CLINICAL QUESTION: Is there a difference in efficacy between older and newer antihypertensive medications in preventing cardiovascular morbidity and mortality?

BACKGROUND: It is well known that b-blockers and diuretics decrease cardiovascular morbidity and mortality.¹ However, the efficacy of newer classes of antihypertensive drugs, such as angiotensin-converting enzyme (ACE) inhibitors and calcium antagonists, has not been established.

POPULATION STUDIED: Subjects included 6628 hypertensive men and women aged 70 to 84 years from 312 health centers in Sweden. Hypertension was defined as a reading of >179 mm Hg systolic, >104 mm Hg diastolic, or both.

STUDY DESIGN AND VALIDITY: This was a prospective randomized trial. Patients were assigned treatment to 1 of 3 categories of medications: conventional antihypertensive drugs, ACE inhibitors, or calcium antagonists. Conventional drugs used were oral atenolol 50 mg, metoprolol 100 mg, pindolol 5 mg, or fixed-ratio hydrochlorothiazide 25 mg plus amiloride 2.5 mg, all given once daily. The ACE inhibitors were enalapril 10 mg or lisinopril 10 mg given once daily, and the calcium antagonists were felodipine 2.5 mg or isradipine 2.5 mg given once daily. If the target blood pressure of 160/95 mm Hg had not been reached by 2 months, combination therapy was instituted. Patients on b-blockers or ACE inhibitors were given a diuretic, while those on diuretics or calcium antagonists were given a b-blocker. After the initial dose-titration periods, patients were seen twice each year. At each visit heart rate and blood pressure were measured. Adverse events were evaluated from the patient’s history. Laboratory tests and electrocardiograms were done annually and on an as-needed basis.

OUTCOMES MEASURED: The primary end point was the rate of cardiovascular mortality. Secondary outcomes included the rates of fatal and nonfatal stroke, fatal and nonfatal myocardial infarction, atrial fibrillation, congestive heart failure, diabetes mellitus, and all-cause mortality. Subgroup analysis was performed on people with diabetes.

RESULTS: Most patients in this study had Stage 3 hypertension > 180 mm Hg systolic or 110 mm Hg diastolic). The rates of the primary and secondary end points were similar among the 3 treatment arms. The only difference was fewer fatal and nonfatal myocardial infarctions and less congestive heart failure among patients taking ACE inhibitors than those taking calcium antagonists. Although 46% of patients required more than one drug to control their hypertension, 61% to 66% of the patients in each group were on their original regimen at the end of the trial. Adverse events were common in all 3 groups: 25.5% of patients taking calcium antagonists had ankle edema, 30% on an ACE inhibitor had cough, and 25% to 28% in each group had dizziness.

CLINICAL QUESTION: Is there a difference in efficacy between older and newer antihypertensive medications in preventing cardiovascular morbidity and mortality?

BACKGROUND: It is well known that b-blockers and diuretics decrease cardiovascular morbidity and mortality.¹ However, the efficacy of newer classes of antihypertensive drugs, such as angiotensin-converting enzyme (ACE) inhibitors and calcium antagonists, has not been established.

POPULATION STUDIED: Subjects included 6628 hypertensive men and women aged 70 to 84 years from 312 health centers in Sweden. Hypertension was defined as a reading of >179 mm Hg systolic, >104 mm Hg diastolic, or both.

STUDY DESIGN AND VALIDITY: This was a prospective randomized trial. Patients were assigned treatment to 1 of 3 categories of medications: conventional antihypertensive drugs, ACE inhibitors, or calcium antagonists. Conventional drugs used were oral atenolol 50 mg, metoprolol 100 mg, pindolol 5 mg, or fixed-ratio hydrochlorothiazide 25 mg plus amiloride 2.5 mg, all given once daily. The ACE inhibitors were enalapril 10 mg or lisinopril 10 mg given once daily, and the calcium antagonists were felodipine 2.5 mg or isradipine 2.5 mg given once daily. If the target blood pressure of 160/95 mm Hg had not been reached by 2 months, combination therapy was instituted. Patients on b-blockers or ACE inhibitors were given a diuretic, while those on diuretics or calcium antagonists were given a b-blocker. After the initial dose-titration periods, patients were seen twice each year. At each visit heart rate and blood pressure were measured. Adverse events were evaluated from the patient’s history. Laboratory tests and electrocardiograms were done annually and on an as-needed basis.

OUTCOMES MEASURED: The primary end point was the rate of cardiovascular mortality. Secondary outcomes included the rates of fatal and nonfatal stroke, fatal and nonfatal myocardial infarction, atrial fibrillation, congestive heart failure, diabetes mellitus, and all-cause mortality. Subgroup analysis was performed on people with diabetes.

RESULTS: Most patients in this study had Stage 3 hypertension > 180 mm Hg systolic or 110 mm Hg diastolic). The rates of the primary and secondary end points were similar among the 3 treatment arms. The only difference was fewer fatal and nonfatal myocardial infarctions and less congestive heart failure among patients taking ACE inhibitors than those taking calcium antagonists. Although 46% of patients required more than one drug to control their hypertension, 61% to 66% of the patients in each group were on their original regimen at the end of the trial. Adverse events were common in all 3 groups: 25.5% of patients taking calcium antagonists had ankle edema, 30% on an ACE inhibitor had cough, and 25% to 28% in each group had dizziness.

CLINICAL QUESTION: Is there a difference in efficacy between older and newer antihypertensive medications in preventing cardiovascular morbidity and mortality?

BACKGROUND: It is well known that b-blockers and diuretics decrease cardiovascular morbidity and mortality.¹ However, the efficacy of newer classes of antihypertensive drugs, such as angiotensin-converting enzyme (ACE) inhibitors and calcium antagonists, has not been established.

POPULATION STUDIED: Subjects included 6628 hypertensive men and women aged 70 to 84 years from 312 health centers in Sweden. Hypertension was defined as a reading of >179 mm Hg systolic, >104 mm Hg diastolic, or both.

STUDY DESIGN AND VALIDITY: This was a prospective randomized trial. Patients were assigned treatment to 1 of 3 categories of medications: conventional antihypertensive drugs, ACE inhibitors, or calcium antagonists. Conventional drugs used were oral atenolol 50 mg, metoprolol 100 mg, pindolol 5 mg, or fixed-ratio hydrochlorothiazide 25 mg plus amiloride 2.5 mg, all given once daily. The ACE inhibitors were enalapril 10 mg or lisinopril 10 mg given once daily, and the calcium antagonists were felodipine 2.5 mg or isradipine 2.5 mg given once daily. If the target blood pressure of 160/95 mm Hg had not been reached by 2 months, combination therapy was instituted. Patients on b-blockers or ACE inhibitors were given a diuretic, while those on diuretics or calcium antagonists were given a b-blocker. After the initial dose-titration periods, patients were seen twice each year. At each visit heart rate and blood pressure were measured. Adverse events were evaluated from the patient’s history. Laboratory tests and electrocardiograms were done annually and on an as-needed basis.

OUTCOMES MEASURED: The primary end point was the rate of cardiovascular mortality. Secondary outcomes included the rates of fatal and nonfatal stroke, fatal and nonfatal myocardial infarction, atrial fibrillation, congestive heart failure, diabetes mellitus, and all-cause mortality. Subgroup analysis was performed on people with diabetes.

RESULTS: Most patients in this study had Stage 3 hypertension > 180 mm Hg systolic or 110 mm Hg diastolic). The rates of the primary and secondary end points were similar among the 3 treatment arms. The only difference was fewer fatal and nonfatal myocardial infarctions and less congestive heart failure among patients taking ACE inhibitors than those taking calcium antagonists. Although 46% of patients required more than one drug to control their hypertension, 61% to 66% of the patients in each group were on their original regimen at the end of the trial. Adverse events were common in all 3 groups: 25.5% of patients taking calcium antagonists had ankle edema, 30% on an ACE inhibitor had cough, and 25% to 28% in each group had dizziness.

CLINICAL QUESTION: What is the efficacy and tolerability of risperidone for treating elderly demented patients with aggression and other behavioral symptoms?

BACKGROUND: Aggression and other behavioral symptoms of dementia are significant predictors of caregiver burden and may underlie the decision to institutionalize demented patients. Conventional neuroleptics are often used to manage disruptive behaviors. Adverse drug effects, however, such as movement disorders, extrapyramidal symptoms (EPS), anticholinergic effects, and drug-drug interactions limit their usefulness. Atypical antipsychotics such as risperidone may offer added benefit in elderly patients with dementia.

POPULATION STUDIED: The study recruited 371 nursing home patients from 51 centers in 8 countries. All had been given a diagnosis of primary degenerative dementia of the Alzheimer’s type, vascular dementia, or mixed dementia. Ages ranged from 56 to 97 years; 99% were white; and 56% were women. The median duration of institutionalization was 4 months. According to standardized measures, these patients had cognitive and functional deficits severe enough to affect basic daily activities. Mean Mini-Mental State Examination (MMSE) scores were 7.9 to 8.8.

STUDY DESIGN AND VALIDITY: Following a 1-week single-blind washout phase during which all psychotropic medications were discontinued, 344 patients were randomized to double-blind treatment with risperidone, haloperidol, or placebo. The study groups were comparable at baseline. The 12-week treatment period started with 0.25 mg (1 mg/mL oral solution) per day of risperidone or haloperidol. The dose was increased by 0.25 mg every 4 days up to a maximum of 2 mg twice daily. Efficacy was judged using several established behavioral assessment tools. Assessment of tolerability included evaluation for EPS, the level of sedation, Functional Assessment Staging, MMSE score, and the incidence of adverse drug effects. Outcomes were analyzed both by intention to treat (end point data) and observed case analysis that included only the 223 patients who continued treatment for 12 weeks (week 12 data). Of note, supplemental lorazepam was allowed in the first 4 weeks of the study, but concomitant use of antipsychotics, antidepressants, lithium, carbamazepine, and valproic acid was not otherwise permitted. This study was funded in part by Janssen Pharmaceuticals, maker of Risperdal (risperidone).

OUTCOMES MEASURED: The primary outcome was clinically significant improvement of disturbing behavior defined as a 30% or greater change on the Behavior Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD) total score. Many secondary outcomes were reported regarding the efficacy of risperidone compared with placebo and its tolerability compared with both placebo and haloperidol.

RESULTS: The percentage of patients with clinical improvement (30% improvement in BEHAVE-AD total score) in the risperidone, haloperidol, and placebo groups was 54%, 63%, and 47% respectively by intention-to-treat analysis. This difference was not statistically significant (P = .25 with 80% power to detect a difference of 20%). The high placebo response may explain the poor effect overall of active treatment.¹ Non-intention-to-treat analysis and secondary measures of behavior, particularly those assessing aggression, showed a statistically significant benefit of risperidone over placebo. This study was not intended to compare the efficacy of risperidone with that of haloperidol although a post hoc analysis was reported. In terms of tolerability, the severity of EPS was significantly greater with haloperidol than risperidone. There was no significant difference in the occurrence of serious adverse events. Dropout rates for the risperidone, haloperidol, and placebo groups were high (41%, 30%, and 35%, respectively). The most common reasons cited for discontinuation were adverse events (50.4%) and lack of efficacy (43.8%). The mean dose of medication was approximately 1 mg per day in both active groups.

CLINICAL QUESTION: What is the efficacy and tolerability of risperidone for treating elderly demented patients with aggression and other behavioral symptoms?

BACKGROUND: Aggression and other behavioral symptoms of dementia are significant predictors of caregiver burden and may underlie the decision to institutionalize demented patients. Conventional neuroleptics are often used to manage disruptive behaviors. Adverse drug effects, however, such as movement disorders, extrapyramidal symptoms (EPS), anticholinergic effects, and drug-drug interactions limit their usefulness. Atypical antipsychotics such as risperidone may offer added benefit in elderly patients with dementia.

POPULATION STUDIED: The study recruited 371 nursing home patients from 51 centers in 8 countries. All had been given a diagnosis of primary degenerative dementia of the Alzheimer’s type, vascular dementia, or mixed dementia. Ages ranged from 56 to 97 years; 99% were white; and 56% were women. The median duration of institutionalization was 4 months. According to standardized measures, these patients had cognitive and functional deficits severe enough to affect basic daily activities. Mean Mini-Mental State Examination (MMSE) scores were 7.9 to 8.8.

STUDY DESIGN AND VALIDITY: Following a 1-week single-blind washout phase during which all psychotropic medications were discontinued, 344 patients were randomized to double-blind treatment with risperidone, haloperidol, or placebo. The study groups were comparable at baseline. The 12-week treatment period started with 0.25 mg (1 mg/mL oral solution) per day of risperidone or haloperidol. The dose was increased by 0.25 mg every 4 days up to a maximum of 2 mg twice daily. Efficacy was judged using several established behavioral assessment tools. Assessment of tolerability included evaluation for EPS, the level of sedation, Functional Assessment Staging, MMSE score, and the incidence of adverse drug effects. Outcomes were analyzed both by intention to treat (end point data) and observed case analysis that included only the 223 patients who continued treatment for 12 weeks (week 12 data). Of note, supplemental lorazepam was allowed in the first 4 weeks of the study, but concomitant use of antipsychotics, antidepressants, lithium, carbamazepine, and valproic acid was not otherwise permitted. This study was funded in part by Janssen Pharmaceuticals, maker of Risperdal (risperidone).

OUTCOMES MEASURED: The primary outcome was clinically significant improvement of disturbing behavior defined as a 30% or greater change on the Behavior Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD) total score. Many secondary outcomes were reported regarding the efficacy of risperidone compared with placebo and its tolerability compared with both placebo and haloperidol.

RESULTS: The percentage of patients with clinical improvement (30% improvement in BEHAVE-AD total score) in the risperidone, haloperidol, and placebo groups was 54%, 63%, and 47% respectively by intention-to-treat analysis. This difference was not statistically significant (P = .25 with 80% power to detect a difference of 20%). The high placebo response may explain the poor effect overall of active treatment.¹ Non-intention-to-treat analysis and secondary measures of behavior, particularly those assessing aggression, showed a statistically significant benefit of risperidone over placebo. This study was not intended to compare the efficacy of risperidone with that of haloperidol although a post hoc analysis was reported. In terms of tolerability, the severity of EPS was significantly greater with haloperidol than risperidone. There was no significant difference in the occurrence of serious adverse events. Dropout rates for the risperidone, haloperidol, and placebo groups were high (41%, 30%, and 35%, respectively). The most common reasons cited for discontinuation were adverse events (50.4%) and lack of efficacy (43.8%). The mean dose of medication was approximately 1 mg per day in both active groups.

CLINICAL QUESTION: What is the efficacy and tolerability of risperidone for treating elderly demented patients with aggression and other behavioral symptoms?

BACKGROUND: Aggression and other behavioral symptoms of dementia are significant predictors of caregiver burden and may underlie the decision to institutionalize demented patients. Conventional neuroleptics are often used to manage disruptive behaviors. Adverse drug effects, however, such as movement disorders, extrapyramidal symptoms (EPS), anticholinergic effects, and drug-drug interactions limit their usefulness. Atypical antipsychotics such as risperidone may offer added benefit in elderly patients with dementia.

POPULATION STUDIED: The study recruited 371 nursing home patients from 51 centers in 8 countries. All had been given a diagnosis of primary degenerative dementia of the Alzheimer’s type, vascular dementia, or mixed dementia. Ages ranged from 56 to 97 years; 99% were white; and 56% were women. The median duration of institutionalization was 4 months. According to standardized measures, these patients had cognitive and functional deficits severe enough to affect basic daily activities. Mean Mini-Mental State Examination (MMSE) scores were 7.9 to 8.8.

STUDY DESIGN AND VALIDITY: Following a 1-week single-blind washout phase during which all psychotropic medications were discontinued, 344 patients were randomized to double-blind treatment with risperidone, haloperidol, or placebo. The study groups were comparable at baseline. The 12-week treatment period started with 0.25 mg (1 mg/mL oral solution) per day of risperidone or haloperidol. The dose was increased by 0.25 mg every 4 days up to a maximum of 2 mg twice daily. Efficacy was judged using several established behavioral assessment tools. Assessment of tolerability included evaluation for EPS, the level of sedation, Functional Assessment Staging, MMSE score, and the incidence of adverse drug effects. Outcomes were analyzed both by intention to treat (end point data) and observed case analysis that included only the 223 patients who continued treatment for 12 weeks (week 12 data). Of note, supplemental lorazepam was allowed in the first 4 weeks of the study, but concomitant use of antipsychotics, antidepressants, lithium, carbamazepine, and valproic acid was not otherwise permitted. This study was funded in part by Janssen Pharmaceuticals, maker of Risperdal (risperidone).

OUTCOMES MEASURED: The primary outcome was clinically significant improvement of disturbing behavior defined as a 30% or greater change on the Behavior Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD) total score. Many secondary outcomes were reported regarding the efficacy of risperidone compared with placebo and its tolerability compared with both placebo and haloperidol.

RESULTS: The percentage of patients with clinical improvement (30% improvement in BEHAVE-AD total score) in the risperidone, haloperidol, and placebo groups was 54%, 63%, and 47% respectively by intention-to-treat analysis. This difference was not statistically significant (P = .25 with 80% power to detect a difference of 20%). The high placebo response may explain the poor effect overall of active treatment.¹ Non-intention-to-treat analysis and secondary measures of behavior, particularly those assessing aggression, showed a statistically significant benefit of risperidone over placebo. This study was not intended to compare the efficacy of risperidone with that of haloperidol although a post hoc analysis was reported. In terms of tolerability, the severity of EPS was significantly greater with haloperidol than risperidone. There was no significant difference in the occurrence of serious adverse events. Dropout rates for the risperidone, haloperidol, and placebo groups were high (41%, 30%, and 35%, respectively). The most common reasons cited for discontinuation were adverse events (50.4%) and lack of efficacy (43.8%). The mean dose of medication was approximately 1 mg per day in both active groups.

CLINICAL QUESTION: Should bed rest be prescribed for any condition?

BACKGROUND: Bed rest is a traditional and frequently prescribed treatment for various medical conditions. Its therapeutic value should be critically assessed just as any other treatment modality.

POPULATION STUDIED: The authors identified a total of 39 randomized controlled trials of bed rest as a therapeutic intervention published between January 1966 and June 1998. The studies represented 17 conditions and a total of 5777 patients. Therapeutic uses of bed rest were used as prophylactic treatment after medical procedures and as primary treatment. Procedures included lumbar puncture (2 studies), spinal anesthesia (4), radiculography (4), cardiac catheterization (9), skin graft of burn (1), liver biopsy (1), fixation of femoral fracture (1), pressure sore surgery (1), and gastric surgery (1). The conditions for primary treatment included acute low back pain (5), spontaneous labor (1), proteinuric hypertension during pregnancy (2), early threatened abortion (1), uncomplicated myocardial infarction (4), pulmonary tuberculosis (1), rheumatoid arthritis (1), and acute infectious hepatitis (1). Control groups had to receive the same treatment other than bed rest and in the same environment (eg, hospital, home).

STUDY DESIGN AND VALIDITY: This was a systematic review of the literature with well-described methodology regarding search strategy and selection criteria. The authors did not present an assessment of the methodologic quality of the included studies. They determined that no pooled analyses were possible and presented their results appropriately in tables.

OUTCOMES MEASURED: The measure of interest for this review was presence or absence of statistically significant differences between treatment groups in the studies identified.

RESULTS: There were a total of 64 outcomes reported in the included studies. These were classified as better or worse with bed rest. In the 24 trials of bed rest as prophylaxis after procedures, there were 7 outcomes that were better with bed rest, none significantly. There were 26 outcomes worse with bed rest, 9 significantly. The significantly worse outcomes included nausea after lumbar puncture, headache after spinal anesthesia, dizziness after radiculography, hematoma, pain, back pain after cardiac catheterization, and time to normal bowel function after gastric surgery. In the 15 trials of bed rest as primary treatment, 6 outcomes were better with treatment (none significantly) and 25 outcomes were worse with treatment (8 significantly). The significantly worse outcomes included disability index at day 1 for acute low back pain, length of first stage of labor, contraction strength, assisted delivery, analgesia required during labor, 5-minute Apgar score, venous thrombosis after myocardial infarction, and time for recovery from acute infectious hepatitis.

CLINICAL QUESTION: Should bed rest be prescribed for any condition?

BACKGROUND: Bed rest is a traditional and frequently prescribed treatment for various medical conditions. Its therapeutic value should be critically assessed just as any other treatment modality.

POPULATION STUDIED: The authors identified a total of 39 randomized controlled trials of bed rest as a therapeutic intervention published between January 1966 and June 1998. The studies represented 17 conditions and a total of 5777 patients. Therapeutic uses of bed rest were used as prophylactic treatment after medical procedures and as primary treatment. Procedures included lumbar puncture (2 studies), spinal anesthesia (4), radiculography (4), cardiac catheterization (9), skin graft of burn (1), liver biopsy (1), fixation of femoral fracture (1), pressure sore surgery (1), and gastric surgery (1). The conditions for primary treatment included acute low back pain (5), spontaneous labor (1), proteinuric hypertension during pregnancy (2), early threatened abortion (1), uncomplicated myocardial infarction (4), pulmonary tuberculosis (1), rheumatoid arthritis (1), and acute infectious hepatitis (1). Control groups had to receive the same treatment other than bed rest and in the same environment (eg, hospital, home).

STUDY DESIGN AND VALIDITY: This was a systematic review of the literature with well-described methodology regarding search strategy and selection criteria. The authors did not present an assessment of the methodologic quality of the included studies. They determined that no pooled analyses were possible and presented their results appropriately in tables.

OUTCOMES MEASURED: The measure of interest for this review was presence or absence of statistically significant differences between treatment groups in the studies identified.

RESULTS: There were a total of 64 outcomes reported in the included studies. These were classified as better or worse with bed rest. In the 24 trials of bed rest as prophylaxis after procedures, there were 7 outcomes that were better with bed rest, none significantly. There were 26 outcomes worse with bed rest, 9 significantly. The significantly worse outcomes included nausea after lumbar puncture, headache after spinal anesthesia, dizziness after radiculography, hematoma, pain, back pain after cardiac catheterization, and time to normal bowel function after gastric surgery. In the 15 trials of bed rest as primary treatment, 6 outcomes were better with treatment (none significantly) and 25 outcomes were worse with treatment (8 significantly). The significantly worse outcomes included disability index at day 1 for acute low back pain, length of first stage of labor, contraction strength, assisted delivery, analgesia required during labor, 5-minute Apgar score, venous thrombosis after myocardial infarction, and time for recovery from acute infectious hepatitis.

CLINICAL QUESTION: Should bed rest be prescribed for any condition?

BACKGROUND: Bed rest is a traditional and frequently prescribed treatment for various medical conditions. Its therapeutic value should be critically assessed just as any other treatment modality.

POPULATION STUDIED: The authors identified a total of 39 randomized controlled trials of bed rest as a therapeutic intervention published between January 1966 and June 1998. The studies represented 17 conditions and a total of 5777 patients. Therapeutic uses of bed rest were used as prophylactic treatment after medical procedures and as primary treatment. Procedures included lumbar puncture (2 studies), spinal anesthesia (4), radiculography (4), cardiac catheterization (9), skin graft of burn (1), liver biopsy (1), fixation of femoral fracture (1), pressure sore surgery (1), and gastric surgery (1). The conditions for primary treatment included acute low back pain (5), spontaneous labor (1), proteinuric hypertension during pregnancy (2), early threatened abortion (1), uncomplicated myocardial infarction (4), pulmonary tuberculosis (1), rheumatoid arthritis (1), and acute infectious hepatitis (1). Control groups had to receive the same treatment other than bed rest and in the same environment (eg, hospital, home).

STUDY DESIGN AND VALIDITY: This was a systematic review of the literature with well-described methodology regarding search strategy and selection criteria. The authors did not present an assessment of the methodologic quality of the included studies. They determined that no pooled analyses were possible and presented their results appropriately in tables.

OUTCOMES MEASURED: The measure of interest for this review was presence or absence of statistically significant differences between treatment groups in the studies identified.

RESULTS: There were a total of 64 outcomes reported in the included studies. These were classified as better or worse with bed rest. In the 24 trials of bed rest as prophylaxis after procedures, there were 7 outcomes that were better with bed rest, none significantly. There were 26 outcomes worse with bed rest, 9 significantly. The significantly worse outcomes included nausea after lumbar puncture, headache after spinal anesthesia, dizziness after radiculography, hematoma, pain, back pain after cardiac catheterization, and time to normal bowel function after gastric surgery. In the 15 trials of bed rest as primary treatment, 6 outcomes were better with treatment (none significantly) and 25 outcomes were worse with treatment (8 significantly). The significantly worse outcomes included disability index at day 1 for acute low back pain, length of first stage of labor, contraction strength, assisted delivery, analgesia required during labor, 5-minute Apgar score, venous thrombosis after myocardial infarction, and time for recovery from acute infectious hepatitis.