Could metformin be used in patients with diabetes and advanced chronic kidney disease?

Diabetes is an important cause of end stage renal failure worldwide. As renal impairment progresses, managing hyperglycaemia can prove increasingly challenging, as many medications are contra-indicated in moderate to severe renal impairment. Whilst evidence for tight glycaemic control reducing progression to renal failure in patients with established renal disease is limited, poor glycaemic control is not desirable, and is likely to lead to progressive complications. Metformin is a first-line therapy in patients with Type 2 diabetes, as it appears to be effective in reducing diabetes related end points and mortality in overweight patients. Cessation of metformin in patients with progressive renal disease may not only lead to deterioration in glucose control, but also to loss of protection from cardiovascular disease in a cohort of patients at particularly high risk. We advocate the need for further study to determine the role of metformin in patients with severe renal disease (chronic kidney disease stage 4-5), as well as patients on dialysis, or pre-/peri-renal transplantation. We explore possible roles of metformin in these circumstances, and suggest potential key areas for further study.

Which peer teaching methods do medical students prefer?

BACKGROUND: The beneficial effects of peer teaching in medical education have been well-described in the literature. However, it is unclear whether students prefer to be taught by peers in small or large group settings. This study's aim was to identify differences in medical students' preferences and perceptions of small-group versus large-group peer teaching. METHODS: Questionnaires were administered to medical students in Year 3 and Year 4 (first 2 years of clinical training) at one institution in the United Kingdom to identify their experiences and perceptions of small-and large-group peer teaching. For this study, small-group peer teaching was defined as a tutorial, or similar, taught by peer tutor to a group of 5 students or less. Large-group peer teaching was defined as a lecture, or similar, taught by peer tutors to a group of more than 20 students. RESULTS: Seventy-three students (81% response rate) completed the questionnaires (54% males; median age of 23). Nearly 55% of respondents reported prior exposure to small-group peer teaching but a larger proportion of respondents (86%) had previously attended large-group peer teaching. Of all valid responses, 49% did not have a preference of peer teaching method while 47% preferred small-group peer teaching. The majority of Year 3 students preferred small-group peer teaching to no preference (62.5% vs 37.5%, Fisher's exact test; P = 0.035) whereas most Year 4 students did not report a particular preference. Likert-scale responses showed that the majority of students held negative perceptions about large-group peer teaching, in comparison with small-group peer teaching, with respect to (1) interactivity, (2) a comfortable environment to ask questions, and (3) feedback received. DISCUSSION: Most respondents in this study did not report a preference for small-versus large-group settings when taught by peers. More Year 3 respondents were likely to prefer small-group peer teaching as opposed to Year 4 respondents.