Edwin Sy Chan

A randomised controlled trial evaluating the impact of targeted vitamin D supplementation on endothelial function in type 2 diabetes mellitus: The DIMENSION trial

We sought to determine if vitamin D supplementation, to target 25(OH)D concentrations of 30–40 ng/mL, improves endothelial function in Singapore’s multi-ethnic type 2 diabetes mellitus population. We randomised 64 type 2 diabetes mellitus patients with hypovitaminosis D to cholecalciferol 4000 International Unit/matching placebo [baseline 25(OH)D < 20 ng/mL] or cholecalciferol 2000 International Unit/matching placebo [baseline 25(OH)D: 20–30 ng/mL] daily for 16 weeks with a down titration at 8 weeks if 25(OH)D > 30 ng/mL. Endothelial function was assessed by peripheral tonometry (reactive hyperaemia index–endothelial peripheral arterial tonometry) and vascular biomarkers: E-selectin, von-Willebrand factor and high-sensitivity C-reactive protein. We compared the change from baseline parameters in the two groups using Student’s t-test or Kruskal–Wallis test. A log-normal multivariate regression analysis was used to adjust for relevant baseline variables. The median reactive hyperaemia index in the vitamin D group increased from 0.65 (interquartile range: 0.42) to 0.73 (interquartile range: 0.36), whereas it decreased from 0.73 (interquartile range: 0.65) to 0.65 (interquartile range: 0.38) (p = 0.02) in the placebo group. After adjustment for baseline variables, the change was not statistically significant for reactive hyperaemia index (p = 0.07) and for other vascular biomarkers (p > 0.05). Targeted vitamin D supplementation for 16 weeks resulted in a small but non-significant improvement in endothelial function in a type 2 diabetes mellitus cohort.

Chlorhexidine's role in skin antisepsis: questioning the evidence

1344 www.thelancet.com Vol 384 October 11, 2014 antiseptics. This misinterpretation has been perpetuated in the literature, including evidence-based guidelines, and has affected all levels of evidence assessment. In fact, little evidence exists supporting the use of chlorhexidine alone. A widespread but incorrect percep tion has arisen in the health-care community suggesting that evid ence for the chlorhexidine–alcohol combination constitutes evidence for chlorhexidine. While investigating the relevant literature, we encountered inconsistencies in a prominent Article published in The Lancet in 1991 by Dennis Maki and colleagues. This Article reported on a parallel three-arm trial of skin antiseptics for vascular catheter insertion and maintenance using chlorhexidine, isopropanol, and povidone-iodine as individual antiseptic agents. Microbial catheter colonisation and catheter-related bloodstream infection were the main measured outcomes. The overall conclusion of the Article—that chlorhexidine was significantly better than the other two antiseptics at preventing device-related infection—depended on statistical analyses comparing chlorhexidine against the combined outcomes of isopropanol and povidone-iodine. This mode of analysis was apparently chosen despite the fact that the three trial arms were supposedly independent of each other. When we reviewed the data, we noted that none of the primary numerical outcomes were signifi cant in favour of chlorhexidine being better than isopropanol (table), for both combined and separate analyses for arterial and venous catheters. Only one mathematically-adjusted percentage for catheter colonisation in the isopropanol arm (table) had the potential to be signifi cant, depending on further analyses. Additionally, the trial was supported by a chlorhexidine-producing company. Why is this observation relevant? The Article was, after all, published case detection among children is equal to that among adults. Therefore, that report substantially underestimates the true disease burden in children. We share and support the goal of Sismanidis and colleagues to pursue innovative ways to improve these burden estimates.

Non-steroidal anti-inflammatory drugs (NSAIDS) for trigger finger

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To review the benefits and safety of non-steroidal anti-inflammatory drugs (NSAIDs) for trigger finger. We will compare the effectiveness of topical, oral and injectable NSAIDs with placebo or corticosteroid.