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Vol. 3 No. 37

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

Adjustments were made for:

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

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

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


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

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

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

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

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

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

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

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

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


Diabetes assessment views relationship
between DKA and Alzheimer’s dementia

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

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

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

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

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

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

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

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

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


Clinician Reviews consult item addresses
dangers associated with use of NSAIDs

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



Vol. 3 No. 36


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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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


High childhood BMI association seen
with slipped capital femoral epiphysis

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

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

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

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

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

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

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



Fractures linked to economic burdens
on Medicare patients with risk factors

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

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

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

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

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

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

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

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

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

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

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



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

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

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

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

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

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

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

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

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

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



Clinician Reviews article assesses
osteoporosis-treatment approaches

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


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