Cardiology

The United States Preventive Services Task Force has updated its recommendation on the age of screening for prediabetes and type 2 diabetes in the primary care setting – lowering the age from 40 to 35 years for asymptomatic patients who are overweight or obese and encouraging greater interventions when patients do show a risk.

KatarzynaBialasiewicz/Thinkstock

“The USPSTF concludes with moderate certainty that screening for prediabetes and type 2 diabetes and offering or referring patients with prediabetes to effective preventive interventions has a moderate net benefit,” the task force concludes in its recommendation, published Aug. 24 in JAMA.

“Clinicians should offer or refer patients with prediabetes to effective preventive interventions,” they write.

Experts commenting on the issue strongly emphasize that it’s not just the screening, but the subsequent intervention that is needed to make a difference.

“If young adults newly identified with abnormal glucose metabolism do not receive the needed intensive behavioral change support, screening may provide no benefit,” write Richard W. Grant, MD, MPH, and colleagues in an editorial published with the recommendation.

“Given the role of our obesogenic and physically inactive society in the shift toward earlier onset of diabetes, efforts to increase screening and recognition of abnormal glucose metabolism must be coupled with robust public health measures to address the underlying contributors.”
 

BMI cutoff lower for at-risk ethnic populations

The recommendation, which updates the task force’s 2015 guideline, carries a “B” classification, meaning the USPSTF has high certainty that the net benefit is moderate. It now specifies screening from age 35to 70 for persons classified as overweight (body mass index at least 25) or obese (BMI at least 30) and recommends referral to preventive interventions when patients are found to have prediabetes.

In addition to recommendations of lifestyle changes, such as diet and physical activity, the task force also endorses the diabetes drug metformin as a beneficial intervention in the prevention or delay of diabetes, while noting fewer overall health benefits from metformin than from the lifestyle changes.

A lower BMI cutoff of at least 23 is recommended for diabetes screening of Asian Americans, and, importantly, screening for prediabetes and diabetes should be considered at an even earlier age if the patient is from a population with a disproportionately high prevalence of diabetes, including American Indian/Alaska Native, Black, Hawaiian/Pacific Islander, Hispanic/Latino, the task force recommends.

Screening tests should include fasting plasma glucose, hemoglobin A1c, or an oral glucose tolerance test. Although screening every 3 years “may be a reasonable approach for adults with normal blood glucose levels,” the task force adds that “the optimal screening interval for adults with an initial normal glucose test result is uncertain.”
 

Data review: Few with prediabetes know they have it

The need for the update was prompted by troubling data showing increasing diabetes rates despite early signs that can and should be identified and acted upon in the primary care setting to prevent disease progression.

Data from the Centers for Disease Control and Prevention, for instance, show that while 13% of all U.S. adults 18 years or older have diabetes and 35% meet criteria for prediabetes, as many as 21% of those with diabetes were not aware of or did not report having the disease. Furthermore, only a small fraction – 15% of those with prediabetes – said they had been told by a health professional that they had this condition, the task force notes.

The task force’s final recommendation was based on a systematic review of evidence regarding the screening of asymptomatic, nonpregnant adults and the harms and benefits of interventions, such as physical activity, behavioral counseling, or pharmacotherapy.

Among key evidence supporting the lower age was a 2014 study showing that the number of people necessary to obtain one positive test for diabetes with screening sharply drops from 80 among those aged 30-34 years to just 31 among those aged 36-39.

Opportunistic universal screening of eligible people aged 35 and older would yield a ratio of 1 out of just 15 to spot a positive test, the authors of that study reported.

In addition, a large cohort study in more than 77,000 people with prediabetes strongly links the risk of developing diabetes with increases in A1c level and with increasing BMI.
 

ADA recommendations differ

The new recommendations differ from American Diabetes Association guidelines, which call for diabetes screening at all ages for people who are overweight or obese and who have one or more risk factors, such as physical inactivity or a first-degree relative with diabetes. If results are normal, repeat screening at least every 3 years is recommended.

The ADA further recommends universal screening for all adults 45 years and older, regardless of their risk factors.

For the screening of adults over 45, the ADA recommends using a fasting plasma glucose level, 2-hour plasma glucose level during a 75-g oral glucose tolerance test, or A1c level, regardless of risk factors.

The American Association of Clinical Endocrinology also recommends universal screening for prediabetes and diabetes for all adults 45 years or older, regardless of risk factors, and also advises screening those who have risk factors for diabetes regardless of age.
 

Screening of little benefit without behavior change support

In an interview, Dr. Grant added that broad efforts are essential as those at the practice level have clearly not succeeded.

“The medical model of individual counseling and referral has not really been effective, and so we really need to think in terms of large-scale public health action,” said Dr. Grant, of the division of research, Kaiser Permanente Northern California, Oakland.

His editorial details the sweeping, multifactorial efforts that are needed.

“To turn this recommendation into action – that is, to translate screening activities into improved clinical outcomes – change is needed at the patient-clinician level (recognizing and encouraging eligible individuals to be screened), health care system level (reducing screening barriers and ensuring access to robust lifestyle programs), and societal level (applying effective public health interventions to reduce obesity and increase exercise),” they write.

A top priority has to be a focus on individuals of diverse backgrounds and issues such as access to healthy programs in minority communities, Dr. Grant noted.

“Newly diagnosed adults are more likely to be African-American and Latinx,” he said.

“We really need to invest in healthier communities for low-income, non-White communities to reverse the persistent health care disparities in these communities.”

While the challenges may appear daunting, history shows they are not necessarily insurmountable – as evidenced in the campaign to discourage tobacco smoking.

“National smoking cessation efforts are one example of a mostly successful public health campaign that has made a difference in health behaviors,” Grant noted.

The recommendation is also posted on the USPSTF web site .

Dr. Grant reports receiving grants from the National Institutes of Health and the Patient-Centered Outcomes Research Institute.

The United States Preventive Services Task Force has updated its recommendation on the age of screening for prediabetes and type 2 diabetes in the primary care setting – lowering the age from 40 to 35 years for asymptomatic patients who are overweight or obese and encouraging greater interventions when patients do show a risk.

KatarzynaBialasiewicz/Thinkstock

“The USPSTF concludes with moderate certainty that screening for prediabetes and type 2 diabetes and offering or referring patients with prediabetes to effective preventive interventions has a moderate net benefit,” the task force concludes in its recommendation, published Aug. 24 in JAMA.

“Clinicians should offer or refer patients with prediabetes to effective preventive interventions,” they write.

Experts commenting on the issue strongly emphasize that it’s not just the screening, but the subsequent intervention that is needed to make a difference.

“If young adults newly identified with abnormal glucose metabolism do not receive the needed intensive behavioral change support, screening may provide no benefit,” write Richard W. Grant, MD, MPH, and colleagues in an editorial published with the recommendation.

“Given the role of our obesogenic and physically inactive society in the shift toward earlier onset of diabetes, efforts to increase screening and recognition of abnormal glucose metabolism must be coupled with robust public health measures to address the underlying contributors.”
 

BMI cutoff lower for at-risk ethnic populations

The recommendation, which updates the task force’s 2015 guideline, carries a “B” classification, meaning the USPSTF has high certainty that the net benefit is moderate. It now specifies screening from age 35to 70 for persons classified as overweight (body mass index at least 25) or obese (BMI at least 30) and recommends referral to preventive interventions when patients are found to have prediabetes.

In addition to recommendations of lifestyle changes, such as diet and physical activity, the task force also endorses the diabetes drug metformin as a beneficial intervention in the prevention or delay of diabetes, while noting fewer overall health benefits from metformin than from the lifestyle changes.

A lower BMI cutoff of at least 23 is recommended for diabetes screening of Asian Americans, and, importantly, screening for prediabetes and diabetes should be considered at an even earlier age if the patient is from a population with a disproportionately high prevalence of diabetes, including American Indian/Alaska Native, Black, Hawaiian/Pacific Islander, Hispanic/Latino, the task force recommends.

Screening tests should include fasting plasma glucose, hemoglobin A1c, or an oral glucose tolerance test. Although screening every 3 years “may be a reasonable approach for adults with normal blood glucose levels,” the task force adds that “the optimal screening interval for adults with an initial normal glucose test result is uncertain.”
 

Data review: Few with prediabetes know they have it

The need for the update was prompted by troubling data showing increasing diabetes rates despite early signs that can and should be identified and acted upon in the primary care setting to prevent disease progression.

Data from the Centers for Disease Control and Prevention, for instance, show that while 13% of all U.S. adults 18 years or older have diabetes and 35% meet criteria for prediabetes, as many as 21% of those with diabetes were not aware of or did not report having the disease. Furthermore, only a small fraction – 15% of those with prediabetes – said they had been told by a health professional that they had this condition, the task force notes.

The task force’s final recommendation was based on a systematic review of evidence regarding the screening of asymptomatic, nonpregnant adults and the harms and benefits of interventions, such as physical activity, behavioral counseling, or pharmacotherapy.

Among key evidence supporting the lower age was a 2014 study showing that the number of people necessary to obtain one positive test for diabetes with screening sharply drops from 80 among those aged 30-34 years to just 31 among those aged 36-39.

Opportunistic universal screening of eligible people aged 35 and older would yield a ratio of 1 out of just 15 to spot a positive test, the authors of that study reported.

In addition, a large cohort study in more than 77,000 people with prediabetes strongly links the risk of developing diabetes with increases in A1c level and with increasing BMI.
 

ADA recommendations differ

The new recommendations differ from American Diabetes Association guidelines, which call for diabetes screening at all ages for people who are overweight or obese and who have one or more risk factors, such as physical inactivity or a first-degree relative with diabetes. If results are normal, repeat screening at least every 3 years is recommended.

The ADA further recommends universal screening for all adults 45 years and older, regardless of their risk factors.

For the screening of adults over 45, the ADA recommends using a fasting plasma glucose level, 2-hour plasma glucose level during a 75-g oral glucose tolerance test, or A1c level, regardless of risk factors.

The American Association of Clinical Endocrinology also recommends universal screening for prediabetes and diabetes for all adults 45 years or older, regardless of risk factors, and also advises screening those who have risk factors for diabetes regardless of age.
 

Screening of little benefit without behavior change support

In an interview, Dr. Grant added that broad efforts are essential as those at the practice level have clearly not succeeded.

“The medical model of individual counseling and referral has not really been effective, and so we really need to think in terms of large-scale public health action,” said Dr. Grant, of the division of research, Kaiser Permanente Northern California, Oakland.

His editorial details the sweeping, multifactorial efforts that are needed.

“To turn this recommendation into action – that is, to translate screening activities into improved clinical outcomes – change is needed at the patient-clinician level (recognizing and encouraging eligible individuals to be screened), health care system level (reducing screening barriers and ensuring access to robust lifestyle programs), and societal level (applying effective public health interventions to reduce obesity and increase exercise),” they write.

A top priority has to be a focus on individuals of diverse backgrounds and issues such as access to healthy programs in minority communities, Dr. Grant noted.

“Newly diagnosed adults are more likely to be African-American and Latinx,” he said.

“We really need to invest in healthier communities for low-income, non-White communities to reverse the persistent health care disparities in these communities.”

While the challenges may appear daunting, history shows they are not necessarily insurmountable – as evidenced in the campaign to discourage tobacco smoking.

“National smoking cessation efforts are one example of a mostly successful public health campaign that has made a difference in health behaviors,” Grant noted.

The recommendation is also posted on the USPSTF web site .

Dr. Grant reports receiving grants from the National Institutes of Health and the Patient-Centered Outcomes Research Institute.

The United States Preventive Services Task Force has updated its recommendation on the age of screening for prediabetes and type 2 diabetes in the primary care setting – lowering the age from 40 to 35 years for asymptomatic patients who are overweight or obese and encouraging greater interventions when patients do show a risk.

KatarzynaBialasiewicz/Thinkstock

“The USPSTF concludes with moderate certainty that screening for prediabetes and type 2 diabetes and offering or referring patients with prediabetes to effective preventive interventions has a moderate net benefit,” the task force concludes in its recommendation, published Aug. 24 in JAMA.

“Clinicians should offer or refer patients with prediabetes to effective preventive interventions,” they write.

Experts commenting on the issue strongly emphasize that it’s not just the screening, but the subsequent intervention that is needed to make a difference.

“If young adults newly identified with abnormal glucose metabolism do not receive the needed intensive behavioral change support, screening may provide no benefit,” write Richard W. Grant, MD, MPH, and colleagues in an editorial published with the recommendation.

“Given the role of our obesogenic and physically inactive society in the shift toward earlier onset of diabetes, efforts to increase screening and recognition of abnormal glucose metabolism must be coupled with robust public health measures to address the underlying contributors.”
 

BMI cutoff lower for at-risk ethnic populations

The recommendation, which updates the task force’s 2015 guideline, carries a “B” classification, meaning the USPSTF has high certainty that the net benefit is moderate. It now specifies screening from age 35to 70 for persons classified as overweight (body mass index at least 25) or obese (BMI at least 30) and recommends referral to preventive interventions when patients are found to have prediabetes.

In addition to recommendations of lifestyle changes, such as diet and physical activity, the task force also endorses the diabetes drug metformin as a beneficial intervention in the prevention or delay of diabetes, while noting fewer overall health benefits from metformin than from the lifestyle changes.

A lower BMI cutoff of at least 23 is recommended for diabetes screening of Asian Americans, and, importantly, screening for prediabetes and diabetes should be considered at an even earlier age if the patient is from a population with a disproportionately high prevalence of diabetes, including American Indian/Alaska Native, Black, Hawaiian/Pacific Islander, Hispanic/Latino, the task force recommends.

Screening tests should include fasting plasma glucose, hemoglobin A1c, or an oral glucose tolerance test. Although screening every 3 years “may be a reasonable approach for adults with normal blood glucose levels,” the task force adds that “the optimal screening interval for adults with an initial normal glucose test result is uncertain.”
 

Data review: Few with prediabetes know they have it

The need for the update was prompted by troubling data showing increasing diabetes rates despite early signs that can and should be identified and acted upon in the primary care setting to prevent disease progression.

Data from the Centers for Disease Control and Prevention, for instance, show that while 13% of all U.S. adults 18 years or older have diabetes and 35% meet criteria for prediabetes, as many as 21% of those with diabetes were not aware of or did not report having the disease. Furthermore, only a small fraction – 15% of those with prediabetes – said they had been told by a health professional that they had this condition, the task force notes.

The task force’s final recommendation was based on a systematic review of evidence regarding the screening of asymptomatic, nonpregnant adults and the harms and benefits of interventions, such as physical activity, behavioral counseling, or pharmacotherapy.

Among key evidence supporting the lower age was a 2014 study showing that the number of people necessary to obtain one positive test for diabetes with screening sharply drops from 80 among those aged 30-34 years to just 31 among those aged 36-39.

Opportunistic universal screening of eligible people aged 35 and older would yield a ratio of 1 out of just 15 to spot a positive test, the authors of that study reported.

In addition, a large cohort study in more than 77,000 people with prediabetes strongly links the risk of developing diabetes with increases in A1c level and with increasing BMI.
 

ADA recommendations differ

The new recommendations differ from American Diabetes Association guidelines, which call for diabetes screening at all ages for people who are overweight or obese and who have one or more risk factors, such as physical inactivity or a first-degree relative with diabetes. If results are normal, repeat screening at least every 3 years is recommended.

The ADA further recommends universal screening for all adults 45 years and older, regardless of their risk factors.

For the screening of adults over 45, the ADA recommends using a fasting plasma glucose level, 2-hour plasma glucose level during a 75-g oral glucose tolerance test, or A1c level, regardless of risk factors.

The American Association of Clinical Endocrinology also recommends universal screening for prediabetes and diabetes for all adults 45 years or older, regardless of risk factors, and also advises screening those who have risk factors for diabetes regardless of age.
 

Screening of little benefit without behavior change support

In an interview, Dr. Grant added that broad efforts are essential as those at the practice level have clearly not succeeded.

“The medical model of individual counseling and referral has not really been effective, and so we really need to think in terms of large-scale public health action,” said Dr. Grant, of the division of research, Kaiser Permanente Northern California, Oakland.

His editorial details the sweeping, multifactorial efforts that are needed.

“To turn this recommendation into action – that is, to translate screening activities into improved clinical outcomes – change is needed at the patient-clinician level (recognizing and encouraging eligible individuals to be screened), health care system level (reducing screening barriers and ensuring access to robust lifestyle programs), and societal level (applying effective public health interventions to reduce obesity and increase exercise),” they write.

A top priority has to be a focus on individuals of diverse backgrounds and issues such as access to healthy programs in minority communities, Dr. Grant noted.

“Newly diagnosed adults are more likely to be African-American and Latinx,” he said.

“We really need to invest in healthier communities for low-income, non-White communities to reverse the persistent health care disparities in these communities.”

While the challenges may appear daunting, history shows they are not necessarily insurmountable – as evidenced in the campaign to discourage tobacco smoking.

“National smoking cessation efforts are one example of a mostly successful public health campaign that has made a difference in health behaviors,” Grant noted.

The recommendation is also posted on the USPSTF web site .

Dr. Grant reports receiving grants from the National Institutes of Health and the Patient-Centered Outcomes Research Institute.

Joseph E. Scherger, MD, MPH, is a family physician of 40 years and an avid runner who has carried over his passion for fitness and nutrition into treating patients.

He achieved this through moving to practicing functional medicine a decade ago.

According to Dr. Scherger, functional medicine “shifts the whole approach [to family medicine], recognizing that people’s chronic diseases, like hypertension and diabetes, are completely reversible, and the reason why is because they’re caused by what we eat and how we live.”

Practicing functional medicine continues to make working exciting for Dr. Scherger, he says.

“Now that I’ve shifted into nutrition and lifestyle, I feel like I’m a healer, you know? I’m not just refilling prescriptions anymore,” he said.

The burden of disease brought about by bad nutrition and our profit-hungry food industry is staggering, explained Dr. Scherger, As such, he encourages his patients to adopt lifestyle and nutritional changes that allow the body to become healthy again.

Dr. Scherger’s shift into lifestyle-oriented medicine reflects his own experiences with healthy living, and how it has impacted his life.

“I’m 70 years old, and I’m still running, and I feel the same as when I was 40 or 50.” He has completed 40 marathons, ten 50K and five 50-mile ultramarathon trail runs, and, although retired from long-distance running, he is currently training for an upcoming 5K Thanksgiving turkey trot with his 6-year-old grandson. “He loves it. He’s faster than I am, I have trouble keeping up with him,” he confessed.

Earlier days of career

“I’ve been very blessed to have a career that kept changing every 5-10 years,” he said. “I’ve been able to evolve in a way of shifting my interests from one area to another,” he said.

Dr. Scherger has held many positions in the medical field, from serving in the National Health Service Corps in Dixon, Calif., as a migrant health physician during 1978-1980, to being chair of graduate medical education at Eisenhower Medical Center in Rancho Mirage, Calif., from 2009 to 2015. In between, he taught at the University of California, Davis, and served as founding dean of the Florida State University College of Medicine.

Originally from Ohio, Dr. Scherger was born in 1950 in the small town of Delphos. He graduated from the University of Dayton in 1971 before attending medical school at University of California, Los Angeles, for 4 years. He then completed a family medicine residency and a masters in public health at the University of Washington, Seattle, in 1978.

A resident of the Golden State for 50 years now, Dr. Scherger describes himself as a “true Californian.” Currently, he is in practice at Eisenhower Health in La Quinta, Calif., where he is a core faculty member in the family medicine residency program. He is also a physician under the health center’s Primary Care 365 program, which offers patients regular communication with and increased access to their physicians, emphasizing on telemedicine. He also founded Restore Health – Disease Reversal, a wellness center in Indian Wells, Calif., that focuses on improving patients’ health through changes in nutrition and lifestyle.

Within his medical practice, Dr. Scherger is seen by colleagues as a doctor who not only advocates for his patients, but also goes above and beyond to solve their problems.

“He’s a leader, an advocate, and he inspires others to do what they do,” said Julia L. Martin, MD, a fellow family medicine practitioner who has been working with Dr. Scherger at the Eisenhower Medical Center for the past 5 years. “Being a physician is a very challenging role. You need to be patient and understanding in trying to investigate what the patient wants and work through that to try to find the solution. Dr. Scherger is really good at that.”
 

Inspiration for writing

Apart from his roles as a physician and faculty member, Dr. Scherger is also an author of two books: “40 Years in Family Medicine” (Scotts Valley, Calif.: CreateSpace, 2014) and “Lean and Fit: A Doctor’s Journey to Healthy Nutrition and Greater Wellness” (Scotts Valley, Calif.: CreateSpace, 2015). He admits to not being a naturally gifted writer, and is more intrinsically skilled at speaking. When he was in medical school, however, a mentor told him that the written word is eternal, and this left a deep impression on him.

“When I think of something that’s worth writing about, that I think will be a contribution to my field, I don’t hesitate to begin to write and develop,” said Dr. Scherger. “ I’ve done some research that I’m proud of, but most of [my writings] are hopefully thoughtful essays to help move my field along, and it’s enormously satisfying to make these contributions.”
 

Awards and other contributions to family medicine

Dr. Scherger’s contributions to the field of family medicine have been recognized continuously over his career.

He has served on the board of directors of the American Academy of Family Physicians and the American Board of Family Medicine. He is also the recipient of numerous awards, such as being chosen as Family Physician of the Year by the American Academy of Family Physicians and the California Academy of Family Physicians in 1989. From 1988 to 1991, he was a fellow in the Kellogg National Fellowship Program.

While he has managed to reinvent his own practice and medical focus, Dr. Scherger is also concerned with the need to remodel the current state of primary care and family medicine. Regarding challenges facing the field, he mentions the burnout faced by many doctors.

Nowadays, the work of family medicine includes much more than those common acute illnesses – it includes preventive medicine, chronic illness management and mental health counseling. “Yet, somehow, the whole economic and schedule model is based on brief visits,” said Dr. Scherger. “I think the most common reason that a lot of family doctors are burned out is that they’re expected to see so many people a day, and they know they don’t have enough time to do a really good job.”

He elaborated: “The real challenge now for family practice is to be re-engineered to be for the modern age, and not be still stuck in a ‘make an appointment, come and get it’ model of care, which is outdated. So I’ve been working a long time in trying to reinvent primary care. And, you know, it’s hard to make those changes, and it’s still a work in progress.”

One of the ways Dr. Scherger has been working on the primary care model is to help redesign it for the computer age. He started doing telemedicine and online care in 1997, even though other doctors gave him pushback for doing so at the time. Today, in his practice, half of his patients are remote, and under Eisenhower’s Primary Care 365 service, he uses telemedicine to its fullest potential.

Dr. Martin calls Dr. Scherger an “innovator,” adding: “He really tries to find what works for a solution, in different ways – not just one cookie cutter way.”

Despite nearly 50 years of being a doctor, the profession has not gotten any less rewarding for Dr. Scherger, who says he does not intend to retire as long as he is any good at it.

“My mother always said, ‘Joe, your life should be dedicated to making the world a better place.’ I really took that to heart and realized that my greatest joy is to help other people.”

Joseph E. Scherger, MD, MPH, is a family physician of 40 years and an avid runner who has carried over his passion for fitness and nutrition into treating patients.

He achieved this through moving to practicing functional medicine a decade ago.

According to Dr. Scherger, functional medicine “shifts the whole approach [to family medicine], recognizing that people’s chronic diseases, like hypertension and diabetes, are completely reversible, and the reason why is because they’re caused by what we eat and how we live.”

Practicing functional medicine continues to make working exciting for Dr. Scherger, he says.

“Now that I’ve shifted into nutrition and lifestyle, I feel like I’m a healer, you know? I’m not just refilling prescriptions anymore,” he said.

The burden of disease brought about by bad nutrition and our profit-hungry food industry is staggering, explained Dr. Scherger, As such, he encourages his patients to adopt lifestyle and nutritional changes that allow the body to become healthy again.

Dr. Scherger’s shift into lifestyle-oriented medicine reflects his own experiences with healthy living, and how it has impacted his life.

“I’m 70 years old, and I’m still running, and I feel the same as when I was 40 or 50.” He has completed 40 marathons, ten 50K and five 50-mile ultramarathon trail runs, and, although retired from long-distance running, he is currently training for an upcoming 5K Thanksgiving turkey trot with his 6-year-old grandson. “He loves it. He’s faster than I am, I have trouble keeping up with him,” he confessed.

Earlier days of career

“I’ve been very blessed to have a career that kept changing every 5-10 years,” he said. “I’ve been able to evolve in a way of shifting my interests from one area to another,” he said.

Dr. Scherger has held many positions in the medical field, from serving in the National Health Service Corps in Dixon, Calif., as a migrant health physician during 1978-1980, to being chair of graduate medical education at Eisenhower Medical Center in Rancho Mirage, Calif., from 2009 to 2015. In between, he taught at the University of California, Davis, and served as founding dean of the Florida State University College of Medicine.

Originally from Ohio, Dr. Scherger was born in 1950 in the small town of Delphos. He graduated from the University of Dayton in 1971 before attending medical school at University of California, Los Angeles, for 4 years. He then completed a family medicine residency and a masters in public health at the University of Washington, Seattle, in 1978.

A resident of the Golden State for 50 years now, Dr. Scherger describes himself as a “true Californian.” Currently, he is in practice at Eisenhower Health in La Quinta, Calif., where he is a core faculty member in the family medicine residency program. He is also a physician under the health center’s Primary Care 365 program, which offers patients regular communication with and increased access to their physicians, emphasizing on telemedicine. He also founded Restore Health – Disease Reversal, a wellness center in Indian Wells, Calif., that focuses on improving patients’ health through changes in nutrition and lifestyle.

Within his medical practice, Dr. Scherger is seen by colleagues as a doctor who not only advocates for his patients, but also goes above and beyond to solve their problems.

“He’s a leader, an advocate, and he inspires others to do what they do,” said Julia L. Martin, MD, a fellow family medicine practitioner who has been working with Dr. Scherger at the Eisenhower Medical Center for the past 5 years. “Being a physician is a very challenging role. You need to be patient and understanding in trying to investigate what the patient wants and work through that to try to find the solution. Dr. Scherger is really good at that.”
 

Inspiration for writing

Apart from his roles as a physician and faculty member, Dr. Scherger is also an author of two books: “40 Years in Family Medicine” (Scotts Valley, Calif.: CreateSpace, 2014) and “Lean and Fit: A Doctor’s Journey to Healthy Nutrition and Greater Wellness” (Scotts Valley, Calif.: CreateSpace, 2015). He admits to not being a naturally gifted writer, and is more intrinsically skilled at speaking. When he was in medical school, however, a mentor told him that the written word is eternal, and this left a deep impression on him.

“When I think of something that’s worth writing about, that I think will be a contribution to my field, I don’t hesitate to begin to write and develop,” said Dr. Scherger. “ I’ve done some research that I’m proud of, but most of [my writings] are hopefully thoughtful essays to help move my field along, and it’s enormously satisfying to make these contributions.”
 

Awards and other contributions to family medicine

Dr. Scherger’s contributions to the field of family medicine have been recognized continuously over his career.

He has served on the board of directors of the American Academy of Family Physicians and the American Board of Family Medicine. He is also the recipient of numerous awards, such as being chosen as Family Physician of the Year by the American Academy of Family Physicians and the California Academy of Family Physicians in 1989. From 1988 to 1991, he was a fellow in the Kellogg National Fellowship Program.

While he has managed to reinvent his own practice and medical focus, Dr. Scherger is also concerned with the need to remodel the current state of primary care and family medicine. Regarding challenges facing the field, he mentions the burnout faced by many doctors.

Nowadays, the work of family medicine includes much more than those common acute illnesses – it includes preventive medicine, chronic illness management and mental health counseling. “Yet, somehow, the whole economic and schedule model is based on brief visits,” said Dr. Scherger. “I think the most common reason that a lot of family doctors are burned out is that they’re expected to see so many people a day, and they know they don’t have enough time to do a really good job.”

He elaborated: “The real challenge now for family practice is to be re-engineered to be for the modern age, and not be still stuck in a ‘make an appointment, come and get it’ model of care, which is outdated. So I’ve been working a long time in trying to reinvent primary care. And, you know, it’s hard to make those changes, and it’s still a work in progress.”

One of the ways Dr. Scherger has been working on the primary care model is to help redesign it for the computer age. He started doing telemedicine and online care in 1997, even though other doctors gave him pushback for doing so at the time. Today, in his practice, half of his patients are remote, and under Eisenhower’s Primary Care 365 service, he uses telemedicine to its fullest potential.

Dr. Martin calls Dr. Scherger an “innovator,” adding: “He really tries to find what works for a solution, in different ways – not just one cookie cutter way.”

Despite nearly 50 years of being a doctor, the profession has not gotten any less rewarding for Dr. Scherger, who says he does not intend to retire as long as he is any good at it.

“My mother always said, ‘Joe, your life should be dedicated to making the world a better place.’ I really took that to heart and realized that my greatest joy is to help other people.”

Joseph E. Scherger, MD, MPH, is a family physician of 40 years and an avid runner who has carried over his passion for fitness and nutrition into treating patients.

He achieved this through moving to practicing functional medicine a decade ago.

According to Dr. Scherger, functional medicine “shifts the whole approach [to family medicine], recognizing that people’s chronic diseases, like hypertension and diabetes, are completely reversible, and the reason why is because they’re caused by what we eat and how we live.”

Practicing functional medicine continues to make working exciting for Dr. Scherger, he says.

“Now that I’ve shifted into nutrition and lifestyle, I feel like I’m a healer, you know? I’m not just refilling prescriptions anymore,” he said.

The burden of disease brought about by bad nutrition and our profit-hungry food industry is staggering, explained Dr. Scherger, As such, he encourages his patients to adopt lifestyle and nutritional changes that allow the body to become healthy again.

Dr. Scherger’s shift into lifestyle-oriented medicine reflects his own experiences with healthy living, and how it has impacted his life.

“I’m 70 years old, and I’m still running, and I feel the same as when I was 40 or 50.” He has completed 40 marathons, ten 50K and five 50-mile ultramarathon trail runs, and, although retired from long-distance running, he is currently training for an upcoming 5K Thanksgiving turkey trot with his 6-year-old grandson. “He loves it. He’s faster than I am, I have trouble keeping up with him,” he confessed.

Earlier days of career

“I’ve been very blessed to have a career that kept changing every 5-10 years,” he said. “I’ve been able to evolve in a way of shifting my interests from one area to another,” he said.

Dr. Scherger has held many positions in the medical field, from serving in the National Health Service Corps in Dixon, Calif., as a migrant health physician during 1978-1980, to being chair of graduate medical education at Eisenhower Medical Center in Rancho Mirage, Calif., from 2009 to 2015. In between, he taught at the University of California, Davis, and served as founding dean of the Florida State University College of Medicine.

Originally from Ohio, Dr. Scherger was born in 1950 in the small town of Delphos. He graduated from the University of Dayton in 1971 before attending medical school at University of California, Los Angeles, for 4 years. He then completed a family medicine residency and a masters in public health at the University of Washington, Seattle, in 1978.

A resident of the Golden State for 50 years now, Dr. Scherger describes himself as a “true Californian.” Currently, he is in practice at Eisenhower Health in La Quinta, Calif., where he is a core faculty member in the family medicine residency program. He is also a physician under the health center’s Primary Care 365 program, which offers patients regular communication with and increased access to their physicians, emphasizing on telemedicine. He also founded Restore Health – Disease Reversal, a wellness center in Indian Wells, Calif., that focuses on improving patients’ health through changes in nutrition and lifestyle.

Within his medical practice, Dr. Scherger is seen by colleagues as a doctor who not only advocates for his patients, but also goes above and beyond to solve their problems.

“He’s a leader, an advocate, and he inspires others to do what they do,” said Julia L. Martin, MD, a fellow family medicine practitioner who has been working with Dr. Scherger at the Eisenhower Medical Center for the past 5 years. “Being a physician is a very challenging role. You need to be patient and understanding in trying to investigate what the patient wants and work through that to try to find the solution. Dr. Scherger is really good at that.”
 

Inspiration for writing

Apart from his roles as a physician and faculty member, Dr. Scherger is also an author of two books: “40 Years in Family Medicine” (Scotts Valley, Calif.: CreateSpace, 2014) and “Lean and Fit: A Doctor’s Journey to Healthy Nutrition and Greater Wellness” (Scotts Valley, Calif.: CreateSpace, 2015). He admits to not being a naturally gifted writer, and is more intrinsically skilled at speaking. When he was in medical school, however, a mentor told him that the written word is eternal, and this left a deep impression on him.

“When I think of something that’s worth writing about, that I think will be a contribution to my field, I don’t hesitate to begin to write and develop,” said Dr. Scherger. “ I’ve done some research that I’m proud of, but most of [my writings] are hopefully thoughtful essays to help move my field along, and it’s enormously satisfying to make these contributions.”
 

Awards and other contributions to family medicine

Dr. Scherger’s contributions to the field of family medicine have been recognized continuously over his career.

He has served on the board of directors of the American Academy of Family Physicians and the American Board of Family Medicine. He is also the recipient of numerous awards, such as being chosen as Family Physician of the Year by the American Academy of Family Physicians and the California Academy of Family Physicians in 1989. From 1988 to 1991, he was a fellow in the Kellogg National Fellowship Program.

While he has managed to reinvent his own practice and medical focus, Dr. Scherger is also concerned with the need to remodel the current state of primary care and family medicine. Regarding challenges facing the field, he mentions the burnout faced by many doctors.

Nowadays, the work of family medicine includes much more than those common acute illnesses – it includes preventive medicine, chronic illness management and mental health counseling. “Yet, somehow, the whole economic and schedule model is based on brief visits,” said Dr. Scherger. “I think the most common reason that a lot of family doctors are burned out is that they’re expected to see so many people a day, and they know they don’t have enough time to do a really good job.”

He elaborated: “The real challenge now for family practice is to be re-engineered to be for the modern age, and not be still stuck in a ‘make an appointment, come and get it’ model of care, which is outdated. So I’ve been working a long time in trying to reinvent primary care. And, you know, it’s hard to make those changes, and it’s still a work in progress.”

One of the ways Dr. Scherger has been working on the primary care model is to help redesign it for the computer age. He started doing telemedicine and online care in 1997, even though other doctors gave him pushback for doing so at the time. Today, in his practice, half of his patients are remote, and under Eisenhower’s Primary Care 365 service, he uses telemedicine to its fullest potential.

Dr. Martin calls Dr. Scherger an “innovator,” adding: “He really tries to find what works for a solution, in different ways – not just one cookie cutter way.”

Despite nearly 50 years of being a doctor, the profession has not gotten any less rewarding for Dr. Scherger, who says he does not intend to retire as long as he is any good at it.

“My mother always said, ‘Joe, your life should be dedicated to making the world a better place.’ I really took that to heart and realized that my greatest joy is to help other people.”

U.S. prescribing data from 160,000 adults with type 2 diabetes and diabetic kidney disease showed a notable uptick in new prescriptions for sodium-glucose cotransporter 2 inhibitors and less dramatic gains for glucagonlike peptide–1 receptor agonists during 2019 and continuing into early 2020, compared with prior years, with usage levels of both classes during the first quarter of 2020 rivaling those of more traditional agents including metformin and insulin.

During the first 3 months of 2020, initiation of a SGLT2 inhibitor constituted 13% of all new starts of an antidiabetes drug among adults with type 2 diabetes and diabetic kidney disease (DKD). This compared with initiation rates during the same early 2020 period of 17% for GLP-1 receptor agonists, 19% for metformin, 16% for sulfonylureas, 15% for insulins, 14% for thiazolidinediones, and 6% for dipeptidyl peptidase–4 inhibitors, the seven drug classes examined in a study published in Diabetes Care.

Early 2020 was the first time that starts of a GLP-1 receptor agonist ranked second (behind only metformin) among these seven drug classes in the studied U.S. population, and early 2020 also marked an unprecedentedly high start rate for SGLT2 inhibitors that nearly tripled the roughly 5% rate in place as recently as 2018.
 

Rises are ‘what we expected’

The recent rise of SGLT2 inhibitors and GLP-1 receptor agonists in these patients “was what we expected,” given the evidence for both classes in slowing progression of DKD, said Julie M. Paik, MD, senior author on the study and a nephrologist and pharmacoepidemiologist at Brigham and Women’s Hospital in Boston.

“We’ve seen other beneficial drugs slow on the uptake, so it’s not surprising to see it here, and I’m optimistic” about further increases going forward, she said in an interview.

Both drug classes “were originally marketed as diabetes drugs,” and it is only since 2019, with the publication of trials showing dramatic renal benefits from canagliflozin (Invokana) in CREDENCE, and from dapagliflozin (Farxiga) in DAPA-CKD in 2020 that the evidence became truly compelling for SGLT2 inhibitors. This evidence also led to new renal-protection indications approved by the Food and Drug Administration for canagliflozin and for dapagliflozin, noted Dr. Paik.

Evidence for renal protection also emerged in 2017 for the GLP-1 receptor agonist liraglutide (Victoza) in the LEADER trial, and for dulaglutide (Trulicity) in the AWARD-7 trial, although neither drug has received a renal indication in its labeling.

By 2020, guidelines for managing patients with type 2 diabetes and chronic kidney disease from the influential Kidney Disease: Improving Global Outcomes organization had identified agents from the SGLT2 inhibitor class as top-tier options, along with metformin, for treating these patients, with agents from the GLP-1 receptor agonist class as the top third class to add in patients who require additional glycemic control.

Additional analyses Dr. Paik and associates ran showed how this played out in terms of which specialists prescribed these drugs during the full period studied beginning in 2013. Throughout this roughly 7-year span, about 70% of the prescriptions written for either SGLT2 inhibitors or for GLP-1 receptor agonists were from internal medicine physicians, followed by about 20% written by endocrinologists. Prescriptions from nephrologists, as well as from cardiologists, have hovered at about 5% each, but seem poised to start rising based on the recently added indications and newer treatment recommendations.

“It’s good to see the recent uptick in use since 2019,” Katherine R. Tuttle, MD, commented in an interview. It’s a positive development for U.S. public health, “but we need to do more to disseminate and implement these life-, kidney-, and heart-saving therapies.”

Future use could approach 80% of DKD patients

Dr. Tuttle estimated that “target” levels of use for SGLT2 inhibitors and for GLP-1 receptor agonists “could reasonably approach 80%” for patients with type 2 diabetes and diabetic kidney disease.

“We will likely move to combination therapy” with simultaneous use of agents from both classes in a targeted way using “precision phenotyping based on clinical characteristics, and eventually perhaps by biomarkers, kidney biopsies, or both.” Combined treatment with both an SGLT2 inhibitor and a GLP-1 receptor agonist may be especially suited to patients with type 2 diabetes, atherosclerotic cardiovascular disease, low estimated glomerular filtration rate, and need for better glycemic control and weight loss, a profile that is “pretty typical” in real-world practice, said Dr. Tuttle, a nephrologist and endocrinologist and executive director for research at Providence Healthcare in Spokane, Wash.
 

Study included patients with commercial or Medicare Advantage coverage

The study used information in an Optum database that included patients enrolled in either commercial or in Medicare Advantage health insurance plans from 2013 to the first quarter of 2020. This included 160,489 adults with type 2 diabetes and DKD who started during that period at least one agent from any of the seven included drug classes.

This focus may have biased the findings because, overall, U.S. coverage of the relatively expensive agents from the SGLT2 inhibitor and GLP-1 receptor agonist classes has often been problematic.

“There are issues of cost, coverage, and access” using these medications, as well as limited data on cost-effectiveness, Dr. Paik acknowledged. Additional issues that have helped generate prescribing lags include concerns about possible adverse effects, low familiarity by providers with these drugs early on, and limited trial experience using them in older patients. The process of clinicians growing more comfortable prescribing these new agents has depended on their “working through the evidence,” she explained.

The FDA’s approval in July 2021 of finerenone (Kerendia) for treating patients with type 2 diabetes and chronic kidney disease threw yet another new variable into the prescribing mix for these patients.

“SGLT2 inhibitors are here to stay as a new standard of care for patients with diabetic kidney disease, but combination with finerenone might be especially useful for patients with diabetic kidney disease and heart failure,” Dr. Tuttle suggested. A new generation of clinical trials will likely soon launch to test these combinations, she predicted.

Dr. Paik had no disclosures. Dr. Tuttle has been a consultant to AstraZeneca, Bayer, Boehringer Ingelheim, Gilead, Goldfinch Bio, Eli Lilly, and Novo Nordisk.

mzoler@mdedge.com

U.S. prescribing data from 160,000 adults with type 2 diabetes and diabetic kidney disease showed a notable uptick in new prescriptions for sodium-glucose cotransporter 2 inhibitors and less dramatic gains for glucagonlike peptide–1 receptor agonists during 2019 and continuing into early 2020, compared with prior years, with usage levels of both classes during the first quarter of 2020 rivaling those of more traditional agents including metformin and insulin.

During the first 3 months of 2020, initiation of a SGLT2 inhibitor constituted 13% of all new starts of an antidiabetes drug among adults with type 2 diabetes and diabetic kidney disease (DKD). This compared with initiation rates during the same early 2020 period of 17% for GLP-1 receptor agonists, 19% for metformin, 16% for sulfonylureas, 15% for insulins, 14% for thiazolidinediones, and 6% for dipeptidyl peptidase–4 inhibitors, the seven drug classes examined in a study published in Diabetes Care.

Early 2020 was the first time that starts of a GLP-1 receptor agonist ranked second (behind only metformin) among these seven drug classes in the studied U.S. population, and early 2020 also marked an unprecedentedly high start rate for SGLT2 inhibitors that nearly tripled the roughly 5% rate in place as recently as 2018.
 

Rises are ‘what we expected’

The recent rise of SGLT2 inhibitors and GLP-1 receptor agonists in these patients “was what we expected,” given the evidence for both classes in slowing progression of DKD, said Julie M. Paik, MD, senior author on the study and a nephrologist and pharmacoepidemiologist at Brigham and Women’s Hospital in Boston.

“We’ve seen other beneficial drugs slow on the uptake, so it’s not surprising to see it here, and I’m optimistic” about further increases going forward, she said in an interview.

Both drug classes “were originally marketed as diabetes drugs,” and it is only since 2019, with the publication of trials showing dramatic renal benefits from canagliflozin (Invokana) in CREDENCE, and from dapagliflozin (Farxiga) in DAPA-CKD in 2020 that the evidence became truly compelling for SGLT2 inhibitors. This evidence also led to new renal-protection indications approved by the Food and Drug Administration for canagliflozin and for dapagliflozin, noted Dr. Paik.

Evidence for renal protection also emerged in 2017 for the GLP-1 receptor agonist liraglutide (Victoza) in the LEADER trial, and for dulaglutide (Trulicity) in the AWARD-7 trial, although neither drug has received a renal indication in its labeling.

By 2020, guidelines for managing patients with type 2 diabetes and chronic kidney disease from the influential Kidney Disease: Improving Global Outcomes organization had identified agents from the SGLT2 inhibitor class as top-tier options, along with metformin, for treating these patients, with agents from the GLP-1 receptor agonist class as the top third class to add in patients who require additional glycemic control.

Additional analyses Dr. Paik and associates ran showed how this played out in terms of which specialists prescribed these drugs during the full period studied beginning in 2013. Throughout this roughly 7-year span, about 70% of the prescriptions written for either SGLT2 inhibitors or for GLP-1 receptor agonists were from internal medicine physicians, followed by about 20% written by endocrinologists. Prescriptions from nephrologists, as well as from cardiologists, have hovered at about 5% each, but seem poised to start rising based on the recently added indications and newer treatment recommendations.

“It’s good to see the recent uptick in use since 2019,” Katherine R. Tuttle, MD, commented in an interview. It’s a positive development for U.S. public health, “but we need to do more to disseminate and implement these life-, kidney-, and heart-saving therapies.”

Future use could approach 80% of DKD patients

Dr. Tuttle estimated that “target” levels of use for SGLT2 inhibitors and for GLP-1 receptor agonists “could reasonably approach 80%” for patients with type 2 diabetes and diabetic kidney disease.

“We will likely move to combination therapy” with simultaneous use of agents from both classes in a targeted way using “precision phenotyping based on clinical characteristics, and eventually perhaps by biomarkers, kidney biopsies, or both.” Combined treatment with both an SGLT2 inhibitor and a GLP-1 receptor agonist may be especially suited to patients with type 2 diabetes, atherosclerotic cardiovascular disease, low estimated glomerular filtration rate, and need for better glycemic control and weight loss, a profile that is “pretty typical” in real-world practice, said Dr. Tuttle, a nephrologist and endocrinologist and executive director for research at Providence Healthcare in Spokane, Wash.
 

Study included patients with commercial or Medicare Advantage coverage

The study used information in an Optum database that included patients enrolled in either commercial or in Medicare Advantage health insurance plans from 2013 to the first quarter of 2020. This included 160,489 adults with type 2 diabetes and DKD who started during that period at least one agent from any of the seven included drug classes.

This focus may have biased the findings because, overall, U.S. coverage of the relatively expensive agents from the SGLT2 inhibitor and GLP-1 receptor agonist classes has often been problematic.

“There are issues of cost, coverage, and access” using these medications, as well as limited data on cost-effectiveness, Dr. Paik acknowledged. Additional issues that have helped generate prescribing lags include concerns about possible adverse effects, low familiarity by providers with these drugs early on, and limited trial experience using them in older patients. The process of clinicians growing more comfortable prescribing these new agents has depended on their “working through the evidence,” she explained.

The FDA’s approval in July 2021 of finerenone (Kerendia) for treating patients with type 2 diabetes and chronic kidney disease threw yet another new variable into the prescribing mix for these patients.

“SGLT2 inhibitors are here to stay as a new standard of care for patients with diabetic kidney disease, but combination with finerenone might be especially useful for patients with diabetic kidney disease and heart failure,” Dr. Tuttle suggested. A new generation of clinical trials will likely soon launch to test these combinations, she predicted.

Dr. Paik had no disclosures. Dr. Tuttle has been a consultant to AstraZeneca, Bayer, Boehringer Ingelheim, Gilead, Goldfinch Bio, Eli Lilly, and Novo Nordisk.

mzoler@mdedge.com

U.S. prescribing data from 160,000 adults with type 2 diabetes and diabetic kidney disease showed a notable uptick in new prescriptions for sodium-glucose cotransporter 2 inhibitors and less dramatic gains for glucagonlike peptide–1 receptor agonists during 2019 and continuing into early 2020, compared with prior years, with usage levels of both classes during the first quarter of 2020 rivaling those of more traditional agents including metformin and insulin.

During the first 3 months of 2020, initiation of a SGLT2 inhibitor constituted 13% of all new starts of an antidiabetes drug among adults with type 2 diabetes and diabetic kidney disease (DKD). This compared with initiation rates during the same early 2020 period of 17% for GLP-1 receptor agonists, 19% for metformin, 16% for sulfonylureas, 15% for insulins, 14% for thiazolidinediones, and 6% for dipeptidyl peptidase–4 inhibitors, the seven drug classes examined in a study published in Diabetes Care.

Early 2020 was the first time that starts of a GLP-1 receptor agonist ranked second (behind only metformin) among these seven drug classes in the studied U.S. population, and early 2020 also marked an unprecedentedly high start rate for SGLT2 inhibitors that nearly tripled the roughly 5% rate in place as recently as 2018.
 

Rises are ‘what we expected’

The recent rise of SGLT2 inhibitors and GLP-1 receptor agonists in these patients “was what we expected,” given the evidence for both classes in slowing progression of DKD, said Julie M. Paik, MD, senior author on the study and a nephrologist and pharmacoepidemiologist at Brigham and Women’s Hospital in Boston.

“We’ve seen other beneficial drugs slow on the uptake, so it’s not surprising to see it here, and I’m optimistic” about further increases going forward, she said in an interview.

Both drug classes “were originally marketed as diabetes drugs,” and it is only since 2019, with the publication of trials showing dramatic renal benefits from canagliflozin (Invokana) in CREDENCE, and from dapagliflozin (Farxiga) in DAPA-CKD in 2020 that the evidence became truly compelling for SGLT2 inhibitors. This evidence also led to new renal-protection indications approved by the Food and Drug Administration for canagliflozin and for dapagliflozin, noted Dr. Paik.

Evidence for renal protection also emerged in 2017 for the GLP-1 receptor agonist liraglutide (Victoza) in the LEADER trial, and for dulaglutide (Trulicity) in the AWARD-7 trial, although neither drug has received a renal indication in its labeling.

By 2020, guidelines for managing patients with type 2 diabetes and chronic kidney disease from the influential Kidney Disease: Improving Global Outcomes organization had identified agents from the SGLT2 inhibitor class as top-tier options, along with metformin, for treating these patients, with agents from the GLP-1 receptor agonist class as the top third class to add in patients who require additional glycemic control.

Additional analyses Dr. Paik and associates ran showed how this played out in terms of which specialists prescribed these drugs during the full period studied beginning in 2013. Throughout this roughly 7-year span, about 70% of the prescriptions written for either SGLT2 inhibitors or for GLP-1 receptor agonists were from internal medicine physicians, followed by about 20% written by endocrinologists. Prescriptions from nephrologists, as well as from cardiologists, have hovered at about 5% each, but seem poised to start rising based on the recently added indications and newer treatment recommendations.

“It’s good to see the recent uptick in use since 2019,” Katherine R. Tuttle, MD, commented in an interview. It’s a positive development for U.S. public health, “but we need to do more to disseminate and implement these life-, kidney-, and heart-saving therapies.”

Future use could approach 80% of DKD patients

Dr. Tuttle estimated that “target” levels of use for SGLT2 inhibitors and for GLP-1 receptor agonists “could reasonably approach 80%” for patients with type 2 diabetes and diabetic kidney disease.

“We will likely move to combination therapy” with simultaneous use of agents from both classes in a targeted way using “precision phenotyping based on clinical characteristics, and eventually perhaps by biomarkers, kidney biopsies, or both.” Combined treatment with both an SGLT2 inhibitor and a GLP-1 receptor agonist may be especially suited to patients with type 2 diabetes, atherosclerotic cardiovascular disease, low estimated glomerular filtration rate, and need for better glycemic control and weight loss, a profile that is “pretty typical” in real-world practice, said Dr. Tuttle, a nephrologist and endocrinologist and executive director for research at Providence Healthcare in Spokane, Wash.
 

Study included patients with commercial or Medicare Advantage coverage

The study used information in an Optum database that included patients enrolled in either commercial or in Medicare Advantage health insurance plans from 2013 to the first quarter of 2020. This included 160,489 adults with type 2 diabetes and DKD who started during that period at least one agent from any of the seven included drug classes.

This focus may have biased the findings because, overall, U.S. coverage of the relatively expensive agents from the SGLT2 inhibitor and GLP-1 receptor agonist classes has often been problematic.

“There are issues of cost, coverage, and access” using these medications, as well as limited data on cost-effectiveness, Dr. Paik acknowledged. Additional issues that have helped generate prescribing lags include concerns about possible adverse effects, low familiarity by providers with these drugs early on, and limited trial experience using them in older patients. The process of clinicians growing more comfortable prescribing these new agents has depended on their “working through the evidence,” she explained.

The FDA’s approval in July 2021 of finerenone (Kerendia) for treating patients with type 2 diabetes and chronic kidney disease threw yet another new variable into the prescribing mix for these patients.

“SGLT2 inhibitors are here to stay as a new standard of care for patients with diabetic kidney disease, but combination with finerenone might be especially useful for patients with diabetic kidney disease and heart failure,” Dr. Tuttle suggested. A new generation of clinical trials will likely soon launch to test these combinations, she predicted.

Dr. Paik had no disclosures. Dr. Tuttle has been a consultant to AstraZeneca, Bayer, Boehringer Ingelheim, Gilead, Goldfinch Bio, Eli Lilly, and Novo Nordisk.

mzoler@mdedge.com

Background: Direct oral anticoagulants have proven to be more efficacious, safe, and easy to use, compared with warfarin, in patients with atrial fibrillation (Afib). An indirect comparison showed apixaban to be more effective and safer than rivaroxaban. But randomized controlled trials and head-to-head comparison data regarding the same have been lacking until now.

This observational study has several limitations including an inability to balance unmeasured confounding factors, both ICD-9 and ICD-10 codes being used for defined outcomes, an inability to account for time-varying confounders for stroke or bleeding, an inability to capture patients from locations other than primary internist and cardiologists, and a shorter follow-up period, compared with that of clinical trials.

Bottom line: In routine practice, apixaban is more effective and safer than rivaroxaban with a lower rate of strokes, systemic embolism, and major bleeding.

Citation: Fralick M et al. Effectiveness and safety of apixaban compared with rivaroxaban for patients with atrial fibrillation in routine practice: a cohort study. Ann Intern Med. 2020 Apr 7. doi: 10.7326/M19-2522.

Dr. Almagdub is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Direct oral anticoagulants have proven to be more efficacious, safe, and easy to use, compared with warfarin, in patients with atrial fibrillation (Afib). An indirect comparison showed apixaban to be more effective and safer than rivaroxaban. But randomized controlled trials and head-to-head comparison data regarding the same have been lacking until now.

This observational study has several limitations including an inability to balance unmeasured confounding factors, both ICD-9 and ICD-10 codes being used for defined outcomes, an inability to account for time-varying confounders for stroke or bleeding, an inability to capture patients from locations other than primary internist and cardiologists, and a shorter follow-up period, compared with that of clinical trials.

Bottom line: In routine practice, apixaban is more effective and safer than rivaroxaban with a lower rate of strokes, systemic embolism, and major bleeding.

Citation: Fralick M et al. Effectiveness and safety of apixaban compared with rivaroxaban for patients with atrial fibrillation in routine practice: a cohort study. Ann Intern Med. 2020 Apr 7. doi: 10.7326/M19-2522.

Dr. Almagdub is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Direct oral anticoagulants have proven to be more efficacious, safe, and easy to use, compared with warfarin, in patients with atrial fibrillation (Afib). An indirect comparison showed apixaban to be more effective and safer than rivaroxaban. But randomized controlled trials and head-to-head comparison data regarding the same have been lacking until now.

This observational study has several limitations including an inability to balance unmeasured confounding factors, both ICD-9 and ICD-10 codes being used for defined outcomes, an inability to account for time-varying confounders for stroke or bleeding, an inability to capture patients from locations other than primary internist and cardiologists, and a shorter follow-up period, compared with that of clinical trials.

Bottom line: In routine practice, apixaban is more effective and safer than rivaroxaban with a lower rate of strokes, systemic embolism, and major bleeding.

Citation: Fralick M et al. Effectiveness and safety of apixaban compared with rivaroxaban for patients with atrial fibrillation in routine practice: a cohort study. Ann Intern Med. 2020 Apr 7. doi: 10.7326/M19-2522.

Dr. Almagdub is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

The presence of chronic kidney disease (CKD) or end-stage renal disease (ESRD) is associated with worse in-hospital and short-term outcomes after left atrial appendage (LAA) closure, a nationwide study shows.

Patients with ESRD were particularly vulnerable, having about 6.5-fold higher odds of in-hospital mortality than those without CKD and about 11.5-fold higher odds than those with CKD, even after adjustment for potential confounders.

Patients with CKD had higher rates of stroke or transient ischemic attack (TIA) and more short-term readmissions for bleeding, Keerat Rai Ahuja, MD, Reading Hospital-Tower Health, West Reading, Pennsylvania, and colleagues reported August 16 in JACC: Cardiovascular Interventions.

CKD and ESRD are known to be associated with an increased risk for stroke and bleeding in patients with atrial fibrillation (AFib), yet data are limited on the safety and efficacy of LAA closure for stroke prevention in AFib patients with CKD or ESRD, they note.  

“It’s important to know about CKD and understand that there may be an association with worse levels of CKD and worse outcomes, but the data that strikes me is really that for end-stage renal disease,” Matthew Sherwood, MD, MHS, who was not involved with the study, said in an interview.

He noted that data have not been published for patients with CKD and ESRD enrolled in the pivotal PROTECT-AF and PREVAIL trials of Boston Scientific’s Watchman device or from large clinical registries such as EWOLUTION and the company’s continued access protocol registries.

Further, it’s not well understood what the best strategy is to prevent stroke in AFib patients with ESRD and whether they benefit from anticoagulation with warfarin or any of the newer agents. “Thus, it’s hard to then say: ‘Well they have worse outcomes with Watchman,’ which is true as shown in this study, but they may not have any other options based upon the lack of data for oral anticoagulants in end-stage kidney disease patients,” said Dr. Sherwood, from the Inova Heart and Vascular Institute, Falls Church, Virginia.

The lack of clarity is concerning, given rising atrial fibrillation cases and the prevalence of abnormal renal function in everyday practice. In the present study – involving 21,274 patients undergoing LAA closure between 2016 and 2017 in the Nationwide Readmissions Database – 18.6% of patients had CKD stages I to V and 2.7% had ESRD based on ICD-10 codes.

In-hospital mortality was increased only in patients with ESRD. In all, 3.3% of patients with ESRD and 0.4% of those with no CKD died in hospital (adjusted odds ratio [aOR], 6.48), as did 0.5% of patients with CKD (aOR, 11.43; both P <.001).

“These patients represent a sicker population at baseline and have an inherent greater risk for mortality in cardiac interventions, as noted in other studies of structural heart interventions,” Dr. Ahuja and colleagues write.

Patients with CKD had a higher risk for in-hospital stroke or TIA than patients with no CKD (1.8% vs. 1.3%; aOR, 1.35; P = .038) and this risk continued up to 90 days after discharge (1.7% vs. 1.0%; aOR, 1.67; P = .007).

The in-hospital stroke rate was numerically higher in patients with ESRD compared with no CKD (aOR, 1.18; P = .62).

The authors point out that previous LAA closure and CKD studies have reported no differences in in-hospital or subsequent stroke/TIA rates in patients with and without CKD. Possible explanations are that patients with CKD in the present study had higher CHA2DS2-VASc scores than those without CKD (4.18 vs. 3.62) and, second, patients with CKD and AFib are known to have higher risk for thromboembolic events than those with AFib without CKD.

CKD patients were also more likely than those without CKD to experience in-hospital acute kidney injury or hemodialysis (aOR, 5.02; P <.001).

CKD has been shown to be independently associated with acute kidney injury (AKI) after LAA closure. AKI may have long-term thromboembolic consequences, the authors suggest, with one study reporting higher stroke risk at midterm follow-up in patients with AKI.

“As with other cardiac interventions in patients with CKD, efforts should be made to optimize preoperative renal function, minimize contrast volume, and avoid abrupt hemodynamic changes such as hypotension during the procedure to prevent AKI,” Dr. Ahuja and colleagues write.

Patients with CKD and ESRD had longer index length of stay than those without CKD but had similar rates of other in-hospital complications, such as systemic embolization, bleeding/transfusion, vascular complications, and pericardial tamponade requiring intervention.

Among the short-term outcomes, 30- and 90-day all-cause readmissions were increased in patients with CKD and ESRD compared with those without CKD, and 30-day bleeding readmissions were increased within the CKD cohort.

“With Watchman and left atrial appendage closure, what we see is that they have higher rates of readmission and other problems,” Dr. Sherwood said. “I think we understand that that’s probably related not to the procedure itself, not because the Watchman doesn’t work for end-stage kidney disease, but because the patients themselves are likely higher risk.”

Commonly used risk scores for atrial fibrillation, however, don’t take into account advanced kidney disease, he added.

Besides the inherent limitations of observational studies, Dr. Sherwood and the authors point to the lack of laboratory variables and procedural variables in the database, the fact that CKD was defined using ICD-10 codes, that outcomes were not clinically adjudicated, that unmeasured confounders likely still exist, and that long-term follow-up is lacking.

Dr. Sherwood, who wrote an editorial accompanying the study, said that the release of outcomes data from CKD and ESRD patients in the major clinical trials would be helpful going forward, as would possible involvement with the Kidney Disease Improving Global Outcomes organization.

“One of the main points of this study is that we just need a lot more research diving into this patient population,” he said.

The authors report no relevant financial relationships. Dr. Sherwood reports honoraria from Janssen and Medtronic. Editorial coauthor Sean Pokorney reports research grant support from Gilead, Boston Scientific, Pfizer, Bristol Myers Squibb, Janssen, and the Food and Drug Administration; and advisory board, consulting, and honoraria supports from Medtronic, Boston Scientific, Pfizer, Bristol Myers Squibb, Philips, and Zoll.

A version of this article first appeared on Medscape.com.

The presence of chronic kidney disease (CKD) or end-stage renal disease (ESRD) is associated with worse in-hospital and short-term outcomes after left atrial appendage (LAA) closure, a nationwide study shows.

Patients with ESRD were particularly vulnerable, having about 6.5-fold higher odds of in-hospital mortality than those without CKD and about 11.5-fold higher odds than those with CKD, even after adjustment for potential confounders.

Patients with CKD had higher rates of stroke or transient ischemic attack (TIA) and more short-term readmissions for bleeding, Keerat Rai Ahuja, MD, Reading Hospital-Tower Health, West Reading, Pennsylvania, and colleagues reported August 16 in JACC: Cardiovascular Interventions.

CKD and ESRD are known to be associated with an increased risk for stroke and bleeding in patients with atrial fibrillation (AFib), yet data are limited on the safety and efficacy of LAA closure for stroke prevention in AFib patients with CKD or ESRD, they note.  

“It’s important to know about CKD and understand that there may be an association with worse levels of CKD and worse outcomes, but the data that strikes me is really that for end-stage renal disease,” Matthew Sherwood, MD, MHS, who was not involved with the study, said in an interview.

He noted that data have not been published for patients with CKD and ESRD enrolled in the pivotal PROTECT-AF and PREVAIL trials of Boston Scientific’s Watchman device or from large clinical registries such as EWOLUTION and the company’s continued access protocol registries.

Further, it’s not well understood what the best strategy is to prevent stroke in AFib patients with ESRD and whether they benefit from anticoagulation with warfarin or any of the newer agents. “Thus, it’s hard to then say: ‘Well they have worse outcomes with Watchman,’ which is true as shown in this study, but they may not have any other options based upon the lack of data for oral anticoagulants in end-stage kidney disease patients,” said Dr. Sherwood, from the Inova Heart and Vascular Institute, Falls Church, Virginia.

The lack of clarity is concerning, given rising atrial fibrillation cases and the prevalence of abnormal renal function in everyday practice. In the present study – involving 21,274 patients undergoing LAA closure between 2016 and 2017 in the Nationwide Readmissions Database – 18.6% of patients had CKD stages I to V and 2.7% had ESRD based on ICD-10 codes.

In-hospital mortality was increased only in patients with ESRD. In all, 3.3% of patients with ESRD and 0.4% of those with no CKD died in hospital (adjusted odds ratio [aOR], 6.48), as did 0.5% of patients with CKD (aOR, 11.43; both P <.001).

“These patients represent a sicker population at baseline and have an inherent greater risk for mortality in cardiac interventions, as noted in other studies of structural heart interventions,” Dr. Ahuja and colleagues write.

Patients with CKD had a higher risk for in-hospital stroke or TIA than patients with no CKD (1.8% vs. 1.3%; aOR, 1.35; P = .038) and this risk continued up to 90 days after discharge (1.7% vs. 1.0%; aOR, 1.67; P = .007).

The in-hospital stroke rate was numerically higher in patients with ESRD compared with no CKD (aOR, 1.18; P = .62).

The authors point out that previous LAA closure and CKD studies have reported no differences in in-hospital or subsequent stroke/TIA rates in patients with and without CKD. Possible explanations are that patients with CKD in the present study had higher CHA2DS2-VASc scores than those without CKD (4.18 vs. 3.62) and, second, patients with CKD and AFib are known to have higher risk for thromboembolic events than those with AFib without CKD.

CKD patients were also more likely than those without CKD to experience in-hospital acute kidney injury or hemodialysis (aOR, 5.02; P <.001).

CKD has been shown to be independently associated with acute kidney injury (AKI) after LAA closure. AKI may have long-term thromboembolic consequences, the authors suggest, with one study reporting higher stroke risk at midterm follow-up in patients with AKI.

“As with other cardiac interventions in patients with CKD, efforts should be made to optimize preoperative renal function, minimize contrast volume, and avoid abrupt hemodynamic changes such as hypotension during the procedure to prevent AKI,” Dr. Ahuja and colleagues write.

Patients with CKD and ESRD had longer index length of stay than those without CKD but had similar rates of other in-hospital complications, such as systemic embolization, bleeding/transfusion, vascular complications, and pericardial tamponade requiring intervention.

Among the short-term outcomes, 30- and 90-day all-cause readmissions were increased in patients with CKD and ESRD compared with those without CKD, and 30-day bleeding readmissions were increased within the CKD cohort.

“With Watchman and left atrial appendage closure, what we see is that they have higher rates of readmission and other problems,” Dr. Sherwood said. “I think we understand that that’s probably related not to the procedure itself, not because the Watchman doesn’t work for end-stage kidney disease, but because the patients themselves are likely higher risk.”

Commonly used risk scores for atrial fibrillation, however, don’t take into account advanced kidney disease, he added.

Besides the inherent limitations of observational studies, Dr. Sherwood and the authors point to the lack of laboratory variables and procedural variables in the database, the fact that CKD was defined using ICD-10 codes, that outcomes were not clinically adjudicated, that unmeasured confounders likely still exist, and that long-term follow-up is lacking.

Dr. Sherwood, who wrote an editorial accompanying the study, said that the release of outcomes data from CKD and ESRD patients in the major clinical trials would be helpful going forward, as would possible involvement with the Kidney Disease Improving Global Outcomes organization.

“One of the main points of this study is that we just need a lot more research diving into this patient population,” he said.

The authors report no relevant financial relationships. Dr. Sherwood reports honoraria from Janssen and Medtronic. Editorial coauthor Sean Pokorney reports research grant support from Gilead, Boston Scientific, Pfizer, Bristol Myers Squibb, Janssen, and the Food and Drug Administration; and advisory board, consulting, and honoraria supports from Medtronic, Boston Scientific, Pfizer, Bristol Myers Squibb, Philips, and Zoll.

A version of this article first appeared on Medscape.com.

The presence of chronic kidney disease (CKD) or end-stage renal disease (ESRD) is associated with worse in-hospital and short-term outcomes after left atrial appendage (LAA) closure, a nationwide study shows.

Patients with ESRD were particularly vulnerable, having about 6.5-fold higher odds of in-hospital mortality than those without CKD and about 11.5-fold higher odds than those with CKD, even after adjustment for potential confounders.

Patients with CKD had higher rates of stroke or transient ischemic attack (TIA) and more short-term readmissions for bleeding, Keerat Rai Ahuja, MD, Reading Hospital-Tower Health, West Reading, Pennsylvania, and colleagues reported August 16 in JACC: Cardiovascular Interventions.

CKD and ESRD are known to be associated with an increased risk for stroke and bleeding in patients with atrial fibrillation (AFib), yet data are limited on the safety and efficacy of LAA closure for stroke prevention in AFib patients with CKD or ESRD, they note.  

“It’s important to know about CKD and understand that there may be an association with worse levels of CKD and worse outcomes, but the data that strikes me is really that for end-stage renal disease,” Matthew Sherwood, MD, MHS, who was not involved with the study, said in an interview.

He noted that data have not been published for patients with CKD and ESRD enrolled in the pivotal PROTECT-AF and PREVAIL trials of Boston Scientific’s Watchman device or from large clinical registries such as EWOLUTION and the company’s continued access protocol registries.

Further, it’s not well understood what the best strategy is to prevent stroke in AFib patients with ESRD and whether they benefit from anticoagulation with warfarin or any of the newer agents. “Thus, it’s hard to then say: ‘Well they have worse outcomes with Watchman,’ which is true as shown in this study, but they may not have any other options based upon the lack of data for oral anticoagulants in end-stage kidney disease patients,” said Dr. Sherwood, from the Inova Heart and Vascular Institute, Falls Church, Virginia.

The lack of clarity is concerning, given rising atrial fibrillation cases and the prevalence of abnormal renal function in everyday practice. In the present study – involving 21,274 patients undergoing LAA closure between 2016 and 2017 in the Nationwide Readmissions Database – 18.6% of patients had CKD stages I to V and 2.7% had ESRD based on ICD-10 codes.

In-hospital mortality was increased only in patients with ESRD. In all, 3.3% of patients with ESRD and 0.4% of those with no CKD died in hospital (adjusted odds ratio [aOR], 6.48), as did 0.5% of patients with CKD (aOR, 11.43; both P <.001).

“These patients represent a sicker population at baseline and have an inherent greater risk for mortality in cardiac interventions, as noted in other studies of structural heart interventions,” Dr. Ahuja and colleagues write.

Patients with CKD had a higher risk for in-hospital stroke or TIA than patients with no CKD (1.8% vs. 1.3%; aOR, 1.35; P = .038) and this risk continued up to 90 days after discharge (1.7% vs. 1.0%; aOR, 1.67; P = .007).

The in-hospital stroke rate was numerically higher in patients with ESRD compared with no CKD (aOR, 1.18; P = .62).

The authors point out that previous LAA closure and CKD studies have reported no differences in in-hospital or subsequent stroke/TIA rates in patients with and without CKD. Possible explanations are that patients with CKD in the present study had higher CHA2DS2-VASc scores than those without CKD (4.18 vs. 3.62) and, second, patients with CKD and AFib are known to have higher risk for thromboembolic events than those with AFib without CKD.

CKD patients were also more likely than those without CKD to experience in-hospital acute kidney injury or hemodialysis (aOR, 5.02; P <.001).

CKD has been shown to be independently associated with acute kidney injury (AKI) after LAA closure. AKI may have long-term thromboembolic consequences, the authors suggest, with one study reporting higher stroke risk at midterm follow-up in patients with AKI.

“As with other cardiac interventions in patients with CKD, efforts should be made to optimize preoperative renal function, minimize contrast volume, and avoid abrupt hemodynamic changes such as hypotension during the procedure to prevent AKI,” Dr. Ahuja and colleagues write.

Patients with CKD and ESRD had longer index length of stay than those without CKD but had similar rates of other in-hospital complications, such as systemic embolization, bleeding/transfusion, vascular complications, and pericardial tamponade requiring intervention.

Among the short-term outcomes, 30- and 90-day all-cause readmissions were increased in patients with CKD and ESRD compared with those without CKD, and 30-day bleeding readmissions were increased within the CKD cohort.

“With Watchman and left atrial appendage closure, what we see is that they have higher rates of readmission and other problems,” Dr. Sherwood said. “I think we understand that that’s probably related not to the procedure itself, not because the Watchman doesn’t work for end-stage kidney disease, but because the patients themselves are likely higher risk.”

Commonly used risk scores for atrial fibrillation, however, don’t take into account advanced kidney disease, he added.

Besides the inherent limitations of observational studies, Dr. Sherwood and the authors point to the lack of laboratory variables and procedural variables in the database, the fact that CKD was defined using ICD-10 codes, that outcomes were not clinically adjudicated, that unmeasured confounders likely still exist, and that long-term follow-up is lacking.

Dr. Sherwood, who wrote an editorial accompanying the study, said that the release of outcomes data from CKD and ESRD patients in the major clinical trials would be helpful going forward, as would possible involvement with the Kidney Disease Improving Global Outcomes organization.

“One of the main points of this study is that we just need a lot more research diving into this patient population,” he said.

The authors report no relevant financial relationships. Dr. Sherwood reports honoraria from Janssen and Medtronic. Editorial coauthor Sean Pokorney reports research grant support from Gilead, Boston Scientific, Pfizer, Bristol Myers Squibb, Janssen, and the Food and Drug Administration; and advisory board, consulting, and honoraria supports from Medtronic, Boston Scientific, Pfizer, Bristol Myers Squibb, Philips, and Zoll.

A version of this article first appeared on Medscape.com.

Tweets from a black female medical student about the perils of being on call after lengthy hospital shifts was met with a stinging rebuke from the Twitter account of the Connecticut chapter of the American College of Cardiology – prompting an apology and some high-octane exchanges on medical Twitter.

In a series of Tweets, “queen of anonymous medicine” @QueenMD202X describes one friend “working 87 hours this week and 13 days straight” and a second, a third-year medical student working a 15-hour surgical shift. “That is cruel,” she writes, “15-hour shift? For what?????”

In response to a Tweet suggesting that being on call can be a valuable experience for students to know what they’re facing once they get to residency, @QueenMD202X pointed out the 15-hour shifts aren’t just a one-off.

In a now-deleted Tweet that nevertheless appears in several additional tweets as a screenshot, @ConnecticutACC replied: “You might be in the wrong field. You sound very angry probably unsuitable for patient care when your mental state is as you describe it. Emotions are contagious.”

The response from the medical and broader Twitter community was swift, with several tweets calling the chapter’s reply insensitive and racist.

In another Tweet, @BrittGratreak responded by stating: “I think institutions need to be more transparent how they basically weigh the costs & benefits of writing a memorial statement for students who die by suicide rather than investing in changing the toxic culture of medical education to prevent deaths & producing harmed physicians.”

Within hours, Connecticut-ACC issued an apology from their now-deleted account and questioned the origins of the Tweet. “We sincerely apologize for the earlier post as the views do not represent the values or beliefs of the Chapter or broader ACC. We are working to ID its origins. Burnout & well-being are critical issues [that] ACC/CCACC is working to address on behalf of members at all career stages.”

Speaking to this news organization, Connecticut-ACC president and governor Craig McPherson, MD, Yale University, New Haven, Conn., said the chapter believes its account was hacked.

“We provide limited password access to our Twitter account, and we assume, since we’ve contacted most of the individuals who had access to the current password and all of the them deny any knowledge, the account got hacked … it’s just one of those unfortunate aspects of social media,” he said.

The password was quickly changed after the chapter learned of the Tweet on Wednesday and the account has since been closed, at Dr. McPherson’s request.

“We don’t condone that kind of language, that kind of remark. It’s highly inappropriate, and I certainly agree with anyone that voiced that opinion in the Twitterstorm that followed,” he said. “But as I said at the outset, I have no control over what people say on social media once it’s out there. All we can do is apologize for the fact our Twitter feed was used as a vehicle for those comments, which we consider inappropriate.”

Asked whether he considered the remarks racist, Dr. McPherson replied: “That’s not for me to judge.”

ACC president Dipti Itchhaporia, MD, however, weighed in this afternoon with a Tweet citing the need to address clinician well-being and an inclusive workplace.

Some on Twitter recalled their own long hours as a medical student or defended the need to inculcate students in the long hours they’ll face as physicians. Others observed that neither ACC nor its Connecticut chapter addressed the issue of medical student hours in their response. Although fellow and resident hours are regulated, Dr. McPherson pointed out that it’s up to each individual medical school to set the hours for their students.

A version of this article first appeared on Medscape.com.

Tweets from a black female medical student about the perils of being on call after lengthy hospital shifts was met with a stinging rebuke from the Twitter account of the Connecticut chapter of the American College of Cardiology – prompting an apology and some high-octane exchanges on medical Twitter.

In a series of Tweets, “queen of anonymous medicine” @QueenMD202X describes one friend “working 87 hours this week and 13 days straight” and a second, a third-year medical student working a 15-hour surgical shift. “That is cruel,” she writes, “15-hour shift? For what?????”

In response to a Tweet suggesting that being on call can be a valuable experience for students to know what they’re facing once they get to residency, @QueenMD202X pointed out the 15-hour shifts aren’t just a one-off.

In a now-deleted Tweet that nevertheless appears in several additional tweets as a screenshot, @ConnecticutACC replied: “You might be in the wrong field. You sound very angry probably unsuitable for patient care when your mental state is as you describe it. Emotions are contagious.”

The response from the medical and broader Twitter community was swift, with several tweets calling the chapter’s reply insensitive and racist.

In another Tweet, @BrittGratreak responded by stating: “I think institutions need to be more transparent how they basically weigh the costs & benefits of writing a memorial statement for students who die by suicide rather than investing in changing the toxic culture of medical education to prevent deaths & producing harmed physicians.”

Within hours, Connecticut-ACC issued an apology from their now-deleted account and questioned the origins of the Tweet. “We sincerely apologize for the earlier post as the views do not represent the values or beliefs of the Chapter or broader ACC. We are working to ID its origins. Burnout & well-being are critical issues [that] ACC/CCACC is working to address on behalf of members at all career stages.”

Speaking to this news organization, Connecticut-ACC president and governor Craig McPherson, MD, Yale University, New Haven, Conn., said the chapter believes its account was hacked.

“We provide limited password access to our Twitter account, and we assume, since we’ve contacted most of the individuals who had access to the current password and all of the them deny any knowledge, the account got hacked … it’s just one of those unfortunate aspects of social media,” he said.

The password was quickly changed after the chapter learned of the Tweet on Wednesday and the account has since been closed, at Dr. McPherson’s request.

“We don’t condone that kind of language, that kind of remark. It’s highly inappropriate, and I certainly agree with anyone that voiced that opinion in the Twitterstorm that followed,” he said. “But as I said at the outset, I have no control over what people say on social media once it’s out there. All we can do is apologize for the fact our Twitter feed was used as a vehicle for those comments, which we consider inappropriate.”

Asked whether he considered the remarks racist, Dr. McPherson replied: “That’s not for me to judge.”

ACC president Dipti Itchhaporia, MD, however, weighed in this afternoon with a Tweet citing the need to address clinician well-being and an inclusive workplace.

Some on Twitter recalled their own long hours as a medical student or defended the need to inculcate students in the long hours they’ll face as physicians. Others observed that neither ACC nor its Connecticut chapter addressed the issue of medical student hours in their response. Although fellow and resident hours are regulated, Dr. McPherson pointed out that it’s up to each individual medical school to set the hours for their students.

A version of this article first appeared on Medscape.com.

Tweets from a black female medical student about the perils of being on call after lengthy hospital shifts was met with a stinging rebuke from the Twitter account of the Connecticut chapter of the American College of Cardiology – prompting an apology and some high-octane exchanges on medical Twitter.

In a series of Tweets, “queen of anonymous medicine” @QueenMD202X describes one friend “working 87 hours this week and 13 days straight” and a second, a third-year medical student working a 15-hour surgical shift. “That is cruel,” she writes, “15-hour shift? For what?????”

In response to a Tweet suggesting that being on call can be a valuable experience for students to know what they’re facing once they get to residency, @QueenMD202X pointed out the 15-hour shifts aren’t just a one-off.

In a now-deleted Tweet that nevertheless appears in several additional tweets as a screenshot, @ConnecticutACC replied: “You might be in the wrong field. You sound very angry probably unsuitable for patient care when your mental state is as you describe it. Emotions are contagious.”

The response from the medical and broader Twitter community was swift, with several tweets calling the chapter’s reply insensitive and racist.

In another Tweet, @BrittGratreak responded by stating: “I think institutions need to be more transparent how they basically weigh the costs & benefits of writing a memorial statement for students who die by suicide rather than investing in changing the toxic culture of medical education to prevent deaths & producing harmed physicians.”

Within hours, Connecticut-ACC issued an apology from their now-deleted account and questioned the origins of the Tweet. “We sincerely apologize for the earlier post as the views do not represent the values or beliefs of the Chapter or broader ACC. We are working to ID its origins. Burnout & well-being are critical issues [that] ACC/CCACC is working to address on behalf of members at all career stages.”

Speaking to this news organization, Connecticut-ACC president and governor Craig McPherson, MD, Yale University, New Haven, Conn., said the chapter believes its account was hacked.

“We provide limited password access to our Twitter account, and we assume, since we’ve contacted most of the individuals who had access to the current password and all of the them deny any knowledge, the account got hacked … it’s just one of those unfortunate aspects of social media,” he said.

The password was quickly changed after the chapter learned of the Tweet on Wednesday and the account has since been closed, at Dr. McPherson’s request.

“We don’t condone that kind of language, that kind of remark. It’s highly inappropriate, and I certainly agree with anyone that voiced that opinion in the Twitterstorm that followed,” he said. “But as I said at the outset, I have no control over what people say on social media once it’s out there. All we can do is apologize for the fact our Twitter feed was used as a vehicle for those comments, which we consider inappropriate.”

Asked whether he considered the remarks racist, Dr. McPherson replied: “That’s not for me to judge.”

ACC president Dipti Itchhaporia, MD, however, weighed in this afternoon with a Tweet citing the need to address clinician well-being and an inclusive workplace.

Some on Twitter recalled their own long hours as a medical student or defended the need to inculcate students in the long hours they’ll face as physicians. Others observed that neither ACC nor its Connecticut chapter addressed the issue of medical student hours in their response. Although fellow and resident hours are regulated, Dr. McPherson pointed out that it’s up to each individual medical school to set the hours for their students.

A version of this article first appeared on Medscape.com.

For patients with coronary heart disease (CHD), following a Mediterranean diet is more effective in reducing progression of atherosclerosis than following a low-fat diet, according to new data from the CORDIOPREV randomized, controlled trial.

OksanaKiian/Getty Images

“The current study is, to our knowledge, the first to establish an effective dietary strategy for secondary cardiovascular prevention, reinforcing the fact that the Mediterranean diet rich in extra virgin olive oil (EVOO) could prevent the progression of atherosclerosis,” the study team said.

The data also show that patients with a higher atherosclerotic burden might benefit the most from the Mediterranean diet.

The study was published online Aug. 10, 2021, in Stroke.
 

Mediterranean or low fat?

“It is well established that lifestyle and dietary habits powerfully affect cardiovascular risk,” study investigator Elena M. Yubero-Serrano, PhD, with Reina Sofia University Hospital/University of Cordoba (Spain), told this news organization.

“The effectiveness of the Mediterranean diet in reducing cardiovascular risk has been seen in primary prevention. However, currently there is no consensus about a recommended dietary model for the secondary prevention of cardiovascular disease,” she said.

The Coronary Diet Intervention With Olive Oil and Cardiovascular Prevention (CORDIOPREV) study is an ongoing prospective study comparing the effects of two healthy diets for secondary prevention of cardiovascular disease (CVD) in 1002 patients.

The comparative effect of the diets in reducing CVD risk, assessed by quantification of intima-media thickness of the common carotid arteries (IMT-CC), is a key secondary endpoint of the study.

During the study, half of the patients follow a Mediterranean diet rich in EVOO, fruit and vegetables, whole grains, fish, and nuts. The other half follow a diet low in fat and rich in complex carbohydrates.

A total of 939 participants (459 in the low-fat diet group and 480 in the Mediterranean diet group) completed IMT-CC evaluation at baseline, and 809 (377 and 432, respectively) completed the IMT-CC evaluation at 5 years; 731 (335 and 396, respectively) did so at 7 years.

The Mediterranean diet significantly decreased IMT-CC both after 5 years (–0.027; P < .001) and after 7 years (–0.031 mm; P < .001), relative to baseline. In contrast, the low-fat diet did not exert any change on IMT-CC after 5 or 7 years, the researchers report.

The higher the IMT-CC at baseline, the greater the reduction in this parameter.

The Mediterranean diet also produced a greater decrease in IMT-CC and carotid plaque maximum height, compared with the low-fat diet throughout follow-up.

There were no between-group differences in carotid plaque numbers during follow-up.

“Our findings, in addition to reinforcing the clinical benefits of the Mediterranean diet, provide a beneficial dietary strategy as a clinical and therapeutic tool that could reduce the high cardiovascular recurrence in the context of secondary prevention,” Dr. Yubero-Serrano said in an interview.

Earlier data from CORDIOPREV showed that, after 1 year of eating a Mediterranean diet, compared with the low-fat diet, endothelial function was improved among patients with CHD, even those with type 2 diabetes, which was associated with a better balance of vascular homeostasis.

The Mediterranean diet may also modulate the lipid profile, particularly by increasing HDL cholesterol levels. The anti-inflammatory capacity of the Mediterranean diet could be another factor that contributes to reducing the progression of atherosclerosis, the researchers say.
 

Important study

Reached for comment, Alan Rozanski, MD, professor of medicine, Icahn School of Medicine at Mount Sinai and cardiologist at Mount Sinai Morningside, New York, said: “We know very well that lifestyle factors, diet, and exercise in particular are extremely important in promoting health, vitality, and decreasing risk for chronic diseases, including heart attack and stroke.

“But a lot of the studies depend on epidemiological work. Until now, we haven’t had important prospective studies evaluating different kinds of dietary approaches and how they affect carotid intimal thickening assessments that we can do by ultrasound. So having this kind of imaging study which shows that diet can halt progression of atherosclerosis is important,” said Dr. Rozanski.

“Changing one’s diet is extremely important and potentially beneficial in many ways, and being able to say to a patient with atherosclerosis that we have data that shows you can halt the progression of the disease can be extraordinarily encouraging to many patients,” he noted.

“When people have disease, they very often gravitate toward drugs, but continuing to emphasize lifestyle changes in these people is extremely important,” he added.

The CORDIOPREV study was supported by the Fundación Patrimonio Comunal Olivarero. Dr. Yubero-Serrano and Dr. Rozanski disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

For patients with coronary heart disease (CHD), following a Mediterranean diet is more effective in reducing progression of atherosclerosis than following a low-fat diet, according to new data from the CORDIOPREV randomized, controlled trial.

OksanaKiian/Getty Images

“The current study is, to our knowledge, the first to establish an effective dietary strategy for secondary cardiovascular prevention, reinforcing the fact that the Mediterranean diet rich in extra virgin olive oil (EVOO) could prevent the progression of atherosclerosis,” the study team said.

The data also show that patients with a higher atherosclerotic burden might benefit the most from the Mediterranean diet.

The study was published online Aug. 10, 2021, in Stroke.
 

Mediterranean or low fat?

“It is well established that lifestyle and dietary habits powerfully affect cardiovascular risk,” study investigator Elena M. Yubero-Serrano, PhD, with Reina Sofia University Hospital/University of Cordoba (Spain), told this news organization.

“The effectiveness of the Mediterranean diet in reducing cardiovascular risk has been seen in primary prevention. However, currently there is no consensus about a recommended dietary model for the secondary prevention of cardiovascular disease,” she said.

The Coronary Diet Intervention With Olive Oil and Cardiovascular Prevention (CORDIOPREV) study is an ongoing prospective study comparing the effects of two healthy diets for secondary prevention of cardiovascular disease (CVD) in 1002 patients.

The comparative effect of the diets in reducing CVD risk, assessed by quantification of intima-media thickness of the common carotid arteries (IMT-CC), is a key secondary endpoint of the study.

During the study, half of the patients follow a Mediterranean diet rich in EVOO, fruit and vegetables, whole grains, fish, and nuts. The other half follow a diet low in fat and rich in complex carbohydrates.

A total of 939 participants (459 in the low-fat diet group and 480 in the Mediterranean diet group) completed IMT-CC evaluation at baseline, and 809 (377 and 432, respectively) completed the IMT-CC evaluation at 5 years; 731 (335 and 396, respectively) did so at 7 years.

The Mediterranean diet significantly decreased IMT-CC both after 5 years (–0.027; P < .001) and after 7 years (–0.031 mm; P < .001), relative to baseline. In contrast, the low-fat diet did not exert any change on IMT-CC after 5 or 7 years, the researchers report.

The higher the IMT-CC at baseline, the greater the reduction in this parameter.

The Mediterranean diet also produced a greater decrease in IMT-CC and carotid plaque maximum height, compared with the low-fat diet throughout follow-up.

There were no between-group differences in carotid plaque numbers during follow-up.

“Our findings, in addition to reinforcing the clinical benefits of the Mediterranean diet, provide a beneficial dietary strategy as a clinical and therapeutic tool that could reduce the high cardiovascular recurrence in the context of secondary prevention,” Dr. Yubero-Serrano said in an interview.

Earlier data from CORDIOPREV showed that, after 1 year of eating a Mediterranean diet, compared with the low-fat diet, endothelial function was improved among patients with CHD, even those with type 2 diabetes, which was associated with a better balance of vascular homeostasis.

The Mediterranean diet may also modulate the lipid profile, particularly by increasing HDL cholesterol levels. The anti-inflammatory capacity of the Mediterranean diet could be another factor that contributes to reducing the progression of atherosclerosis, the researchers say.
 

Important study

Reached for comment, Alan Rozanski, MD, professor of medicine, Icahn School of Medicine at Mount Sinai and cardiologist at Mount Sinai Morningside, New York, said: “We know very well that lifestyle factors, diet, and exercise in particular are extremely important in promoting health, vitality, and decreasing risk for chronic diseases, including heart attack and stroke.

“But a lot of the studies depend on epidemiological work. Until now, we haven’t had important prospective studies evaluating different kinds of dietary approaches and how they affect carotid intimal thickening assessments that we can do by ultrasound. So having this kind of imaging study which shows that diet can halt progression of atherosclerosis is important,” said Dr. Rozanski.

“Changing one’s diet is extremely important and potentially beneficial in many ways, and being able to say to a patient with atherosclerosis that we have data that shows you can halt the progression of the disease can be extraordinarily encouraging to many patients,” he noted.

“When people have disease, they very often gravitate toward drugs, but continuing to emphasize lifestyle changes in these people is extremely important,” he added.

The CORDIOPREV study was supported by the Fundación Patrimonio Comunal Olivarero. Dr. Yubero-Serrano and Dr. Rozanski disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

For patients with coronary heart disease (CHD), following a Mediterranean diet is more effective in reducing progression of atherosclerosis than following a low-fat diet, according to new data from the CORDIOPREV randomized, controlled trial.

OksanaKiian/Getty Images

“The current study is, to our knowledge, the first to establish an effective dietary strategy for secondary cardiovascular prevention, reinforcing the fact that the Mediterranean diet rich in extra virgin olive oil (EVOO) could prevent the progression of atherosclerosis,” the study team said.

The data also show that patients with a higher atherosclerotic burden might benefit the most from the Mediterranean diet.

The study was published online Aug. 10, 2021, in Stroke.
 

Mediterranean or low fat?

“It is well established that lifestyle and dietary habits powerfully affect cardiovascular risk,” study investigator Elena M. Yubero-Serrano, PhD, with Reina Sofia University Hospital/University of Cordoba (Spain), told this news organization.

“The effectiveness of the Mediterranean diet in reducing cardiovascular risk has been seen in primary prevention. However, currently there is no consensus about a recommended dietary model for the secondary prevention of cardiovascular disease,” she said.

The Coronary Diet Intervention With Olive Oil and Cardiovascular Prevention (CORDIOPREV) study is an ongoing prospective study comparing the effects of two healthy diets for secondary prevention of cardiovascular disease (CVD) in 1002 patients.

The comparative effect of the diets in reducing CVD risk, assessed by quantification of intima-media thickness of the common carotid arteries (IMT-CC), is a key secondary endpoint of the study.

During the study, half of the patients follow a Mediterranean diet rich in EVOO, fruit and vegetables, whole grains, fish, and nuts. The other half follow a diet low in fat and rich in complex carbohydrates.

A total of 939 participants (459 in the low-fat diet group and 480 in the Mediterranean diet group) completed IMT-CC evaluation at baseline, and 809 (377 and 432, respectively) completed the IMT-CC evaluation at 5 years; 731 (335 and 396, respectively) did so at 7 years.

The Mediterranean diet significantly decreased IMT-CC both after 5 years (–0.027; P < .001) and after 7 years (–0.031 mm; P < .001), relative to baseline. In contrast, the low-fat diet did not exert any change on IMT-CC after 5 or 7 years, the researchers report.

The higher the IMT-CC at baseline, the greater the reduction in this parameter.

The Mediterranean diet also produced a greater decrease in IMT-CC and carotid plaque maximum height, compared with the low-fat diet throughout follow-up.

There were no between-group differences in carotid plaque numbers during follow-up.

“Our findings, in addition to reinforcing the clinical benefits of the Mediterranean diet, provide a beneficial dietary strategy as a clinical and therapeutic tool that could reduce the high cardiovascular recurrence in the context of secondary prevention,” Dr. Yubero-Serrano said in an interview.

Earlier data from CORDIOPREV showed that, after 1 year of eating a Mediterranean diet, compared with the low-fat diet, endothelial function was improved among patients with CHD, even those with type 2 diabetes, which was associated with a better balance of vascular homeostasis.

The Mediterranean diet may also modulate the lipid profile, particularly by increasing HDL cholesterol levels. The anti-inflammatory capacity of the Mediterranean diet could be another factor that contributes to reducing the progression of atherosclerosis, the researchers say.
 

Important study

Reached for comment, Alan Rozanski, MD, professor of medicine, Icahn School of Medicine at Mount Sinai and cardiologist at Mount Sinai Morningside, New York, said: “We know very well that lifestyle factors, diet, and exercise in particular are extremely important in promoting health, vitality, and decreasing risk for chronic diseases, including heart attack and stroke.

“But a lot of the studies depend on epidemiological work. Until now, we haven’t had important prospective studies evaluating different kinds of dietary approaches and how they affect carotid intimal thickening assessments that we can do by ultrasound. So having this kind of imaging study which shows that diet can halt progression of atherosclerosis is important,” said Dr. Rozanski.

“Changing one’s diet is extremely important and potentially beneficial in many ways, and being able to say to a patient with atherosclerosis that we have data that shows you can halt the progression of the disease can be extraordinarily encouraging to many patients,” he noted.

“When people have disease, they very often gravitate toward drugs, but continuing to emphasize lifestyle changes in these people is extremely important,” he added.

The CORDIOPREV study was supported by the Fundación Patrimonio Comunal Olivarero. Dr. Yubero-Serrano and Dr. Rozanski disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A 63-year-old man undergoes cardiac bypass surgery. He is able to be extubated at 8 hours. The next morning he has a fever to 38.5° C His exam shows no redness at the surgical site, or at his IV sites. His lung exam is unremarkable. His urinalysis is without white blood cells. His white blood cell count is 8,500, and his chest x-ray shows atelectasis without other abnormalities.

What is the most likely cause of this patient’s fever? The research papers cited below suggest what it isn’t and what it might be.

One of the earliest things I was taught in my clinical years were the causes of postoperative fever, or the 5Ws, which are wind, water, wound, walk, and wonder drug.

Atelectasis was touted as the cause of early postoperative fever. This became clear fact in my medical student mind, not something that I had ever questioned.  But investigation into whether there is evidence of this shows it is only a myth. In actuality, there is scant evidence, if any, for atelectasis causing fever. Frequently, no cause of postoperative fever has been found, despite aggressive attempts to look for one.

What the research says

Fanning and colleagues prospectively looked at 537 women who were undergoing major gynecologic surgery.¹ Postoperative fever occurred in 211 of them. In 92% of these patients, no cause for fever was found.

Atelectasis is frequently seen postoperatively. Schlenker and colleagues reported that, in patients with postoperative atelectasis, temperature elevation on the first postoperative day was directly related to the degree of atelectasis, but the white blood cell count elevation was inversely related.²

In this study, atelectasis was diagnosed by auscultation, with chest x-rays ordered at the discretion of the physician. There was little correlation with the auscultatory findings and presence or absence of atelectasis in the patients who did receive chest x-rays.

Engoren did a study to prospectively evaluate 100 postoperative patients with daily chest x-rays and continuous temperature monitoring.³ Results from the day of surgery (day 0) to the second postoperative day showed an increase in presence of atelectasis from 43% on the day of surgery to 79% by day 2.

Fever, defined as temperature greater than 38° C, fell from 37% on the day of surgery to 17% by day 2. Engoren found no association between fever and degree of atelectasis.

Mavros and colleagues did a comprehensive review to determine whether there was evidence to support atelectasis causing fever.⁴ They concluded that there was no clinical evidence supporting the concept that atelectasis is associated with early postoperative fever.
 

A possible cause of fever

Mavros and colleagues’ paper suggested that early postoperative fever was caused by stress derived by surgery, which can increase the patient’s interleukin-6 levels and thermostatic set point. This was demonstrated in a small study by Wortel and colleagues, who measured IL-6 levels in the portal and peripheral blood of patients following pancreaticoduodenectomy.⁵ They found IL-6 levels correlated strongly with peak body temperature.

In conclusion, atelectasis is not a well-established cause of postoperative fever.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at imnews@mdedge.com.

References

1. Fanning J et al. Infect Dis Obstet Gynecol. 1998; 6(6):252-5 .

2. Schlenker JD and Hubay CA. Arch Surg 1973;107:846-50

3. Engoren M. Chest. 1995;107(1):81-4 .

4. Michael N et al. Chest. 2011;140(2):418-24

5. Wortel CH et al. Surgery. 1993;114(3):564-70 .

A 63-year-old man undergoes cardiac bypass surgery. He is able to be extubated at 8 hours. The next morning he has a fever to 38.5° C His exam shows no redness at the surgical site, or at his IV sites. His lung exam is unremarkable. His urinalysis is without white blood cells. His white blood cell count is 8,500, and his chest x-ray shows atelectasis without other abnormalities.

What is the most likely cause of this patient’s fever? The research papers cited below suggest what it isn’t and what it might be.

One of the earliest things I was taught in my clinical years were the causes of postoperative fever, or the 5Ws, which are wind, water, wound, walk, and wonder drug.

Atelectasis was touted as the cause of early postoperative fever. This became clear fact in my medical student mind, not something that I had ever questioned.  But investigation into whether there is evidence of this shows it is only a myth. In actuality, there is scant evidence, if any, for atelectasis causing fever. Frequently, no cause of postoperative fever has been found, despite aggressive attempts to look for one.

What the research says

Fanning and colleagues prospectively looked at 537 women who were undergoing major gynecologic surgery.¹ Postoperative fever occurred in 211 of them. In 92% of these patients, no cause for fever was found.

Atelectasis is frequently seen postoperatively. Schlenker and colleagues reported that, in patients with postoperative atelectasis, temperature elevation on the first postoperative day was directly related to the degree of atelectasis, but the white blood cell count elevation was inversely related.²

In this study, atelectasis was diagnosed by auscultation, with chest x-rays ordered at the discretion of the physician. There was little correlation with the auscultatory findings and presence or absence of atelectasis in the patients who did receive chest x-rays.

Engoren did a study to prospectively evaluate 100 postoperative patients with daily chest x-rays and continuous temperature monitoring.³ Results from the day of surgery (day 0) to the second postoperative day showed an increase in presence of atelectasis from 43% on the day of surgery to 79% by day 2.

Fever, defined as temperature greater than 38° C, fell from 37% on the day of surgery to 17% by day 2. Engoren found no association between fever and degree of atelectasis.

Mavros and colleagues did a comprehensive review to determine whether there was evidence to support atelectasis causing fever.⁴ They concluded that there was no clinical evidence supporting the concept that atelectasis is associated with early postoperative fever.
 

A possible cause of fever

Mavros and colleagues’ paper suggested that early postoperative fever was caused by stress derived by surgery, which can increase the patient’s interleukin-6 levels and thermostatic set point. This was demonstrated in a small study by Wortel and colleagues, who measured IL-6 levels in the portal and peripheral blood of patients following pancreaticoduodenectomy.⁵ They found IL-6 levels correlated strongly with peak body temperature.

In conclusion, atelectasis is not a well-established cause of postoperative fever.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at imnews@mdedge.com.

References

1. Fanning J et al. Infect Dis Obstet Gynecol. 1998; 6(6):252-5 .

2. Schlenker JD and Hubay CA. Arch Surg 1973;107:846-50

3. Engoren M. Chest. 1995;107(1):81-4 .

4. Michael N et al. Chest. 2011;140(2):418-24

5. Wortel CH et al. Surgery. 1993;114(3):564-70 .

A 63-year-old man undergoes cardiac bypass surgery. He is able to be extubated at 8 hours. The next morning he has a fever to 38.5° C His exam shows no redness at the surgical site, or at his IV sites. His lung exam is unremarkable. His urinalysis is without white blood cells. His white blood cell count is 8,500, and his chest x-ray shows atelectasis without other abnormalities.

What is the most likely cause of this patient’s fever? The research papers cited below suggest what it isn’t and what it might be.

One of the earliest things I was taught in my clinical years were the causes of postoperative fever, or the 5Ws, which are wind, water, wound, walk, and wonder drug.

Atelectasis was touted as the cause of early postoperative fever. This became clear fact in my medical student mind, not something that I had ever questioned.  But investigation into whether there is evidence of this shows it is only a myth. In actuality, there is scant evidence, if any, for atelectasis causing fever. Frequently, no cause of postoperative fever has been found, despite aggressive attempts to look for one.

What the research says

Fanning and colleagues prospectively looked at 537 women who were undergoing major gynecologic surgery.¹ Postoperative fever occurred in 211 of them. In 92% of these patients, no cause for fever was found.

Atelectasis is frequently seen postoperatively. Schlenker and colleagues reported that, in patients with postoperative atelectasis, temperature elevation on the first postoperative day was directly related to the degree of atelectasis, but the white blood cell count elevation was inversely related.²

In this study, atelectasis was diagnosed by auscultation, with chest x-rays ordered at the discretion of the physician. There was little correlation with the auscultatory findings and presence or absence of atelectasis in the patients who did receive chest x-rays.

Engoren did a study to prospectively evaluate 100 postoperative patients with daily chest x-rays and continuous temperature monitoring.³ Results from the day of surgery (day 0) to the second postoperative day showed an increase in presence of atelectasis from 43% on the day of surgery to 79% by day 2.

Fever, defined as temperature greater than 38° C, fell from 37% on the day of surgery to 17% by day 2. Engoren found no association between fever and degree of atelectasis.

Mavros and colleagues did a comprehensive review to determine whether there was evidence to support atelectasis causing fever.⁴ They concluded that there was no clinical evidence supporting the concept that atelectasis is associated with early postoperative fever.
 

A possible cause of fever

Mavros and colleagues’ paper suggested that early postoperative fever was caused by stress derived by surgery, which can increase the patient’s interleukin-6 levels and thermostatic set point. This was demonstrated in a small study by Wortel and colleagues, who measured IL-6 levels in the portal and peripheral blood of patients following pancreaticoduodenectomy.⁵ They found IL-6 levels correlated strongly with peak body temperature.

In conclusion, atelectasis is not a well-established cause of postoperative fever.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at imnews@mdedge.com.

References

1. Fanning J et al. Infect Dis Obstet Gynecol. 1998; 6(6):252-5 .

2. Schlenker JD and Hubay CA. Arch Surg 1973;107:846-50

3. Engoren M. Chest. 1995;107(1):81-4 .

4. Michael N et al. Chest. 2011;140(2):418-24

5. Wortel CH et al. Surgery. 1993;114(3):564-70 .

The U.S. Food and Drug Administration approved empagliflozin (Jardiance) as a treatment for adults with heart failure with reduced ejection fraction (HFrEF) regardless of whether patients have diabetes on Aug. 18, making it the second agent from the sodium-glucose transporter 2 inhibitor class to received this indication.

Empagliflozin first received FDA marketing approval in 2014 for improving glycemic control in patients with type 2 diabetes, and in 2016 the agency added a second indication of reducing cardiovascular death in patients with type 2 diabetes and cardiovascular disease. The newly granted indication for patients with HFrEF without regard to glycemic status was for reducing the risk for cardiovascular death and hospitalization for heart failure, according to a statement from Boehringer Ingelheim and Lilly, the two companies that together market empagliflozin.

The statement also said that the approval allowed for empagliflozin treatment in patients with HFrEF and an estimated glomerular filtration rate (eGFR) as low as 20 mL/min per 1.73 m², in contrast to its indication for improving glycemic control in patients with type 2 diabetes that limits use to patients with an eGFR of at least 30 mL per 1.73 m².


EMPEROR-Reduced results drive approval

The FDA based its decision on results from the EMPEROR-Reduced study, first reported in August 2020, that showed treatment of patients with HFrEF with empagliflozin on top of standard therapy for a median of 16 months cut the incidence of cardiovascular death or hospitalization for worsening heart failure by 25% relative to placebo, and by an absolute 5.3%, compared with placebo-treated patients.

Patients enrolled in EMPEROR-Reduced had chronic heart failure in New York Heart Association functional class II-IV and with a left ventricular ejection fraction of 40% or less, the standard ejection fraction criterion for defining HFrEF. Half the enrolled patients had diabetes, and analysis showed no heterogeneity in the primary outcome response based on diabetes status at enrollment.


Empagliflozin joins dapagliflozin for treating HFrEF

Dapagliflozin (Farxiga) was the first agent from the SGLT2 inhibitor class to receive an FDA indication, in 2020, for treating patients with HFrEF regardless of their diabetes status, a decision based on results from the DAPA-HF trial. Results from DAPA-HF showed that treatment with dapagliflozin in patients with HFrEF for a median of 18 months led to a 26% relative reduction in the incidence of cardiovascular death or worsening heart failure and a 4.9% absolute reduction, compared with placebo when added to standard treatment. DAPA-HF enrolled patients using similar criteria to EMPEROR-Reduced, and 42% of enrolled patients had diabetes with no heterogeneity in the primary outcome related to baseline diabetes status.

Subsequent to the report of results from the EMPEROR-Reduced trial nearly a year ago, heart failure experts declared that treatment with an agent from the SGLT2 inhibitor class had become a “new pillar of foundational therapy for HFrEF,” and they urged rapid initiation of an SGLT2 inhibitor (along with other appropriate medications) at the time of initial diagnosis of HFrEF.

mzoler@mdedge.com

The U.S. Food and Drug Administration approved empagliflozin (Jardiance) as a treatment for adults with heart failure with reduced ejection fraction (HFrEF) regardless of whether patients have diabetes on Aug. 18, making it the second agent from the sodium-glucose transporter 2 inhibitor class to received this indication.

Empagliflozin first received FDA marketing approval in 2014 for improving glycemic control in patients with type 2 diabetes, and in 2016 the agency added a second indication of reducing cardiovascular death in patients with type 2 diabetes and cardiovascular disease. The newly granted indication for patients with HFrEF without regard to glycemic status was for reducing the risk for cardiovascular death and hospitalization for heart failure, according to a statement from Boehringer Ingelheim and Lilly, the two companies that together market empagliflozin.

The statement also said that the approval allowed for empagliflozin treatment in patients with HFrEF and an estimated glomerular filtration rate (eGFR) as low as 20 mL/min per 1.73 m², in contrast to its indication for improving glycemic control in patients with type 2 diabetes that limits use to patients with an eGFR of at least 30 mL per 1.73 m².


EMPEROR-Reduced results drive approval

The FDA based its decision on results from the EMPEROR-Reduced study, first reported in August 2020, that showed treatment of patients with HFrEF with empagliflozin on top of standard therapy for a median of 16 months cut the incidence of cardiovascular death or hospitalization for worsening heart failure by 25% relative to placebo, and by an absolute 5.3%, compared with placebo-treated patients.

Patients enrolled in EMPEROR-Reduced had chronic heart failure in New York Heart Association functional class II-IV and with a left ventricular ejection fraction of 40% or less, the standard ejection fraction criterion for defining HFrEF. Half the enrolled patients had diabetes, and analysis showed no heterogeneity in the primary outcome response based on diabetes status at enrollment.


Empagliflozin joins dapagliflozin for treating HFrEF

Dapagliflozin (Farxiga) was the first agent from the SGLT2 inhibitor class to receive an FDA indication, in 2020, for treating patients with HFrEF regardless of their diabetes status, a decision based on results from the DAPA-HF trial. Results from DAPA-HF showed that treatment with dapagliflozin in patients with HFrEF for a median of 18 months led to a 26% relative reduction in the incidence of cardiovascular death or worsening heart failure and a 4.9% absolute reduction, compared with placebo when added to standard treatment. DAPA-HF enrolled patients using similar criteria to EMPEROR-Reduced, and 42% of enrolled patients had diabetes with no heterogeneity in the primary outcome related to baseline diabetes status.

Subsequent to the report of results from the EMPEROR-Reduced trial nearly a year ago, heart failure experts declared that treatment with an agent from the SGLT2 inhibitor class had become a “new pillar of foundational therapy for HFrEF,” and they urged rapid initiation of an SGLT2 inhibitor (along with other appropriate medications) at the time of initial diagnosis of HFrEF.

mzoler@mdedge.com

The U.S. Food and Drug Administration approved empagliflozin (Jardiance) as a treatment for adults with heart failure with reduced ejection fraction (HFrEF) regardless of whether patients have diabetes on Aug. 18, making it the second agent from the sodium-glucose transporter 2 inhibitor class to received this indication.

Empagliflozin first received FDA marketing approval in 2014 for improving glycemic control in patients with type 2 diabetes, and in 2016 the agency added a second indication of reducing cardiovascular death in patients with type 2 diabetes and cardiovascular disease. The newly granted indication for patients with HFrEF without regard to glycemic status was for reducing the risk for cardiovascular death and hospitalization for heart failure, according to a statement from Boehringer Ingelheim and Lilly, the two companies that together market empagliflozin.

The statement also said that the approval allowed for empagliflozin treatment in patients with HFrEF and an estimated glomerular filtration rate (eGFR) as low as 20 mL/min per 1.73 m², in contrast to its indication for improving glycemic control in patients with type 2 diabetes that limits use to patients with an eGFR of at least 30 mL per 1.73 m².


EMPEROR-Reduced results drive approval

The FDA based its decision on results from the EMPEROR-Reduced study, first reported in August 2020, that showed treatment of patients with HFrEF with empagliflozin on top of standard therapy for a median of 16 months cut the incidence of cardiovascular death or hospitalization for worsening heart failure by 25% relative to placebo, and by an absolute 5.3%, compared with placebo-treated patients.

Patients enrolled in EMPEROR-Reduced had chronic heart failure in New York Heart Association functional class II-IV and with a left ventricular ejection fraction of 40% or less, the standard ejection fraction criterion for defining HFrEF. Half the enrolled patients had diabetes, and analysis showed no heterogeneity in the primary outcome response based on diabetes status at enrollment.


Empagliflozin joins dapagliflozin for treating HFrEF

Dapagliflozin (Farxiga) was the first agent from the SGLT2 inhibitor class to receive an FDA indication, in 2020, for treating patients with HFrEF regardless of their diabetes status, a decision based on results from the DAPA-HF trial. Results from DAPA-HF showed that treatment with dapagliflozin in patients with HFrEF for a median of 18 months led to a 26% relative reduction in the incidence of cardiovascular death or worsening heart failure and a 4.9% absolute reduction, compared with placebo when added to standard treatment. DAPA-HF enrolled patients using similar criteria to EMPEROR-Reduced, and 42% of enrolled patients had diabetes with no heterogeneity in the primary outcome related to baseline diabetes status.

Subsequent to the report of results from the EMPEROR-Reduced trial nearly a year ago, heart failure experts declared that treatment with an agent from the SGLT2 inhibitor class had become a “new pillar of foundational therapy for HFrEF,” and they urged rapid initiation of an SGLT2 inhibitor (along with other appropriate medications) at the time of initial diagnosis of HFrEF.

mzoler@mdedge.com

Spending more free time seated combined with engaging in low physical activity is associated with an increased risk of stroke in adults aged between 40 and 60 years, according to a new analysis.

While the risk of stroke increased more than fourfold among sedentary people under the age of 60, no significant increase in risk was observed among older individuals, according to the study based on self-reported data from more than 140,000 people. This highlights the need for relevant public health messaging directed at younger people, reported lead author, Raed A. Joundi, MD, DPhil, a stroke fellow at the University of Calgary (Alta.), and colleagues, in the paper published in Stroke.

“Sedentary time has increased over the past 2 decades in the United States and Canada, particularly in the young, raising the importance of characterizing its effect on long-term health , ” the investigators wrote. “A better understanding of the risk of sedentary time specific to stroke may be important for public health campaigns to reduce sedentary behavior.” Dr. Joundi and colleagues reviewed data from the Canadian Community Health Survey, including 143,180 healthy individuals without baseline history of cancer, heart disease, or stroke. Those under the age of 40 years were also excluded from the analysis.

Excess sedentary leisure time was defined as 8 or more hours of sedentary leisure time per day, whereas low physical activity was defined as less than 3.5 metabolic equivalent hours per week. The analysis also included a range of demographic and medical covariates, such as age, sex, marital status, smoking status, presence of hypertension, and others.

After a median follow-up of 9.4 years, 2,965 stroke events occurred, with a median time from survey response of 5.6 years. Risk of stroke among individuals aged younger than 60 years who engaged in low physical activity and excess sedentary leisure time was increased 4.5-fold, compared with individuals with low physical activity who were sedentary less than 4 hours per day (fully adjusted hazard ratio, 4.50; 95% confidence interval, 1.64-12.3).
 

Findings highlight benefits of physical activity

Similar risk elevations were not observed among individuals aged 60-79 years, or those older than 80. And among people younger than 60, high physical activity appeared to eliminate the additional risk imposed by excess sedentary leisure time.

“Sedentary time is associated with higher risk of stroke in inactive individuals, but not an active individual, ” Dr. Joundi said in an interview. “So it suggests that there’s two ways to lower risk: One would be to lower your sedentary time, and the other would be to engage in physical activity.”

These interpretations are speculative, Dr. Joundi cautioned, as the study was not interventional. Even so, he said that the findings “bring the spotlight back on physical activity,” thereby aligning with previous research.

“The more you exercise, the more that relationship between sedentary time and poor health outcomes is blunted, and in fact, can be completely negated with enough physical activity,” he said.

How exactly physical activity offers such protection remains unclear, Dr. Joundi added. He speculated that regularity of exercise may be key, with each session counteracting the adverse effects of prolonged sedentary time, which may include reduced blood flow, increased insulin resistance, and inflammatory changes that can affect blood vessels.

“This study is particularly a message for younger individuals,” Dr. Joundi said, suggesting that the findings may alter behavior, as many people have witnessed, or are aware of, the long-term impacts of stroke.

“There’s a sort of social or cognitive aversion to stroke, I think, in the general population, because of how disabling it can be, and how it can lower your quality of life,” he said.
 

Subtle lifestyle changes may be enough.

For those aiming to lower their risk of stroke, Dr. Joundi suggested that subtle lifestyle changes may be enough.

“Ultimately, what we saw is that even minimal amounts of physical activity – walking 3 hours a week, for example – could blunt the impact of sedentary time,” he said. “Doing what you can, even if it’s a small amount, tends to be quite meaningful over a long period of time.”

Daniel T. Lackland, DrPH, professor of epidemiology in the department of neurology at the Medical University of South Carolina, Charleston, offered a similar takeaway, noting that small efforts can lead to great benefits.

“Less intense activity is still better than being sedentary,” he said in an interview. “For many people, if you do get up and you just walk around, move your arms around – do any kind of movement – that’s better than being sedentary.”

Dr. Lackland applauded the practicality of studying sedentary leisure time, versus overall leisure time, as many people can’t control their work environment.

“You can’t do very much about how you work your job,” Dr. Lackland said. “Sometimes we have to sit, and I guess there are things you can do – you can put a treadmill instead of a chair and that kind of thing – but more often than not, you don’t really have that choice to do something. With leisure time, though, you’re in full control. And so what do you do with your leisure time? Do you sit and watch TV, or do you engage in some type of activity? Not necessarily aerobic activity, but some type of activity that would not let you be sedentary. You want to be active as much as you possibly can.”

Dr. Joundi disclosed grant support from the Canadian Institutes of Health Research. The other investigators and Dr. Lackland reported no relevant disclosures.

Spending more free time seated combined with engaging in low physical activity is associated with an increased risk of stroke in adults aged between 40 and 60 years, according to a new analysis.

While the risk of stroke increased more than fourfold among sedentary people under the age of 60, no significant increase in risk was observed among older individuals, according to the study based on self-reported data from more than 140,000 people. This highlights the need for relevant public health messaging directed at younger people, reported lead author, Raed A. Joundi, MD, DPhil, a stroke fellow at the University of Calgary (Alta.), and colleagues, in the paper published in Stroke.

“Sedentary time has increased over the past 2 decades in the United States and Canada, particularly in the young, raising the importance of characterizing its effect on long-term health , ” the investigators wrote. “A better understanding of the risk of sedentary time specific to stroke may be important for public health campaigns to reduce sedentary behavior.” Dr. Joundi and colleagues reviewed data from the Canadian Community Health Survey, including 143,180 healthy individuals without baseline history of cancer, heart disease, or stroke. Those under the age of 40 years were also excluded from the analysis.

Excess sedentary leisure time was defined as 8 or more hours of sedentary leisure time per day, whereas low physical activity was defined as less than 3.5 metabolic equivalent hours per week. The analysis also included a range of demographic and medical covariates, such as age, sex, marital status, smoking status, presence of hypertension, and others.

After a median follow-up of 9.4 years, 2,965 stroke events occurred, with a median time from survey response of 5.6 years. Risk of stroke among individuals aged younger than 60 years who engaged in low physical activity and excess sedentary leisure time was increased 4.5-fold, compared with individuals with low physical activity who were sedentary less than 4 hours per day (fully adjusted hazard ratio, 4.50; 95% confidence interval, 1.64-12.3).
 

Findings highlight benefits of physical activity

Similar risk elevations were not observed among individuals aged 60-79 years, or those older than 80. And among people younger than 60, high physical activity appeared to eliminate the additional risk imposed by excess sedentary leisure time.

“Sedentary time is associated with higher risk of stroke in inactive individuals, but not an active individual, ” Dr. Joundi said in an interview. “So it suggests that there’s two ways to lower risk: One would be to lower your sedentary time, and the other would be to engage in physical activity.”

These interpretations are speculative, Dr. Joundi cautioned, as the study was not interventional. Even so, he said that the findings “bring the spotlight back on physical activity,” thereby aligning with previous research.

“The more you exercise, the more that relationship between sedentary time and poor health outcomes is blunted, and in fact, can be completely negated with enough physical activity,” he said.

How exactly physical activity offers such protection remains unclear, Dr. Joundi added. He speculated that regularity of exercise may be key, with each session counteracting the adverse effects of prolonged sedentary time, which may include reduced blood flow, increased insulin resistance, and inflammatory changes that can affect blood vessels.

“This study is particularly a message for younger individuals,” Dr. Joundi said, suggesting that the findings may alter behavior, as many people have witnessed, or are aware of, the long-term impacts of stroke.

“There’s a sort of social or cognitive aversion to stroke, I think, in the general population, because of how disabling it can be, and how it can lower your quality of life,” he said.
 

Subtle lifestyle changes may be enough.

For those aiming to lower their risk of stroke, Dr. Joundi suggested that subtle lifestyle changes may be enough.

“Ultimately, what we saw is that even minimal amounts of physical activity – walking 3 hours a week, for example – could blunt the impact of sedentary time,” he said. “Doing what you can, even if it’s a small amount, tends to be quite meaningful over a long period of time.”

Daniel T. Lackland, DrPH, professor of epidemiology in the department of neurology at the Medical University of South Carolina, Charleston, offered a similar takeaway, noting that small efforts can lead to great benefits.

“Less intense activity is still better than being sedentary,” he said in an interview. “For many people, if you do get up and you just walk around, move your arms around – do any kind of movement – that’s better than being sedentary.”

Dr. Lackland applauded the practicality of studying sedentary leisure time, versus overall leisure time, as many people can’t control their work environment.

“You can’t do very much about how you work your job,” Dr. Lackland said. “Sometimes we have to sit, and I guess there are things you can do – you can put a treadmill instead of a chair and that kind of thing – but more often than not, you don’t really have that choice to do something. With leisure time, though, you’re in full control. And so what do you do with your leisure time? Do you sit and watch TV, or do you engage in some type of activity? Not necessarily aerobic activity, but some type of activity that would not let you be sedentary. You want to be active as much as you possibly can.”

Dr. Joundi disclosed grant support from the Canadian Institutes of Health Research. The other investigators and Dr. Lackland reported no relevant disclosures.

Spending more free time seated combined with engaging in low physical activity is associated with an increased risk of stroke in adults aged between 40 and 60 years, according to a new analysis.

While the risk of stroke increased more than fourfold among sedentary people under the age of 60, no significant increase in risk was observed among older individuals, according to the study based on self-reported data from more than 140,000 people. This highlights the need for relevant public health messaging directed at younger people, reported lead author, Raed A. Joundi, MD, DPhil, a stroke fellow at the University of Calgary (Alta.), and colleagues, in the paper published in Stroke.

“Sedentary time has increased over the past 2 decades in the United States and Canada, particularly in the young, raising the importance of characterizing its effect on long-term health , ” the investigators wrote. “A better understanding of the risk of sedentary time specific to stroke may be important for public health campaigns to reduce sedentary behavior.” Dr. Joundi and colleagues reviewed data from the Canadian Community Health Survey, including 143,180 healthy individuals without baseline history of cancer, heart disease, or stroke. Those under the age of 40 years were also excluded from the analysis.

Excess sedentary leisure time was defined as 8 or more hours of sedentary leisure time per day, whereas low physical activity was defined as less than 3.5 metabolic equivalent hours per week. The analysis also included a range of demographic and medical covariates, such as age, sex, marital status, smoking status, presence of hypertension, and others.

After a median follow-up of 9.4 years, 2,965 stroke events occurred, with a median time from survey response of 5.6 years. Risk of stroke among individuals aged younger than 60 years who engaged in low physical activity and excess sedentary leisure time was increased 4.5-fold, compared with individuals with low physical activity who were sedentary less than 4 hours per day (fully adjusted hazard ratio, 4.50; 95% confidence interval, 1.64-12.3).
 

Findings highlight benefits of physical activity

Similar risk elevations were not observed among individuals aged 60-79 years, or those older than 80. And among people younger than 60, high physical activity appeared to eliminate the additional risk imposed by excess sedentary leisure time.

“Sedentary time is associated with higher risk of stroke in inactive individuals, but not an active individual, ” Dr. Joundi said in an interview. “So it suggests that there’s two ways to lower risk: One would be to lower your sedentary time, and the other would be to engage in physical activity.”

These interpretations are speculative, Dr. Joundi cautioned, as the study was not interventional. Even so, he said that the findings “bring the spotlight back on physical activity,” thereby aligning with previous research.

“The more you exercise, the more that relationship between sedentary time and poor health outcomes is blunted, and in fact, can be completely negated with enough physical activity,” he said.

How exactly physical activity offers such protection remains unclear, Dr. Joundi added. He speculated that regularity of exercise may be key, with each session counteracting the adverse effects of prolonged sedentary time, which may include reduced blood flow, increased insulin resistance, and inflammatory changes that can affect blood vessels.

“This study is particularly a message for younger individuals,” Dr. Joundi said, suggesting that the findings may alter behavior, as many people have witnessed, or are aware of, the long-term impacts of stroke.

“There’s a sort of social or cognitive aversion to stroke, I think, in the general population, because of how disabling it can be, and how it can lower your quality of life,” he said.
 

Subtle lifestyle changes may be enough.

For those aiming to lower their risk of stroke, Dr. Joundi suggested that subtle lifestyle changes may be enough.

“Ultimately, what we saw is that even minimal amounts of physical activity – walking 3 hours a week, for example – could blunt the impact of sedentary time,” he said. “Doing what you can, even if it’s a small amount, tends to be quite meaningful over a long period of time.”

Daniel T. Lackland, DrPH, professor of epidemiology in the department of neurology at the Medical University of South Carolina, Charleston, offered a similar takeaway, noting that small efforts can lead to great benefits.

“Less intense activity is still better than being sedentary,” he said in an interview. “For many people, if you do get up and you just walk around, move your arms around – do any kind of movement – that’s better than being sedentary.”

Dr. Lackland applauded the practicality of studying sedentary leisure time, versus overall leisure time, as many people can’t control their work environment.

“You can’t do very much about how you work your job,” Dr. Lackland said. “Sometimes we have to sit, and I guess there are things you can do – you can put a treadmill instead of a chair and that kind of thing – but more often than not, you don’t really have that choice to do something. With leisure time, though, you’re in full control. And so what do you do with your leisure time? Do you sit and watch TV, or do you engage in some type of activity? Not necessarily aerobic activity, but some type of activity that would not let you be sedentary. You want to be active as much as you possibly can.”

Dr. Joundi disclosed grant support from the Canadian Institutes of Health Research. The other investigators and Dr. Lackland reported no relevant disclosures.