A useful review of the management of diabetic retinopathy, which fortunately for laser-challenged readers includes a good section on prevention as part of management.  Control glycaemia down to an HbA1c of 7.5ish: although theoretically you could try for lower, returns diminish and complications increase. Control blood pressure down to…nobody knows, probably till the patient falls over. Then it’s over to the laser boys, who don’t know quite how early to intervene; but once the retinopathy is severe, pan-retinal treatment (sparing the macula) is definitely the thing. If the jelly of the eye gets bled into repeatedly, it’s best to remove it (vitrectomy). Marvellous what chaps like Lord Darzi can do. If only they would confine themselves to what they know about.

If you look retrospectively at outcomes of bariatric surgery in the USA, the message is the same.  Total mortality at a mean follow-up of 7 years was reduced, particularly deaths from diabetes, heart disease and cancer. However, accidents and suicide were higher in the surgical group.

You think it horrible that lust and rage
Should dance attention upon my old age;
They were not such a plague when I was young;
What else have I to spur me into song?
wrote Yeats when he was 71. Leaving aside the rage, this study sheds some light on how common lust is at Yeats’ age and indeed beyond. Not uncommon at all; if he were an modern American male in his early seventies, there would be about a one-third likelihood of him having sex at least once a month. Should you need more detail, horrible or otherwise, turn to the extensive tabulation of this masterly, or rather Mastersly-Johnsonian, study.

Isolated systolic hypertension is really just the main subset of a condition which could be called EPPA – elevated pulse pressure of age. I think I’ve coined that acronym myself, but somebody may have got there first, so save your rotten eggs for her/him, not me. Without some magic way of rejuvenating stiffened (sometimes calcified) main capacitance arteries, it is always going to be hard to treat. I can’t say I found this article much help.

Atrial fibrillation gets commoner the older you are and is a potent risk factor for stroke and heart failure, so how might we best screen for it in primary care? Should we do ECGs on everybody over a certain age (65 in this study) or should we just take the pulse opportunistically? Although at first glance you might think this study addresses this question, in fact it doesn’t. Both the ECG group and the pulse-taking group were called in for examination, so this was not “opportunistic” in the sense we usually use the word, i.e. done if the patient happens to turn up. Oddly enough, one third of patients who were found to have an irregular pulse refused to have an ECG – something I have never known happen in 30 years. But whatever the quirks of this study, it does appear to show that pulse-taking followed by ECG is as good as mass ECG screening for detecting AF, and much cheaper.

Children should not have needles stuck into them without good reason. Does acute pyelonephritis count as one? Not as far as antibiotic treatment goes: oral co-amoxiclav proved as good as parenteral ceftriaxone in this large Italian study. They did however have to have a needle for the dimercaptosuccinic acid (DMSA) scans they all had.

DMSA scanning at 4-6 months after an acute UTI in children under 3 years old is perhaps the most important innovation in the NICE guideline for urinary tract infection in children, which does away with the barbaric practice of testing for vesico-ureteric reflux.

An annual fasting blood sugar is now part of the routine follow-up of all patients with coronary heart disease – and this Italian study of patients after recent myocardial infarction shows why. Their incidence rate for impaired FBS was 27.5% per year, as opposed to 1.8% in the general population. The study attempted to measure diet but not exercise (except by treadmill test capacity) and confirms the benefit of a Mediterranean intake, rich in vegetables, fruit, fish and olive oil.

I approach every new review of polycystic ovarian syndrome with a mixture of dread and curiosity. They are all long, inconclusive, and apt to wander off into inaccessible realms of sex hormone metabolite ratios and transvaginal follicle measurements. Don’t look for clear definitions or diagnostic pathways: you will always be disappointed. The treatment section here, however, is comprehensive and modestly useful. Although appetite suppressants have never been formally studied in this group, I suspect that for many they might be the most effective treatment.

I have not commented on the BMJ’s current debate about the literature of medical education, because most of it is so trite, but I was intrigued by the title of this personal article, inconvenient truths about effective clinical teaching, by Brendan Reilly. It is brilliantly wise and well-written, and worth more than the entire archive of most journals on the subject.

Selenium is a strange moony element which is included (perhaps just for its name) in many popular “health products” containing trace elements. Now and again someone claims to prove something in its favour but this study does not. Far from preventing diabetes, as had been suggested by animal studies, selenium supplementation probably increases your chance of getting it.

Here is a systematic review of a cardiovascular topic which is unlikely to date badly, but will probably need revision within those two years. Implantable cardioverter defibrillators undoubtedly prevent sudden death due to ventricular arrhythmias in adults with left ventricular systolic dysfunction. But they remain very expensive and prone to malfunction. Most people fitted with one never receive a discharge but are exposed to all the ICD-related risks. So not only do we need more studies, but we also need better analysis of individual patient data to see which subgroups get the most benefit.

In time it accumulates several smooth grey trunks, and the sight of one covered with frost in winter is more beautiful than the sight of one flowering now. Well worth the considerable space it requires.

In this next study, two-thirds of the patients were still alive five years after a diagnosis of stage III colon cancer, i.e. cancer that had spread to local lymph nodes. The main purpose of the trial was to compare chemotherapy regimes, but detailed dietary questionnaires were used to distinguish between those who followed a “prudent diet”, defined as one rich in fruit, vegetables, poultry and fish, as opposed to a “Western diet” rich in other meat, fat, refined grains and dessert. There was a three-fold difference in favour of the “prudent” group, after adjustment for a wide variety of confounders. Of course these diets represented personal choices rather than randomised allocation, but it does seem reasonable to recommend these nice foods to people who people who have come through bowel cancer.

We’ve all been taught that diabetes not only increases the risk of coronary disease but also worsens outcomes after acute coronary events; but is this still true in the era of rapid intervention? The eleven trials of the TIMI series from 1997-2006 confirm that in the first year following ACS, diabetics still fare worse, but thereafter the added risk fades away.

Every now and again, somebody pops up to suggest we are measuring the wrong lipids for cardiac risk, or that we should do one measurement for men and another for women. A paper from Framingham comes to silence our groans: carry on measuring total cholesterol and HDL cholesterol and you can derive a score that is just as good as one based on fancy apolipoproteins (apo B:apo A-1) in both men and women.

High density lipoprotein cholesterol is often called “good” cholesterol because of its association with reduced cardiovascular morbidity, but attempts to raise people’s good cholesterol always seem to go wrong. One small trial, you may remember, even tried infusing the stuff into people’s coronary arteries. In the latest issue of Evidence Based Medicine I describe HDL-raising as a therapeutic cul-de-sac which ought to carry a traffic warning: this systematic review bears me out, though it is less damning in its conclusions.

Opponents of abortion are always trying to find evidence that it does physical harm to women so that they won’t enter into mortal sin by having such procedures. But this study of subsequent pregnancies after medical abortion in Denmark shows no increased risk of ectopic pregnancy, miscarriage or preterm birth.

If you have extensive small-cell lung cancer, you will die, probably within six months. You may wish to spend one or more of these months receiving chemotherapy and then one or more receiving prophylactic cranial irradiation, which will raise your mean survival from 5.4 months to 6.7 months, and your chance of reaching a year from 13% to 27%. The investigators suggest that it should therefore “be part of standard care for all patients with small-cell lung cancer who have a response to initial chemotherapy.” Care? For me, that would be an Italian hillside and a good choice of music.

Treating psoriasis is tiresome; as this review of psoralen and ultraviolet A light therapy points out, most patients find their treatment unsatisfactory. They can’t forget their disease, especially when they take their clothes off; and doctors can’t explain it or do more than control it. Still, old-fashioned PUVA does work, a bit better in most patients than narrow-band UVB. If you want to understand how, there is some classic artwork on p.685 featuring colour combinations you may wish to avoid in your living room.

A good clear single-author review of carpal tunnel syndrome tells you what you want to know. The diagnosis lies more in the history than the classic tests, and although neurophysiology is the “gold standard”, it is not a particularly good one. Figures for sensitivity and specificity are given, but it’s not clear where they come from, and of course they won’t be the same in primary care as in a hand clinic. Anyway, try a splint; maybe try an injection; but for a cure, get a decompression done (it doesn’t matter which procedure).

In the last couple of years, drug-eluting stents and COX-2 specific anti-inflammatory drugs have come in for a bit of a bashing. Combine the two and you have – perhaps the best possible outcome for percutaneous revascularisation.  But it’s early days: this South Korean trial added celecoxib to aspirin and clopidogrel following the insertion of paclitaxel-eluting stents and measured the formation of neointima within stents. There was considerably less in the celecoxib group. I should explain that it is intimal regrowth, not atheroma, that leads to stent blockage (see editorial). But of course we don’t really know whether giving celecoxib to post-stent patients in the long term is a good idea.

Another dotty-sounding notion is that by squeezing the arm you can protect the heart. This trial randomised patients about to have coronary artery bypass surgery to have three 5-minute cycles of right upper limb ischaemia caused by inflating a cuff to 200mg mercury after induction of anaesthesia, or none. The outcome measure was troponin release after surgery. But why on earth? Well, it’s long been known that patients with a history of angina before myocardial infarction do better than those who get infarcts out of the blue. The mechanism has been dignified with the name of ischaemic preconditioning, whereby the myocardium gets used to coping with periods of ischaemic stress, mediated by various inflammatory chemicals. So, the argument goes, if you release the inflammatory markers from some other part of the circulatory system before subjecting the myocardium to the stress of bypass surgery, fewer myocytes will get damaged. Bizarrely enough, it seemed to work in this small study. As ever, bigger trials with harder endpoints are needed.

Ever since the H5N1 avian flu virus started killing chicken farmers in East Asia, we have been preparing for a possible pandemic, and rapid vaccine production is seen as key to containment. Egg-based vaccines are slow to produce, but this study shows that much smaller amounts will be immunogenic if you mix them with an adjuvant consisting of a few cheap chemicals. Moreover the vaccine produces the kind of cross-immunogenicity which we might need if these viruses ever become capable of human-human transmission and mutation.

The Lancet is determined to its bit for stroke prevention this week by bringing us up to date on the two principal risk factors, hypertension and atrial fibrillation. Three international experts put together a serviceable summary of where we are with measuring and treating blood pressure, while the cover of the journal declares that the “The time has come to abandon the hypertension/normotension dichotomy and to focus on global risk reduction.” No, Richard Horton, the time really came long ago. Far below the ivory tower, there are little places where global risk reduction has been going on for years. I work in one.

And so to the management of atrial fibrillation. Over the last decade, I’ve heralded many false dawns – direct thrombin inhibitors to replace bothersome warfarin, better antirrhythmics to replace horrible amiodarone, and pathway ablation to replace shockingly crude direct current cardioversion. But alas, we are still largely where we were. People still even use digoxin.