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Hot Topics in Internal Medicine

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Hot Topics in Internal Medicine

  1. 1. Hot Topics in Internal Medicine Molly Cooke MD Chair-elect, Board of Governors
  2. 2. Questions <ul><li>Does intensive glucose control improve outcomes in Type 2 diabetes? </li></ul><ul><li>What is the optimal prophylaxis to prevent contrast-induced acute kidney injury? </li></ul><ul><li>Do inhaled medications increase morbidity and/or mortality in patients with COPD? </li></ul>
  3. 3. Questions <ul><li>Does intensive glucose control improve outcomes in Type 2 diabetes? </li></ul><ul><li>What is the optimal prophylaxis to prevent contrast-induced acute kidney injury? </li></ul><ul><li>Do inhaled medications increase morbidity and/or mortality in patients with COPD? </li></ul>
  4. 4. Does intensive glucose control improve outcomes in Type 2 diabetes? <ul><li>ACCORD Effects of intensive glucose lowering in Type 2 diabetes N Engl J Med 2008; 358: 2545-59 </li></ul><ul><li>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 </li></ul><ul><li>Duckworth W et al. Glucose control and vascular complications in veterans with Type 2 diabetes. N Engl J Med 2009; 360:129-39. </li></ul>
  5. 5. Background
  6. 6. ACCORD 2008 <ul><li>RCT 10,251 patients </li></ul><ul><li>Intensive therapy HgbA 1 c 6.4% </li></ul><ul><li>vs. standard therapy HgbA 1 c 7.5% </li></ul><ul><li>Terminated early after 3.5 years </li></ul>
  7. 7. ADVANCE 2008 RCT 11,140 patients Median follow up 5 years Intensive control HgbA 1 c 6.5% Standard control HgbA 1 c 7.3%
  8. 8. ADVANCE 2008
  9. 9. Glucose control and vascular complications (Duckworth) 2008 <ul><li>RCT 1791 veterans, median follow up 5.6 years </li></ul><ul><li>Intensive therapy HgbA 1 c 6.9% vs. standard therapy HgbA 1 c 8.4% </li></ul><ul><li>Adverse effects, particularly hypoglycemia, 17.6% in standard therapy vs. 24.1% in intensive therapy </li></ul>
  10. 10. Questions <ul><li>Does intensive glucose control improve outcomes in Type 2 diabetes? </li></ul><ul><li>What is the optimal prophylaxis to prevent contrast-induced acute kidney injury? </li></ul><ul><li>Do inhaled medications increase morbidity and/or mortality in patients with COPD? </li></ul>
  11. 11. Risk of death associated with medications for recently diagnosed COPD Lee 2008
  12. 12. Inhaled corticosteroids in patients with stable COPD Drummond Ann Intern Med 2008
  13. 13. Long-term daily erythromycin and COPD exacerbations Seemungal Am J Resp Crit Care Med 2008
  14. 14. Questions <ul><li>Does intensive glucose control improve outcomes in Type 2 diabetes? </li></ul><ul><li>What is the optimal prophylaxis to prevent contrast-induced acute kidney injury? </li></ul><ul><li>Do inhaled medications increase morbidity and/or mortality in patients with COPD? </li></ul>
  15. 15. Summary <ul><li>Does intensive glucose control improve outcomes in Type 2 diabetes? </li></ul><ul><ul><li>No, and it is associated with excess morbidity and mortality </li></ul></ul><ul><li>What is the optimal prophylaxis to prevent contrast-induced acute kidney injury? </li></ul><ul><ul><li>Discontinuation of NSAID’s, pre-procedure hydration, possibly possibly sodium bicarbonate > sodium chloride, probably N-acetylcysteine </li></ul></ul><ul><li>Do inhaled medications increase morbidity and/or mortality in patients with COPD? </li></ul><ul><ul><li>Inhaled steroids are associated with increased pneumonia </li></ul></ul><ul><ul><li>Ipatropium may be associated with increased mortality </li></ul></ul><ul><ul><li>Daily macrolide prophylaxis appears to decrease exacerbations </li></ul></ul>
  16. 16. Acute Kidney Injury <ul><li>Sensitivity and specificity of a single emergency department measurement of urinary neutrophil gelatinase-associated lipocalin for diagnosing acute kidney injury </li></ul>Nickolas T, et al. Ann Intern Med 2008; 148(11):810-819
  17. 17. Neutrophil Gelatinase-Associate Lipocalin (NGAL) <ul><li>Small protein belonging to the lipocalin family of proteins </li></ul><ul><li>Expressed by neutrophils and various epithelia, including the renal proximal tubules </li></ul><ul><li>Functions are not completely understood </li></ul><ul><ul><li>Upregulated in cells under “stress” </li></ul></ul><ul><ul><li>Released from secondary granules of activated neutrophils </li></ul></ul><ul><ul><li>Initially proposed as a marker for infections and certain adenocarcinomas </li></ul></ul><ul><li>NGAL has an early and dramatic rise in urine </li></ul><ul><li>after renal injury </li></ul>
  18. 19. Print Nikolas et al Ann Intern Med 2008
  19. 20. <ul><ul><li>A single measurement of urinary NGAL helps to distinguish acute injury from normal renal function, prerenal azotemia, and CKI </li></ul></ul><ul><ul><li>This may help patient disposition from the ED to home, observation unit for hydration, versus full admission </li></ul></ul>
  20. 21. Acute kidney injury with iodinated contrast McCullough PA. Crit Care Med 2008; 36(4Suppl):S204-211
  21. 22. Acute Kidney Injury
  22. 23. Meta-analysis - Nephrotoxicity of high- and low- osmolality iodinated contrast medium Barrett 1993, as presented in McCullough 2008
  23. 24. Acute Kidney Injury <ul><li>Prevention, incidence, and outcomes of contrast-induced acute kidney injury </li></ul>Weisbord SD, et al. Arch Intern Med 2008; 168(12):1325-32
  24. 25. Use of preventive therapy is variable Weisbord SD, et al. Arch Intern Med 2008; 168(12):1325-32
  25. 28. Acute Kidney Injury (AKI) <ul><li>Meta-analysis: effectiveness of drugs for preventing contrast-induced nephropathy </li></ul><ul><ul><li>Kelly AM, et al. Ann Intern Med 2008; 148(4):284-294. </li></ul></ul>
  26. 29. Dopamine Fenoldopam Furosemide N-Acetylcysteine Theophylline 0.62 (0.44-0.88)
  27. 30. Acute Kidney Injury (AKI) <ul><li>Bottomline </li></ul><ul><ul><li>CIAKI is associated with poor outcomes </li></ul></ul><ul><ul><li>Need to standardize contrast induced acute kidney injury (CIAKI) prophylaxis </li></ul></ul><ul><ul><li>Patients with risk factors for CIAKI (chronic kidney disease and diabetes) should receive non-ionic contrast </li></ul></ul><ul><ul><li>NAC is more effective in preventing CIAKI injury than hydration alone </li></ul></ul>
  28. 31. Summary <ul><li>Does intensive glucose control improve outcomes in Type 2 diabetes? </li></ul><ul><li>What is the optimal prophylaxis to prevent contrast-induced acute kidney injury? </li></ul><ul><li>Do inhaled medications increase morbidity and/or mortality in patients with COPD? </li></ul>
  29. 32. <ul><li>Systematic abstracting of papers from > 130 journals </li></ul><ul><li>Ratings of each article for quality and newsworthiness </li></ul><ul><li>Customizable email alerts </li></ul><ul><li>Cumulative searchable database of alerts from 2003 </li></ul>https://plus.mcmaster.ca/acpjc/Registration.aspx

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