Objective: Although weight management is an important component in the treatment of type 2 diabetes, there has been concern about the use of liquid meal replacements (MRs) in treating obese patients with type 2 diabetes because of the sugar content of the MRs. The goal of this study was to evaluate the safety and feasibility of using MRs for weight loss in obese patients with type 2 diabetes. Research Methods and Procedures: Seventy-five subjects with type 2 diabetes, treated only with oral agents, were recruited for this 12-week clinical study. Subjects were randomized into three groups using either a MR containing lactose, fructose, and sucrose, a MR in which fructose and sucrose were replaced with oligosaccharides (sugar-free Slim-Fast), or an exchange diet plan (EDP) using the proportion of macronutrients recommended by the American Diabetes Association. Results: Fifty-seven patients (41 MR and 16 EDP) finished the study. None developed serious adverse effects, including major hypoglycemic reactions. Weight losses in the MR 1 and MR 2 groups were comparable (6.4% and 6.7%, respectively) and greater than the weight loss in the EDP group (4.9%). Fasting glucose level was significantly reduced in the MR group compared with the EDP group (p ϭ 0.012). There was a significant reduction in the MR group in total cholesterol and low-density lipoprotein cholesterol that was not seen in the EDP group. Discussion:We have shown that liquid MRs are a safe and effective weight loss tool for obese subjects with type 2 diabetes, and can result in improvements in body weight, glucose, insulin, hemoglobin A1c and lipid levels.

In this study, we found that leptin and insulin were related in weight loss. The data suggest that insulin may act as a strong regulator of leptin secretion during weight loss and that circulating leptin levels can be predicted by insulin level. Using sibutramine in conjunction with hypocaloric diet reduced body weight and decreased fat mass significantly. Visceral and subcutaneous abdominal fat depots were shown to decrease. Whether sibutramine exerts any selective reduction of visceral abdominal fat as opposed to total body fat mass will require further clinical investigation.

There are miscellaneous topics in emergency medicine (EM) that are important to clinical practice and to performance on standardized EM tests, including emergency medical services (EMS), disaster medicine, and legal issues. Most EM physicians work closely with EMS and need to understand the basics of medical control and care in the prehospital setting. Although disasters are, fortunately, rare events, EM physicians need to know the basics of how to respond in such situations because they will often be at the forefront of care. Legal aspects of the practice of medicine are rarely taught in medical school or residency. Unfortunately, many physicians are forced to take a hands-on crash course the first time that they are confronted with a lawsuit, administrative investigation, or other legal inquiry. The legally oriented questions in the chapter will help the learner to become acquainted with some of the basics within the legal realm of medical practice, including the Health Insurance Portability and Accountability Act (HIPAA), informed consent, the Emergency Medical Treatment and Labor Act (EMTALA), malpractice liability, and mandatory reporting.

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