BackgroundIt is essential to anticipate and limit the social, economic and sanitary cost of type 2 diabetes (T2D), which is in constant progression worldwide.When blood glucose targets are not achieved with diet and lifestyle intervention, insulin is recommended whether or not the patient is already taking hypoglycaemic drugs. However, the benefit/risk balance of insulin remains controversial. Our aim was to determine the efficacy and safety of insulin vs. hypoglycaemic drugs or diet/placebo on clinically relevant endpoints.MethodsA systematic literature review (Pubmed, Embase, Cochrane Library) including all randomised clinical trials (RCT) analysing insulin vs. hypoglycaemic drugs or diet/placebo, published between 1950 and 2013, was performed. We included all RCTs reporting effects on all-cause mortality, cardiovascular mortality, death by cancer, cardiovascular morbidity, microvascular complications and hypoglycaemia in adults ≥ 18 years with T2D. Two authors independently assessed trial eligibility and extracted the data. Internal validity of studies was analyzed according to the Cochrane Risk of Bias tool. Risk ratios (RR) with 95 % confidence intervals (95 % CI) were calculated, using the fixed effect model in first approach. The I2 statistic assessed heterogeneity. In case of statistical heterogeneity, subgroup and sensitivity analyses then a random effect model were performed. The alpha threshold was 0.05. Primary outcomes were all-cause mortality and cardiovascular mortality. Secondary outcomes were non-fatal cardiovascular events, hypoglycaemic events, death from cancer, and macro- or microvascular complications.ResultsTwenty RCTs were included out of the 1632 initially identified studies. 18 599 patients were analysed: Insulin had no effect vs. hypoglycaemic drugs on all-cause mortality RR = 0.99 (95 % CI =0.92–1.06) and cardiovascular mortality RR = 0.99 (95 % CI =0.90–1.09), nor vs. diet/placebo RR = 0.92 (95 % CI = 0.80–1.07) and RR = 0.95 (95 % CI 0.77–1.18) respectively. No effect was found on secondary outcomes either. However, severe hypoglycaemia was more frequent with insulin compared to hypoglycaemic drugs RR = 1.70 (95 % CI = 1.51–1.91).ConclusionsThere is no significant evidence of long term efficacy of insulin on any clinical outcome in T2D. However, there is a trend to clinically harmful adverse effects such as hypoglycaemia and weight gain. The only benefit could be limited to reducing short term hyperglycemia. This needs to be confirmed with further studies.Electronic supplementary materialThe online version of this article (doi:10.1186/s12902-016-0120-z) contains supplementary material, which is available to authorized users.

-Background and purpose: Pre-graduate ambulatory clerkships in medicine have taken many years to become a reality. A 3-month training session was developed over the past two years and the university carried out an evaluation in order to enhance it. The questions pertaining to this research revolved around students' appreciation of the experience and what they learned. Methods: A qualitative study was conducted using the focus group method. It reviewed students' ideas before, immediately after completion and one year after the 3-month training. Results: The results show that students step into a world that is unknown to them and completely different from hospital clerkships. They were delighted to meet patients, to have their own designated teachers and to put into practice what they learned. Yet the wide range of situations and responsibilities seriously concerned them. They discovered that they had to choose how they perform and organize their work. Even though they were satisfied on the whole, they emphasized the practical problems (distance, financial concerns, weariness) in completing a first-rate clerkship. Conclusion: Even if they did not choose to work as general practitioners, they were happy with the opportunity of having a second look at the work of GPs.