The South African Journal of Diabetes & Vascular Disease presents: Problems and challenges in patients with type 1 diabetes.
Larry A Distiller
Centre for Diabetes and Endocrinology
Johannesburg
http://www.diabetesjournal.co.za
JUPITER (Justification for the Use of Statins in Primary Prevention: An Inter...theheart.org
- 4-year, double-blind, placebo-controlled, randomized clinical trial
- Population and treatment:
17 802 patients with normal LDL-C (median 108 mg/dL) and elevated CRP (>2.0 mg/L) randomized to rosuvastatin 20 mg/d or placebo
- Primary outcome:
Composite of nonfatal MI, nonfatal stroke, hospitalization for unstable angina, revascularization, and confirmed death from CV causes
See the article at http://www.theheart.org/article/917181.do
The South African Journal of Diabetes & Vascular Disease presents: Problems and challenges in patients with type 1 diabetes.
Larry A Distiller
Centre for Diabetes and Endocrinology
Johannesburg
http://www.diabetesjournal.co.za
JUPITER (Justification for the Use of Statins in Primary Prevention: An Inter...theheart.org
- 4-year, double-blind, placebo-controlled, randomized clinical trial
- Population and treatment:
17 802 patients with normal LDL-C (median 108 mg/dL) and elevated CRP (>2.0 mg/L) randomized to rosuvastatin 20 mg/d or placebo
- Primary outcome:
Composite of nonfatal MI, nonfatal stroke, hospitalization for unstable angina, revascularization, and confirmed death from CV causes
See the article at http://www.theheart.org/article/917181.do
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Jeremy Chow
Cardiologist, Electrophysiologist
Asian Heart & Vascular Centre
www.ahvc.com.sg
Un nuevo horizonte en el tratamiento de las dislipemias
14/09/15 18:00h-19:30h Casa del Corazón (Madrid)
http://objetivoLDL.secardiologia.es
#objetivoLDL
Abordaje terapéutico de la dislipemia en el paciente con enfermedad renal crónica
Dr. Jesús Egido de los Ríos, Jefe Servicio Nefrología e Hipertensión Fundación Jiménez Díaz (Madrid)
Crown Medical Research and Pharmaceutical Sciences College of Canada offers opportunities to expand your experience beyond the classroom and support them with guidance on career opportunities.
Our professors, consultants, and course developers are recognized leaders in professional development and training in the field of pharmaceutical, natural health products, quality assurance and quality control, regulatory affairs and submissions, pharmacovigilance and drug safety reporting, clinical research, cosmetics, food sciences, biopharmaceutical, and health care policy and services management.
We strive to continuously evolve and expand our programs in an attempt to respond effectively to changing technologies and workforce demands in the industry. It is with this strategy that our programs will prepare our learners for their future.
When attending our college, you will be exposed to highly qualified professionals and professors as well as students with diverse backgrounds and proven professional abilities seeking to improve their skill set and employment outlook.
We are located at Richmond Hill, in the Greater Toronto Area, that is one of the 3 biggest financial and social center in North America. This gives learners access to the head quarters of many industries and to be exposed to personal, and professional growth opportunities.
Our college offers academic counseling program through one-on-one meetings with professors and collaborators and we offer faculty-mentoring program to assist students in improving their learning and working strategies for reaching faster their career goals.
When you are considering to enroll in a certificate course offered by our college, please explore the program information on the website and contact us for a one-on-one mentoring meeting, to visit the campus, and to get a career consultation at any time. Our intensive courses start every month and our learners can start their program with us at any time during the year.
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Jeremy Chow
Cardiologist, Electrophysiologist
Asian Heart & Vascular Centre
www.ahvc.com.sg
Un nuevo horizonte en el tratamiento de las dislipemias
14/09/15 18:00h-19:30h Casa del Corazón (Madrid)
http://objetivoLDL.secardiologia.es
#objetivoLDL
Abordaje terapéutico de la dislipemia en el paciente con enfermedad renal crónica
Dr. Jesús Egido de los Ríos, Jefe Servicio Nefrología e Hipertensión Fundación Jiménez Díaz (Madrid)
Crown Medical Research and Pharmaceutical Sciences College of Canada offers opportunities to expand your experience beyond the classroom and support them with guidance on career opportunities.
Our professors, consultants, and course developers are recognized leaders in professional development and training in the field of pharmaceutical, natural health products, quality assurance and quality control, regulatory affairs and submissions, pharmacovigilance and drug safety reporting, clinical research, cosmetics, food sciences, biopharmaceutical, and health care policy and services management.
We strive to continuously evolve and expand our programs in an attempt to respond effectively to changing technologies and workforce demands in the industry. It is with this strategy that our programs will prepare our learners for their future.
When attending our college, you will be exposed to highly qualified professionals and professors as well as students with diverse backgrounds and proven professional abilities seeking to improve their skill set and employment outlook.
We are located at Richmond Hill, in the Greater Toronto Area, that is one of the 3 biggest financial and social center in North America. This gives learners access to the head quarters of many industries and to be exposed to personal, and professional growth opportunities.
Our college offers academic counseling program through one-on-one meetings with professors and collaborators and we offer faculty-mentoring program to assist students in improving their learning and working strategies for reaching faster their career goals.
When you are considering to enroll in a certificate course offered by our college, please explore the program information on the website and contact us for a one-on-one mentoring meeting, to visit the campus, and to get a career consultation at any time. Our intensive courses start every month and our learners can start their program with us at any time during the year.
Journal Article Analysis: Ticagrelor versus Clopidogrel in ACS (PLATO)Paul Pasco
A journal article analysis ("journal club") I composed of a notable clinical trial during an internship/Advanced Pharmacy Practice Experience (APPE) in a community pharmacy at a hospital.
PPT on all important trials of traumatic brain injury. - includes design, setting, statistical analysis,outcome, strength, limitations, conclusion#DECRA#RESCUEicp#BEST TRIP#CRASH1#CRASH3#SAFE TBI#EUROTHERM3939#POLAR TRIAL
Also includes trial related BTF guidelines
Atrioventricular blocks are related to delay in conduction of the AV node..
Their recognition is primarily by ECG, anatomical correlation is by EP study.
ST elevation is not always due to STEMI. Other causes to be kept in mind to prevent the undue complications of thrombolysis. wrong patient and wrong management
The electrocardiogram, a basic tool in cardiology has been developed two centuries ago. It was recorded by a giant machine at that time, which is now being recorded on a mobile. Such is the advancement in ECG, which is still the gold standard in diagnosis of VT .
SGLT2I The paradigm change in diabetes managementPraveen Nagula
Just like ARNI, SGLT2I have changed the face of diabetes management and they have a good profile in multimodality management because of pleiotropic effects
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
2. HOST – ASSURE ( Harmonizing Optimal Strategy
for Treatment of Coronary Artery Stenosis – Safety
& Effectiveness of DrUg Eluting Stents & Anti –
Platelet REgimen)
ClincalTrials.gov number NCT01267734.
Kyung Woo Park ,MD,PhD ,Si Hyuck Kang ,MD. et al
Seoul National University Hospital ,Seoul , Republic of Korea.
JACC –CARDIOVASCULAR INTERVENTIONS,Vol .6,No.9.,2013
3. Background
• Antiplatelet regimen is an integral component of medical therapy
after percutaneous coronary intervention (PCI).
• Inhibition of platelet reactivity in the first month post PCI is known
to be critical in preventing thrombotic events,since higher on
treatment platelet reactivity is reported to be associated with higher
risk of hard endpoints.
• A 1-week duration of doubling the dose of clopidogrel was shown to
improve outcome at 1 month compared with the conventional dose
in ACS pts undergoing PCI.
• In Asia including Korea,the addition of cilostazol as a third
antiplatelet agent is used in high risk patients,however no large-scale
comparison has been done.
4. Objectives
To test the noninferiority of triple antiplatelet therapy (TAT) versus
double-dose clopidogrel dual antiplatelet therapy (DDAT)in pts
undergoing percutaneous coronary intervention(PCI).
5. Study design
• Prospective, randomized, blinded endpoint evaluation, multicenter
trial conducted at 40 sites in the Republic of Korea.
• 2*2 factorial design – randomization for type of DES and type of
APT .
• 1:1 to either TAT or DDAT.
• 2:1 to either Platinum Chromium based Everolimus – eluting
stents or Cobalt Chromium based Zotarolimus – eluting stents.
6. Trial Profile
A total of 3,755 patients were randomly assigned to either triple antiplatlet therapy (n = 1,879) or double-dose
clopidogrel dual antiplatelet therapy (n = 1,876). The analysis was performed on an intention-to-treat basis.
DDAT = double-dose clopidogrel dual antiplatelet therapy; TAT = triple antiplatelet therapy.
7. • Participants were 18 yrs of age or older ,had atleast 1 clinically
significant stenotic lesion amenable to PCI in the coronary artery or
venous or arterial grafts.
• No exclusion criteria for lesion type,number of stents used,the no. of
lesions treated,or the diagnosis at presentation –all comers’ study.
EXCLUSION CRITERIA
1. Severe Left ventricular systolic dysfunction (EF<25%)
2.Cardiogenic shock
3.H/o bleeding diathesis
4.coagulopathy
5.GI,GU bleeding within the previous 3 months
6.Major surgery within 2 months
8. • Before Index PCI - all pts received loading doses of 300 mg Aspirin
and 300 to 600 mg of Clopidogrel .
• TAT group – additional loading dose of 200 mg Cilostazol, followed
by 100mg bid *1 month.
• DDAT group – 150 mg/d maintenance dose of Clopidogrel *1month.
• UFH administered throughout the procedure (ACT > 250msec)
• GpIIb/IIIa inhibitors – at the discretion of treating physician.
• After PCI – all pts were recommended to receive optimal Rx.
9. PRIMARY END POINT –
(composite of the following at 1
month )
SECONDARY END POINT
Cardiac death
All individual components of the
primary composite end point
Non fatal Myocardial Infarction
All death
Stent Thrombosis
PLATO minor bleeding
Stroke
Target vessel revascularization
PLATO major bleeding
Target lesion revascularization
Secondary per protocol analysis – pts adhering to allocated therapy at 1
month follow up and those with clinical events were included in analysis.
10. • Clinical events were defined as per ARC recommendations.
1. MI – clinical signs + CKMB or Trop T/I increase above upper
normal limit.
2. Stent thrombosis – definite or probable .
3. Stroke – new neurological deficit,confirmed by Neurologist or
imaging.
4. PLATO major bleeding
Life threatening major bleeding - fatal , IC ,intrapericardial bleed
with cardiac tamponade or hypovolemic shock or severe
hypotension requiring pressors or surgery, associated decrease in
hemoglobin > 5g/dl or transfusion of >4U of whole blood or
packed RBCs .
Disabling major bleeding - intraocular bleeding with permanent
visual loss , decrease in Hb 3-5g/dl , transfusion of 2-3U whole
blood or packed RBC.
11. • Subgroup of pts – platelet function tests using the Verify Now
P2Y12 assay were performed
– At baseline (12-24 h after loading dose of Clopidogrel 300600mg +/- Cilostazol 200 mg )
– At 1 month follow up under maintenance dose ( Clopidogrel
75-150mg/day +/- Cilostazol 100 mg bid)
– At follow up after maintenance dose 2 -6 h after morning dose.
12. Statistical Analysis
• With assumption that the primary outcome rate would be 2% and
3% in the TAT and DDAT group respectively, an estimation of
requirement of 3,750 pts for study was made to have > 90% power
showing noninferiority margin of 0.75%.
• TAT would be considered to be noninferior to DDAT If the
upper limit of a 1–sided 97.5% CI of the difference was less than
the pre specified non inferiority margin.
13. Characteristics of Study Pts
•
•
•
•
June 2010 to November 2011
TAT ( n = 1,879 );DDAT ( n = 1,876)
Baseline characteristics were well balanced
Mean age and frequency of h/o MI higher in DDAT , PAD lower
in DDAT.
• No differences in Hb, Platelet count ,LDL levels in 2 groups.
• Medications were also balanced
• CCBs more in DDAT group.
Mode of presentation –
•
•
•
•
65.5% - ACS
53.8% - MVD
3%
- PCI for Left main disease
16.2% - PCI for bifurcation lesion
14. Results
• 1 end point - TAT 23 pts (1.2% ) , 27 pts (1.4%) DDAT
• Non inferiority of TAT was confirmed with an upper limit of the 1sided 97.5% CI of 0.52% (prespecified noninferiority margin was
0.75%).
• Regarding superiority, no significant difference between two groups.
(Hazards ratio :0.85 ,95% CI :0.49 to1.48)
• Rates of individual components of 1 end point –showed similar
trends.
• PLATO major bleeding were the same in TAT ,DDAT groups.
• PLATO minor bleeding were numerically higher in TAT group.
• No significant interaction between the antiplatelet regimen and
stent randomization arms regarding any study outcome.
15.
16. Figure Legend:
Cumulative Kaplan-Meier Estimates for the Primary Endpoint and PLATO Major Bleeding at 1 Month
Kaplan-Meier curves show the cumulative incidence of the net clinical outcome (the primary endpoint), a composite of cardiac
death, nonfatal myocardial infarction, stent thrombosis, stroke, or PLATO major bleeding (A) and PLATO major bleeding (B).
Abbreviations as in Figure 1.
17. Compliance and per protocol analysis
• After randomization 97.4% were allocated TAT ,92.2% DDAT.
• 5.2% refused the additional dose of clopidogrel in DDAT.
• Upto 1 month follow up – 5.8% pts in TAT group , 5.7% DDAT
non adherent
• At 1 month adherence rates were 91.6% TAT,86.5% DDAT.
• Drug related adverse events led to discontinuation in
– TAT –Headache, easy bruisability, bleeding ,GI side effects,skin
rash,tachycardia.
– DDAT – GI, easy bruisability.
18. Per protocol analysis
• 1.2% TAT ,1.6% DDAT – primary outcome.
• Spontaneous MI occured more frequently in DDAT group
Platelet function tests ( 36.1% pts ,n= 1,356)
• Mean OPR was lower and % of inhibition significantly higher in
TAT group compared to DDAT group – no change after
multivariable adjustment for baseline factors.
• Mean OPR > 228 PRU at 12-24 hrs after loading dose in all when
plotted for thrombotic events.
19. On-treatment Platelet Reactivity
Scatterplot of on-treatment platelet reactivity in the TAT and DDAT groups at 12 to 24 h after a
loading dose (A) and at 1 month after a maintenance dose (B). Abbreviations as in Figure 1.
20. Discussion
• Adjunctive use of cilostazol for 1 month in addition to conventional
dual APT was noninferior to doubling the maintenance dose of
clopidogrel with regard to net clinical outcome.
• No differences between the two treatment group regarding the
individual components of primary outcome.
21. Potent inhibition of platelet reactivity during the first month after
PCI is one of the key factors in a successful outcome.
HOPR associated with increased risk of thrombotic outcomes –
most profound association seen in the first month post PCI .
Rate of HOPR exceeds 50% in East Asians.
Frequency of CYP2C19 LOF carriers > 60%
22. • Doubling the maintenance dose of Clopidogrel (150mg/d) - was used in
high risk pts - MI,increased platelet reactivity , CYP2C19 loss of
function carriers.
This was proven benefit in following trials
– OPTIMUS ( Optimizing Antiplatelet Therapy in Diabetes) trial .
– ARYMDA (Antiplatelets for Reduction of Myocardial Damage During
Angioplasty ) DDAT – associated with higher platelet inhibition,better
flow mediated vasodilation ,low hsCRP .
– CURRENT –OASIS7 trial – 1 wk duration of DD Clopidogrel –
improve outcome at 1 month in pts undergoing PCI .
23. • Post PCI – Left main artery stenting ,multivessel stenting - cilostazol
is used as a third agent rather than an
in maintenance dose of
clopidogrel - in East Asia.( TAT proven to be of benefit in
pharmacodynamics studies)
• In long lesion stenting ,diabetics – TAT >DDAT due to inhibition of
neointima formation ,decreased target lesion revascularization
• CILON – T ( influence of CILostazol based triple antiplatelet
therapy ON ischemic complications after drug eluting stenT
implantation) : mean OPR was less in TAT.
• TAT – more efficacious in pts with documented HOPR ,
Diabetics,Acute MI, CKD,CYP2C19 LOF allele .
24. • Stent thrombosis and non fatal MI – occurred less frequently in
TAT group.
• Spontaneous MI in DDAT group ,no event in TAT group.
• PLATO
– Major bleeding – similar in two groups.
– Minor bleeding – more in TAT group ,not significant.(low OPR
in TAT group)
25. Limitations
1. The event rates were extremely lower than that expected from the
original power calculation .
Occurrence of 1 endpoint – 3%(expected) – 1.2% (result),1.4%
control - 48% relative risk increase as being non inferior with no.
of pts in study under powered to concretely prove that TAT is
noninferior to DDAT.
2.Underreporting of events
Post PCI events are less in East Asia - genetic factors, IVUS usage
during PCI.
3.Periprocedural rates - MI were low - cardiac enzymes measured
only in pts with significant chest discomfort.
4.Adherence was only 91.6% TAT ,86.5% DDAT -may have affected
the outcomes.
26. Take Home Message
• Adjunctive use of Cilostazol in addition to conventional dual
antiplatelet therapy is noninferior to doubling the maintenance dose
of clopidogrel in pts undergoing PCI with DES.
• HOPR associated with higher risk of thrombotic cardiovascular
events especially first month post PCI .
• HOPR > 50% in East Asian ,CYP2C19 LOF carriers >60%.
27. • DDAT beneficial proven in
• Diabetics (OPTIMUS) ,
• PCI pts(ARYMDA) ,
• CURRENT OASIS 7 trial .
• Beneficial effects of Cilostazol – in DES pts - CILON –T.
• TAT beneficial in pts with
•
•
•
•
•
HOPR ,
Diabetics,
Acute MI,
CKD,
CYP2C19 LOF allele compared to DDAT .
• Post PCI rates low in East Asians – genetic factors.