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The first iteration of Crisis Point addresses the obesity crisis in the United States and beyond, with expert interviews and discussion.  

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Connor Iapoce is an assistant editor for 

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Patients infected with COVID-19 frequently experience both 

, due to induction of coagulopathy manifesting as elevation of dimerized plasmin fragment D level.

A recent study thus assessed the rate of postdischarge thrombosis in patients with COVID-19, identified factors associated with the risk of postdischarge VTE, and evaluated the association of postdischarge anticoagulation use with incidence of VTE.

Led by Pin Li, PhD, Department of Public Health Sciences, Henry Ford Health System, the team of investigators found that patients at high risk of new onset VTE following discharge from the hospital may benefit the most from postdischarge therapeutic anticoagulation use.

The analysis consisted of adult patients hospitalized with a diagnosis of COVID-19 confirmed by a positive polymerase chain reaction test at the 5 hospitals of Henry Ford Health System from March - November 2020. They noted that the first VTE or ATE events were identified up to 90 days after discharge from the index admission, with event and mortality rates calculated at 90 days.

The electronic health records obtained the patient's demographic characteristics, body mass index, pre existing medical conditions, inpatient data, peak and predischarge laboratory results, use of AC during hospitalization and following discharge.

The investigators noted that race was assessed in the study due to Black patients having higher rates of incident VTE and pulmonary embolism compared to patients of other races.

In statistical analysis, investigators used a nonparametric Mann-Kendall trend test to test the monotonic trend of event number over time after discharge.

Further, univariable and multivariable logistic regression methods assessed factors associated with the risk of and medications for thrombosis. Additionally, propensity scores were used to evaluate the association of postdischarge AC use with new onset of VTE.

The cohort study consisted of 2832 adult patients hospitalized with COVID-19, with a mean age of 63.4 years, 47.6% male (n = 1347), 38.9% Black (n = 1102), and 50.7% White (n = 1437).

From that total, 36 (1.3%) experienced new onset of VTE after discharge, of whom 16 had pulmonary embolism, 18 had deep vein thrombosis, and 2 had portal vein thrombosis. Additionally, 15 patients (0.5%) with COVID-19 had new onset of ATE after discharge, 1 had transient ischemic attack, and 14 had acute coronary syndrome.

Data show the incidence of VTE decreased with time, with a median time to event of 16 days (Mann-Kendall trend test, 

 <.001), but they observed no change in the risk of ATE with time (Mann-Kendall trend test, 

 = .37), at a median time to event of 37 days. Over time, mortality was shown to decrease (Mann-Kendall trend test, 

 <.001), with a median time to death of 17 days.

Among factors associated with increased risk, the results of the multivariable analysis showed that patients with predischarge CRP levels ≥10 mg/dL (OR, 3.02; 95% CI, 1.45 - 6.29), peak D-dimer levels ≥2 μg/mL (OR, 3.76; 95% CI, 1.86 - 7.57), and predischarge C-reactive protein level ≥10 mg/dL (OR, 3.02; 95% CI, 1.45 - 6.29) were more likely to experience VTE after discharge.

Li and colleagues noted that 682 patients (24.1%) received AC at discharge, with 188 patients (6.6%) receiving a prophylactic dose and 494 patients (17.4%) receiving a therapeutic dose.

Those who received the therapeutic AC at discharge had a reduced risk of experiencing new onset of VTE (OR, 0.18; 95% CI, 0.04 - 0.75, 

“Although extended thromboprophylaxis in unselected patients with COVID-19 is not supported, these findings suggest that postdischarge anticoagulation may be considered for high-risk patients who have a history of venous thromboembolism, peak D-dimer level greater than 3 μg/mL, and predischarge C-reactive protein level greater than 10 mg/dL, if their bleeding risk is low,” investigators wrote.

Factors Associated With Risk of Postdischarge Thrombosis in Patients With COVID-19

Articles

Patients with history of VTE, peak D-dimer ≥3 μg/mL, and predischarge CRP ≥10 mg/dL were at high risk of experiencing new onset of VTE after hospital discharge. 

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Postdischarge Anticoagulation Use Reduces VTE Risk After COVID-19 Hospitalization 

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A recent investigation from Sweden suggested that there were overlapping risk factor patterns associated with 

Though the increase in cases of asthma, rhinitis, and eczema had been thoroughly studies in children and adolescents, according to investigators, the risk factor pattern of atopic diseases, especially as they pertain to eczema, had been underdeveloped in adult patients.

With the number of studies on these patterns being few, investigators led by Roxana Mincheva, MD, PhD, Krefting Research Center, University of Gothenburg, compared the risk factor patterns of these 3 conditions in a randomly selected adult population.

For their study, Mincheva and colleagues issued a questionnaire survey on atopic diseases which was mailed to 30,000 randomly selected adults in West Sweden, a region home to a population of 1.6 million people.

A total of 15,000 subjects were selected from the metropolitan area of Gothenburg, and 15,000 subjects were selected from the remainder of the country.

The response rate to the questionnaires was 62%, with a total of 18,087 participants enrolled in the study. Among these responders, 2000 were invited to clinical examinations while 1172 (59%) participated.

The questionnaire consisted of 3 parts, all of which were administered at the same time.

The first part was the Swedish OLIN study questionnaire, which covered asthma, thinitis, COPD, respiratory symptoms, and possible risk factors of disease such as smoking and a family history of airway disease.

The second part of the questionnaire featured questions regarding occupational and environmental exposures as well as health status.

The third and final part consisted of the Swedish Global Allergy and Asthma questionnaire, which addressed respiratory symptoms and diseases with added question about eczema.

Clinical examinations were also conducted and included objective measures of height and weight, as well as. A structured interview and a drawn blood sample.

Investigators reported that the prevalence of current asthma was 11.8 %, while the prevalence of current rhinitis and current eczema were 42.8 %, and 13.5%, respectively. A total of 2.3 % had all 3 conditions 
while 13.9 % had at least 2 conditions.

No mutual risk factor was identified for all 3 conditions.

The prevalence of asthma and eczema at any age, as well as current rhinitis in adult participants were all inversely associated with increasing age, as was family history of asthma and rhinitis.

Additionally, the use of rhinitis medications in the previous 12 months were more common among younger subjects, and the prevalence of allergic sensitization was 29.7% , which was decreased by age and more common among male participants.

Allergic sensitization was a strong risk factor for current asthma (OR 4.1 CI 2.7–6.3) and current rhinitis (OR 5.1CI 3.8–6.9) but not so for current eczema.

Finally, obesity was a risk factor for current asthma and current rhinitis, while farm childhood decreased the risk for current asthma and current rhinitis, and occupational exposure to gas dust or fumes and female sex was associated with an increased risk of current asthma and current eczema.

The investigators noted that no common risk factors were identified in all 3 conditions

“However, some exposures and covariates, such as obesity, farm childhood and allergic sensitization are risk factors for two of the conditions but not all 3,” the team wrote. “Future epidemiological research on the combined determinants of the diseases is needed and especially for rhinitis and eczema.”

“Different risk factor patterns for adult asthma, rhinitis and eczema: results from West Sweden Asthma Study,”

 was published online in Clinical and Translational Allergy.

Despite some overlapping risk factors,  investigators noted that no common risk factors were identified in all 3 conditions.

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Risk Factor Patterns Recorded in Adults with Asthma, Rhinitis, and Eczema

A new investigation from China suggested that maternal pre-pregnancy overweight and obesity could possibly increase the risk of atopic dermatitis in infants via intrauterine mechanisms.

Investigators added that the association with wheezing in mothers might be confounded by uncontrolled familial factors, and that this new data could be valuable in early-life prevention of allergic diseases.

Earlier studies referenced in the present investigation had linked pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) to allergic disorders in offspring.

However, the associations observed in these studies remained inconsistent and possibly confounded by unmeasured familial factors.

As such Jianrong He, MD, Guangzhou Women and Children’s Medical Center, Guangdong, and other investigators examined the association of maternal weight with offspring allergic disorders by using parental BMI as a negative control exposure.

For the present study, He and colleagues included data from the Born in Guangzhou Cohort Study (BIGCS) that occurred from 2012-2017.

Women were recruited for the BIGCS prior to 20 weeks’ gestation at the Guangzhou Women and Children’s Medical Center, and subsequent follow-ups were recorded during the second and third trimester of pregnancy, at delivery, and from 6 weeks postpartum until the children reached adulthood.

Data from that study consisted of maternal weight obtained from questionnaires and obstetric records, and paternal weight was determined through a series of questionnaires.

Additionally, atopic dermatitis and wheezing at the age of 1 year were defined in the study according to parent-reported physician diagnosis.

A total of 12,845 pregnant mothers who gave birth between February 2012 and December 2017 and attended the 1-year follow-up were included in the analysis. Investigators also included data on 10,522 children from the BIGCS.

Risk ratios for each child were estimated by log-binominal regression, with mutual adjustments for maternal and paternal weight status.

He and fellow investigators reported that more than half (67.3%) of the women included in the study had normal BMI, while 22.5% were underweight and 10.2% were either overweight or obese.

Regarding GWG, 46.3% of mothers were adequate, while that of 26.3% and 27.4% of mothers were considered inadequate and excessive, respectively.

Additionally, more than half (56.3%) of the fathers had a normal BMI. Among the participants included, 16.2% and 7.9% of the children had atopic dermatitis and wheezing, respectively.

The investigators observed that maternal pre-pregnancy BMI was not associated with the risk of atopic dermatitis in infancy, as a continuous variable.

However, when considered as a categorial variable, maternal pre-pregnancy overweight/obesity was associated with a 20% increased risk of atopic dermatitis in infants (aRR, 1.20; 95%CI, 1.04-1.37), compared to normal weight.

Maternal pre-pregnancy BMI (continuous) was associated with an increased risk of wheezing in infancy (aRR 1.13; 95% CI, 1.00–1.27 for per 5 kg/m2 increase in BMI), and a similar association of paternal pre-pregnancy BMI was association with the risks of wheezing.

Compared with children of mothers with both normal weight before pregnancy and adequate GWG, children of mothers that were overweight/obese before pregnancy and excessive GWG had a higher risk of AD (aRR 1.64; 95%CI, 0.96-2.80).

Overall, when investigators used paternal BMI as a negative control exposure, they found that maternal pre-pregnancy overweight/obesity was associated with increased risk of atopic dermatitis in children, while both maternal pre-pregnancy BMI and paternal BMI were associated with a higher risk of infants’ wheezing.

“These results suggest that maternal overweight/obesity might increase the risk of AD in infants, possibly through intrauterine effects, while its association with wheezing might be partly confounded by familial clustering factors,” the team wrote. “If confirmed in future studies, our findings may have important implications in early-life prevention for offspring allergic diseases.”

“Associations of maternal weight status with the risk of offspring atopic dermatitis and wheezing by one year of age,”

 was published online in Pediatric Allergy and Immunology.

Investigators added that this risk might possibly be through intrauterine effects, while associations with wheezing might be confounded by familial clustering factors.





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Pre-Pregnancy Obesity Potentially Linked to Increased Risk of AD in Infants

 We talked a little about ways to reduce the risk of specific complications. We should take a moment to talk about some of the advances in the care of patients with diabetes and chronic kidney disease. Would you mind taking a moment to talk about how the care of such patients has expanded dramatically in recent years, particularly with the wrap-up of the key finerenone trials? We’re entering a new space for the care of such patients that will hopefully change their traditional trajectory of kidney failure.

 One of the main problems with microvascular complications in patients with diabetes is that for a long time there was no treatment other than ACE inhibitors and ARBs [angiotensin-receptor blockers], which are well established in patients with microalbuminuria in type 1 and type 2 diabetes. We’ve entered an era where we have medications to prevent kidney complications very effectively in patients with diabetes. Obviously, we have the SGLT2 inhibitors, which are well established through the CREDENCE and DAPA-CKD trials. DAPA-CKD extended this benefit from patients with diabetes to patients without diabetes. Then we have newer agents, like finerenone, which falls into the mineralocorticoid antagonist group. The idea came out of early spironolactone data, which had shown less progression in albuminuria in patients with type 2 diabetes. We went on to finerenone, and now the FIDELIO-DKD trial had been completed, which included about 5000 patients with type 2 diabetes and an increased albumin-to-creatinine ratio and retinopathy, whereas the second arm in the study had higher levels of the albumin-to-creatinine ratio.

In this study, the primary outcome was a composite of kidney failure decrease in the GFR [glomerular filtration rate] to less than 40 mL/min from baseline over a period. It also included death from renal causes. There was a significant reduction in the primary end point, 17.8% primary end point occurrence in the group with finerenone vs 21% with placebo. That’s a protective effect. This extends our armamentarium of all the data we’re looking at with SGLT2 inhibitors or mineralocorticoid receptor antagonists on top of the ACE and ARBs. We extended the armamentarium from ACE and ARBs to SGLT2 inhibitors and now to mineralocorticoid receptor antagonists. One important question is, what happens when we combine these optimal ACEs and ARBs plus an SGLT2 inhibitor plus a mineralocorticoid receptor antagonist, such as finerenone? What will we see? How much of morbidity and renal-related mortality can we reduce with these novel agents? But these are very promising new approaches, and it’s a very exciting area to be in the care for diabetes with all the all the new developments.

 It’s an exciting time. Before we move on, I want to mention that there are nonpharmacological options that convey outcome benefits as well. I’m guilty of probably not referring my patients to at least consider the option of bariatric surgery as often or as early as I should in the course of their disease. When we think about the outcomes data that we’ve seen in the bariatric surgery studies, they often aren’t randomized trials, but they’re very well conducted and complete studies—many of which were conducted in Sweden, which has very robust health care data for all its citizens. It’s very clear that the earlier patients with diabetes and obesity undergo bariatric surgery as clinically appropriate, the more likely they are to experience a remission in diabetes, at least in the short term after surgery, and the greater the reduction in their risk of both microvascular and macrovascular complications. It doesn’t always have to be something we achieve through use of medications.

Of course, weight loss is a very important intervention. The type of weight loss we see with bariatric surgery has very meaningful benefits in our patient population. But if we wait too long, those benefits are minimized to some extent, so I’m personally trying to not wait until all other options to improve a person’s health are exhausted before I consider the option of bariatric surgery. That has perhaps been the traditional way that bariatric surgery is considered—as a last resort—when we need to be thinking about it very early on in the course of disease.

Thank you, Dr Bruemmer. And I’d like to thank everyone for watching this 

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Thought leaders discuss recent advances in treatments for patients with type 2 diabetes with chronic kidney disease.

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Controlling Chronic Kidney Disease in Type 2 Diabetes

Continuous glucose monitors (CGM) used by people with 

 have been a focus of recent conversations both inside and outside the healthcare space. Superstar Nick Jonas has been raising awareness of this technology through his platforms and in new TV commercials, and companies like Apple are exploring glucose monitoring as an indicator for general health and wellness. All this attention has led to more people with diabetes becoming aware of this life-changing technology, and in turn, heading to their primary care provider to ask for a CGM.

With 34.2 million Americans living with diabetes, nearly every primary care provider is guiding treatment plans for people with type 1, type 2 and even pre-diabetes, but many healthcare providers are still not aware of CGM technology and how it can benefit patients. As healthcare providers, we work to keep pace with the latest treatments, technologies and tools available to be prepared to address patient questions and ultimately improve health outcomes. This is more important now than ever, as we’re starting to see a gap in healthcare provider knowledge and consumer awareness in an era where endless healthcare resources and information is at our patients’ fingertips.

While patients are doing their own research, they still expect us, as their healthcare provider, to be the experts on what tools and treatments we believe will best help them. A recent survey

 of people with insulin-treated diabetes found that patients believe it is the responsibility of their healthcare provider to bring new standards of care to their attention, like CGM systems.

CGM technology is widely considered the standard of care and clinically proven to improve outcomes for people with diabetes taking insulin. For those of us who may not be as familiar with the technology but want to inform future conversations with patients, here are 3 things you need to know about CGM systems:

How CGM systems differ from blood glucose monitoring: fingersticks

A CGM uses a small, wearable sensor and transmitter to measure and send real-time glucose values wirelessly to a smart device or receiver every five minutes. It eliminates the need for multiple daily fingersticks used in blood glucose monitoring (BGM).

A BGM shows glucose values at a single moment in time and patients may often miss or forget to take a reading, leaving many unknowns. A CGM connects the dots and provides a complete picture of glucose management, filling in the gaps for both patients and healthcare providers. The data gleaned from CGM technology show trends in glucose levels, the rate of change in readings and even alerts users of dangerously low or high glycemic levels. 

These data arm patients with real-time insights to inform short-term actions like taking medication or insulin, and long-term lifestyle adjustments as they can see how their body reacts to certain foods, physical activities or behaviors.

The benefits of CGM technology for people with type 1 and type 2 of all ages

The benefits of CGM systems for people of all ages have been clinically proven, from two years old to Medicare patients. The recent 

 study has shown the benefits of CGM technology for children ages 2-7 with type 1 diabetes in reducing hypoglycemia and parental burden and fear. The 

 study of adults ages 60 and older with type 1 diabetes found that CGM systems help to significantly lower A1C, reduce hypoglycemia and increase the amount of time a user spends in target glucose ranges. The technology is truly easy to use for all demographics.

We are also now seeing more evidence of the benefits of CGM for broader populations, including people with type 2 diabetes. Earlier this year the 

 study was the first of its kind to affirm that people with type 2 diabetes on basal insulin benefit from the use of CGM technology, with study participants showing significant increases in time in range and decreases in A1C. These outcomes occurred independent of direct provider interventions, so even getting a patient on the device to learn for themselves can be a win.

A CGM makes appointments more tailored and efficient

Not only does CGM technology give the power back to patients by arming them with information to make treatment decisions in real-time, it also provides healthcare providers with the insights and data needed to develop tailored medication and treatment regimens. The reports available to providers help make appointments with patients more efficient as you can quickly see potential issues, leaving more time to get to know the patient and discuss together ways to improve diabetes management and outcomes.

Diabetes patients are making healthcare treatment decisions nearly every minute of every day and are looking for new and better ways to ease the burden of managing their condition. Patients are asking, and it’s up to us as healthcare providers to educate and provide them with the best tools available to manage their diabetes.

 (Study of Improved Glucose Monitoring and Assessment) and 

 have great resources available to help you learn more about CGM technology and better understand how it can support your patients.

The demand for CGM technology will only continue to grow, and now is the time for healthcare providers to educate themselves on the proven benefits of the technology.

Aaron King, MD, is a family practitioner and diabetes specialist with Baptist Health System.

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1. Dexcom, U.S. data on file, November 2020

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. Prior to joining MJH Life Sciences in 2019, he worked as a digital reporter covering nanotechnology, life sciences, material science and more with 

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There was no differences in complications by site in either the left or right subclavian vein. 

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Patients With Multiple Myeloma At Increased Risk of Breakthrough COVID-19 Infection 

Women in the study had an earlier sleep schedule and lower sleep fragmentation.

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Several companies are testing live microbiota therapies for C difficile infections.

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Platelet-Rich Plasma Ineffective in the Management of Knee Osteoarthritis

From 1976 to 2018, data show the prevalence of obesity in the United States increased from 6.2% to 32.7%. 

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Leonard H. Calabrese, DO; Sheetal Desai, MD; and Ana-Maria Orbai, MD, MHS, discuss the impact of psoriatic arthritis on a patient’s quality of life (QoL) and describe tools for measuring QoL.

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Latest News

Postdischarge Anticoagulation Use Reduces VTE Risk After COVID-19 Hospitalization

Risk Factor Patterns Recorded in Adults with Asthma, Rhinitis, and Eczema

Pre-Pregnancy Obesity Potentially Linked to Increased Risk of AD in Infants

Controlling Chronic Kidney Disease in Type 2 Diabetes

3 Things Primary Care Providers Need to Know About Continuous Glucose Monitoring Technology