Orlistat 120 mg improves glycaemic control in type 2 diabetic patients with or without concurrent weight loss

BACKGROUND

Both obesity and type 2 diabetes are associated with increased morbidity and mortality. Published data suggest that orlistat 120 mg, a lipase inhibitor used to treat obesity, may improve glycaemic parameters through weight loss-independent effects.

AIM

To investigate the effect of orlistat 120 mg on weight loss, and assess whether changes in glycaemic parameters [fasting plasma glucose (FPG) and haemoglobin A1c (HbA1c)] are independent of weight loss.

METHODS

This retrospective analysis of pooled data from seven multicentre, double-blind, placebo-controlled studies involved overweight or obese patients with type 2 diabetes (aged 18-70 years). Patients were required to have a body mass index of 27-43 kg/m2, HbA1c of 6.5 to <13%, and stable weight for > or =3 months. Subjects received orlistat 120 mg tid or placebo for 6 or 12 months.

RESULTS

A total of 2550 overweight or obese patients with type 2 diabetes were enrolled and randomized to treatment with orlistat 120 mg tid (n = 1279) or placebo (n = 1271). For the whole population, patients treated with orlistat 120 mg had significantly greater mean decreases in FPG compared with placebo-treated patients (-1.39 mmol/l vs. -0.47 mmol/l; p < 0.0001). In addition, orlistat 120 mg provided significantly larger mean decreases in HbA1c compared with placebo (-0.74% vs. -0.31%; p < 0.0001). For patients with minimal weight loss (< or =1% of baseline body weight), orlistat 120 mg still provided a significantly greater decrease in the least squares mean value for both FPG (-0.83 mmol/l vs. +/-0.02 mmol/l; p = 0.0052) and HbA1c -0.29% vs. +/-0.14%; p = 0.0008). This suggested that the improvement of glycaemic control with orlistat 120 mg was independent of weight loss. Using linear regression analysis, improvement in glycaemic control (FPG and HbA1c) with orlistat 120 mg was less strongly correlated with weight loss than for placebo.

CONCLUSION

Orlistat 120 mg appears to improve glycaemic control more than would be predicted by weight loss alone in overweight or obese patients with type 2 diabetes. Postulated mechanisms underlying this effect include an improvement of insulin sensitivity, a slower and incomplete digestion of dietary fat, reduction of postprandial plasma non-esterified fatty acids, decreased visceral adipose tissue, and stimulation of glucagon-like peptide-1 secretion in the lower small intestine.

Post-Traumatic Short-Lasting Unilateral Headache With Cranial Autonomic Symptoms (SUNA)

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome is a rare headache syndrome classified among the trigeminal autonomic cephalalgias. It is usually idiopathic, although infrequent secondary forms have been described. Recently the term short-lasting unilateral headache with cranial autonomic symptoms (SUNA) has been defined by the International Headache Society (ICHD-2) as similar to SUNCT with less prominent or absent conjunctival injection and lacrimation. We report two patients with paroxysmal orbito-fronto-temporal pains, phenotypically suggesting SUNA, occurring after traumatic head injury.

Massive chondroid hamartoma of the lung clinically masquerading as bronchogenic carcinoma

Chondroid hamartomas of the lung are uncommon lesions which are generally small sized and asymptomatic. Herein we describe a case of a large-sized pulmonary chondroid hamartoma which clinically mimicked bronchogenic carcinoma. A large hilar growth was detected in the left lung on radiological studies. Left upper lobectomy was done. The growth was well defined with a lobulated bluish cut surface. Histopathology disclosed lobules of mature cartilage rimmed by long slit-like epithelial channels admixed with mature adipose tissue.

[Laparoscopy in the management of endometrial cancer]

Recent advance in laparoscopy have changed the surgical approach of endometrial cancer patients. The Swissendos Center, Fribourg, in collaboration with AGO (Groupe de travail pour la gynécologie oncologique) and AGE (groupe de travail pour la gynécologie endoscopique) have established a consensus based on the available evidence for the use of laparoscopy in the management of patients with endometrial cancer The main objective was to define Swiss clinical practice guidelines appropriate to the country and consistent with the needs of the physicians.

Hypothermia in VGKC antibody-associated limbic encephalitis

Voltage-gated potassium channel antibody (VGKC-Ab)-associated limbic encephalitis (LE) is a recently described syndrome that broadens the spectrum of immunotherapy-responsive central nervous system disorders. Limbic encephalitis is typically characterised by a sub-acute onset of disorientation, amnesia and seizures, but the clinical spectrum is not yet fully defined and the syndrome could be under-diagnosed. We here describe the clinical profile of four patients with VGKC-Ab-associated LE who had intermittent, episodic hypothermia. One of the patients also described a prodrome of severe neuropathic pain preceding the development of limbic symptoms. Both of these novel symptoms responded well to immunosuppressive therapy, with concurrent amelioration of amnesia/seizures.

Epidemiological studies of leukaemia in children and young adults around nuclear facilities: a critical review

The existence of an increased risk of childhood leukaemia near nuclear installations is a recurrent issue. A review of the related epidemiological literature is presented here. Results for 198 nuclear sites throughout 10 countries were included in the review. In addition to local studies, 25 multi-site studies have been published for eight countries. A large variability was noticed in the quality of the data as well as in the definition of the study population and in the methods of analysis. Many studies present important limits that make the results difficult to interpret. The review confirms that some clusters of childhood leukaemia cases exist locally. However, results based on multi-site studies around nuclear installations do not indicate an increased risk globally. Many studies were launched to investigate possible origins of the observed clusters around specific sites, but up to now, none of the proposed hypotheses have explained them.

Colocutaneous fistula complicating therapeutic mesenteric embolisation

Percutaneous embolotherapy has now assumed an important role in the management of massive colonic haemorrhage. However, this therapeutic option is associated with a significant risk of irreversible segmental colonic ischaemia. We present a case where distal segmental ischaemia led to a colocutaneous fistula, a complication not reported so far in the literature.

Totally extra-peritoneal repair of inguinal hernia by a glove-balloon: Technical innovation

Totally extra-peritoneal (TEP) laparoscopic repair of an inguinalhernia involves the creation of an extra-peritoneal space by blunt dissection or the use of commercial balloons. This new technique demonstrates the use of a device to create this extra-peritoneal space, without the need for any commercial balloons. The extra-peritoneal space was created using a glove-balloon. A total of 107 consecutive TEP repairs were carried out using the glove-balloon technique, these included ten bilateral and 17 recurrent inguinal hernias. This method is simple, cost-effective and easy to teach.

CMV colitis presenting as acute abdomen requires early diagnosis and treatment to avoid mortality

OBJECTIVE

Acute CMV-colitis is an unusual cause of emergency colectomy in a general surgical department. The aim of this article is to report our experience on CMV colitis as a cause of acute abdomen.

METHODS

Five patients were referred to general surgery during a three-year period with acute abdomen due to gastrointestinal CMV disease. All patients underwent serology for CMV except case 5. In all patients a gastroscopy or colonoscopy or both, based on individual clinical symptoms, was performed. Abdominal CT scan was requested in patients 1 and 2. Antiviral therapy was instituted in all patients. One patient (case 5) underwent surgery without prior diagnosis of CMV.

RESULTS

There were four men and a woman with a median age of 56 years. Abdominal CT revealed perforation in one patient, later confirmed at laparotomy. Four patients had a positive CMV diagnosis either on serology or tissue biopsy or both. Three patients were treated surgically of whom two died of multiorgan failure.

CONCLUSIONS

CMV may behave in the intestine as a non-pathogenic bystander. However, any condition that compromises the immune status may be sufficient to trigger its virulence. Severe colitis commits clinicians to start or increase immunosuppression regimens, whereas in gastrointestinal CMV disease such an approach inevitably aggravates the clinical picture. Tissue biopsy remains the gold standard test in CMV colitis. However, a positive diagnosis by 'any means' should prompt early antiviral treatment. Surgery should be limited to acute complications of CMV colitis and to unresponsive disease.

New insight into solvent-related end-stage renal disease: occupations, products and types of solvents at risk

OBJECTIVES

It has been shown that all-solvent exposure is associated with the progression of primary glomerulonephritis to end-stage renal disease (ESRD), but little is known about the type of solvents that are high risk. The aim of this study was to investigate the role of solvents by occupation, product and type.

METHODS

Using a retrospective cohort design, the authors studied 269 patients with non-end-stage and biopsy-proven primary glomerulonephritis diagnosed between 1994 and 2001 in Paris and its suburbs. Two industrial hygienists evaluated patients' exposures from lifetime occupational histories collected by interview from 2002-4, and using a list of the 30 most common solvents. The studied outcome was ESRD, defined as glomerular filtration rate <15 ml/mn/1.73 m(2) or dialysis. It was recorded during a mean follow-up of five years. Cox models were used to estimate adjusted hazard ratios (HR) of ESRD related to exposures.

RESULTS

Eighteen per cent of the patients had ever been exposed to solvents. Those with the highest risk of progression to ESRD were exposed machinery fitters and machine assemblers (HR 4.7, 95% CI 1.2 to 17.4) and plumbers/welders (HR 4.2, 95% CI 1.3 to 13.6), as compared to never exposed patients, as well as those who ever handled printing inks and petroleum products (HR 12.6 (95% CI 1.7 to 94.9) and 3.2 (95% CI 1.4 to 7.2), respectively). Among solvents, the highest risks were found for: toluene/xylene (HR 5.1, 95% CI 1.8 to 14.8), gasoline, fuel and gas-oil (HR 8.6, 95% CI 2.7 to 27.4), and ketones (HR 13.3, 95% CI 1.4 to 123.5).

CONCLUSION

This study highlights the potential nephrotoxicity of several solvents. Intervention to promote screening for proteinuria in exposed workers may prevent the progression of glomerulonephritis to ESRD.

[Placenta praevia totalis et increta. Cause of life-threatening haemorrhaging during a caesarean section]

Placenta increta is a rare but potentially life-threatening risk constellation after a previous caesarean section. We present the case of a 29-year-old gravida 2 para 1 patient, who developed dramatic haemorrhaging caused by this abnormal placentation, which could only be resolved by a postpartal hysterectomy. This demonstrates that in the case of a combination of the two most common predisposing factors, repeat caesarean section and placenta praevia, the possibility of a placenta increta should be considered and suitable precautions should be taken.

Evidenzbasierte Medizin

Founded on evidence based medicine (EBM), medical decisions should involve the best possible external scientific evidence as well as the expertise of the individual physician, while taking into consideration the subjective perspective of the patient. The Institute for Quality and Cost Effectiveness (Institut für Qualität und Wirtschaftlichkeit, IQWIG), which is financed through membership contributions to the statutory health insurance, deviates drastically in its evaluations for innovative medications from this concept. All publications on a medication are reduced to only a few "relevant" studies so that the statistics from the resulting meta-analysis are invalid. The resulting method dependent lack of statistical significance is considered by IQWIG authors to show the non-superiority of the test products, which are then speculatively discredited in terms of their safety. The "recommendations" of the IQWIG are accepted uncritically by the cost carriers. The aim of this article is to evaluate IQWIG-EBM in comparison with international standards on the basis of published IQWIG reports on metabolically active medications. The example of the reports on statins, short-term insulin analogues and inhaled insulin shows a methodology which suggests the misuse of study results and can best be characterized by the term "evidently biased medicine."

Frequent alteration of DNA damage signalling and repair pathways in human colorectal cancers with microsatellite instability

Accumulation of frameshift mutations at genes containing coding mononucleotide repeats is thought to be the major molecular mechanism by which mismatch repair-deficient cells accumulate functional alterations. These mutations resulting from microsatellite instability (MSI) can affect genes involved in pathways with a putative oncogenic role, but may also arise in genes without any expected role in MSI carcinogenesis because of the high mutation background of these tumours. We here screened 39 MSI colorectal tumours for the presence of mutations in 25 genes involved in DNA damage signalling and repair pathways. Using a maximum likelihood statistical method, these genes were divided into two different groups that differed significantly in their mutation frequencies, and likely represent mutations that do or do not provide selective pressure during MSI tumour progression. Interestingly, the so-called real-target mutational events were found to be distributed among genes involved in different functional pathways of the DNA metabolism, for example, DNA damage signalling (DNA-PKcs, ATR), double-strand break (DSB) repair (DNA-PKcs, RAD50), mismatch repair (MSH3, MSH6, MBD4) and replication (POLD3). In particular, mutations in MRE11 and/or RAD50 were observed in the vast majority of the tumours and resulted in the concomitant loss of immunohistochemical expression of both proteins. These data might explain why MSI colorectal cancers (CRC) behave differently in response to a wide variety of chemotherapeutic agents, notably those targeting DNA. More generally, they give further insights into how MSI leads to functional changes with synergistic effects in oncogenic pathways.

[Perspectives in the treatment of subarachnoid-hemorrhage-induced cerebral vasospasm]

Cerebral vasospasm is still the most important cause of death and disability after rupture of intracranial aneurysms. The therapeutic strategies in the treatment of subarachnoid hemorrhage induced vasospasm vasospasm include four groups: 1) prevention of vasospasm; 2) reversion of vasospasm; 3) improvement of cerebral perfusion; and 4) neuroprotection and rescue therapies. Recent experimental studies allowed the design of phase II clinical studies which demonstrated positive results with medications and compounds such as statins (simvastatin and pravastatin) and endothelin-1 receptor antagonists (clasozentan). Moreover, experimental and clinical evidences showed the advantages of early cerebrospinal fluid drainage, intrathecal administration of NO-donors, effects of Ca2+ protein kinase inhibitor (Fasudil) and catecholamines on the cerebral vessels. This review article summarizes the stage of investigation of these medications and therapeutic strategies which will be relevant in the treatment of cerebral vasospasm.

Sphincter incontinence: is regenerative medicine the best alternative to restore urinary or anal sphincter function?

Incontinence is a major public health concern in aging societies. It is caused by age-dependent spontaneous apoptosis of muscle cells in the urinary and fecal sphincters, and is aggravated in women due to birth trauma. Compared to other currently employed invasive surgical management techniques associated with morbidity and recurrence, replacement or regeneration of dysfunctional sphincter through stem cell therapy and tissue engineering techniques hold great promise. This review focuses on the pathophysiological analysis of urinary incontinence and the possible application of muscle-derived-stem cells, satellite cells, chondrocytes and adipose-derived-stem cells in restoring sphincter functions.

Clinical heterogeneity in mild chronic inflammatory demyelinating polyneuropathy

We describe the clinical presentation, progression and electrodiagnostic features of three patients with a mild form of chronic inflammatory demyelinating polyneuropathy (CIDP). The unusually mild but also variable clinical picture was a cause of diagnostic uncertainty in all, but CIDP was eventually confirmed by extensive electrophysiological studies in each case, as well as by histology in one. Cerebrospinal fluid protein was raised in only one patient. Two patients were treated by intravenous immunoglobulins and both improved. Awareness of the existence of this relatively benign form of CIDP in its various presentations is essential as it can be functionally disabling, progress to more severe symptomatology, and as patients may benefit from immunomodulatory therapy.

Pharmakotherapie des Diabetes mellitus Typ 2

Patients with diabetes type 2 are not directly endangered by dysglycemia but they suffer vascular complications. The diabetic patient with existing cardiovascular disease has a particularly high risk for further cardiovascular complications and therefore requires specific attention. This is not only due to the hyperglycemia, but due to the coexistence of further cardiovascular risk factors, such as hypertension, dyslidemia, visceral fat accumulation, chronic inflammation and coagulopathy, also clinically described as the metabolic syndrome. These patients need an intense and multi-modal therapeutic approach, not only for improvement of glycemic control. Also other vascular risk factors should be handled aggressively, such as blood pressure, coagulopathy and dyslipidemia. Recent studies--as STENO 2--indicate that a multi-modal and aggressive approach in diabetic patients can markedly improve their prognosis. Therefore, the current practice of a glucocentric approach should be changed towards a more vascular approach.

Herz-Diabetes-Netz—

Diabetic patients with heart disease are high risk patients for further vascular complications and therefore need an intensive and multimodal, interdisciplinary intervention. Due to the "segmentation" of medical care into primary care physician, specialists, acute and secondary care (rehabilitation) clinics, the patients will be taken care of on each individual segment with regard to the current requirements and specialties of the care provider. Such--each section, the GP, the cardiologist and the diabetologist, the heart centre and the rehabilitation clinic, represent individual and often strictly separate segments, which each will focus only on the acute problem and will collect (only) data required for the care in their particular segment. A multimodal approach can improve the chronic care and prognosis of these patients, as shown in several studies. The proposed network model should increase multi-disciplinary cooperation of the different levels of health care segments and overcome current barriers. It is thus necessary to provide common guidelines for diagnostic and therapeutic procedures and to improve communication between each individual sector. This could help to improve the secondary prevention in these high risk patients.