Arch Intern Med
-
Randomized Controlled Trial Comparative Study Clinical Trial
Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison.
Chronic sleep-onset insomnia is a prevalent health complaint in adults. Although behavioral and pharmacological therapies have been shown to be effective for insomnia, no placebo-controlled trials have evaluated their separate and combined effects for sleep-onset insomnia. The objective of this study was to evaluate the clinical efficacy of behavioral and pharmacological therapy, singly and in combination, for chronic sleep-onset insomnia. ⋯ These findings suggest that young and middle-age patients with sleep-onset insomnia can derive significantly greater benefit from CBT than pharmacotherapy and that CBT should be considered a first-line intervention for chronic insomnia. Increased recognition of the efficacy of CBT and more widespread recommendations for its use could improve the quality of life of a large numbers of patients with insomnia.
-
This article discusses the evolution of smokeless tobacco in the United States and interprets the available data on cardiovascular risk factors and cardiovascular mortality associated with its use. There has been a resurgence of smokeless tobacco use since 1970. Smokeless tobacco consistently produces levels of nicotine higher than those seen with smoking and causes similar sympathetic neural stimulation and acute cardiovascular effects. ⋯ Although the evidence is not conclusive, the adverse cardiovascular effects of smokeless tobacco use are less than those caused by smoking but are more than those found in nonusers. It is advisable to counsel all current users of smokeless tobacco to quit. Behavioral counseling, sustained-release bupropion hydrochloride therapy, and nicotine replacement therapy may be safe therapeutic modalities for treatment of smokeless tobacco use.
-
Social inequalities in the incidence of type 2 diabetes and the relation of health behaviors and psychosocial factors to the incidence of type 2 diabetes are not well established. ⋯ An inverse relationship exists between social position and incidence of diabetes that is partly explained by health behaviors and other risk factors. Effort-reward imbalance, which is reportedly associated with coronary heart disease, is also associated with type 2 diabetes.
-
The number of patients undergoing major noncardiac surgery has steadily increased over the last decade. Cardiovascular complications are important and often feared by patients, surgeons, and anesthesiologists. Although preoperative risk assessment has improved since Goldman and colleagues published their landmark article that introduced the Multifactorial Index of Cardiac Risk 25 years ago, it continues to require modification, especially with the increasing prevalence of heart failure and the increase in procedures performed in the elderly. This review will summarize preoperative assessment and perioperative management with an emphasis on heart failure.