Clinical Briefs By Louis Kuritzky, MD
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is an advisor for Endo, Kowa, Pricara, and Takeda.
Lose-Dose Abdominal CT for Appendicitis
Source: Kim K, et al. Low-dose abdominal CT for evaluating suspected appendicitis. N Engl J Med 2012;366:1596-1605.
Radiation exposure from ct is quite substantial. A "typical" abdominal CT (AB-CT) examination exposes a patient to X-radiation equivalent to more than 500 chest X-rays. The dose-response relationship between diagnostic/therapeutic radiation and untoward consequences is uncertain; nonetheless, the magnitude of radiation from imaging combined with the ever-increasing frequency with which high-dose diagnostic imaging is used prompts concern. Perspicacity for wise use of radiation is imperative, especially in younger persons, in whom the lag time for adverse impact of radiation is most pertinent and in whom the likelihood of additional radiation exposure is increased.
When appendicitis is suspected, AB-CT has become the diagnostic imaging of choice. Standard-dose AB-CT exposes the patient to approximately 500 mGy/cm of radiation. Low-dose AB-CT exposes the patient to approximately 100 mGy/cm, but it is not widely used because of uncertainty about its accuracy (compared to standard AB-CT).
Kim et al randomized young adult patients with suspected appendicitis (n = 891) to low-dose or standard-dose AB-CT. The primary outcome of the study was the number of appendectomies performed that did not demonstrate appendicitis.
The negative appendectomy rate did not differ significantly between the two groups (3.2% vs 3.5%). Statistical criteria were satisfied that low-dose AB-CT is noninferior to standard dose AB-CT. Clinicians may wish to ascertain the radiation dose used in AB-CT for appendicitis at their institutions.
Degludec, a New Ultra-long-acting Basal Insulin for Diabetes
Source: Garber AJ, et al. Insulin degludec, an ultra-longacting basal insulin, versus insulin glargine in basal-bolus treatment with mealtime insulin aspart in type 2 diabetes (BEGIN Basal-Bolus Type 2): A phase 3, randomised, open-label, treat-to-target non-inferiority trial. Lancet 2012;379:1498-1507.
The advent of basal insulins that do not have a prominent peak plasma level so-called "flat" pharmacodynamic activity was a welcome addition to diabetes management, since their predecessor, NPH, was often limited by problematic hypoglycemia. Utilization of glargine and detemir insulins, the two basal insulin analogs most recently available in the United States, has mushroomed in response to their superior tolerability compared to NPH insulin: a reduction of about 20% in hypoglycemic episodes and less weight gain. Degludec has recently been submitted to the FDA for approval. It is considered an ultra-long-acting basal insulin.
Garber et al performed a controlled trial in type 2 diabetic patients (n = 972) to compare degludec with glargine as part of a basal-bolus regimen. The primary endpoint of the trial was achieved A1c, but rates of hypoglycemia were also compared.
Both insulins achieved similar A1c improvement, and the overall rate of hypoglycemia was low in both groups. However, the degludec patients experienced almost 20% fewer hypoglycemic episodes (defined as glucose < 56 mg/dL) than the glargine group.
Degludec insulin, if FDA approved, may provide a superior hypoglycemia risk profile than insulin glargine while achieving a similar level of A1c reduction.
Prevention Benefits of Aspirin: Cancer, Vascular, or Both?
Source: Rothwell PM, et al. Short-term effects of daily aspirin on cancer incidence, mortality, and non-vascular death: Analysis of the time course of risks and benefits in 51 randomised controlled trials. Lancet 2012;379:1602-1612.
American clinicians have typically thought of aspirin as a preventive (primary and secondary prevention) for cardiovascular (CV) events. Recently, the role of aspirin for primary prevention of CV events has been embattled because although clinical trial data indicate reduction in CV events, total mortality has not been convincingly favorably impacted.
Aspirin appears to have at least two favorable effects upon cancer. It appears to decrease the incidence of colon cancer, and as a consequence of what otherwise might appear to be an adverse effect enhances detection rates of existing colon cancers by increasing their proclivity to bleed.
Rothwell et al performed an analysis of trial data from 51 randomized, controlled aspirin prevention trials. Among almost 70,000 participants, risk of cancer death was reduced by approximately 15%, and incidence of cancer was reduced by about one-fourth. Although there is a reduction in vascular events with the use of aspirin, bleeding events induced by aspirin tend to balance this out in the earliest years of aspirin use.
Since cancer is well-entrenched as the No. 2 cause of death in America (and is inching into the No. 1 slot), when we think of the preventive benefits of aspirin, it is time to reframe our thinking into appreciation of the combined benefits of cancer mortality reduction in addition to CV event reduction.Radiation exposure from ct is quite substantial. A "typical" abdominal CT (AB-CT) examination exposes a patient to X-radiation equivalent to more than 500 chest X-rays.
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