Dr. Aaronson's Must Not Miss: Additional Benefits of the SGLT2 Inhibitors and Treating Diabetes 6.12.2020

Start in the center and read like a clock, starting at 1 o'clock and ending at 11.
What are 2 additional benefits of the SGLT2 inhibitors?

What are 2 additional benefits of the SGLT2 inhibitors in addition to blood sugar control?

Note: your primary provider or endocrinologist will prescribe these medications for you. We nephrologists collaborate with your team to help prevent worsening chronic kidney disease. It's important to know the different providers' roles in the management of your care.

In patients with diabetes mellitus and chronic kidney disease, medications in the SGLT2 (Sodium-glucose Cotransporter-2) class of medications, medications that include dapagliflozin (also called Farxiga), empagliflozin (also called Jardiance), and Canagliflozin (also called Invokana) can provide 2 additional benefits besides sugar control. These benefits include:

1. Weight loss: patients can excrete up to 100 grams of glucose per day in the urine. That amount equates to around 300 calories a day of sugar. That's equivalent to around 2 cans of soda pop.
2. The SGLT2 inhibitors decrease the risk of kidney disease and protect patients against acute kidney injury in the future.

When tolerated, the SGLT2 inhibitors are frequently combined with metformin. If you have more interest in this modality of therapy, ask your doctor for more information.

Recommended reading: SGLT2 inhibitors for the prevention of kidney failure in patients with Type 2 diabetes.

Beatrice Dialysis Unit Ranks First Taking Care of Patients with End Stage Kidney Disease

This certificate is awarded to Beatrice Dialysis in Beatrice, Nebraska in recognition of achieving the first Quartile Leaderboard: May 2020

Beatrice Dialysis has been recognized as having been placed in the top 15% of units nationwide. Dr. Michael Aaronson, who is part of the team and currently follows the patients there, has decided to opine:

Dr. Michael Aaronson: Board Certified Nephrologist: The pleasure, the privilege is mine -- Morrissey  on Youtube.

There Is a Light That Never Goes Out...

In summary: Michael Aaronson, Nephrologist / Kidney Doctor and High Blood pressure specialist, who sees the kidney dialysis patients at Beatrice in Nebraska is part of a team recognized for achieving very high-quality scores suggesting the patients at Beatrice Dialysis are getting world-class care.

Dr. Michael Aaronson

I'm I Still Ill? Dr. Michael Aaronson Recommends Preventing the Spread of Covid-19 by Wearing a Mask in Public Places

The risk of transmission of Covid-19 from one person to another: the novel coronavirus is rarely transmitted from person to person when all parties wear a mask. This very low risk of transmission includes the case where a person who has Covid-19 is close to someone who does not have it.

Ask me why (sans mask), and I'll die. Ask me why, and I'll die. And if you must.... Go to work, tomorrow. [Just please remember to wear a mask.]

I'm I still ill? -- Morrissey on YouTube

Historians note: A recent study found that people are most contagious two days before they have symptoms. Another study indicated that if at least 80% of the population wore a mask, we could reduce the spread of COVID-19 by over 90%.

Dr. Aaronson suggests wearing a mask whilst in public to prevent the spread of Covid-19, the novel coronavirus.

Dr. Aaronson Gives Kudos To The University of Nebraska for Their Participation in Remdesivir Trial

The National Institute of Health study demonstrated that Remdesivir sped the recovery in patients with advanced coronavirus, also known as COVID-19.

The first trial participant in the ACTT trial was an American who was repatriated after being quarantined on the Diamond Princess cruise ship that docked in Yokohama, Japan, and volunteered to participate in the study at the first study site, the University of Nebraska Medical Center/Nebraska Medicine, in February 2020.

Morrissey: an oracle and "a reasonably good buy."

Interesting drug, the one that you took. Tell the truth! It really helped you, an interesting drug!

Morrissey An Interesting Drug Live on YouTube

Read more about the ACTT Remdesivir trial.

Dr. Aaronson Suggests Virtually Riding on Zwift with Shane Miller (GPLama) and Von to Mitigate Your Risk During the Covid-19 Pandemic

Dr. Michael Aaronson biking on Zwift. Screenshot taken May 3rd, 2020. Dr. Aaronson is currently at level 29 on Zwift. His goal is to achieve level 50. 

I insist on doing everything I can to stay healthy during this pandemic. I need to be cautious and try to mitigate my risk of developing Covid-19, so I can stay healthy and take care of the patients I serve. We can all try to do our best to stay healthy and avoid contracting the virus.

One strategy to defeat the virus is to get or stay motivated and exercise, trying to be as fit as you can. Why? Your chances are improved if you are in better shape, especially if you are at higher risk (see below). Said another way, if you get coronavirus there are ways to improve your chances of fighting the virus.

Some have argued that we may have at least 2 more years of this "new normal way of life (read more)."  Based on these articles, if at least 60-70% of the population needs to be infected (to achieve herd immunity) or an effective vaccine needs to be discovered and people immunized before we can go back to the way things were, I would suggest that you become as healthy as you can during this period of time through diet and exercise to improve your chances for survival. So if you, or when you, contract the disease, your chances of experiencing a mild case of Covid-19 are more likely than a severe one. I have been offering this generalized stay healthy advice for years, but now it is more important than ever.

This approach to indoor exercise is easier said than done. Getting and staying on a bike, that is, keeping motivated, is hard to do. The more ways we have to stay motivated and burn calories and work the cardiovascular system, the better off we are.

Here is what we know about who is at higher risk from the CDC, and I'll cut and paste the risk factors that are important to a kidney-based practice. However, and with that said, in general, if you have health problems, or you are older, you are at risk. Here is the list of what makes a person higher risk from a kidney perspective:

• People 65 years and older
• People with severe obesity (body mass index [BMI] of 40 or higher)
• People with diabetes
• People with chronic kidney disease undergoing dialysis

What can a person do to try to mitigate or lessen their risk of getting very sick if they contract Covid-19? What am I doing? Well, what you might try, and what I'm doing, is exercising at home using interactive cycling software like Zwift, Rouvy, and Fulgaz. I am able to decrease exposure risk (I'm not around others). At the same time, I am trying to improve the risk factors that can be improved, namely, avoiding becoming overweight.

Said another way, you can't change your age. However, you can change your weight through exercise and diet. You can also maintain your weight using this strategy.

But Dr. Aaronson, I have Zwift, and I am still bored riding indoors. Yes, biking can be boring over time, regardless of how hard Zwift tries to challenge you, or how many gorgeous scenes Rouvy presents to you, or from a personal perspective, how many times Fulgaz reminds me of my recent trip to Australia.

Dr. Aaronson at the Moeraki Boulders. 

Dr. Aaronson with the Lazy Sunbathers -- Morrissey on YouTube in Australia.

So to help my biking experience without getting too technical, I have started having some "company" during my rides. While biking on Zwift, I like to watch Shane Miller and his wife, Von, from Australia livestream their Zwift rides on YouTube. I perform my ride either during their livestream or afterwards. (Given the time difference, I sometimes watch the recorded stream. Historians note: Dr. Aaronson is in Lincoln, Nebraska which is central time, so that's a 15-hour difference.)

I take the cue from
Certain people I know
I use the cue
And then I
Hand it on to you...

Certain People I Know Live -- Morrissey YouTube

If watching live, you can ask questions or comment to be part of the conversation. If you want to watch older episodes, they are available. If you prefer other platforms, Shane offers livestream options on Twitch or Facebook live.

Why does this work? Why not watch Netflix instead? Well, you can. But this approach is different in that it makes you feel like you are riding with people. It feels like discord (Zwift's online chatting app), but adds the visual component with less setup and is always there for you.

Sidebar: I have found this channel to be helpful learning how to navigate through Zwift and learn about hardware that works with the program. You also get to spend quality time with Shane Miller and his wife Von. They have a lovely family.

In conclusion, and to reiterate, you want to find ways to motivate yourself to keep yourself fit during this crisis. One way to stay motivated and add another dimension to your indoor biking experience is to watch Shane's Zwift livestream. It really does help pass the time.

Furthermore, if you are waiting for a trainer (there is currently a world-wide shortage), power pedals, or for cadence and speed sensors to arrive so that you can retrofit an older excise bike and are planning to join Zwift in the future, consider getting on that stationary bike now. You can turn on Shane's YouTube channel and start spinning. Once your devices get to your home, you can connect and really immerse yourself in the experience, but the time to get started is now.

How Soon is Now? -- Morrissey / The Smiths on YouTube.

Allowing Kidney Injury in the Setting of Ventilator Need

Patients who have coronavirus are at risk for fluid overload. Please be cautious using too much during the Covid-19 crisis.

Please note: these suggestions are just that, suggestions, which are  based on the current situation.  It is important to tailor your situation accordingly and collaborate via a team-based approach.

I had a great discussion with my critical care colleagues the other day.  We were discussing the paradigm shifting approach to treating Covid-19 which is very different from the current sepsis guidelines. The goal is to avoid the need to intubate a patient.

When a person is infected with the novel coronavirus, the patient appears to be at high risk for fluid overload and the need for intubation -- which by definition requires a ventilator. As we all know, there is a ventilator shortage. We need to do everything possible to avoid using ventilators while saving lives. Can kidney doctors (nephrologists) work with their critical care colleagues and emergency room physicians to facilitate? Yes, we can!

Caring for these patients, we physicians are normally asked to provide the patient with intravenous fluid -- lots of it. In fact, hospitals can get "into trouble" if they don't give patients who present with severe infection several liters of fluid. Note: there are 33 ounces in 1 liter.

It is turning out that if we avoid this approach (use less fluid) we can avoid ventilator use and keep more people alive, especially when there is a ventilator need. There is a shortage of ventilators.

Consider that as of April 1st, it is projected that Nebraska is going to have a ventilator deficit of 169.

Learn more: Covid-19 projections. Click to find the projected ventilator need in your state.

Invasive ventilators needed in the state of Nebraska: 169 ventilators (projected).

A fascinating abstract in emergency medicine news has suggested that we keep patients relatively volume down (dehydrated) despite a faster heart rate and worsening kidney function (acute kidney injury).

Learn more about the recommendation to allow kidney injury, keeping patients dry to avoid the need to use ventilators and keep patients alive.

The recommendations are constantly changing. The above link provides updated information.

So, how to maintain blood pressure in the patients we serve if we aren't going to give them lots of intravenous fluid?

Again, try to avoid fluid overloading these patients.

Consider the early use of low dose pressors to support the blood pressure.  If the patient appears to be severely dehydrated, consider a small bolus of intravenous fluid. 500 ml of normal saline has been suggested. In contrast, it is usually suggested to give patients with suspected shock caused by a severe sepsis viral infection up to 2000 milliliters of fluid over thirty to sixty minutes, with additional fluid challenges given as required.

500 ml of normal saline as an initial bolus is suggested if the patient appears to be dehydrated and in kidney failure.

Also, avoid maintenance intravenous fluids, especially if the patient's oxygen status is low. Moreover, if the patient is low on oxygen and has normal blood pressure, it has been suggested that a dose of furosemide (also called Lasix) be given. Some have suggested that this will delay the need to use a ventilator for days. This may be a way to mitigate the above ventilators required curve.

So in the short term, while we weather the Covid-19 storm, we need to allow some kidney failure. We need to be patient and treat accordingly as we wait for the coronavirus vaccine.

I know this is paradigm shifting, but I do think this approach will save lives.

I am not a dog on a chain, I use my own brain -- Morrissey on YouTube

That said,  I would suggest following the surviving sepsis campaign as much as possible.



Read more:  Dr. Aaronson Back on the Chain Gang. Stay Healthy and Exercise at Home as We Wait for the Covid-19 Vaccine.

Dr. Aaronson Offers Telehealth and Curbside Options For Patients During Covid-19 Crisis 

Dr. Aaronson Back on the Chain Gang. Stay Healthy and Exercise at Home as We Wait for the Covid-19 Vaccine.

Dr. Aaronson is back on the chain gang, social distancing, riding his indoor bicycle using a power meter. The platform is Rouvy. The route is Ironman. Another great platform to consider is Kinomap.

As people are asked to stay home, social distance, and stay safe, they find themselves bored out of their minds. After the third puzzle or second binge-watch of their favorite Netflix series, some turn to eating out of boredom.

The sanest days are mad! Why don't you find out for yourself? -- Morrissey on YouTube

One option I have not heard on the news is exercising at home to stay healthy and mitigate the risk with respect to Covid-19.

What difference does it make? -- Morrissey on YouTube

If you can afford an indoor power meter to track your progress on an exercise bike, I would suggest it.

"Circumstance beyond our control... " Back on the Chain Gang -- Morrissey on YouTube

God forbid you develop Covid-19, the novel coronavirus. You want as much lung reserve as possible. You want to be as fit as possible. You want to be as healthy as possible. A sedentary life style and eating junk food will in my opinion increase your risk if you contract the disease.

Given the appropriate social distancing recommendations we have been placed under, you can't go to the gym. Most people have to stay at home. And you should follow these recommendations. So, how do you prepare your body for the stress if you get coronavirus? You should eat right and exercise.

I'm not suggesting that exercise "cures" the disease. What I'm suggesting is that if you get Covid-19, your chances of staying alive might be improved if you are healthier than a couch potato (defined as a human who does not exercise and rather spends most of the day sedentary viewing content on a device).

I'm basing my opinions on how coronavirus kills and the epidemiologic data of the infectious disease. Please keep reading to learn more.

Has my Dad gone crazy from social distancing? 

 Has My Dad, Dr. Aaronson, Gone Crazy? -- Eminem on YouTube (Clean)

and Oh, so many illustrations -- Morrissey on YouTube

Morrissey practices social distancing in America. Please try to stay 6 feet (1.83 meters) away from others at all times!

In addition to what is currently suggested, a vaccine will protect us. The problem is this takes time. How do we get the vaccine sooner? Some have opined we test in young, "healthy" volunteers.

One of the biggest hurdles will be showing that a vaccine works. Typically, this is done through large phase III studies, in which thousands to tens of thousands of people receive either a vaccine or a placebo, and researchers track who becomes infected in the course of their daily lives. 

A quicker option would be to conduct a ‘human challenge’ study, argue scientists in a provocative preprint published this week. This would involve exposing perhaps 100 healthy young people to the virus and seeing whether those who get the vaccine escape infection. Read more: Should scientists infect healthy people with the coronavirus to test vaccines?

I'm not necessarily suggesting this option. But what does seem clear is that most scientists would agree that a healthier population mitigates our risk in general. Why? Because younger, healthier people require less hospitalization and fewer ventilators. In addition, healthier patients have less of a need for hospitalization caused by illnesses such as heart disease. This makes hospital beds available to the ones in dire need.

You may not be "young," but if you are healthier, you will most likely have more "heart" reserve and have a better chance to survive while we wait for the Covid-19 vaccine. What I find refreshing from the quoted article above is that researchers are doing everything they can to find a vaccine as soon as possible.

For those states less stricken with coronavirus, don't be fooled with a false sense of security. Be smart. Continue to keep the risk low and stay home as much as possible. Practice social distancing if you do need to go out. And avoid panic.

Panic on the streets of London. Panic on the streets of Birmingham. I wonder to myself, Could life ever be sane again? -- Morrissey on YouTube

Learn more: Here is the link I am using to determine what is happening with the coronavirus in my state:

COVID-19 Projections (link)

Expected deaths per day at the peak of the Covid-19 crisis in Nebraska. This site provides great information.

What you get: assuming full social distancing through May 2020

• Number of days until peak resource use: Data grab as of April 1:
• For example, in Nebraska, the peak is expected to be April 23. But that changes based on the data.  Click the projections link above to get up-to-the-minute data.
• Resources needed for COVID-19 patients on peak date
• Nebraska needs 169 ventilators.
• And more for your state and the United States at large.

So in addition to PPE, masks, and social distancing, consider eating right and exercising at home. Indoor cycling or using a treadmill, etc. are options to consider.

"Now we're back in the fight" -- Back on the Chain Gang  Morrissey on YouTube.

I have many resources on my web page that will help you cost effectively set up an exercise bike at home that can be used with the above services.

Learn more ways to mitigate the risk of the Covid-19 pandemic: Allowing Kidney Injury in the Setting of Ventilator Need

Dr. Aaronson Offers Telehealth and Curbside Options For Patients During Covid-19 Crisis



@BCBSAssociation @MedicareGov #morrissey

Dr. Aaronson Offers Telehealth and Curbside Options For Patients During Covid-19 Crisis

During the coronavirus crisis most insurance companies are offering Telemedicine services to accommodate the desperate need for patients to see their doctor while avoiding the risk of transmitting Covid-19.

Are you curious if you qualify to be seen using this modality? Please ask our front desk to see if you can be seen using this approach.

How does it work?

It is so easy! There are three ways to connect:
1. Use the web -- click here for the link to start a telehealth encounter.


Click here to go to our web page to start a telehealth call with Dr. Aaronson.

2. We can text you on your phone. The process is easy. No app installation is required.
3. We can email you to either your computer, tablet, or phone. No app installation is required.

For all the options you click on the link (any of the three above), and you are sent to the Welcome screen. Enter your name and you will be sent to the virtual waiting room.

Welcome to Dr. Aaronson's Telehealth waiting room.
Enter your name, check in, and you are all set.

Make sure your device has a camera, so we can see you.

There are many benefits of Telehealth:
- HIPAA compliant, so you have your privacy.
- The approach is fully encrypted. No one will be watching.
- After the doctor visit, you can securely chat through text with nursing.
- It doesn't matter if you have Android, Windows, or Apple products. This system works with everything. All you need is a web browser and a camera of course to be able to video chat.
- No travel time required to get to your telehealth appointment. Your nurse will be with you shortly followed by your doctor.

Please note: we are also offering curbside options. Many are covered using this modality if you don't want to come into the office.

Why is it so important to see your doctor and not postpone your visit?

I think postponing your appointment has risk and may be dangerous. If you are not experiencing Covid-19 symptoms, or are in quarantine, or are concerned about transmission, you might want to consider telehealth if it is an option. If your insurance company is not offering this service, you might want to call them and ask them why not.

Feeling Socially Isolated From Social Distancing, Consider Relax Listening and Perhaps Something More.

Marconi Union's 10-hour anti-anxiety song  Weightless is available on YouTube. 

Are you feeling socially isolated from socially distancing yourself? Are you in self-isolation for 2 weeks waiting to rid yourself of that pesky coronavirus? Consider listening to Marconi Union's anti-anxiety song Weightless to help get you through. I'm using it at night instead of white noise to help me get a good night's sleep. Some people I know are listening to this song during the day to help alleviate anxiety.

Want something upbeat? Add Your Arsenal to your arsenal. Listen to Glamorous Glue -- Morrissey on YouTube.

Morrissey: Your Arsenal

Third week with "the Jar"

You find

Everything dies -- Morrissey

Want access to the best list of relaxing songs available today? Check out myNoise on YouTube.  Created by Dr. Ir. Stéphane Pigeon, it's the greatest collection of sound to focus, relax, and sleep out there.

Please note: there are other ways to help prevent anxiety and depression during these trying times while staying away from others. Be creative. An example: the Aaronson family opted to foster a puppy at risk and saved a life, read more.

The pleasure brought to the Aaronson Family: Morrissey's New Album I Am Not A Dog on a Chain. Dr. Aaronson and Family Save a Life.

Read more about social distancing during this coronavirus Covid-19 crisis: Dr. Aaronson Suggests Social Distancing to Prevent Coronavirus Spread.

Dr. Aaronson Suggests Social Distancing to Prevent Coronavirus Spread

The predicted exponential growth of the coronavirus in Minnesota. Source: Jonathan Sellman, MD, MPH

Attention Nebraskans: learn the power of exponential growth and how fast coronavirus can spread from the above graft I sourced from Dr. Sellman, an infectious disease specialist (learn more from Dr. Sellman here.)


Minnesota currently has 54 documented coronavirus or COVID19 cases. The state of Minnesota is on track to have an outbreak, similar to outbreaks seen throughout the world which have consistently shown an exponential rise in the number of cases of coronavirus, which double every 3 days.

For perspective, unless we change the above curve, by April 11th, 2020, and as shown above, Minnesota will have approximately 18,000 cases. By April 26th, the state is projected to have 373,000 cases.

How about Nebraska? What are the numbers here? CURRENT COVID-19 STATISTICS AS OF MARCH 13, 2020
State of Nebraska cases: 12
UPDATE: March 17, 2020: 23

But don't be fooled!

Look again at the above graft. Note how infectious the coronavirus disease is. Note how quickly it goes from 54 to 373,000 (exponential rate of growth). Think about what is happening in other parts of the United States. Ponder about what is happening in Italy. And then consider that until a cure and or vaccine is available for this pandemic we have one option that does indeed work:

Social distancing means you keep away from others. This strategy is critical to avoid spreading this highly infectious disease. We need to take this approach seriously. Also remember to wash your hands, cough into your elbow, don't touch your face, stay at least 3 feet (0.91 meters), and preferably 6 feet (1.83 meters), apart from others when you must interact, and if you feel sick stay at home.

That said, if you have concerns about going to your doctor's appointment, and you have been exposed to coronavirus (or don't know) and are currently experiencing any of the following:
·  Fever of 100 degrees or higher
·  Sore throat
·  Cough
·  Difficulty breathing

I encourage you to please call your doctor, your specialist, for next steps.  There are hotlines, drive-thrus, specific locations to go to for testing if you qualify for assessment, and lab testing location options to consider.

Let's do our best to try preventing the spread of this highly contagious infectious disease.

#Stay_safe.