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Vol. 3 No. 40

ADA’s clinical recommendations provide
roadmap for patients to center of care

FREDERICKSBURG, VA. – Patients are at the center of care in new, revised clinical-practice recommendations, Standards of Medical Care in Diabetes - 2019, issued by the American Diabetes Association (ADA).

The recommendations, published in January in Diabetes Care, provide a roadmap for medication selection and therapeutic approaches based on patients’ individual health, and include updates targeting heart failure, strokes, and heart attacks.

Also addressed: insulin delivery, blood-glucose meters, automated insulin-delivery devices, evidence-based recommendations for diagnosis and treatment of diabetes, and personalized diabetes care.

Four recommendations of special note---involving nutrition, shared decision-making, older adults, and screening for cognitive impairment and depression---were recently assessed by Scott Urquhart, PA-C, of Diabetes and Thyroid Associates, Fredericksburg, Va., who is faculty-conference chair of the Metabolic & Endocrine Disease Summit (MEDS).

Urquhart, an adjunct clinical professor, James Madison University physician assistant (PA) program, Harrisonburg, Va., discussed these recommendations:

•    Medical nutrition therapy/diet: Recommendation that patients be referred to and work with registered dieticians (RDs) to create personalized-nutrition plans.

“I always recommend that my patients schedule either one-on-one or group visits with an RD who has expertise in diabetes and weight management.  Even if my patients have received education in the past, I offer a referral for a refresher course for Medical Nutrition Therapy (MNT), since healthy eating a proper nutrition is a lifelong journey, and extremely valuable to diabetes management.”

•    Decision-making: Suggesting the need for ongoing assessment and shared decision-making to achieve care goals, help reduce therapeutic inertia and improve patient self-management. Stating the ongoing process of managing diabetes. Includes: meal planning, planned physical activity, blood-glucose monitoring, taking diabetes medicines, handling episodes of illness and of low- and high-blood glucose, managing diabetes when traveling. Recommendation that patients design self-management treatment plan in consultation with medical practitioners.

“Diabetes self-management education and support is imperative to having favorable outcomes in those with diabetes. It requires a whole team of clinicians and other providers to ensure timely interactions and changes that avoid clinical inertia. Physician assistants (PAs) and nurse practitioners (NPs) who care for patients with diabetes need to stay current with therapies and guidelines as it pertains to MNT, lifestyle interventions, glucose control, lipids, hypertension, as well as one’s referral-base in the community.”

•    Elderly: Suggesting that health-care professionals address unique nutritional and physical-activity needs and considerations for those over 65 with diabetes, including a new recommendation on lifestyle management---optimal nutrition-and-protein intake, regular exercise, including aerobic activity and resistance training, for those who can do so safely.

“Since the majority of PA, NP, and even MD programs don’t include adequate, if any, nutrition coursework, many clinicians are not prepared or well-versed in specific nutrition recommendations. I don’t feel in general that the 65-and-older population is being served well by their providers when it comes to recommendations for optimal nutrition, adequate protein intake, and physical activity/exercise. Advancing age and worse in conjunction with diabetes is associated with loss of muscle mass and strength and therefore risk for diminished quality of living and falls.  Muscle mass generally starts to decrease after age 40, so by the time a patient is over 65, significant muscle atrophy has already occurred.

“Education regarding nutritional counseling and therapeutic-lifestyle interventions is of utmost importance for U.S. clinicians.  Patients expect us to know this information, or at least a little something about everything. We don’t need to know the depths of nutrition of that of a registered dietician, but we should know enough to make an influence for positive changes in our patients.”

•    Psycho-social issues: Consider screening diabetes patients 65-and-older for cognitive impairment and depression.

“This is absolutely do-able and recommended. We so often deal with the ‘measurables’ of diabetes care (such as blood pressure, lipids, blood glucose, and A1c), but we unfortunately don’t spend any or adequate time assessing psycho-social issues/health. Diabetes distress and burn-out is very common, for 30%-or-more of patients, which has direct consequences on ideal glycemic management and outcomes. Regarding the elderly, screening for cognitive impairment, memory loss and overt dementia is a must, since these increase with advancing age, and are strongly associated with diabetes.

“Screening for depression is of great importance, since more-than-25% of patients with Type 1 and Type 2 diabetes have depression. Cognitive Impairment and depression complicate diabetes management for patients and their caregivers. If these are suspected, patients can be treated, or can be referred to providers specializing in mental health or those who can perform formal neuropsychological evaluations.”

CITATION: Standards of Medical Care in Diabetes-2019. Diabetes Care. January 2019, 42 (Supplement 1)


Stroke-prevention intervention research
points to several ESKD-patient categories

SYDNEY – Recent research on groups that may benefit from targeted stroke- prevention interventions points to several categories of end-stage kidney disease (ESKD) patients.
The study published in February in BMJ Open notes that ESKD patients at higher risk of stroke death are:

  • older
  • women
  • those with cerebrovascular disease
  • those with hypertensive/renovascular or polycystic kidney disease cause of ESKD
  • those with earlier year of ESKD treatment and receiving dialysis

The study’s authors---including Nicole Louise De La Mata, University of Sydney, Sydney, and Maria Alfaro-Ramirez, University of Wollongong, New South Wales, Australia---analyzed and described risk factors for stroke mortality in the Australian and New Zealand ESKD populations.

They identified all patients with incident ESKD in Australia (1980-to-2013) and New Zealand (1988-to-2012) from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) registry, and included 60,823 people with ESKD.

There were 941 stroke deaths and 33,377 non-stroke deaths during 381,874 person-years of follow-up.

The cumulative incidence of stroke death was 0.9%, and non-stroke death was 36.8%, five years after starting ESKD treatment.

Most factors that led to an increased risk of stroke death were non-modifiable, including older age, female sex, year of ESKD and cause of ESKD. The sex difference in stroke mortality in the ESKD population is not seen in the general population.

This raises questions as to whether female patients with ESKD have other clinical characteristics that place them at a greater risk, or whether prevention strategies are not prescribed in women as often as men.

Also, implementing prevention strategies in those with prior cerebrovascular disease has the potential to prevent secondary stroke in patients with ESKD.

It is unclear whether stroke-prevention strategies are as effective in the ESKD population as in the general population. The authors recommend further research into the use and effectiveness of stroke prevention in the ESKD population to evaluate means of reducing stroke mortality among those with cerebrovascular disease and in females.

CITATION: Nicole Louise De La Mata, Maria Alfaro-Ramirez, et. al. Absolute risk and risk factors for stroke mortality in patients with end-stage kidney disease (ESKD): population-based cohort study using data linkage. BMJ Open. Received August 25, 2018. Revised November 6, 2018. Accepted December 19, 2018. First published February 22, 2019. Online issue publication
February 22, 2019.


Study: Overweight and obesity may play a role
in RCC pathogenesis as early as adolescence

ÖREBRO, SWEDEN – Data from a recent population‐based cohort study shows a clear association between higher body mass index (BMI) during adolescence and subsequent risk of renal-cell carcinoma (RCC), suggesting that overweight and obesity play a role in RCC pathogenesis as early as adolescence.

The study published in February in the International Journal of Cancer indicates that the rationale underlying efforts to reduce childhood-and-adolescent obesity may extend to RCC prevention.

Its authors---including Anna Landberg and Anna Fält, Örebro University, Örebro, Sweden---suggest that the link between overweight/obesity and RCC is already established in late adolescence.

They identified a cohort of 238,788 Swedish men who underwent mandatory military-conscription assessment between 1969-and-1976 at a mean age of 18.5 years.

At the time of conscription assessment, physical-and-psychological tests were performed, including measurements of height and weight.

Men with severe disabilities, chronic disease, or those incarcerated were exempt from conscription, leaving 96% eligible.

Participants were followed through linkage to the Swedish Cancer Registry to identify incident diagnoses of RCC. The association between BMI at conscription assessment and subsequent RCC was evaluated using multivariable Cox regression.

During a follow‐up of up to 37 years, 266 men were diagnosed with RCC. The researchers observed a trend for higher RCC risk with increasing BMI during adolescence, where a one‐unit increase in BMI conferred a 6% increased risk of RCC. Compared to normal-weight men, men with overweight or obesity had hazard ratios for RCC of 1.76 and 2.87, respectively.

The researchers also observed that taller men had an increased RCC risk.

CITATION: Anna Landberg, Anna Fält, et. al. Overweight and obesity during adolescence increases the risk of renal cell carcinoma. International Journal of Cancer. First published: 20 February 2019.


Cataracts said to be independently linked
to increased osteoporosis-and-fracture risk

HUALIEN, TAIWAN – Cataracts are independently associated with increased osteoporosis-and-fracture risk, according to a recent study indicating that there might be an association between cataract surgery and lower risks of osteoporosis and fracture.

The nationwide population-based retrospective study published in February in the Journal of the American Geriatric Society utilized Taiwan's National Health Insurance Research Database.

Its authors---including Huei‐Kai Huang and Shu‐Man Lin, Buddhist Tzu Chi General Hospital, Hualien, Taiwan---assessed information on subjects with and without cataracts.

The subjects were matched one: one for age, sex, and index year. Those with cataracts were further divided into cataract surgery and non-surgery groups.

Incidences and hazard ratios (HRs) for risks of developing osteoporosis and fracture were calculated using Cox proportional hazard-regression models.

During mean follow-up of 6.4 years, 17,450 participants with cataracts and 12,627 without developed osteoporosis or fractures. Having cataracts was significantly associated with risk of developing osteoporosis or fracture.

In analyses for each event, cataracts were significantly associated with greater likelihood of all outcomes (osteoporosis, hip fracture, vertebral fracture, other fractures).

Participants who underwent cataract surgery were at significantly lower risk of osteoporosis or fracture than those who did not. Undergoing cataract surgery was also associated with lower risks of all individual events (osteoporosis; hip, vertebral, other fracture).

CITATION: Huang HK, Lin SM, et. al. Association Between Cataract and Risks of Osteoporosis and Fracture: A Nationwide Cohort Study. Journal of the American Geriatric Society. 2019 Feb;67(2):254-260. PMID: 30281143.


Efforts to educate youths on smoking dangers
called especially critical for asthma patients

ATLANTA – A study published in February in the Journal of Asthma suggests that, given adverse respiratory effects of smoking tobacco and marijuana, efforts to educate youth about the dangers of those substances is critical---especially among asthma patients.

Its authors---including Sherry Everett Jones and Brian A. King, Centers for Disease Control and Prevention, Atlanta---assessed the prevalence and trends in current use of cigarettes, cigars, and marijuana among U.S. high-school students, with-and-without-asthma.

They utilized the national Youth Risk Behavior Survey (YRBS), a biennial, school-based, nationally-representative survey of U.S. students in grades nine-to-12. Trends during 2003-to-2017 in current (past 30-day) use of cigarettes, cigars, and marijuana among students, with-and-without asthma, were examined using logistic regression.

Asthma was defined as reporting that a doctor or nurse ever told students they had asthma. T-tests were used to compare cigarette, cigar, and marijuana use by asthma status and year, frequency of use, and student characteristics.

During the years 2003-to-2017, current cigarette and cigar smoking decreased, with similar rates among students with-and-without asthma.

There was no significant linear change in current marijuana use, irrespective of asthma status. During most years, cigarette, cigar, and marijuana use were more common among students with asthma than without. In 2017, the most frequent use of cigarettes, cigars, and marijuana was among those with asthma than without. Differences in cigarette, cigar, and marijuana use by asthma status were apparent by demographic sub-groups.

CITATION: Sherry Everett Jones, Ph.D., MPH, JD, Brian A. King, Ph.D., MPH, et. al. Trends in the use of cigarettes, cigars, and marijuana among students with and without asthma, 2003–2017. Journal of Asthma. Received 15 Nov 2018. Accepted 17 Jan 2019. Published online: 07 Feb 2019.


ADPKD awareness, diagnosis approaches
are targeted in Global Academy activity

The Global Academy for Medical Education offers a Continuing Medical Education (CME)/Continuing Education (CE) activity involving the identification of clinical approaches for the early recognition, efficient evaluation, and timely diagnosis of autosomal dominant polycystic kidney disease (ADPKD). Understanding Patients’ Perspectives to Improve ADPKD Awareness, Diagnosis, and Management offers data-driven approaches to comprehensive care for ADPKD patients, and also focuses on ways to recognize which patients are most likely to benefit from currently-available and emerging therapies. More information is available at


CV, kidney anti-hyperglycemic drug benefits
are addressed in article in Clinician Reviews

An article posted in March in Clinician Reviews addresses newer anti-hyperglycemic drugs with distinctive cardiovascular (CV) and kidney benefits. Written by Andrew D. Bowser and citing an article in Circulation, the item notes that the drugs that lower CV risk have different effects on specific cardiovascular-and-kidney disease outcomes in patients with type 2 diabetes. A meta-analysis suggests that sodium-glucose contransporter-2 (SGLT2) inhibitors significantly reduce hospitalization from heart failure, whereas glucagon-like peptide-1 receptor agonists (GLP-1 RAs) don’t. The GLP-1–RA class reduces risk of kidney-disease progression, largely driven by a reduction in macroalbuminuria, while only the SGLT2 inhibitors reduce adverse kidney-disease outcomes in a composite excluding that biomarker. The article can be accessed at    



Vol. 3 No. 39

An expanding program targets AKIs
through interaction among providers

OCEANSIDE, CALIF. – An expanding, innovative program takes a NINJA stance—-literally—against acute kidney injuries (AKIs).

The Nephrotoxic Injury Negated by Just-in-Time Action (NINJA) program, was rolled out at Cincinnati Children’s Hospital Medical Center in 2016 as detailed in a study published in Kidney International. NINJA generates daily reports detailing patient exposures to nephrotoxic medications and alerting the pharmacist when triple nephrotoxic medications are ordered. These triple exposures are among the most common AKI causes among hospitalized children.

The NINJA program was highlighted at the recent American Society of Nephrology meeting in San Diego attended by Kim Zuber, PA-C, executive director of the American Academy of Nephrology PAs and past chair of the National Kidney Foundation/Council of Advanced Practitioners.

Zuber, of Oceanside, Calif., a faculty member of the Metabolic & Endocrine Disease Summit (MEDS), says NINJA was such a phenomenal success (a 64% decrease in AKI episodes in 1 year) it is now being adopted by 10 children’s hospitals nationwide, with a goal to move it to all hospital systems.

NINJA, says Zuber, is “simple, brilliant, self-sustaining, and made a HUGE difference in pediatric AKI cases.” She says Stuart L. Goldstein, who laid the groundwork for NINJA, “offers it free to anyone who wants it” and that it “fosters interaction” among health-care providers, including physician assistants (PAs) and nurse practitioners (NPs).

The NINJA program suggests such approaches as:

  • efficient, reliable data for clinical-decision support
  • intervention built into routine daily operations (rounds)
  • refinement of role descriptions (clinical pharmacists)
  • data regularly shared with clinical teams
  • evaluation of adverse events to identify potential system weaknesses

“I like the fact that NINJA is not an automated alert,” says Zuber. “We all have alert fatigue. With NINJA, the pharmacist calls the practitioners (and this is often a PA or NP in the NICU) to alert them that a medication can affect the kidneys. And NINJA forces us to talk to each other. NINJA allows the whole community to discuss ways to protect patients. Otherwise, we all tend to work in our own worlds---cardiologists just focus on the heart, and so on. This allows the medical community to come together.”

The 2016 NINJA study notes that some positive results aren’t sustained when resources initially used for the project are diverted elsewhere.

“That is the management side of a hospital,” says Zuber, “and part of the problem. We are paid to care for patients with issues, not to keep problems from occurring; we’re paid more to care for patients with AKI rather than to prevent AKI. We need to put resources into a preventative/prophylactic system. We need to keep patients healthy to begin with.”

She adds that “in some ways, this seems to be the way medicine is going: Medicare has an innovation group to look at decreasing readmissions. AKI increases readmissions.”

Providers’ reactions to NINJA, says Zuber, are encouraging.

“You would think that when pharmacists make these calls,” says Zuber, “there would be pushback, but in 90% of the cases, medications are switched. But is this specific to pediatrics? Are pediatric practitioners nicer? Would cardiothoracic surgeons or the chief of cardiology, for instance, push back?  With pediatrics, there has been no drama, no ego.”

In a 2018 Kidney International study, an episode of AKI was shown to increase the chance of chronic kidney disease (CKD), end stage renal disease (ESRD) and death. The importance of battling AKI was borne out in a study published in October in the American Journal of Kidney Diseases supporting identification of sub-group of patients with AKI who may benefit from more intensive follow-up to potentially avoid recurrent episodes.

“While the follow-up of AKI patients is important, a major challenge here”, says Zuber,” is the number of missed AKI diagnoses.”

As an example, she recalls one patient, “an older woman with diabetes and high blood pressure who caught a cold from her grandchildren. She was dehydrated, took over the counter NSAIDS and ended up in the hospital. Her creatinine level was 3; after being treated, her SCr went down to 1.5. By KDIGO definition, she didn’t have AKI; her SCr went down in the hospital. But she did have AKI; community-acquired AKI. We miss a significant amount of AKI this way. It is estimated that up to 65% of AKI is community-acquired.”

CITATION: Stuart L. Goldstein, Theresa Mottes, et. al. A sustained quality improvement program reduces nephrotoxic medication-associated acute kidney injury. Kidney International. 2016 Jul;90(1):212-21. Epub 2016 May 21.  Emily J. See, Kushani Jayasinghe, et. al. Long-term risk of adverse outcomes after acute kidney injury: a systematic review and meta-analysis of cohort studies using consensus definitions of exposure. Kidney International. Published online: November 22, 2018. Accepted: August 23, 2018. Received in revised form: August 21, 2018. Received: July 7, 2018.  Kathleen D. Liu, Jingrong Yang, et. al. Risk Factors for Recurrent Acute Kidney Injury in a Large Population-Based Cohort. American Journal of Kidney Diseases. Published online: October 25, 2018.


Research indicates that weight impacts
HDL-cholesterol in the obesity spectrum

FRAMINGHAM, MASS. – Weight change significantly affects HDL-cholesterol concentrations throughout the obesity spectrum, according to a study published in December in the Journal of Clinical Lipidology.

Its authors---including Michael Dansinger and Paul T. Williams, Boston Heart Diagnostics, Framingham, Mass.---found that HDL-cholesterol decreased with concurrent weight increases in 28,090 patients.

The researchers also indicate that HDL includes multiple sub-classes divisible by a particle migration (charge) and size.

In order to assess the associations between HDL and body mass index (BMI) in a very large cohort, the authors measured age-and sex-adjusted apolipoprotein (APO) A1 concentrations within 10 HDL subfractions in 14,121 women and 13,969 men, using two-dimensional HDL-mapping.

HDL-cholesterol decreased significantly in:

  • healthy-weight patients who became overweight
  • overweight patients who became class I or class II obese
  • class I obese patients who became class II obese
  • class II obese patients who became class III

In contrast, HDL-cholesterol increased among:

  • class III obese patients who became class II or class I
  • class II obese patients who became class I or overweight
  • class I patients who became overweight or healthy weight
  • overweight patients who became healthy weight
  • healthy-weight patients who became underweight

CITATION: Michael Dansinger, MD, Paul T. Williams, Ph.D., et. al. Effects of weight change on HDL-cholesterol and its subfractions in over 28,000 men and women. Journal of Clinical Lipidology. Published online: Dec. 18, 2018. Accepted: Dec. 9, 2018. Received: July 12, 2018.


AF prevalence in hospital encounters
with end-stage COPD said to increase

SHANGHAI, CHINA – Atrial fibrillation (AF) prevalence in hospital encounters with end-stage chronic obstructive pulmonary disease (COPD) increased from 2003-to-2014, according to research indicating that better management strategies for end-stage COPD patients comorbid with AF are needed---especially among the elderly.

Authors of the study published in January in CHEST Journal include Xiaochun Xiao and Hedong Han, who are affiliated with Second Military Medical University, Shanghai, China.

They set out to evaluate the prevalence of AF in hospital encounters with end-stage chronic COPD on home oxygen admitted for COPD exacerbation.

The researchers used the 2003-to-2014 Nationwide Inpatient Sample to conduct a retrospective analysis.

The study included all patients aged 18-and-older with a primary diagnosis of COPD on home oxygen who were hospitalized for COPD exacerbation, using multivariate-adjusted models to evaluate the association of AF with clinical factors, cost, length of stay, and hospital outcomes.

In total, 1,345,270 patients were included, of whom 244,488 had AF. The AF prevalence increased from 12.9% in 2003 to 21.3% in 2014, and varied by age, sex, race, income, insurance type, and hospital region.

Advancing age, female sex, white race, high income, and large hospital size were associated with increased odds of AF.

Presence of AF was a risk predictor for:

  • in-hospital death
  • acute respiratory failure
  • invasive mechanical ventilation
  • non-invasive mechanical ventilation
  • acute kidney injury
  • sepsis
  • stroke

AF was also associated with increased cost and length of stay.

CITATION: Xiaochun Xiao, MPH, Hedong Han, Ph.D., et. al. Prevalence of atrial fibrillation in hospital encounters with end-stage chronic obstructive pulmonary disease on home oxygen: National trends in the United States. CHEST Journal. Available online 23 January 2019.


Study shows that severe vitamin D deficiency
is significantly associated with RHF in adults

INCHEON, SOUTH KOREA – Recent research indicates that severe vitamin D deficiency is significantly associated with increasing renal hyperfiltration (RHF) prevalence in a relatively-healthy adult population.

The study was published in December in The American Journal of Clinical Nutrition.

Its authors---including Jong Hyun Jhee, Inha University College of Medicine, Incheon, South Korea---investigated the association between RHF and vitamin D status in a relatively-healthy population.

They retrieved data from the Korean National Health and Nutrition Examination Survey (KNHANES), a nationwide population-based cross-sectional study from 2008-to-2015. Overall, 33,210 subjects with normal renal function were included in the final analysis.

Severe vitamin D deficiency was defined as serum 25-hydroxyvitamin D concentration of less-than-10 ng/mL. RHF was defined as estimated glomerular filtration rate with residual in the less-than-95th percentile after adjustment for age, sex, height, weight, and history of hypertension or diabetes.

The mean plus-or-minus standard deviation (SD) of subjects was 48.1 plus-or-minus 15.9 years, and the number of women was 18,779. Estimated glomerular filtration rate was negatively associated with serum 25-hydroxyvitamin D concentrations in multivariable linear-regression analysis.

Also, 1,637 subjects were categorized into the RHF group, and RHF prevalence was significantly higher in the severe vitamin-D deficiency group than in the sufficiency group. In a multivariable logistic regression model, severe vitamin D deficiency was a significant risk factor for RHF.

CITATION: Jong Hyun Jhee, Ki Heon Nam, et. al. Severe vitamin D deficiency is a risk factor for renal hyperfiltration. The American Journal of Clinical Nutrition. Published: 12 December 2018. Received: 23 March 2018. Accepted: 18 July 2018.


Lifestyle changes urged in assessment
of the societal battle against diabetes

YISHUN, SINGAPORE – Greater emphasis should be placed on implementing lifestyle changes on a societal level to battle diabetes, according to a study published in January in the Journal of Clinical Nursing.

Its authors---including Ling Jie Cheng, National Healhcare Group, Yishun, Singapore, and Wenru Wang, National University of Singapore, Singapore---performed a systematic-review search and critical review of empirical evidence of factors affecting glycemic control among type 1 or 2 diabetes mellitus patients.

Their review presented the factors associated with glycemic control that may pose significant socio‐economic problems to most nations and impede development nationally, regionally, and globally.

The authors conducted a mixed‐method systematic review using the Preferred Reporting Items for Systematic review and Meta‐Analysis 2009 flow diagram, integrating evidence from qualitative and quantitative studies.

A systematic review of literature published from 2006-to-2017 was conducted in seven electronic databases (CINAHL, MEDLINE, Scopus, Embase, PsycINFO, PubMed, and ScienceDirect) using the search terms “diabetes mellitus,” “glycemic control,” “self‐concept,” “knowledge,” “self‐efficacy,” “empowerment,” “race,” “ethnicity,” “duration,” “medication,” “obesity,” and “comorbidity.”

Of 1,582 articles initially retrieved, 24 were included in this systematic-literature review. The overall empirical evidence suggested that higher socio‐economic status, greater dietary knowledge, and higher self‐efficacy and empowerment improve glycemic control among patients with diabetes mellitus.

CITATION: Ling Jie Cheng, Wenru Wang, et. al. Factors associated with glycemic control in patients with diabetes mellitus: A systematic literature review. Journal of Clinical Nursing. First published: 22 January 2019.


Perspectives on basal-insulin therapy
are offered in Global Academy activity

The Global Academy for Medical Education offers a Continuing Medical Education (CME)/Continuing Education (CE) activity for nurse practitioners (NPs), physician assistants (PAs), and other health-care professionals (HCPs) interested in endocrine diseases---especially those who provide care for adults with type 2 diabetes mellitus (T2DM). Rationale, Recognition, and Recommendations: Expert Perspectives on Combining Basal Insulin and GLP-1 RAs to Intensify Treatment of T2DM features clinically-relevant information regarding the intensification of basal-insulin therapy, including the use of basal insulin/GLP-1 RA fixed-ratio coformulations. More information is available at


Ties between heart failure, hypothyroidism
are examined in Clinician Reviews article

A recent article in Clinician Reviews reports that short-term risk of developing heart failure in patients with newly-identified hypothyroidism, whether overt or sub-clinical, is double that of euthyroid patients. Written by Bruce Jancin, the posting notes reporting from American Heart Association scientific sessions indicating that while the association with heart failure has previously been shown in hyperthyroidism, it’s new knowledge that hypothyroidism is associated with immediate risk of heart failure. Caroline H. Noergaard, MD, a Ph.D. student in epidemiology at Aalborg (Denmark) University, presented a study of over 1 million adults with no history of heart failure who had their first thyroid-function tests. The article can be accessed at



Vol. 3 No. 38

Lists called ineffective in effort
to deal with PIM, polypharmacy

DALLAS – Conventional-medical wisdom for dealing with multiple-medication (polypharmacy) and potentially-inappropriate medication (PIM) use is to track meds via patient-compiled lists.

But one professional who practices medicine and trains other providers says that it’s time to take things up a notch.

“I don’t use lists,” says Denise K. Link, PA-C, who works in nephrology as a physician assistant (PA) at the University of Texas Southwestern Medical Center in Dallas, “because we often see errors in the lists patients fill out; medical illiteracy among patients is high. I have patients bring in medication bottles to make sure they understand what they are taking, so they get ownership of this and avoid PIMs and polypharmacy. I go over each bottle with the patients, and I take the caps off the bottles and show them their pills, and make sure they know their medication times, including a.m. and p.m.”

Link, a faculty member of Cardiovascular, Allergy, & Respiratory Summit (CARPS), cares for chronic kidney disease (CKD), dialysis, and post-transplant patients, and trains PA, nurse practitioner (NP), and MD students.

Her experiences with patients jell with the results of the Atherosclerosis Risk in Communities study published in August in Drugs & Aging. The research involving more than 6,000 subjects indicates that it is common for older adults to use several medications at the same time and to use medications deemed inappropriate for one’s age or kidney function.

The study also indicates that PIM use should be avoided or carefully monitored in the setting of older age or CKD to mitigate preventable adverse effects.

“With patients with kidney or liver ailments,” Link says, “some medications can be toxic, and we have to be aware of side-effects: All patients must be evaluated for PIMs.”

And what Link calls “a key area” of concern, echoed in the study, is coordination of care across providers to reduce polypharmacy and PIM use in populations vulnerable to adverse events from medication.

“Practitioners,” she says, “must help patients with chronic multiple co-morbidities (such as advanced age and CKD). It is essential that providers use electronic medical records (EMRs) to avoid PIMs or polypharmacy. It is important that we have access to their other providers’ records.”

Link says Medicare can help smooth this process by doing a “better job of reimbursement coordination of care with NPs and PAs so we can see patients more often to coordinate care, and so we can see patients more frequently for follow-ups.”

She says such coordination---along with patients bringing in medication bottles---leads to “better education for patients, including the elderly, so they realize that any medication at their age can be dangerous. And when it comes to levels of kidney function, their disease can progress with some meds. NPs and PAs in geriatric care need to make their patients aware that meds can be very good, or very dangerous: I have patients contact our office whenever they have new medications prescribed.”

Medicare, Link adds, “encourages providers to use EMRs. They have been adding codes to the system, including education codes relating to advanced-care planning. Medicare is also in the process of defining telehealth, which private insurers have already done. For private insurers, this can, for instance, involve e-mail use. This increases coordination, and leads to a pathway for follow-up visits, and reduces PIM/polypharmacy.”

Link would like to see Medicare provider-reimbursement codes for NPs and PAs for follow-ups for medication management.

“Physicians,” she says, “often don’t have the time for this; providing codes for this for NPs and PAs can improve patients’ quality-of-life. All of this comes down to the importance of knowledge: Patients don’t know, nine-times-out-of-10 among the elderly population, names, dosages and frequencies of their medications.”

Finally, Link says patients and providers need more education.

“NPs and PAs,” she says, “spend hours in medical-pharmacology education, but we don’t know what it means to educate medically-illiterate patients. We need more education. We need to be advocates for patients of advanced age with multiple-health problems, and to explain to patients how their diseases interact, especially with the huge influx of baby-boomers.”

Link concludes that “we need more education for everybody. We need to better utilize NPs and PAs. Doctors should encourage PAs and NPs to provide better care for their patients, instead of being competitive.”

CITATION: Alex Secora, G. Caleb Alexander, et. al. Kidney Function, Polypharmacy, and Potentially Inappropriate Medication Use in a Community-Based Cohort of Older Adults. Drugs & Aging. 2018 Aug; 35(8): 735-750.


Research supports use of PARS over API
for children with mild-to-moderate asthma

CINCINNATI – The Pediatric Asthma Risk Score (PARS) performed better than the Asthma Predictive Index (API) in children with mild-to-moderate asthma in a study published in December in The Journal of Allergy and Clinical Immunology.

Its authors---including Jocelyn M. Biagini Myers and Eric Schauberger, Cincinnati Children’s Hospital Medical Center, Cincinnati---sought to develop a quantitative-personalized tool to predict asthma development in young children.

They utilized data from the Cincinnati Childhood Allergy and Air Pollution Study (CCAAPS) birth cohort, involving 762 subjects, to identify factors predicting asthma development.

The PARS was constructed by integrating demographic-and-clinical data. The sensitivity and specificity of PARS were compared with those of the API and replicated in the Isle of Wight birth cohort.

PARS reliably predicted asthma development in the CCAAPS. Although both the PARS and API predicted asthma in high-risk children, the PARS had improved ability to predict asthma in children with mild-to-moderate asthma risk.

In addition to parental asthma, eczema and wheezing apart from colds, variables that predicted asthma in the PARS included:

  • early wheezing
  • sensitization to two-or-more food allergens and/or aeroallergens
  • African-American race

The PARS was replicated in the Isle of Wight birth cohort, demonstrating that it is a robust, valid, and generalizable asthma-predictive tool.

CITATION: Jocelyn M. Biagini Myers, Ph.D., Eric Schauberger, DO, Ph.D., et. al. A Pediatric Asthma Risk Score to better predict asthma development in young children. The Journal of Allergy and Clinical Immunology. Published online: December 13, 2018. Accepted: September 18, 2018. Received in revised form: August 31, 2018. Received: October 13, 2017.


Study of patients in LMICs demonstrates
strong link between diabetes, cataracts

BEIRA, MOZAMBIQUE – A recent study assessing more than 42,000 patients in low-and-middle-income countries (LMICs) shows a strong association between diabetes and cataracts.

Authors of the study published in December in Diabetes Research and Clinical Practice recommend bi-directional screening and treatment for cataracts because of their impact on health and quality of life.

Researchers include Damiano Pizzol, Doctors with Africa, Beira, Mozambique, and Nicola Veronese, Neuroscience Institute, Aging Branch, Padova, Italy.

The authors utilized cross-sectional, community-based data from the Study on Global Ageing and Adult Health (SAGE) involving 42,469 subjects 18 years-of-age-and older, collected over a five-year-period from self-reported diagnosis of cataracts.

Three definitions for cataract were used:

  • a. self-reported diagnosis and/or past 12-month symptoms
  • b. solely self-reported diagnosis
  • c. surgical treatment for cataracts over the past five years

Diabetes was based on self-reported diagnosis; multi-variable logistic regression was conducted to assess the associations.

Overall, the prevalence of diabetes was 3.1%, and that of cataracts based on the three different definitions was: a-13.3%, b-4.4%, and c-1.7%.

After adjustment, the association was significantly elevated: a-OR=2.10, b-OR=2.62, c-OR=2.80.

These associations were particularly pronounced among those under 50 years-of-age.

CITATION: Damiano Pizzol, Nicola Veronese, et. al. The association between diabetes and cataract among 42,469 community-dwelling adults in six low- and middle-income countries. Diabetes Research and Clinical Practice. Published online: December 07, 2018. Accepted: December 3, 2018. Received in revised form: November 13, 2018. Received: August 9 2018.


Assessment of cancer and excess weight
highlights rejuvenated intervention focus

ATLANTA – Recent research indicating a rapid increase in prevalence of excess body weight and the associated cancer burden highlights the need for a rejuvenated focus on identifying, implementing, and evaluating interventions to prevent and control excess body weight.

The study published in December in CA: A Cancer Journal for Clinicians notes that the prevalence of excess body weight and the associated cancer burden have been rising globally in recent decades.

Its authors---including Hyuna Sung and Rebecca L. Siegel, American Cancer Society, Atlanta---point out that between 1975 and 2016, the prevalence of excess body weight in adults increased from nearly 21% in men and 24% in women to approximately 40% in both sexes.

They also note that the prevalence of obesity quadrupled in men and more than doubled in women. This change, combined with population growth, resulted in a more than six‐fold increase in the number of obese adults.

The largest absolute increase in obesity occurred among men and boys in high‐income Western countries and among women and girls in Central Asia, the Middle East, and North Africa.

The simultaneous rise in excess body weight in almost all countries is thought to be driven largely by changes in the global food system, which promotes energy‐dense, nutrient‐poor foods, alongside reduced opportunities for physical activity.
Given the pandemic proportion of excess body weight in high‐income countries and the increasing prevalence in low‐ and middle‐income countries, the global cancer burden attributable to this condition is likely to increase in the future.

There is emerging consensus on opportunities for obesity control through the multi-sectoral coordinated implementation of core policy actions to promote an environment conducive to a healthy diet and active living.

Also: A study published in January in The Journal of Pediatrics indicates a strong association between adverse childhood experiences (ACEs) and weight status among adolescents. The study involving more than 105,000 public-school students can be accessed at

CITATION: Hyuna Sung, Ph.D., Rebecca L. Siegel MPH, et. al. Global patterns in excess body weight and the associated cancer burden. CA: A Cancer Journal for Clinicians. First published: 12 December 2018.


Use of oral bisphosphonates is said
not to increase cancer-risk incidence

XINING, CHINA – Taken together, oral bisphosphonates (BPs) do not increase the risk of incidence of all-cause cancer, according to a recent study indicating that they can reduce the incidence of breast, endometrial, and upper-gastrointestinal cancers among post-menopausal osteoporotic females.

The analysis published in December in Archives of Osteoporosis, stratified by gender, suggests that oral BPs may increase liver-cancer incidence in mixed genders, while no significant association was observed in females.

Its authors---including Yingfang Deng and Zhen Zhang, Affiliated Hospital of Qinghai University, Xining, China---suggest that careful analysis of post-marketing data should be conducted to address the clinical relevance of their results.

The researchers retrieved relevant studies published in such data-bases such as PubMed, Embase, and Cochrane Library from inception to Aug. 25, 2018.

Maximum adjusted-hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) were then extracted from the retrieved studies. Thirteen cohort studies involving 1,510,763 participants were enrolled into this meta-analysis.

No significant relationship was found between oral BPs and the risk of all-cause cancer in osteoporosis patients among the entire population.

Also, oral BPs could remarkably reduce the incidence of breast cancer and endometrial cancer in post-menopausal osteoporotic females. In addition, oral BPs were also found to evidently reduce the incidence of upper-gastrointestinal cancer in osteoporotic patients among the entire population.

However, oral BPs may lead to increased risk of liver cancer in mixed genders.

CITATION: Yingfang Deng, Zhen Zhang, et al. Oral bisphosphonates and incidence of cancers in patients with osteoporosis: a systematic review and meta-analysis. Archives of Osteoporosis. First online: 17 December 2018.


Global Academy offers activity
aimed at battling flu-season woes

The 2017-2018 influenza season was the deadliest in four decades, due to lower-than-optimal vaccination rates, relatively-low vaccine efficacy, and resistance to anti-viral treatments. Urgent-care clinicians, who are on the frontlines of influenza prevention and treatment, should be aware that the Global Academy for Medical Education offers a timely activity under its Continuing Medical Education (CME)/Continuing Education (CE) Program---Influenza Update for Urgent Care: Preparing Your Center for the 2018-2019 Flu Season. This activity offers expert guidance on best practices preventing outbreaks, treating patients, and appropriate use of anti-virals, including a new treatment option. More information can be accessed at


Clinician Reviews: Good, bad news
on HCV and chronic kidney disease

A post in Clinical Reviews addresses hepatitis C virus (HCV) in chronic kidney disease (CKD) patients. The article written by Randy Dotinga notes that while the new generation of drugs that cures HCV is effective in this population, infection outbreaks still plague dialysis clinics. The item also states that although there are signs that HCV treatment may boost survival in CKD patients on dialysis, the Centers for Disease Control and Prevention (CDC) aware of 21 HCV outbreaks of two-or-more cases in dialysis clinics during 2008-to-2017. The article can be accessed at



Vol. 3 No. 37

Winter is said to be a vital season
for awareness of vitamin D levels

LAGUNA NIGUEL, CALIF. – While medical professionals always need to be aware of patients’ adequate vitamin D levels, that awareness may be especially vital for some patients during the winter.

“It is important,” says Ji Hyun Chun, PA-C, BC-ADM, president of the American Society of Endocrine Physician Assistants (ASEPA), “that medical providers are aware of the importance of adequate vitamin D levels, especially in people at higher risk of vitamin D deficiency.”

Chun---who is affiliated with OptumCare Medical Group, Laguna Niguel, Calif., and is a faculty member of Metabolic & Disease Summit (MEDS)---says those patients include the elderly, particularly the institutionalized and home-bound, as well as those:

  • with renal/hepatic insufficiency
  • with darker skin
  • with malabsorptive syndrome
  • who are overweight or obese
  • with osteopenia/osteoporosis
  • who take medications that cause low vitamin D, including phenytoin, phenobarb. glucocorticoids, and bile-acid sequestrants

Chun, citing a study on the subject published in 2011 in The Journal of Clinical Endocrinology & Metabolism, says that in such cases, “patients should be screened as needed.”
He adds that “we can recommend patients to take daily recommended amounts of vitamin D”:

  • up to 12 months, more than 400 international units [IU]
  • one-to-18 years, less than 600 IU
  • over 19 and pregnant or breast-feeding, more than 1,000 IU

Some experts, Chun notes, recommend taking 2,000 IU daily (with higher doses for those with malabsorptive conditions and/or obesity to avoid expensive vitamin D testing, “as the risk of harm of 2,000 IU daily is very low, and will most likely get them into adequate range.”

Chun also comments on another study, published in August in the International Journal of Chronic Obstructive Pulmonary Disease, addressing vitamin D supplementation for chronic obstructive pulmonary disease (COPD) patients.

Chun calls the study “interesting” and suggests further research, including intervention trials to verify its hypotheses that year-round vitamin D supplementation would benefit house-bound COPD patients’ functional health.

Regarding the observational study’s recommendation of winter-time vitamin D supplementation for non-house-bound COPD patients, Chun supports winter-time supplementation for people living in areas without a lot of sun exposure---but not limiting this recommendation to those with non-house-bound or house-bound COPD.

This recommendation, Chun adds, is “mainly for bone health rather than for their functional health until a prospective randomized-control trial proves the hypothesis.”

As to ways nurse practitioners (NPs) and physician assistants (PAs) can best help patients in terms of vitamin D supplementation, Chun asserts that such recommendations “should be the same for general vitamin D supplementation for the general public as well as the COPD population, until further data is available for COPD patients specifically.”

CITATION: Emma L. Carson, L. Kirsty Pourshahidi, et. al. Vitamin D status is associated with muscle strength and quality of life in patients with COPD: a seasonal prospective observation study, International Journal of Chronic Obstructive Pulmonary Disease. Received: 28 February 2018. Accepted for publication: 2 June 2018. Published: 28 August 2018. Volume 2018:13. Pages 2613-2622.  
Holic MF et al. Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline.  J Clin Endocrinol Metab.2011;96(7):1911-30


Study: Sarcopenic obesity-related fall risk
high for post-menopausal women 50-to-79

TUCSON, AZ. – A recent study involving a multi-ethnic cohort of post-menopausal women indicates that sarcopenic obesity-related fall risk is high among women aged 50-to-79.

The research published in October in the Journal of the American Geriatrics Society also indicates that sarcopenic obesity poses the highest fall risk for Hispanic women.

Its authors---including Shawna Follis, University of Arizona, Tucson, Az., and Alan Cook, Chandler Regional Medical Center, Chandler, Az.---support identification of causal factors and health disparities in sarcopenic obesity to customize fall-prevention strategies and ameliorate this significant public-health burden.

Their prospective-cohort study was conducted at three Women's Health Initiative (WHI) clinical centers, located in Tucson‐Phoenix, Pittsburgh, and Birmingham, Ala.

Participating were 11,020 post-menopausal women aged 50-to-79 enrolled in the WHI who underwent bone-and-body composition scans using dual‐energy X‐ray absorptiometry at baseline.

Sarcopenia was defined as the lowest 20th percentile of appendicular lean mass, correcting for height-and-body fat. Obesity was defined as body-fat percentage greater than 42%.

Sarcopenic obesity was defined as co‐occurrence of sarcopenia and obesity. Fall outcome was defined as falling twice-or-more in any year during seven years of follow‐up.

The risk of falls associated with sarcopenic obesity was analyzed using log-binomial regression models stratified according to age and race/ethnicity.

Sarcopenic obesity was associated with greater risk of falls in women aged 50-to-64 and 65-to-79.

Sarcopenic obesity-related fall risk was higher in Hispanic women than non‐Hispanic white women.

CITATION: Shawna Follis MS, Alan Cook MD, et. al. Association Between Sarcopenic Obesity and Falls in a Multiethnic Cohort of Postmenopausal Women. Journal of the American Geriatrics Society. First published: 30 October 2018.


Research connects sleep duration, quality
to end stage kidney disease for CKD patients

OSAKA, JAPAN – Shorter-and-longer sleep duration and poor-sleep quality are associated with end stage kidney disease (ESKD) in patients with chronic kidney disease (CKD), according to a study published in November in the Clinical Journal of the American Society of Nephrology.

Its authors---including Ryohei Yamamoto, Osaka University, Toyonaka, Osaka, Japan, and Maki Shinzawa, Osaka University Graduate School of Medicine, Suita, Osaka---noted that shorter-or-longer sleep duration and poor-sleep quality are risk factors for numerous cardio-metabolic diseases, cardiovascular disease, and mortality in subjects with normal kidney function.

In order to research the association of sleep duration and sleep quality with health outcomes in CKD patients, they conducted a four-year prospective-cohort study in 17 nephrology centers in Japan.

Their CKD Japan Cohort (CKD-JAC) Study assessed an association of self-reported sleep duration and sleep quality, on the basis of the Pittsburgh Sleep Quality Index (PSQI) questionnaire, with incidence of ESKD in 1,601 patients with eGFRs of 10-to-59 ml/min per 1.73 m2 using multivariable-adjusted Cox proportional-hazards models.

Poor-sleep quality (PSQI global score of at least six) was common (588 patients).
During a median of 4.0 (2.6-to-4.3) years of the follow-up period, 282 patients progressed to ESKD.

Adjustments were made for:

  • age
  • sex
  • eGFR
  • urinary-albumin excretion
  • smoking status
  • body mass index (BMI)
  • history of diabetes and cardiovascular disease
  • systolic blood pressure
  • blockade of the renin-angiotensin system
  • use of hypnotics
  • Beck depression inventory score

After those adjustments, both shorter (five-hours-or-less) and longer (more than eight hours) sleep duration were associated with ESKD, suggesting a U-shaped relationship between sleep duration and ESKD.

CITATION: Ryohei Yamamoto, Maki Shinzawa, et. al. Sleep Quality and Sleep Duration with CKD are Associated with Progression to ESKD. Clinical Journal of the American Society of Nephrology. November 2018, CJN.01340118.


Education, living with family called factors
in hypertension-recommendation adherence

WROCLAW, POLAND – Recent research indicates that variables of age, education level, and living with family are statistically-significant in explaining therapeutic-recommendation adherence rates for hypertension (HT).

The study published in November in Clinical Interventions in Aging suggests that health-care professionals should pay more attention to older HT patients with low-education levels who lack social support.

Its authors---including Bartosz Uchmanowicz and Anna Chudiak, Wroclaw Medical University, Wroclaw, Poland---recommend tailored education to help these patients understand, and adhere to, medication treatment.

The researchers note that HT is one of the most common disorders in the general population, especially among older adults. They set out to identify demographic, socio-economic, and clinical factors affecting older adults with HT.

Their cross-sectional study included 150 patients (including 84 women) with mean age of 72.1 years. The Hill-Bone Compliance to High Blood Pressure Therapy Scale (Hill-Bone CHBPTS) was used to evaluate adherence to therapeutic recommendations for HT.

The mean score obtained by the patients in the Hill-Bone CHBPTS was 20.19. The linear-regression model showed the independent predictors of the total score:

  • age---each subsequent year of life raises the total score by an average of 0.2 points
  • gender---males raise it by an average of 1.34 points compared to females
  • education---a secondary, higher, or higher professional education lowers it by an average of 1.75 points compared to a primary education or no education
  • living with family---having familial support lowers it by an average of 1.91 points

CITATION: Bartosz Uchmanowicz, Anna Chudiak, et. al. Factors influencing adherence to treatment in older adults with hypertension. Clinical Interventions in Aging. Received: 6 August 2018. Accepted for publication: 7 October 2018. Published: 28 November 2018. Volume 2018:13. Pages 2425-2441.


Diabetes assessment views relationship
between DKA and Alzheimer’s dementia

TAINAN, TAIWAN – Type 2 diabetes patients with diabetic ketoacidosis (DKA) are at increased risk of Alzheimer’s dementia, but not non-Alzheimer’s dementia, according to a study involving more than 4,400 subjects.

The retrospective nationwide population-based cohort study published in January in Diabetes Research and Clinical Practice utilized Taiwan’s National Health Insurance Database.

Its authors---including Yu-Li Chen, Chi Mei Medical Center, Chia-Li Branch, Tainan, Taiwan, and Shih-Feng Weng, Kaohsiung Medical University, Kaohsiung, Taiwan---extracted claims data for 4,451 patients with type 2 diabetes and DKA and 8,902 diabetic controls matched for:

  • age
  • gender
  • diabetes-complication severity index
  • frequency of clinic visits and baseline comorbidities between 2000 and 2002

Patients with type 1 diabetes or prior hypoglycemia before index date were excluded. All patients were tracked until new dementia diagnosis, death, or the end of 2011.

The incidence rate ratio (IRR) for dementia was 1.62 for patients with DKA versus diabetic patients without DKA.

After adjusting for age, baseline comorbidities, geographic area, and income, patients with DKA were found to have 1.86 times the risk of developing dementia, compared to controls.

They were found to have a higher risk of Alzheimer’s dementia, but not non-Alzheimer’s dementia.

CITATION: Yu-Li Chen, Shih-Feng Weng, et. al. Diabetic ketoacidosis further increases risk of Alzheimer’s disease in patients with type 2 diabetes. Diabetes Research and Clinical Practice. January 2019. Volume 147, Pages 55-61.


Clinician Reviews consult item addresses
dangers associated with use of NSAIDs

A Renal Consult item posted in Clinician Reviews addresses the risks of using non-steroidal anti-inflammatory drugs (NSAIDs). Written by Ellen Apple, MSN, APRN, FNP-C, Dickson School Family Clinic, Dickson, Tenn., in response to a question about the use of ketorolac, the article notes that prolonged NSAID use increases the risk for acute kidney injury (AKI) or chronic kidney disease (CKD) progression. It also cautions that while these issues are associated with patients at higher risk for CKD---such as those who are older or who have diabetes or hypertension---AKI can occur in anyone. Lastly, with the opioid crisis much in the national conversation, and with non-narcotic alternatives for pain control in demand, education of patients and their families about these concerns is vital. The article can be accessed at



Vol. 3 No. 36


NPs, PAs are called ‘valuable allies’
in patients’ acceptance of diabetes

FREDERICKSBURG, VA. – Diabetes patients’ emotions can impact acceptance—or denial---of their disease and even interfere with treatment adherence.

The results of a recent study stressing these findings are supported by a medical professional who says physician assistants (PAs) and nurse practitioners (NPs) can be “valuable allies” in helping patients accept the diagnosis and empower them to take charge of their diabetes.

Scott Urquhart, PA-C, of Diabetes and Thyroid Associates, Fredericksburg, Va., says the findings of a study published in June in BMC Public Health reflect his experiences with diabetes patients.

Urquhart, an adjunct clinical professor, James Madison University physician assistant (PA) program, Harrisonburg, Va., and faculty conference chair of the Metabolic & Endocrine Disease Summit (MEDS), is not surprised by the study’s comparison of the effect of a diabetes diagnosis with stages of mourning.

“Patients respond differently when they are informed about a new diagnosis of diabetes,” he says, “especially if it is type 1 or type 2 diabetes. It goes without saying that the acceptance or denial of diabetes affects adherence to treatment. I do see several of the emotions associated with mourning: denial, anger, bargaining, depression, and acceptance.”

Urquhart adds that since diabetes conjures thoughts of death and suffering from complications, “an overlap of emotions would be reasonably expected; I see patients expressing pre-occupation of thoughts, anxiety, depressed feelings, self-defeat and failure. Unfortunately, I frequently witness patients being apathetic about having diabetes, especially type 2, since it is so common and they feel well most days despite having high blood glucose.”

Urquhart cites another finding in the study---anger expressed by patients’ learning of their diabetes diagnoses---as an element of care that PAs and NPs can target.

“When a patient responds with anger or any other negative emotion to the new diagnosis of diabetes,” he says, “it is important to engage and validate the patient in an open discussion about his or her feelings”. This can be a challenge to allocate adequate time to discuss in the midst of a busy patient load, so it would be advisable to consider a follow-up visit or phone call in the very near future.

“We should sincerely try to uncover the root of their anger, self-blame, and anxieties, as well as alleviate concerns and resolve any misinformation they have regarding diabetes,” Urquhart says. He supports a “safe-and-open environment from the outset for growth and trust of the patient-clinician relationship” as well as the consideration of referring patients to Certified Diabetes Educators for one-on-one education and group classes, or to mental-health specialists in cases of such challenges as depression and anxiety.

Education is backed by the study, as well as by Urquhart, especially in the first three-to-six months of diagnosis, when education “is much more intense because it needs to evolve into important behavioral changes related to diet, physical activity, medication adherence, and many aspects of diabetes self-management and self-care.”

Urquhart says “education and support comes from clinicians, diabetes educators, dieticians, spouses, friends and family. Clinicians manage the disease, direct diet and activity, order the labs, prescribe medications and supplies. We must create a positive atmosphere at each and every visit that empowers and encourages them to succeed.”

NPs and PAs, he concludes, “are valuable allies in helping patients accept their diagnoses of diabetes. Fostering acceptance is achieved by ensuring patients about the ability to maintain great control of their diabetes, reiterating that diabetes in and of itself doesn’t have to lead to complications, keeping patients apprised of all updates with regard to new medications, diabetes-care devices, and technology. We should also make sure we are aware of local support groups to refer patients who need or prefer one.”

CITATION: Jose Adailton da Silva, Elizabethe Cristina Fagundes de Souza, et. al. Diagnosis of diabetes mellitus and living with a chronic condition: participatory study. BMC Public Health. Received: 11 December 2018. Accepted: 30 May 2018. Published: 5 June 2018.


Research: Women with asthma likelier
to suffer from post-partum depression

MONTREAL – Research published in The Journal of Allergy and Clinical Immunology: In Practice suggests that women with asthma are more likely to suffer from post-partum depression.

The study posted in October---whose authors include Lucie Blais and Sherief Ibrahim, Université de Montréal, Montreal---supports close monitoring of signs of depression among pregnant women with asthma in order to allow for prompt and efficient interventions when needed.

The researchers utilized a cohort of 35,520 pregnancies in women with asthma during pregnancy and 197,057 pregnancies in women without asthma who delivered between 1998 and 2009, as extracted from the Quebec Asthma and Pregnancy Database (QAPD).

Subjects were followed from the day of delivery up to a year post-partum. A generalized estimating-equation model was used to estimate the adjusted odds ratios (ORs) of post-partum depression with 95% confidence intervals (CIs) in women with asthma during pregnancy versus women without asthma.

Post-partum depression within one year after delivery occurred in 6.1% of women with asthma versus 2.9% of women without.

After adjusting for several potential confounders, including depression/post-partum depression up to 10 years before pregnancy, the authors found that women with asthma were 58% more likely to experience post-partum depression within one year after delivery than women without asthma during pregnancy.

CITATION: Lucie Blais, Ph.D., Sherief Ibrahim, MSc, et. al. Risk of postpartum depression among women with asthma. The Journal of Allergy and Clinical Immunology: In Practice. Published online: October 05, 2018. Accepted: September 20, 2018. Received in revised form: September 20, 2018. Received: January 29, 2018


High childhood BMI association seen
with slipped capital femoral epiphysis

LIVERPOOL, ENGLAND – High childhood body mass index (BMI) is strongly associated with slipped capital femoral epiphysis (SCFE), according to a study published in November in Pediatrics.

Its authors---including Daniel C. Perry, University of Liverpool, Alder Hey Children’s Hospital, Liverpool, England---indicate that the magnitude of the association, temporal relationship, and dose response added to the plausible mechanism offer the strongest evidence available to support a causal association.
The researchers performed a cohort study using routine data from health-screening examinations at primary school entry (five-to-six-year-olds) in Scotland, linked to a nationwide hospital-admissions database.

A sub-group had a further screening examination at primary school exit (11-to-12-year-olds).

BMI was available for 597,017 children at five-to-six-years of age in school and 39,468 at 11-to-12. There were 4.26 million child-years at risk for SCFE.

Among children with obesity at five-to-six years, 75% remained obese at 11-to-12. There was a strong biological gradient between childhood BMI at five-to-six and SCFE, with the risk of disease increasing by a factor of 1.7 for each integer increase in BMI z score.

The risk of SCFE was almost negligible among children with the lowest BMI. Those with severe obesity at five-to-six had 5.9 times greater risk of SCFE compared with those with a normal BMI; those with severe obesity at 11-to-12 had 17.0 times the risk of SCFE.

Also: The Journal of the American Medical Association in October published a study indicating that among patients with type 2 diabetes and severe obesity who underwent surgery, compared with those who did not undergo surgery, bariatric surgery was associated with a lower risk of macrovascular outcomes. The study can be accessed at
CITATION: Daniel C. Perry, David Metcalfe, et. al. Childhood Obesity and Slipped Capital Femoral Epiphysis. Pediatrics. November 2018. Volume 142, Issue 5.



Fractures linked to economic burdens
on Medicare patients with risk factors

ARLINGTON, VA. – A recent study indicates that fractures impose a significant economic burden, especially in the first year after the fracture, for Medicare beneficiaries with at least one fracture-risk factor.

The sample in the study published in October in the Journal of the American Geriatrics Society was limited to community-dwelling individuals.

The authors---including Kandice A. Kapinos, RAND Corporation, Arlington, Va., and Shira H. Fischer, RAND Corporation, Boston---were unable to control for fracture history before the study period.

The researchers also noted that costs may be greater for those in skilled-nursing and similar facilities and for those with previous fractures; they retrospectively analyzed claims and survey data in the U.S. over a three-year period from the Health and Retirement Study (HRS), a nationally-representative biennial study of individuals aged 50 and older.

Participants in the study of medical costs for osteoporosis-related fractures in-high-risk Medicare beneficiaries were HRS respondents who:

  • consented to have their Medicare claims data linked to the HRS data
  • were aged 65 or older
  • had at least one risk factor for fracture observable in the data
  • experienced a fracture between 1996-and-2008 (689 participants) and their propensity score-matched controls (689 participants)

Total Medicare, in-patient, out-patient, emergency department, physician-office visit, and prescription drug-care expenditures were primary outcomes. Two-staged generalized-linear models were estimated using a difference-in-differences model.

Fracture cases' total Medicare expenditures increased by $13,929 more than those of matched controls from the year before the index or fracture date to one year after the index date.

In-patient expenditures of $12,751 more for fracture cases than comparison cases primarily drove this increase. Two and three years after fracture, there were no significant differences in growth in expenditures between the two groups.

Results did not vary according to whether the fracture was at the hip or other site.

CITATION: Kandice A. Kapinos, Shira H. Fischer, et. al. Medical Costs for Osteoporosis-Related Fractures in High-Risk Medicare Beneficiaries. Journal of the American Geriatrics Society. 2018 Oct. 5.



Lower serum chloride levels are said
to predict death, cardiovascular events

OSAKA, JAPAN – Lower serum chloride (Cl) levels are an independent predictor of death and cardiovascular events, according to a recent study indicating that the incremental prognostic value of Cl is superior to that of serum sodium (Na) in patients with chronic kidney disease (CKD).

Authors of the retrospective-cohort study published in October in Nephrology Dialysis Transplantation include Keiichi Kubota and Yusuke Sakaguchi, Osaka University Graduate School of Medicine, Osaka, Japan.

Their research utilized data from patients with Stages G3-to-G5 CKD who visited the nephrology out-patient department of Osaka University Hospital from April, 2005, to December, 2014.

The main exposure was time-varying serum Cl levels categorized as quartiles. The study outcome was a composite of all-cause death and cardiovascular events.

A total of 2,661 CKD patients was included in the analysis; during a median follow-up of 4.0 years, 284 deaths and 416 cardiovascular events occurred.

Compared with patients in the third Cl quartile, those in the first Cl quartile showed a significantly-higher risk of the outcome after adjustment for demographics and clinical factors including:

  • time-varying serum Na
  • serum albumin and bicarbonate levels
  • use of diuretics, sodium bicarbonate, and anion gap

Adding serum Cl levels, but not serum Na levels, to the multi-variable model significantly improved net reclassification index and integrated discrimination improvement.

CITATION: Keiichi Kubota, Yusuke Sakaguchi, et. al. Prognostic value of hypochloremia versus hyponatremia among patients with chronic kidney disease---a retrospective cohort study. Nephrology Dialysis Transplantation. 20 October 2018.



Clinician Reviews article assesses
osteoporosis-treatment approaches

A November article in Clinician Reviews breaks down osteoporosis-treatment options and notes that the morbidity and mortality associated with osteoporosis can be improved with non-pharmacologic and pharmacologic approaches. Written by Benjamin J. Smith, MPAS, PA-C, DFAAPA,  Florida State University,Tallahassee, Fla., the article lists such non-pharmacologic approaches as weight-bearing exercise, adequate calcium-and-vitamin D intake, smoking cessation, avoidance of heavy alcohol use, and fall-prevention education. Pharmacologic approaches include: oral bisphosphonates, intravenous bisphosphonates, selective estrogen-receptor modulators (SERMs), calcitonin nasal spray, parathyroid-hormone analogs, and denosumab, a human monoclonal antibody. The article can be accessed at


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