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CABG rather than PTCA for subset of diabetics
New
birthweight charts for diabetic pregnancies
New charts that will enable large-forgestational-age infants to be identified more accurately in diabetic pregnancies are being developed for different ethnic groups in the UK. The work done by Dr : Dornhorst and colleagues at The Postgraduate Medical School and St Mary’s Hospital Medical School, London, was presented at the European Association for the Study of Diabetes in Stock: holm, Sweden. The present UK percentile charts in common use such as those of the Medical Research Council are not corrected for ethnicity, and according to Dornhorst, Asian gestational diabetes mellitus pregnancies are more commonly observed with large-for-gestational-age infants than are white pregnancies, a difference that is apparent only when birthweight is corrected for ethnicity. : The new charts are based on birthweights of boys and girls from 162447 white, 12113 black, and 30418 Asian singleton non-diabetic pregnancies. These were consecutive births delivered between 37-42 weeks’ gestation. The new charts will be used nationally. One basic way they , may be presented is shown in the figure.
: :
:
Royal
:
Gestation (weeks)
Birthweight percentile charts: constructed with birthweight from 82 871 white, 6097 black, and 15 548 Asian male singletons from non-diabetic pregnancies.
:
When the new charts were used for identifying large-for-gestational-age infants (>90th percentile) born to 21 Asian and 27 white mothers with gestational diabetes and similar degrees of obe- : sity, more Asian 9/21 (43%) than white infants 3/27 (11%) were large for gestational age (p<004). In comparison, the present Medical Research Council charts
Talking about gastroenterological
matters
lack of evidence to justify virtually any between primary and secondary stance or you look for the answer. : encouraged by the British SociAnother session included presentations ety of Gastroenterology at its recent meeton the benefit of perioperative nutritional ing in mid-September. Prof Roger Jones (Wolfson Professor of General Practice, supplements. A randomised controlled UMDS, London) defined the areas of trial in 100 postoperative Londoners showed that ad-libitum oral supplementacommunication that make up this interface. General practice research is starting tion with Fortisip (Nutricia) was benefito deliver the information required to cial ; fewer major complications, better make sensible public health decisions. : muscle power, and less weight loss were Rational use of treatment against Heli- ; significantly associated with the supplemental food (Gut 1995; 37 [suppl 2]: : cobacter pylori and diagnostic tests remain areas of debate. Expenditure on gasA43). A similar trial was done in Scarborough with both preoperative and postoptroscopy and drugs for dyspepsia is high believe that erative sip feeding in addition to normal and many treatment of heliwill reduce The cobacter it. problem is ; diet. Fewer patients participated but the zealots mere whiff results were confirmatory: hospital stay that for some the of the was demands treatment to significantly shorter and weight loss designed organism less in the patients who received suppleinduce its extinction. Others believe an ments before and after operation (Gut : attempt ought to be made to ensure that the patient is actually infected before 1995; 37 [suppl 2]: A43). In Dundee, it was shown that oral supplementary or treatment. Yet some others attempt eradication only in conditions that have been nasogastric tube feeding were significantly better at increasing the weight of malshown to benefit from it. A debate between the president of the BSG (Prof nourished patients in hospital, although Ian Bouchier) and founder of the Primary near-perfect nutritional energy requireCare Society for Gastroenterology (Prof ments were best achieved with nasogastric : tube feeding (Gut 1995; 37 [suppl 2]: : Roger Jones) did not settle the dilemma. There simply are no adequate data on A43). These randomised controlled trials all suggest that nutritional support in whether serological screening for helimalnourished and cobacter would identify all appropriate surgical patients should become routine. The direct costs young patients for endoscopy, or whether are low, the clinical results good, and the patients without ulcers on long-term H2 antagonists benefit from eradication of indirect savings are potentially enormous. Helicobacter pylori. There are two ways of viewing this problem; either you use the R P Walt
Dialogue care was
896
identified 5/27 (18-5%) of the white infants as being large for gestational age. Insulin lispro, the rapid-acting insulin produced by recombinant DNA technology, received much attention. Dr Michael Trautmann, Eli Lilly, Germany, presented the results of a randomised crossover study involving 1037 type 1 diabetic patients treated with multiple-daily-dose insulin therapy. They received either insulin lispro or human soluble insulin for 3 months and then switched for the next 3 months. Since insulin lispro is more rapidly absorbed than human soluble insulin, it was given 10-15 min before each meal instead of the 30-45 min for soluble insulin. 79% of patients used human isophane insulin as the basal insulin, while the remaining 21% used human ultralente. Insulin lispro reduced the overall rate of hypoglycaemia by about one episode a month (6-44 [SD 763] per month on insulin lispro vs 7.19 [8’08] on human soluble insulin [p<0’001]) and control improved postprandial glucose compared with human soluble insulin. Fasting blood glucose and HbAlc did not differ statistically between the two groups.
Robert Short
CABG rather than PTCA for subset of diabetics The US National Heart, Lung, and Blood Institute has issued a clinical alert recom-
mending coronary artery bypass graft (CABG) surgery over percutaneous transluminal coronary angioplasty (PTCA) for patients who require either an oral hypoglycaemic agent or insulin to treat their diabetes mellitus, have blockages of two or more
coronary
arteries, and
are
undergo-
ing revascularisation for the first time. The NHLBI recommendations (Sept 23) were based on an analysis of data from the Bypass Angioplasty Revascularization Investigation, the largest clinical trial yet conducted comparing outcomes of the two procedures. The analysis looked at the 5-year mortality data for 352 diabetic patients receiving either oral hypoglycaemic agents or insulin who had been randomly assigned to undergo CABG or PTCA for first-time revascularisation to treat significant blockage of two or more coronary vessels. The study found that, at 5 years, the death rate was 35% among those treated with a PTCA and 19% among those treated with a CABG (p=0002). The mortality rates among the drug-treated diabetics who underwent PTCA were not due to complications of the procedure but may be due to differences in how the blood vessels in these diabetics respond to the local injury caused by PTCA, the NHLBI said. Michael
McCarthy
birthweight charts for diabetic pregnancies
New charts that will enable large-forgestational-age infants to be identified more accurately in diabetic pregnancies are being developed for different ethnic groups in the UK. The work done by Dr : Dornhorst and colleagues at The Postgraduate Medical School and St Mary’s Hospital Medical School, London, was presented at the European Association for the Study of Diabetes in Stock: holm, Sweden. The present UK percentile charts in common use such as those of the Medical Research Council are not corrected for ethnicity, and according to Dornhorst, Asian gestational diabetes mellitus pregnancies are more commonly observed with large-for-gestational-age infants than are white pregnancies, a difference that is apparent only when birthweight is corrected for ethnicity. : The new charts are based on birthweights of boys and girls from 162447 white, 12113 black, and 30418 Asian singleton non-diabetic pregnancies. These were consecutive births delivered between 37-42 weeks’ gestation. The new charts will be used nationally. One basic way they , may be presented is shown in the figure.
: :
:
Royal
:
Gestation (weeks)
Birthweight percentile charts: constructed with birthweight from 82 871 white, 6097 black, and 15 548 Asian male singletons from non-diabetic pregnancies.
:
When the new charts were used for identifying large-for-gestational-age infants (>90th percentile) born to 21 Asian and 27 white mothers with gestational diabetes and similar degrees of obe- : sity, more Asian 9/21 (43%) than white infants 3/27 (11%) were large for gestational age (p<004). In comparison, the present Medical Research Council charts
Talking about gastroenterological
matters
lack of evidence to justify virtually any between primary and secondary stance or you look for the answer. : encouraged by the British SociAnother session included presentations ety of Gastroenterology at its recent meeton the benefit of perioperative nutritional ing in mid-September. Prof Roger Jones (Wolfson Professor of General Practice, supplements. A randomised controlled UMDS, London) defined the areas of trial in 100 postoperative Londoners showed that ad-libitum oral supplementacommunication that make up this interface. General practice research is starting tion with Fortisip (Nutricia) was benefito deliver the information required to cial ; fewer major complications, better make sensible public health decisions. : muscle power, and less weight loss were Rational use of treatment against Heli- ; significantly associated with the supplemental food (Gut 1995; 37 [suppl 2]: : cobacter pylori and diagnostic tests remain areas of debate. Expenditure on gasA43). A similar trial was done in Scarborough with both preoperative and postoptroscopy and drugs for dyspepsia is high believe that erative sip feeding in addition to normal and many treatment of heliwill reduce The cobacter it. problem is ; diet. Fewer patients participated but the zealots mere whiff results were confirmatory: hospital stay that for some the of the was demands treatment to significantly shorter and weight loss designed organism less in the patients who received suppleinduce its extinction. Others believe an ments before and after operation (Gut : attempt ought to be made to ensure that the patient is actually infected before 1995; 37 [suppl 2]: A43). In Dundee, it was shown that oral supplementary or treatment. Yet some others attempt eradication only in conditions that have been nasogastric tube feeding were significantly better at increasing the weight of malshown to benefit from it. A debate between the president of the BSG (Prof nourished patients in hospital, although Ian Bouchier) and founder of the Primary near-perfect nutritional energy requireCare Society for Gastroenterology (Prof ments were best achieved with nasogastric : tube feeding (Gut 1995; 37 [suppl 2]: : Roger Jones) did not settle the dilemma. There simply are no adequate data on A43). These randomised controlled trials all suggest that nutritional support in whether serological screening for helimalnourished and cobacter would identify all appropriate surgical patients should become routine. The direct costs young patients for endoscopy, or whether are low, the clinical results good, and the patients without ulcers on long-term H2 antagonists benefit from eradication of indirect savings are potentially enormous. Helicobacter pylori. There are two ways of viewing this problem; either you use the R P Walt
Dialogue care was
896
identified 5/27 (18-5%) of the white infants as being large for gestational age. Insulin lispro, the rapid-acting insulin produced by recombinant DNA technology, received much attention. Dr Michael Trautmann, Eli Lilly, Germany, presented the results of a randomised crossover study involving 1037 type 1 diabetic patients treated with multiple-daily-dose insulin therapy. They received either insulin lispro or human soluble insulin for 3 months and then switched for the next 3 months. Since insulin lispro is more rapidly absorbed than human soluble insulin, it was given 10-15 min before each meal instead of the 30-45 min for soluble insulin. 79% of patients used human isophane insulin as the basal insulin, while the remaining 21% used human ultralente. Insulin lispro reduced the overall rate of hypoglycaemia by about one episode a month (6-44 [SD 763] per month on insulin lispro vs 7.19 [8’08] on human soluble insulin [p<0’001]) and control improved postprandial glucose compared with human soluble insulin. Fasting blood glucose and HbAlc did not differ statistically between the two groups.
Robert Short
CABG rather than PTCA for subset of diabetics The US National Heart, Lung, and Blood Institute has issued a clinical alert recom-
mending coronary artery bypass graft (CABG) surgery over percutaneous transluminal coronary angioplasty (PTCA) for patients who require either an oral hypoglycaemic agent or insulin to treat their diabetes mellitus, have blockages of two or more
coronary
arteries, and
are
undergo-
ing revascularisation for the first time. The NHLBI recommendations (Sept 23) were based on an analysis of data from the Bypass Angioplasty Revascularization Investigation, the largest clinical trial yet conducted comparing outcomes of the two procedures. The analysis looked at the 5-year mortality data for 352 diabetic patients receiving either oral hypoglycaemic agents or insulin who had been randomly assigned to undergo CABG or PTCA for first-time revascularisation to treat significant blockage of two or more coronary vessels. The study found that, at 5 years, the death rate was 35% among those treated with a PTCA and 19% among those treated with a CABG (p=0002). The mortality rates among the drug-treated diabetics who underwent PTCA were not due to complications of the procedure but may be due to differences in how the blood vessels in these diabetics respond to the local injury caused by PTCA, the NHLBI said. Michael
McCarthy