CLINICAL BRIEFS

By Louis Kuritzky, MD

Clinical Assistant Professor, University of Florida, Gainesville

Dr. Kuritzky is a retained consultant for Boehringer Ingelheim, Daiichi Sankyo, Forest Pharmaceuticals, Janssen, Lilly, Novo Nordisk, Pfizer, and Sanofi.

Another Win for Bariatric Surgery in Type 2 Diabetes

Source: Sjostrom L, et al. Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications. JAMA 2014;311:2297-2304.

Currently required FDA labeling for oral hypoglycemic agents includes the following wording: "There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with _____ or any other antidiabetic drug." Since cardiovascular events are the No. 1 cause of death in type 2 diabetes, what does work?

The Swedish Obese Subjects study is a prospective trial that enrolled patients for bariatric surgery vs "usual care" between 1987-2001, and continues to follow their outcomes. Surgical interventions include nonadjustable banding (n = 61), vertical banded gastroplasty (n = 227), and gastric bypass (n = 55).

Remission of type 2 diabetes subsequent to surgery was impressive: At 2 years, 72% of surgical patients remained in remission, and at 15 years, still 30% of type 2 diabetes patients were in remission (compared with 16% and 7%, respectively, in the "usual care" group). Both microvascular complications (twice as frequent in the control group) and macrovascular endpoints (32% fewer in the surgical group), favored bariatric surgery patients.

The evidence accumulating on bariatric surgery has been consistently favorable, including perioperative 90-day mortality rates of < 1%. Benefits of bariatric surgery are prompt and enduring.

Weighing the Risk:Benefit Equation of Azithromycin for Pneumonia

Source: Mortensen EM, et al. Association of azithromycin with mortality and cardiovascular events among older patients hospitalized with pneumonia. JAMA 2014;311:2199-2208.

Azithromycin is generally considered to be an antibiotic associated with a low risk of important adverse effects, reflecting its frequent use in diverse outpatient disorders such as sinusitis, otitis, and bronchitis. It has been recently recognized that azithromycin is uncommonly associated with QT prolongation, which could — at least in theory — lead to cardiac toxicity. Contradicting that belief are at least two large data sets that failed to identify any cardiovascular risk signal.

Mortensen et al performed a retrospective cohort study in older patients (≥ 65 years of age; mean age = 77.8 years) who had been hospitalized with pneumonia to compare outcomes in patients who had been treated with azithromycin (n = 31,863) vs other antibiotics (n = 31,863).

Ninety-day mortality was found to be lower in the group who had been treated with azithromycin than comparator antibiotics (odds ratio [OR] = 0.73). Even though there was a small relative increased risk of myocardial infarction (OR = 1.17; absolute event rate increase = 0.7%) in the azithromycin group, this was not sufficient to counteract the overall mortality advantage.

Because the population from which these data were drawn included only Veterans Administration patients, subjects were almost exclusively male (98.2%). Nonetheless, no differences in outcomes were discerned between genders (female study population, n = 1134).

Hemospermia: What’s the Outcome?

Source: Zargooshi J, et al. Hemospermia: Long-term outcome in 165 patients. Int J Impot Res 2014;26:83-86.

The presence of blood in the semen is an unsettling experience for men and usually stimulates prompt consultation. Fortunately, this research article by Zargooshi et al provides very reassuring outcomes data.

From a general urology clinic in Iran, the investigators included all patients with hemospermia seen in their outpatient clinic over a 16-year span (n = 165). Mean age of the subjects was 38 years, but almost 20% of subjects were over age 50. Mean follow-up was 7 years. Study subjects underwent ultrasound of the testes and abdomen, and laboratory evaluation. In the absence of positive findings, subjects were empirically treated with a course of a fluoroquinolone plus a nonsteroidal anti-inflammatory drug (NSAID).

Pathology was discerned in only 3 of 165 patients: one case of tuberculosis, one case of bladder cancer, and one case of ejaculatory duct stones. The authors point out that during the 15-year span of the study, no patient developed life-threatening disease, and post-treatment recurrences were rare.

According to this trial, if hemospermia resolves after a course of antibiotics and NSAIDs, further investigation is unlikely to disclose meaningful pathology. Full evaluation should be reserved for recurrences or other high-risk indicators.