Insulin for acute stroke - no benefit

In acute stroke previous research has suggested that managing hyperglycaemia could limit neurological damage and improve outcomes. However, a recent Cochrane review suggests that there is no benefit.

"Evidence from this systematic review indicates that, compared with control intervention, the administration of insulin to maintain glucose within a specific range immediately after acute ischaemic stroke does not reduce dependency, neurological deficit or mortality at 30 days or 90 days. These findings did not change in the subgroup analysis of those with diabetes mellitus compared to those without diabetes mellitus. There was, however, a significant increase in episodes of hypoglycaemia in the treatment group. This review provides no evidence to support the use of intensive insulin therapy for tight glucose control after acute stroke." [1]

1. Bellolio MF, Gilmore RM, Stead LG. Insulin for glycaemic control in acute ischaemic stroke. Cochrane Database Syst Rev 2011;9:CD005346. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005346.pub3/full

Jury still out on 'pay for performance'

Recent Cochrane review published on financial incentives and quality of healthcare in primary care [1] shows that the jury is still out. "there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care. Implementation should proceed with caution and incentive schemes should be more carefully designed before implementation."

In the last couple of years some research published by Imperial College in London suggested there was some benefit for certain types of patients in diabetes. [2] [3]

Quality interventions are often multi-factorial. Although they may appear to have high face-validity but to be certain that particular aspects work as intended more careful study is required of how they change behaviour. The jury is still out on whether 'pay for performance' is beneficial.

1. Scott A, Sivey P, Ait Ouakrim D, Willenberg L, Naccarella L, Furler J, Young D. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database Syst Rev 2011;9:CD008451. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008451.pub2/full

2. Alshamsan R, Millett C, Majeed A, Khunti K. Has pay for performance improved the management of diabetes in the United Kingdom? Prim Care Diabetes 2010 Jul;4(2):73-78. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20363200

3. Millett C, Bottle A, Ng A, Curcin V, Molokhia M, Saxena S, Majeed A. Pay for perfomance and the quality of diabetes management in individuals with and without co-morbid medical conditions. J R Soc Med 2009 Sep;102(9):369-377. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19734534

Foam dressings for diabetic foot ulcers - Cochrane Review

Cochrane review of foam dressings for healing diabetic foot ulcers concludes:

"We found no evidence that foam dressings promote the healing of diabetic foot ulcer compared with basic wound contact dressings. When data from two studies (eight and 12 weeks follow-up) were pooled, there was no statistically significant difference in ulcer healing between alginate and foam dressings. Similarly there was no evidence of a difference in the number of diabetic foot ulcers healed between foam and hydrocolloid (matrix) dressings. We note that most included studies were evaluating treatments on participants with non-complex foot ulcers. This means the body of literature presented may be of limited use to health professional in the treatment of patients with harder to heal foot ulcers as it is difficult to generalise from the included studies to patients with more co-morbidities or complications; this is a limitation of the RCTs that have been undertaken in this field thus far. Included trials were small and therefore statistically underpowered to detect important treatment differences should they exist." [1]

No evidence of clinical benefit from foam dressings and generally poor quality studies. This is a good reminder that it is not often about what you "put on" the ulcer but what pressure you "take off".

1. Dumville JC, Deshpande S, O’Meara S, Speak K. Foam dressings for healing diabetic foot ulcers. Cochrane Database Syst Rev 2011;9:CD009111. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009111.pub2/full

Reminder of the poor outcomes for foot care in diabetes

In this study - a prospective cohort of 291 patients managed to current evidence-based guidelines in French hospitals - the authors concluded:

"Most of the wounds were located on the toes and forefoot, and infection was most often graded as moderate; nevertheless, in about 50% of patients, osteomyelitis was suspected. Also, 87% of patients had peripheral neuropathy and 50-62% had peripheral artery disease. Gram-positive cocci, and Staphylococcus aureus in particular, were by far the most frequently isolated microorganisms. During hospitalization, lower-limb amputation was performed in 35% of patients; in 52%, the wound healed or had a favourable outcome. A year after discharge, 150 non-amputated patients were examined: at this time, 19% had to undergo amputation, whereas 79% had healed their wounds with no relapse. Risk factors for amputation were location (toes), severity of the wound and presence of osteomyelitis. Peripheral artery disease was associated with a poor prognosis, yet was very often neglected.

In spite of being managed at specialized centres that were, in general, following the agreed-upon published guidelines, the prognosis for diabetic foot infection remains poor, with a high rate (48%) of lower-limb amputation."

1. Richard J-L, Lavigne J-P, Got I, Hartemann A, Malgrange D, Tsirtsikolou D, Baleydier A, Senneville E. Management of patients hospitalized for diabetic foot infection: results of the French OPIDIA study. Diabetes Metab. 2011 Jun;37(3):208-215. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21169044

Metformin and exercise

There seems to be some antagonism between metformin and exercise.

Researchers from Canada looked at the effects of metformin or placebo with exercise on detailed exercise physiological variables in patients with Type 2 Diabetes.

"In conclusion, our study reports several novel findings regarding the concomitant use of metformin and exercise, specifically: 1) increased HR during exercise with metformin, 2) higher plasma metformin concentrations with exercise, and 3) nonadditive effects of metformin and exercise on the glycemic response to feeding. In our opinion, the magnitudes of these effects were small but have the potential to reduce the effectiveness of this therapeutic combination in diabetes treatment. Additional research could help optimize the concurrent use of these important and widely prescribed treatment modalities for diabetes."


1. Boulé NG, Robert C, Bell GJ, Johnson ST, Bell RC, Lewanczuk RZ, Gabr RQ, Brocks DR. Metformin and exercise in type 2 diabetes: examining treatment modality interactions. Diabetes Care 2011 Jul;34(7):1469-1474. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21602430

Chocolate may be good for you ...

say researchers in the BMJ who conducted a meta-analysis.

"Based on observational evidence, levels of chocolate consumption seem to be associated with a substantial reduction in the risk of cardiometabolic disorders. Further experimental studies are required to confirm a potentially beneficial effect of chocolate consumption." [1]

Of course, making it Fairtrade, makes it even better for you!

1. Buitrago-Lopez A, Sanderson J, Johnson L, Warnakula S, Wood A, Di Angelantonio E, Franco OH. Chocolate consumption and cardiometabolic disorders: systematic review and meta-analysis. BMJ 2011;343:d4488. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21875885

Call for papers - Patient Perspective Case Reports

BMJ Case Reports is coming up to publishing its 3000th report soon but one aspect that hasn't been explored as much as others is the patient perspective.

The patient's voice is an important aspect to come through in a case report but their input often ends with signing the consent form! It doesn't have to be like that. The consequences of a particular condition or treatment on the person are often important reminders of clinical lessons or the sources of new hypotheses. The experience of patients with healthcare systems can help document and improve clinical performance.

Any e-patients out there that want to work on a patient perspective style case report? I'd be very happy to help.