Journals Watch - Renal surgery, obesity and diabetes

Too busy to read the journals? Let Dr Louise Newson keep you up to date with the latest research.

Renal artery stenosis: percutaneous revascularisation improves patency but shows limited clinical benefit
Renal artery stenosis: percutaneous revascularisation improves patency but shows limited clinical benefit

Medical treatment better for renal artery stenosis - N Engl J Med 2009; 361: 1953-62
Many patients with atherosclerotic renovascular disease undergo percutaneous revascularisation of their renal arteries. Although this technique improves the patency of the blood vessels, actual evidence of a clinical benefit is still limited.

In this study, more than 800 patients with atherosclerotic renovascular disease were randomised either to undergo revascularisation in addition to medical therapy or to receive medical therapy alone. The median follow-up was 34 months.

Results showed no demonstrable clinical benefit of undergoing a revascularisation procedure compared with receiving medical therapy, and there were substantial risks from the procedure - including deaths and amputations of toes or limbs.

Managing overweight and obese children - BMJ 2009; 339: b3308
The scale of childhood obesity in the UK is very concerning and I often wonder whether or not we can really make an impact on improving it.

In this Australian study, children aged five-10 years who were overweight or obese were identified and half of them received four consultations over a 12-week period. These consultations addressed nutrition, physical activity and sedentary behaviour.

Purpose-designed family materials were also provided.

The results were very disappointing - those in the intervention group did not improve their BMI, physical activity or nutrition. Obviously, costs of performing interventions like this are likely to be considerable.

These results reinforce my notion that we are fighting a losing battle by trying to address and manage childhood obesity in primary care.

Onset of diabetes can be delayed - Lancet 2009; 374: 1677-86
The Diabetes Prevention Program (DPP) was a major multicentre study, which demonstrated that the incidence of diabetes in high-risk adults was reduced with intensive lifestyle intervention and with metformin, compared with placebo.

This study followed patients from the trial for an additional follow-up period of around five years. Those who had been taking metformin continued to take it and additional lifestyle support was given to those who were originally in the lifestyle intervention group.

The results were that the prevention or delay of diabetes with lifestyle intervention or metformin actually persisted for at least 10 years. Diabetes incidence in the 10 years since DPP randomisation was reduced by 34 per cent in the lifestyle group and 18 per cent in the metformin group, compared with placebo.

The results might support use of metformin in patients with a high risk of developing diabetes in the future, such as those with impaired glucose tolerance.

Hip fracture is a concern in patients with heart failure - Eur Heart J 2009; doi:10.1093/eurheartj/ehp483
This US study investigated the impact of heart failure on hip fracture risk by following up more than 5,500 participants of the Cardiovascular Health Study for an average of 11.5 years.

Researchers found that the annual rates of hip fracture in those with and without heart failure were 14.0 and 6.8 cases per 1,000 person-years respectively. In addition, those patients who had a hip fracture after a diagnosis of heart failure were more likely to die than those with heart failure alone.

The authors recommend that future research should investigate strategies to reduce osteoporosis and fracture risk in heart failure patients.

High rates of complications with vaginal ring pessaries - BJOG 2009; 116: 1715-21
I have several elderly female patients who have had ring pessaries inserted. They all seem delighted with them and I cannot think of a patient recently who has had problems.

So I was surprised to read this research from Australia, which looked at the length of use and complications of pessary use over a 10-year period. Over half of the women experienced complications from their pessaries; these included bleeding, extrusion, severe vaginal discharge, pain and constipation.

Less than a tenth continued with using a pessary at the end of this study. I wonder whether these patients are comparable to those we see in primary care.

Ivabradine shows efficacy in diabetics with stable CAD - Am J Cardiol 2009; doi:10.1016/j.amjcard.2009.08.642
Ivabradine is a specific heart-rate lowering anti-anginal agent that inhibits the If current, the primary modulator of spontaneous diastolic depolarisation in the sinoatrial node.

Pooled data from eight studies were used to evaluate the safety and efficacy of ivabradine in over 500 patients with diabetes mellitus. As in non-diabetic individuals, ivabradine treatment in diabetic patients was associated with an approximately 15 per cent reduction in resting heart rate and improvement in exercise tolerance measures.

Reassuringly, ivabradine had no adverse impact on glucose metabolism. Although beta-blockers are still used for first-line treatment of stable angina, ivabradine is an effective alternative for diabetic patients in whom beta-blockers are contraindicated or not tolerated.

  • Dr Newson is a GP in the West Midlands, and a member of our team who regularly review the journals

The Quick Study

  • Percutaneous revascularisation may not be clinically beneficial for renal artery stenosis.
  • Childhood obesity did not improve after a primary care intervention.
  • Metformin use can delay onset of diabetes in high-risk patients.
  • Heart failure patients with hip fracture have higher mortality rates.
  • Ring pessaries were associated with complications such as bleeding, pain and constipation.
  • Ivabradine is an effective alternative to beta-blockers for diabetic patients with angina.

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