1. Standard lipid panels provide important information but may not fully characterize cardiovascular risk, as they do not analyze lipoprotein particles.
2. Advanced lipid testing can provide additional details on lipoprotein composition and particle number that better predict risk.
3. Measuring LDL particle number is a better indicator of risk than LDL cholesterol alone, as people with the same LDL cholesterol can have different numbers of LDL particles.
1- Talk more about the industry background half a page !In.docxSONU61709
1- Talk more about the industry background half a page !
Industry background :
Industry name is “Babble” is streaming company - like Hulu and Netflix !
“The industry is constantly evolving due to technological influences. It is characterized by rapidly developing trends in streaming of music, videos, movies, programs and so much more. It is a very rewarding industry, and due to this, also very competitive as it attracts new entrants by the day. The industry is known for unending customer demand for high-quality streaming services and due to this, companies like Netflix and Hulu invest highly in digital media production by attracting suitable talents, skills, knowledge, technology and expertise to actualize this. The streaming media industry is a recently discovered industry that is shaping up entertainment. It is full of untapped market and opportunities. “CONTINUE”
2- talk about “Marketing strategy” for the company enough for 3 slides powerpoint !
Such as company will target different age kids , adult / or services that will be different from Netflix or Hulu plus like streaming music or ad free !
For Example :
· Babble is an online video streaming service
· The tent pole of Apple’s new Entertainment division
· Standard issue on Apple TV, available in the App Store and Google Play
· 60 day free trial, $15/mo for full access
· Apple TV users get an extra 60 days free
· Commercial free with subscription
· Movies, television, specials, original content
· Access to full library globally, ability to filter search results by country of origin but no regional limitations
· iMessage functionality
· instantly share and start a discussion about what you're watching, send a link in app
· Potential for deeper integration, across platforms as well - gamifying binge watching, more social functions, etc.
The Wicked Problem: Heart Failure
Let’s start with some basic facts. It is estimated that there are 400,000 Canadians living with congestive heart failure (CHF): of those, about 40,000 experience cardiac arrest every year; and
less than five per cent of those who have a cardiac arrest outside of a hospital (the majority of cases) survive. Depending on the severity of symptoms, heart dysfunction, age and other factors, CHF can be associated with an annual mortality of between five and 50 per cent. Between 40 and 50 per cent of people with con- gestive heart failure die within five years of diagnosis.
Now let’s look at what this means for the health care system. A study by the Canadian Cardiovascular Society that exam- ined hospital discharges for fiscal 2000 found that a total of 1.38 million hospital days were associated with CHF. The average hospital stay was slightly less than 13 days. Re-admission to hos- pital was also examined. There were a total of 106,130 discharges for CHF in 85,679 patients – suggesting that there were 20,451 re-admissions among these patients. This is a re- admission rate that Dr. Ross Tsuyuki, associate prof ...
1- Talk more about the industry background half a page !In.docxSONU61709
1- Talk more about the industry background half a page !
Industry background :
Industry name is “Babble” is streaming company - like Hulu and Netflix !
“The industry is constantly evolving due to technological influences. It is characterized by rapidly developing trends in streaming of music, videos, movies, programs and so much more. It is a very rewarding industry, and due to this, also very competitive as it attracts new entrants by the day. The industry is known for unending customer demand for high-quality streaming services and due to this, companies like Netflix and Hulu invest highly in digital media production by attracting suitable talents, skills, knowledge, technology and expertise to actualize this. The streaming media industry is a recently discovered industry that is shaping up entertainment. It is full of untapped market and opportunities. “CONTINUE”
2- talk about “Marketing strategy” for the company enough for 3 slides powerpoint !
Such as company will target different age kids , adult / or services that will be different from Netflix or Hulu plus like streaming music or ad free !
For Example :
· Babble is an online video streaming service
· The tent pole of Apple’s new Entertainment division
· Standard issue on Apple TV, available in the App Store and Google Play
· 60 day free trial, $15/mo for full access
· Apple TV users get an extra 60 days free
· Commercial free with subscription
· Movies, television, specials, original content
· Access to full library globally, ability to filter search results by country of origin but no regional limitations
· iMessage functionality
· instantly share and start a discussion about what you're watching, send a link in app
· Potential for deeper integration, across platforms as well - gamifying binge watching, more social functions, etc.
The Wicked Problem: Heart Failure
Let’s start with some basic facts. It is estimated that there are 400,000 Canadians living with congestive heart failure (CHF): of those, about 40,000 experience cardiac arrest every year; and
less than five per cent of those who have a cardiac arrest outside of a hospital (the majority of cases) survive. Depending on the severity of symptoms, heart dysfunction, age and other factors, CHF can be associated with an annual mortality of between five and 50 per cent. Between 40 and 50 per cent of people with con- gestive heart failure die within five years of diagnosis.
Now let’s look at what this means for the health care system. A study by the Canadian Cardiovascular Society that exam- ined hospital discharges for fiscal 2000 found that a total of 1.38 million hospital days were associated with CHF. The average hospital stay was slightly less than 13 days. Re-admission to hos- pital was also examined. There were a total of 106,130 discharges for CHF in 85,679 patients – suggesting that there were 20,451 re-admissions among these patients. This is a re- admission rate that Dr. Ross Tsuyuki, associate prof ...
For full accreditation info click here:
https://www.carevive.com/whats-new-in-acute-myelogenous-leukemia/
Acute myelogenous leukemia (AML) is a disease of older adults, with a median age of presentation of 67 years; only 5-10% of patients are alive at 5 years. Traditionally older patients have not received intensive induction chemotherapy to avoid toxicities, yet current research shows fit patients treated with intensive chemotherapy have better outcomes than patients with no treatment.
The goal of this program is to close existing cancer clinician competency gaps regarding new data on investigational agents for AML along with evolving evidence-based guidelines and current understanding of treatment outcomes among older patients with AML. Hematology care teams will receive updates on current treatment treatments, the new data on investigational agents for AML, and how to make risk-based decisions among older patients with AML.L.
Target Audience
This activity is intended for hematologists, hematology Nurse Practitioners (NPs) and Physician Assistants (PAs) and oncology nurses engaged in the care of patients with acute myelogenous leukemia (AML).
Educational Objectives
At the conclusion of these educational initiatives, participants should be able to:
Assess clinical data on newly approved agents for relapsed/refractory AML
Select appropriate treatment for AML according to patient risk group
Integrate evidence-based guidelines into practice to treat patients with AML guided by molecular and cytogenetic and testing and patient-specific characteristics
Faculty
Thomas W. LeBlanc, MD
Associate Professor of Medicine
Duke Cancer Institute
Geriatric Assessment in Older Patients with Acute Myelogenous Leukemia: Treat...Carevive
For full accreditation info click here:
https://www.carevive.com/geriatric-assessment-in-older-patients-with-aml-treatment-updates-and-implications/
Acute myelogenous leukemia (AML) is a disease of older adults, with a median age of presentation of 67 years; only 5-10% of patients are alive at 5 years. Traditionally older patients have not received intensive induction chemotherapy to avoid toxicities, yet current research shows fit patients treated with intensive chemotherapy have better outcomes than patients with no treatment.
The goal of this program is to close existing cancer clinician competency gaps regarding new data on investigational agents for AML along with evolving evidence-based guidelines and current understanding of treatment outcomes among older patients with AML. Hematology care teams will receive updates on current treatment treatments, the new data on investigational agents for AML, and how to make risk-based decisions among older patients with AML
TARGET AUDIENCE
This activity is intended for hematologists, hematology Nurse Practitioners (NPs) and Physician Assistants (PAs) and oncology nurses engaged in the care of patients with acute myelogenous leukemia (AML).
EDUCATIONAL OBJECTIVES
At the conclusion of these educational initiatives, participants should be able to: • Select appropriate treatment for AML according to patient risk group
• Assess frailty status among older patients newly diagnosed with AML or those
needing a new line of therapy
FACULTY
Ashley Leak Bryant, PhD, RN-BC, OCN
University of North Carolina Lineberger Comprehensive Cancer Center
I am going to show you why the context-less outlier detection methods proposed practically everywhere, are almost useless, and why t̲h̲o̲u̲g̲h̲t̲l̲e̲s̲s̲ removal of outliers, instead of embracing and LEARNING from them, is so wrong.
After reading the attached document, you should be able to understand why people, who remove outliers blindly, without attempting to investigate it and who don't even try to learn the context, either completely don't understand what they do, don't care, or they lie intentionally.
Don't be an ignoramus, don't lie, investigate both missing data and outliers.
Outliers? I'll show you cases, where the truly worrying data aren't even visible.
Can Cardiovascular Disease be PreventedParticipantsA.docxhumphrieskalyn
Can Cardiovascular Disease be Prevented?
Participants
:
Alfred A. Bove, MD, PhD, F
Robert S. Schwartz, MD, FACC
COPYRIGHT 2012 Healthology Inc.
Cardiovascular disease affects all aspects of heart function, from the arteries that supply it with blood, to the valves to the heart muscle itself.
RICHARD P. LEWIS, MD: Cardiovascular disease is the commonest chronic illness in our society, and I think in the world now. It causes about half of the deaths in our country today in one form or another, either as a heart attack or sudden death or dying of congestive heart failure.
Strokes are also a manifestation of cardiovascular disease, and a final one is called intermittent claudication, which is disease to the leg blood vessels that may lead to an amputation of the legs if it's severe.
ANNOUNCER: There are factors that can add to a patient's risk for the disease.
SUZANNE HUGHES, MSN, RN: There are only three risk factors for heart disease that we can't change. We haven't found the Fountain of Youth, so we can't turn back the clock: Age is a huge risk factor for cardiovascular disease. Being a man early in life is a risk factor for heart disease, which certainly is not changeable. And then the third thing is that we can't choose our parents. Family history is a risk factor for cardiovascular disease.
ANNOUNCER: Different medications can be prescribed to help prevent or control cardiovascular disease
ADOLPH M. HUTTER, Jr., MD: There are a number of medications that are actually very effective in preventing heart attacks and other forms of atherosclerosis. One is the simple drug aspirin. Aspirin has been shown to reduce strokes in women and heart attacks in men.
Another very important class of drugs are the drugs called statins. The statins are drugs that lower the bad cholesterol, the LDL. They lower it very effectively, and many studies have shown that these drugs can prevent the onset of heart disease and the progression of heart disease if you already have it.
A class of drugs called beta blockers can be very effective in protecting people who have already had a heart attack. They're also helpful in controlling blood pressure and controlling angina, which is a symptom of chest discomfort due to a blockage in the artery.
ANNOUNCER: It is also crucial that a patient makes lifestyle modifications.
ADOLPH M. HUTTER, Jr., MD: Heart disease is very preventable. You must absolutely stop smoking. You must have a low cholesterol, particularly the low bad cholesterol, the LDL. You must have your blood pressure controlled. You should exercise regularly and keep a lean weight.
RICHARD P. LEWIS, MD: We have made enormous strides in treating cardiovascular disease in all types. We can prevent the progression of this disease or the occurrence of clinically significant disease with our modern treatments if people will but do them. And it's not a disaster, even if you have the disease
Source Citation :
Can Cardiovascular Disease be Prevented? Alfre ...
For full accreditation info click here:
https://www.carevive.com/whats-new-in-acute-myelogenous-leukemia/
Acute myelogenous leukemia (AML) is a disease of older adults, with a median age of presentation of 67 years; only 5-10% of patients are alive at 5 years. Traditionally older patients have not received intensive induction chemotherapy to avoid toxicities, yet current research shows fit patients treated with intensive chemotherapy have better outcomes than patients with no treatment.
The goal of this program is to close existing cancer clinician competency gaps regarding new data on investigational agents for AML along with evolving evidence-based guidelines and current understanding of treatment outcomes among older patients with AML. Hematology care teams will receive updates on current treatment treatments, the new data on investigational agents for AML, and how to make risk-based decisions among older patients with AML.L.
Target Audience
This activity is intended for hematologists, hematology Nurse Practitioners (NPs) and Physician Assistants (PAs) and oncology nurses engaged in the care of patients with acute myelogenous leukemia (AML).
Educational Objectives
At the conclusion of these educational initiatives, participants should be able to:
Assess clinical data on newly approved agents for relapsed/refractory AML
Select appropriate treatment for AML according to patient risk group
Integrate evidence-based guidelines into practice to treat patients with AML guided by molecular and cytogenetic and testing and patient-specific characteristics
Faculty
Thomas W. LeBlanc, MD
Associate Professor of Medicine
Duke Cancer Institute
Geriatric Assessment in Older Patients with Acute Myelogenous Leukemia: Treat...Carevive
For full accreditation info click here:
https://www.carevive.com/geriatric-assessment-in-older-patients-with-aml-treatment-updates-and-implications/
Acute myelogenous leukemia (AML) is a disease of older adults, with a median age of presentation of 67 years; only 5-10% of patients are alive at 5 years. Traditionally older patients have not received intensive induction chemotherapy to avoid toxicities, yet current research shows fit patients treated with intensive chemotherapy have better outcomes than patients with no treatment.
The goal of this program is to close existing cancer clinician competency gaps regarding new data on investigational agents for AML along with evolving evidence-based guidelines and current understanding of treatment outcomes among older patients with AML. Hematology care teams will receive updates on current treatment treatments, the new data on investigational agents for AML, and how to make risk-based decisions among older patients with AML
TARGET AUDIENCE
This activity is intended for hematologists, hematology Nurse Practitioners (NPs) and Physician Assistants (PAs) and oncology nurses engaged in the care of patients with acute myelogenous leukemia (AML).
EDUCATIONAL OBJECTIVES
At the conclusion of these educational initiatives, participants should be able to: • Select appropriate treatment for AML according to patient risk group
• Assess frailty status among older patients newly diagnosed with AML or those
needing a new line of therapy
FACULTY
Ashley Leak Bryant, PhD, RN-BC, OCN
University of North Carolina Lineberger Comprehensive Cancer Center
I am going to show you why the context-less outlier detection methods proposed practically everywhere, are almost useless, and why t̲h̲o̲u̲g̲h̲t̲l̲e̲s̲s̲ removal of outliers, instead of embracing and LEARNING from them, is so wrong.
After reading the attached document, you should be able to understand why people, who remove outliers blindly, without attempting to investigate it and who don't even try to learn the context, either completely don't understand what they do, don't care, or they lie intentionally.
Don't be an ignoramus, don't lie, investigate both missing data and outliers.
Outliers? I'll show you cases, where the truly worrying data aren't even visible.
Can Cardiovascular Disease be PreventedParticipantsA.docxhumphrieskalyn
Can Cardiovascular Disease be Prevented?
Participants
:
Alfred A. Bove, MD, PhD, F
Robert S. Schwartz, MD, FACC
COPYRIGHT 2012 Healthology Inc.
Cardiovascular disease affects all aspects of heart function, from the arteries that supply it with blood, to the valves to the heart muscle itself.
RICHARD P. LEWIS, MD: Cardiovascular disease is the commonest chronic illness in our society, and I think in the world now. It causes about half of the deaths in our country today in one form or another, either as a heart attack or sudden death or dying of congestive heart failure.
Strokes are also a manifestation of cardiovascular disease, and a final one is called intermittent claudication, which is disease to the leg blood vessels that may lead to an amputation of the legs if it's severe.
ANNOUNCER: There are factors that can add to a patient's risk for the disease.
SUZANNE HUGHES, MSN, RN: There are only three risk factors for heart disease that we can't change. We haven't found the Fountain of Youth, so we can't turn back the clock: Age is a huge risk factor for cardiovascular disease. Being a man early in life is a risk factor for heart disease, which certainly is not changeable. And then the third thing is that we can't choose our parents. Family history is a risk factor for cardiovascular disease.
ANNOUNCER: Different medications can be prescribed to help prevent or control cardiovascular disease
ADOLPH M. HUTTER, Jr., MD: There are a number of medications that are actually very effective in preventing heart attacks and other forms of atherosclerosis. One is the simple drug aspirin. Aspirin has been shown to reduce strokes in women and heart attacks in men.
Another very important class of drugs are the drugs called statins. The statins are drugs that lower the bad cholesterol, the LDL. They lower it very effectively, and many studies have shown that these drugs can prevent the onset of heart disease and the progression of heart disease if you already have it.
A class of drugs called beta blockers can be very effective in protecting people who have already had a heart attack. They're also helpful in controlling blood pressure and controlling angina, which is a symptom of chest discomfort due to a blockage in the artery.
ANNOUNCER: It is also crucial that a patient makes lifestyle modifications.
ADOLPH M. HUTTER, Jr., MD: Heart disease is very preventable. You must absolutely stop smoking. You must have a low cholesterol, particularly the low bad cholesterol, the LDL. You must have your blood pressure controlled. You should exercise regularly and keep a lean weight.
RICHARD P. LEWIS, MD: We have made enormous strides in treating cardiovascular disease in all types. We can prevent the progression of this disease or the occurrence of clinically significant disease with our modern treatments if people will but do them. And it's not a disaster, even if you have the disease
Source Citation :
Can Cardiovascular Disease be Prevented? Alfre ...
About this webinar: This talk will introduce what cancer rehabilitation is, where it fits into the cancer trajectory, and who can benefit from it. In addition, the current landscape of cancer rehabilitation in Canada will be discussed and the need for advocacy to increase access to this essential component of cancer care.
This document is designed as an introductory to medical students,nursing students,midwives or other healthcare trainees to improve their understanding about how health system in Sri Lanka cares children health.
LGBTQ+ Adults: Unique Opportunities and Inclusive Approaches to CareVITASAuthor
This webinar helps clinicians understand the unique healthcare needs of the LGBTQ+ community, primarily in relation to end-of-life care. Topics include social and cultural background and challenges, healthcare disparities, advanced care planning, and strategies for reaching the community and improving quality of care.
International Cancer Survivors Day is celebrated during June, placing the spotlight not only on cancer survivors, but also their caregivers.
CANSA has compiled a list of tips and guidelines of support:
https://cansa.org.za/who-cares-for-cancer-patients-caregivers/
Chandrima Spa Ajman is one of the leading Massage Center in Ajman, which is open 24 hours exclusively for men. Being one of the most affordable Spa in Ajman, we offer Body to Body massage, Kerala Massage, Malayali Massage, Indian Massage, Pakistani Massage Russian massage, Thai massage, Swedish massage, Hot Stone Massage, Deep Tissue Massage, and many more. Indulge in the ultimate massage experience and book your appointment today. We are confident that you will leave our Massage spa feeling refreshed, rejuvenated, and ready to take on the world.
Visit : https://massagespaajman.com/
Call : 052 987 1315
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
Trauma Outpatient Center is a comprehensive facility dedicated to addressing mental health challenges and providing medication-assisted treatment. We offer a diverse range of services aimed at assisting individuals in overcoming addiction, mental health disorders, and related obstacles. Our team consists of seasoned professionals who are both experienced and compassionate, committed to delivering the highest standard of care to our clients. By utilizing evidence-based treatment methods, we strive to help our clients achieve their goals and lead healthier, more fulfilling lives.
Our mission is to provide a safe and supportive environment where our clients can receive the highest quality of care. We are dedicated to assisting our clients in reaching their objectives and improving their overall well-being. We prioritize our clients' needs and individualize treatment plans to ensure they receive tailored care. Our approach is rooted in evidence-based practices proven effective in treating addiction and mental health disorders.
Rate Controlled Drug Delivery Systems, Activation Modulated Drug Delivery Systems, Mechanically activated, pH activated, Enzyme activated, Osmotic activated Drug Delivery Systems, Feedback regulated Drug Delivery Systems systems are discussed here.
Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondHealth Catalyst
Join us as we delve into the crucial realm of quality reporting for MSSP (Medicare Shared Savings Program) Accountable Care Organizations (ACOs).
In this session, we will explore how a robust quality management solution can empower your organization to meet regulatory requirements and improve processes for MIPS reporting and internal quality programs. Learn how our MeasureAble application enables compliance and fosters continuous improvement.
Empowering ACOs: Leveraging Quality Management Tools for MIPS and Beyond
Advanced lipoprotein analysis (printer friendly)
1. 12/30/13 Advanced Lipoprotein Analysis (printer-friendly)
www.medscape.org/viewarticle/815311_print 1/16
www.medscape.org
This article is a CME certified activity. To earn credit for this activity visit:
http://www.medscape.org/viewarticle/815311
CME Information
CME Released: 12/13/2013 ; Valid for credit through 12/13/2014
Target Audience
This activity was developed for practicing primary care physicians, nurse practitioners, physician assistants, and
other healthcare professionals who manage patients with lipid disorders.
Goal
Lipoproteins are complex molecules containing proteins, cholesterol, and phospholipid. While standard lipid panels
provide important clinical information, they may not fully characterize a patient's cardiovascular disease and
cardiometabolic risk. In these cases, advanced lipid testing can often provide this additional information. Join us as
Karol E. Watson, MD, PHD, FACC, discusses advanced lipid testing and its place in clinical practice.
Learning Objectives
Upon completion of this activity, participants should be able to:
1. Identify in their clinical practice patients who are at increased cardiometabolic risk even with adequate
cholesterol lowering.
2. More confidently include advanced lipid testing in screening and treatment strategies for select patients at
increased cardiometabolic risk.
Credits Available
Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™
All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of
participation.
Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Accreditation Statements
For Physicians
The Omnia-Prova Education Collaborative, Inc. (TOPEC) is accredited by the Accreditation Council for Continuing
Medical Education (ACCME) to provide continuing medical education for physicians.
The Omnia-Prova Education Collaborative, Inc., designates this enduring material for a maximum of 0.25 AMA PRA
Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in
2. 12/30/13 Advanced Lipoprotein Analysis (printer-friendly)
www.medscape.org/viewarticle/815311_print 2/16
Faculty and Disclosures
Author
Karol E. Watson, MD, PHD, FACC
Professor of Medicine/Cardiology, University of California at Los Angeles, Los Angeles, California
the activity.
Contact This Provider
For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted
above. For technical assistance, contact CME@medscape.net
Instructions for Participation and Credit
There are no fees for participating in or receiving credit for this online educational activity. For information on
applicability and acceptance of continuing education credit for this activity, please consult your professional licensing
board.
This activity is designed to be completed within the time designated on the title page; physicians should claim only
those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must
complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA
Category 1 Credit™, you must receive a minimum score of 75% on the post-test.
Follow these steps to earn CME/CE credit*:
1. Read the target audience, learning objectives, and author disclosures.
2. Study the educational content online or printed out.
3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing
score as designated at the top of the test. In addition, you must complete the Activity Evaluation to provide
feedback for future programming.
You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot
alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period
you can print out the tally as well as the certificates from the CME/CE Tracker.
*The credit that you receive is based on your user profile.
Hardware/Software Requirements
To access activities, users will need:
A computer with an Internet connection.
Internet Explorer 7.x or higher, Firefox 4.x or higher, Safari 2.x or higher, or any other W3C standards
compliant browser.
Adobe Flash Player and/or an HTML5 capable browser may be required for video or audio playback.
Occasionally other additional software may be required such as PowerPoint or Adobe Acrobat Reader.
3. 12/30/13 Advanced Lipoprotein Analysis (printer-friendly)
www.medscape.org/viewarticle/815311_print 3/16
Disclosure: Dr. Watson is a consultant for Aegerion and on the clinical trial adjudication committee for Merck.
Reviewer
Gregory Pokrywka, MD, FACP, FNLA, NCMP
Director, Baltimore Lipid Center, Fellow, National Lipid Association, Assistant Professor, Johns Hopkins University
School of Medicine, Baltimore, Maryland
Disclosure: Dr. Pokrywka is on the commercial Interest speakers bureau for Astra Zeneca, Daichii Sankyo
International, Genentech, Health Diagnostics Labs, Kowa Pharmaceuticals America, Inc., Lilly USA, LLC, and
LipoScience.
Planners
Barry A. Fiedel, PhD
Vice President, Clinical and Scientific Affairs, The Omnia-Prova Education Collaborative, Fort Washington, PA
Disclosure: No relationship to report.
Christine Finnegan
Clinical Education Director, Prova Education, Fort Washington, PA
Disclosure: No relationship to report.
Sean T. Saunders, CCMEP
VP, CME, Outcomes and Communications, The Omnia-Prova Education Collaborative, Fort Washington, PA
Disclosure: No relationship to report.
Erica Spengler
Activity Manager, The Omnia-Prova Education Collaborative, Fort Washington, PA
Disclosure: No relationship to report.
Karol E. Watson, MD, PHD, FACC
This CME activity is based on a lecture presented by Dr. Karol Watson at Prova Education's From Guideline to
Practice: Managing Challenging Cases in Primary Care program held on October 25, 2013, in Pasadena, California.
Lipoproteins allow lipids such as cholesterol to be transported in the blood stream.
Advanced Lipoprotein Analysis CME
CME Released: 12/13/2013 ; Valid for credit through 12/13/2014
4. 12/30/13 Advanced Lipoprotein Analysis (printer-friendly)
www.medscape.org/viewarticle/815311_print 4/16
Slide 1.
The most dense and largest of them, mostly triglyceride-carrying lipoproteins, are chylomicrons and the very low
density lipoproteins (VLDLs); also included are low- and high- density lipoproteins (LDLs and HDLs, respectively), the
latter the only anti-inflammatory, anti-atherosclerotic lipoprotein.
5. 12/30/13 Advanced Lipoprotein Analysis (printer-friendly)
www.medscape.org/viewarticle/815311_print 5/16
Slide 2.
Cholesterol carried in LDL (LDL-C) has the most direct relationship to atherosclerosis.
Based on 2004 Guidelines, the LDL-C target for high-risk patients is <100 mg/dL; for the very high-risk patient the
target LDL-C is <70 mg/dL. Low risk is <160 mg/dL while moderately high risk falls in between at <130 mg/dL.
6. 12/30/13 Advanced Lipoprotein Analysis (printer-friendly)
www.medscape.org/viewarticle/815311_print 6/16
Slide 3.
What exactly are lipoproteins, how are they constructed, and what is their structural relationship with cholesterol?
Lipoproteins are physiologically complex: a non-polar lipid core surrounded with a polar surface coat, plus
(apo)proteins. For such a complicated particle, it is surprising we reduce it down to just LDL-C in our Standard Lipid
Panel.
Is the typical standard lipid panel suboptimal?
7. 12/30/13 Advanced Lipoprotein Analysis (printer-friendly)
www.medscape.org/viewarticle/815311_print 7/16
Slide 4.
The standard lipid panel typically provides information on total cholesterol, HDL cholesterol, triglycerides, and
sometimes VLDL. What some physicians and many patients may not realize is that the LDL-C value received in the
report is in almost all cases a calculated LDL-C, and not directly measured. It is calculated by taking total cholesterol
and then subtracting the sum of HDL plus triglycerides divided by 5. For a measured LDL-C, the actual value of
cholesterol present in LDL, a direct LDL-C measurement may need to be ordered.
Moreover, certain lipid subanalyses are often absent in the lipid profile report. One that may have import is the LDL
particle (LDL-P) number.
A recent consensus statement from the American Diabetes Association (ADA) and the American College of
Cardiology (ACC) suggests that direct LDL-C measurements are better than calculated...and ...assessment of
LDL particles (LDL-P) is actually better than measuring the LDL cholesterol, as LDL-P number is a better
predictor of cardiovascular risk than LDL-C alone.
8. 12/30/13 Advanced Lipoprotein Analysis (printer-friendly)
www.medscape.org/viewarticle/815311_print 8/16
Slide 5.
Another important point is that among individuals who have the exact same LDL-C level, they may have very different
LDL-P numbers. For illustration's sake, say the LDL-C is100 mg/dL. There could be a few large particles with an
average amount of cholesterol per particle, or there could be many small particles with less cholesterol per particle;
in the end, exactly the same LDL-C but the total number of LDL-P is different.
Why might this be important?
The relationship between LDL-C level and LDL-P number has been known for many years. Fredricksen and
colleagues in 1967 said:
"LDL particles are the causal agents in atherosclerosis."
"The more LDL particles a person has, the higher the risk of plaque buildup that causes heart attacks,
regardless of how much cholesterol those particles carry."
That remains basically true. The American Diabetes Association in a consensus statement relates that:
"The mean concentration of LDL cholesterol in those [patients] with type 2 diabetes is not significantly
different from that in those individuals who [do] not have diabetes. However, qualitative changes in LDL
cholesterol may be present.
"Patients with diabetes tend to have higher proportions of smaller and denser LDL-P, which is more
susceptible to oxidation and may, therefore, increase the risk of cardiovascular events in
9. 12/30/13 Advanced Lipoprotein Analysis (printer-friendly)
www.medscape.org/viewarticle/815311_print 9/16
atherosclerosis."
Slide 6.
Clearly, assessing more than just the cholesterol content is important. This is true for LDL, and it is also true for
HDL. These are data from the VA-HIT Study. This study evaluated individuals at risk for cardiovascular disease, using
a fibrate to help target an increase in HDL level, the primary end point being a decrement in cardiovascular risk.
The result was not fully expected.
The amount of cholesterol carried in HDL turned out to be a weak predictor of fibrate benefit and decrement in risk. A
similar result was observed with Apo-A1, though a somewhat better (though not significantly significant) predictor of
benefit.
HDL particle number was by far the best predictor of protection in this study, an outcome that was also statistically
significant. Thus, as with LDL, where LDL particle number is the best predictor of negative events, HDL particle
number is the best predictor of protection against such events.
If we are to believe that when assessing LDL-P number along with LDL-C we are potentially identifying a level of extra
CVD risk for patients, exactly how much and how significant is that extra risk?
Data gleaned from three (3) clinical trials help answer that question: 1) Framingham Heart Study; 2) the Multi-Ethnic
Study of Atherosclerosis; and 3) the VA-HIT Study.
10. 12/30/13 Advanced Lipoprotein Analysis (printer-friendly)
www.medscape.org/viewarticle/815311_print 10/16
Slide 7.
The Framingham Heart Study demonstrated a discordant relationship between LDL-C and LDL-P in that patients with
high LDL-C (and low LDL-P) had relatively less risk for a poor outcome (measured as Event-Free Survival) when
compared with patients with a low LDL-C but high LDL-P.
11. 12/30/13 Advanced Lipoprotein Analysis (printer-friendly)
www.medscape.org/viewarticle/815311_print 11/16
Slide 8.
Data from the Multi-Ethnic Study of Atherosclerosis (or MESA), which evaluated carotid atherosclerosis,
demonstrated that while carotid atherosclerosis risk was lower in individuals whose LDL-C was normal (<100 mg/dL)
when coincident with a low LDL-P number (Q1), as LDL-P numbers became progressively higher (Q2 through Q4)
carotid atherosclerosis risk continued to climb in a statistically significant trend.
12. 12/30/13 Advanced Lipoprotein Analysis (printer-friendly)
www.medscape.org/viewarticle/815311_print 12/16
Slide 9.
This relationship between LDL-C and LDL-P was also illustrated the VA HIT Study. When a patient's LDL-C level was
high that alone represented an increased risk for a CHD event, though not statistically significant. Similar findings
were observed for for non-HDL and APO-B as markers for increased CHD event risk.
Conversely, when LDL-P was assessed, it was found to be a statistically significant marker for increased CHD event
risk.
There are a number of advanced lipid tests that can assist the clinician when assessing a patient's CVD or
cardiometabolic risk status despite what appears to be a favorable LDL-C. There are basically three technical
methods for measuring LDL-P.
They are:
1. The Berkeley Heart Advanced Lipid Profile. Berkeley uses a gradient gel electrophoresis technique.
2. The Vertical Automated Profile, also short-handed as VAP. VAP measures particle density by gradient
ultracentrifugation.
3. Nuclear Magnetic Resonance (NMR) spectroscopy to differentiate various LDL particle numbers.
13. 12/30/13 Advanced Lipoprotein Analysis (printer-friendly)
www.medscape.org/viewarticle/815311_print 13/16
Slide 10.
Berkeley utilizes gradient gel electrophoresis to sift/separate different lipoproteins based on their electrophoretic
characteristic sizes through a process called "mobility shifts." This technique does not give information about
cholesterol, but does offer information about size. Thus, it provides quantification of the number of particles of different
sizes and an estimate can be obtained with regard to particle number.
This is the type of profile obtained; it can provide information about LDL size, particle number, etc.
14. 12/30/13 Advanced Lipoprotein Analysis (printer-friendly)
www.medscape.org/viewarticle/815311_print 14/16
Slide 11.
The VAP technique employs ultracentrifugation to separate lipoprotein fractions. The technique permits resolution of
different lipoprotein subclasses based on their densities. A computerized system then provides the needed
information with regard to the different lipoprotein classes.
15. 12/30/13 Advanced Lipoprotein Analysis (printer-friendly)
www.medscape.org/viewarticle/815311_print 15/16
Slide 12.
With NMR spectroscopy, each lipoprotein subclass broadcasts a unique NMR "sound." These sounds can be
separated through NMR spectroscopy and the signals deconstructed. A computerized system provides the needed
information with regard to the different lipoprotein classes in the sample.
In closing, lipoproteins are very complex molecules containing proteins, cholesterol, and phospholipid. Standard lipid
panels provide important clinical information, no question, but they do not provide the complete picture. Additional
information beyond the standard lipid panel is sometimes needed to adequately assess risk, and advanced lipid
testing can provide additional information that may help you to better define your patient's risk.
NOTE ADDED IN PROOF
Impact of 2013 Updated ACC/AHA Guidelines on the Treatment of Blood Cholesterol
On November 12, 2013 new ACC/AHA guidelines on the treatment of blood cholesterol to reduce atherosclerotic
cardiovascular disease (ASCVD) risk in adults was published in Circulation (see:
http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.full.pdf).
A seminal component of the new guidelines is the absence of set LDL-C targets, replaced by four (4) categories of
patients (termed Major Statin Benefit Groups) with recommendation for consideration of different intensity statin
intervention based on use of a risk calculator assessing 10-year risk for developing ASCVD.
As described in this CME activity and based in part on three (3) critical clinical trials, advanced lipid testing, notably