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THE NATIONAL MEDICAL JOURNAL OF INDIA
VOL. 21, NO. 1, 2008
Masala
According to an industry-sponsored study, gastric banding far
outperformed conventional therapy in achieving remission of type
2 diabetes in obese subjects. Obese patients (body mass index
[BMI] 30–40) with type 2 diabetes were randomized to laparoscopic
adjustable gastric banding or ‘best practice’ conventional therapy.
When assessed 2 years later, 73% of the surgical group had
achieved remission compared with 13% of the conventional therapy
group. Likewise, weight loss averaged 20% of baseline with
surgery and 1.4% with conventional therapy. The accompanying
editorial stated that guidelines for diabetes care ‘do not mention
surgery at all, even for severely obese patients’ and professional
societies and clinicians should ‘reconsider the role of surgery to
treat diabetes’ (JAMA 2008;299:316–23).
The longer one can do the treadmill, the longer one can expect
to live. In a study, nearly 16 000 male veterans underwent
treadmill exercise testing and then were followed for about 7.5
years. After adjustment for cardiac medications, age and other
risk factors, all-cause mortality risk fell by 13% for every 1-MET
increase in exercise capacity. In fact, exercise capacity was a
stronger predictor of death than were cardiovascular risk
factors, age or BMI. The findings were similar regardless of
race or presence of cardiovascular disease (Circulation 2008;
117:614–22).
The sepsis therapeutics trial results have taken a ‘U’ turn. In a
recent study it was found that corticosteroids do not improve
survival in septic shock, regardless of the patient’s responsiveness
to corticotrophin testing. The study included about 500 subjects
randomized to receive intravenous corticosteroids for over a
week or a placebo. At entry, about half the patients did not have
a response to corticotrophin challenge. At the 28-day mark,
neither the patients’ treatment group nor their response to
corticotrophin testing made any difference in survival (N Engl
J Med 2008;358:111–24).
There was more bad news for sepsis treatment endeavours in
the same issue of the New England Journal of Medicine (N Engl
J Med 2008;358:125–39). Intensive insulin therapy and
pentastarch resuscitation were both independently linked to
adverse events in septic shock. In this study over 500 patients
were randomized to receive either intensive or conventional
insulin therapy, along with either 10% pentastarch or modified
Ringer lactate for fluid resuscitation. The mean morning blood
glucose level was 112 mg/dl in the intensive therapy group and
151 mg/dl in the conventional therapy group. The safety
monitoring board stopped the study early due to an increased
number of hypoglycaemic events in patients who were given
intensive insulin therapy. The organ failure score or the mortality
rate at 28 days did not differ between the insulin groups.
Further, there was a significantly greater incidence of renal
failure and a trend toward higher 90-day mortality among those
receiving pentastarch.
Exercise may be good but watching stressful sporting events may
not be all that great. Sports fans beware—you may be doubling
the risk for cardiovascular events while watching stressful matches
according to a recent report (N Engl J Med 2008;358:475–83). In
this study, the incidence of cardiovascular events among German
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Black
residents during World Cup football matches involving the
German team in 2006 was compared with the incidence during a
control period. The risk for such events was significantly increased
during these soccer games when the home team was playing
(incidence ratio 2.7), with the highest incidence during the first 2
hours of a match. Risk elevations were seen for ST segment
elevation myocardial infarction (MI), non-ST–T MI/unstable
angina and cardiac arrhythmia. Risk increases were significant
regardless of gender or cardiovascular history, but were highest
among men and those with a history of coronary artery disease.
Fond of sugar-sweetened soft drinks or fruit juices; then think
about this. In a prospective follow up study that lasted 12 years,
46 000 men health professionals in the age group of 40–75 years
completed food-frequency questionnaires at baseline and every
4 years thereafter. High consumption of sugar-sweetened soft
drinks and fructose was found to increase the risk for gout
(BMJ 2008;336:309–12). Compared with men who consumed
less than one sugary soft drink a month, those consuming 5–6
drinks a week had a 29% increased risk; and those taking one a
day experienced a 45% increase; and two or more daily, an 85%
increase. The risk also increased with higher consumption of
other high-fructose products such as fruit juice, apples and
oranges.
Probiotics may not be ‘pro’ all the time. A recent study found that
using probiotic therapy to reduce infectious complications in
severe pancreatitis actually increased mortality. In this study 300
odd patients with severe acute pancreatitis were randomized to
receive a 28-day course of either placebo or a combination of
Lactobacillus, Lactococcus and Bifidobacterium species via a
feeding tube or later ingested orally. Though at 90 days rates of
infectious complications between the groups did not differ, those
on probiotic therapy had mortality rates twice as high as those on
placebo, and 9 suffered bowel ischaemia with 8 deaths. The authors
speculate that increased oxygen demands of the infused bacteria
may have led to the ischaemia. It is possible that probiotics may not
be all that safe adjuncts to enteral nutrition, especially in critically
ill patients (Lancet, 14 February 2008 Epub ahead of print).
Here is a new game, a deadly one though, called the ‘choking
game’. The ‘choking game’ is defined as self-strangulation or
strangulation by another person with the hands or a noose to
achieve a brief euphoric state caused by cerebral hypoxia. It is
also known as the ‘blackout game’, ‘pass-out game’, ‘scarf
game’, ‘space monkey’ and by other names. In the USA alone,
at least 82 children have died of accidental strangulation attributed
to this game since 1995. According to a report in (MMWR 2008;
57:141–4) deaths occurred among youths playing this game
with a noose. Most of the victims were male and the mean age
was 13. An editorial note recommends that healthcare providers
watch for warning signs including mention of the choking game,
bloodshot eyes, marks on the neck, frequent severe headaches,
disorientation after spending time alone, and ropes or belts tied
to bedroom furniture or doorknobs. It also states that ‘although
asphyxial games might have been played by youths for
generations, the use of a ligature while playing alone appears to
be a new practice that can be fatal’.
GOPESH K. MODI
3/1/2008, 10:17 AM