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All you need to read in the other general journals

BMJ 2009; 338 doi: http://dx.doi.org/10.1136/bmj.b1826 (Published 05 May 2009) Cite this as: BMJ 2009;338:b1826

Unhealthy lifestyles blamed for most new diabetes in older adults

Unhealthy lifestyles could be responsible for nine out of ten new cases of diabetes mellitus among older US adults, say researchers. A cohort study that tracked 4883 men and women aged 65 or over for ten years suggested that if all older people exercised more, stopped smoking (or never started), ate a healthy diet, drank moderately, and had a body mass index of less than 25, the incidence of drug dependent diabetes in this age group would fall by 89% (95% CI 23% to 99%). The analysis found a clear dose-response effect. Risk of diabetes fell in a stepwise fashion with each extra healthy lifestyle factor.

All five factors were linked to incident diabetes independently of each other and of age, sex, ethnic background, education, and income. Even without body mass index, which is hard to modify, the population attributable risk of the other four factors combined was 81% (95% CI 42% to 94%).

The participants were randomly selected from lists of adults who were eligible for state funded health care (Medicare), and the mean age at baseline was 72 years. Lifestyle advice seems to be just as important for older people as it is for anyone else, say the researchers. If the associations reported here are causal, even modest changes in lifestyle could have a big effect on the incidence of diabetes among the fastest growing sector of the US population.

Exogenous erythropoietins reduce survival in people with cancer

Cancer patients given synthetic erythropoietins to prevent or treat anaemia had a higher mortality than controls (hazard ratio 1.17, 95% CI 1.06 to 1.30), in the latest meta-analysis to look at this controversial issue.

Researchers led by a team from Germany analysed data from nearly 14 000 patients in 53 trials of epoetin and darbepoetin. Around half of the participants had breast or lung cancer, and many were in advanced stages. Trial results were generally consistent across different trial populations and treatment regimens. Close analysis found no particular patient subgroups that benefited from synthetic erythropoietins; however, the excess mortality was non-significantly smaller in an analysis confined to patients who had received chemotherapy (1.10, 0.98 to 1.24).

The companies who make or market synthetic erythropoietins contributed data but had no other influence on the meta-analysis, which was paid for by grants from the German government and two universities.

The researchers say their findings are the most reliable indication so far that stimulating erythropoiesis can be harmful in patients with cancer. The mechanism of this effect is unknown, although plausible theories include an increased risk of thromboembolism and a direct effect of synthetic erythropoietins on tumour growth.

Higher mortality must be weighed against the documented benefits of these agents—a reduced need for blood transfusions and less fatigue—say the researchers. Whether synthetic erythropoietins improve quality of life is not yet clear.

Mortality remains high after treatment for HIV in sub-Saharan Africa

In rich countries, antiretroviral treatment has reduced mortality from HIV to the point where some infected adults have life expectancies approaching normal for their age. The picture is somewhat different in sub-Saharan Africa, however, where mortality is much higher than that of the general population, even after treatment.

In a new study, researchers calculated an overall standard mortality ratio of 18.7 per 100 patient years (95% CI 17.7 to 19.8) for 13 249 infected men and women given antiretroviral drugs by programmes in Cote d’Ivoire, South Africa, Malawi, and Zimbabwe. Relative death rates were lowest for the minority of patients who started treatment early in the course of disease—the standard mortality ratio fell to 3.44 (1.91 to 6.17) for those who at baseline had CD4 counts of at least 200 cells/μl and were in World Health Organization stage I or II. Death rates also fell with longer treatment.

By the end of two years, those patients treated earliest in the course of their disease had a standard mortality ratio of just 1.14 (0.47 to 2.77), comparable to the excess mortality associated with diabetes. Unfortunately, 85% of the cohort had advanced disease before starting treatment. Standard mortality ratios for those individuals with the worst disease parameters peaked at over 500.

Pharmacists reduce drug errors in outpatients with cardiovascular disease

Having a pharmacist on the team can help prevent drug errors and adverse drug events in hospital patients. There are fewer studies in the outpatient setting though, so researchers in the US reanalysed data from two trials set up to measure the impact of an outpatient pharmacist on adherence. Both trials also collected data on drug errors and adverse drug events. One study recruited patients with heart failure, the other patients with hypertension.

After combining the two trials, researchers found that the dedicated services of a pharmacist reduced the incidence of harmful or potentially harmful drug events by around a third (risk ratio 0.66; 95% CI 0.50 to 0.88). These events included mistakes in prescribing, mistakes in monitoring, preventable drug interactions, and near misses—mistakes that could have harmed someone but didn’t. Most adverse drug events in this analysis occurred in the 484 patients with complicated hypertension or heart failure.

Both trials were set in a single pharmacy serving one primary care centre in Indiana. The pharmacists gave advice and information; answered questions; kept track of patients and their treatment; and alerted doctors and nurses at the clinic to potential drug related problems. Which elements of the service reduced the incidence of adverse drug events is not yet clear.

Notes

Cite this as: BMJ 2009;338:b1826