Early intensive anti-diabetic treatment may improve β-cell function

Source: Chen HS, et al. Beneficial effects of insulin on glycemic control and β-cell function in newly diagnosed type 2 diabetes with severe hyperglycemia after short-term intensive insulin therapy. Diabetes Care 2008;31:1927-1932.

Approximately 50% of β-cell function has been lost at the time of initial diagnosis of type 2 diabetes. The UKPDS suggested that neither insulin, metformin, nor oral agents demonstrated any particular advantage as far as progressive subsequent decline in β-cell function is concerned. Whether intensive initial glucose control with insulin followed by routine diabetic control with either insulin or oral agents improves control and/or β-cell function was the subject of this publication by Chen et al.

Newly diagnosed type 2 diabetics with severe hyperglycemia (n = 74) were hospitalized and received intensive basal-prandial insulin therapy to maintain near-normal fasting, preprandial, and bedtime glucose; once good glycemic control had been attained and maintained for 10-14 days, subjects were discharged and randomized to continued maintenance of tight control with basal-prandial insulin or oral agents (metformin and/or sulfonylurea titrated to maintain FBS 90-130 mg/dL).

The insulin-maintenance group had significantly greater improvements in A1c at 6 months, although FBS levels were similar to the oral agent group. A comparison of β-cell function at 6 months indicated that patients receiving basal-prandial insulin treatment had better outcomes than those on oral agents.

Evolution of management techniques for type 2 diabetes continues to suggest an earlier and more prominent role for insulin therapy. These data suggest that how one gets to goal may be important, and that early introduction of insulin may have advantages over oral agents.

How long should 'clear sailing' certificate last after colonoscopy?

Source: Imperiale TF, et al. Five-year risk of colorectal neoplasia after negative screening colonoscopy. N Engl J Med 2008;359:1218-1224.

The 2008 guidelines from the American Cancer Society (ACS) have given the green light to support a variety of different colon cancer screening tools, though colonoscopy (COL) continues to have the greatest advocacy from health professionals. The currently recommended interval for re-examination after a negative COL is 10 years in average-risk individuals. Imperiale et al looked at the yield of COL performed 5 years after an initial negative screening COL in average-risk individuals (n = 1256).

Upon rescreening, no cancers were found. Advanced adenomas were found in 1.3%; the relative risk for a new advanced adenoma was 3-fold higher in men than in women.

These data are somewhat surprising when contrasted with a recent study of individuals undergoing two colonoscopies the same day at Indiana University, in which the adenoma miss rate of colonoscopy by experienced endoscopists was 24%! Nonetheless, in neither study does it appear that frank carcinoma was missed. Although this trial does not confirm that a 10-year interval, as recommended by current ACS guideline, is appropriate, it indicates that over a 5-year interval, no new cancers were discovered.

The Swedish Diabetes CVD Risk Score

Source: Cederholm J, et al. Risk prediction of cardiovascular disease in type 2 diabetes. Diabetes Care 2008;31:2038-2043.

Cardiovascular disease (CVD) risk prediction helps to identify persons at high risk, stratify treatment groups, and motivate healthful behaviors and modification of risk factors. Diabetic patients are at particularly high risk of CVD, yet currently available risk scoring systems have not performed particularly well.

The Swedish National Diabetes Register provided the patient population from which a new CVD risk predictor has been developed.

During a mean follow-up of 5.6 years (n = 11,646 adult diabetics), 1482 first CVD events occurred. Risk factors with strong association to CVD events were confirmed to be A1c, age at onset of diabetes, duration of diabetes, gender, BMI, smoking, SBP, use of antihypertensive medication, and use of lipid-lowering medication. When these risk factors were used in randomly selected subgroups from the population, accuracy of CVD risk prediction was excellent.

Because this risk prediction tool utilizes information that is generally readily clinically available, and is structured to inform us about predicted 5-year risk (rather than 10-year risk in several other popularly used risk scores), the Swedish Diabetes CVD Risk Score may find popular utility.

Ethnic disparity in colon polyps detected during routine screening

Source: Lieberman DA, et al. Prevalence of colon polyps detected by colonoscopy screening in asymptomatic black and white patients. JAMA 2008;300:1417-1422.

Both the incidence and rate of mortality of colon cancer (CCa) is higher in black men and women than whites; CCa also occurs at a younger age in blacks than in whites. Health care access issues, lesser adherence to screening recommendations, or less frequent screening recommendations by health care providers to some minority groups might explain some—but not all—of this disparity. Sociopolitcal and economic issues aside, there may simply be a greater incidence of CCa and precancer (i.e., polyps) in black men and women.

Lieberman et al evaluated data from sites (n = 67) routinely performing screening colonoscopy in asymptomatic individuals. During the 2004-2005 interval, 80,061 white and 5464 black persons underwent screening colonoscopy. The primary endpoint of the data analysis was the prevalence of large polyps (> 9.0 mm).

Overall, black women were 62% more likely than white women to have a large polyp discovered on screening colonoscopy; black men were 16% more likely to have a large polyp found. This information should encourage clinicians to be particularly vigilant that black men and women participate in timely screening colonoscopy.

Cannabis withdrawal: Under-recognized

Source: Hasin DS, et al. Cannabis withdrawal in the United States: Results from NESARC. Am J Psychiatry2008;69:1354-1363.

Opinions on the consequences of marijuana use are wide-ranging: Some experts express grave concern that it may induce COPD, increase risk of lung cancer, promote the emergence of schizophrenia, and lead to "heavy drug" use; others essentially dismiss these (potential) adversities as inadequately established to permit accusations that marijuana has any commonplace serious adverse effects. Like alcohol, where there is an established "dose-response curve," indicating that alcohol in moderation is associated with beneficial health outcomes, as opposed to excessive alcohol, which leads to numerous adverse events, there may be a particular degree of marijuana use that leads to toxicity.

There is no specific DSM-IV diagnostic code for marijuana withdrawal, perhaps reflecting the commonplace observation at the time of its publication that few reports had documented such a specific syndrome. The National Epidemiologic Survey on Alcohol and Related Conditions may change that.

During 2001-2002, live interviews were conducted with frequent cannabis users, defined as at least 3x/wk utilization (n = 2613). To make sure that discontinuation syndromes upon cessation of marijuana were not confounded by discontinuation of other substances sometimes concomitantly used (e.g, alcohol), there was a separate subgroup of "cannabis-only" users (n = 1119).

Frequent marijuana users commonly reported withdrawal symptoms in two primary patterns: a weakness-hypersomnia-psychomotor retardation constellation and an anxiety-restlessness-depression-insomnia cluster.

The incidence of withdrawal was essentially identical among cannabis-only users to that of multi-substance users. Finally, the noted withdrawal symptoms were reported to produce a significant degree of impairment. When presented with such symptoms, clinicians may need to consider marijuana withdrawal.

Effect of PUFAs on chronic heart failure

Source: GISSI-HF Investigators. Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure. Lancet 2008;372:1223-1230.

The pharmacologic treatment of chronic heart failure (CHF) is already complex, often requiring an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, beta-blocker, aldosterone antagonist, nitrates, hydralazine, and diuretics. Despite risk reduction with each of these tools, residual risk remains substantial. Polyunsaturated fatty acids (PUFAs) may be another tool to reduce residual risk in CHF.

Some secondary prevention trials of myocardial infarction have indicated risk reduction with PUFAs use, primarily due to prevention of sudden death (attributed to antiarrhythmic properties of PUFAs). Whether similar benefits might be seen in patients with CHF was the subject of this clinical trial.

CHF patients (n = 6975) were enrolled in a randomized placebo-controlled trial of 1 g/d PUFAs (administered as one daily capsule containing eicosapentanoic acid and docosahexanoic acid). At 3.9 years (mean), there was a statistically significant 9% relative risk reduction of all-cause mortality in those who received PUFAs. The tolerability profile of PUFAs was similar to placebo. PUFAs therapy may provide meaningful risk reduction in patients with CHF.