Prevention of Diabetes with Lifestyle Intervention or Metformin

This large clinical trial compared changes in diet and physical activity with metformin for the prevention of diabetes in persons at high risk for the disease. Although both interventions were effective in preventing diabetes, the lifestyle intervention was more effective than metformin.

Metformin is a biguanide that acts by improving sensitivity to insulin. Although it reduced the risk of diabetes in high-risk persons, weight loss through dietary change and regular exercise were even more effective. These observations are important for the 10 million persons in the United States who are at risk for diabetes.

Benefit of Atrial Pacing in Sleep Apnea Syndrome

Both central sleep apnea and obstructive sleep apnea are characterized by episodes of apnea and hypopnea during sleep. Many patients also have associated arrhythmias and therefore receive permanent atrial pacemakers. This study found that, in such patients, atrial overdrive pacing at a rate 15 beats per minute above the base-line rate resulted in a substantial reduction in the frequency of episodes of apnea and hypopnea.

The mechanism of the beneficial effect of pacing is not clear but may involve a reversal of excess vagal tone. Whether or not atrial overdrive pacing would have a similar beneficial effect in patients with sleep apnea that is not associated with bradycardia cannot be determined from this study, but this question should be the subject of further investigation.

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Fluoroquinolone Resistance in Salmonella enterica Serotype Choleraesuis

Salmonella enterica serotype choleraesuis is a cause of serious systemic infections. Data from a surveillance system in Taiwan document the rapid emergence of fluoroquinolone resistance in this serotype. The rate of resistance has reached 60 percent. Molecular typing indicates that the source of the resistant isolates is likely to be herds of swine raised for food.

This report provides further evidence of the spread of resistant bacteria from food animals to humans. Fluoroquinolone resistance is of major concern because fluoroquinolones are used for the treatment of severe salmonella infections, especially in areas where salmonella are resistant to many other antibiotics.

p53 and Outcome of Malignant Gliomas in Children

The clinical and histologic features of high-grade gliomas in children are not always useful prognostic indicators. This study investigated the prognostic usefulness of evaluating gliomas in children for the presence of p53, a protein involved in numerous aspects of the life and death of a cell. Children with tumors that contained many p53-positive cells had a much poorer outcome than children with tumors that contained few or no p53-positive cells.

The number of p53-positive cells in the tumor appears to be an independent prognostic marker in children with high-grade gliomas. This finding may contribute to better stratification of children who enter clinical trials of treatment for high-grade gliomas.

Images In Clinical Medicine: Aspergilloma as a Complication of Pacemaker Implantation

Current Concepts: Community-Acquired Pneumonia in Children

Pneumonia remains a common and potentially serious infection in children. This review summarizes the problems involved in making the diagnosis and establishing a cause and offers a practical guide to treatment. Decisions should be based first on the age of the child, then on clinical and epidemiologic considerations, and finally, on the findings on chest radiography.

Clinical Problem Solving: More Than Your Average Wheeze

A 59-year-old man with a history of a nonproductive cough and wheezing presents with increasing shortness of breath. His symptoms have not responded to treatment with bronchodilators and inhaled corticosteroids or to treatment for sinusitis and esophageal reflux, but they improve when he takes oral prednisone.

Oregon's Death with Dignity Act — The Law and Challenges

This issue of the Journal contains two articles on Oregon's Death with Dignity Act. In a Health Policy Report, Steinbrook provides an overview of the 1994 Oregon law legalizing physician-assisted suicide. He discusses the effects of the law on the care of terminally ill patients and the various legal challenges that have been made to the law. The most recent challenge is the directive issued by the attorney general of the United States, John Ashcroft.

In a Sounding Board article, Lowenstein and Wanzer discuss Ashcroft's directive and their perceptions about its effect on medical practice. The authors make the case that the attorney general's challenge to the Oregon law represents an inappropriate intrusion into medical practice and may have implications far beyond physician-assisted suicide.

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