VADT is yet another negative trial showing a lack of benefit from controlling blood sugars.
That makes three negative trials in the last 12 months.
ADVANCE trial: 11,140 people randomized to gliclazide in order to lower the A1c to 6.5, the control group achieved 7.3%. This lowered combined micro- and macrovascular complications by 10% 18.1% vs 20% after a median of 5 yrs (p=0.01). However the difference was entirely driven by a 21% reduction in nephropathy, with no reduction in retinopathy, macrovascular complications or reduction in CV death or death from any cause.
ACCORD Trial: 10,251 people randomized to usual care (A1c 7.0-7.9) or intensive care (A1c under 6%). There was no difference in the primary composite outcome of non-fatal heart attack and strokes and CV mortality. Unfortunately there was a significant increase in total mortality (p=0.04) with high mortality in the intensive therapy group.
All three of these trials were looking to prove that better glycemic control could reduce strokes and heart attacks. We have known since the early nineties that good glycemic control prevents or delays microvascualr complications (kidney disease, blindness, neuropathy) but the data on cardiovascular disease was lacking. This is important because relatively few diabetics develop ESRD and most patients die of heart disease, a macrovascular complication. For example in type 1 diabetics the 20 year risk of developing ESRD is only 2.2%, while the risk of death is four times that at around 10%.
Unfortunately, this looks like a bust. Not one of the trials have shown any sign that improved glycemic control translates into reduced heart attacks or strokes
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What's going on with diabetes
January 23, 2009
Non Visible Hematuria
Many clinicians are not sure what constitutes clinically relevant haematuria; they are also unsure about when patients with haematuria should be referred for
specialist assessment and whether they should be referred to a urologist, nephrologist, or both.This review article deals with this nicely..
MRC Dyspnoea Score
Dyspnoea should be assessed with a validated instrument such as the MRC (Medical Research Council) dyspnoea score. This defines five grades of breathlessness related to normal activities and patients are asked to select the level that best describes how breathlessness affects them. The five levels are:
1 Not troubled by breathlessness except on strenuous exercise
2 Short of breath when hurrying or walking up a slight hill
3 Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace
4 Stops for breath after walking about 100 metres or after a few minutes on level ground
5 Too breathless to leave the house, or breathless when dressing or undressing.
Bisphosphonate nephrotoxicity
Initial drugs for Moderate Hypertension
January 18, 2009
RAS inhibitor/CCB combination therapy
The combination of RAS inhibitors with DHP-CCBs may provide more intensive BP control to currently recommended targets and cardiovascular protective effects that lead to more global risk-factor reduction in patients with hypertension. Given their excellent and complementary tolerability profiles, combination therapy with an ARB or ACEI with a long-acting DHP-CCB is a rational choice for patients requiring two or more antihypertensive agents.Read the review article here..
Oxygen A-a gradient
MRSA infected Stethescopes
Doctors Please Clean your Steths. In this Emergency setting, MRSA was found on approximately one in three stethoscopes of emergency professionals. A longer length of time since the last stethoscope cleaning increased the odds of MRSA colonization.Read more...
Bisphosphonates and Osteonecrosis of Jaw
January 8, 2009
This has become a serious concern for dentist.. The association is real, but it was overhyped. Read more..
ITP - Not always Idiopathic
When clinical conditions warrant consider these underlying diseases:
SLE
Antipholpholipid syndrome
H. pylori infection---here the association is controversial, but some studies indicate a high rate of improvement or remission of thrombocytopenia following eradication.
Hepatitis C---screen all patients with chronic thrombocytopenia for hep C. Thrombocytopenia may improve with treatment of the underlying disease.
HIV
From Current Opinion in Hematology
So testing for H Pylori is warranted in ITP Read more..
Alien Hand Syndrome
Alien hand syndrome is a rare condition that can result from neurodegenerative disorders, tumors, or strokes. This is an acute presentation of alien hand syndrome from a right parietal ischemic stroke. The condition was not recognized by the emergency department, delaying diagnosis and appropriate treatment. Early recognition of unusual manifestations of stroke, such as an acute alien hand syndrome, can lead to timely diagnosis and therapy. Read this interesting case report..
Exercise Capacity on Treadmill and CV events
Reduced exercise capacity is associated with an increased risk of myocardial infarction, unstable angina, and coronary revascularization in patients referred for exercise treadmill testing for clinical indications. The prognostic importance of reduced exercise capacity for nonfatal coronary events is independent of demographic factors, clinical factors, and other exercise treadmill testing measures. Reduced exercise capacity may identify patients in whom aggressive risk-factor modification, further diagnostic testing, and close follow-up is warranted. Read the article..
Infective Endocarditis- Surgical Treatment
January 7, 2009
Infection of native and prosthetic valves is still commonly seen and some cases require surgical management. This article concisely deals with this subject.. Read here..
Hyperglycemia management updated-2009
January 6, 2009
The statement, produced jointly by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), recommends that if target glycemic goals are not met with initial lifestyle interventions and metformin, rapid transition to new regimens should be initiated.Read this PDF article..
Cheese and Hypertensive Crisis
Posted by arif at 9:57 AM View Comments
Labels: Drugs and Adverse Effecs, Hypertension
Move to top of post.Dual Anti Platelet Therapy
Dual anti platelet therapy in Cardiovascular diseases in frequently used sometime with no definite evidence. Also duration of such combination therapy is arguable..Read this article in PDF format..
Posted by arif at 9:13 AM View Comments
Labels: Drugs and Adverse Effecs, Primary care
Move to top of post.Once A Day CV drugs
once daily medications have become norm of the lady and it is always becomes a problem when patients asks you when to take a particular once a drug. This article talks about once a day dosing of Cardiovascular drugs..Read more..
Health care Associated Pneumonia
This outcome study published this year looks at heath care associated pneumonia and its increased mortality. Read more..
Nail Disorders - Drug Induced
January 1, 2009
Nail disorders are common in primary care and it is important for us to know the culprit drugs. Read more this article..
