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BMJ 2009; 338 doi: (Published 01 April 2009) Cite this as: BMJ 2009;338:b1296

Tight glucose control increases mortality in critically ill patients

A surprise result from a trial of intensive glucose control in critically ill patients leaves clinicians in “something of a quandary,” says an editorial (p 1346). The trial compared tight control to a target concentration between 4.5 mmol/l and 6 mmol/l with more liberal control to a target between 8 mmol/l and 10 mmol/l. The authors expected the tighter control to save lives. It didn’t, and it may even have cost some. More patients died within 90 days in the intensively treated group (27.5% (829/3054) v 24.9% (751/3050)). The odds of death were higher by a significant 14% (odds ratio 1.14, 95% CI 1.02 to 1.28). The editorial lists plenty of plausible candidates for the excess deaths, including hypoglycaemia. Glucose concentrations were lower throughout the trial in patients treated more intensively, and severe hypoglycaemia was significantly more likely (6.8% (206/3016) v 0.5% (15/3014)). Many intensive care units are geared up to control blood sugar concentrations with insulin automatically, so how should staff respond to these findings?

It is important not to over-react and return to the bad old days of “sliding scales” and haphazard glucose control, says the editorial. We still need to optimise glucose concentrations in critically ill patients and particularly need to avoid the extremes. We now know, however, that we have nothing to gain from reducing glucose concentrations below 8 mmol/l—the lower boundary of the target for controls in this large and convincing trial.

Circumcision protects men against genital herpes and HPV

We know that circumcision helps protect men from heterosexually acquired HIV. It can also protect them from herpes simplex virus type 2 (HSV-2) and human papillomaviruses (HPVs), according to a new analysis of two randomised trials from Uganda. The trials were originally designed to look at the effect of circumcision on HIV infection, but they also included more than 3000 men …

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