Highlights

Choosing the right ARBs for diabetes

Compared with other drugs in their class, telmisartan and valsartan were associated with lower risk of admission to hospital with acute myocardial infarction, stroke or heart failure among older adults with diabetes. So finds a Canadian retrospective population-based study that examined the comparative effectiveness of angiotensin-receptor blockers among residents of Ontario aged 66 years and older with a diagnosis of diabetes. In this patient group, it may be preferable to use either telmisartan or valsartan for the prevention of macrovascular disease, say the authors. See Research, page 1035

There is still no high-quality evidence to support choosing any one angiotensin-receptor blocker over another for cardioprotection in patients with type 2 diabetes, according to Mark Cooper, in his discussion of the recent research by Antoniou and colleagues. Although the findings of their retrospective study — that valsartan and telmisartan may afford superior cardiovascular benefits — are intriguing, they cannot influence guidelines for the management of type 2 diabetes; randomized controlled trials would be more informative. See Commentary, page 1023

Massive transfusion at a 1:1:1 ratio

A strategy of transfusing red blood cells, plasma and platelets at a 1:1:1 ratio to manage coagulopathy and hemorrhagic shock was found to be feasible in patients with severe trauma who required massive transfusion. In this pilot randomized controlled trial, blood components were transfused at a 1:1:1 ratio in 57% (21/37) of the patients assigned to the fixed-ratio group, as compared with 6% (2/32) assigned to usual care (laboratory-results–guided transfusion). The study protocol did not appear to increase significantly the risk of death or acute respiratory distress syndrome. A larger randomized trial is needed to evaluate its efficacy. See Research, page E583

Quality of primary care

The quality of primary care has been difficult to assess because of inadequate knowledge about what it consists of and how to measure it. In this study of different types of practices in urban and other settings, Beaulieu and colleagues found that the organizational structure of the practice setting is important, as are characteristics such as remuneration method and specific disease-management processes. See Research, page E590

Cognitive enhancers

The use of cognitive enhancers to augment the performance of healthy individuals appears to be on the rise, with a prevalence of use among university students of up to 11%. Forlini and colleagues report that there are uncertain benefits and harms with the use of cognitive enhancers. This, coupled with limited health care resources and ethical questions, led the authors to conclude that physicians should seriously consider not prescribing medications for cognitive enhancement to health individuals. See Analysis, page 1047

Hyponatremia and polyuria

A 77-year-old woman with critical stenosis of her left renal artery, as well as adrenal insufficiency and hypothyroidism treated with prednisone and levothyroxine, presented with malaise, vomiting and decreased oral intake. She was found to have hypo-osmolar hyponatremia, and further investigation showed an unusual cause. Afra and James provide a practical approach to investigating this syndrome. See Practice, page 1055

Pulmonary infarction

On the basis of a pleural-based consolidation, pneumonia was diagnosed in a 48-year-old man with cough and hemoptysis. The consolidation was later determined to be a pulmonary infarction from a popliteal deep vein thrombosis. Miniati reviews the clinical and radiographic findings in pulmonary infarction, with an emphasis on using prediction tools to diagnose pulmonary embolism. See Practice, page 1059

Entamoeba histolytica

Image courtesy of CDC

Entamoeba histolytica is a pathogen; Entamoeba dispar is not. One requires treatment; the other does not. Showler and Boggild review the different clinical approaches to these two common amoebae. See Practice, page 1064