6-1 PHYSICIANS� AND PATIENTS� CHOICES IN EVIDENCE BASED MEDICINE
      Clinical decisions must include consideration of: the patient�s clinical and physical circumstances to establish what is wrong and what treatment options are available; 2) research evidence concerning the efficacy (as reported in systematic reviews); effectiveness (as applied in the real world of clinical practice) and efficiency (the benefit/harm-cost ratio) of the options; and 3) consideration of the patient�s preferences and likely actions (in terms of what interventions she or he is ready and able to accept).
      Finally, clinical expertise is needed to bring these considerations together and recommend the treatment that the patient is agreeable to accepting.
      The term �evidence based medicine� was developed to encourage practitioners and patients to pay due respect � no more, no less � to current best evidence in making decisions.
      Practical point: Best research evidence does not apply to the great majority of individual patients presenting to primary care. Primary care clinicians must deal with a large group of patients as best they can without firm evidence on which to base decisions. The clinician will extrapolate from the evidence, and rely on best clinical judgment, expert doctor-patient communication, and patient preferences.

6-2 PUTTING THE PATIENT IN PATIENT-SAFETY
      Medical error has been addressed primarily through malpractice litigation. When in courts, patients rarely speak. They are spoken for.
      A study in this issue of JAMA invites physicians to take a step away from the �community of experts� approach to patient safety and move a step closer to the patient. It categorizes complaints as relating to communication, humaneness, care and treatment access and availability, or billing. It finds no category of complaint more likely than any other to predict litigation.
      Health care organizations need to elicit patients� stories, capture information relevant to safety, and feed that information back to the professionals who organize and deliver care.
      Medical practice can be improved by providing earlier and more reliable warning of problems rather than waiting for suits to be filed. Hospitals must be enabled to learn about valid claims from patients whether or not the rarer and more chilling event of formal litigation ensues. �Uncaring medicine is itself bad medicine, something that tends to be overlooked in the rush to achieve technical perfection.�
      �A small number of physicians experience a disproportionate share of malpractice claims. If malpractice risk is related to factors such as patient dissatisfaction with interpersonal behaviors, care and treatment, and access, it might be possible to monitor physicians� risk of being sued.�
      Practical point: Establish rapport, provide access, administer care consistent with expectations, and communicate effectively.

6-3 WHEN INCREASED THERAPEUTIC BENEFIT COMES AT INCREASED COST
      A study in this issue of NEJM 1 compared cost effectiveness in reducing recurrent cardiovascular events using 1) aspirin alone, 2) clopidogrel alone, and 3) aspirin + clopidogrel. (A secondary prevention study)
      The investigators estimated cost effectiveness of the strategies. Given the extraordinarily low cost of aspirin, the estimated cost of each quality-adjusted year of life gained using aspirin alone was $11 000. Clopidogrel alone or in combination would cost $130 000 for each quality-adjusted year of life gained. (Present cost of one 75 mg tablet of clopidogrel [Plavix] is over $3) Is the benefit worth the harms and cost?
      Practical point: Primary care clinicians must increasingly consider the cost factor in the benefit/harm-cost ratio.

6-4 THERAPY WITH HYDROXYMETHYLGLUTARYL COENZYME-A REDUCTASE INHIBITORS (STATINS) AND ASSOCIATED RISK OF INCIDENT CARDIOVASCULAR EVENTS IN OLDER ADULTS
      Use of statins was associated with decreased risk of incident cardiovascular events among elderly adults
      Practical point: Age per se in not a contraindication.

6-5 STATIN THERAPY IN OLDER PERSONS: Pertinent Issues
      There is growing evidence that LDL-lowering therapy is effective in reducing risk for CHD in older persons. Practical point: statins are recommended for select elderly individuals.

6-6 WHAT WE NEED TO KNOW ABOUT AGE-RELATED MEMORY LOSS
      Strategies for maintaining brain health.
      Stress reduction
      Physical activity
      Healthy diet: (Include a daily multivitamin supplement).
      Mental activity
      Social involvement
      Adopt lifestyle measures to reduce risk of atherosclerotic disease in order to protect the cerebrovascular circulation. This includes moderate amounts of alcohol and smoking cessation.
      Putative protective factors: NSAIDs, postmenopausal estrogen, statin drugs, and aerobic conditioning.

6-7 GLUCOSE METABOLISM IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION AND NO PREVIOUS DIAGNOSIS OF DIABETES MELLITUS.
      Previously undiagnosed diabetes and impaired glucose tolerance are common in patients with AMI. These abnormalities can be detected early. They could be used as early markers of high-risk.
      Practical point: Surveillance and treatment of glucose intolerance may improve prognosis in patients with acute myocardial infarction.

6-8 ACARBOSE FOR PREVENTION OF TYPE 2 DIABETES MELLITUS
      Acarbose, by reducing glycemic load, delays development of type 2 diabetes in patients with impaired glucose tolerance.
      Practical point: Reduce glycemic load to lessen progression of glucose intolerance and risk of diabetes.

6-9 VITAMINS FOR CHRONIC DISEASE PREVENTION IN ADULTS
      �Most people do not consume an optimal amount of vitamins by diet alone. Pending strong evidence of effectiveness from randomized trials, it appears prudent for all adults to take vitamin supplements.� It is reasonable to consider a dose of two ordinary multivitamins daily for the elderly, especially since there is a high prevalence of suboptimal vitamin D and B12 intake.
      Practical point: �We recommend that all adults take one multivitamin daily.� They are safe and inexpensive. �We recommend multivitamins, rather than individual vitamins, because they are cheaper and simpler to take, and because a large proportion of the population needs supplementation of more than one.�

6-10 FOLIC ACID, AGEING, DEPRESSION, AND DEMENTIA
      Folates are important for the nervous system at all ages. There is growing evidence of their involvement in the aging brain, especially in mood and cognitive function. Low folate concentrations in serum, red cells, and cerebrospinal fluid, and the associated rise in plasma homocysteine, are associated with depression and dementia. �Some of the deficiency may be related to ageing, some may be secondary to mental illness, and some primary. But, whether it is primary or secondary, open and controlled treatment studies confirm an aetological link with specific effects of the vitamin on mood, drive, initiative, alertness, concentration, psychomotor speed, and social activity.�
      �Clearly, further clinical trials in precisely defined clinical categories are needed.�
      Practical point: Daily multivitamin supplement contains RDA amount of folic acid.

6-11 DECISION MAKING WITH CARDIAC TROPONIN TESTS
      �Cardiac troponin assays offer clinicians a valuable tool for diagnosing myocardial infarction even at the level of microinfarction.�
      Cardiac-specific troponins come close to fulfilling many of the criteria for an ideal biologic marker. They convey prognostic information useful in making therapeutic decisions regarding patients with acute coronary syndromes.
      Microinfarction can produce elevations of cardiac troponins. Levels can increase without any elevation of creatine kinase MB fraction (CK-MB). Troponins are much more sensitive to damage to small areas of myocardium. Given the nearly absolute specificity of cardiac troponins, they are now considered the preferred biologic markers for diagnosing myocardial infarction
Measurement may be useful for distinguishing unstable angina from MI without ST elevation. About 30% of patients previously considered to have unstable angina on the basis of CK-MB levels are now given a diagnosis of MI without ST elevation on the basis of troponin levels. Troponins also help to establish prognosis, select therapy, and diagnose reinfarction.
      Patients with an acute coronary syndrome who are troponin-positive are more likely to have coronary thrombi, to have intermittent showers of emboli in the coronary microvasculature, and to have depressed ventricular function. The benefits of glycoprotein IIb/IIIa inhibitors, low molecular weight heparin, and an early invasive strategy are far greater in troponin-positive patients.
      Practical point: Cardiac troponin screening by primary care clinicians may aid diagnosis, triage, and treatment of patients with symptoms suggesting unstable angina and acute myocardial infarction.

6-12 TROPONIN T LEVELS IN PATIENTS WITH ACUTE CORONARY SYNDROMES, WITH AND WITHOUT RENAL DYSFUNCTION
      Given that renal dysfunction is common in patients with coronary disease, the ability of cardiac troponin levels to predict outcomes irrespective of creatinine clearance expands their clinical usefulness.
      Practical point: cardiac troponin T predicted short-term prognosis in patients with ACS regardless of their level of creatinine clearance.

6-13 SIROLIMUS-ELUTING CORONARY STENTS
      A sirolimus-eluting stent, as compared with a standard stent, shows considerable promise for prevention of neointimal restenosis. The gradual elution occurs over a period of 30 days. Only a small quantity of the drug is required. This avoids systematic adverse effects.
      Practical point: Primary care clinicians follow developments along with their cardiologist consultants.

6-14 ALVEOLAR AND POSTCRANIAL BONE DENSITY IN POSTMENOPAUSAL WOMEN RECEIVING HORMONE/ESTROGEN REPLACEMENT THERAPY
      HRT combined with supplemental calcium and vitamin D, produced significant improvement in oral bone mass.
      Practical point: Informing postmenopausal women of this risk may increase compliance with anti-osteoporotic therapy.

6-15 ORAL CONTRACEPTIVES AND THE RISK OF BREAST CANCER
      Among women age 35-64, current or former use of OC was not associated with a significantly increased risk of BC.
      Practical point: Primary care clinicians may reassure patients taking birth control pills.

6-16 LANSOPRAZOLE FOR THE PREVENTION OF RECURRENCES OF ULCER COMPLICATIONS FROM LONG-TERM LOW-DOSE ASPIRIN USE
      In patients with H Pylori infection who had gastric or duodenal ulcer bleeding related to long-term use of low-dose aspirin, treatment with the proton-pump inhibitor, lansoprazole, in addition to eradication of the infection, reduced the rate of recurrence of bleeding despite continuation of aspirin.
      Practical point: proton pump inhibitors protect against NSAID-induced ulcers.

6-17 NUT CONSUMPTION AND DECREASED RISK OF SUDDEN CARDIAC DEATH IN THE PHYSICIAN�S HEALTH STUDY
      This study suggests that the inverse association between nut consumption and total coronary heart disease death is primarily due to a reduction in risk of sudden cardiac death.
      Practical point: nuts are part of the healthy diet.

6-18 RESULTS OF SCREENING COLONOSCOPY AMONG PERSONS 40 TO 49 YEARS OF AGE
      Up to 1000 persons this age would have to be screened with colonoscopy to detect one cancer. Sigmoidoscopy would detect about 50% of these.
      Practical point: the current recommendations to begin screening at age 50 are unchanged.

6-19 SPIRITUAL BELIEFS MAY AFFECT OUTCOME OF BEREAVEMENT
      Absence of spiritual belief may be a risk factor for delayed or complicated grief. People who profess stronger spiritual beliefs seem to resolve their grief more rapidly and completely after the death of a close person.

Many will not fit the inclusion criteria; some may be medically illiterate and unable to comply; some will not understand because of language barriers; many who fit the criteria will choose not to participate in the specific treatment advised or will withdraw prematurely; more will withdraw because of adverse effects; some will be unable to continue because of social barriers. (age, infirmity, transport, finances, lack of family support); some will not comply for a variety of other reasons.

Female physicians are less likely than male physicians to generate complaints, or provoke lawsuits.
Surgeons are more likely than non-surgeons to prompt these events.
The number of complaints by patients predicts likelihood of being sued.

1) Clopidogrel vs placebo � NNT to benefit one patient over 12 months = 50.
2) Clopidogrel vs aspirin � NNT = 200 over one year.
3) Clopidogrel vs placebo = NNT over one year to harm one patient (major bleeding) = 100.

1. This observational study investigated the association of statin use with incidence of cardiovascular disease in over 1800 individuals. All were over age 65 (mean = 72). All free of known cardiovascular disease. (A primary prevention study.) According to National Cholesterol Education Program guidelines reduction in cholesterol was recommended for all
2. Some received statin + dietary therapy; some dietary therapy alone.
3. At baseline:

   	Drug therapy recommended (n = 717)	Dietary treatment alone (n = 946)
   Total cholesterol	259	229
   LDL cholesterol	177	147
   HDL cholesterol	51	53

4. End point = incident cardiovascular events. Follow-up = 7 years.

1. Cardiovascular events:

   	Person years	No. of cardiovascular events	Outcomes per 1000 patient-years
   No drug	9453	347	37
   Statin	1129	17	15

2. Cardiovascular deaths:

   No drug	10 131	141	14
   Statin	1250	9	7

   (By my calculation NNT for 7 years to benefit one = 45.)
3. Compared with no use, adjusted hazard ratio of statin use for cardiovascular events = 0.44; for all cause mortality = 0.56. Cardiovascular mortality was similar.
4. Benefits were observed in subjects over age 74 at baseline as well as younger subjects.

1. This study observed a 50% reduction in risk of cardiovascular events and all-cause mortality in patients for whom cholesterol-lowering was recommended and who were at average age of 72 years at baseline.
2. �For primary prevention among older persons, drug therapy should be considered for those at high risk, including persons with diabetes, multiple risk factors, or subclinical disease.�
3. �In this study 80% of subjects would be considered at high risk by the definitions used by 2001 guidelines.�

      Patients with non-coronary forms of clinical atherosclerotic disease calls for intensive therapy: peripheral artery disease, abdominal aortic aneurysm, carotid artery disease, and a 10-year risk for CHD greater than 20% by the Framingham risk scoring. ¹
      The goal of LDL-cholesterol for patients with diabetes is set at 100mg/dL.
      As patients age, the accuracy of the Framingham risk predictions declines. Advancing age becomes the predominant risk factor.
      In deciding about primary prevention in older patients, a distinction between young old (65-74) and old old (> 75) may be useful. Many in the 65-74 group are at high risk for CHD even if they are otherwise healthy. And use of statins for primary prevention is justifiable. In older patients, statins should be used more cautiously for primary prevention. This group often contains individuals with impaired drug metabolism, many taking multiple drugs, many with multisystem disease, more women with low body weight, and more frequent surgical procedures. Clinical judgment must be used on whether to use statins in the first place. A more conservative approach seems appropriate even though some efficacy in reducing CHD risk almost certainly exists. �Undoubtedly, some patients in this age range will benefit from statin therapy and should be treated.�

1. Prospective study enrolled over 180 patients (mean age = 64) admitted to the coronary care unit with AMI.
2. None had a previous diagnosis of diabetes. All had a blood glucose under 200 mg/dL (11.1 mmol/L) recorded as soon as possible after admission.
3. Measured HbA1c (their upper normal = 5.3%) the morning after admission.
4. Recorded fasting glucose concentrations daily during the hospital stay, and a standardized glucose tolerance test at discharge.
5. Three months after discharge obtained HbA1c and a new oral glucose tolerance test.
6. Classified patients as having diabetes and impaired glucose tolerance according to WHO and ADA criteria.

1.  

   	At discharge (4 days)	At 3 months
   Diabetes	31%	25%
   Impaired glucose tolerance	35%	40%
   Normal glucose tolerance	34%	35%

2. Elevated concentrations of HbA1c and a fasting glucose above normal independently predicted impaired glucose tolerance at 3 months.

1. There was a high prevalence of abnormal glucose metabolism in patients with AMI. There was a strong correlation between the 2-h glucose at discharge and at 3 months. Raised glucose early in the course of AMI is not only related to stress induced by the ischemic event ¹ but due to underlying abnormal glucose tolerance in some individuals.
2. The abnormality can be detected before hospital discharge.
3. If individuals with AMI with known diabetes before admission are included, the prevalence of diabetes associated with AMI would be much higher.
4. In this study, fewer than 35% of patients had normal glucose tolerance at 3 months. By this time the effects of acute stress, left ventricular dysfunction, and inflammatory processes should have subsided.
5. Abnormal glucose metabolism on admission to hospital with AMI predicts long-term outlook. Metabolic intervention improves outcome.
6. Patients with impaired glucose tolerance have increased risk of developing diabetes and its microvascular complications as well as cardiovascular disease. Early detection of impaired glucose tolerance would permit initiation of preventive measures.
7. Patients admitted with AMI should be tested for glucose tolerance along with conventional risk factors.
8. Another possibility would be to expose these individuals to early administration of insulin-glucose.

Individuals with type 2 diabetes have an increased risk of developing AMI at a rate similar to non-diabetic patients who have established coronary heart disease. Diabetic patients who sustain an AMI have an increased risk of dying. Even mild degrees of glucose intolerance (including elevated fasting glucose in the non-diabetic range) are associated with increased risk of coronary heart disease.
The editorialist repeats the observation that the ADA fasting blood glucose criterion for diabetes is not a good indicator of diabetes as that defined by the 2-h post 75 g oral glucose tolerance test.
�It is reasonable to suggest an oral glucose tolerance test at discharge after an AMI.�

1. Double-blind, placebo-controlled, randomized trial entered over 1400 patients. (Mean age = 54; mean body mass index = 31; mean waist circumference = 102 cm; mean fasting glucose = 112 mg/dL; mean 2-h glucose = 166).
2. All had impaired glucose tolerance (2-h glucose levels 140 to 200 after a 75 g glucose load.) And a fasting glucose of 100 to 139 � �a value that is associated with a 3.4-fold increase in risk of progression to type 2 diabetes�.¹
3. Randomized to: 1) acarbose 100 mg three times daily taken with the first bite of each meal; or 2) placebo.
4. Primary end-point = development of DM-2 on the basis of a yearly glucose tolerance test. (Plasma glucose 200 or greater 2 hours after glucose load.)
5. Follow-up = a mean of 3 years.

1. Thirty two percent (32%) of those assigned to acarbose developed DM-2 vs 42% of placebo patients. (Absolute difference = 10%; NNT for 3 years to prevent one patient from developing DM-2 = 10)
2. Acarbose significantly increased reversion of impaired glucose tolerance to normal.²
3. Adverse effects of acarbose � flatulence and diarrhea; 31% of acarbose patients and 19% of placebo patients discontinued treatment early.

1. Pharmacological intervention with acarbose in patients with impaired glucose tolerance delayed progression to type 2 diabetes. This was irrespective of age, sex, and body mass index, and loss of weight.
2. Acarbose therapy may cause reversion of impaired glucose tolerance to normal.²
3. �The drug has no toxic effects.�
4. The higher the 2-h glucose after a 75 g glucose load, the higher the rate of conversion to DM-2. Acarbose significantly reduces the postprandial rise in glucose.
5. Acarbose is effective preventive therapy in addition to life-style changes.

      Suboptimal folic acid, B6 and B12 levels are related to increased risk of cardiovascular disease, neural tube defects, and breast cancer. Many people in the general population have increased serum homocysteine levels which fall with vitamin supplementation.
      Low levels of antioxidant vitamins (A, E, and C) may increase risk for several chronic diseases (coronary heart disease, prostate cancer).
      Low levels of vitamin D contribute to osteopenia and fractures. Elevated levels of parathyroid hormone fall with vitamin D supplementation.

1. Analyzed outcomes of over 7000 patients. All had one or more episodes of angina while at rest that lasted over 5 minutes and a new ST-segment depression of at least 0.5 mm, or an abnormal result on troponin T testing. (Abnormal = level of 0.1 ng/mL or higher. A lower cut point of 0.03ng/mL was also considered.)
2. Creatinine clearance was calculated in all. ¹
3. Primary endpoint = composite of death and myocardial infarction (MI) within 30 days.

1. Death or MI occurred in 581 (8%)
2. When creatinine clearance was considered as a continuous variable after accounting for other confounders, the troponin T level was independently predictive of risk across the entire spectrum of renal function.
3. Outcomes in 30 days:

   	Myocardial infarction or death
   Creatinine clearance	Troponin T > 0.1 ng/mL	Troponin T < 0.1 ng/mL
   First quartile (< 54 mL/min)	20%	9%
   Forth quartile (> 98 mL/min)	5%	2%
   	Troponin T > 0.03 ng/mL	Troponin T < 0.03 ng/mL
   First quartile	18%	8%
   Forth quartile	5%	1%

4. Troponin T levels were higher than 0.1 in 52% or patients; over 0.03 in 64%. An abnormal troponin T at baseline was associated with an increased risk of death within 30 days.
5. A troponin T level above 0.1 combined with a low creatinine clearance was associated with an increased mortality and MI as compared with a level of 0.1 combined with normal creatinine clearance.

1. Among patients presenting with ACS, base-line measurement of cardiac troponin T was strongly predictive of risk of death or myocardial infarction, even when renal dysfunction was present.
2. Given that renal dysfunction is common in patients with coronary disease, the ability of cardiac troponin levels to predict outcomes irrespective of creatinine clearance expands their clinical usefulness.

1. Randomized, double-blind, placebo-controlled study entered 135 postmenopausal women. None had evidence of moderate or severe periodontal disease.
2. Randomized to: 1) oral conjugated estrogen (Preparing 0.625 mg) alone, or in combination with medroxyprogesterone (Prempro; [0.625 � 2.5 mg] ) , or 2) placebo.
3. All received supplemental calcium and vitamin D.
4. Measured alveolar crest height by radiography, and alveolar bone density by digital subtraction radiography. Also measured BMD at the proximal femur and lumbar spine by dual-energy X-ray absorptiometry.
5. All received regular dental care. Follow-up = 3 years.

1. Compared with placebo, HRT significantly increased alveolar bone mass (+1.8%), and tended to improve alveolar crest height ( +4.8%).
2. BMD in the proximal femur, neck, and trochanter also increased in the HRT group.
3. Changes in the alveolar bone mass correlated with BMD of the total femur and trochanter.

1. In this study of postmenopausal women, HRT produced a significant improvement in alveolar bone mass and strengthened the dental attachment apparatus in postmenopausal women.
2. Tooth loss may be a manifestation of osteoporosis. By extension, protection from alveolar bone loss or increases in oral bone mass should result in reduced tooth loss.
3. Edentulous women are more likely to have low BMD than dentate women. Three large retrospective cohort studies indicated that estrogen users have more teeth and a lower prevalence of edentulism.
4. This study was not powered to detect differences in tooth loss, which would be a relatively rare event over 3 years in good oral health and no clinically significant periodontal disease.
5. In the presence of periodontal disease and poor oral hygiene, systemic bone loss plays a lesser role than oral disease in disrupting the attachment apparatus.
6. Actually the placebo group also experienced increase in alveolar crest height, possibly due to supplemental calcium and vitamin D. �Thus, dental care and dietary supplementation may be sufficient to prevent postmenopausal oral bone loss.�

1. Case control study interviewed over 9000 women age 35-64. Half had BC and half were controls.

1. The relative risk of BC in women currently using OC was 1.0 (confidence interval = 0.8 to 1.3).
2. The relative risk of BC was 0.9 in women who had previously used OC.
3. The relative risk did not increase consistently with longer periods of use or with higher doses of estrogen.
4. OC was not associated with increased risk among women with a family history of BC.
5. Initiation at an early age was not associated with increased risk.

1. In the pooled analysis referred to above, the relative risk of BC in women currently taking OC was 1.3 compared with never-users. The current study found no increase in risk ( RR = 1.0).
2. The pooled analysis also reported a slight increased risk among women who had used OC within 10 years previously.
3. Note that the pooled analysis included some women under age 35 with BC. The current study did not include this age group.

1. Enrolled over 120 patients (mean age 70) who had bleeding ulcer (gastric or duodenal) in the past after using low-dose aspirin. All had H Pylori infection. All were treated to eradicate the infection. (Eradication failed in 4 patients despite 2 courses of therapy. These were eliminated from the study.)
2. Then randomized to: 1) lansoprazole (Prevacid) 30 mg daily, or 2) placebo. All continued to receive aspirin 100 mg daily.
3. Primary end-point = recurrence of ulcer bleeding.
4. Follow-up = 12 months.

1. Recurrence of bleeding:

   Lansoprazole	Placebo
   1 of 62 (1.6%)	9 of 61 (15%)

2. NNT to benefit one patient = 7

1. In patients who had past bleeding ulcer, eradication of H Pylori infection followed by PPI treatment significantly reduced rate of recurrent bleeding, as compared with eradication of H Pylori alone.
2. Eradication of H Pylori alone did not completely abolish the ulcerogenic effect of aspirin.
3. Epidemiological studies have reported a reduced risk of ulcer bleeding in patients taking a PPI with aspirin (primary prevention). Reduction in acid production is likely related to the benefit.

1. Prospective study assessed whether increased frequency of nut consumption was associated with lower risk of sudden death and coronary heart disease in over 21 000 male physicians.
2. Assessed nut consumption by food-frequency questionnaire.
3. Follow-up = average 17 years.

1. Nut consumption was associated with a statistically significant reduced risk of sudden death after controlling for known cardiac risk factors and other dietary habits.
2. Persons consuming nuts 2 or more times weekly had a relative risk of sudden cardiac death of 0.53 compared with men who rarely or never consumed nuts
3. Relative risk of total coronary heart disease deaths was also decreased. (Relative risk = 0.70) The effect appeared linear.
4. Nut intake was not associated with reduced risk of non-sudden coronary heart disease death or non-fatal myocardial infarction.

1. In this large prospective study, nut intake was associated with a significantly reduced risk of sudden cardiac death after controlling for other risk factors.
2. Risk for non-fatal myocardial infarction and other types of coronary heart disease death was not reduced
3. As for fatty acids in fish, the fatty acid in nuts may have anti-arrhythmic activity. Walnuts in particular contain high amounts of alpha-linolenic acid. Nuts are also rich in polyunsaturated and monounsaturated fatty acids which improve the lipoprotein profile when substituted for other fats in the diet.
4. Three large prospective studies have also reported inverse associations between nut consumption and fatal coronary disease.

1. Prospective cohort study followed 135 relatives and close friends of patients admitted to a center offering specialist care for terminal illnesses. Patients were admitted regardless of their religious affiliation.
2. Measured core bereavement items, a standardized measure of grief, at 1, 9, and 14 months.
3. The aim was to test the null hypothesis that spiritual belief has no effect on the grieving process.
   (Ie, the investigators at outset considered that religious beliefs would not have any effect on the grieving process.) And to study possible confounders which could be associated with spiritual beliefs and bereavement outcomes.

1. People reporting no spiritual belief (n = 21) had not resolved their grief by 14 months after the death. They had a slight and temporary lower level of grief at 9 months. The symptoms of grief intensified again by 14 months.
2. Participants with strong beliefs (n = 55) resolved their grief progressively, in a linear fashion, over 14 months.
3. Participants with low level beliefs (n = 53) showed little change in the first 9 months, but thereafter resolved their grief.
4. Strength of spiritual belief remained an important predictor after controlling for relevant confounding variables.
5. Age and sex of participants did not significantly affect the findings. Men had higher grief scores than women initially, but not by 9 months.
6. Mean scores on the hospital anxiety and depression scale before the death were significantly associated with initial levels of grief. But these scores were not related to any major effect on the strength of belief.
7. Closeness to the dying patient predicted higher grief scores.
8. After all of these possible confounders were entered into the model, the strength of spiritual belief retained its significance.

1. �Our main finding is that the strength of spiritual belief is an important predictor of bereavement outcome.�
2. Spiritual beliefs may provide an existential framework in which grief is resolved more readily. Most spiritual beliefs, whether or not associated with religious practice, contain tenets about the course of human life and existence beyond it.
3. Strong beliefs may be a proxy for better adjustment and less psychological distress. But the analysis suggests that the strength of belief affected the course of bereavement independently of psychological status.
4. �We are not suggesting that an intervention concerning spiritual matters is appropriate for people with no professed beliefs. Rather it might help in identifying people who are having difficulty in readjusting to life, after their loss.�