A few lectures

This one was mostly review for me, but there was also some new stuff and it was a ‘sort of okay’ lecture even if I was highly skeptical about a few points covered. I was debating whether to even post the lecture on account of those points of contention, but I figured that by adding a few remarks below I could justify doing it. So below a few skeptical comments relating to content covered in the lecture:

a) 28-29 minutes in he mentions that the cutoff for hypertension in diabetics is a systolic pressure above 130. Here opinions definitely differ, and opinions about treatment cutoffs differ; in the annual report from the Danish Diabetes Database they follow up on whether hospitals and other medical decision-making units are following guidelines (I’ve talked about the data on the blog, e.g. here), and the BP goal of involved decision-making units evaluated is currently whether diabetics with systolic BP above 140 receive antihypertensive treatment. This recent Cochrane review concluded that: “At the present time, evidence from randomized trials does not support blood pressure targets lower than the standard targets in people with elevated blood pressure and diabetes” and noted that: “The effect of SBP targets on mortality was compatible with both a reduction and increase in risk […] Trying to achieve the ‘lower’ SBP target was associated with a significant increase in the number of other serious adverse events”.

b) Whether retinopathy screenings should be conducted yearly or biennially is also contested, and opinions differ – this is not mentioned in the lecture, but I sort of figure maybe it should have been. There’s some evidence that annual screening is better (see e.g. this recent review), but the evidence base is not great and clinical outcomes do not seem to differ much in general; as noted in the review, “Observational and economic modelling studies in low-risk patients show little difference in clinical outcomes between screening intervals of 1 year or 2 years”. To stratify based on risk seems desirable from a cost-effectiveness standpoint, but how to stratify optimally seems to not be completely clear at the present point in time.

c) The Somogyi phenomenon is highly contested, and I was very surprised about his coverage of this topic – ‘he’s a doctor lecturing on this topic, he should know better’. As the wiki notes: “Although this theory is well known among clinicians and individuals with diabetes, there is little scientific evidence to support it.” I’m highly skeptical, and I seriously question the advice of lowering insulin in the context of morning hyperglycemia. As observed in Cryer’s text: “there is now considerable evidence against the Somogyi hypothesis (Guillod et al. 2007); morning hyperglycemia is the result of insulin lack, not post-hypoglycemic insulin resistance (Havlin and Cryer 1987; Tordjman et al. 1987; Hirsch et al. 1990). There is a dawn phenomenon—a growth hormone–mediated increase in the nighttime to morning plasma glucose concentration (Campbell et al. 1985)—but its magnitude is small (Periello et al. 1991).”

I decided not to embed this lecture in the post mainly because the resolution is unsatisfactorily low so that a substantial proportion of the visual content is frankly unintelligible; I figured this would bother others more than it did me and that a semi-satisfactory compromise solution in terms of coverage would be to link to the lecture, but not embed it here. You can hear what the lecturer is saying, which was enough for me, but you can’t make out stuff like effect differences, p-values, or many of the details in the graphic illustrations included. Despite the title of the lecture on youtube, the lecture actually mainly consists of a brief overview of pharmacological treatment options for diabetes.

If you want to skip the introduction, the first talk/lecture starts around 5 minutes and 30 seconds into the video. Note that despite the long running time of this video the lectures themselves only take about 50 minutes in total; the rest of it is post-lecture Q&A and discussion.

October 3, 2015 - Posted by | diabetes, Lectures, mathematics, medicine

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