In a randomized clinical trial that enrolled 95 children and adults with type 1 diabetes mellitus
and impaired hypoglycemic awareness, Ly and colleagues investigated the effect of sensor-augmented
insulin pump therapy with an automated insulin suspension function on the incidence of major
hypoglycemic events. The authors report that compared with standard insulin pump therapy,
sensor-augmented insulin pump therapy with automated insulin suspension—for up to 2 hours when
patients did not respond to a low glucose alarm—reduced the rate of severe and moderate
hypoglycemic events. In an Editorial, Choudhary discusses the potential of sensor-augmented insulin
pump therapy with a threshold-suspension function to reduce episodes of nocturnal hypoglycemia.
In a multicenter cohort study that enrolled 2131 adults presenting to the emergency department
with acute headache and no neurologic defects, Perry and colleagues assessed the accuracy,
reliability, acceptability, and potential for refinement of 3 decision rules to rule out
subarachnoid hemorrhage (SAH). The authors found that the Ottawa SAH Rule—a refinement of an
existing rule, which specifies the need for investigation when any of following exist: age older
than 40 years, neck pain or stiffness by history or examination, witnessed loss of consciousness,
onset with exertion, and instant maximal pain (“thunderclap headache”)—was highly
sensitive for identifying subarachnoid hemorrhage. In an Editorial, Newman-Toker and Edlow discuss
use of the Ottawa SAH Rule in clinical practice.
In a cohort of 802 older individuals who had 2 measures of femoral neck bone mineral density
(BMD)—a baseline measurement at mean age 75 years and a second measurement taken a mean 4
years later—Berry and colleagues assessed the risk of hip or major osteoporotic fracture in
the 12 years following the second BMD test. The authors found that 4-year change in BMD provided
little additional information beyond baseline BMD for predicting fracture risk.
Author Video Interview
Biomechanical and inflammatory factors etiologic in knee osteoarthritis (OA) are exacerbated by
obesity. In an 18-month randomized trial that enrolled 454 overweight and obese individuals with
knee OA, Messier and colleagues investigated the effects of body weight reduction induced by
diet—with or without exercise—compared with exercise alone on knee joint load,
inflammation, pain, and function. Among the authors’ findings were that both diet groups had
greater weight loss and reductions in interleukin-6 than did the exercise alone-group; the
diet-alone group had greater reductions in knee joint load than the exercise-alone group; and
participants in the combined diet and exercise group had less knee pain and better function than
those in the diet-alone and exercise-alone groups.
Ms H, a 91-year-old African American woman whose hypertension had been reasonably well controlled
for 20 years, now has difficult-to-control hypertension despite a 4-drug regimen. In this Clinical
Crossroads article, Lipsitz discusses features that distinguish hypertension in elderly patients
from hypertension in younger patients. These features include a predominant systolic component;
variability in blood pressure and vulnerability to hypotension during common daily activities;
associations with cognitive and functional decline as well as adverse cardiovascular outcomes; and
evidence that hypertension may be beneficial in frail, elderly individuals.
Continuing Medical Education
A woman recently diagnosed with ovarian cancer presents with painful, necrotic leg ulcers and
scattered purpuric patches of 3 months’ duration. Laboratory investigation reveals slight
elevations in creatinine and lupus anticoagulant levels and slightly prolonged prothrombin and
partial thromboplastin times. What would you do next?
Highlights. JAMA. 2013;310(12):1203-1205. doi:10.1001/jama.2013.5325