ACTUALIZACIONES

Atención Primaria en Reino UnidoPoblación ≥3 años con dolor de

garganta agudo

CONCLUSIONES

Uso selectivo de antibióticos para el dolor de garganta agudo basado en la puntuación clínica reduce el uso de antibióticos.

Las pruebas de antígenos utilizados de beneficios similares.

E-cigarettes and the marketing push that surprised everyone

BMJ 2013;347:f5780

No diferencias con otros métodos sustitutivos de la nicotina

Fruit consumption and risk of type 2 diabetes: results from three prospective longitudinal cohort studies BMJ 2013;347:f5001

Abstract Objective To determine whether individual fruits are differentially associated with risk of type 2 diabetes. Design Prospective longitudinal cohort study. Setting Health professionals in the United States. Participants 66105 women from the Nurses’ Health Study (1984-2008), 85104 women from the Nurses’    

Health Study II (1991-2009), and 36173 men from the Health Professionals Follow-up Study (1986-2008)  who were free of major chronic diseases at baseline in these studies.

Main outcome measure Incident cases of type 2 diabetes, identified through self report and confirmed by supplementary questionnaires.

Results During 3464641 person years of follow-up, 12198 participants developed type 2 diabetes. After      adjustment for personal, lifestyle, and dietary risk factors of diabetes, the pooled hazard ratio of type 2 diabetes for every three servings/week of total whole fruit consumption was 0.98 (95% confidence interval 0.96 to 0.99). With mutual adjustment of individual fruits, the pooled hazard ratios of type 2 diabetes for every three servings/week were 0.74 (0.66 to 0.83) for blueberries, 0.88 (0.83 to 0.93) for grapes and raisins, 0.89 (0.79 to 1.01) for prunes, 0.93 (0.90 to 0.96) for apples and pears, 0.95 (0.91 to 0.98) for bananas, 0.95 (0.91 to 0.99) for grapefruit, 0.97 (0.92 to 1.02) for peaches, plums, and apricots, 0.99 (0.95 to 1.03) for oranges, 1.03 (0.96 to 1.10) for strawberries, and 1.10 (1.02 to 1.18) for cantaloupe. The pooled hazard ratio for the same increment in fruit juice consumption was 1.08 (1.05 to 1.11). The associations with risk of type 2 diabetes differed significantly among individual fruits (P<0.001 in all cohorts).

Conclusion Our findings suggest the presence of heterogeneity in the associations between individual fruit consumption and risk of type 2 diabetes. Greater consumption of specific whole fruits, particularly blueberries, grapes, and apples, is significantly associated with a lower risk of type 2 diabetes, whereas greater consumption of fruit juice is associated with a higher risk.

Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study

BMJ 2013;347:f5577

Abstract Objective To determine the comparative effectiveness of exercise versus drug interventions on mortality

outcomes. Design Metaepidemiological study. Eligibility criteria Meta-analyses of randomised controlled trials with mortality outcomes comparing the

effectiveness of exercise and drug interventions with each other or with control (placebo or usual care). Data sources Medline and Cochrane Database of Systematic Reviews, May 2013. Main outcome measure Mortality. Data synthesis We combined study level death outcomes from exercise and drug trials using random effects

network meta-analysis. Results We included 16 (four exercise and 12 drug) meta-analyses. Incorporating an additional three recent

exercise trials, our review collectively included 305 randomised controlled trials with 339274 participants.  Across all four conditions with evidence on the effectiveness of exercise on mortality outcomes (secondary prevention of coronary heart disease, rehabilitation of stroke, treatment of heart failure, prevention of diabetes), 14716 participants were randomised to physical activity interventions in 57 trials. No statistically  detectable differences were evident between exercise and drug interventions in the secondary prevention of coronary heart disease and prediabetes. Physical activity interventions were more effective than drug treatment among patients with stroke (odds ratios, exercise v anticoagulants 0.09, 95% credible intervals 0.01 to 0.70 and exercise v antiplatelets 0.10, 0.01 to 0.62). Diuretics were more effective than exercise in heart failure (exercise v diuretics 4.11, 1.17 to 24.76). Inconsistency between direct and indirect comparisons was not significant.

Conclusions Although limited in quantity, existing randomised trial evidence on exercise interventions suggests that exercise and many drug interventions are often potentially similar in terms of their mortality benefits in the secondary prevention of coronary heart disease, rehabilitation after stroke, treatment of heart failure, and prevention of diabetes.

In addition we separately identified 12 meta-analyses of drug interventions (out of 534 titles and abstracts in Medline), which were considered to be relevant drug options for each of the four conditions that had evidence on exercise interventions: statins,18 β blockers,37 angiotensin converting enzyme inhibitors,38 and antiplatelets for the secondary prevention of coronary heart disease39; anticoagulants40 and antiplatelets41 for stroke42; angiotensin converting enzyme inhibitors,43 diuretics,44 β blockers,45 and angiotensin receptor blockers for heart failure46; α glucosidase inhibitors, thiazolidinediones, biguanides, angiotensin converting enzyme inhibitors, and glinides for prediabetes.36 Publication dates for meta-analyses of drug interventions ranged from 1999 to 2013 (see supplementary table).

Characteristics of exercise interventionsThe characteristics of the exercise interventions varied across treatment areas. Differences included the mode of physical activity and its frequency, intensity, and duration. Exercise based cardiac rehabilitation was typically a component of comprehensive cardiac care of patients with coronary heart disease.33 Rehabilitation in this population included inpatient, outpatient, community based, or home based exercise interventions. Patients with stroke received a mix of cardiorespiratory and muscle strengthening exercises.34 Similarly, exercise interventions targeting patients with chronic heart failure included aerobic and resistance training.35 Physical activity was often a component of multifactorial lifestyle modification interventions to prevent diabetes among people with impaired glucose tolerance and impaired fasting glucose—that is, prediabetes.3