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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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