CME sites

Cleveland Clinic
http://www.clevelandclinicmeded.com/

American Heart Association Criteria

American Heart Association/Updated NCEP
There is confusion as to whether AHA/NHLBI intended to create another set of guidelines or simply update the NCEP ATP III definition. According to Scott Grundy, University of Texas Southwestern Medical School, Dallas, Texas, the intent was just to update the NCEP ATP III definition and not create a new definition.^[6][7]:

• Elevated waist circumference:
  • Men — Equal to or greater than 40 inches (102 cm)
  • Women — Equal to or greater than 35 inches (88 cm)
• Elevated triglycerides: Equal to or greater than 150 mg/dL (1.7 mmol/L)
• Reduced HDL (“good”) cholesterol:
  • Men — Less than 40 mg/dL (1.03 mmol/L)
  • Women — Less than 50 mg/dL (1.29 mmol/L)
• Elevated blood pressure: Equal to or greater than 130/85 mm Hg or use of medication for hypertension
• Elevated fasting glucose: Equal to or greater than 100 mg/dL (5.6 mmol/L) or use of medication for hyperglycemia

medication choice brief from 10 steps article

Everyone newly diagnosed with type 2 diabetes should be offered a structured education programme along with locally appropriate weight management and exercise opportunities. If this fails to achieve a lowering of glycosylated haemoglobin (HbA_1c) to an individually tailored target, the latest National Institute for Health and Clinical Excellence (NICE) guidance (CG 66 and CG 87)^[13] supports the use of an increasingly complex cocktail of medications, including insulin. Certainly, triple therapy with metformin, a sulphonylurea and either a glitazone or a gliptin (dipeptidyl peptidase [DPP] IV inhibitor) should be used where appropriate. Many practices are achieving competence in using insulin regimens, which now have licences to be used with pioglitazone or sitagliptin, as well as metformin. The recently licensed injectible incretin mimetics (exanatide and liraglutide) may well become established primary care drugs in the future but for now they are probably best grouped with insulins, i.e. if you have the confidence, skills and knowledge to initiate insulin, you can certainly initiate incretin mimetics. The role of weight should always be borne in mind, and any intervention that lowers weight is likely to have a beneficial impact on diabetes control. Adjusting the energy balance (eat less, do more) is the cornerstone of weight management, but the use of weight-reducing drugs (orlistat is now the sole remaining licenced drug in this area) and bariatric surgery is recommended, the latter achieving normoglycaemia in over 50% of cases.^[14]

Metabolic syndrome

American Heart Association/National Heart, Lung and Blood Institute criteria

3/5

1) waist circumference >35" in women (>40" in men)

2) triglyceride level >150 mg/dL

3) HDL-C level <50 mg/dL in women (<40 mg/dL in men)

4) blood pressure = >130/85 mm Hg

5) fasting glucose >100 mg/dL.


CRP elevation correlates with number of indicators

Pathophysiology

development of visceral fat > adipocytes  cells  increase plasma levels of TNFα and alter levels of other substances (e.g., adiponectin, resistin, PAI-1). TNFα triggers production of inflammatory cytokines and possibly insulin resistance. experiment with rats fed a diet one-third sucrose. The sucrose first elevated blood levels of triglycerides, which induced visceral fat and ultimately resulted in insulin resistance.  The progression from visceral fat to increased TNFα to insulin resistance has some parallels to human development of metabolic syndrome.

Reference Sites

Merck Manual: Merck Manual: http://www.merck.com/mmhe/index.html

Ultimate Physicians Referance: http://www.globalrph.com/reference_library.htm

cystic fibrosis

Cystic fibrosis

Mutation in the CFTR gene

CFTR = Chloride channel.

Result is too much luminal chloride so sweat and secretions become hypertonic

800 CFTR mutations described mild to sever

Pancrease exocrine but not endocrine function effected (islet cells not affected)

Lungs: Bronchiectasis, scarring, 95% die of lung infections.  S Aureus, Pseudomonas, Hemophilis

Liver: Bile ducts and canniculie become clogged. Hepatic inflammation. Cirrhosis

Small intestine involvement

Genitalia: Ovaries, Testes, Even mild males are absent vas deferens and azoospermia

Clinical:

Sinopulmonary S&S

GI: pancreas, intestinal

Male genitalia always affected

Dx: Sweat chloride analysis & DNA testing

ezetimibe

ezetimibe: http://en.wikipedia.org/wiki/Ezetimibe

Ezetimibe localises at the brush border of the small intestine, where it inhibits the absorption of cholesterol from the intestine. Specifically, it appears to bind to the Niemann-Pick C1-Like 1 (NPC1L1) protein on the gastrointestinal tract epithelialcells as well as in hepatocytes. In addition to this direct effect, decreased cholesterol absorption leads to an upregulation of LDL-receptors on the surface of cells and an increased LDL-cholesterol uptake into cells, thus decreasing levels of LDL in the blood plasma which contribute to atherosclerosis and cardiovascular events.


Even though ezetimibe decreases cholesterol levels, the results of two major, high-quality clinical trials (in 2008 and 2009) showed that it did not improve clinically significant outcomes, such as major coronary events, and actually made some outcomes, such as artery wall thickness, worse. Indeed, a panel of experts concluded in 2008 that it should "only be used as a last resort".^[1] In one of those studies, a head-to-head trial in 2009, a much less expensive medication (extended-release niacin) was found to be superior. Ezetimibe actually increased the thickness of artery walls (a measurement of atherosclerosis) and caused more major cardiovascular events.^[2] However, in combination with simvastatin, a 2010 trial has shown it to be better than atorvastatin and rosuvastatin at lowering lipid levels.^[3] A significantly more positive view of the benefits of Ezetimibe is offered by Britain's NICE.^[4]