Thursday, 29 September 2011

"SMS for Life" Tanzania

Heard Alex Nemetz talk at Global Health 2011 about the "SMS for Life" project to reduce malaria in Tanzania.

Alex is the head of mHealth at Vodafone and described how the nurses in clinics were given phones to text the levels of stock to a central system. The problem was that stock was running out in some places but going out of date in others so this simple technological solution using mobile phones helped solve it. The real trick to get the healthcare workers to engage in the project was simple - give them free text bundles for their mobile phones.

GLP-1 agonists and CV risk

Given the high profile of failures of recent 'blockbuster' drugs in Type 2 diabetes it is not surprising there is anxiety about the risks associated with newer drugs.

In a recent meta-analysis of trials of glucagon-like-peptide 1 receptor agonists (trials that were originally designed to assess metabolic outcomes) the authors conclude there was no evidence to suggest a "detrimental effect of GLP-1 receptor agonists on cardiovascular events. Specifically designed longer-term trials are needed to verify the possibility of a beneficial effect." [1]

1. Monami M, Cremasco F, Lamanna C, Colombi C, Desideri CM, Iacomelli I, Marchionni N, Mannucci E. Glucagon-like peptide-1 receptor agonists and cardiovascular events: a meta-analysis of randomized clinical trials. Exp Diabetes Res 2011;2011:215764. Available from:

Tuesday, 6 September 2011

Nutritional therapy in diabetes - does it change anything?

You would think that those people with diabetes in Europe would have undergone nutritional education and therefore have different diets to their non-diabetic fellows. Not so but there are a few small differences. People with diabetes tend to drink more soft drinks but less juice, wine and beer (and sweets). People with diabetes tend to eat a little more vegetables, fish and meat. Otherwise researchers who looked at the populations in the European Prospective Investigation into Cancer and Nutrition Study (EPIC) and the Multiethnic Cohort Study (MEC) found "only small differences in dietary behavior in comparison with cohort members without diabetes". [1]

Changing dietary habits is hard work. Does this mean that nutritional therapy in diabetes doesn't take place, that it is ineffective or that we need to do a lot more of it?

1. Nöthlings U, Boeing H, Maskarinec G, Sluik D, Teucher B, Kaaks R, Tjønneland A, Halkjaer J, Dethlefsen C, Overvad K, Amiano P, Toledo E, Bendinelli B, Grioni S, Tumino R, Sacerdote C, Mattiello A, Beulens JWJ, Iestra JA, Spijkerman AMW, van der A DL, Nilsson P, Sonestedt E, Rolandsson O, Franks PW, Vergnaud A-C, Romaguera D, Norat T, Kolonel LN. Food intake of individuals with and without diabetes across different countries and ethnic groups. Eur J Clin Nutr 2011 May;65(5):635-641. Available from:

Diabetes communication technology - not how but what.

A chat line helps children and young adults with Type 1 diabetes [1] and mobile phone and web-based collaborative care helps adults with Type 2 diabetes [2]. However, telephone support for underserved ethnic minorities does not seem to help [3].

I feel that these mixed results of these new technologies (many published this year already) mean that efficacy is less to do with the mode of communication and more to do with the quality and relevance of the content of the communication with the diabetes team that is important. To compare these studies we need a lot more information about what was said, how it was said, how the teams were trained and supported, and the frequency of communication.

1. Iafusco D, Galderisi A, Nocerino I, Cocca A, Zuccotti G, Prisco F, Scaramuzza A. Chat line for adolescents with type 1 diabetes: a useful tool to improve coping with diabetes: a 2-year follow-up study. Diabetes Technol. Ther 2011 May;13(5):551-555. Available from:

2. Lyles CR, Harris LT, Le T, Flowers J, Tufano J, Britt D, Hoath J, Hirsch IB, Goldberg HI, Ralston JD. Qualitative evaluation of a mobile phone and web-based collaborative care intervention for patients with type 2 diabetes. Diabetes Technol. Ther 2011 May;13(5):563-569. Available from:

3. Anderson DR, Christison-Lagay J, Villagra V, Liu H, Dziura J. Managing the space between visits: a randomized trial of disease management for diabetes in a community health center. J Gen Intern Med 2010 Oct;25(10):1116-1122. Available from:

Sunday, 4 September 2011

Uncertainties in stroke

Patent Foramen Ovale and cryptogenic stroke

There was a case discussion, at the Friday lunchtime meeting, of a young man with cryptogenic stroke who, on testing, was found to have a patent foramen ovale (PFO). He was offered the option of life-long warfarin or percutaneous closure of the PFO.

The evidence in this area is lacking. [1] PFO is common in the general population and, though a theoretical cause of stroke by paradoxical embolus, it is not proven even with the associated atrial septal aneurysm that may be present.

"Patent foramen ovale, alone or together with ASA, was not associated with an increased stroke risk in this multiethnic cohort. The independent role of ASA needs further assessment in appositely designed and powered studies." [2]

"In patients with otherwise [cryptogenic stroke], approximately one third of discovered PFOs are likely to be incidental and hence not benefit from closure. This probability is sensitive to patient characteristics such as age and the presence of an atrial septal aneurysm, suggesting the importance of patient selection in therapeutic decision-making." [3]

Interestingly the patient presented with a posterior circulation infarct. This is not impossible for an embolus [4] but less likely than a more typical anterior circulation paradoxical embolus. There was also no obvious source of venous thromboembolism either.

Diagram of PFO

Closure may be of benefit [5], and was the option chosen by this patient, but we await the results of more ongoing studies [6] to change the current practice of simply discussing it with the patient and being open about the uncertainty. [7]

(image of patent foramen ovale and percutaneous repair from )

The current NICE guidance includes a useful booklet for patients considering undergoing the procedure.

Arterial pathologies

Another two cases of stroke were presented both of which involved arterial pathology. One of internal carotid artery dissection with pseudoaneuysm and another of vertebral artery dissection. Both had excellent Magnetic Resonance Angiogram images.

This is another area where the best management (antiplatelets vs. anticoagulation, duration of treatment) is awaiting evidence and both patients were enrolled in the CADISS trial. [8]

1. Irwin B, Ray S. Patent Foramen Ovale-Assessment and Treatment. Cardiovasc Ther 2011 Feb; Available from:

2. Di Tullio MR, Sacco RL, Sciacca RR, Jin Z, Homma S. Patent foramen ovale and the risk of ischemic stroke in a multiethnic population. J. Am. Coll. Cardiol 2007 Feb;49(7):797-802. Available from:

3. Alsheikh-Ali AA, Thaler DE, Kent DM. Patent foramen ovale in cryptogenic stroke: incidental or pathogenic? Stroke 2009 Jul;40(7):2349-2355. Available from:

4. Tanaka H, Fujita N, Enoki T, Matsumoto K, Watanabe Y, Murase K, Nakamura H. Relationship between Variations in the Circle of Willis and Flow Rates in Internal Carotid and Basilar Arteries Determined by Means of Magnetic Resonance Imaging with Semiautomated Lumen Segmentation: Reference Data from 125 Healthy Volunteers. AJNR Am J Neuroradiol 2006 Sep;27(8):1770-1775. Available from:

5. Paciaroni M, Agnelli G, Bertolini A, Pezzini A, Padovani A, Caso V, Venti M, Alberti A, Palmiero RA, Cerrato P, Silvestrelli G, Lanari A, Previdi P, Corea F, Balducci A, Ferri R, Falcinelli F, Filippucci E, Chiocchi P, Grandi FC, Ferigo L, Musolino R, Bersano A, Ghione I, Sacco S, Carolei A, Baldi A, Ageno W. Risk of recurrent cerebrovascular events in patients with cryptogenic stroke or transient ischemic attack and patent foramen ovale: the FORI (Foramen Ovale Registro Italiano) study. Cerebrovasc. Dis 2011;31(2):109-116. Available from:

6. Furlan AJ, Reisman M, Massaro J, Mauri L, Adams H, Albers GW, Felberg R, Herrmann H, Kar S, Landzberg M, Raizner A, Wechsler L. Study design of the CLOSURE I Trial: a prospective, multicenter, randomized, controlled trial to evaluate the safety and efficacy of the STARFlex septal closure system versus best medical therapy in patients with stroke or transient ischemic attack due to presumed paradoxical embolism through a patent foramen ovale. Stroke 2010 Dec;41(12):2872-2883. Available from:

7. NICE. Percutaneous closure of patent foramen ovale for the secondary prevention of recurrent paradoxical embolism [Internet]. 2011; Available from:

8. Cervical Artery Dissection in Stroke Study Trial Investigators. Antiplatelet therapy vs. anticoagulation in cervical artery dissection: rationale and design of the Cervical Artery Dissection in Stroke Study (CADISS). Int J Stroke 2007 Nov;2(4):292-296. Available from: