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Vol. 3 No. 58

Vigilance essential for young asthma patients,
especially considering COVID-19 risk for elderly

BOISE, IDAHO – While young asthma patients don’t generally face the worst of COVID-19, vigilance remains urgent---especially taking into account their contact with older people.

That’s the assessment of one asthma expert in reaction to two recent studies on the issue.

Research published in July in the Journal of Adolescent Health notes the medical vulnerability of young adults to severe COVID-19 illness and concludes that lower young-adult vulnerability for non-smokers versus a full sample bears out the importance of smoking prevention. And a study published in June in The Journal of Allergy and Clinical Immunology: In Practice indicates that children with asthma don’t appear to be disproportionately affected by COVID-19---possibly because there is more adherence, reduced exposure, and virtual-doctor visits.

Brian K. Bizik, MS, PA-C, Physician Assistant, Terry Reilly Health Center, Boise, Idaho, past president and current conference chair of the Association of PAs in Allergy, Asthma and Immunology, and faculty member of Cardiovascular, Allergy, & Respiratory Summit (CARPS), recently addressed the studies in terms of his experience.

How do you approach your patients, including younger ones, since the onset of the virus?

“We have tried to identify those patients, especially younger ones, who may seem ‘invincible’ or at low risk and have made a concerted effort to educate them on both the risk that they have, even if this is low, and the risk they have in transmission. That while they may be low risk, they will likely come in contact with many people who are at higher risk.  

“The most heartbreaking story I have from my clinic is two elderly grandparents who both passed away after attending a graduation party for their granddaughter. One person at the party was COVID-19 positive but went anyway, saying she did not want to ‘ruin’ the graduation. Very tragic.

“So, our message is ‘wear the mask for them, not just for you.’

“The other change is that we screen everyone, from employees to patients, before they enter the building. For our younger patients we really try to ask questions about the less-common COVID symptoms like loss of taste or smell; this seems to hit the younger patients first, often without fever or headache.”

Do you see a pattern of changed behavior among patients---including youth---since the virus hit your area?

“I don’t know that I have seen a change in patient behavior in any great numbers. We are really working hard on vaping reduction. I don’t have any data specifically on vaping and COVID outcomes, but the vulnerability study was interesting and shows the risk is higher. I’d like to see data on vaping versus smoking tobacco. I know I have had a few patients who have stopped vaping during this time, but the number is small; I think two or three of mine have.”

As I know you sometimes use lists, and rules, in trying to change patients’ potentially-dangerous behavior, do you employ any lists and/or rules for patients that tie into the new reality surrounding us with the pandemic?

“I don’t have anything on this yet. We have Centers for Disease Control and Prevention (CDC) handouts, and everyone gets those. Everyone with any of the symptoms of COVID and their families get a series of handouts on prevention, transmission and care. So we are doing that for everyone and we now document that the handouts have been given.”

Do you have any anecdotes regarding this topic with respect to any (anonymous) patients you would like to share?

Aside from the story above, there was a softball team that had four players contract COVID from a single game. The game was outside, but they all sat together on the bench. The one player who infected her four teammates was sick at the time of the game, with a headache and loss of taste for one day. So again, if she had followed guidelines she would not have gone to the game. Those four other girls did fine, though one transmitted COVID to her mom; that family was lost to follow up so I don’t know if it stopped there.”

CITATION: Sally H. Adams, Ph.D., M. Jane Park, M.P.H., et. al. Medical Vulnerability to Severe COVID-19 Illness---Data From the National Health Interview Survey. Journal of Adolescent Health. July 13, 2020.  Nikolaos G. Papadopoulos, MD, Ph.D., FRCP, FAAAAI, Adnan Custovic, MSc, DM, MD, Ph.D., FRCP, et. al. Impact of COVID-19 on Pediatric Asthma: Practice Adjustments and Disease Burden. The Journal of Allergy and Clinical Immunology: In Practice. Published: June 16, 2020.


Diabetes associated with poor early outcomes
among hospitalized patients who have COVID-19

BOSTON – Recent research indicates that among hospitalized patients with COVID-19, diabetes is associated with poor early outcomes, after adjustment for obesity.

The findings in the study published in September in Diabetes Care can help inform patient-centered care decision-making for people with diabetes at risk for COVID-19.

Its authors---including Jacqueline Seiglie and Jesse Platt, Massachusetts General Hospital, Boston---used data from the Massachusetts General Hospital (MGH) COVID-19 Data Registry of patients hospitalized with COVID-19 between March 11, 2020, and April 30, 2020.

Primary outcomes were:

  • admission to the intensive care unit (ICU)
  • need for mechanical ventilation
  • death within 14 days of presentation to care

Logistic-regression models were adjusted for demographic characteristics, obesity, and relevant comorbidities.

Among 450 patients, 178 had diabetes---mostly type 2. Among patients with diabetes versus patients without diabetes, a higher proportion was admitted to the ICU (42.1% versus 29.8%), required mechanical ventilation (37.1% versus 23.2%), and died (15.9% versus 7.9%).

In multivariable-logistic regression models, diabetes was associated with greater odds of ICU admission (odds ratio 1.59 [95% confidence interval 1.01-to-2.52]), mechanical ventilation (1.97 [1.21-to-3.20]), and death (2.02 [1.01-to-4.03]) at 14 days.

Obesity was associated with greater odds of ICU admission (2.16 [1.20-to-3.88]) and mechanical ventilation (2.13 [1.14-to-4.00]) but not with death.

CITATION: Jacqueline Seiglie, Jesse Platt, et. al. Diabetes as a Risk Factor for Poor Early Outcomes in Patients Hospitalized With COVID-19. Diabetes Care. September 2020, Volume 43, Issue 9.


BMD in adult hypophosphatasia patients
is said to not be systematically reduced

WUERZBURG, GERMANY – Bone mineral density (BMD) in adult hypophosphatasia (HPP) patients is not systematically reduced, according to recent research.

The study published in September in Osteoporosis International also indicates that increased lumbar-spine BMD appears to be associated with severely compromised mineralization and increased risk for HPP-related fractures, while BMD at the hip appears unaffected by indicators of disease severity---suggesting suitability of this anatomic location for assessing and discerning disorders with increased fracture risk owing to reduced BMD-like osteoporosis.

Its authors, include Franca Genest, University of Wuerzburg, Wuerzburg, Germany, note that HPP is a rare inherited metabolic disorder caused by deficient activity of the tissue-non-specific alkaline phosphatase (TNAP). Clinical manifestation in adult HPP patients is manifold including an increased risk for fractures,

Retrospective single-center analysis of dual x-ray absorptiometry (DXA) scans in patients with confirmed HPP (documented mutation, clinical symptoms, low alkaline phosphatase [ALP] activity).

Further data evaluation included:
•    disease-related fractures
•    laboratory results (alkaline phosphatase, pyridoxal phosphate, phosphoethanolamine)
•    medical history

Analysis included 110 patients (84 female, mean age of 46.2 years) of whom 41 were harboring two mutations.

Average T-Score level at the lumbar spine was − 0.1 (SD 1.9), and mean total hip T-Score was − 1.07 (SD 0.15).

Both lower ALP activity and higher substrate levels (pyridoxal phosphate and phosphoethanolamine) were significantly correlated with increased lumbar spine T-Score levels, while BMD at the hip was not affected by indicators of disease severity.

Increased lumbar spine BMD was significantly associated with an increased risk for HPP-related fractures, prevalent in 22 patients, with 21 having biallelic mutations.

CITATION: F. Genest, L. Clauben, et. al. Bone mineral density and fracture risk in adult patients with hypophosphatasia. Osteoporosis International. 2 September 20.


WC, WHtR, BF% are seen as additions
to BMI in assessing a risk of mortality

TAIWAN – A recent study suggests that while body mass index (BMI) should remain the primary marker for screening excessive adiposity, waist circumference (WC), waist-to-height ratio (WHtR), and/or body-fat percentage (BF%) are also supported when assessing the risk of mortality.

The research was published in September in Clinical Nutrition. Authors include Tsung Yu, National Cheng Kong University, Taiwan, and Yacong Bo, Chinese University of Hong Kong, Hong Kong.

The researchers compared the associations of mortality with BMI, WC, WHtR, and BF%, using data from 463,002 adults recruited between 1996 and 2017. Vital data was obtained from the National Death Registry System in Taiwan. A Cox proportional hazards model was used to assess the associations of BMI, WC, WHtR, and BF% with mortality.

Clear U-shape relationships were observed for all four parameters. In both men and women, the lowest risk of mortality was observed in the BMI category of 23.5-to-24.9 kg/m 2. Regarding WC, men in the third quintile (79.0-to-82.9 cm) and women in the fourth quintile (70.0-to-74.9 cm) had the lowest mortality risk.

For WHtR, men in the third quintile (0.46-to-0.49) and women in the fourth quintile (0.45-to-0.48) had the lowest risk of mortality.

For BF%, both men and women in the fourth quintile (24.0-to-27.2% and 28.7-to-32.8%, respectively) had the lowest risk of mortality. WC, WHtR, and BF% exhibited slight associations with the risk of mortality across the three BMI categories (low [10.8-to-20.9 kg/m 2]), normal (21.0-to-27.4 kg/m 2) and high (27.5-to-51.7 kg/m 2). C-statistics of the four parameters ranged from 0.51 to 0.69.

CITATION: Tsung Yu, Yacong Bo, et. al. Adiposity and risk of death: a prospective cohort study of 463,002 adults. Clinical Nutrition. Sept. 15, 2020.


Research: Substance abuse disorders considered
COVID-19 issues, particularly in African-Americans

CLEVELAND – Recent research indicates that at a macroscopic level, there is evidence that substance-abuse disorders (SUD) should be considered as conditions that increase risk for COVID-19, a comorbidity that has particularly deleterious effects to African-Americans.

The study published in September in Molecular Psychiatry has implications to health-care as it relates to expanding testing and making decisions of who might need hospitalizations.
Its authors---including Quan Qiu Wang, Case Western Reserve University, Cleveland, and David C. Kaelber, the MetroHealth System, Cleveland---point out that when a vaccine or other treatments become available, this has implication for deciding who is at greater risk.

They also highlight the exacerbation of health-care disparities from COVID-19 driven by social and economic factors that place certain groups at increased risks for both SUD as well as risk and adverse outcomes from COVID-19.

Their findings also underscore the importance of providing support for the treatment and recovery of individuals with SUD as part of the strategy to control the COVID pandemic.

The researchers conducted a retrospective case-control study of electronic health records (EHRs) data of 73,099,850 unique patients, of whom 12,030 had a diagnosis of COVID-19.

Patients with a diagnosis of SUD within the past year were at significantly increased risk for COVID-19, an effect that was strongest for individuals with opioid-use- disorders (OUD), followed by individuals with tobacco use disorder (TUD).

Compared to patients without SUD, patients with SUD had significantly higher prevalence of chronic kidney, liver, lung diseases, cardiovascular diseases, type 2 diabetes, obesity and cancer. Among patients with recent diagnosis of SUD, African Americans had significantly higher risk of COVID-19 than Caucasians.

CITATION: Quan Qiu Wang, David C. Kaelber, et. al. COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States. Molecular Psychiatry. Sept. 14, 2020.



Vol. 3 No. 57

Osteoporosis study’s high-trauma focus
called possible ‘tipping point’ for fractures

OXFORD, CONN. – A study supporting the inclusion of high-trauma fractures for clinical assessment of underlying osteoporosis “may become a tipping point for looking at all fractures,” according to an expert on the condition who asserts the findings will make it easier for primary-care practitioners to evaluate patients.

The research published in March in Osteoporosis International involved a study population of 64,428 women and men with no prior fractures, 858 with prior high-trauma fractures, and 14,758 with prior low-trauma fractures. Its authors concluded that high-trauma and low-trauma fractures show similar relationships with low bone-mineral density (BMD) and future-fracture risk.

The study surprised Oxford, Conn., resident Rick Pope, (PA-C), Clinical Professor, Quinnipiac University, North Haven, Conn., “from the standpoint standpoint that three other studies have been suggested this going all the way back to 1998. All three, and now this study, have shown that high-trauma fractures in men and women over 40 are associated with low BMD Z-scores. This is a completely different viewpoint for primary care as to what constitutes risk of a future fracture.”

The Geelong Osteoporosis Study was published in 1998 in the Journal of Bone and Mineral Research; a study on high-trauma fractures was published in the Journal of American Medicine in 2007; and findings on the Osteoporotic Fractures in Men Study were published in Therapeutic Advance in Musculoskeletal Disease in 2016.

Pope, founder and past president of the Society of Physician Assistants in Rheumatology (SPAR), and faculty member of the Metabolic & Endocrine Disease Summit (MEDS), says, “all four of these studies suggest that clinical guidelines be updated to include high-trauma fractures as risk factors for future fractures.”

He adds that “this would simplify the evaluation of adults for future fractures. The lack of recognition of high-trauma fractures may have added to a post-fracture gap analysis. Going forward, national organizations will need to evaluate high-trauma fractures as well as fragility fractures as risks.”

The issue of fractures involving men was also addressed in the 2019 study, which noted that the 858 subjects with high-trauma fractures were slightly younger than the 14,858 with low-trauma fracture and less-often female; the hazard ratios (HRs) for both high-trauma and low-trauma fractures tended to be greater in men than women; and that the odds-ratio of a fracture related to high-trauma fracture among men was three times greater than among that of women adjusted for other risk factors.

“It is not surprising,” says Pope, “that men are more likely to have high-trauma fractures than women. The correlation between low BMD in these patients complements three other studies about high-trauma fractures in men. In 2020, most of the men are still not being considered as higher risk. This study could be pivotal in changing that paradigm.”

The study also indicates that attempts to define the level of trauma leading to fracture are counter-productive and that all fractures in older adults warrant evaluation for possible underlying osteoporosis---and that such a strategy, if supported by consistent evidence, might simplify clinical practice guidelines.

“Anything that simplifies evaluation of a risk, especially in family medicine and general practice, should increase evaluation for men and women.” Pope says, “This will simplify evaluations: have you had a fracture as an adult over the age of 40? Check the box yes or no. This will avoid deciphering the mechanism of injury, for example an automobile accident or athletic injury. You won’t need to go through that process, as all fractures as an adult will be entered in as a yes in the FRAX calculator.”

CITATION: W.D. Leslie, J.T. Schousboe, et. al. Fracture risk following high-trauma versus low-trauma fracture: a registry-based cohort study. Osteoporosis International. Published: 16 March 2020.   Mackey D.C., Kui Ly, et. al. High-trauma fractures and low bone mineral density in older women and men. JAMA. 2007. Nov. 28.  Peggy M. Cawthon, Mohammad Shahnazari, et. al. Osteoporosis in men: findings from the Osteoporotic Fractures in Men Study (MrOS). Therapeutic Advance in Musculoskeletal Disease. February 2016. Sanders KM, Pasc JA, et. al. The exclusion of high trauma fractures may underestimate the prevalence of bone fragility fractures in the community: the Geelong Osteoporosis Study. Journal of Bone and Mineral Research. August 1998.



Asthma-COVID-19 connection questioned
in research into those 65-and-younger

NEW YORK – Recent research indicates that among hospitalized patients 65-years-or-younger with severe COVID-19, asthma diagnosis is not associated with worse outcomes, regardless of age, obesity, or other high-risk comorbidities.

Authors of the study published in August in The Journal of Allergy and Clinical Immunology---including Stephanie Lovinsky-Desir and Deepti R. Deshpande, Columbia University, New York---recommend future population-based studies to investigate the risk of developing COVID-19 among patients with asthma once universal testing becomes readily available.

Given the high prevalence of asthma in the New York City area, the authors set out to determine whether underlying asthma was associated with poor outcomes among hospitalized patients with severe COVID-19 compared with patients without asthma.

Electronic heath records were reviewed for 1,298 sequential patients age 65-or-younger without chronic obstructive pulmonary disease (COPD) who were admitted to the hospital with a confirmed positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test result.

The overall prevalence of asthma among all hospitalized patients with COVID-19 was 12.6%, yet a higher prevalence (23.6%) was observed in the subset of 55 patients younger than 21 years.

There was no significant difference in hospital length of stay, need for intubation, length of intubation, tracheostomy tube placement, hospital re-admission, or mortality between patients with-and-without asthma.

Observations between patients with-and-without asthma were similar when stratified by:

  • obesity
  • other comorbid conditions (such as hypertension, hyperlipidemia, and diabetes)
  • use of controller asthma medication
  • absolute eosinophil count

CITATION: Stephanie Lovinsky-Desir, MD, MS, Deepti R. Deshpande, MBBS, MPH, et. al. Asthma among hospitalized patients with COVID-19 and related outcomes. The Journal of Allergy and Clinical Immunology. Aug. 5, 2020.



Renal Information System is developed
to boost health care for U.S. veterans

ANN ARBOR, MICH. – The recently-developed United States Department of Veterans Affairs (VA) Renal Information System (VA-REINS), according to recent research, can be leveraged for disease surveillance, population-health management, and improving quality and value of care, enhancing the VA’s capacity as a patient-centered learning-health system for U.S. veterans.

The study was published in September in the American Journal of Kidney Diseases. Authors include Rajiv Saran and Aaron Pearson, University of Michigan, Ann Arbor, Mich.

The researchers noted that kidney disease is a common, complex, costly and life-limiting condition, and that most kidney-disease registries or information systems have been limited to single institutions or regions.

The authors described the creation of VA-REINS and presented key initial findings related to chronic kidney disease (CKD) without kidney replacement therapy (KRT).

Data from the VA’s Corporate Data Warehouse was processed and linked with national Medicare data on CKD patients receiving KRT. Operational definitions for “VA user,” CKD, acute kidney injury (AKI), and kidney failure were developed.

Among seven million VA users in fiscal year 2014, CKD was identified using either a “strict” or a “liberal” operational definition, in 1.1 million (16.4%) and 2.5 million (36.3%) veterans, respectively.

Most were identified using an eGFR laboratory phenotype, some via proteinuria assessment, and very few via ICD-9 coding.

The VA spent approximately $18 billion for the care of patients with CKD without KRT, the majority of which was for CKD Stage 3, with higher per-patient costs by CKD stage.

CITATION: Rajiv Saran, MBBS, MD, MRCP, MS, Aaron Pearson, MA, MSI, et. al. Burden and Cost of Caring for US Veterans With CKD: Initial Findings From the VA Renal Information System (VA-REINS). American Journal of Kidney Diseases. Sept. 2, 2020.


Clustering of hypertension, obesity, diabetes
is said to increase Blacks’ Covid-19 mortality

NEW ORLEANS – A recent study indicates that among predominantly-Black patients hospitalized for COVID-19, the clustering of hypertension, obesity, and diabetes as metabolic syndrome (MetS) increases the odds of mortality compared with these comorbidities individually.

The study was published in September in Diabetes Care. Authors include John Xie and Yuanhao Zu, who are affiliated with Tulane University, New Orleans.

The researchers noted that COVID-19 mortality is high in patients with hypertension, obesity, and diabetes, and examined the association between hypertension, obesity, and diabetes, individually and clustered as MetS, and COVID-19 outcomes in patients hospitalized in New Orleans during the peak of the outbreak.

They collected data from 287 consecutive patients with COVID-19 hospitalized at two hospitals in New Orleans, from March 30 to April 5, 2020. MetS was identified per World Health Organization criteria.

Among those patients (mean age 61.5 years; female, 56.8%; non-Hispanic Black, 85.4%), MetS was present in 188.

MetS was significantly associated with mortality, intensive care unit (ICU) admissions, invasive mechanical ventilation (IMV), and acute respiratory distress syndrome (ARDS) compared with non-MetS.

Multivariable analyses of hypertension, obesity, and diabetes individually showed no association with mortality. Obesity was associated with ICU, ARDS, and IMV.

Diabetes was associated with ICU and IMV, and hypertension was not significantly associated with any outcome.

Inflammatory biomarkers associated with MetS, CRP, and lactate dehydrogenase (LDH) were associated with mortality and LDH.

CITATION: John Xie, Yuanhao Zu, et. al. Metabolic Syndrome and COVID-19 Mortality Among Adult Black Patients in New Orleans. Diabetes Care. September 2020. Volume 43, Issue 9. Received July 8, 2020.  Accepted July 29, 2020.  Published online ahead of print August 25, 2020.



Obesity-Covid-19 association targeted
among Mexicans 50-years-and-younger

CUERNAVACA, MEXICO – A study of Mexican patients indicates that obesity, diabetes, and hypertension are significantly associated with severe COVID-19 on admission, with the association of obesity stronger in patients aged 50 and younger.

The research published in July in Obesity (Wiley) points to the importance of combatting and preventing obesity in order to reduce the burden of chronic diseases and adverse outcomes to viral pandemics.

Its authors---including Edgar Denova‐Gutiérrez, Instituto Nacional de Salud Pública, Cuernavaca, Morelos, Mexico, and Hugo Lopez‐Gatell, Secretaria de Salud, Mexico City, Mexico---suggest the need for studies that evaluate the mechanisms associated with increased severity of COVID‐19 in patients with obesity, as well as the need for prevention strategies for these patients.

A total of 23,593 patient samples was evaluated by a laboratory from the Mexican Institute of Epidemiological Diagnosis and Reference. Of these, 18,443 were negative for COVID‐19, 3,844 were positive for COVID‐19, and 1,306 were positive for other respiratory viruses.

Severe types of respiratory disease were defined by the presence of pneumonia and other organ failure requiring intensive care. Multivariable logistic regression models were used to explore factors associated with severe COVID‐19 on admission.

Patients who tested positive for COVID‐19 had a higher proportion of obesity (17.4%), diabetes (14.5%), and hypertension (18.9%) compared with those without a confirmed diagnosis.

Compared with patients without obesity, those with obesity showed 1.43‐fold higher odds of developing severe COVID‐19 on admission, whereas subjects with diabetes and hypertension showed 1.87‐fold and 1.77‐fold higher odds of developing severe COVID‐19 on admission, respectively.

CITATION: Edgar Denova‐Gutiérrez, Hugo Lopez‐Gatell, et. al. The Association of Obesity, Type 2 Diabetes, and Hypertension with Severe Coronavirus Disease 2019 on Admission Among Mexican Patients. Obesity (Wiley). July 1, 2020.



Vol. 3 No. 56

Kidney expert on losses to COVID-19:
‘Hardest’ are deaths among the staff

(Last of two parts.)

ST. PETERSBURG, FLA. – In the last issue, we spoke to kidney expert Kim Zuber about the impact of COVID-19 in her area of the health-care community. After assessing the damage that the virus has done to patients’ kidney health---with more than one-third of those hospitalized for COVID-19 in a large New York health-care system developing acute kidney injuries (AKIs)---we turn to what can be expected for the remainder of 2020 and beyond.

St. Petersburg, Fla., resident Zuber, PA-C, executive director of the American Academy of Nephrology PAs (physician assistants), is past chair of the National Kidney Foundation/Council of Advanced Practitioners, and a faculty member of the Metabolic & Endocrine Disease Summit (MEDS). Her responses to several COVID-19 queries follow.

*Are you surprised by some of the information that came out of this research: that the Kidney International study of COVID-19 patients admitted to the 23 hospitals in New York’s Northwell Health system reported that of 5,449 patients admitted, 36.6% developed AKI, and 5.2% of the total—some 285 patients—required dialytic support?

“In Europe, they are reporting 75% of admitted hospital patients developing AKI. We are at 50% in NYC. Whether it’s two-of-every-four patients or three-of-every-four patients is not as important as reminding practitioners to monitor the post-COVID AKI patient in the months and years to come. Patients even with only one AKI episode are twice-as-likely to develop chronic kidney disease (CKD) in the future. Just because someone has ‘recovered’ from COVID does not mean they are out of the woods!”

*Four ways to stretch resources jumped out at me; I wonder if any of these in particular stood out to you, and whether you have any additional ones in mind:

  • Continuous renal replacement therapy (CRRT) experts asked how best to use resources, with one expert suggesting adapting hemodialysis machines to provide CRRT in the intensive care unit (ICU) through sustained low-efficiency dialysis (SLED)—providing dialysis over eight hours instead of the normal three-or-four-hour session. 
  • Cohorting: When dialysis machines couldn’t handle patient overflow, dialysis patients were grouped where one dialysis nurse could provide their care needs.
  • Many patients got prolonged intermittent renal replacement therapy (RRT) instead of CRRT, with the machine flipped to the next patient after 12-or-24 hours. In some instances, SLED was used with hemodialysis machines, enabling the removal of three-or-four patients daily from the CRRT census.
  • Manual exchanges of peritoneal dialysis (PD), which is relatively low-tech and easy to teach.

“I have always thought we underutilize PD, and to see it in the hospital ICU is fantastic. Worldwide, PD is the most common treatment for kidney failure, especially in third-world countries. PD does not require electricity or machines, and is easy to train helpers; we train family members and patients all the time! In the U.S., we jump to hemodialysis and CRRT, bypassing the nice, gentle treatment of PD. PD was first used during the Korean War with great success. For those of us old enough to remember M*A*S*H (the TV show), the M*A*S*H doctors demonstrated the slow PD treatment saving patients. Just because something is ‘new-and-improved’ doesn’t mean there isn’t something to learn from the older treatments.”
*Do you have any recollections or anecdotes regarding medical staff contracting the virus?

“Much has been made of the heroes who have worked in the hospitals, the paramedics, the grocery workers, etc., but the dialysis staff, in-patient and mainly out-patient, have been left out. These are the people who have gone to work every day, dealing with very critically immune-compromised patients. Dialysis staff have to be ‘in-your-face’ so to speak to hook you up to a dialysis machine, monitor you for four-to-five hours and then deal with the sickness and deaths in this patient population. “The very first documented COVID patient in the U.S. was a dialysis patient in Washington state. The staff, prior to implementation of COVID precautions, using years of training on sterile technique that has been practically beaten into their subconscious, never had a case at that unit. However, we cannot say that for every dialysis worker. Our staffs include nurses, techs, social workers, secretaries and dieticians. The medical staff has been doing weekly rounds via phone/telemedicine/ or if not possible, in full personal protective equipment (PPE) in person.

“But the medical staffers are not who spends hours with the patients---it’s our dialysis techs who are the true heroes. Holding hands and listening to fears while trying to put their own fears behind. Many of our staff come from the same communities as our dialysis patients and many of the staff have similar risk factors: race, age, co- morbidities, exposure, and multi-generational housing.

“One of my units, who had won infection-control awards from the state and Centers for Medicare & Medicare Services (CMS), had three of their five nurses in the hospital, two in ICUs and one tech who died at Washington Hospital Center, all within the month of March…before we knew what we know now.

“Sandy was the face of my dialysis unit. She was open and friendly and the first one to greet anyone and everyone who walked through the door. Every patient loved her. If you were to look at her, you would see a high-risk person (overweight, borderline diabetic, asthma, Black, over 60, lived with daughter and grandchildren) but all I saw was a much-loved and respected member of my staff. Sandy’s death scared both my staff and patients, and the only rainbow I can claim for losing her was the camaraderie that developed among every single person in the unit; staff looking out for patients and patients taking such incredible care of my staff. We have lost patients, but it is the staff, the ones you are not supposed to lose, that are the hardest.”
*Looking at the lessons learned, both in terms of adapting to shortages, and to such oversights as not stocking up on fluids, as well as staffing issues (including those who contracted the disease), what shape is the medical community in should a potential autumn second wave occur?

“We’re still in the first wave here in Florida. The older crowd is paranoid, and appropriately so. We have masked and cut back eating out, had a lot of grocery delivery, and the neighborhoods are deathly quiet. Visitors and the younger crowd seem less worried---but that is slowly changing.

“The aggressive treatment of the clotting issues seen in COVID have changed protocols. Many of the out-patient suggestions such as starting acetylsalicylic acid (ASA) early, putting off intubation and dialysis and the equipment and fluid/staff backfill done after things slowed down in May, have put us in good stead. But we are all just one bad week away from everything falling apart again!”

CITATION: More Than One-Third of Hospitalized COVID-19 Patients Develop AKI, Study Finds. Kidney News Online. July 2020. Volume 12, Number 7. Hirsch JS, et. al. AKI in patients hospitalized with COVID-19. Kidney International. Published online May 16, 2020. Daniel Batlle, et. al. Acute kidney injury in COVID-19: Emerging evidence of a distinct pathophysiology. Journal of the American Society of Nephrology. May 2020. Cheng Y, et. al. Kidney disease is associated with in-hospital deaths of patients with COVID-19. Kidney International 2020;97:829-838. Arentz, M, et. al. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington state. JAMA 2020; 323:1612-1614. Kidney News. June 2020. Volume 12, Number 6. Jeffrey Silberzweig, T. Alp Ikizler, et. al. Rationing Scarce Resources: The Potential Impact of COVID-19 on Patients with Chronic Kidney Disease. Journal of the American Society of Nephrology. July 2020. Volume 31, Issue 7.


Unsaturated fat intake associated
with increased COVID-19 mortality

JOHNSON CITY, TENN. – Unsaturated fat intake is associated with increased mortality from COVID-19, according to recent research indicating that unsaturated fatty acids (UFAs) cause injuries---organ failures resembling COVID-19.

The study published in August in Gastroenterology also indicates that early albumin and calcium supplements can bind unsaturated fatty acids and reduce injury.

Its authors---including Bara El-Kurdi and Biswajit Khatua, East Tennessee State University, Johnson City, Tenn.---report that both calcium and albumin are inexpensive and readily available, and if supplemented early during COVID-19 hospitalization, they may reduce organ failure and intensive care unit (ICU) requirements despite a lack of proven anti-viral therapies.

The researchers also indicate that while most COVID-19 infections are self-limited, some develop into sepsis and multi-system organ failure (MSOF), resembling lipotoxic acute pancreatitis.

They also note that ascertainment of underlying mechanisms may guide supportive care while clinical trials are ongoing, and that obesity is a shared risk factor between severe acute pancreatitis and severe COVID-19, along with lipase elevation, hypoalbuminemia, and hypocalcemia.

Undetected progression of hypoalbuminemia and hypocalcemia may occur because calcium-albumin correction calculations can pseudo-normalize calcium values---calcium alleviates MSOF, and UFAs cause non-endocrine hypocalcemia.

Adipocytes containing triglycerides and adipocyte triglyceride lipase (ATGL) and pancreatic acini expressing pancreatic triglyceride lipase (PNLIP) inhabit the ACE2 receptor.

CITATION: Bara El-Kurdi, Biswajit Khatua, et. al. Mortality From Coronavirus Disease 2029 Increases With Unsaturated Fat and May Be Reduced by Early Calcium and Albumin Supplementation. Gastroenterology. Aug. 19, 2020. Bara El-Kurdi, Biswajit Khatua, et. al. Mortality From Coronavirus Disease 2029 Increases With Unsaturated Fat and May Be Reduced by Early Calcium and Albumin Supplementation. Gastroenterology. May 26, 2020.


Research: Use of lung-specific risk factors
may benefit fracture prediction for smokers

PITTSBURGH – Recent research suggests that the incorporation of lung-specific risk factors into fracture-risk assessment tools may more accurately predict fracture risk in smokers.

Authors of the study published in August in the Journal of Bone and Mineral Research--- including Jessica Bon and Seyed Mehdi Nouraie, University of Pittsburgh, Pittsburgh--- noted that hip fractures are associated with significant morbidity and mortality in smokers with lung disease.

The researchers set out to determine whether lung‐specific factors associate with incident hip fracture and improve risk discrimination of traditional fracture-risk models in smokers.

Their analysis consisted of a convenience sample of 9,187 current-and-former smokers (58,477 participant follow‐up years) taking part in the Genetic Epidemiology of chronic obstructive pulmonary disease (COPD) longitudinal observational-cohort study. Participants were enrolled between 2008 and 2011, with follow‐up data collection through July, 2018.

Traditional risk factors associated with incident hip fracture included:

  • age
  • female sex
  • osteoporosis
  • prevalent spine-and-hip fracture
  • rheumatoid arthritis
  • diabetes

Lung‐specific risk factors included Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification, presence of computed tomography (CT)‐determined emphysema, symptom scores, six‐minute walk distance, body mass index (BMI), airflow obstruction, dyspnea, and exercise (BODE) index, total exacerbations, and annual exacerbations.

In multivariable modeling, age, Black race, osteoporosis, prevalent hip-and-spine fracture, rheumatoid arthritis, and diabetes were associated with incident hip fracture.

The presence of emphysema, six‐minute walk distance, and total number of exacerbations added to traditional models improved risk discrimination.

CITATION: Jessica Bon, Seyed Mehdi Nouraie, et. al. Lung-Specific Risk Factors Associated With Incident Hip Fracture in Current and Former Smokers. Journal of Bone and Mineral Research. Aug. 4, 2020.


Study: Patients with asthma, COPD likely
to have different risks of severe COVID‐19

WUHAN, CHINA – Patients with asthma and chronic obstructive pulmonary disease (COPD) probably have different risks of severe COVID‐19, according to a recent study also indicating that the diseases may be associated with different angiotensin‐converting enzyme II (ACE2) expressions.

The study was published in July in Allergy. Its authors---including Jia Song and Ming Zeng,  Huazhong University of Science and Technology, Wuhan, China---set out to explore the influence of asthma and COPD comorbidity on disease expression and outcomes, and the potential underlying mechanisms in COVID‐19 patients.

Nine-hundred-sixty-one hospitalized COVID‐19 patients with definite clinical outcomes (death or discharge) were retrospectively enrolled. Demographic-and-clinical information was extracted from medical records.

Lung-tissue sections from patients suffering from lung cancer were used for immune-histochemistry study of ACE2 expression. An adenovirus‐12 SV40 hybrid virus transformed bronchial epithelial cells (BEAS-2B) cell line was stimulated with various cytokines.

In this cohort, 21 subjects had COPD and 22 had asthma. After adjusting for confounding factors, COPD patients had a higher risk of developing severe illness and acute respiratory distress syndrome than asthmatics. COPD patients, particularly those with severe COVID‐19, had lower counts of CD4 +  T and CD8 +  T cells and B cells and higher levels of TNF‐α, IL‐2 receptor, IL‐10, IL‐8, and IL‐6 than asthmatics.

COPD patients had increased, whereas asthmatics had decreased ACE2 protein expression in lower airways, compared with that in control subjects without asthma and COPD. IL‐4 and IL‐13 down-regulated, but TNF‐α, IL‐12, and IL‐17A up-regulated ACE2 expression in BEAS‐2B cells.

CITATION: Jia Song, Ming Zeng, et. al. Distinct effects of asthma and COPD comorbidity on disease expression and outcome in patients with COVID-19. Allergy. July 27, 2020.


AHA details heart issues as features
considered to be common to COVID-19

DALLAS – The American Heart Association (AHA) reports that heart issues appear to be common features of COVID-19 and that risk of death from COVID-19-related heart damage seems to be as or more important as other mortality-risk factors including age, diabetes mellitus, chronic pulmonary disease or past history of cardiovascular disease.

The association, located in Dallas, stated in August that figures from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) showed more U.S. cases of COVID-19 than any other country and quoted AHA’s president’s statements on cardiac complications of the virus.

“Much remains to be learned about COVID-19 infection and the heart,” says Mitchell S.V. Elkind, MD, MS, FAHA, FAAN. “Although we think of the lungs being the primary target, there are frequent biomarker elevations noted in infected patients that are usually associated with acute heart injury. Moreover, several devastating complications of COVID-19 are cardiac in nature and may result in lingering cardiac dysfunction during the course of the viral illness itself. We simply don’t have enough information to providethe definitive answers people want and need.”

The AHA also states that while most COVID-19 patients appear to recover well, a smaller number experience severe, exaggerated inflammation throughout the body, known as a cytokine storm, which can cause widespread clotting, organ failure and/or damage to the heart and other organs.

The association also warns of possible harm to the heart from the use of the anti-viral and anti-malarial agent hydroxychloroquine as a COVID-19 treatment, and points out concern that severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) may have lasting or even delayed effects on the cardiovascular and nervous systems.

CITATION: Severe COVID-19 associated with heart issues; much yet to discover. American Heart Association. Aug. 14, 2020.



Vol. 3 No. 55

Sugary-drink warning strategy spurs
a cautionary stance, COVID-19 issues

KING GEORGE, VA. – The findings of a recent meta-analysis backing sugary-drink warnings as a strategy to reduce purchases and drive behavioral change win the support of the faculty co-chair of the Metabolic & Endocrine Disease Summit (MEDS)--- along with some cautionary advice that ties in with the coronavirus crisis.

The study published in May in PLOS Medicine reports that an international body of experimental literature approves of such warnings as tools to alter behavior, emotions, perceptions, and intentions.

Assessing 23 experiments representing more than 16,000 subjects, its authors weighed the impact of sugary-drink warnings versus control conditions and found that such warnings reduce self-reported and objectively-measured purchases. The report concludes that required warnings would represent a promising policy-strategy to inform consumers and reduce sugary-drink consumption.

“I believe that health-based warnings on consumer products can have a positive impact on food/drink choices when purchasing or imbibing sugary products,” says nurse practitioner (NP) Christine Kessler, founder of Metabolic Medicine Associates in King George, Va. “It is a logical presumption, given what was done with smoking public- education/warnings. Some people still smoke, but that is an informed choice.”

“Don’t take choice away,” she adds, “because then you will have a black market for these products. Think prohibition!”

Kessler stresses, too, that the fact that the coronavirus poses worse outcomes for those with such underlying comorbidities as obesity, diabetes, and cardiovascular disease illustrates the importance of behavioral changes.

“These are health risks,” she says. “And some behaviors will promote these risks—such as intake of a lot of sugary drinks. A number of my weight-challenged patients, family members, and neighbors have self-eliminated weight-inducing beverages and food and can be seen walking a lot more. On the other hand, those who are forced to self- sequester for weeks or have lost their jobs, may seek greater carb intake to promote Dopamine 1 receptor stimulation to promote calm. For them, a sugary drink is their anxiolytic ‘drug’ of choice, which they may perceive as having greater benefit than harm at that moment. As you can see, it is a complicated issue.”

As to the benefit in battling at-risk patients’ habits, Kessler says “it depends on what health risks you are warning patients about: obesity, worsening diabetes, increasing cardiovascular risks (ups triglycerides – a major metabolic syndrome marker). I teach patients a very important point—food is a drug, with benefits and risks, i.e., significant side effects. If we experience a bad side effect from a medication—we are likely to avoid that drug, but we don’t do that with food that harms us.”

She asserts that “sugary drinks do not prove harmful to everyone. Many people can eat lots of saturated fat without harm (I am one of those people); some can eat abnormally high amounts of calories without weight gain—we all know those folks; and many people can eat several Snickers bars and not raise their blood glucose. It is the genetic influence. However, a majority of people will have a long-term negative metabolic response to sugary drinks. For that reason, and since we are not able to easily identify nutrigenomic risk, the blanket public education of health risks from sugary drinks is reasonable.”

As to the question of warnings involving nutrients, as opposed to health, Kessler says. “addressing overall health is something that could hook some people (especially the health-conscious millennials and older folks with underlying morbidities). Once that groundwork is laid—then talk about the evidence-based impact of the varied nutrients on health. This kind of national dialogue has at least led to removing fructose from some sugary drinks and using sucrose instead. Fructose is truly a devastating sugar that affects the brain, and metabolism in a significantly different way than sucrose and glucose and promotes non-alcoholic fatty liver disease (NFALD) and greater hunger.”

The first thing Kessler does for patients with diabetes “is encourage them to stop or reduce intake of sugary drinks, including sweet juices—I mean, eat the fruit, don’t just drink the juice. This can be a real problem for glycemic control.”

As to attempts to restrict sugary-drink advertising (tried last year in San Francisco), Kessler hates “legislation that comes across like we are all children needing government to verbally spank us or tax us to change behavior. As research has proven—taxes don’t work, nor does prohibition of products. I believe in freedom of choice. Education is key. As fewer people choose to purchase products that they perceive as unhealthy, the market will produce fewer such products and, perhaps, provide safer alternatives. Hopefully such products can be purchased at reasonable prices—which is a real problem in locales with food/nutrient-deficits.”

CITATION: Anna H. Grummon, Marissa G. Hall, et. al. Sugary drink warnings: A meta- analysis of experimental studies. PLOS Medicine. Published May 20, 2020.


Diffuse-alveolar lung injuries are tied
to patients who have severe COVID-19

SEATTLE – Recent research indicates the central role of diffuse alveolar damage-type lung injuries in patients with severe COVID-19.

The study, which includes data involving chronic kidney disease (CKD) patients, was published in July in The Lancet.

The research indicates that micro-thrombotic disease and endothelial injuries are not as pronounced as reported in previous studies.

Its authors---including Benjamin T. Bradley and Heather Maioli, University of Washington, Seattle--- found broad tropism for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with coronavirus-like particles identified in the pulmonary system, kidneys, and gastrointestinal tract.

Their results also raise the question as to whether SARS-CoV-2 can cause direct myocardial injury and if direct infection of lymphocytes promotes viral dissemination and immune dysregulation. These findings provide histological context for clinical observations and help characterize the patho-physiology of SARS-CoV-2, hopefully leading to novel treatment strategies.

The researchers state that the primary pathology observed in their cohort was diffuse alveolar damage, with virus located in the pneumocytes and tracheal epithelium. Micro- thrombi, where observed, were scarce, and endotheliitis was not identified.

Patients with a positive antemortem or post-mortem SARS-CoV-2 result were considered eligible for enrollment in this case series.

Post-mortem examinations were done on 14 people who died with COVID-19 at the King County Medical Examiner's Office, Seattle, and Snohomish County Medical Examiner's Office, Everett, Wash., in negative-pressure isolation suites during February and March, 2020.

The median age of cohorts was 73.5 years, all patients had clinically-significant comorbidities, the most common being hypertension, CKD, obstructive sleep apnea,
and metabolic disease including diabetes and obesity.

The major pulmonary finding was diffuse alveolar damage in the acute or organizing phases, with five patients showing focal pulmonary micro-thrombi. Coronavirus-like particles were detected in the respiratory system, kidney, and gastrointestinal tract. Lymphocytic myocarditis was observed in one patient, with viral RNA detected in the

CITATION: Benjamin T. Bradley, MD, Heather Maioli, MD, et. al. Histopathology and ultrastructural findings of fatal COVID-19 infections in Washington State: a case series.
The Lancet. July 16, 2020.


Osteoporosis assessment doesn’t support
increased fracture risk for ICS treatment

WINNIPEG, MANITOBA – Recent research into the effects of long-term inhaled corticosteroid (ICS) treatment on fragility fractures in older women does not support an increased risk of major osteoporotic fracture in these subjects with chronic-respiratory diseases due to long-term ICS use.

Authors of the study published in March in Osteoporosis International include William D. Leslie, who is affiliated with University of Manitoba, Winnipeg, Manitoba.

The researchers utilized Manitoba health administrative data-bases and the provincial bone mineral density (BMD) registry (1996-to-2013) to identify women at least 40 years of age with asthma and/or chronic obstructive pulmonary disease (COPD) within three years preceding the baseline BMD test.

The authors followed these subjects until the first major osteoporotic fracture or the conclusion of the study, whichever came first. ICS use, stratified by exposure tertiles, was measured within the 12-month period following the baseline BMD test (by total days and quantity, primary outcome), and over the entire follow-up period (by medication possession ratio [MPR] and average annual dose, secondary outcome).

The hazard ratio of fracture with ICS use was estimated using a Cox proportional hazards model, controlling for baseline determinants of fracture.

Of 6,880 older women with asthma (38%) or COPD (62%), 810 experienced a major osteoporotic fracture over a mean follow-up of 7.7 years.

ICS use at any tertile was not associated with an increased risk of fracture. Similarly, ICS use at any tertile during the entire follow-up period was not associated with an increased risk of fracture.

CITATION: B.C. Ng, W.D. Leslie, et. al. Effects of long-term inhaled corticosteroid treatment on fragility fractures in older women: the Manitoba BMD registry study. Osteoporosis International. 2 March 2020.


Careful RAS targeting may optimize
outcomes for diabetes/SARS-CoV-2

INDIANAPOLIS – Careful targeting of the systemic-and-tissue renin-angiotensin system (RAS) may optimize clinical outcomes in diabetes patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), according to a study published in Diabetes.

Its authors---including Alexander G. Obukhov, Indiana University School of Medicine, Indianapolis---note that diabetes patients suffering from COVID-19 exhibit increased morbidity and mortality compared with individuals without diabetes, and argue that this is due to a dysregulated RAS.

The researchers state they have previously shown that loss of angiotensin-I converting enzyme 2 (ACE2) promotes the ACE/angiotensin-II (Ang-II)/angiotensin type 1 receptor (AT1R) axis, a deleterious arm of RAS, unleashing its detrimental effects in diabetes.

As suggested by recent reports regarding the pathogenesis of SARS-CoV-2 upon entry into the host, this virus binds to the extra-cellular domain of ACE2 in nasal, lung, and gut epithelial cells through its spike glycoprotein sub-unit S1.

The authors of the research published in August hypothesize that during this process, reduced ACE2 could result in clinical deterioration in COVID-19 patients with diabetes via aggravating Ang-II-dependent pathways and partly driving not only lung but also bone marrow-and-gastrointestinal pathology.

In addition to systemic RAS, they add, the path-ophysiological response of the local RAS within the intestinal epithelium involves mechanisms distinct from that of RAS in the lung; however, both lung and gut are impacted by diabetes-induced bone marrow dysfunction.

CITATION: Alexander G. Obukhov, Bruce R. Stevens, et. al. SARS-CoV-2 Infections and ACE2: Clinical Outcomes Linked With Increased Morbidity and Mortality in Individuals With Diabetes. Diabetes. August 2020.


Research finds asthmatic children are not
disproportionately affected by COVID-19

MANCHESTER, ENGLAND – Children with asthma do not appear to be disproportionately affected by COVID-19, according to research published in The Journal of Allergy and Clinical Immunology: In Practice.

Authors of the study published in June---including Nikolaos G. Papadopoulos, The University of Manchester, Manchester, England, and Adnan Custovic, Imperial College London---set out to describe the impact of the COVID-19 pandemic on pediatric-asthma services and on disease burden in their patients.

They indicate that outcomes may even have improved, possibly through increased adherence and/or reduced exposures, and that clinical services have rapidly responded to the pandemic by limiting and replacing physical appointments with virtual encounters.

The researchers sent an online survey to members of the Pediatric Asthma in Real Life think tank and the World Allergy Organization Pediatric Asthma Committee. It included questions on service provision, disease burden, and the clinical course of confirmed cases of COVID-19 infection among children with asthma.

Ninety-one respondents, caring for an estimated population of more than 133,000 children with asthma, completed the survey. COVID-19 significantly impacted pediatric asthma services: 39% ceased physical appointments, 47% stopped accepting new patients, and 75% limited patients' visits.

Consultations were almost halved to a median of 20 patients per week. Virtual clinics and helplines were launched in most centers.

Better-than-expected disease control was reported in 20% (10%-to-40%) of patients, whereas control was negatively affected in only 10% (7.5%-to-12.5%).

Adherence also appeared to increase. Only 15 confirmed cases of COVID-19 were reported among the population; the estimated incidence is not apparently different from the reports of general-pediatric cohorts.

CITATION: Nikolaos G. Papadopoulos, MD, Ph.D., FRCP, FAAAAI, Adnan Custovic, MSc, DM, MD, Ph.D., FRCP, et. al. Impact of COVID-19 on Pediatric Asthma: Practice Adjustments and Disease Burden. The Journal of Allergy and Clinical Immunology: In Practice. Published: June 16, 2020.



Vol. 3 No. 54

Asthma expert: Even general practitioners
may be unaware of steroid-treatment issues

BOISE, IDAHO – Recent research into the association of asthma with osteopenia, osteoporosis, osteomalacia, and fractures spotlights a link to steroid treatments one asthma expert says may not be known by patients, or health-care professionals---including general practitioners.

The cross-sectional study published in March in Allergy and Asthma Proceedings reflects data involving 198,102,435 children and adults, including 10,129,307 with asthma from the 2006-to-2012 National Emergency Department Sample, including a 20- percent sample of emergency-care visits throughout the U.S. It concludes that emergency department (ED) visits with asthma are associated with osteopenia, osteoporosis, osteomalacia, and pathological fractures.

Brian K. Bizik, MS, PA-C, Physician Assistant, Terry Reilly Health Center, Boise, Idaho, says the study’s conclusions reflect his medical experience.

“This is what we see,” says Bizik, past president and current conference chair of the Association of PAs in Allergy, Asthma, and Immunology, and faculty member of Cardiovascular, Allergy, & Respiratory Summit (CARPS), “especially in patients who have been on oral steroids on-and-off throughout their lives, and particularly among older patients.”

The study also notes that patients with asthma and long-term inhaled glucocorticoid use have higher odds of ED visits with osteoporosis-related fractures compared with asthma without long-term inhaled glucocorticoid use---a conclusion that may be news to some health-care practitioners.

“Those of us who specialize in asthma and chronic obstructive pulmonary disease (COPD) are aware of this,” says Bizik, “but I don’t think most general practitioners are. A fair number of health-care providers are not aware of it. We are taught to be cautious with the use of steroid creams but often the same level of concern does not follow inhaled steroids. Using multiple forms of steroids can be a big concern.”

Another key research finding is that men who are prescribed inhaled corticosteroids (ICS) or systemic corticosteroids (SCS) for COPD or asthma have a nearly two-fold increased risk of osteoporosis of the spine.

Its authors, in addressing this and other connections between prescribed medications and osteoporosis, recommend that patients should be asked about their history of fractures and glucocorticoid use---and that SCS should be used cautiously in the out-patient and emergency setting.

Osteoporosis, Bizik stresses, “is often overlooked in men. Four times as many women as men are diagnosed with osteoporosis. Even men at higher risk of osteoporosis, including men who have been on inhaled and oral corticosteroid therapy are often not screened for fracture risk. Older men actually fare much worse than older women if they do experience an osteoporotic fracture.”

Bizik concurs with the study’s point that weight-bearing and muscle-strengthening exercises help proper bone-remodeling and reduce fall-and-fracture risk---and that asthma patients often have lower cardio-respiratory fitness and are less physically active as their asthma can limit activity. But he is quick to add that health-care professionals, including PAs and nurse practitioners (NPs), can make a difference for asthma patients.

“Pulmonary rehabilitation improves cardio-vascular health for people with lung diseases like COPD and asthma. It also can also protect bone health,” Bizik says. “Because of this I like to ask activity-related questions like how far can you walk without stopping to rest, or checking in and making sure that asthma is not holding patients back from desired activity.”

Bizik differs with the study’s support of devices attached to inhalers to monitor non-adherence.

“At this point the technology is not quite ready to be used on a daily basis and help primary-care practitioners track inhaler use,” he says. “We are close, however, and I would guess that in the next few years electronic tracking of inhaler use will be part of routine care. This emerging technology will help us maximize controller inhaler use and minimize exacerbations.”

Bizik concludes that “the chance of in-patient admission is reduced by about half when patients use their controller inhalers as prescribed. The risk of being put on oral steroid medications also is decreased, which helps reduce the lifelong risk of fractures and poor bone health.”

CITATION: Mohammed S. Shaheen, J.D., and Jonathan I. Silberberg, M.D., Ph.D., M.P.H. Association of asthma with osteopenia, osteoporosis, osteomalacia, and fractures. Allergy and Asthma Proceedings. March, 2020. Clin. Orthop. Relat. Res. 2011 Jul; 1900-1905.


AKI requiring dialysis tied to bleeding
independent of anticoagulant use

MONTREAL – Acute kidney injury (AKI) requiring dialysis is associated with incident in-hospital bleeding independent of anti-coagulant administration, according to research indicating that further study is needed to better understand how AKI affects coagulation and clinical outcomes.

The study published in May in the Journal of Critical Care also indicates that AKI can affect organ function and increase non-renal complications, and that incident bleeding after AKI is not independently associated with an increased risk of death.

Its authors---including Farah Zarka and Alexandre Tayler-Gomez, University of Montreal, Montreal---conducted a single-center retrospective-cohort study, excluding re-admissions, admissions in less than 24 hours, end-stage kidney disease (ESKD) or kidney transplants. The primary outcome was the development of incident bleeding analyzed by multivariate time-dependent Cox models.

Among 1,001 patients, bleeding occurred in 48% of AKI and 57% of non-AKI patients. To identify predictors of incident bleeding, the researchers excluded patients who bled before intensive care unit (ICU) (488).

In bleeding-free patients (513), the authors observed a trend toward higher risks of bleeding in AKI (22% vs. 16%), and a higher risk of bleeding in AKI-requiring dialysis (38% vs. 17%).

Cirrhosis, AKI-requiring dialysis, anti-coagulation, and coronary-artery disease were associated with bleeding, while SOFA score and sepsis had a protective association. Incident bleeding was not associated with mortality.

CITATION: Farah Zarka, Alexandre Tayler-Gomez, et. al. Risk of incident bleeding after acute kidney injury: A retrospective cohort study. Journal of Critical Care. May 20, 2020.


Physical-activity interventions can improve
several domains of cognition, study indicates

XI’AN, CHINA – Physical-activity (PA) interventions can improve several domains of cognition, especially core-executive functions (EFs) and non-EFs, according to a recent study indicating that the effects are impacted by PA characteristics among overweight and obese youth.

Authors of the study published in May in Pediatric Research include Xiaomin Sun and Yixuan Li, who are affiliated with Xi’An Jiaotong University Health Science Center, Xi’an, China.

The researchers listed the following as additional impact items from their study:

  • physical-activity interventions seem to not positively affect metacognition (higher-level EFs and cognitive-life skills) and academic performance
  • physical-task characteristics could influence the effect of chronic exercise on cognitive performance
  • short-term PA programs may be particularly beneficial to affect core-EFs

The authors systematically searched PubMed to identify relevant studies published up to October, 2019. Standardized mean differences (SMD) of pre-post intervention were calculated in meta-analysis.

Seventeen studies met the inclusion criteria; eight were included in the meta-analysis.

Meta-analysis revealed that PA interventions improved core-EFs and non-EFs, but not metacognition and academic performance. Core-EFs benefited from enriched PA and enhanced and enriched PA interventions, while the non-EFs benefited more from enhanced PA.

Interventions with a favorable effect on adiposity measures resulted in a significantly greater improvement in core-EFs than those with no effects.

CITATION: Xiaomin Sun, Yixuan Li, et. al. Effects of physical activity interventions on cognitive performance of overweight or obese children and adolescents: a systematic review and meta-analysis. Pediatric Research. 10 May 2020.


No significant outcome differences are seen
for weekly teriparatide, bisphosphonate arms

NAGANO, JAPAN – Recent research indicates that in multi-level lumbar inter-body fusion (M-LIF), no significant differences are seen for bone-fusion rate, bone-fusion score, or clinical outcome between weekly teriparatide (WT) and bisphosphonate (BP) arms.

However, the study published in July in Spine also indicates that the rate of complete bone fusion at six months post-operatively tends to be higher in the WT group.

Its authors, including Hiroki Oba and Jun Takahashi, who are affiliated with Shinshu University School of Medicine, Nagano, Japan, report that bone-contact (BC) status immediately after surgery has a major impact on bone fusion. In M-LIF, bone fusion is more difficult to obtain as compared with single-level lumbar interbody fusion (S-LIF.)

The researchers’ multi-center, prospective randomized study also indicates that careful cartilage endplate dissection and adequate bone grafting are needed to improve bone-fusion rate when performing M-LIF.

They noted that WT has been reported to significantly improve bone fusion following posterior or transforaminal interbody fusion in osteoporosis patients.

The authors assessed data involving patients older than 50 years and osteoporotic, defining the fusion of two-or-more consecutive intervertebral levels as M-LIF.

After surgical indication for M-LIF, the subjects were randomly allocated to receive either subcutaneous WT from one week to six months post-operatively (WT arm, 50 subjects) or a bisphosphonate (BP; BP arm, 54).

Blinded radiological evaluations were performed using computed tomography (CT). Evaluation of bone fusion was performed at the intervertebral disc located at the bottom of the fixed range.

Mean bone-fusion score at six months post-operatively was 3.9 points in the WT group and 4.2 points in the BP group.

The bone-fusion rate at six months post-operatively tended to be higher in the WT group.

CITATION: Oba, Hiroki MD, Ph.D., Takahashi, Jun MD, Ph.D., et. al. Weekly Teriparatide Versus Bisphosphonate for Bone Union During 6 Months After Multi-Level Lumbar Interbody Fusion for Osteoporotic Patients. Spine. July 1, 2020 - Volume 45 - Issue 13 - p 863-871.


Diabetes distress said notably prevalent
among elderly patients who have T2DM

TEHRAN, IRAN – Diabetes distress (DD) is notably prevalent among the elderly with type 2 diabetes mellitus (T2DM), according to research suggesting that attention to diabetes’ psychological aspects is a health priority---especially among women and other high-risk groups.

The study published in April in Diabetes Research and Clinical Practice was designed to investigate the prevalence of DD and some of its related factors on the elderly living in Qom, Iran.

Authors of the cross-sectional study---including Mojtaba Azadbakht, University of Social Welfare and Rehabilitation Services, Tehran, Iran, and Parisa Taheri Tanjani, Shahid Beheshti University of Medical Sciences, Tehran, Iran---assessed data involving 519 community-dwelling people aged 60-and-older over a three-month period.

Participants’ distress was measured by diabetes distress scale (DDS). Socio-demographic information was also assessed.

In order to determine factors of DD, logistic-regression analysis was applied.

The mean age of the participants was 68.38, with the majority being female (53.6%).

A multi-variable logistic regression analysis showed the following to be predictors of DD:

  • being female
  • sedentary lifestyle
  • complications
  • body mass index (BMI) of 25 or more
  • duration of disease below 10 years
  • two, or three or more comorbidities

CITATION: Mojtaba Azadbakht, Parisa Taheri Tanjani, et. al. The prevalence and predictors of diabetes distress in elderly with type 2 diabetes mellitus. Diabetes Research and Clinical Practice. 2020 Apr. 6;163;108133.


Vol. 3 No. 53

‘Every little effort’ makes a difference
in T2D battle against inactive lifestyles

LAGUNA NIGUEL, CALIF. – When it comes to medical providers’ attack plans against sedentary lifestyles as risks to developing type 2 diabetes (T2D), one expert on the disease says, “every little effort adds value.”

Ji Hyun Chun, PA-C, BC-ADM, immediate past president of the American Society of Endocrine Physician Assistants (ASEPA), says physician assistants (PAs) and nurse practitioners (NPs) know that most patients are well-aware of the connection between an inactive lifestyle and the disease.

“There’s plenty of evidence,” says Chun---of OptumCare Medical Group, Laguna Niguel, Calif., and a faculty member of Metabolic & Disease Summit (MEDS)---“linking low physical activity and T2D to a degree that is a common-sense knowledge to the public. Patients are less likely to distrust that statement.”

Chun points to these American Diabetes Association guidelines used by NPs and PAs to identify patients at diabetes or pre-diabetes risk:

  • age 45 or older
  • African-American, Hispanic/Latino, American Indian, Asian-American, Pacific Islander
  • family history of diabetes
  • overweight
  • physically inactive
  • have high blood pressure or take medicine for high blood pressure
  • have low HDL cholesterol and/or high triglycerides
  • had diabetes during pregnancy
  • have been diagnosed with polycystic ovary syndrome

For at-risk patients, Chun cautions that “it is important to make the statement that a sedentary lifestyle is a risk for developing T2D as a health-care provider, as even if it is something they already know, it is much more impactful when it comes from their health-care provider. Sometimes that is enough for patients to make lifestyle changes.”

Chun adds, though, that patients might resist for other reasons, “and it is our job to find out what their barriers are---including lack of time and joint pain---and give practical advice to work around it.”

A study published in March in BMJ Open assessing young and middle-aged adults indicates that long hours lying down (as a proxy for sedentary behavior) are associated with increased diabetes risk---with a positive association present in less physically- active subjects and absent among high-active ones.

That research underscores the need to motivate patients who are reluctant to exercise, which Chun says sometimes points out the need to abandon an all-or-nothing approach: “Start with any level of activity and build it up from there.”

“There are non-modifiable risk factors (such as age and family history) and modifiable risk factors, and sedentary lifestyle is modifiable in most patients.”

Some helpful activities, Chun says, can blend in with sedentary habits.

“For example, start by doing sets of exercises (including leg raises, sit-ups, push-ups, planks and squats) when watching TV. It could be as little as one set at each commercial break. It can evolve into ‘can you maintain a partial sit-up position when watching TV?’ or getting video games that involve physical activity.”

As for habits that limit physical activity---such as laptop and cell-phone use---there are remedies like screen-time limits and setting up reminders to take breaks to stand up, stretch, walk around, or do a quick set of exercises.

“We now have many wearable device options,” Chun points out, “that can track your steps, activities, and even give reminders (through mild vibration) to break the sedentary status.”

NPs and PAs can follow up with patients to ensure they are improving their habits via conversations with them, as well as by recommending technological help.

“Following up via general questions on how patients’ behavior has changed can be helpful,” Chun says, “but more objective measures would be more specific, and we can also encourage patients to be more motivated or self-accountable.”

In terms of technology, Chun says “it doesn’t have to be a device like Fitbit if one can’t afford it. Most people have smartphones with embedded health apps that can track steps, and, if not, free apps are available. Otherwise, simple pedometers are available at low cost.”

CITATION: Ernest O Asante, Yi-Qian Sun, et. al. Hours lying down per day, as a proxy for sedentary behaviour and risk of diabetes in young and middle-aged adults in Norway: an 11-year follow-up of the HUNT study. BMJ Open. March 25, 2020.


Study on smoking-induced osteoporosis
cites cadmium as likely causative factor

GOTHENBURG, SWEDEN – Cadmium exposure is likely to be an important causative factor in smoking‐induced osteoporosis, according to a recent study suggesting the strategy of reducing osteoporosis by decreasing smoking.

Authors of the study published in March in the Journal of Bone and Mineral Research include Huiqi Li and Maria Walli, who are affiliated with the University of Gothenburg, Gothenburg, Sweden. The researchers suggest that measures should be taken to reduce environmental pollution of cadmium, because cadmium in the environment will be taken up by crops and tobacco leaves.

The researchers investigated the hypothesis that part of smoking‐induced osteoporosis may be mediated via cadmium from tobacco smoke using mediation analysis in a Swedish cohort of elderly men.

This study was performed in 886 subjects from the Swedish cohort of the Osteoporotic Fractures in Men (MrOS) study. Urinary samples, bone mineral density (BMD), smoking data, and other background information was obtained at baseline in 2002-to-2004.

Urinary cadmium was analyzed in baseline samples and adjusted for creatinine. The cohort was followed until August, 2018, for fracture incidence, based on the X‐ray register.

Mediation analysis was conducted to evaluate the indirect effect (via cadmium) of smoking on both BMD and fractures. Time to first fracture was analyzed using the accelerated failure time (AFT) model and Aalen’s additive hazard model.

There were significant inverse associations between smoking and total body, total hip, and trochanter BMD. The indirect effects via cadmium were estimated to be 43% of the total effects of smoking for whole‐body BMD, and even more for total hip and trochanter BMD. Smoking was also associated with higher risk of all fractures and major osteoporosis fractures.

The indirect effects via cadmium were largest in non-vertebral osteoporosis fractures and hip fractures, constituting at least one‐half of the total effects, in both the AFT and Aalen’s model.

CITATION: Huiqi Li, Maria Walli, et. al. Smoking-Induced Risk of Osteoporosis is Partly Mediated by Cadmium From Tobacco Smoke: The MrOS Sweden Study. Journal of Bone and Mineral Research. 19 March 2020.


Early graft loss after kidney transplantation
called catastrophe, with high mortality rates

LEIDEN, NETHERLANDS – Early graft loss (EGL) after kidney transplantation, according to recent research, is a medical catastrophe with high mortality rates, low relisting rates, and increased risk of recurrent EGL following re-transplantation.

The study published in February in Kidney International implies that detrimental outcomes also involve convergence of risk factors in recipients with EGL, and that the 8.2% incidence of EGL minimally impacted population mortality, indicating this incidence is acceptable.

Its authors---including Michele J. de Kok and Alexander F. Schaapherder, who are affiliated with Leiden University Medical Center, Leiden, Netherlands---noted that EGL is a feared outcome of kidney transplantation, with kidneys with an anticipated risk of EGL declined for transplantation.

In the most favorable scenario, with optimal use of available donor kidneys, the donor pool size is balanced by risk of EGL, with a tradeoff dictated by the consequences of EGL.

To gauge the consequence of EGL, the researchers systematically evaluated its impact in an observational study that included all 10,307 deceased-donor kidney transplantations performed in the Netherlands between 1990-and-2018.

Incidence of EGL, defined as graft loss within 90 days, in primary transplantation was 8.2%. The main causes were graft rejection (30%), primary non-function (25%), and thrombosis or infarction (20%).

EGL profoundly impacted short- and long-term patient survival (adjusted hazard ratio; 95% confidence interval: 8.2; 5.1-13.2 and 1.7; 1.3-2.1, respectively).

Of the EGL recipients who survived 90 days after transplantation (617 of 699) only 440 of the 617 were relisted for re-transplantation.

Of those relisted, only 298 were ultimately re-transplanted, leading to an actual re-transplantation rate of 43%. Noticeably, re-transplantation was associated with a doubled incidence of EGL, but similar long-term graft survival (adjusted hazard ratio 1.1; 0.6-1.8).

CITATION: Michèle J. de Kok, Alexander F. Schaapherder, et. al. A nationwide evaluation of deceased donor kidney transplantation indicates detrimental consequences of early graft loss. Kidney International. Published online: February 28, 2020. Accepted: Jan. 31, 2020. Received in revised form: Jan. 10, 2020. Received: Aug. 17, 2019.


Research: Omalizumab cuts exacerbations
in children with moderate-to-severe asthma

AURORA, COLORADO – Recent research indicates that omalizumab reduces exacerbations in children with moderate-to-severe persistent allergic asthma, and may provide greater benefit in children with more severe asthma sub-types.

The ad-hoc analysis of three randomized-controlled trials published in April in The Journal of Allergy and Clinical Immunology: In Practice used multiple markers of asthma severity to demonstrate that exacerbation reduction with omalizumab is greater in pediatric patients with more severe asthma.

Its authors---including Stanley J. Szefler, University of Colorado School of Medicine, Aurora, Colorado, and Thomas B. Casale, University of South Florida, Tampa, Fla.--- noted that greater severity in childhood asthma negatively impacts physical/social functioning and quality of life and that omalizumab is effective in children aged six-years-and-up with moderate-to-severe persistent asthma.

The researchers found that consistent treatment benefits were observed among children with moderate-to-severe persistent asthma, and that improvements were greater in children with more severe sub-types.

These findings, they indicated, support the use of omalizumab in these sub-populations.

The authors analyzed randomized placebo-controlled studies of omalizumab stratified by body mass index (BMI), eosinophil count, fractional exhaled nitric oxide levels, and baseline severity-indicators. Poisson regression analysis examined exacerbation rate reductions for BMI, biomarkers, and severity indicators.

Subjects included 576 children aged six-to-11 in IA05 (56% white, 17% black, 26% other/missing); ICATA (237; 55% black, 43% Hispanic), and PROSE (342; 59% black, 35% Hispanic).

Trends indicative of greater exacerbation rate change were observed for low baseline lung function, prior hospitalizations, frequent baseline exacerbations, and high baseline eosinophil count.

CITATION: Stanley J. Szefler, MD, Thomas B. Casale, MD, et. al. Treatment Benefit with Omalizumab in Children by Indicators of Asthma Severity. The Journal of Allergy and Clinical Immunology: In Practice. Published online: April 13, 2020. Accepted: March 18, 2020. Received in revised form: March 16, 2020. Received: July 31, 2019.


Consumption of chocolate said associated
with lower adiposity markers for U.S. adults

CAMBRIDGE, ENGLAND – Chocolate consumption was associated with lower markers of adiposity in a recent study of a representative sample of U.S. adults.

The study published in February in the American Journal of Medicine suggests further research using a longitudinal or experimental design to establish the direction of causation.

Its authors---including Lee Smith, Anglia Ruskin University, Cambridge, England, and Igor Grab, Medical University of Vienna, Vienna, Austria---utilized cross-sectional data from 13,626 non-diabetic adults (at least 20 years of age) participating in the National Health and Nutrition Examination Survey, aggregated using five study cycles from 2005-to-2006 through 2013-to-2014.

Chocolate consumption was based on two 24-hour dietary recalls. Body mass index(BMI) and waist circumference were objectively measured.

The researchers used multivariable linear regression to test associations of any chocolate consumption and total amount of chocolate consumption (grams per day, in quartiles) with BMI and waist circumference.

Models controlled for socio-demographic, lifestyle, health-related, and dietary covariates.

Overall, 11.1% of the population self-reported any chocolate consumption in either of their two 24-hour dietary recalls.

Adjusted linear regression models showed that subjects reporting any chocolate consumption had 0.92 kg/m  2 lower BMI, and 2.07 cm lower waist circumference than those who reported no chocolate consumption.

In models examining the association of amount of chocolate consumption and weight status, compared with those who did not consume chocolate, lower BMI and waist circumference were observed in the first, second, and third quartiles of total chocolate consumption.

CITATION: Lee Smith, Ph.D., Igor Grab, et. al. Chocolate Consumption and Indicators of Adiposity in US Adults. American Journal of Medicine. Feb. 15, 2020.



Vol. 3 No. 52

‘Fascinating’ study shines a light
on slowing progression of CKD

ST. PETERSBURG, FLA. – A study assessing the link between low socio-economic status (SES) and chronic kidney disease (CKD)—-based on a prospective cohort of more than 3,400 blacks living in the American South—-shines a light on a resounding positive in CKD treatment.

For while the research published in the Clinical Journal of the American Society of Nephrology (CJASN) indicates that lower cumulative lifetime SES is substantially tied to CKD incidence, CKD progression and kidney failure remain the same between all SES groups.

The study, which considered such SES variables as childhood SES, education, and income, was termed “fascinating” by one kidney expert.

“I am stunned,” says Kim Zuber, PA-C, executive director of the American Academy of Nephrology PAs (physician assistants), “that we are doing pretty well in slowing the progression of kidney disease.”

Zuber, past chair of the National Kidney Foundation/Council of Advanced Practitioners, adds that the research published in February utilizing the Jackson Heart Study (JHS), which assessed 3,422 blacks in Jackson, Miss., “showed the incidence of CKD is higher among those of lower SES---and that CKD decline was not different over 17 years between those with higher or lower SES.”

And while the faculty member of the Metabolic & Endocrine Disease Summit (MEDS) notes the study’s findings connecting low SES with kidney disease incidence among black Americans, she points out that “there is no difference in progression and kidney failure: We must be doing a good job of managing CKD.”

Zuber, of St Petersburg, Fla., says one way to continue doing so involves keeping a keen eye on prescription drugs. She says patients in the studied CKD population, “on average, are taking 10 medications. This is an issue for those without insurance, the working poor. We have to make sure the medications we prescribe can be paid for.”

As to reasons for the high CKD incidence in the targeted population, Zuber points to such risk factors as hypertension, family history, diabetes---and air pollution.

A study also published in February in CJASN states that racial minorities in the U.S. experience a “pollution disadvantage,” as they are exposed to 56%-to-63% more pollution than is caused by their consumption, while non-Hispanic whites experience a “pollution advantage” of 17% less pollution than is caused by their consumption.

This “pollution inequity,” is of particular concern to those who battle CKD, as the study notes that evidence overall suggests that air pollution is an important risk factor in the development and progression of kidney disease.

“This is a phenomenal study,” says Zuber. “It says that areas of the world with more pollution have a higher incidence of kidney disease.”

Underlying the risk impacting those of lower SES is the “not-in-my backyard” syndrome.

“In poorer parts of towns, that’s where you have factories, and freeways,” Zuber says. “And pollution affects the poorer parts of town. Propose a freeway through their neighborhood, and rich people will be up in arms.”

Zuber, who witnessed first-hand pollution problems plaguing her native California, where she grew up in the 1960s, asserts that the new pollution research “dovetails well with the other study: That CKD incidence is higher in poorer populations. which also have a higher rate of air pollution. I’m not sure that the average PA or nurse practitioner (NP) can do much to change this.”

CITATION: Joseph Lunyera, John W. Stanifer, et. al. Life Course Socioeconomic Status, Allostatic Load, and Kidney Health in Black Americans. Clinical Journal of the American Society of Nephrology. Feb. 19, 2020. Ziyad Al-Aly, Benjamin Bowe, et. al. Air Pollution and Kidney Disease. Clinical Journal of the American Society of Nephrology. Feb. 27, 2020. Matthew F. Blum, Aditya Surapaneni, et. al. Particulate Matter and Albuminuria, Glomerular Filtration Rate, and Incident CKD. Clinical Journal of the American Society of Nephrology. Feb. 27, 2020.


Osteoporotic assessment indicates
fracture rates no longer declining

ALBUQUERQUE, N.M. – A study involving more than 900,000 subjects indicates that, following a consistent decline in fracture rate from 2007-to-2013, trends from 2014-to- 2017 indicate rates are no longer declining, and are rising for some fracture types.

The osteoporotic-fracture study published in February in Osteoporosis International also finds that age- and sex-adjusted fracture rates in the U.S. plateaued or increased through mid-2017 in a population of commercially-insured and Medicare Advantage health-plan enrollees, in contrast to a decline from 2007-to-2013.

Its authors---including E. Michael Lewiecki, who is affiliated with the New Mexico Clinical Research & Osteoporosis Center, Albuquerque, N.M., and Benjamin Chastek, Optum, Eden Prairie, M.N.---evaluated fracture trends in U.S. commercial and Medicare Advantage health-plan members aged 50-and-older between 2007-and-2017 through a retrospective analysis of the Optum Research Database from Jan. 1, 2007, to May 31,

Of 1,841,263 patients identified with an index fracture, 930,690 were case-qualifying and included in this analysis. The overall age- and sex-adjusted fracture rate decreased from 14.67/1,000 person-years (py) in 2007 to 11.79/1,000 py in 2013, followed by a plateau for the next three years, followed by an increase to 12.50/1,000 py in mid-2017.

For females aged 65-and-older, fracture rates declined from 27.49/1,000 py in 2007 to 22.08/1,000 py in 2013, then increased to 24.92/1,000 py in mid-2017.

Likewise, fracture rates in males aged 65-and-older declined from 2007 (12.00/1,000 py) to 2013 (10.72/1,000 py), then increased to 12.04/1,000 py in mid-2017.

The age- and sex-adjusted fracture rates for most fracture sites declined from 2007-to-2013 by 3.7% per year.

CITATION: E. Michael Lewiecki, Benjamin Chastek, et. al. Osteoporotic fracture trends in a population of US managed care enrollees from 2007 to 2017. Osteoporosis International. 15 February 2020.


Appearance-related teasing said to spur
use of alcohol during early adolescence

MANSFIELD, CONN. – Recent research indicates that appearance-related teasing may play a role in the origins of alcohol use during early adolescence.

The study published in February in Psychology of Addictive Behaviors emphasizes the need to mitigate the effects of such teasing and prevent early substance use.

Its authors---including Melanie Klinck, University of Connecticut, Mansfield, Conn., and Anna Vannucci, Connecticut Children’s Medical Center, Hartford, Conn.---examined the relationship between appearance-related teasing and alcohol-and-marijuana use in a sample of 1,344 students (52% female; 51% non-Hispanic white; ages 11-to-14) from five public middle schools.

Participants completed a survey assessing:

  • demographic characteristics
  • weight status
  • depressive symptoms
  • general peer victimization
  • experiences of appearance-related teasing perpetrated by family and peers
  • substance use in the fall of 2016

Findings at baseline indicated that more frequent appearance-related teasing was associated with higher concurrent levels of total alcohol consumption, binge drinking, and marijuana use.

Longitudinally, more frequent appearance-related teasing in fall, 2016, at predicted greater increases in total alcohol consumption and binge-drinking frequency. Moderation analyses generally suggested that the positive associations between appearance-related teasing and alcohol-use measures were stronger among adolescents who were girls, and who were overweight or obese.

Lead study author Klinck told Yahoo Lifestyle that appearance-related teasing---a pervasive form of bullying---“is incredibly common and has many negative effects for adolescents. The combination of appearance-related teasing and the increased sensitivity to body image during adolescence may create a heightened risk for substance abuse.”

CITATION: Klinck, Melanie,  Vannucci, Anna, et. al. Appearance-related teasing and substance use during early adolescence. Psychology of Addictive Behaviors. Feb. 10, 2020. Study Connects Body Shaming Teen Girls With Increased Alcohol & Drug Use. Feb. 26, 2020. Yahoo Lifestyle.


Dysfunctional breathing is associated
with poorer asthma control, lower QoL

COPENHAGEN, DENMARK – Dysfunctional breathing (DB) is common among patients with difficult asthma, according to recent research indicating it is associated with significantly poorer asthma control and lower quality of life (QoL).

The study published in February in Respiratory Medicine also indicates that assessment and treatment of DB is an important part of the management of difficult asthma.

Its authors---including Farnam Barati Sedeh and Anna Von Bulow, who are affiliated with Bispebjerg Hospital, Copenhagen, Denmark---note that difficult asthma is defined as asthma requiring high-dose treatment, and that systematic assessment is required to differentiate severe asthma from difficult-to-treat asthma.

They also note that DB is a common comorbidity in difficult asthma, which may contribute to symptoms.

During the course of their research, all adult asthma patients seen in four respiratory clinics over one year were screened prospectively, and patients with possible severe asthma according to ERS/ATS criteria (Difficult asthma: high–dose inhaled corticosteroids/oral corticosteroids) underwent systematic assessment.

DB symptoms were assessed utilizing a symptom-based subjective tool, Nijmegen questionnaire (NQ), and objective signs of DB with the Breathing Pattern Assessment Tool (BPAT).

Asthma control and QoL were evaluated with the Asthma Control Questionnaire (ACQ) and the mini Asthma Quality of Life Questionnaire (AQLQ).

A total of 117 patients were included. Among these, 29.9% had DB according to the NQ. Patients with DB had a poorer asthma control and lower QoL compared to patients without DB.

Similarly, patients with objective signs of DB according to the BPAT score had worse asthma control.

CITATION: Farnam Barati Sedeh, Anna Von Bulow, et. al. The impact of dysfunctional breathing on the level of asthma control in difficult asthma. Respiratory Medicine. Feb, 8, 2020.


Research suggests that T1DM patients
have two-fold increased fracture rates

MUNICH – Recent research indicates that type 1 diabetes (T1DM) patients have a two-fold increased fracture rates compared with healthy controls.

The study published in February in Osteoporosis International also indicates that fractures are associated with increased age and high HbA1c values.

Its authors---including Ulla Stumpf, Munich University Hospital LMU, Munich, and Peyman Hadji, Philips-University of Marburg, Marburg, Germany---recommended further studies and preventive measures.

Their retrospective study investigated the incidence of fracture in 4,420 T1DM patients. Their research is based on the German Disease Analyzer data-base and included 4,258 adults with a T1DM diagnosis documented between January, 2000, and December, 2015, in 1,203 general practices in Germany.

Individual matching of T1DM and non-diabetic patients was performed. The cumulative incidence of new fractures was shown for up to 10 years after the index date using Kaplan-Meier curves.

Cox proportional hazard models (dependent variable: incident fracture) were used to estimate the effect of T1DM on fracture incidence, as well as the effect of pre-defined variables on fracture incidence.

After 10 years of follow-up, the cumulative fracture incidence was 18.4% for T1DM patients and 9.9% for non-diabetic patients.

A strong association between T1DM and fractures was found in both female and male patients. Significant differences between T1DM and non-diabetes patients were found in lower leg/ankle, foot and toe, shoulder/upper arm, and rib(s), sternum and thoracic spine fractures. A significant association between higher age and fracture incidence was observed in T1DM patients.

CITATION: Ulla Stumpf, Peyman Hadji, et. al. Incidence of fractures in patients with type 1 diabetes mellitus—a retrospective study with 4420 patients. Osteoporosis International. Published: 23 Feb., 2020.



Vol. 3 No. 51

Empathy, compassion called essential
as weapons against diabetes burnout

FREDERICKSBURG, VA. – Empathy and compassion are essential weapons in the battle against burnout among diabetes patients.

That’s the assessment of one expert on the disease in reaction to findings in a study published in December in the American Journal of Nursing indicating that detachment from illness identity, diabetes self-care, and support systems may explain poor outcomes in those experiencing diabetes burnout.

Scott Urquhart, PA-C, of Diabetes and Thyroid Associates, Fredericksburg, Va., who is faculty-conference chair of the Metabolic & Endocrine Disease Summit (MEDS), notes that while the research focused on those with type 1 diabetes, its findings in many cases match those with type 2 diabetes.

Urquhart, an adjunct clinical professor, James Madison University physician assistant (PA) program, Harrisonburg, Va., says his medical experience reflects the study’s concentration on exhaustion, frustration and inconsistent self-care as primary barriers to treatment adherence.

“Feeling exhausted and frustrated with the daily ongoing self-care and treatment expectations involving diabetes is the strongest reason for sub-optimal adherence,” he says. “The article cites that as many as one-third of adult patients with diabetes experience ‘diabetes burnout’ as their primary barrier to treatment adherence.”

Urquhart adds that, “although this article-and-study focuses on type I diabetes patients, in my 24 years of practicing endocrinology, I see this in my type 2 diabetes patients who are taking multiple daily injections of insulin.”

When the study quotes those challenged by diabetes experiencing mental, emotional and physical exhaustion from dealing with the disease’s demands, the patients complain of exhaustion with “the constant attention to details day-after-day,” and from having to worry “about everything you eat, everything you do, every move you make.”

Physician assistants (PAs) and nurse practitioners (NPs), says Urquhart, have the power to help patients beset with these issues to turn their attitudes around.

“First and foremost,” he stresses, “a strong sense of empathy and compassion are essential. Patients need to feel safe and secure when discussing their concerns, problems, and frustrations about managing their diabetes. They need not feel they are
constantly being evaluated and judged about such things as having to ‘meet the mark of perfection’ with blood sugars, A1c, exercise, and diet recommendations.”

Also vital, the study’s authors state, are support systems; Urquhart seconds this assertion, illustrated in the research by one patient who lacks “anyone to confide in, to talk to.” Medical professionals, including NPs and PAs, Urquhart says, need to help patients battle alienation.

“Social support,” he notes, “doesn’t only have to come from those living with diabetes and those treating diabetes. This can come from friends, family, co-workers, church, and even organized diabetes-support groups in the community.”

“The important thing is that the patient chooses a support system and/or people who are not only encouraging, caring and honest, but who can help hold them accountable to taking good care of themselves.”

The importance of a positive mindset---as opposed to the lament from one patient quoted in the study who would rather “deal with the results of the disease,” and let apathy remove her from self-adherence---rings through this research, which doesn’t
surprise Urquhart.

“After many, many, years of caring for diabetes patients,” he says, “I feel like I’ve heard it all. Probably one of the most important things I’ve learned is that patients will change on their time, not on mine or anybody else’s.”

“Their change must come from within, but has to be fortified and nurtured from all of those around them. Sometimes, there’s nothing greater than celebrating the patient’s new success and positive mindset after dealing with diabetes burnout and apathy for many years.”

In conclusion, Urquhart adds that, “with the novel advances in diabetes technology over the past few years, we have already seen a significant decrease in diabetes distress/burnout, with our new Continuous Glucose Monitoring systems (CGMs) and even more so with our integrated CGM---automated insulin-pump systems.”

These developments, he says, “lift the burden for patients as well as the clinicians caring for them.”

CITATION: Abdoli, Samereh Ph.D., RN; Hessler, Danielle Ph.D., et. al. Experiences of Diabetes Burnout: A Qualitative Study Among People with Type 1 Diabetes. American Journal of Nursing. December 2019. Volume 119. Issue 12. P22-31.


Anti-asthmatic drug use may be tied
to risk of childhood diabetes type 1

HELSINKI – Recent research indicates that children using inhaled corticosteroids or inhaled β-agonists may be at increased risk of type 1 diabetes.

Authors of the study published in January in the American Journal of Epidemiology include Johanna Metsälä and Annamari Lundqvist, Finnish Institute for Health and Welfare, Helsinki.

They utilized a nationwide, register-based case-cohort study to examine whether the use of anti-asthmatic drugs is associated with childhood type 1 diabetes development, and identified all children born in Finland between Jan. 1, 1995, and Dec, 31, 2008 and diagnosed with the disease by 2010---a total of 3,342.

A 10% random-sample from each birth-year cohort was selected as a reference cohort (80,909).

Information on all dispensed anti-asthmatic drugs from 1995-to-2009 was obtained, and the associations between the use of anti-asthmatic drugs and type 1 diabetes development were investigated using time-dependent and time-sequential Cox regression models.

Dispensed inhaled corticosteroids and inhaled β-agonists were associated with an increased risk of type 1 diabetes after adjusting for:

  • other anti-asthmatic drugs
  • asthma
  • sex
  • birth decade

CITATION: Johanna Metsälä, Annamari Lundqvist, et. al. Use of Antiasthmatic Drugs and the Risk of Type 1 Diabetes in Children: a Nationwide Case-Cohort Study. American Journal of Epidemiology. Received: 13 May 2019. Revision received: 28 December 2019. Accepted: 06 January 2020. Published: 23 January 2020.


Sickle-cell trait, disease consideration
is suggested in evaluation of CKD risk

BOSTON – The findings of a recent observational-cohort study suggest that physicians caring for black patients should consider sickle-cell trait and sickle-cell disease status and interactions with comorbidities when evaluating chronic kidney disease (CKD) risk.

The study involving data on nearly 1,500 blacks with sickle-cell trait or sickle-cell disease was published in January in the Journal of the American Society of Nephrology.

Its authors---including Kabir O. Olaniran and Andrew S. Allegretti, who are affiliated with Harvard Medical School, Boston---used a multi-center, observational study utilizing registry data collected from January, 2005, through June, 2018.

Their research included adult black patients with sickle-cell trait or disease (exposures) or normal hemoglobin-phenotype (reference) status (ascertained by electrophoresis) and at least one year of follow-up and three estimated glomerular-filtration rate (eGFR) values.

The authors used linear-mixed models to evaluate the difference in the mean change in eGFR per year.

They identified 1,251 patients with sickle-cell trait, 230 with sickle-cell disease, and 8,729 reference patients, with a median follow-up of eight years.

After adjustment, eGFR declined significantly faster in patients with sickle-cell trait or sickle-cell disease, compared with reference patients; it also declined significantly faster in patients with sickle-cell disease than in patients with sickle-cell trait.

The researchers suggest that prospective and mechanistic studies are needed to develop best practices to attenuate eGFR decline in such patients.

CITATION: Kabir O. Olaniran, Andrew S. Allegretti, et. al. Kidney Function Decline among Black Patients with Sickle Cell Trait and Sickle Cell Disease: An Observational Cohort Study. Journal of the American Society of Nephrology. January 2020.


Anti-osteoporosis intervention seen
as beneficial at higher BMD in PLHIV

AARHUS, DENMARK – Recent research indicates that while osteoporosis management among patients living with HIV (PLHIV) follows general guidelines, increased fracture risk is not fully explained by lower bone-mineral density (BMD)---indicating that anti-osteoporosis intervention may be beneficial at a higher BMD in PLHIV.

Authors of the study published in January in the Journal of Acquired Immune Deficiency Syndrome include Jakob Starup-Linde and Simone Bruhn Rosendahl, Aarhus University Hospital, Aarhus, Denmark.

The researchers noted that osteoporosis is reported as a common comorbidity in PLHIV and used a systematic review and meta-analysis to assess the evidence on:

  • fracture risk in PLHIV
  • BMD in PLHIV compared with controls
  • longitudinal changes in BMD in PLHIV
  • the effect of anti-osteoporosis treatment in PLHIV

A systematic-literature search was conducted using the Medline at PubMed and EMBASE data-bases.

Eligibility criteria followed the aim of the study and include randomized-controlled trials and observational studies. Two reviewers extracted the data independently.

Meta-analysis was performed using random-effects models assessing fracture risk, BMD compared with controls, and changes in BMD.

One-hundred forty-two of 2,397 papers identified were included in the systematic review, and subsequently, 84 were included in the meta-analysis. The risks of a fragility fracture and hip fracture were increased.

PLHIV have lower BMD at the hip-and-lumbar spine compared with controls.

The reduced BMD did not fully explain the increased fracture risk in PLHIV.

CITATION: Starup-Linde, Jakob Ph.D., Rosendahl, Simone Bruhn BScMed, et. al. Management of Osteoporosis in Patients Living With HIV—A Systematic Review and Meta-analysis. Journal of Acquired Immune Deficiency Syndrome. January 1, 2020 - Volume 83 - Issue 1 - p 1-8.


Research links weight in childhood
to subsequent adult mental health

YORK, ENGLAND – Childhood weight is an important determinant of subsequent adult mental health, according to research indicating that being overweight in childhood is associated with increased odds of lifetime major-depressive disorder (MDD).

The study published in January in BMC Pediatrics also indicates that the magnitude of the risk is uncertain given the small numbers of participants with lifetime MDD.

Its authors---including Deborah Gibson-Smith, University of York, York, England, and Thorhallur I. Halldorsson, University of Iceland, Reykjavik, Iceland---point out that no clear association was observed between childhood-and-adolescent overweight/obesity and late-life depressive symptoms irrespective of late-life body-mass index (BMI).

They also suggest further studies examining childhood obesity and lifetime MDD.

Their analysis is based on a sub-sample of 889 Age, Gene/Environment Susceptibility (AGES)-Reykjavik participants with measured BMI data from early life.

Late-life depressive symptoms were measured with the Geriatric Depression Scale (GDS), and lifetime MDD was assessed at late-life using the Mini International Neuropsychiatric Interview.

Logistic-regression analysis was used to estimate the relationships between BMI (continuous and categorical) at age eight or 13 years, and late-life depressive symptoms or lifetime MDD, adjusted for:

  • sex
  • education
  • physical activity
  • smoking status
  • alcohol use

In a separate model, additional adjustments were made for late-life BMI.

One-hundred-and-one subjects had depressive symptoms at late-life, and 39 had lifetime MDD.

Being overweight or obese at age eight or 13 years was not associated with higher depressive symptoms during late-life, irrespective of late-life BMI.

Being overweight or obese at age eight, but not 13, was associated with an increased risk of lifetime MDD in this Icelandic sample.

CITATION: Deborah Gibson-Smith, Thorhallur I. Halldorsson, et. al. Childhood overweight and obesity and the risk of depression across the lifespan. BMC Pediatrics. Jan 21, 2020.



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