The primary objective of this pilot study was to evaluate the effect of active video games on children's physical activity levels.Twenty children (mean +/- SD age = 12 +/- 1.5 years; 40% female) were ...randomised to receive either an active video game upgrade package or to a control group (no intervention). Effects on physical activity over the 12-week intervention period were measured using objective (Actigraph accelerometer) and subjective (Physical Activity Questionnaire for Children PAQ-C) measures. An activity log was used to estimate time spent playing active and non-active video games.Children in the intervention group spent less mean time over the total 12-week intervention period playing all video games compared to those in the control group (54 versus 98 minutes/day difference = -44 minutes/day, 95% CI -92, 2, p = 0.06). Average time spent in all physical activities measured with an accelerometer was higher in the active video game intervention group compared to the control group (difference at 6 weeks = 194 counts/min, p = 0.04, and at 12 weeks = 48 counts/min, p = 0.06).This preliminary study suggests that playing active video games on a regular basis may have positive effects on children's overall physical activity levels. Further research is needed to confirm if playing these games over a longer period of time could also have positive effects on children's body weight and body mass index.
ACTRN012606000018516.
Guidelines recommend intensive blood pressure (BP) lowering in patients at high risk. While placebo-controlled trials have demonstrated 22% reductions in coronary heart disease (CHD) and stroke ...associated with a 10-mmHg difference in systolic BP, it is unclear if more intensive BP lowering strategies are associated with greater reductions in risk of CHD and stroke. We did a systematic review to assess the effects of intensive BP lowering on vascular, eye, and renal outcomes.
We systematically searched Medline, Embase, and the Cochrane Library for trials published between 1950 and July 2011. We included trials that randomly assigned individuals to different target BP levels. We identified 15 trials including a total of 37,348 participants. On average there was a 7.5/4.5-mmHg BP difference. Intensive BP lowering achieved relative risk (RR) reductions of 11% for major cardiovascular events (95% CI 1%-21%), 13% for myocardial infarction (0%-25%), 24% for stroke (8%-37%), and 11% for end stage kidney disease (3%-18%). Intensive BP lowering regimens also produced a 10% reduction in the risk of albuminuria (4%-16%), and a trend towards benefit for retinopathy (19%, 0%-34%, p = 0.051) in patients with diabetes. There was no clear effect on cardiovascular or noncardiovascular death. Intensive BP lowering was well tolerated; with serious adverse events uncommon and not significantly increased, except for hypotension (RR 4.16, 95% CI 2.25 to 7.70), which occurred infrequently (0.4% per 100 person-years).
Intensive BP lowering regimens provided greater vascular protection than standard regimens that was proportional to the achieved difference in systolic BP, but did not have any clear impact on the risk of death or serious adverse events. Further trials are required to more clearly define the risks and benefits of BP targets below those currently recommended, given the benefits suggested by the currently available data.
To explore the likely optimum blood pressure (BP) level for patients with a history of cerebrovascular disease.
The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) was a randomized, ...placebo-controlled trial that established the beneficial effects of BP lowering in 6105 patients with cerebrovascular disease. The present study comprises two series of post hoc analyses. The first was designed to investigate the effects of randomized treatment on recurrent stroke by baseline BP levels, and the second was a corresponding observational analysis investigating the association between achieved follow-up BP levels and recurrent stroke risk.
Analyses of the randomized treatment comparisons showed that BP lowering with combination therapy produced similar risk reductions in each of four subgroups defined by baseline BP of less than 120, 120-139, 140-159, and 160 mmHg or greater (P homogeneity = 0.5). The effects of single-drug therapy were also comparable across these subgroups (P homogeneity = 0.2), but consistently greater benefits were observed with combination compared to single-drug therapy. The analyses of achieved follow-up BP showed that the lowest risk of recurrence was among the one-quarter of participants with the lowest follow-up BP levels (median 112/72 mmHg), and that risks rose progressively with higher follow-up BP levels. Minor side-effects were progressively more common at lower BP levels (P homogeneity = 0.04), but there was no excess of serious complications (all P homogeneity > 0.2).
These analyses provide no evidence of a J-curve relationship between BP level and stroke risk among patients with cerebrovascular disease, and identify no patient group among whom more intensive BP lowering would not be expected to produce greater risk reductions.
To assess the blood pressure and lipid-lowering efficacy and tolerability of 'polypills' used in cardiovascular disease prevention trials.
Systematic review and meta-analysis.
The Cochrane Central ...Register of Controlled Trials, Medline, and PubMed databases were searched for eligible trials. Study inclusion criteria: Randomised controlled trials of at least six weeks duration, which compared a 'polypill' (that included at least one anti-hypertensive and one lipid-lowering medication) with a placebo (or one active component).
Change from baseline in systolic and diastolic blood pressures, and total and LDL-cholesterol; discontinuation of study medication and reported adverse effects. Of 44 potentially eligible studies, six trials (including 2,218 patients without previous cardiovascular disease) fulfilled the inclusion criteria. Compared with placebo, 'polypills' reduced systolic blood pressure by -9.2 mmHg (95% confidence interval (CI): -13.4, -5.0) diastolic blood pressure by -5.0 mmHg (95%CI: -7.4, -2.6), total cholesterol by -1.22 mmol/L (95%CI: -1.60, -0.84) and LDL-cholesterol by -1.02 mmol/L (95%CI: -1.37, -0.67). However, those taking a 'polypill' (vs. placebo or component) were more likely to discontinue medication (20% vs 14%) (Odds ratio: 1.5 (95% CI: 1.2, 1.9)). There was no significant difference in reported adverse effects amongst those on a 'polypill' (36% vs. 28%) (OR: 1.3 (95%CI: 0.7, 2.5)). There was high statistical heterogeneity in comparisons for blood pressure and lipid-lowering but use of random-effects and quality-effects models produced very similar results.
Compared with placebo, the 'polypills' reduced blood pressure and lipids. Tolerability was lower amongst those on 'polypills' than those on placebo or one component, but differences were moderate. Effectiveness trials are needed to help clarify the status of 'polypills' in primary care and prevention strategies.
Abstract Purpose This article summarizes the results of a recent systematic review and meta-analysis of the safety and efficacy of intensive blood pressure (BP) lowering, including an update with the ...SPRINT (Systolic Blood Pressure Intervention Trial) results. We discuss the consistency of results within this set of trials (eg, ACCORD Action to Control Cardiovascular Risk in Diabetes and SPRINT) and the results in the context of other BP-lowering trials, including the recently published HOPE3 (Heart Outcomes Prevention Evaluation–3) study. Methods This study was a narrative review with updated meta-analysis from systematic review of trials comparing more- versus less-intensive BP lowering. Findings With the addition of SPRINT, there are >20 trials comparing more- versus less-intensive treatment with 54,350 participants overall. Over an average of 3.9 years of follow-up, the average systolic BP was 133 mm Hg in the more-intensive treatment arms and 140 mm Hg in the less-intensive treatment arms. More-intensive BP lowering reduced the risk of major vascular events, with benefits seen across a range of groups defined according to baseline systolic BP (120–139 mm Hg, 140–159 mm Hg, or ≥160 mm Hg), age (<70 or >70 years), and main entry criterion (hypertension, diabetes, or renal disease). Implications The evidence accumulated thus far provides clear evidence of the benefits of BP lowering in the 120- to 140-mm Hg range for various high-risk patient groups. Although intensive BP lowering has side effects, these trials indicate that the benefits will predominate for those at high risk of major vascular events.
...we would go further: any initial blood pressure-lowering monotherapy, whatever the drug class, could be a missed prevention opportunity because of the likelihood that it becomes long-term ...monotherapy.2 This possibility is a real risk since treatment inertia occurs in over 80% of instances of high blood pressure clinic readings,2 and all monotherapies are less effective than combination therapy at lowering blood pressure.3 Any long-term monotherapy reduces potential benefit, since each extra mm Hg reduction of systolic blood pressure (SBP) lowers cardiovascular disease risk by about 2–3% across all SBP levels above 110 mm Hg.4 The current ESH (2023) and previous ESH and European Society of Cardiology guidelines (2018) have been at the forefront of promoting initial combination therapy as the norm.5,6 Furthermore, 2023 ESH guidelines appropriately recommend that β blockers are used in combination with other indicated agents in patients with raised blood pressure and common comorbidities such as coronary disease, heart failure, or atrial fibrillation. The randomised evidence of treatment benefit at SBP levels below 140 mm Hg has been statistically and clinically significant, and unequivocal for over a decade.7 There is more randomised trial evidence of benefits in individuals at high risk of cardiovascular disease with a mean SBP of 130–140 mm Hg than for any other blood pressure range.8 The absolute benefits can be large, since they are driven by both baseline cardiovascular disease risk and blood pressure reduction.9 The ESH guideline developers cite some of this evidence, acknowledge that current hypertension thresholds are arbitrary, and state “there is a continuous relationship between blood pressure and cardiovascular or renal morbid or fatal events starting from an office SBP >115/75 mm Hg”.5 They also comprehensively review the impact of other cardiovascular disease risk factors on blood pressure-related cardiovascular disease risk and acknowledge that the benefits of lowering blood pressure are similar over almost the entire blood pressure range. A hybrid approach, as recommended in the American Heart Association and American College of Cardiology guidelines,6 whereby treatment decisions are based on a combination of blood pressure and predicted cardiovascular disease risk, is the best way to optimise capacity to benefit.9 Lipid guidelines provide a good model, where for more than a decade, the use of low-efficacy regimens has been actively discouraged, and recommendations have been driven by predicted cardiovascular disease risk levels as well as LDL cholesterol levels.12 This approach should be adopted for managing raised blood pressure.
Summary Background Twice-daily raltegravir with once-daily tenofovir-emtricitabine is an effective initial antiretroviral regimen for patients with HIV-1. On the basis of pharmacokinetic data ...suggesting efficacy of once-daily raltegravir and because adherence is often improved with once-daily dosing, we aimed to compare these dosing schedules. Methods In our international, double-blind, randomised, phase 3 non-inferiority study, we enrolled antiretroviral-naive patients with HIV RNA loads of more than 5000 copies per mL and no baseline resistance to tenofovir or emtricitabine at 83 centres worldwide. We randomly allocated patients (1:1) by use of a computer-generated sequence to receive raltegravir once daily (two 400 mg tablets taken together every 24 h), or twice daily (one 400 mg tablet every 12 h), both in combination with once-daily co-formulated tenofovir 300 mg plus emtricitabine 150 mg. The primary outcome was virological response at 48 weeks (viral RNA loads <50 copies per mL) in patients who received at least one dose of study drug, counting non-completers as failure. We assessed non-inferiority in terms of the proportion of patients in both treatment groups who achieved the primary outcome, with a non-inferiority margin of −10%. This study is registered with ClinicalTrials.gov , number NCT00745823. Findings From Oct 15, 2008, to Nov 2, 2009, we randomly allocated 775 patients, of whom 382 (99%) of 386 patients in the once-daily group and 388 (99%) of 389 in the twice-daily group received at least one dose of study drug. At baseline, 304 (39%) of 770 treated patients had viral loads of more than 100 000 copies per mL and 188 (24%) had CD4 cell counts of fewer than 200 cells per μL. 318 (83%) of 382 patients in the once-daily group had virological response compared with 343 (89%) of 386 in the twice-daily group (difference −5·7%, 95% CI −10·7 to −0·83; p=0·044). Serious adverse events were reported in 26 (7%) of 382 once-daily recipients and 40 (10%) of 388 twice-daily recipients, and adverse events leading to discontinuation occurred in four (1%) patients in each group. Interpretation Despite high response rates with both regimens, once-daily raltegravir cannot be recommended in place of twice-daily dosing. Funding Merck.
Estimates of the disease burden due to multiple risk factors can show the potential gain from combined preventive measures. But few such investigations have been attempted, and none on a global ...scale. Our aim was to estimate the potential health benefits from removal of multiple major risk factors.
We assessed the burden of disease and injury attributable to the joint effects of 20 selected leading risk factors in 14 epidemiological subregions of the world. We estimated population attributable fractions, defined as the proportional reduction in disease or mortality that would occur if exposure to a risk factor were reduced to an alternative level, from data for risk factor prevalence and hazard size. For every disease, we estimated joint population attributable fractions, for multiple risk factors, by age and sex, from the direct contributions of individual risk factors. To obtain the direct hazards, we reviewed publications and re-analysed cohort data to account for that part of hazard that is mediated through other risks.
Globally, an estimated 47% of premature deaths and 39% of total disease burden in 2000 resulted from the joint effects of the risk factors considered. These risks caused a substantial proportion of important diseases, including diarrhoea (92%–94%), lower respiratory infections (55–62%), lung cancer (72%), chronic obstructive pulmonary disease (60%), ischaemic heart disease (83–89%), and stroke (70–76%). Removal of these risks would have increased global healthy life expectancy by 9·3 years (17%) ranging from 4·4 years (6%) in the developed countries of the western Pacific to 16·1 years (43%) in parts of sub-Saharan Africa.
Removal of major risk factors would not only increase healthy life expectancy in every region, but also reduce some of the differences between regions. The potential for disease prevention and health gain from tackling major known risks simultaneously would be substantial.
Advances in technology allowed the development of a novel smoking cessation program delivered by video messages sent to mobile phones. This social cognitive theory-based intervention (called "STUB ...IT") used observational learning via short video diary messages from role models going through the quitting process to teach behavioral change techniques.
The objective of our study was to assess the effectiveness of a multimedia mobile phone intervention for smoking cessation.
A randomized controlled trial was conducted with 6-month follow-up. Participants had to be 16 years of age or over, be current daily smokers, be ready to quit, and have a video message-capable phone. Recruitment targeted younger adults predominantly through radio and online advertising. Registration and data collection were completed online, prompted by text messages. The intervention group received an automated package of video and text messages over 6 months that was tailored to self-selected quit date, role model, and timing of messages. Extra messages were available on demand to beat cravings and address lapses. The control group also set a quit date and received a general health video message sent to their phone every 2 weeks.
The target sample size was not achieved due to difficulty recruiting young adult quitters. Of the 226 randomized participants, 47% (107/226) were female and 24% (54/226) were Maori (indigenous population of New Zealand). Their mean age was 27 years (SD 8.7), and there was a high level of nicotine addiction. Continuous abstinence at 6 months was 26.4% (29/110) in the intervention group and 27.6% (32/116) in the control group (P = .8). Feedback from participants indicated that the support provided by the video role models was important and appreciated.
This study was not able to demonstrate a statistically significant effect of the complex video messaging mobile phone intervention compared with simple general health video messages via mobile phone. However, there was sufficient positive feedback about the ease of use of this novel intervention, and the support obtained by observing the role model video messages, to warrant further investigation.
Australian New Zealand Clinical Trials Registry Number: ACTRN12606000476538; http://www.anzctr.org.au/trial_view.aspx?ID=81688 (Archived by WebCite at http://www.webcitation.org/5umMU4sZi).
To provide estimates of the global burden of disease attributable to non-optimal blood pressure by age and sex for adults aged > or = 30 years, by WHO subregion.
Estimates of attributable burden were ...made using population impact fractions, which used data on mean systolic blood pressure levels, disease burden in deaths and/or disability-adjusted life years (DALYs) and relative risk corrected for regression dilution bias. Estimates were made of burden attributable to a population distribution of blood pressure with a mean systolic blood pressure of greater than 115 mmHg.
Globally, approximately two-thirds of stroke and one-half of ischaemic heart disease were attributable to non-optimal blood pressure. These proportions were highest in the more developed parts of the world. Worldwide, 7.1 million deaths (approximately 12.8% of the global total) and 64.3 million DALYs (4.4% of the global total) were estimated to be due to non-optimal blood pressure. Overall approximately, two-thirds of the attributable burden of disease occurred in the developing world, approximately two-thirds in the middle age groups (45-69 years) and approximately one-half occurred in those with systolic blood pressure levels between 130 and 150 mmHg.
The burden of non-optimal blood pressure is almost double that of the only previous global estimates, which is largely explained by the correction for regression dilution adopted in these analyses. High blood pressure is a leading cause of global burden of disease, and most of it occurs in the developing world.
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