Sie sind auf Seite 1von 2

E FFECTIVE P HYSICIAN : N EW A STHMA G UIDELINES , PAGE 19

VO L . 4 0 , N O. 2 3
Internal Medicine News www.eclinicalpsychia
www.inter nalmedicinenews.com
tr ynews.com
T he Leading Inde p endent Ne wspaper for the Inter nist—Since 1968 DECEMBER 1, 2007

INSIDE
Fenofibrate Curbed
Retinopathy in
S HERI M ATTES /E LSEVIER G LOBAL M EDICAL N EWS
Diabetic Patients
Need for laser therapy was cut by 37%.
Early Signs of BY MITCHEL L. ZOLER with [diabetic retinopathy] is very
Parkinson’s Philadelphia Bureau exciting. It’s exciting to use it to
Preclinical brain changes can treat patients, and it opens a
be seen on SPECT images. O R L A N D O — Treatment with whole new area of research,”
fenofibrate led to a substantial commented Dr. Virgil Brown,
PAGE 13 drop in the need for laser treat- professor of internal medicine at
Improved reimbursement is “a very urgent issue,” said Dr. David ments for retinopathy in a con- Emory University, Atlanta.
C. Dale, president of the American College of Physicians. trolled trial of nearly 10,000 pa- The benefits of fenofibrate for
tients with type 2 diabetes. microvascular disease of diabetes
Family History Physicians should “consider us- appeared to extend beyond its sig-

Medical Home Set Genetics column looks at


new applications for
family health history.
ing fenofibrate on all patients
with diabetes, even patients al-
ready on a statin and at their tar-
nificant effect on retinopathy. Pa-
tients treated with fenofibrate also
had less progression of albumin-

To Move Forward PAGE 28


get lipid levels, to further reduce
their risk and microvascular com-
plications,” Dr. Anthony C. Keech
uria, and fewer amputations, Dr.
Keech and his associates reported.
“The results were very clear-
said at an industry-sponsored cut. It’s very hard to make a co-
BY KERRI WACHTER dorsed the tool as a way for prac- press briefing during the annual herent argument not to use
Senior Writer tices to qualify as medical homes scientific sessions of the Ameri- fenofibrate” in patients with dia-
in pilot demonstration projects can Heart Association. betes, said Dr. Keech, professor of
W A S H I N G T O N — Medical slated to begin as early as 2008. “Having a new tool to deal See Fenofibrate page 20
home advocates hope a new set “I think of medical home as
of metrics will help primary care the standard of care for primary
physicians move closer to imple-
menting this model of care.
care. That’s the type of care that
we all want to provide,” said Dr. Oral Purgatives Linked
The metrics assess how patient Vera F. Tait, associate executive
centered an office-based practice
is and how well the practice’s
director of the American Acade-
my of Pediatrics. Toe Tips With Acute Kidney Injury
care delivery system works. Not everyone is clear on what Clinical pearls for the BY ROBERT FINN tained after adjustment for many
Scores on the tool correlate with exactly a medical home is, not- diagnosis and treatment of San Francisco Bureau potential confounders, and was
enhanced clinical performance ed Dr. James King, president of onychomycosis. based on a definition of acute
and lead to voluntary designation the American Academy of Fam- S A N F R A N C I S C O — Acute kidney injury as a 50% increase in
PAGE 26
as a patient-centered medical ily Physicians. “A lot of people kidney injury may not be as rare serum creatinine, said Col. Frank
home, according to Dr. Greg [are] starting to use the phrase a consequence of oral sodium P. Hearst, MC, USA, and his col-
Pawlson, executive vice president See Medical Home page 5 phosphate bowel purgatives as leagues at the Walter Reed Army
of the National Committee for previously thought, researchers Medical Center, Washington.
Quality Assurance (NCQA). VITAL SIGNS said at the annual meeting of the The study involved 6,432 pa-
Having a set of metrics is “a American Society of Nephrology. tients who received oral sodium
very important step on the way In a retrospective study of phosphate and 3,367 who re-
to ... a series of large-scale pilot Average Workweeks in Selected Primary Care nearly 10,000 patients, those giv- ceived polyethylene glycol as out-
demonstration projects,” Dr. Specialties Were Similar in 2006 en oral sodium phosphate purga- patients prior to colonoscopy. All
Pawlson said at a press briefing to tives prior to colonoscopy had patients were at least 50 years
unveil the tool. “Most impor- Internal medicine: pediatric (n = 76) 38.7 hours 2.35 times the chance of devel- old, and all had serum creatinine
tantly, it provides a road map for oping acute kidney injury as did measurements within 365 days
where a practice needs to go Internal medicine: general (n = 3,368) 37.0 hours those given polyethylene glycol before and after the procedure
from where it is now to where it purgatives. This result was ob- See Purgatives page 6
needs to be as a patient-centered Pediatric: hospitalist (n = 62) 36.6 hours
medical home,” he said.
The American College of Family practice (without OB) (n = 4,634) 36.6 hours
E LSEVIER G LOBAL M EDICAL N EWS

Physicians, the American Acade-


my of Family Physicians, the Pediatric: general (n = 2,390) 35.7 hours
American Academy of Pediatrics,
and the American Osteopathic Pediatric: infectious disease (n = 14) 33.1 hours
Association worked with NCQA
on the development of Physician Note: Mean hours that clinician is involved in direct patient care.
Practice Connections. These four Source: Medical Group Management Association
primary care groups have en-
6 News INTERNAL MEDICINE NEWS • December 1, 2007

Nephropathy Risk Quantified ure (relative risk 2.03), contrast exposure


(relative risk 1.70), and age (relative risk
nephropathy. The pathophysiology ap-
pears to involve obstructive calcium phos-
Purgatives from page 1 1.06 per year). The use of oral sodium phate crystalluria and intratubular nephro-
phosphate purgatives was thus accompa- calcinosis. Of 7,349 nontransplant renal
date. The investigators noted in their kidney injury would be expected to occur nied by a greater risk of acute kidney in- biopsies, 31 revealed nephrocalcinosis; at
poster presentation that they excluded pa- for every 81 patients given oral sodium jury than were these other risk factors. least 21 of those were associated with the
tients who used purgatives for reasons phosphate instead of polyethylene glycol. Patients who developed acute kidney in- use of oral sodium phosphate purgatives.
other than screening colonoscopy, as well With use of a more stringent criterion jury typically did not return to baseline lev- Patients with nephrocalcinosis had a
as those who had end-stage renal disease. for acute kidney injury—a doubling in els of renal function. Their mean prepro- mean baseline serum creatinine of 1.0
The unadjusted absolute risk of acute the serum creatinine level—the adjusted cedure creatinine level was 0.98 mg/dL. mg/dL, which had increased to 3.9 mg/dL
kidney injury was 1.31% with oral sodium relative risk associated with oral sodium This rose to a mean of 1.78 mg/dL after the at presentation. After a mean follow-up of
phosphate and 0.92% with polyethylene phosphate purgatives was 3.81, and the procedure. An average of 280 days later, the 17 months, 4 of the 21 patients developed
glycol, for a 0.39% increase in absolute number needed to harm was 288. mean values had declined to 1.38 mg/dL. end-stage renal disease. Of the remaining
risk. After adjustment for confounders, Other factors emerged in the multivari- In a separate talk, Dr. Glen S. Markowitz 17 patients, 16 had a decline in serum cre-
the relative risk associated with oral sodi- ate analysis as being independently asso- of Columbia University, New York, de- atinine to a mean of 2.4 mg/dL, and 4 of
um phosphate was 2.35. One case of acute ciated with acute kidney injury: heart fail- scribed his earlier study of acute phosphate the 17 reached 2.0 mg/dL, but none re-
turned to baseline levels.
In response to this report and others, the
Food and Drug Administration in May
2006 issued a warning on acute phosphate
nephropathy associated with oral sodium
phosphate purgatives, stating that individ-
uals at increased risk include those with ad-
vanced age and decreased intravascular vol-
ume, and people taking certain medications
including ACE inhibitors, angiotensin II re-
ceptor blockers, and possibly NSAIDs.
Dr. Markowitz said that other probable
risk factors are inadequate hydration, ex-
cess phosphate dosing, a short interval be-
I,m getting tween oral sodium phosphate doses, and
fasting prior to the procedure to decrease

aggressive the risk of aspiration during sedation.


Other possible risk factors are female gen-
der and small body habitus.

with prehypertension,
Several professional societies—includ-
ing the American Society of Colon and
Rectal Surgeons—have added such warn-
naturally. ings to their consensus documents on
bowel preparation.
This increased awareness will likely lead
to a decline in acute phosphate nephropa-
thy, Dr. Markowitz said. Clinicians will be
more careful in selecting purgatives for
each patient. Several manufacturers of
bowel preparations have decreased their
phosphate content by 16%-20%. Also, clin-
icians are increasingly recommending bet-
ter hydration, to provide at least 72 ounces
before, during, and after the use of oral
sodium phosphate purgatives. ■

EDITORIAL
A DV I S O RY B OA R D
ROY D. ALTMAN, M.D., California
Introducing ameal bp™ – the new dietary supplement containing the naturally derived active ingredient
JON O. EBBERT, M.D., Minnesota
AmealPeptide®, clinically shown to maintain healthier blood pressure in prehypertensive patients.*
FAITH T. FITZGERALD, M.D., California
AmealPeptide® is a naturally occurring ACE inhibitor derived from enzymatically hydrolized WILLIAM E. GOLDEN, M.D., Arkansas
casein (milk proteins). Fourteen double-blind, placebo-controlled studies have shown a SIDNEY GOLDSTEIN, M.D., Michigan
clinically significant lowering of both systolic and diastolic blood pressure ROBERT H. HOPKINS, M.D., Arkansas
Stratified analysis of 8 clinical studies by start value of blood pressure
(Post-hoc analysis, 606 subjects from 8 studies) with AmealPeptide®. It has also been shown to be safe and well-tolerated.
Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg)
HOLLY J. KRAMER, M.D., Illinois
10
~160 159~150 149~140 139~130 ~100 99~95 94~90 89~85 ameal bp™ is available online or at major drugstores in easy-to-swallow J. LEONARD LICHTENFELD, M.D., Georgia
0 capsules and chewable tablets. DIANE E. MEIER, M.D., New York
-10
**
**
Start prehypertensive patients on ameal bpTM when you F. MICHAEL MELEWICZ, M.D., California
*** **
-20
*** ***
***
AmealPeptide ®
start them on a diet and exercise program. ALAN R. NELSON, M.D., Washington, D.C.
-30 Placebo
JOHN R. NELSON, M.D., Washington
Significant difference from placebo (t-test): **P<0.01, ***P<0.001.
Visit www.amealbp.com for more information.
BARBARA L. SCHUSTER, M.D., Ohio
Reference: 1. Data on file. Post-hoc analysis adapted from
AmealPeptide® clinical studies. DONNA E. SWEET, M.D., Kansas
ERIC G. TANGALOS, M.D., Minnesota
PETER G. TUTEUR, M.D., Missouri
JOHN H. VASSALL II, M.D., Washington
*This statement has not been evaluated by the Food and Drug Administration.
This product is not intended to diagnose, treat, cure, or prevent any disease. JOHN J. WHYTE, M.D., Washington, D.C.
ameal bp™ and AmealPeptide® are trademarks of Calpis Co., Ltd. Helps maintain healthy blood pressure* ROWEN K. ZETTERMAN, M.D., Nebraska
©2007 Calpis Co., Ltd. A02
Technical Consultant:
GILMAN D. GRAVE, M.D.

Das könnte Ihnen auch gefallen