Table of Contents

Many people supplement their dietary intake with selenium. To evaluate the safety of this practice, Stranges and colleagues examined the incidence of type 2 diabetes in participants in a large randomized trial designed to assess the effect of selenium supplementation on cancer incidence. During 7.7 years of taking the supplements or placebo, participants assigned to selenium supplementation were more likely to develop type 2 diabetes than were participants assigned to placebo. Diabetes, however, was self-reported and was a secondary end point in the parent trial.

Clinicians often use systematic reviews to obtain current evidence to guide clinical decisions and health care policy. Shojania and coworkers studied 100 quantitative systematic reviews to see how quickly the conclusions changed as new evidence became available. Conclusions about the effectiveness or harms of therapies frequently changed soon after publication of the systematic review. The median survival time without a change in the conclusions was 5.5 years. Significant new evidence had become available within 2 years for 23%. The evidence supporting preferred clinical practices is unstable.

Avoiding outbreaks of hospital-acquired invasive group A streptococcal infection could reduce morbidity and mortality. Daneman and colleagues conducted prospective surveillance of these infections in Ontario, Canada, from 1992 to 2000. Two hundred ninety-one cases occurred, and 29 of these cases occurred during 20 hospital outbreaks. Seventy-five percent of the index cases were nosocomial, and 25% were community-acquired infections (mostly necrotizing fasciitis) that required intensive care. Most secondary infections were acquired from health care workers.

Nephropathic cystinosis, an autosomal recessive storage disease, is the most common cause of the renal Fanconi syndrome in childhood. Persons with the disease are now living longer because of renal replacement therapy. Gahl and coworkers assessed the severity of cystinosis in 100 adults age 18 to 45 years. Ninety-two persons received a renal allograft. Most persons had complications of the disease, such as hypothyroidism, hypergonadotropic hypogonadism, pulmonary insufficiency, myopathy, retinopathy, and diabetes. One third of the persons died. A history of long-term cysteamine therapy seemed to be associated with decreased risk for complications and death.

This Update in Perioperative Medicine features 13 articles published in 2006. Topics include preoperative revascularization, prevention of cardiac and pulmonary complications, and postoperative delirium.

This systematic review summarizes the evidence on the benefits and harms of implantable cardioverter defibrillators (ICDs) in adult patients with left ventricular systolic dysfunction. The ICDs reduced all-cause mortality by 20% (95% CI, 10% to 29%) in 12 randomized trials and were associated with a 46% reduction (CI, 32% to 57%) in 76 observational studies. Death associated with ICD implantation occurred in 1.2% (CI, 0.9% to 1.5%) of procedures.

In this issue, Stranges and colleagues report an increased risk for diabetes among participants randomly assigned to receive selenium supplements in the Nutritional Prevention of Cancer trial. The public health implications of these findings are substantial. The U.S. public needs to know that most people in this country receive adequate selenium from their diet. By taking selenium supplements on top of an adequate dietary intake, people may increase their risk for diabetes.

Many people consider systematic reviews to be the best source of information for making clinical and policy decisions. However, in this issue, Shojania and coworkers describe how quickly the conclusions of 100 systematic reviews went out of date because of newly completed randomized trials. Current evidence also suggests that clinicians and policymakers less frequently use systematic reviews. We urgently need a new type of review.

The International Committee of Medical Journal Editors (ICMJE) initiated a policy in 2005 that required investigators to register their studies into a public clinical trials registry before patient enrollment. Two years later, the ICMJE reevaluated this policy. In this editorial, the Committee comments on policy requirements for registries, the types of studies that require registration, and the publication of trial results in the registry.

The telephone rings at the front desk at our U.S. Air Force EMEDS hospital in Baghdad. It is promptly answered by the Master Sergeant enlisted medic. “Sir, they need you over at the morgue—2 casualties—U.S.” It is early spring in Baghdad, and a light rain is falling.