MASALA [PDF] 314
Eat wise to prevent diabetes. What
is the role of dietary glycaemic index and glycaemic load in
the development of type 2 diabetes mellitus, especially in
populations that traditionally subsist on a diet high in
carbohydrates? Two recent studies have addressed this issue.
In one study, some 40 000 black women without diabetes
completed food-frequency questionnaires and then were followed
for about 8 years. After adjustment for confounders including
age and body mass index (BMI), the risk for type 2 diabetes
increased as dietary glycaemic index increased. Conversely,
risk decreased as consumption of cereal fibre increased (Arch
Intern Med 2007;167:2304–9). In the second study
that followed some 64 000 Chinese women over 5 years,
glycaemic index and intake of carbohydrates (particularly
rice) were positively associated with the development of type
2 diabetes (Arch Intern Med 2007;167:2310–16).
Even respiratory infections have
cardiovascular consequences. Risks for myocardial infarction
and stroke are substantially elevated (odds ratio >3) in the
month after a respiratory infection. These results come from a
case–control analysis based in a large general practice
database in the UK that included over 20 000 cases as well as
matched controls, over a 10-year period. The authors concluded
that ‘the benefits of reducing respiratory infection either
through immunization or treating or preventing infection may
be substantial’ (Eur Heart J, 6 Dec 2007 doi:10.1093/eurheartj/ehm516).
The most
effective treatment for alcohol-dependent patients with liver
cirrhosis is abstinence from alcohol. A randomized,
placebo-controlled study investigated the effectiveness and
safety of baclofen in achieving and maintaining abstinence
from alcohol in patients with cirrhosis of the liver. The
baclofen group had a higher rate of achieving and maintaining
abstinence (71% v. 29%) and a longer length of
cumulative abstinence (Lancet 2007;370:1915–22).
It is well known that more frequent
haemodialysis (e.g. daily dialysis) can improve both the
survival and quality of life of patients with chronic kidney
disease. This will mandate the development of new means of
delivering haemodialysis. A small study assessed the safety
and efficiency of an experimental wearable haemodialysis
device. Eight patients with end-stage renal disease wore the
device (powered by a standard 9-volt battery and weighing
about 5 kg) for 4–8 hours. There were no important
cardiovascular changes and no adverse changes in serum
electrolytes or acid–base balance. A comment in the same issue
calls the work ‘a small first step in the long road to
wearable blood-cleansing devices’. Though small, it is
definitely an exciting innovation (Lancet 2007;370:
2005–10).
Adults should not
be screened for asymptomatic carotid artery stenosis (CAS).
The US Preventive Services Task Force (USPSTF) examined the
evidence on the natural history of CAS—systematic reviews of
the accuracy of screening tests, observational studies of the
harms of screening and treatment of asymptomatic CAS, and
randomized, controlled trials of the benefits of treatment for
CAS with carotid endarterectomy. The task force concluded that
duplex ultrasonography leads to many false-positive results
thereby leading to unnecessary confirmatory cerebral
angio-graphies or possibly unnecessary carotid
endarterectomies. It was estimated that more than 4000 people
would need to be screened to prevent 1 stroke over 5 years. It
is perhaps more prudent to focus on optimal medical management
of the risk factors of stroke (Ann Intern Med 2007;147:854–9).
No more pricks for prophylaxis of deep vein
thrombosis. Dabigatran etexilate, an oral, direct thrombin
inhibitor that does not require monitoring or dose adjustment
was studied for its potential utility for prophylaxis against
venous thrombo-embolism (J Thromb Haemost 2007;5:2178–85).
In the RE-MODEL trial, over 2000 subjects were randomized to
receive dabigatran etexilate or enoxaparin after total knee
replacement surgery. Dabigatran etexilate was at least as
effective and with a similar safety profile as enoxaparin for
the prevention of venous thromboembolism after total
knee-replacement surgery.
Yet another
‘scopy’—breast ductoscopy. This involves endoscopy of the
female breast. Breast ductoscopy derives from the recent
technical developments in ductoscopes and micro-instruments.
Diagnostic ductoscopy is now performed by many breast
physicians worldwide and interventional ductoscopy depends on
an additional working channel and a variety of
micro-instruments 0.4–0.8 mm in size for procedures inside the
breast duct. Autofluorescence ductoscopy is a new imaging
technique that could be used to identify intraductal lesions.
Laser ductoscopy for removal of intraductal papillomas and
3-dimensional intraductal tracking systems are the future in
this field (Onkologie 2007; 30:545–9).
The conventional bedside manner of the
practising clinician stands challenged. Clinicians frequently
warn patients of discomfort before potentially painful
procedures. A study compared two communications (one with, and
the other without, a warning of a ‘sting’) immediately before
i.v. cannulation in order to measure differences in perceived
pain by patients during the procedure (Br J Anaesth
2007;99:871–5). The communication immediately before
i.v. cannulation consisted of either ‘I am going to apply the
tourniquet and insert the needle in a few moments. It’s a
sharp scratch and it may sting a little’ (Group S) or ‘I am
going to apply the tourniquet on the arm. As I do this many
people find the arm becomes heavy, numb and tingly. This
allows the drip to be placed more comfortably’ (Group NS). The
results showed that warning patients of a ‘sting’ before i.v.
cannulation may not be helpful and more patients vocalized
their pain or withdrew the arm in the warning group (Group S).
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