Faculty Peer Reviewed
Macrovascular Control: In the New England Journal of Medicine, a new study re-addresses the question of whether tight glycemic control in diabetes prevents macrovascular complications. “Glucose Control and Vascular Complications in Veterans with Type 2 Diabetes” was an open-label study, which randomized 1791 diabetic veteran to either intensive or standard glucose control. The subjects were mostly men with a mean age of 60.4 and carried the diagnosis of type 2 diabetes for a mean of 11.5 years. Forty percent of subjects had suffered a prior cardiovascular event. The primary outcome was the time from randomization to a “major cardiac event,” a composite of vascular complications, including myocardial infarction and stroke. Upon entry into the study, the mean glycated hemoglobin was 9.4%, dropping to 8.4% in the standard-therapy group and 6.9% in the intensive-therapy group. After a mean follow-up of 5.6 years, the primary outcome occurred in 264 standard-therapy patients and 235 intensive-therapy patients, yielding a hazard ratio for intensive-therapy of 0.88 (CI 0.74-1.05, P=0.14) – a nonsignificant result. Carvdiovascular death and death from any cause were the same in both groups, while sudden death occurred more frequently in the intensive-therapy group (11 vs. 4 events). This study adds to previous studies (ADVANCE and ACCORD) that have failed to show a decrease in macrovascular complications with intensive glucose control. However, two prior studies (DCCT and UKPDS) performed follow-up analyses ten years after study completion, and did show a reduction in cardiovascular outcomes in the original intensive-therapy groups, suggesting that the tight glycemic control offers a delayed benefit. So, does this new study suggest that we can let the A1C ride high? Certainly not. But we should be reminded of the well-proven means to reduce cardiovascular events in diabetics: by controlling other cardiovascular risk factors, including hypertension and dyslipidemia.
Death in Dementia: In Lancet Neurology, a new study looked further into mortality associated with using antipsychotics in patients with Alzheimer’s disease (AD). The Dementia Antipsychotic Withdrawal Trial randomized 165 patients currently using antipsychotics (thioridazine, chlorpromazine, haloperidol, trifluoperazine,or risperidone) to either continued therapy or substitution with placebo. The primary outcome was death at one year. The cumulative survival was 70% in the antipsychotic group, compared with 77% in the placebo group. This trial should remind us of other more difficult, but benign techniques for dealing with psychiatric symptoms of AD, such re-orientation and environment modification.
Full Disclosure: As reported by The New York Times, the New England Journal of Medicine has intensified its policy on physician disclosure of potential conflicts of interest. The policy change was made in response to criticism of a 2006 article, which suggested that routine screening with CT scans could prevent 80 percent of lung cancer deaths. The journal did not disclose that the study author had licensed a CT-related patent to General Electric. In response to criticism, the journal has now ratcheted up its policy: Physicians are now asked to disclose all royalties and patents related to their work. These disclosures will be published with the articles.
Indian Donor: As reported in The New York Daily News, a Long Island neurosurgeon is suing his estranged wife for either 1.5 million dollars or the return of his kidney. Dr. Batista donated a kidney to his wife in 2001. They are now in the midst of divorce proceeding, and the doctor is demanding the return of his glomerular gift. Emboldened by Dr. Batista and feeling rather fatigued, I have petitioned the Red Cross for the return of the blood that I donated in 2006.
Reviewed by Neil Shapiro MD, Editor in Chief, Clinical Correlations