eMJA: In Other Journals, 21 November 2005

Inhaled insulin holds promise as a management option for patients with type 2 diabetes in whom dual oral therapy (an insulin secretagogue and an insulin sensitiser) is insufficient for glycaemic control. A North American study randomised 309 such patients to receive: inhaled insulin alone (n = 104); inhaled insulin in addition to oral therapy (n = 103); or, to maintain their oral therapy (n = 99). Patients randomised to receive inhaled insulin took it as an aerosolised powder just before meals; the dose was titrated to blood glucose levels. The combination therapy with inhaled insulin was more effective than monotherapy in reducing HbA1c levels after 12 weeks of treatment; both were more effective than usual treatment. Reported side-effects of inhaled insulin included hypoglycaemia, mild weight gain, and mild cough. Inhaled insulin has a faster onset of action than injected rapid-onset insulin, and its effect lasts for 4 to 6 hours.

Marijuana and the lung

Australian authors have advised clinicians to consider marijuana smoking in the differential diagnosis of extensive interstitial fibrosis and lung bullae in young patients, especially when other causes have been excluded. They reported a case with these features in a 26-year-old man who had presented with worsening dry cough and exertional dyspnoea, giving a history of only minimal tobacco use (10 cigarettes per day for 2 years) but heavy marijuana use (10 pipes per day for 5 years). Lung biopsy revealed advanced fibrosis with cystic changes, with infiltration of numerous brown pigmented macrophages. The patient responded to prednisolone 50 mg daily, in addition to cessation of marijuana smoking. This case report adds to others which have suggested a link between marijuana smoking and a variety of adverse respiratory events.

Australas Radiol 2005; 49: 411-414

Mesothelioma biomarker?

In people with a history of exposure to asbestos, a serum biomarker could successfully distinguish between those with pleural mesothelioma and those without cancer, according to US researchers. They used an enzyme-linked immunosorbent assay (ELISA) to detect serum osteopontin levels in 76 study subjects with mesothelioma, 69 subjects with asbestos-related benign lung disease, and 45 subjects with no history of asbestos exposure. Patients with mesothelioma had higher levels of this biomarker, including those with early, Stage 1 disease. Osteopontin, a glycoprotein, is overexpressed in various cancers including lung, breast, colorectal and ovarian cancer, and melanoma.

N Engl J Med 2005; 353: 1564-1573

Beware cashew nut allergy

Cashew nut allergy needs to have the same recognition in clinical practice and in the community as peanut allergy, say Australian researchers. Davoren and Peake had conducted a retrospective chart review of 213 children with a peanut or tree nut allergy seen by a single paediatric allergist in Brisbane over a 42-month period. Although peanut allergy (177 cases) was more common than cashew nut allergy (27 cases), anaphylaxis to cashew nut (20 cases; about 75%) occurred much more commonly than to peanut (54 cases; about 30%).

Arch Dis Child 2005; 90: 1084-1085

Detecting depression

Adding a “help” question to two more standard screening questions for depression seems to sort out the patients with major depression from those without, say Australasian researchers. They studied more than 1000 consecutive patients presenting to six general practices in New Zealand, comparing the results of their simple trio of screening questions —

During the past month have you often been bothered by feeling down, depressed or hopeless?
During the past month have you often been bothered by little interest or pleasure in doing things?

and the “help” question:

Is this something with which you would like help?

— with a reference standard for detecting depression. They found that a positive response to the “help” question made it less likely that positive responses to the first two questions were false positives; and a patient with a negative response to the help question would only have a 1% chance of being depressed.

BMJ 2005; 331: 884

Death after bariatric surgery

Several high-profile reports of death after bariatric surgery have triggered a critical re-appraisal of the safety of bariatric surgery, say US researchers. Now, their new data add to the previous anecdotal concerns. In a nationwide study of post-surgical mortality among more than 16 000 US Medicare patients who had undergone bariatric procedures from 1997 to 2002, they found that the early risk of post-surgical death in this population — a 30-day mortality rate of 2.0% and a 1-year mortality rate of 4.6% — was higher (in this at-risk group) than that suggested by earlier series. They also found that the risk of early death was linked with advancing age, male sex, and lower surgeon volume of bariatric procedures.

JAMA 2005; 294: 1903-1908

Dr Ann Gregory, MJA

The Medical Journal of Australia eMJA