Apr 14, 2017


The story

The obesity and diabetes epidemics are going to shape your career, even if you're always too busy to eat lunch. New studies explore the extent of the problem.

The basics

Since 1990, diabetes has exploded alongside supersized fries and drinks. The Global Burden of Disease report estimates that diabetes had the largest increase in disability burden among 30 common causes between 1990 – 2015. It now ranks 6th among the leading causes of global disease burden, right up there with other clinic stalwarts like low back pain and depression.

The young

The incidence of type 2 diabetes (T2D) increased by almost 5% from 2002 – 2012 among patients aged 10 – 19, according to a study of five youth centers in the United States. Increases were larger in all ethnic and racial groups besides non-Hispanic whites, which many think is related to increases in obesity seen disproportionately in non-white ethnic groups. But in a twist that surprised experts, the incidence of type 1 diabetes also increased in a ethnicity-specific manner that is unlikely to be explained by obesity.

The old

You've mostly heard about Sweden through the Ikea furniture in your med school dorm room, but the country has important data on diabetes outcomes. An enormous cohort study of almost 500,000 Swedish patients with T2D found that while cardiovascular event rates fell for T2D patients from 1998 – 2014, mortality rates for matched controls fell more rapidly (31% decrease vs. 21%, respectively), documenting a large health gap between diabetics and the general population. A 2-minute video has more. 

The takeaway

It's hard to solve a problem if you can't define it, and the two new studies establish racial disparities in diabetes incidence and a mortality gap for T2D patients as epidemiological truths.

Say it on rounds

When your pants feel a little tighter after intern year

A little extra pressure may be good for you. Though the role of high positive end-expiratory pressure (PEEP) in mechanically vented patients remains a subject of debate, a single-center study of post-op cardiac patients found significant advantages for a high PEEP strategy. High PEEPers (13 cm H2O) had shorter ICU stays and fewer hospital days than moderate PEEPers (8 cm H2O), as well as fewer pulmonary complications.

When you sign out a one-time overnight bed check 

A single look gives a lot of info. Take colorectal cancer diagnosis (CRC) and mortality: a multicenter RCT of > 170,000 patients found that a single screening with flexible sigmoidoscopy offered protection from CRC for up to 17 years. In the intention-to-treat analysis, one-time screening reduced colorectal cancer incidence by 26%, while mortality fell by 30%. Outside of the US, where colonoscopy is the screening tool of choice, flexible sigmoidoscopy and fecal occult blood testing are the most commonly used screening tests.

When your black weekend seems like a marathon

Try not to get anybody hurt. A look at cardiac events during big city marathons found a 4% higher 30-day mortality rate on the morning of the big race compared to routine days. Analyses point to closed roads and traffic as likely culprits, as marathon-day patients had longer ambulance travel times and were more likely to present to emergency departments with cardiac arrest.

Brush up

Hemolytic uremic syndrome

Endothelial damage and small vessel platelet thrombi cause hemolytic uremic syndrome (HUS) and it's cousin thrombocytopenic purpura (TTP). Diagnose both disorders with a low platelet count and red blood cell fragmentation on blood smear (termed 'microangiopathic hemolytic anemia'). Signs of end organ damage – classically neurologic dysfunction in TTP and renal dysfunction in HUS – are often absent at initial presentation and can make the diagnosis tricky. Plasma exchange is the mainstay of treatment for TTP, but has unclear benefit in HUS. 

What's the evidence

For eculizumab in atypical HUS?  Endothelial damage is mediated by the complement pathway, and eculizumab is a monoclonal antibody against the terminal complement protein C5. In a paired prospective trial, patients treated with eculizumab had durable increases in platelet counts at 6 months after treatment, and 80% of patients did not require initiation of plasma exchange or dialysis. Eculizumab (Soliris) is one of the world's most expensive drugs, so optimal duration of treatment is under investigation.   

Residency's tough

People are tougher. Peter Gold, a medical student who was shot while trying to stop an attack on a woman outside a New Orleans bar in 2015, watched footage of his rescue attempt on national TV with Matt Lauer. Big ups. 

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