Hot topics in internal medicine
Download
1 / 32

Hot Topics in Internal Medicine - PowerPoint PPT Presentation


  • 655 Views
  • Updated On :

Hot Topics in Internal Medicine Molly Cooke MD Chair-elect, Board of Governors Questions Does intensive glucose control improve outcomes in Type 2 diabetes? What is the optimal prophylaxis to prevent contrast-induced acute kidney injury?

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Hot Topics in Internal Medicine' - JasminFlorian


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Hot topics in internal medicine l.jpg

Hot Topics in Internal Medicine

Molly Cooke MD

Chair-elect, Board of Governors


Questions l.jpg
Questions

  • Does intensive glucose control improve outcomes in Type 2 diabetes?

  • What is the optimal prophylaxis to prevent contrast-induced acute kidney injury?

  • Do inhaled medications increase morbidity and/or mortality in patients with COPD?


Questions3 l.jpg
Questions

  • Does intensive glucose control improve outcomes in Type 2 diabetes?

  • What is the optimal prophylaxis to prevent contrast-induced acute kidney injury?

  • Do inhaled medications increase morbidity and/or mortality in patients with COPD?


Does intensive glucose control improve outcomes in type 2 diabetes l.jpg
Does intensive glucose control improve outcomes in Type 2 diabetes?

  • ACCORD Effects of intensive glucose lowering in Type 2 diabetes N Engl J Med 2008; 358: 2545-59

  • The ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with Type 2 diabetes. N Engl J Med 2008; 358:2560-72

  • Duckworth W et al. Glucose control and vascular complications in veterans with Type 2 diabetes. N Engl J Med 2009; 360:129-39.


Background l.jpg
Background diabetes?


Accord 2008 l.jpg
ACCORD 2008 diabetes?

  • RCT 10,251 patients

  • Intensive therapy HgbA1c 6.4%

    vs. standard therapy HgbA1c 7.5%

  • Terminated early after 3.5 years


Advance 2008 l.jpg
ADVANCE 2008 diabetes?

RCT 11,140 patients Median follow up 5 years

Intensive control HgbA1c 6.5% Standard control HgbA1c 7.3%


Advance 20088 l.jpg
ADVANCE 2008 diabetes?


Glucose control and vascular complications duckworth 2008 l.jpg
Glucose control and vascular complications (Duckworth) 2008 diabetes?

  • RCT 1791 veterans, median follow up 5.6 years

  • Intensive therapy HgbA1c 6.9% vs. standard therapy HgbA1c 8.4%

  • Adverse effects, particularly hypoglycemia, 17.6% in standard therapy vs. 24.1% in intensive therapy


Questions10 l.jpg
Questions diabetes?

  • Does intensive glucose control improve outcomes in Type 2 diabetes?

  • What is the optimal prophylaxis to prevent contrast-induced acute kidney injury?

  • Do inhaled medications increase morbidity and/or mortality in patients with COPD?



Inhaled corticosteroids in patients with stable copd l.jpg
Inhaled corticosteroids in patients with stable COPD diagnosed COPD

Drummond Ann Intern Med 2008


Long term daily erythromycin and copd exacerbations l.jpg
Long-term daily erythromycin and COPD exacerbations diagnosed COPD

Seemungal Am J Resp Crit Care Med 2008


Questions14 l.jpg
Questions diagnosed COPD

  • Does intensive glucose control improve outcomes in Type 2 diabetes?

  • What is the optimal prophylaxis to prevent contrast-induced acute kidney injury?

  • Do inhaled medications increase morbidity and/or mortality in patients with COPD?


Summary l.jpg
Summary diagnosed COPD

  • Does intensive glucose control improve outcomes in Type 2 diabetes?

    • No, and it is associated with excess morbidity and mortality

  • What is the optimal prophylaxis to prevent contrast-induced acute kidney injury?

    • Discontinuation of NSAID’s, pre-procedure hydration, possibly possibly sodium bicarbonate > sodium chloride, probably N-acetylcysteine

  • Do inhaled medications increase morbidity and/or mortality in patients with COPD?

    • Inhaled steroids are associated with increased pneumonia

    • Ipatropium may be associated with increased mortality

    • Daily macrolide prophylaxis appears to decrease exacerbations


Acute kidney injury l.jpg
Acute Kidney Injury diagnosed COPD

  • Sensitivity and specificity of a single emergency department measurement of urinary neutrophil gelatinase-associated lipocalin for diagnosing acute kidney injury

Nickolas T, et al. Ann Intern Med 2008; 148(11):810-819


Neutrophil gelatinase associate lipocalin ngal l.jpg
Neutrophil Gelatinase-Associate Lipocalin (NGAL) diagnosed COPD

  • Small protein belonging to the lipocalin family of proteins

  • Expressed by neutrophils and various epithelia, including the renal proximal tubules

  • Functions are not completely understood

    • Upregulated in cells under “stress”

    • Released from secondary granules of activated neutrophils

    • Initially proposed as a marker for infections and certain adenocarcinomas

  • NGAL has an early and dramatic rise in urine

    after renal injury


Slide19 l.jpg

Print diagnosed COPD

Nikolas et al Ann Intern Med 2008


Slide20 l.jpg


Acute kidney injury with iodinated contrast l.jpg
Acute kidney injury with iodinated contrast acute injury from normal renal function, prerenal azotemia, and CKI

McCullough PA. Crit Care Med 2008; 36(4Suppl):S204-211


Acute kidney injury22 l.jpg
Acute Kidney Injury acute injury from normal renal function, prerenal azotemia, and CKI


Slide23 l.jpg

Meta-analysis - Nephrotoxicity of high- and low- osmolality iodinated contrast medium

Barrett 1993, as presented in McCullough 2008


Acute kidney injury24 l.jpg
Acute Kidney Injury iodinated contrast medium

Prevention, incidence, and outcomes of contrast-induced acute kidney injury

Weisbord SD, et al. Arch Intern Med 2008; 168(12):1325-32


Slide25 l.jpg

Use of preventive therapy is variable iodinated contrast medium

Weisbord SD, et al. Arch Intern Med 2008; 168(12):1325-32


Acute kidney injury aki l.jpg
Acute Kidney Injury (AKI) iodinated contrast medium

Meta-analysis: effectiveness of drugs for preventing contrast-induced nephropathy

Kelly AM, et al. Ann Intern Med 2008; 148(4):284-294.


Slide29 l.jpg

Dopamine iodinated contrast medium

Fenoldopam

Furosemide

N-Acetylcysteine

0.62 (0.44-0.88)

Theophylline


Acute kidney injury aki30 l.jpg
Acute Kidney Injury (AKI) iodinated contrast medium

  • Bottomline

    • CIAKI is associated with poor outcomes

    • Need to standardize contrast induced acute kidney injury (CIAKI) prophylaxis

    • Patients with risk factors for CIAKI (chronic kidney disease and diabetes) should receive non-ionic contrast

    • NAC is more effective in preventing CIAKI injury than hydration alone


Summary31 l.jpg
Summary iodinated contrast medium

  • Does intensive glucose control improve outcomes in Type 2 diabetes?

  • What is the optimal prophylaxis to prevent contrast-induced acute kidney injury?

  • Do inhaled medications increase morbidity and/or mortality in patients with COPD?


Slide32 l.jpg

https://plus.mcmaster.ca/acpjc/Registration.aspx


ad