cancer, and other causes. Supplementation with vitamin D3 significantly reduces overall mortality among older adults; however, before any widespread supplementation, further investigations will be required to establish the optimal dose and duration and whether vitamin D3 and D2 have different effects on mortality risk.

Effects of lifestyle-related interventions on blood pressure in low and middle-income countries: systematic review and meta-analysis.

Despite the overwhelming evidence supporting the effectiveness of antihypertensive medication, hypertension remains poorly controlled in low and middle-income countries (LMICs). Lifestyle intervention studies reporting effects on blood pressure published from January 1977 to September 2012 were searched on various databases. From the 6211 references identified, 52 were included in the systematic review (12, 024 participants) and 43 were included in the meta-analysis (in total 6779 participants). We calculated and pooled effect sizes in mmHg with random-effects models. We grouped interventions into behavioral counseling (1831 participants), dietary modification (1831 participants), physical activity (1014 participants) and multiple interventions (2103 participants). Subgroup analysis and meta-regression were used to evaluate origins of heterogeneity. Lifestyle interventions significantly lowered blood pressure levels in LMIC populations, including in total 6779 participants. The changes achieved in SBP (95% confidence interval) were: behavioral counseling -5.4 (-10.7, -0.0) mmHg, for dietary modification -3.5 (-5.4, -1.5) mmHg, for physical activity -11.4 (-16.0, -6.7) mmHg and for multiple interventions -6.0 (-8.9, -3.3) mmHg. The heterogeneity was high across studies and the quality was generally low. Subgroup analyses showed smaller samples reporting larger effect sizes; intervention lasting less than 6 months showed larger effect sizes and intention-to-treat analysis showed smaller effect sizes Lifestyle interventions may be of value in preventing and reducing blood pressure in LMICs. Nevertheless, the overall quality and sample size of the studies included were low. Improvements in the size and quality of studies evaluating lifestyle interventions are required.