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54 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 12-21-1-Masala.pmd 54 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