Key clinical point: Patients with relapsed or refractory large B-cell lymphoma (LBCL) who were recently exposed to preapheresis bendamustine showed negative treatment outcomes, hematologic toxicity, and severe infections after CD19-targeted chimeric antigen receptor (CAR) T-cell therapy.

Major finding: Patients recently exposed to bendamustine (<9 months) vs those naive to it before apheresis had a significantly lower overall response rate (40% vs 66%; P  =  .01) and shorter overall survival (adjusted hazard ratio [aHR] 2.11; P < .01) and progression-free survival (aHR 1.82; P < .01) after CAR T-cell infusion.

Study details: This retrospective multicenter study included 439 patients with relapsed or refractory LBCL who received CD19-targeted commercial CAR T-cell therapy after ≥2 prior treatment lines, of whom 80 patients had received bendamustine before apheresis.

Disclosures: This study was supported by the Carlos III Health Institute, Spain, and others. Some authors declared serving in consulting or advisory roles for or as members of speakers’ bureaus of or receiving honoraria, research funding, or travel or accommodation expenses from various sources.

Source: Iacoboni G et al. Recent bendamustine treatment before apheresis has a negative impact on outcomes in patients with large B-cell lymphoma receiving chimeric antigen receptor T-cell therapy. J Clin Oncol. 2023 (Oct 24). doi: 10.1200/JCO.23.01097

Key clinical point: Patients with relapsed or refractory large B-cell lymphoma (LBCL) who were recently exposed to preapheresis bendamustine showed negative treatment outcomes, hematologic toxicity, and severe infections after CD19-targeted chimeric antigen receptor (CAR) T-cell therapy.

Major finding: Patients recently exposed to bendamustine (<9 months) vs those naive to it before apheresis had a significantly lower overall response rate (40% vs 66%; P  =  .01) and shorter overall survival (adjusted hazard ratio [aHR] 2.11; P < .01) and progression-free survival (aHR 1.82; P < .01) after CAR T-cell infusion.

Study details: This retrospective multicenter study included 439 patients with relapsed or refractory LBCL who received CD19-targeted commercial CAR T-cell therapy after ≥2 prior treatment lines, of whom 80 patients had received bendamustine before apheresis.

Disclosures: This study was supported by the Carlos III Health Institute, Spain, and others. Some authors declared serving in consulting or advisory roles for or as members of speakers’ bureaus of or receiving honoraria, research funding, or travel or accommodation expenses from various sources.

Source: Iacoboni G et al. Recent bendamustine treatment before apheresis has a negative impact on outcomes in patients with large B-cell lymphoma receiving chimeric antigen receptor T-cell therapy. J Clin Oncol. 2023 (Oct 24). doi: 10.1200/JCO.23.01097

Key clinical point: Patients with relapsed or refractory large B-cell lymphoma (LBCL) who were recently exposed to preapheresis bendamustine showed negative treatment outcomes, hematologic toxicity, and severe infections after CD19-targeted chimeric antigen receptor (CAR) T-cell therapy.

Major finding: Patients recently exposed to bendamustine (<9 months) vs those naive to it before apheresis had a significantly lower overall response rate (40% vs 66%; P  =  .01) and shorter overall survival (adjusted hazard ratio [aHR] 2.11; P < .01) and progression-free survival (aHR 1.82; P < .01) after CAR T-cell infusion.

Study details: This retrospective multicenter study included 439 patients with relapsed or refractory LBCL who received CD19-targeted commercial CAR T-cell therapy after ≥2 prior treatment lines, of whom 80 patients had received bendamustine before apheresis.

Disclosures: This study was supported by the Carlos III Health Institute, Spain, and others. Some authors declared serving in consulting or advisory roles for or as members of speakers’ bureaus of or receiving honoraria, research funding, or travel or accommodation expenses from various sources.

Source: Iacoboni G et al. Recent bendamustine treatment before apheresis has a negative impact on outcomes in patients with large B-cell lymphoma receiving chimeric antigen receptor T-cell therapy. J Clin Oncol. 2023 (Oct 24). doi: 10.1200/JCO.23.01097

ANAHEIM, CALIF. – Gargling and nasal rinsing with saltwater several times a day appeared to be associated with significantly lower COVID-19 hospitalization rates in a small, randomized, double-blind, controlled study.

“The hypothesis was that interventions that target the upper respiratory tract may reduce the frequency and duration of upper respiratory symptoms associated with COVID-19,” said Sebastian Espinoza, first author of the study; he is with Trinity University, San Antonio.

Adults aged 18-65 years who tested positive for SARS-CoV-2 on polymerase chain reaction (PCR) testing between 2020 and 2022 were randomly selected to use low- or high-dose saltwater regimens for 14 days at the Harris Health System, Houston. For patients to be included in the study, 14 days had to have elapsed since the onset of any symptoms associated with COVID.

The low dose was 2.13 grams of salt dissolved in 8 ounces of warm water, and the high dose was 6 grams. Participants gargled the saltwater and used it as a nasal rinse for 5 minutes four times a day.

Primary outcomes included frequency and duration of symptoms associated with SARS-CoV-2 infection; secondary outcomes included admission to the hospital or the intensive care unit, mechanical ventilatory support, or death.

The findings were presented in a poster at the annual meeting of the American College of Allergy, Asthma, and Immunology.

Fifty-eight people were randomly assigned to either the low-saline (n = 27) or the high-saline (n = 28) group; three patients were lost to follow-up in both these groups. The reference control population consisted of 9,398 people with confirmed SARS-CoV-2 infection. Rates of vaccination were similar for all participants.

Hospitalization rates in the low- (18.5%) and high- (21.4%) saline groups were significantly lower than in the reference control population (58.8%; P < .001). No significant differences were noted in other outcomes among these groups.

The average age of patients in the control population (n = 9,398) was 45 years. The average age was similar in the low- and high-saline groups. In the low-saline group (n = 27), the average age was 39, and in the high-saline group, the average age was 41.

In all three groups, body mass index was between 29.6 and 31.7.

Exclusion criteria included chronic hypertension or participation in another interventional study.
 

‘Low risk, small potential benefit’

Allergist Zach Rubin, MD, a spokesperson for the ACAAI, said in an interview that the findings are in line with other small studies that previously reported some benefit in using nasal saline irrigation and gargling to treat a SARS-CoV-2 infection.

“This is a type of intervention that is low risk with some small potential benefit,” he said.

The researchers did not evaluate the potential reason for the saline regimen’s association with fewer hospitalizations, but Dr. Rubin said, “It may be possible that nasal saline irrigation and gargling help improve viral clearance and reduce the risk of microaspiration into the lungs, so it may be possible that this intervention could reduce the risk of pneumonia, which is a major cause of hospitalization.”

Dr. Rubin, who is an allergist at Oak Brook Allergists, Ill., said, “I generally recommend nasal saline irrigation to my patients for allergic rhinitis and viral upper respiratory infections already. It can help reduce symptoms such as nasal congestion, rhinorrhea, postnasal drip, and sinus pain and pressure.”

The intervention may be reasonable beyond an adult population, he said.

“This could be used for pediatric patients as well, if they are developmentally ready to try this intervention,” he said.

Mr. Espinoza said further study is warranted, but he said that if confirmed in later trials, the simple intervention may be particularly helpful in low-resource settings.

Mr. Espinoza and Dr. Rubin have disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

ANAHEIM, CALIF. – Gargling and nasal rinsing with saltwater several times a day appeared to be associated with significantly lower COVID-19 hospitalization rates in a small, randomized, double-blind, controlled study.

“The hypothesis was that interventions that target the upper respiratory tract may reduce the frequency and duration of upper respiratory symptoms associated with COVID-19,” said Sebastian Espinoza, first author of the study; he is with Trinity University, San Antonio.

Adults aged 18-65 years who tested positive for SARS-CoV-2 on polymerase chain reaction (PCR) testing between 2020 and 2022 were randomly selected to use low- or high-dose saltwater regimens for 14 days at the Harris Health System, Houston. For patients to be included in the study, 14 days had to have elapsed since the onset of any symptoms associated with COVID.

The low dose was 2.13 grams of salt dissolved in 8 ounces of warm water, and the high dose was 6 grams. Participants gargled the saltwater and used it as a nasal rinse for 5 minutes four times a day.

Primary outcomes included frequency and duration of symptoms associated with SARS-CoV-2 infection; secondary outcomes included admission to the hospital or the intensive care unit, mechanical ventilatory support, or death.

The findings were presented in a poster at the annual meeting of the American College of Allergy, Asthma, and Immunology.

Fifty-eight people were randomly assigned to either the low-saline (n = 27) or the high-saline (n = 28) group; three patients were lost to follow-up in both these groups. The reference control population consisted of 9,398 people with confirmed SARS-CoV-2 infection. Rates of vaccination were similar for all participants.

Hospitalization rates in the low- (18.5%) and high- (21.4%) saline groups were significantly lower than in the reference control population (58.8%; P < .001). No significant differences were noted in other outcomes among these groups.

The average age of patients in the control population (n = 9,398) was 45 years. The average age was similar in the low- and high-saline groups. In the low-saline group (n = 27), the average age was 39, and in the high-saline group, the average age was 41.

In all three groups, body mass index was between 29.6 and 31.7.

Exclusion criteria included chronic hypertension or participation in another interventional study.
 

‘Low risk, small potential benefit’

Allergist Zach Rubin, MD, a spokesperson for the ACAAI, said in an interview that the findings are in line with other small studies that previously reported some benefit in using nasal saline irrigation and gargling to treat a SARS-CoV-2 infection.

“This is a type of intervention that is low risk with some small potential benefit,” he said.

The researchers did not evaluate the potential reason for the saline regimen’s association with fewer hospitalizations, but Dr. Rubin said, “It may be possible that nasal saline irrigation and gargling help improve viral clearance and reduce the risk of microaspiration into the lungs, so it may be possible that this intervention could reduce the risk of pneumonia, which is a major cause of hospitalization.”

Dr. Rubin, who is an allergist at Oak Brook Allergists, Ill., said, “I generally recommend nasal saline irrigation to my patients for allergic rhinitis and viral upper respiratory infections already. It can help reduce symptoms such as nasal congestion, rhinorrhea, postnasal drip, and sinus pain and pressure.”

The intervention may be reasonable beyond an adult population, he said.

“This could be used for pediatric patients as well, if they are developmentally ready to try this intervention,” he said.

Mr. Espinoza said further study is warranted, but he said that if confirmed in later trials, the simple intervention may be particularly helpful in low-resource settings.

Mr. Espinoza and Dr. Rubin have disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

ANAHEIM, CALIF. – Gargling and nasal rinsing with saltwater several times a day appeared to be associated with significantly lower COVID-19 hospitalization rates in a small, randomized, double-blind, controlled study.

“The hypothesis was that interventions that target the upper respiratory tract may reduce the frequency and duration of upper respiratory symptoms associated with COVID-19,” said Sebastian Espinoza, first author of the study; he is with Trinity University, San Antonio.

Adults aged 18-65 years who tested positive for SARS-CoV-2 on polymerase chain reaction (PCR) testing between 2020 and 2022 were randomly selected to use low- or high-dose saltwater regimens for 14 days at the Harris Health System, Houston. For patients to be included in the study, 14 days had to have elapsed since the onset of any symptoms associated with COVID.

The low dose was 2.13 grams of salt dissolved in 8 ounces of warm water, and the high dose was 6 grams. Participants gargled the saltwater and used it as a nasal rinse for 5 minutes four times a day.

Primary outcomes included frequency and duration of symptoms associated with SARS-CoV-2 infection; secondary outcomes included admission to the hospital or the intensive care unit, mechanical ventilatory support, or death.

The findings were presented in a poster at the annual meeting of the American College of Allergy, Asthma, and Immunology.

Fifty-eight people were randomly assigned to either the low-saline (n = 27) or the high-saline (n = 28) group; three patients were lost to follow-up in both these groups. The reference control population consisted of 9,398 people with confirmed SARS-CoV-2 infection. Rates of vaccination were similar for all participants.

Hospitalization rates in the low- (18.5%) and high- (21.4%) saline groups were significantly lower than in the reference control population (58.8%; P < .001). No significant differences were noted in other outcomes among these groups.

The average age of patients in the control population (n = 9,398) was 45 years. The average age was similar in the low- and high-saline groups. In the low-saline group (n = 27), the average age was 39, and in the high-saline group, the average age was 41.

In all three groups, body mass index was between 29.6 and 31.7.

Exclusion criteria included chronic hypertension or participation in another interventional study.
 

‘Low risk, small potential benefit’

Allergist Zach Rubin, MD, a spokesperson for the ACAAI, said in an interview that the findings are in line with other small studies that previously reported some benefit in using nasal saline irrigation and gargling to treat a SARS-CoV-2 infection.

“This is a type of intervention that is low risk with some small potential benefit,” he said.

The researchers did not evaluate the potential reason for the saline regimen’s association with fewer hospitalizations, but Dr. Rubin said, “It may be possible that nasal saline irrigation and gargling help improve viral clearance and reduce the risk of microaspiration into the lungs, so it may be possible that this intervention could reduce the risk of pneumonia, which is a major cause of hospitalization.”

Dr. Rubin, who is an allergist at Oak Brook Allergists, Ill., said, “I generally recommend nasal saline irrigation to my patients for allergic rhinitis and viral upper respiratory infections already. It can help reduce symptoms such as nasal congestion, rhinorrhea, postnasal drip, and sinus pain and pressure.”

The intervention may be reasonable beyond an adult population, he said.

“This could be used for pediatric patients as well, if they are developmentally ready to try this intervention,” he said.

Mr. Espinoza said further study is warranted, but he said that if confirmed in later trials, the simple intervention may be particularly helpful in low-resource settings.

Mr. Espinoza and Dr. Rubin have disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

SAN FRANCISCO – A large observational registry study of almost 100,000 eyes has found that the diabetes drug semaglutide, a GLP-1 agonist recently approved for weight loss, does not worsen the progression of potentially vision-threatening diabetic retinopathy in the long term in patients taking the drug. However, the researchers said, the findings do not obviate the need for providers to have a conversation about the potential risks to vision posed by the drug.

“In patients that have either no or early or relatively nonadvanced diabetic retinopathy, the absolute risk of having a worsening in their retinopathy is variable,” Zeeshan Haq, MD, a retina specialist at Retinal Consultants of Minnesota, told this news organization. Dr. Hag presented the findings Nov. 3 at the annual meeting of the American Academy of Ophthalmology.

“Based on this preliminary evidence and what we know so far, it suggests that there is a risk of worsening, but it’s quite low for most patients, and so a conversation needs to be had between anyone considering prescribing the drug, such as a general practitioner or a nurse practitioner, and that patient’s optometrist or comprehensive ophthalmologist or retina specialist.”
 

Methodology and results

Dr. Haq reported on a retrospective case series of 96,462 eyes from the Intelligent Research in Sight (IRIS) registry. Patients had type 2 diabetes and began taking injectable semaglutide between January 2013 and December 2021.

The study evaluated eyes with three levels of retinopathy:

• No retinopathy or background retinopathy (71.8%).
• Mild or moderate nonproliferative diabetic retinopathy (NPDR) (18.4%).
• Severe NPDR or proliferative diabetic retinopathy (PDR) (9.8%).

In eyes with no or background retinopathy, 1.3%, 1.2%, 1.6%, and 2.2% experienced a worsening in status of the condition at 3, 6, 12, and 24 months, respectively.

In eyes with mild or moderate NPDR, 2.4%, 3%, 3.4%, and 3.5% showed worsening retinopathy at the respective time intervals.

Improvement of retinopathy rather than worsening was evaluated in the eyes with severe NPDR or PDR. At 3, 6, 12, and 24 months, improvement was observed in 40%, 37.8%, 47.7%, and 58.7% of these eyes, respectively.

Most patients were aged 51-75 years (77.2%), female (55.0%), and White (63.8%).

The study found low rates of the following complications across the same time intervals: vitreous hemorrhage (from 0.1% to 0.15%); traction retinal detachment (0.02% to 0.05%); and neovascular glaucoma (0.03% to –0.04%), Dr. Haq reported.

Dr. Haq noted that understanding the possible consequences that semaglutide has on vision is important as the drug becomes more widely available for both diabetes and weight control. The Centers for Disease Control and Prevention reports that 37.3 million people in the United States have diabetes; 28.7 million cases have been diagnosed, and 8.5 million are undiagnosed.
 

Clinical implications

“Any patient in the United States with diabetes has to undergo screening for diabetic eye disease, and so they’re usually plugged into the eye-care system,” Dr. Haq said. “But if they’re going to be starting this drug and they don’t have any existing diabetic retinopathy, the discussion should be had between their doctor and the eye-care provider, and if they do have a history of DR, an evaluation with the eye-care provider should probably happen upon starting the drug.”

Vaidehi Dedania, MD, a retina specialist at NYU Langone Health in New York, said the findings underscore the importance of counseling patients who are taking semaglutide about potential vision outcomes.

“We know that when patients get rapid control of their diabetes, their diabetic retinopathy can worsen in the short term, although it always ends up doing better in long term anyway,” Dr. Dedania said in an interview. “We always educate our patients that if they get control of the diabetes to not feel discouraged if their diabetic retinopathy worsens despite getting good control, because we know in the long run it always get better.”

The new findings, however, may have masked some worsening of retinopathy because of how the researchers categorized the condition. “It’s hard to assess changes within a designation because they’re so broad,” Dr. Dedania said.

She also noted potential limitations with the IRIS database itself. “The data collected from it are not always as complete as you might need for the purpose of understanding this, so that’s a limitation,” she said. While the high number of patients is a strength of the study, she added, “I still think the limitations are pretty significant.”

Dr. Haq has disclosed no relevant financial relationships. Dr. Dedania has relationships with Genentech/Roche and Regeneron Pharmaceuticals.

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

SAN FRANCISCO – A large observational registry study of almost 100,000 eyes has found that the diabetes drug semaglutide, a GLP-1 agonist recently approved for weight loss, does not worsen the progression of potentially vision-threatening diabetic retinopathy in the long term in patients taking the drug. However, the researchers said, the findings do not obviate the need for providers to have a conversation about the potential risks to vision posed by the drug.

“In patients that have either no or early or relatively nonadvanced diabetic retinopathy, the absolute risk of having a worsening in their retinopathy is variable,” Zeeshan Haq, MD, a retina specialist at Retinal Consultants of Minnesota, told this news organization. Dr. Hag presented the findings Nov. 3 at the annual meeting of the American Academy of Ophthalmology.

“Based on this preliminary evidence and what we know so far, it suggests that there is a risk of worsening, but it’s quite low for most patients, and so a conversation needs to be had between anyone considering prescribing the drug, such as a general practitioner or a nurse practitioner, and that patient’s optometrist or comprehensive ophthalmologist or retina specialist.”
 

Methodology and results

Dr. Haq reported on a retrospective case series of 96,462 eyes from the Intelligent Research in Sight (IRIS) registry. Patients had type 2 diabetes and began taking injectable semaglutide between January 2013 and December 2021.

The study evaluated eyes with three levels of retinopathy:

• No retinopathy or background retinopathy (71.8%).
• Mild or moderate nonproliferative diabetic retinopathy (NPDR) (18.4%).
• Severe NPDR or proliferative diabetic retinopathy (PDR) (9.8%).

In eyes with no or background retinopathy, 1.3%, 1.2%, 1.6%, and 2.2% experienced a worsening in status of the condition at 3, 6, 12, and 24 months, respectively.

In eyes with mild or moderate NPDR, 2.4%, 3%, 3.4%, and 3.5% showed worsening retinopathy at the respective time intervals.

Improvement of retinopathy rather than worsening was evaluated in the eyes with severe NPDR or PDR. At 3, 6, 12, and 24 months, improvement was observed in 40%, 37.8%, 47.7%, and 58.7% of these eyes, respectively.

Most patients were aged 51-75 years (77.2%), female (55.0%), and White (63.8%).

The study found low rates of the following complications across the same time intervals: vitreous hemorrhage (from 0.1% to 0.15%); traction retinal detachment (0.02% to 0.05%); and neovascular glaucoma (0.03% to –0.04%), Dr. Haq reported.

Dr. Haq noted that understanding the possible consequences that semaglutide has on vision is important as the drug becomes more widely available for both diabetes and weight control. The Centers for Disease Control and Prevention reports that 37.3 million people in the United States have diabetes; 28.7 million cases have been diagnosed, and 8.5 million are undiagnosed.
 

Clinical implications

“Any patient in the United States with diabetes has to undergo screening for diabetic eye disease, and so they’re usually plugged into the eye-care system,” Dr. Haq said. “But if they’re going to be starting this drug and they don’t have any existing diabetic retinopathy, the discussion should be had between their doctor and the eye-care provider, and if they do have a history of DR, an evaluation with the eye-care provider should probably happen upon starting the drug.”

Vaidehi Dedania, MD, a retina specialist at NYU Langone Health in New York, said the findings underscore the importance of counseling patients who are taking semaglutide about potential vision outcomes.

“We know that when patients get rapid control of their diabetes, their diabetic retinopathy can worsen in the short term, although it always ends up doing better in long term anyway,” Dr. Dedania said in an interview. “We always educate our patients that if they get control of the diabetes to not feel discouraged if their diabetic retinopathy worsens despite getting good control, because we know in the long run it always get better.”

The new findings, however, may have masked some worsening of retinopathy because of how the researchers categorized the condition. “It’s hard to assess changes within a designation because they’re so broad,” Dr. Dedania said.

She also noted potential limitations with the IRIS database itself. “The data collected from it are not always as complete as you might need for the purpose of understanding this, so that’s a limitation,” she said. While the high number of patients is a strength of the study, she added, “I still think the limitations are pretty significant.”

Dr. Haq has disclosed no relevant financial relationships. Dr. Dedania has relationships with Genentech/Roche and Regeneron Pharmaceuticals.

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

SAN FRANCISCO – A large observational registry study of almost 100,000 eyes has found that the diabetes drug semaglutide, a GLP-1 agonist recently approved for weight loss, does not worsen the progression of potentially vision-threatening diabetic retinopathy in the long term in patients taking the drug. However, the researchers said, the findings do not obviate the need for providers to have a conversation about the potential risks to vision posed by the drug.

“In patients that have either no or early or relatively nonadvanced diabetic retinopathy, the absolute risk of having a worsening in their retinopathy is variable,” Zeeshan Haq, MD, a retina specialist at Retinal Consultants of Minnesota, told this news organization. Dr. Hag presented the findings Nov. 3 at the annual meeting of the American Academy of Ophthalmology.

“Based on this preliminary evidence and what we know so far, it suggests that there is a risk of worsening, but it’s quite low for most patients, and so a conversation needs to be had between anyone considering prescribing the drug, such as a general practitioner or a nurse practitioner, and that patient’s optometrist or comprehensive ophthalmologist or retina specialist.”
 

Methodology and results

Dr. Haq reported on a retrospective case series of 96,462 eyes from the Intelligent Research in Sight (IRIS) registry. Patients had type 2 diabetes and began taking injectable semaglutide between January 2013 and December 2021.

The study evaluated eyes with three levels of retinopathy:

• No retinopathy or background retinopathy (71.8%).
• Mild or moderate nonproliferative diabetic retinopathy (NPDR) (18.4%).
• Severe NPDR or proliferative diabetic retinopathy (PDR) (9.8%).

In eyes with no or background retinopathy, 1.3%, 1.2%, 1.6%, and 2.2% experienced a worsening in status of the condition at 3, 6, 12, and 24 months, respectively.

In eyes with mild or moderate NPDR, 2.4%, 3%, 3.4%, and 3.5% showed worsening retinopathy at the respective time intervals.

Improvement of retinopathy rather than worsening was evaluated in the eyes with severe NPDR or PDR. At 3, 6, 12, and 24 months, improvement was observed in 40%, 37.8%, 47.7%, and 58.7% of these eyes, respectively.

Most patients were aged 51-75 years (77.2%), female (55.0%), and White (63.8%).

The study found low rates of the following complications across the same time intervals: vitreous hemorrhage (from 0.1% to 0.15%); traction retinal detachment (0.02% to 0.05%); and neovascular glaucoma (0.03% to –0.04%), Dr. Haq reported.

Dr. Haq noted that understanding the possible consequences that semaglutide has on vision is important as the drug becomes more widely available for both diabetes and weight control. The Centers for Disease Control and Prevention reports that 37.3 million people in the United States have diabetes; 28.7 million cases have been diagnosed, and 8.5 million are undiagnosed.
 

Clinical implications

“Any patient in the United States with diabetes has to undergo screening for diabetic eye disease, and so they’re usually plugged into the eye-care system,” Dr. Haq said. “But if they’re going to be starting this drug and they don’t have any existing diabetic retinopathy, the discussion should be had between their doctor and the eye-care provider, and if they do have a history of DR, an evaluation with the eye-care provider should probably happen upon starting the drug.”

Vaidehi Dedania, MD, a retina specialist at NYU Langone Health in New York, said the findings underscore the importance of counseling patients who are taking semaglutide about potential vision outcomes.

“We know that when patients get rapid control of their diabetes, their diabetic retinopathy can worsen in the short term, although it always ends up doing better in long term anyway,” Dr. Dedania said in an interview. “We always educate our patients that if they get control of the diabetes to not feel discouraged if their diabetic retinopathy worsens despite getting good control, because we know in the long run it always get better.”

The new findings, however, may have masked some worsening of retinopathy because of how the researchers categorized the condition. “It’s hard to assess changes within a designation because they’re so broad,” Dr. Dedania said.

She also noted potential limitations with the IRIS database itself. “The data collected from it are not always as complete as you might need for the purpose of understanding this, so that’s a limitation,” she said. While the high number of patients is a strength of the study, she added, “I still think the limitations are pretty significant.”

Dr. Haq has disclosed no relevant financial relationships. Dr. Dedania has relationships with Genentech/Roche and Regeneron Pharmaceuticals.

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

Primary care visits for preventive services have nearly doubled since 2001, and new research suggests these visits give clinicians and patients more valuable time together.

The proportion of preventive services–focused visits to primary care increased from 12.8% in 2001 to 24.6% in 2019, according to findings from a cross-sectional study of adult primary care visits that was published in Health Affairs.

The increase over time persisted across all age groups and insurance types, including private insurance, Medicaid, self-pay, and workers’ compensation. Medicare beneficiaries exhibited the largest increases in preventive visits, up 10 percentage points over the two-decade span.

The uptick is likely associated with policies enacted under the Affordable Care Act, which made preventive exams a unique visit type with no copay for Medicare and most other insurance plans, according to the researchers. The data showed a spike in preventive visits for patients aged 18-44 years shortly after the law was passed.

But “other factors in our health care system could have reduced the impact of the policies,” said Lisa Rotenstein, MD, a primary care physician at the Center for Primary Care at Harvard Medical School, Boston, who is the lead author of the study.

National trends show that fewer Americans have a primary care clinician, and those who do see these specialists less frequently than in previous decades. In addition, the primary care workforce is shrinking, even as more nurse practitioners and physician assistants join the specialty.

“I’m surprised and pleased,” said Ann Greiner, president of the Primary Care Coalition, an organization working to expand access to primary care.

Although the study in Health Affairs did not examine trends in primary care visits overall, the researchers highlighted several findings from previous research that found declines in these visits. That research also found that there were fewer adults who had a usual source of primary care.

“We know there’s a decline in primary care visits, which is where preventive care happens,” Ms. Greiner said.

The new study, which used data from the National Ambulatory Medical Care Survey, showed that physicians spent significantly more time with patients during preventive visits, compared with problem-based visits.

Physicians were also significantly more likely to counsel patients, order preventive labs, or order a preventive image or procedure during these exams. Nurse practitioner visits or physician assistant visits were not included in the study.

Christina Breit, MD, a primary care physician at Norton’s Medical Group, Louisville, Ky., said she usually spends 30-40 minutes conducting a physical exam, compared with only 10 or 15 minutes during an acute visit.

“When they come in for the preventive visit is when we really figure out the social determinants of health,” Dr. Breit said.

During this extended time discussing patient health risks, preferences, and daily routine, Dr. Breit starts to pick up on any red flags that she would have missed in a 10-minute acute care appointment, which helps guide care decisions.

On top of the well-established benefits of preventive care, the extended time fosters an improved physician-patient relationship, Dr. Rotenstein said. Longitudinal relationships between doctor and patient are linked to lower patient costs and hospitalizations.

“That’s supposed to be one of our primary goals, is to use preventive care as a stopgap for chronic illness,” said Diane Thierys, NP, a family nurse practitioner in Columbia, Ky.

Over the past 20 years of her 35-year-long career, she has been able to allot more time to these visits while being adequately reimbursed, she said. In spring 2023, she started providing home wellness visits for Medicare enrollees.

“There’s definitely been a long overdue increase” in preventive care visits in the past 20 years, Ms. Thierys told this news organization. “Before that, visits were focused on the chief complaint of the day.”

But an increase in preventive visits may also reflect the fact that patients are seeking out other specialists for various ailments.

“Some of the simple, problem-based visits have actually left primary care,” said Tim Anderson, MD, MAS, a primary care physician and health services researcher at the University of Pittsburgh. “The results may be indicative of the migration of ear infections and sore throats to urgent care and pharmacy-based minute clinics, for instance.”

Although urgent care clinicians usually do not have medical records or patient histories, this setting can be more accessible and convenient, Ms. Greiner said.

One limitation of the study is that it only evaluated trends through 2019. The COVID-19 pandemic put intense stress on primary care clinicians and limited access to this care.

“Will we continue to see increases in preventive visits? We will have to track and see,” Ms. Greiner said.

The study was independently supported. Dr. Rotenstein reports no relevant financial relationships.

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

Primary care visits for preventive services have nearly doubled since 2001, and new research suggests these visits give clinicians and patients more valuable time together.

The proportion of preventive services–focused visits to primary care increased from 12.8% in 2001 to 24.6% in 2019, according to findings from a cross-sectional study of adult primary care visits that was published in Health Affairs.

The increase over time persisted across all age groups and insurance types, including private insurance, Medicaid, self-pay, and workers’ compensation. Medicare beneficiaries exhibited the largest increases in preventive visits, up 10 percentage points over the two-decade span.

The uptick is likely associated with policies enacted under the Affordable Care Act, which made preventive exams a unique visit type with no copay for Medicare and most other insurance plans, according to the researchers. The data showed a spike in preventive visits for patients aged 18-44 years shortly after the law was passed.

But “other factors in our health care system could have reduced the impact of the policies,” said Lisa Rotenstein, MD, a primary care physician at the Center for Primary Care at Harvard Medical School, Boston, who is the lead author of the study.

National trends show that fewer Americans have a primary care clinician, and those who do see these specialists less frequently than in previous decades. In addition, the primary care workforce is shrinking, even as more nurse practitioners and physician assistants join the specialty.

“I’m surprised and pleased,” said Ann Greiner, president of the Primary Care Coalition, an organization working to expand access to primary care.

Although the study in Health Affairs did not examine trends in primary care visits overall, the researchers highlighted several findings from previous research that found declines in these visits. That research also found that there were fewer adults who had a usual source of primary care.

“We know there’s a decline in primary care visits, which is where preventive care happens,” Ms. Greiner said.

The new study, which used data from the National Ambulatory Medical Care Survey, showed that physicians spent significantly more time with patients during preventive visits, compared with problem-based visits.

Physicians were also significantly more likely to counsel patients, order preventive labs, or order a preventive image or procedure during these exams. Nurse practitioner visits or physician assistant visits were not included in the study.

Christina Breit, MD, a primary care physician at Norton’s Medical Group, Louisville, Ky., said she usually spends 30-40 minutes conducting a physical exam, compared with only 10 or 15 minutes during an acute visit.

“When they come in for the preventive visit is when we really figure out the social determinants of health,” Dr. Breit said.

During this extended time discussing patient health risks, preferences, and daily routine, Dr. Breit starts to pick up on any red flags that she would have missed in a 10-minute acute care appointment, which helps guide care decisions.

On top of the well-established benefits of preventive care, the extended time fosters an improved physician-patient relationship, Dr. Rotenstein said. Longitudinal relationships between doctor and patient are linked to lower patient costs and hospitalizations.

“That’s supposed to be one of our primary goals, is to use preventive care as a stopgap for chronic illness,” said Diane Thierys, NP, a family nurse practitioner in Columbia, Ky.

Over the past 20 years of her 35-year-long career, she has been able to allot more time to these visits while being adequately reimbursed, she said. In spring 2023, she started providing home wellness visits for Medicare enrollees.

“There’s definitely been a long overdue increase” in preventive care visits in the past 20 years, Ms. Thierys told this news organization. “Before that, visits were focused on the chief complaint of the day.”

But an increase in preventive visits may also reflect the fact that patients are seeking out other specialists for various ailments.

“Some of the simple, problem-based visits have actually left primary care,” said Tim Anderson, MD, MAS, a primary care physician and health services researcher at the University of Pittsburgh. “The results may be indicative of the migration of ear infections and sore throats to urgent care and pharmacy-based minute clinics, for instance.”

Although urgent care clinicians usually do not have medical records or patient histories, this setting can be more accessible and convenient, Ms. Greiner said.

One limitation of the study is that it only evaluated trends through 2019. The COVID-19 pandemic put intense stress on primary care clinicians and limited access to this care.

“Will we continue to see increases in preventive visits? We will have to track and see,” Ms. Greiner said.

The study was independently supported. Dr. Rotenstein reports no relevant financial relationships.

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

Primary care visits for preventive services have nearly doubled since 2001, and new research suggests these visits give clinicians and patients more valuable time together.

The proportion of preventive services–focused visits to primary care increased from 12.8% in 2001 to 24.6% in 2019, according to findings from a cross-sectional study of adult primary care visits that was published in Health Affairs.

The increase over time persisted across all age groups and insurance types, including private insurance, Medicaid, self-pay, and workers’ compensation. Medicare beneficiaries exhibited the largest increases in preventive visits, up 10 percentage points over the two-decade span.

The uptick is likely associated with policies enacted under the Affordable Care Act, which made preventive exams a unique visit type with no copay for Medicare and most other insurance plans, according to the researchers. The data showed a spike in preventive visits for patients aged 18-44 years shortly after the law was passed.

But “other factors in our health care system could have reduced the impact of the policies,” said Lisa Rotenstein, MD, a primary care physician at the Center for Primary Care at Harvard Medical School, Boston, who is the lead author of the study.

National trends show that fewer Americans have a primary care clinician, and those who do see these specialists less frequently than in previous decades. In addition, the primary care workforce is shrinking, even as more nurse practitioners and physician assistants join the specialty.

“I’m surprised and pleased,” said Ann Greiner, president of the Primary Care Coalition, an organization working to expand access to primary care.

Although the study in Health Affairs did not examine trends in primary care visits overall, the researchers highlighted several findings from previous research that found declines in these visits. That research also found that there were fewer adults who had a usual source of primary care.

“We know there’s a decline in primary care visits, which is where preventive care happens,” Ms. Greiner said.

The new study, which used data from the National Ambulatory Medical Care Survey, showed that physicians spent significantly more time with patients during preventive visits, compared with problem-based visits.

Physicians were also significantly more likely to counsel patients, order preventive labs, or order a preventive image or procedure during these exams. Nurse practitioner visits or physician assistant visits were not included in the study.

Christina Breit, MD, a primary care physician at Norton’s Medical Group, Louisville, Ky., said she usually spends 30-40 minutes conducting a physical exam, compared with only 10 or 15 minutes during an acute visit.

“When they come in for the preventive visit is when we really figure out the social determinants of health,” Dr. Breit said.

During this extended time discussing patient health risks, preferences, and daily routine, Dr. Breit starts to pick up on any red flags that she would have missed in a 10-minute acute care appointment, which helps guide care decisions.

On top of the well-established benefits of preventive care, the extended time fosters an improved physician-patient relationship, Dr. Rotenstein said. Longitudinal relationships between doctor and patient are linked to lower patient costs and hospitalizations.

“That’s supposed to be one of our primary goals, is to use preventive care as a stopgap for chronic illness,” said Diane Thierys, NP, a family nurse practitioner in Columbia, Ky.

Over the past 20 years of her 35-year-long career, she has been able to allot more time to these visits while being adequately reimbursed, she said. In spring 2023, she started providing home wellness visits for Medicare enrollees.

“There’s definitely been a long overdue increase” in preventive care visits in the past 20 years, Ms. Thierys told this news organization. “Before that, visits were focused on the chief complaint of the day.”

But an increase in preventive visits may also reflect the fact that patients are seeking out other specialists for various ailments.

“Some of the simple, problem-based visits have actually left primary care,” said Tim Anderson, MD, MAS, a primary care physician and health services researcher at the University of Pittsburgh. “The results may be indicative of the migration of ear infections and sore throats to urgent care and pharmacy-based minute clinics, for instance.”

Although urgent care clinicians usually do not have medical records or patient histories, this setting can be more accessible and convenient, Ms. Greiner said.

One limitation of the study is that it only evaluated trends through 2019. The COVID-19 pandemic put intense stress on primary care clinicians and limited access to this care.

“Will we continue to see increases in preventive visits? We will have to track and see,” Ms. Greiner said.

The study was independently supported. Dr. Rotenstein reports no relevant financial relationships.

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

Glucagon-like peptide 1 (GLP-1) agonists may help clinicians manage uncontrolled type 2 diabetes in some older patients without the need for additional glucose-controlling medications, according to a study presented Nov. 8 at the annual meeting of the Gerontological Society of America.

The study analyzed charts of 30 adults aged 65-84 years who were seen in clinic from January 2022 to February 2023 and were started on GLP-1 or GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) agonists. Participants had uncontrolled type 2 diabetes with initial A1c levels ranging from 9.6% to 12.6% and a body mass index between 27 and 48.2. The patients also received education about their conditions as well as counseling on diet and lifestyle modifications.

All participants experienced a reduction in A1c to a range of 5.8% to 7.7%, and a moderate reduction in BMI to between 23 and 39.8 within the year.

“The reduction in BMI that we saw in our patients even though they were still in the category of obesity produces a substantial benefit in the management [of type 2 diabetes],” because weight loss helps to control the condition, said Anna Pendrey, MD, assistant professor of clinical family medicine and geriatrics at Indiana University, Indianapolis, and sole author of the study.

In some cases, the addition of a GLP-1 agonist or GLP-1/GIP agonist allowed for clinicians to deprescribe other medications such as insulin and sulfonylureas, which can cause hypoglycemia in older adults, Dr. Pendrey said.

Approximately 11% of U.S. adults have type 2 diabetes, a percentage that is likely to grow given the prevalence of childhood obesity, according to the Centers for Disease Control and Prevention. Dr. Pendrey highlighted the increased incidence of newly diagnosed diabetes in individuals aged 65-79 years.

Previous studies have shown that GLP-1 agonists have the potential to aid in weight reduction, glucose control, and the prevention of major adverse cardiovascular events in these patients.

The new study is one of many post hoc analyses that mark another step forward in addressing the complex challenges associated with diabetes in older adults, according to Rodolfo Galindo, MD, director of the Comprehensive Diabetes Center at the University of Miami Health System in Florida.

“I believe this is important because unfortunately many of our older adults have both diabetes and obesity,” Dr. Galindo, who was not involved with the research, told this news organization. “You can induce remission of type 2 diabetes through weight loss that GLP-1s can cause.”

The treatment paradigm has shifted away from focusing only on lowering glucose levels as the primary means to prevent complications from diabetes, Dr. Galindo said.

Indeed, weight loss can modify diseases and prevent other complications associated with type 2 diabetes, Dr. Pendrey said.

“Weight loss and diabetes mellitus control also produces cardiovascular protection that is significant for patients with diabetes, so this group of patients in my opinion are the ones that benefit the most from GLP-1s,” she said.

Side effects of GLP-1 agonists can include nausea and vomiting, which could lead to dehydration. GLP-1s can also increase the risk for pancreatitis. For older adults, weight loss from the drug could cause sarcopenia, or loss of muscle mass, Dr. Galindo said.

“This is the reason why patients in treatment with GLP-1s have to be in close contact with their providers,” Dr. Pendrey said.

This study was independently supported. Dr. Pendrey and Dr. Galindo report no relevant conflicts.

A version of this article appeared on Medscape.com.

Glucagon-like peptide 1 (GLP-1) agonists may help clinicians manage uncontrolled type 2 diabetes in some older patients without the need for additional glucose-controlling medications, according to a study presented Nov. 8 at the annual meeting of the Gerontological Society of America.

The study analyzed charts of 30 adults aged 65-84 years who were seen in clinic from January 2022 to February 2023 and were started on GLP-1 or GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) agonists. Participants had uncontrolled type 2 diabetes with initial A1c levels ranging from 9.6% to 12.6% and a body mass index between 27 and 48.2. The patients also received education about their conditions as well as counseling on diet and lifestyle modifications.

All participants experienced a reduction in A1c to a range of 5.8% to 7.7%, and a moderate reduction in BMI to between 23 and 39.8 within the year.

“The reduction in BMI that we saw in our patients even though they were still in the category of obesity produces a substantial benefit in the management [of type 2 diabetes],” because weight loss helps to control the condition, said Anna Pendrey, MD, assistant professor of clinical family medicine and geriatrics at Indiana University, Indianapolis, and sole author of the study.

In some cases, the addition of a GLP-1 agonist or GLP-1/GIP agonist allowed for clinicians to deprescribe other medications such as insulin and sulfonylureas, which can cause hypoglycemia in older adults, Dr. Pendrey said.

Approximately 11% of U.S. adults have type 2 diabetes, a percentage that is likely to grow given the prevalence of childhood obesity, according to the Centers for Disease Control and Prevention. Dr. Pendrey highlighted the increased incidence of newly diagnosed diabetes in individuals aged 65-79 years.

Previous studies have shown that GLP-1 agonists have the potential to aid in weight reduction, glucose control, and the prevention of major adverse cardiovascular events in these patients.

The new study is one of many post hoc analyses that mark another step forward in addressing the complex challenges associated with diabetes in older adults, according to Rodolfo Galindo, MD, director of the Comprehensive Diabetes Center at the University of Miami Health System in Florida.

“I believe this is important because unfortunately many of our older adults have both diabetes and obesity,” Dr. Galindo, who was not involved with the research, told this news organization. “You can induce remission of type 2 diabetes through weight loss that GLP-1s can cause.”

The treatment paradigm has shifted away from focusing only on lowering glucose levels as the primary means to prevent complications from diabetes, Dr. Galindo said.

Indeed, weight loss can modify diseases and prevent other complications associated with type 2 diabetes, Dr. Pendrey said.

“Weight loss and diabetes mellitus control also produces cardiovascular protection that is significant for patients with diabetes, so this group of patients in my opinion are the ones that benefit the most from GLP-1s,” she said.

Side effects of GLP-1 agonists can include nausea and vomiting, which could lead to dehydration. GLP-1s can also increase the risk for pancreatitis. For older adults, weight loss from the drug could cause sarcopenia, or loss of muscle mass, Dr. Galindo said.

“This is the reason why patients in treatment with GLP-1s have to be in close contact with their providers,” Dr. Pendrey said.

This study was independently supported. Dr. Pendrey and Dr. Galindo report no relevant conflicts.

A version of this article appeared on Medscape.com.

Glucagon-like peptide 1 (GLP-1) agonists may help clinicians manage uncontrolled type 2 diabetes in some older patients without the need for additional glucose-controlling medications, according to a study presented Nov. 8 at the annual meeting of the Gerontological Society of America.

The study analyzed charts of 30 adults aged 65-84 years who were seen in clinic from January 2022 to February 2023 and were started on GLP-1 or GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) agonists. Participants had uncontrolled type 2 diabetes with initial A1c levels ranging from 9.6% to 12.6% and a body mass index between 27 and 48.2. The patients also received education about their conditions as well as counseling on diet and lifestyle modifications.

All participants experienced a reduction in A1c to a range of 5.8% to 7.7%, and a moderate reduction in BMI to between 23 and 39.8 within the year.

“The reduction in BMI that we saw in our patients even though they were still in the category of obesity produces a substantial benefit in the management [of type 2 diabetes],” because weight loss helps to control the condition, said Anna Pendrey, MD, assistant professor of clinical family medicine and geriatrics at Indiana University, Indianapolis, and sole author of the study.

In some cases, the addition of a GLP-1 agonist or GLP-1/GIP agonist allowed for clinicians to deprescribe other medications such as insulin and sulfonylureas, which can cause hypoglycemia in older adults, Dr. Pendrey said.

Approximately 11% of U.S. adults have type 2 diabetes, a percentage that is likely to grow given the prevalence of childhood obesity, according to the Centers for Disease Control and Prevention. Dr. Pendrey highlighted the increased incidence of newly diagnosed diabetes in individuals aged 65-79 years.

Previous studies have shown that GLP-1 agonists have the potential to aid in weight reduction, glucose control, and the prevention of major adverse cardiovascular events in these patients.

The new study is one of many post hoc analyses that mark another step forward in addressing the complex challenges associated with diabetes in older adults, according to Rodolfo Galindo, MD, director of the Comprehensive Diabetes Center at the University of Miami Health System in Florida.

“I believe this is important because unfortunately many of our older adults have both diabetes and obesity,” Dr. Galindo, who was not involved with the research, told this news organization. “You can induce remission of type 2 diabetes through weight loss that GLP-1s can cause.”

The treatment paradigm has shifted away from focusing only on lowering glucose levels as the primary means to prevent complications from diabetes, Dr. Galindo said.

Indeed, weight loss can modify diseases and prevent other complications associated with type 2 diabetes, Dr. Pendrey said.

“Weight loss and diabetes mellitus control also produces cardiovascular protection that is significant for patients with diabetes, so this group of patients in my opinion are the ones that benefit the most from GLP-1s,” she said.

Side effects of GLP-1 agonists can include nausea and vomiting, which could lead to dehydration. GLP-1s can also increase the risk for pancreatitis. For older adults, weight loss from the drug could cause sarcopenia, or loss of muscle mass, Dr. Galindo said.

“This is the reason why patients in treatment with GLP-1s have to be in close contact with their providers,” Dr. Pendrey said.

This study was independently supported. Dr. Pendrey and Dr. Galindo report no relevant conflicts.

A version of this article appeared on Medscape.com.

New research strengthens the body of evidence demonstrating an increased risk of blood cancer from exposure to low doses of radiation from CT scans. The results suggest that, for every 10,000 children examined with an average low dose of 8 mGy, 1-2 will likely develop a hematologic malignancy related to radiation exposure over the next 12 years.

The findings, published online in Nature Medicine, are based on more than 1.3 million CT scans in nearly 900,000 people younger than 22 years old when scanned.

This study makes a “significant contribution to the understanding of the effects of ionizing radiation, specifically x-rays, on the human body at the levels of radiation exposure encountered in diagnostic CT procedures,” Peter Marsden, PhD, and Jim Thurston, radiation protection experts at Dorset County (England) Hospital, NHS Foundation Trust, said in a press release from the U.K. nonprofit Science Media Centre.

These findings highlight levels of risk that “align with those currently estimated and do not suggest that the use of CT carries a greater risk than previously thought,” Dr. Marsden and Thurston said.

Exposure to moderate- (≥ 100 mGy) to high-dose (≥ 1 Gy) ionizing radiation is a well-established risk factor for leukemia in both children and adults. However, the risk associated with low-dose exposure (< 100 mGy) typically associated with diagnostic CT exams in children and teens remains unclear.

The current study, coordinated by the International Agency for Research on Cancer, aimed to improve direct estimates of cancer risk from low-dose radiation exposure from CT scans performed in childhood and adolescence. The researchers estimated radiation doses to the active bone marrow based on body part scanned, patient characteristics, time period, and inferred CT technical parameters.

A total of 790 hematologic malignancies, including lymphoid and myeloid malignancies, were identified during follow-up. More than half (51%) of the cases were diagnosed in people under age 20 and 88.5% were diagnosed in people under age 30 years.

Overall, the observational study found a nearly twofold excess risk of all hematologic malignancies per 100 mGy in children, adolescents, and young adults, with similar risk estimates observed for lymphoid and myeloid cancers. The excess relative risk for hematologic malignancies increased as the number of CT exams increased – with risk rising by 43% per exam.

The results of this study “strengthen the findings from previous low-dose studies of a consistent and robust dose-related increased risk of radiation-induced hematological malignancies” and highlight the importance of optimizing doses in this patient population, study author Elisabeth Cardis, PhD, with the Barcelona Institute for Global Health, and colleagues concluded.

Sarah McQuaid, PhD, chair of the nuclear medicine special interest group, Institute of Physics and Engineering in Medicine, York, England, agreed.

“This publication indicates that there could be a small cancer risk from CT scans in young people, but it is important for this to be viewed in the context of the substantial benefit these scans bring, due to the important diagnostic information they provide,” Dr. McQuaid said in the press release. Overall, “the number of patients whose medical care will have been improved from these CT scans will have been very high, and lives undoubtedly saved as a result.”

The study had no commercial funding. The authors and outside experts reported no relevant financial relationships.

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

New research strengthens the body of evidence demonstrating an increased risk of blood cancer from exposure to low doses of radiation from CT scans. The results suggest that, for every 10,000 children examined with an average low dose of 8 mGy, 1-2 will likely develop a hematologic malignancy related to radiation exposure over the next 12 years.

The findings, published online in Nature Medicine, are based on more than 1.3 million CT scans in nearly 900,000 people younger than 22 years old when scanned.

This study makes a “significant contribution to the understanding of the effects of ionizing radiation, specifically x-rays, on the human body at the levels of radiation exposure encountered in diagnostic CT procedures,” Peter Marsden, PhD, and Jim Thurston, radiation protection experts at Dorset County (England) Hospital, NHS Foundation Trust, said in a press release from the U.K. nonprofit Science Media Centre.

These findings highlight levels of risk that “align with those currently estimated and do not suggest that the use of CT carries a greater risk than previously thought,” Dr. Marsden and Thurston said.

Exposure to moderate- (≥ 100 mGy) to high-dose (≥ 1 Gy) ionizing radiation is a well-established risk factor for leukemia in both children and adults. However, the risk associated with low-dose exposure (< 100 mGy) typically associated with diagnostic CT exams in children and teens remains unclear.

The current study, coordinated by the International Agency for Research on Cancer, aimed to improve direct estimates of cancer risk from low-dose radiation exposure from CT scans performed in childhood and adolescence. The researchers estimated radiation doses to the active bone marrow based on body part scanned, patient characteristics, time period, and inferred CT technical parameters.

A total of 790 hematologic malignancies, including lymphoid and myeloid malignancies, were identified during follow-up. More than half (51%) of the cases were diagnosed in people under age 20 and 88.5% were diagnosed in people under age 30 years.

Overall, the observational study found a nearly twofold excess risk of all hematologic malignancies per 100 mGy in children, adolescents, and young adults, with similar risk estimates observed for lymphoid and myeloid cancers. The excess relative risk for hematologic malignancies increased as the number of CT exams increased – with risk rising by 43% per exam.

The results of this study “strengthen the findings from previous low-dose studies of a consistent and robust dose-related increased risk of radiation-induced hematological malignancies” and highlight the importance of optimizing doses in this patient population, study author Elisabeth Cardis, PhD, with the Barcelona Institute for Global Health, and colleagues concluded.

Sarah McQuaid, PhD, chair of the nuclear medicine special interest group, Institute of Physics and Engineering in Medicine, York, England, agreed.

“This publication indicates that there could be a small cancer risk from CT scans in young people, but it is important for this to be viewed in the context of the substantial benefit these scans bring, due to the important diagnostic information they provide,” Dr. McQuaid said in the press release. Overall, “the number of patients whose medical care will have been improved from these CT scans will have been very high, and lives undoubtedly saved as a result.”

The study had no commercial funding. The authors and outside experts reported no relevant financial relationships.

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

New research strengthens the body of evidence demonstrating an increased risk of blood cancer from exposure to low doses of radiation from CT scans. The results suggest that, for every 10,000 children examined with an average low dose of 8 mGy, 1-2 will likely develop a hematologic malignancy related to radiation exposure over the next 12 years.

The findings, published online in Nature Medicine, are based on more than 1.3 million CT scans in nearly 900,000 people younger than 22 years old when scanned.

This study makes a “significant contribution to the understanding of the effects of ionizing radiation, specifically x-rays, on the human body at the levels of radiation exposure encountered in diagnostic CT procedures,” Peter Marsden, PhD, and Jim Thurston, radiation protection experts at Dorset County (England) Hospital, NHS Foundation Trust, said in a press release from the U.K. nonprofit Science Media Centre.

These findings highlight levels of risk that “align with those currently estimated and do not suggest that the use of CT carries a greater risk than previously thought,” Dr. Marsden and Thurston said.

Exposure to moderate- (≥ 100 mGy) to high-dose (≥ 1 Gy) ionizing radiation is a well-established risk factor for leukemia in both children and adults. However, the risk associated with low-dose exposure (< 100 mGy) typically associated with diagnostic CT exams in children and teens remains unclear.

The current study, coordinated by the International Agency for Research on Cancer, aimed to improve direct estimates of cancer risk from low-dose radiation exposure from CT scans performed in childhood and adolescence. The researchers estimated radiation doses to the active bone marrow based on body part scanned, patient characteristics, time period, and inferred CT technical parameters.

A total of 790 hematologic malignancies, including lymphoid and myeloid malignancies, were identified during follow-up. More than half (51%) of the cases were diagnosed in people under age 20 and 88.5% were diagnosed in people under age 30 years.

Overall, the observational study found a nearly twofold excess risk of all hematologic malignancies per 100 mGy in children, adolescents, and young adults, with similar risk estimates observed for lymphoid and myeloid cancers. The excess relative risk for hematologic malignancies increased as the number of CT exams increased – with risk rising by 43% per exam.

The results of this study “strengthen the findings from previous low-dose studies of a consistent and robust dose-related increased risk of radiation-induced hematological malignancies” and highlight the importance of optimizing doses in this patient population, study author Elisabeth Cardis, PhD, with the Barcelona Institute for Global Health, and colleagues concluded.

Sarah McQuaid, PhD, chair of the nuclear medicine special interest group, Institute of Physics and Engineering in Medicine, York, England, agreed.

“This publication indicates that there could be a small cancer risk from CT scans in young people, but it is important for this to be viewed in the context of the substantial benefit these scans bring, due to the important diagnostic information they provide,” Dr. McQuaid said in the press release. Overall, “the number of patients whose medical care will have been improved from these CT scans will have been very high, and lives undoubtedly saved as a result.”

The study had no commercial funding. The authors and outside experts reported no relevant financial relationships.

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

Nonalcoholic steatohepatitis, or NASH,^a is the most severe form of nonalcoholic fatty liver disease (NAFLD).

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Nonalcoholic steatohepatitis, or NASH,^a is the most severe form of nonalcoholic fatty liver disease (NAFLD).

Read More

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Nonalcoholic steatohepatitis, or NASH,^a is the most severe form of nonalcoholic fatty liver disease (NAFLD).

Read More

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PARIS – Most diarrhea that leads patients to seek medical advice is actually a false alarm, said gastroenterologist Nassim Hammoudi, MD, PhD, of the Lariboisière Hospital in Paris, during France’s annual general medicine conference (JNMG 2023). He said that doctors need to understand the characteristics of chronic diarrhea and adapt its management accordingly. In his presentation, Dr. Hammoudi highlighted the clinical signs that should be considered.

Mechanisms of chronic diarrhea

Chronic diarrhea can result from different mechanisms, such as motility disorders related to accelerated intestinal transit, malabsorption, osmotic diarrhea, and secretory diarrhea, which are often interlinked. When an endoscopy is performed, it is recommended to conduct multilevel biopsies to detect microscopic colitis, which Dr. Hammoudi believes is “probably underdiagnosed.”

Diarrhea is defined as the passage of frequent stools (more than three a day), soft to liquid in consistency, and a daily weight exceeding 300 g. It is considered chronic when it persists for more than a month.
 

Identifying false diarrhea

Practitioners must first distinguish between genuine and false diarrhea, with the latter presenting in most consultations. “Thorough questioning is fundamental,” Dr. Hammoudi emphasized. It is essential to determine the daily stool count, the presence of nocturnal stools, and stool consistency. “A soft stool passed once a day is not diarrhea,” he said.

The most challenging form of false diarrhea to identify is what he called “constipated person’s diarrhea.” These patients, who are typically elderly, reside in care homes, and are bed-bound and taking morphine, have daily liquid stools but are actually constipated. “Taking antidiarrheal medications makes the situation worse,” said Dr. Hammoudi.

Another type of false diarrhea is tenesmus, in which patients feel like they have a full rectum, even though it is physiologically empty. The recurring urge to defecate results in mucus discharges that resemble diarrhea. Inflammatory rectal involvement could be the cause, necessitating a gastroenterology consultation.

Anal incontinence can also cause false diarrhea. It is more common in elderly people residing in care homes and in women in the postpartum period. This condition is difficult to manage and requires referral to a gastroenterologist.
 

Chronic diarrhea: Could cancer be the culprit?

After ruling out false diarrhea, clinicians should be vigilant for warning signs. The first question to consider, said Dr. Hammoudi, is whether the chronic diarrhea is associated with a lesion. Several criteria should prompt a colonoscopy, especially to search for colorectal cancer lesions:

• Age greater than 50 years
• Personal or family history of colorectal cancer
• Recent changes in bowel habits
• Rectal bleeding
• Nighttime stools
• Unexplained weight loss
• Iron-deficiency anemia

Obvious causes of chronic diarrhea should be prioritized in the management plan. Medications top the list, with more than 500 treatments – for example, ACE inhibitors, proton pump inhibitors (PPIs), antidiabetic drugs, colchicine, magnesium, laxatives – known to have diarrhea as a side effect.

Certain dietary habits can also exacerbate diarrhea, such as milk consumption in cases of lactose intolerance, or excessive sugar intake, which can lead to osmotic diarrhea.
 

IBS is often at play

Once these causes have been ruled out, several etiological pathways should be investigated. The first relates to motility issues, which are the most common diarrhea-related problem, said Dr. Hammoudi.

This type of diarrhea is linked to rapid intestinal transit time and is characterized by postprandial bowel movements (occurring shortly after a meal). Here, patients experience urgency and notice identifiable food debris in their stools. It tends to stop when fasting and can be treated effectively with antidiarrheals.

Irritable bowel syndrome (IBS) is the main cause of rapid intestinal transit diarrhea. It is defined as recurrent abdominal pain (at least 1 day/week) over a period of 3 months, associated with two of the following criteria: pain eases or worsens on passing feces, change in frequency of bowel movements, change in the consistency of stools.

Symptoms may come on suddenly, sometimes after taking antibiotics, and may result in misdiagnosis.

IBS medications treat the symptoms. Antispasmodics, such as trimebutine, phloroglucinol (Spasfon), or pinaverium bromide (Dicetel) are recommended, even there can be a placebo effect. The antidiarrheal medication loperamide (Imodium) can also be used. Probiotics may be beneficial, as an imbalanced intestinal microbiota is often implicated.

Dietary changes can also have a positive impact. Encouraging a diet rich in fruit and vegetables to enhance fiber intake is advised. A low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet, targeting short-chain carbohydrates, can also be tried to identify foods to avoid, although it may be challenging to stick to.

Postinfectious IBS is a frequent cause of rapid intestinal transit diarrhea. It generally follows an episode of acute infectious diarrhea. “Symptoms may come on suddenly, sometimes after taking antibiotics, and may result in misdiagnosis,” said Dr. Hammoudi. This type of IBS often resolves spontaneously within 6 months.
 

Consider the possibility of SIBO

Another cause of rapid intestinal transit diarrhea is small intestinal bacterial overgrowth (SIBO). It is difficult to distinguish between IBS and SIBO. Often, affected patients are diabetic, overweight, or have had bowel surgery.

The only way to diagnose SIBO is by conducting a breath test to measure the production of hydrogen and methane by the microbiota after ingesting sugar. However, the test is difficult to access and not fully covered by social security plans in France, said Dr. Hammoudi.

In cases of suspected SIBO and severe symptoms, a 7- to 10-day course of antibiotics can be attempted to provide relief, although a diagnosis should be confirmed before considering this option, Dr. Hammoudi said.
 

Malabsorption diarrhea

Another major cause of chronic diarrhea is malabsorption, characterized by large, fatty stools that are difficult to flush. Despite a normal diet, this type of diarrhea is associated with weight loss and nutritional deficiencies.

Its diagnosis involves measuring fat in the stools (steatorrhea) and possibly testing fecal elastase, an enzyme produced by the pancreas that is involved in digestion.

The most important causes of malabsorption diarrhea are pancreatic insufficiency, celiac disease, and Crohn’s disease. Generally, any lesion in the small intestine can lead to malabsorption-related diarrhea.

Celiac disease, or gluten intolerance, is an autoimmune condition triggered by a reaction to gluten proteins. Several antibodies can be produced in the presence of gluten proteins. Diagnosis is confirmed by positive antitransglutaminase antibodies and a duodenal biopsy through esophagogastroduodenoscopy.

The only treatment for celiac disease is a lifelong gluten-free diet. Celiac disease is increasingly diagnosed in adults, said Dr. Hammoudi, and should be considered as a possibility. This condition must be distinguished from gluten sensitivity, which can cause digestive issues, possibly leading to rapid intestinal transit diarrhea. “The only treatment for celiac disease is a lifelong gluten-free diet,” Dr. Hammoudi added.

Crohn’s disease, a type of inflammatory bowel disease, affects the entire digestive tract, particularly the terminal small intestine, which promotes malabsorption. In ulcerative colitis, another IBD affecting the rectum, any associated rectal syndrome can result in false diarrhea with stools containing blood and mucus.

Osmotic diarrhea, on the other hand, is linked to the presence of highly osmotic agents in the digestive tract. This type of diarrhea is watery and short-lived, stopping once the agents are no longer absorbed. The main culprits are lactose (in cases of lactose intolerance) and laxatives.
 

Drug-induced microscopic colitis

Secretory diarrhea is characterized by excessive secretions by the digestive tract, leading to significant potassium loss. This type of diarrhea is not related to food intake and is resistant to fasting.

Major causes of secretory diarrhea include microscopic colitis, parasitic infections, and endocrine tumors. Between 10% and 15% of patients with chronic diarrhea and apparently normal colonoscopy have microscopic colitis.

Dr. Hammoudi advised specialists seeking to determine the cause of chronic diarrhea to routinely collect multilevel bowel biopsies during colonoscopies from macroscopically normal mucosa to rule out microscopic colitis.

Microscopic colitis is mainly linked to the use of medications like PPIs and NSAIDs. These drugs can induce malabsorption-related diarrhea by damaging the intestinal wall.

In addition to discontinuing the implicated medication, the treatment for microscopic colitis includes low-dose budesonide (multiple brands). Biologics used in IBD may also be considered in cases of recurrent colitis.

Finally, exudative enteropathy can be a distinct cause of chronic diarrhea. It is characterized by albumin leakage (Waldmann’s disease) and manifests with edema, malnutrition, and significant hypoalbuminemia.

This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.

PARIS – Most diarrhea that leads patients to seek medical advice is actually a false alarm, said gastroenterologist Nassim Hammoudi, MD, PhD, of the Lariboisière Hospital in Paris, during France’s annual general medicine conference (JNMG 2023). He said that doctors need to understand the characteristics of chronic diarrhea and adapt its management accordingly. In his presentation, Dr. Hammoudi highlighted the clinical signs that should be considered.

Mechanisms of chronic diarrhea

Chronic diarrhea can result from different mechanisms, such as motility disorders related to accelerated intestinal transit, malabsorption, osmotic diarrhea, and secretory diarrhea, which are often interlinked. When an endoscopy is performed, it is recommended to conduct multilevel biopsies to detect microscopic colitis, which Dr. Hammoudi believes is “probably underdiagnosed.”

Diarrhea is defined as the passage of frequent stools (more than three a day), soft to liquid in consistency, and a daily weight exceeding 300 g. It is considered chronic when it persists for more than a month.
 

Identifying false diarrhea

Practitioners must first distinguish between genuine and false diarrhea, with the latter presenting in most consultations. “Thorough questioning is fundamental,” Dr. Hammoudi emphasized. It is essential to determine the daily stool count, the presence of nocturnal stools, and stool consistency. “A soft stool passed once a day is not diarrhea,” he said.

The most challenging form of false diarrhea to identify is what he called “constipated person’s diarrhea.” These patients, who are typically elderly, reside in care homes, and are bed-bound and taking morphine, have daily liquid stools but are actually constipated. “Taking antidiarrheal medications makes the situation worse,” said Dr. Hammoudi.

Another type of false diarrhea is tenesmus, in which patients feel like they have a full rectum, even though it is physiologically empty. The recurring urge to defecate results in mucus discharges that resemble diarrhea. Inflammatory rectal involvement could be the cause, necessitating a gastroenterology consultation.

Anal incontinence can also cause false diarrhea. It is more common in elderly people residing in care homes and in women in the postpartum period. This condition is difficult to manage and requires referral to a gastroenterologist.
 

Chronic diarrhea: Could cancer be the culprit?

After ruling out false diarrhea, clinicians should be vigilant for warning signs. The first question to consider, said Dr. Hammoudi, is whether the chronic diarrhea is associated with a lesion. Several criteria should prompt a colonoscopy, especially to search for colorectal cancer lesions:

• Age greater than 50 years
• Personal or family history of colorectal cancer
• Recent changes in bowel habits
• Rectal bleeding
• Nighttime stools
• Unexplained weight loss
• Iron-deficiency anemia

Obvious causes of chronic diarrhea should be prioritized in the management plan. Medications top the list, with more than 500 treatments – for example, ACE inhibitors, proton pump inhibitors (PPIs), antidiabetic drugs, colchicine, magnesium, laxatives – known to have diarrhea as a side effect.

Certain dietary habits can also exacerbate diarrhea, such as milk consumption in cases of lactose intolerance, or excessive sugar intake, which can lead to osmotic diarrhea.
 

IBS is often at play

Once these causes have been ruled out, several etiological pathways should be investigated. The first relates to motility issues, which are the most common diarrhea-related problem, said Dr. Hammoudi.

This type of diarrhea is linked to rapid intestinal transit time and is characterized by postprandial bowel movements (occurring shortly after a meal). Here, patients experience urgency and notice identifiable food debris in their stools. It tends to stop when fasting and can be treated effectively with antidiarrheals.

Irritable bowel syndrome (IBS) is the main cause of rapid intestinal transit diarrhea. It is defined as recurrent abdominal pain (at least 1 day/week) over a period of 3 months, associated with two of the following criteria: pain eases or worsens on passing feces, change in frequency of bowel movements, change in the consistency of stools.

Symptoms may come on suddenly, sometimes after taking antibiotics, and may result in misdiagnosis.

IBS medications treat the symptoms. Antispasmodics, such as trimebutine, phloroglucinol (Spasfon), or pinaverium bromide (Dicetel) are recommended, even there can be a placebo effect. The antidiarrheal medication loperamide (Imodium) can also be used. Probiotics may be beneficial, as an imbalanced intestinal microbiota is often implicated.

Dietary changes can also have a positive impact. Encouraging a diet rich in fruit and vegetables to enhance fiber intake is advised. A low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet, targeting short-chain carbohydrates, can also be tried to identify foods to avoid, although it may be challenging to stick to.

Postinfectious IBS is a frequent cause of rapid intestinal transit diarrhea. It generally follows an episode of acute infectious diarrhea. “Symptoms may come on suddenly, sometimes after taking antibiotics, and may result in misdiagnosis,” said Dr. Hammoudi. This type of IBS often resolves spontaneously within 6 months.
 

Consider the possibility of SIBO

Another cause of rapid intestinal transit diarrhea is small intestinal bacterial overgrowth (SIBO). It is difficult to distinguish between IBS and SIBO. Often, affected patients are diabetic, overweight, or have had bowel surgery.

The only way to diagnose SIBO is by conducting a breath test to measure the production of hydrogen and methane by the microbiota after ingesting sugar. However, the test is difficult to access and not fully covered by social security plans in France, said Dr. Hammoudi.

In cases of suspected SIBO and severe symptoms, a 7- to 10-day course of antibiotics can be attempted to provide relief, although a diagnosis should be confirmed before considering this option, Dr. Hammoudi said.
 

Malabsorption diarrhea

Another major cause of chronic diarrhea is malabsorption, characterized by large, fatty stools that are difficult to flush. Despite a normal diet, this type of diarrhea is associated with weight loss and nutritional deficiencies.

Its diagnosis involves measuring fat in the stools (steatorrhea) and possibly testing fecal elastase, an enzyme produced by the pancreas that is involved in digestion.

The most important causes of malabsorption diarrhea are pancreatic insufficiency, celiac disease, and Crohn’s disease. Generally, any lesion in the small intestine can lead to malabsorption-related diarrhea.

Celiac disease, or gluten intolerance, is an autoimmune condition triggered by a reaction to gluten proteins. Several antibodies can be produced in the presence of gluten proteins. Diagnosis is confirmed by positive antitransglutaminase antibodies and a duodenal biopsy through esophagogastroduodenoscopy.

The only treatment for celiac disease is a lifelong gluten-free diet. Celiac disease is increasingly diagnosed in adults, said Dr. Hammoudi, and should be considered as a possibility. This condition must be distinguished from gluten sensitivity, which can cause digestive issues, possibly leading to rapid intestinal transit diarrhea. “The only treatment for celiac disease is a lifelong gluten-free diet,” Dr. Hammoudi added.

Crohn’s disease, a type of inflammatory bowel disease, affects the entire digestive tract, particularly the terminal small intestine, which promotes malabsorption. In ulcerative colitis, another IBD affecting the rectum, any associated rectal syndrome can result in false diarrhea with stools containing blood and mucus.

Osmotic diarrhea, on the other hand, is linked to the presence of highly osmotic agents in the digestive tract. This type of diarrhea is watery and short-lived, stopping once the agents are no longer absorbed. The main culprits are lactose (in cases of lactose intolerance) and laxatives.
 

Drug-induced microscopic colitis

Secretory diarrhea is characterized by excessive secretions by the digestive tract, leading to significant potassium loss. This type of diarrhea is not related to food intake and is resistant to fasting.

Major causes of secretory diarrhea include microscopic colitis, parasitic infections, and endocrine tumors. Between 10% and 15% of patients with chronic diarrhea and apparently normal colonoscopy have microscopic colitis.

Dr. Hammoudi advised specialists seeking to determine the cause of chronic diarrhea to routinely collect multilevel bowel biopsies during colonoscopies from macroscopically normal mucosa to rule out microscopic colitis.

Microscopic colitis is mainly linked to the use of medications like PPIs and NSAIDs. These drugs can induce malabsorption-related diarrhea by damaging the intestinal wall.

In addition to discontinuing the implicated medication, the treatment for microscopic colitis includes low-dose budesonide (multiple brands). Biologics used in IBD may also be considered in cases of recurrent colitis.

Finally, exudative enteropathy can be a distinct cause of chronic diarrhea. It is characterized by albumin leakage (Waldmann’s disease) and manifests with edema, malnutrition, and significant hypoalbuminemia.

This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.

PARIS – Most diarrhea that leads patients to seek medical advice is actually a false alarm, said gastroenterologist Nassim Hammoudi, MD, PhD, of the Lariboisière Hospital in Paris, during France’s annual general medicine conference (JNMG 2023). He said that doctors need to understand the characteristics of chronic diarrhea and adapt its management accordingly. In his presentation, Dr. Hammoudi highlighted the clinical signs that should be considered.

Mechanisms of chronic diarrhea

Chronic diarrhea can result from different mechanisms, such as motility disorders related to accelerated intestinal transit, malabsorption, osmotic diarrhea, and secretory diarrhea, which are often interlinked. When an endoscopy is performed, it is recommended to conduct multilevel biopsies to detect microscopic colitis, which Dr. Hammoudi believes is “probably underdiagnosed.”

Diarrhea is defined as the passage of frequent stools (more than three a day), soft to liquid in consistency, and a daily weight exceeding 300 g. It is considered chronic when it persists for more than a month.
 

Identifying false diarrhea

Practitioners must first distinguish between genuine and false diarrhea, with the latter presenting in most consultations. “Thorough questioning is fundamental,” Dr. Hammoudi emphasized. It is essential to determine the daily stool count, the presence of nocturnal stools, and stool consistency. “A soft stool passed once a day is not diarrhea,” he said.

The most challenging form of false diarrhea to identify is what he called “constipated person’s diarrhea.” These patients, who are typically elderly, reside in care homes, and are bed-bound and taking morphine, have daily liquid stools but are actually constipated. “Taking antidiarrheal medications makes the situation worse,” said Dr. Hammoudi.

Another type of false diarrhea is tenesmus, in which patients feel like they have a full rectum, even though it is physiologically empty. The recurring urge to defecate results in mucus discharges that resemble diarrhea. Inflammatory rectal involvement could be the cause, necessitating a gastroenterology consultation.

Anal incontinence can also cause false diarrhea. It is more common in elderly people residing in care homes and in women in the postpartum period. This condition is difficult to manage and requires referral to a gastroenterologist.
 

Chronic diarrhea: Could cancer be the culprit?

After ruling out false diarrhea, clinicians should be vigilant for warning signs. The first question to consider, said Dr. Hammoudi, is whether the chronic diarrhea is associated with a lesion. Several criteria should prompt a colonoscopy, especially to search for colorectal cancer lesions:

• Age greater than 50 years
• Personal or family history of colorectal cancer
• Recent changes in bowel habits
• Rectal bleeding
• Nighttime stools
• Unexplained weight loss
• Iron-deficiency anemia

Obvious causes of chronic diarrhea should be prioritized in the management plan. Medications top the list, with more than 500 treatments – for example, ACE inhibitors, proton pump inhibitors (PPIs), antidiabetic drugs, colchicine, magnesium, laxatives – known to have diarrhea as a side effect.

Certain dietary habits can also exacerbate diarrhea, such as milk consumption in cases of lactose intolerance, or excessive sugar intake, which can lead to osmotic diarrhea.
 

IBS is often at play

Once these causes have been ruled out, several etiological pathways should be investigated. The first relates to motility issues, which are the most common diarrhea-related problem, said Dr. Hammoudi.

This type of diarrhea is linked to rapid intestinal transit time and is characterized by postprandial bowel movements (occurring shortly after a meal). Here, patients experience urgency and notice identifiable food debris in their stools. It tends to stop when fasting and can be treated effectively with antidiarrheals.

Irritable bowel syndrome (IBS) is the main cause of rapid intestinal transit diarrhea. It is defined as recurrent abdominal pain (at least 1 day/week) over a period of 3 months, associated with two of the following criteria: pain eases or worsens on passing feces, change in frequency of bowel movements, change in the consistency of stools.

Symptoms may come on suddenly, sometimes after taking antibiotics, and may result in misdiagnosis.

IBS medications treat the symptoms. Antispasmodics, such as trimebutine, phloroglucinol (Spasfon), or pinaverium bromide (Dicetel) are recommended, even there can be a placebo effect. The antidiarrheal medication loperamide (Imodium) can also be used. Probiotics may be beneficial, as an imbalanced intestinal microbiota is often implicated.

Dietary changes can also have a positive impact. Encouraging a diet rich in fruit and vegetables to enhance fiber intake is advised. A low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet, targeting short-chain carbohydrates, can also be tried to identify foods to avoid, although it may be challenging to stick to.

Postinfectious IBS is a frequent cause of rapid intestinal transit diarrhea. It generally follows an episode of acute infectious diarrhea. “Symptoms may come on suddenly, sometimes after taking antibiotics, and may result in misdiagnosis,” said Dr. Hammoudi. This type of IBS often resolves spontaneously within 6 months.
 

Consider the possibility of SIBO

Another cause of rapid intestinal transit diarrhea is small intestinal bacterial overgrowth (SIBO). It is difficult to distinguish between IBS and SIBO. Often, affected patients are diabetic, overweight, or have had bowel surgery.

The only way to diagnose SIBO is by conducting a breath test to measure the production of hydrogen and methane by the microbiota after ingesting sugar. However, the test is difficult to access and not fully covered by social security plans in France, said Dr. Hammoudi.

In cases of suspected SIBO and severe symptoms, a 7- to 10-day course of antibiotics can be attempted to provide relief, although a diagnosis should be confirmed before considering this option, Dr. Hammoudi said.
 

Malabsorption diarrhea

Another major cause of chronic diarrhea is malabsorption, characterized by large, fatty stools that are difficult to flush. Despite a normal diet, this type of diarrhea is associated with weight loss and nutritional deficiencies.

Its diagnosis involves measuring fat in the stools (steatorrhea) and possibly testing fecal elastase, an enzyme produced by the pancreas that is involved in digestion.

The most important causes of malabsorption diarrhea are pancreatic insufficiency, celiac disease, and Crohn’s disease. Generally, any lesion in the small intestine can lead to malabsorption-related diarrhea.

Celiac disease, or gluten intolerance, is an autoimmune condition triggered by a reaction to gluten proteins. Several antibodies can be produced in the presence of gluten proteins. Diagnosis is confirmed by positive antitransglutaminase antibodies and a duodenal biopsy through esophagogastroduodenoscopy.

The only treatment for celiac disease is a lifelong gluten-free diet. Celiac disease is increasingly diagnosed in adults, said Dr. Hammoudi, and should be considered as a possibility. This condition must be distinguished from gluten sensitivity, which can cause digestive issues, possibly leading to rapid intestinal transit diarrhea. “The only treatment for celiac disease is a lifelong gluten-free diet,” Dr. Hammoudi added.

Crohn’s disease, a type of inflammatory bowel disease, affects the entire digestive tract, particularly the terminal small intestine, which promotes malabsorption. In ulcerative colitis, another IBD affecting the rectum, any associated rectal syndrome can result in false diarrhea with stools containing blood and mucus.

Osmotic diarrhea, on the other hand, is linked to the presence of highly osmotic agents in the digestive tract. This type of diarrhea is watery and short-lived, stopping once the agents are no longer absorbed. The main culprits are lactose (in cases of lactose intolerance) and laxatives.
 

Drug-induced microscopic colitis

Secretory diarrhea is characterized by excessive secretions by the digestive tract, leading to significant potassium loss. This type of diarrhea is not related to food intake and is resistant to fasting.

Major causes of secretory diarrhea include microscopic colitis, parasitic infections, and endocrine tumors. Between 10% and 15% of patients with chronic diarrhea and apparently normal colonoscopy have microscopic colitis.

Dr. Hammoudi advised specialists seeking to determine the cause of chronic diarrhea to routinely collect multilevel bowel biopsies during colonoscopies from macroscopically normal mucosa to rule out microscopic colitis.

Microscopic colitis is mainly linked to the use of medications like PPIs and NSAIDs. These drugs can induce malabsorption-related diarrhea by damaging the intestinal wall.

In addition to discontinuing the implicated medication, the treatment for microscopic colitis includes low-dose budesonide (multiple brands). Biologics used in IBD may also be considered in cases of recurrent colitis.

Finally, exudative enteropathy can be a distinct cause of chronic diarrhea. It is characterized by albumin leakage (Waldmann’s disease) and manifests with edema, malnutrition, and significant hypoalbuminemia.

This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.

BOSTON – With the current demand for type 2 diabetes drugs that both improve glycemic control and help patients shed large amounts of weight, liver specialists have speculated that the metabolic benefits could also extend to the liver.

Spoiler alert: they do.

In a retrospective study of patients with metabolic-associated fatty liver disease (MAFLD) and type 2 diabetes mellitus (T2DM) who received either a sodium-glucose cotransporter 2 (SGLT-2) inhibitor or glucagon-like peptide-1 (GLP-1) agonist, 87% of those who lost at least 3% of body weight within 8 weeks eventually experienced normalization of alanine aminotransferase (ALT) levels, reported Takamasa Ohki, MD, PhD, and colleagues from the department of gastroenterology at Mitsui Memorial Hospital in Tokyo.

“Body weight reduction within 8 weeks after administration of these agents was an independent factor [that] contributed to rapid improvement of ALT. Maintenance of body weight and T2DM after normalization of ALT was also very important,” they wrote in a scientific poster presented at the annual meeting of the American Association for the Study of Liver Diseases.
 

The biggest losers benefit most

Dr. Ohki and colleagues evaluated the effectiveness of SGLT-2 inhibitors and GLP-1 agonists as treatment of MAFLD for patients with T2DM.

They conducted a retrospective study of 233 patients who had both conditions and who received either of the drug classes at their institution from June 2010 through December 2021; the most recent follow-up was in December 2022. The primary endpoint of the study was normalization of ALT values.

A total of 54 patients had a 3% or greater reduction in body weight within 8 weeks of beginning treatment with their respective drugs. The researchers found that for 47 of these patients (87%), ALT values normalized; the 12-, 24-, and 36-month cumulative normalization rates were 61%, 73%, and 80%, respectively.

In contrast, among the 179 patients who did not lose weight as robustly or rapidly, 137 (76.5%) demonstrated normalization of ALT, with cumulative normalization rates of 41%, 59% and 69%, respectively (P < .01).

In multivariate analysis that controlled for age, sex, smoking, hypertension, dyslipidemia, weight reduction, and antidiabetes drug use, body weight reduction of at least 3% within 8 weeks of beginning treatment with either an SLT-2 or GLP-1 agent was associated independently with normalization of ALT, with a hazard ratio (HR) of 0.67 (P = .028).

Improvement of T2DM was an independent predictor for ALT normalization (HR, 0.64; P = .015).

Other factors contributing to ALT normalization included use of sulfonylurea (HR, 0.63; P < .01) and insulin (HR, 0.54; P < .01).

In all, 103 of the 184 patients with initial normalization of ALT values experienced a recurrence of ALT elevation during follow-up. In multivariate analysis, body weight gain and exacerbation of T2DM were independent factors for ALT reexacerbation (HR, 0.52 and 0.48, respectively; P < .01 for both comparisons).
 

Duration of effect uncertain

Philip A. Newsome, PhD, FRCPE, professor of experimental hepatology and honorary consultant hepatologist at the University of Birmingham, England, who was not involved in the study, has conducted research into the metabolic effects of SGLT-2 inhibitors and GLP-1 agonists. In an interview, he said that both drug classes are likely to have positive near-term effects on metabolic dysfunction–associated steatohepatitis (MASH, formerly NASH) through their effects on glucose control and reduction in associated comorbidities.

“The unknown question,” he added, is what will happen in the long term. “I think there are some uncertainties around what proportion of patients will essentially be downstaged or downgraded such that they don’t develop any other problem; I suspect that will be the case in very many patients. However, I suspect there will also be a large proportion that end up requiring additional therapy above and beyond weight loss,” said Dr. Newsome.

The investigators did not report a funding source for the study. Dr. Ohki and colleagues have disclosed no relevant financial relationships. Dr. Newsome has consulted on behalf of his institution with Novo Nordisk, BMS, Gilead, Pfizer, Poxel, and Intercept and has received a grant from Pharmaxis and Boehringer Ingelheim.
 

A version of this article appeared on Medscape.com.

BOSTON – With the current demand for type 2 diabetes drugs that both improve glycemic control and help patients shed large amounts of weight, liver specialists have speculated that the metabolic benefits could also extend to the liver.

Spoiler alert: they do.

In a retrospective study of patients with metabolic-associated fatty liver disease (MAFLD) and type 2 diabetes mellitus (T2DM) who received either a sodium-glucose cotransporter 2 (SGLT-2) inhibitor or glucagon-like peptide-1 (GLP-1) agonist, 87% of those who lost at least 3% of body weight within 8 weeks eventually experienced normalization of alanine aminotransferase (ALT) levels, reported Takamasa Ohki, MD, PhD, and colleagues from the department of gastroenterology at Mitsui Memorial Hospital in Tokyo.

“Body weight reduction within 8 weeks after administration of these agents was an independent factor [that] contributed to rapid improvement of ALT. Maintenance of body weight and T2DM after normalization of ALT was also very important,” they wrote in a scientific poster presented at the annual meeting of the American Association for the Study of Liver Diseases.
 

The biggest losers benefit most

Dr. Ohki and colleagues evaluated the effectiveness of SGLT-2 inhibitors and GLP-1 agonists as treatment of MAFLD for patients with T2DM.

They conducted a retrospective study of 233 patients who had both conditions and who received either of the drug classes at their institution from June 2010 through December 2021; the most recent follow-up was in December 2022. The primary endpoint of the study was normalization of ALT values.

A total of 54 patients had a 3% or greater reduction in body weight within 8 weeks of beginning treatment with their respective drugs. The researchers found that for 47 of these patients (87%), ALT values normalized; the 12-, 24-, and 36-month cumulative normalization rates were 61%, 73%, and 80%, respectively.

In contrast, among the 179 patients who did not lose weight as robustly or rapidly, 137 (76.5%) demonstrated normalization of ALT, with cumulative normalization rates of 41%, 59% and 69%, respectively (P < .01).

In multivariate analysis that controlled for age, sex, smoking, hypertension, dyslipidemia, weight reduction, and antidiabetes drug use, body weight reduction of at least 3% within 8 weeks of beginning treatment with either an SLT-2 or GLP-1 agent was associated independently with normalization of ALT, with a hazard ratio (HR) of 0.67 (P = .028).

Improvement of T2DM was an independent predictor for ALT normalization (HR, 0.64; P = .015).

Other factors contributing to ALT normalization included use of sulfonylurea (HR, 0.63; P < .01) and insulin (HR, 0.54; P < .01).

In all, 103 of the 184 patients with initial normalization of ALT values experienced a recurrence of ALT elevation during follow-up. In multivariate analysis, body weight gain and exacerbation of T2DM were independent factors for ALT reexacerbation (HR, 0.52 and 0.48, respectively; P < .01 for both comparisons).
 

Duration of effect uncertain

Philip A. Newsome, PhD, FRCPE, professor of experimental hepatology and honorary consultant hepatologist at the University of Birmingham, England, who was not involved in the study, has conducted research into the metabolic effects of SGLT-2 inhibitors and GLP-1 agonists. In an interview, he said that both drug classes are likely to have positive near-term effects on metabolic dysfunction–associated steatohepatitis (MASH, formerly NASH) through their effects on glucose control and reduction in associated comorbidities.

“The unknown question,” he added, is what will happen in the long term. “I think there are some uncertainties around what proportion of patients will essentially be downstaged or downgraded such that they don’t develop any other problem; I suspect that will be the case in very many patients. However, I suspect there will also be a large proportion that end up requiring additional therapy above and beyond weight loss,” said Dr. Newsome.

The investigators did not report a funding source for the study. Dr. Ohki and colleagues have disclosed no relevant financial relationships. Dr. Newsome has consulted on behalf of his institution with Novo Nordisk, BMS, Gilead, Pfizer, Poxel, and Intercept and has received a grant from Pharmaxis and Boehringer Ingelheim.
 

A version of this article appeared on Medscape.com.

BOSTON – With the current demand for type 2 diabetes drugs that both improve glycemic control and help patients shed large amounts of weight, liver specialists have speculated that the metabolic benefits could also extend to the liver.

Spoiler alert: they do.

In a retrospective study of patients with metabolic-associated fatty liver disease (MAFLD) and type 2 diabetes mellitus (T2DM) who received either a sodium-glucose cotransporter 2 (SGLT-2) inhibitor or glucagon-like peptide-1 (GLP-1) agonist, 87% of those who lost at least 3% of body weight within 8 weeks eventually experienced normalization of alanine aminotransferase (ALT) levels, reported Takamasa Ohki, MD, PhD, and colleagues from the department of gastroenterology at Mitsui Memorial Hospital in Tokyo.

“Body weight reduction within 8 weeks after administration of these agents was an independent factor [that] contributed to rapid improvement of ALT. Maintenance of body weight and T2DM after normalization of ALT was also very important,” they wrote in a scientific poster presented at the annual meeting of the American Association for the Study of Liver Diseases.
 

The biggest losers benefit most

Dr. Ohki and colleagues evaluated the effectiveness of SGLT-2 inhibitors and GLP-1 agonists as treatment of MAFLD for patients with T2DM.

They conducted a retrospective study of 233 patients who had both conditions and who received either of the drug classes at their institution from June 2010 through December 2021; the most recent follow-up was in December 2022. The primary endpoint of the study was normalization of ALT values.

A total of 54 patients had a 3% or greater reduction in body weight within 8 weeks of beginning treatment with their respective drugs. The researchers found that for 47 of these patients (87%), ALT values normalized; the 12-, 24-, and 36-month cumulative normalization rates were 61%, 73%, and 80%, respectively.

In contrast, among the 179 patients who did not lose weight as robustly or rapidly, 137 (76.5%) demonstrated normalization of ALT, with cumulative normalization rates of 41%, 59% and 69%, respectively (P < .01).

In multivariate analysis that controlled for age, sex, smoking, hypertension, dyslipidemia, weight reduction, and antidiabetes drug use, body weight reduction of at least 3% within 8 weeks of beginning treatment with either an SLT-2 or GLP-1 agent was associated independently with normalization of ALT, with a hazard ratio (HR) of 0.67 (P = .028).

Improvement of T2DM was an independent predictor for ALT normalization (HR, 0.64; P = .015).

Other factors contributing to ALT normalization included use of sulfonylurea (HR, 0.63; P < .01) and insulin (HR, 0.54; P < .01).

In all, 103 of the 184 patients with initial normalization of ALT values experienced a recurrence of ALT elevation during follow-up. In multivariate analysis, body weight gain and exacerbation of T2DM were independent factors for ALT reexacerbation (HR, 0.52 and 0.48, respectively; P < .01 for both comparisons).
 

Duration of effect uncertain

Philip A. Newsome, PhD, FRCPE, professor of experimental hepatology and honorary consultant hepatologist at the University of Birmingham, England, who was not involved in the study, has conducted research into the metabolic effects of SGLT-2 inhibitors and GLP-1 agonists. In an interview, he said that both drug classes are likely to have positive near-term effects on metabolic dysfunction–associated steatohepatitis (MASH, formerly NASH) through their effects on glucose control and reduction in associated comorbidities.

“The unknown question,” he added, is what will happen in the long term. “I think there are some uncertainties around what proportion of patients will essentially be downstaged or downgraded such that they don’t develop any other problem; I suspect that will be the case in very many patients. However, I suspect there will also be a large proportion that end up requiring additional therapy above and beyond weight loss,” said Dr. Newsome.

The investigators did not report a funding source for the study. Dr. Ohki and colleagues have disclosed no relevant financial relationships. Dr. Newsome has consulted on behalf of his institution with Novo Nordisk, BMS, Gilead, Pfizer, Poxel, and Intercept and has received a grant from Pharmaxis and Boehringer Ingelheim.
 

A version of this article appeared on Medscape.com.

TOPLINE:

Lower-extremity (LE) lymphedema increases the risk for all types of skin cancer on the lower extremities.

METHODOLOGY:

• In the retrospective cohort study, researchers reviewed reports at Mayo Clinic for all patients who had LE lymphedema, limiting the review to those who had an ICD code for lymphedema.
• 4,437 patients with the ICD code from 2000 to 2020 were compared with 4,437 matched controls.
• The records of patients with skin cancer diagnoses were reviewed manually to determine whether the skin cancer, its management, or both were a cause of lymphedema; cancers that caused secondary lymphedema were excluded.
• This is the first large-scale study evaluating the association between LE lymphedema and LE skin cancer.

TAKEAWAY:

• 211 patients (4.6%) in the LE lymphedema group had any ICD code for LE skin cancer, compared with 89 (2%) in the control group.
• Among those with LE lymphedema, the risk for skin cancer was 1.98 times greater compared with those without lymphedema (95% confidence interval, 1.43-2.74; P < .001). Cases included all types of skin cancer.
• Nineteen of 24 patients with unilateral LE lymphedema had a history of immunosuppression.
• In the group of 24 patients with unilateral LE lymphedema, the lymphedematous LE was more likely to have one or more skin cancers than were the unaffected LE (87.5% vs. 33.3%; P < .05), and skin cancer was 2.65 times more likely to develop on the affected LE than in the unaffected LE (95% CI, 1.17-5.99; P = .02).

IN PRACTICE:

“Our findings suggest the need for a relatively high degree of suspicion of skin cancer at sites with lymphedema,” senior author, Afsaneh Alavi, MD, professor of dermatology at the Mayo Clinic, said in a Mayo Clinic press release reporting the results.

SOURCE:

The study was conducted by researchers at the Mayo Clinic and Meharry Medical College, Nashville. It was published in the November 2023 Mayo Clinic Proceedings.

LIMITATIONS:

This was a single-center retrospective study, and patients with LE lymphedema may be overdiagnosed with LE skin cancer because they have a greater number of examinations.

DISCLOSURES:

Dr. Alavi reports having been a consultant for AbbVie, Boehringer Ingelheim, InflaRx, Novartis, and UCB SA and an investigator for Processa Pharmaceuticals and Boehringer Ingelheim. The other authors had no disclosures.

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

TOPLINE:

Lower-extremity (LE) lymphedema increases the risk for all types of skin cancer on the lower extremities.

METHODOLOGY:

• In the retrospective cohort study, researchers reviewed reports at Mayo Clinic for all patients who had LE lymphedema, limiting the review to those who had an ICD code for lymphedema.
• 4,437 patients with the ICD code from 2000 to 2020 were compared with 4,437 matched controls.
• The records of patients with skin cancer diagnoses were reviewed manually to determine whether the skin cancer, its management, or both were a cause of lymphedema; cancers that caused secondary lymphedema were excluded.
• This is the first large-scale study evaluating the association between LE lymphedema and LE skin cancer.

TAKEAWAY:

• 211 patients (4.6%) in the LE lymphedema group had any ICD code for LE skin cancer, compared with 89 (2%) in the control group.
• Among those with LE lymphedema, the risk for skin cancer was 1.98 times greater compared with those without lymphedema (95% confidence interval, 1.43-2.74; P < .001). Cases included all types of skin cancer.
• Nineteen of 24 patients with unilateral LE lymphedema had a history of immunosuppression.
• In the group of 24 patients with unilateral LE lymphedema, the lymphedematous LE was more likely to have one or more skin cancers than were the unaffected LE (87.5% vs. 33.3%; P < .05), and skin cancer was 2.65 times more likely to develop on the affected LE than in the unaffected LE (95% CI, 1.17-5.99; P = .02).

IN PRACTICE:

“Our findings suggest the need for a relatively high degree of suspicion of skin cancer at sites with lymphedema,” senior author, Afsaneh Alavi, MD, professor of dermatology at the Mayo Clinic, said in a Mayo Clinic press release reporting the results.

SOURCE:

The study was conducted by researchers at the Mayo Clinic and Meharry Medical College, Nashville. It was published in the November 2023 Mayo Clinic Proceedings.

LIMITATIONS:

This was a single-center retrospective study, and patients with LE lymphedema may be overdiagnosed with LE skin cancer because they have a greater number of examinations.

DISCLOSURES:

Dr. Alavi reports having been a consultant for AbbVie, Boehringer Ingelheim, InflaRx, Novartis, and UCB SA and an investigator for Processa Pharmaceuticals and Boehringer Ingelheim. The other authors had no disclosures.

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

TOPLINE:

Lower-extremity (LE) lymphedema increases the risk for all types of skin cancer on the lower extremities.

METHODOLOGY:

• In the retrospective cohort study, researchers reviewed reports at Mayo Clinic for all patients who had LE lymphedema, limiting the review to those who had an ICD code for lymphedema.
• 4,437 patients with the ICD code from 2000 to 2020 were compared with 4,437 matched controls.
• The records of patients with skin cancer diagnoses were reviewed manually to determine whether the skin cancer, its management, or both were a cause of lymphedema; cancers that caused secondary lymphedema were excluded.
• This is the first large-scale study evaluating the association between LE lymphedema and LE skin cancer.

TAKEAWAY:

• 211 patients (4.6%) in the LE lymphedema group had any ICD code for LE skin cancer, compared with 89 (2%) in the control group.
• Among those with LE lymphedema, the risk for skin cancer was 1.98 times greater compared with those without lymphedema (95% confidence interval, 1.43-2.74; P < .001). Cases included all types of skin cancer.
• Nineteen of 24 patients with unilateral LE lymphedema had a history of immunosuppression.
• In the group of 24 patients with unilateral LE lymphedema, the lymphedematous LE was more likely to have one or more skin cancers than were the unaffected LE (87.5% vs. 33.3%; P < .05), and skin cancer was 2.65 times more likely to develop on the affected LE than in the unaffected LE (95% CI, 1.17-5.99; P = .02).

IN PRACTICE:

“Our findings suggest the need for a relatively high degree of suspicion of skin cancer at sites with lymphedema,” senior author, Afsaneh Alavi, MD, professor of dermatology at the Mayo Clinic, said in a Mayo Clinic press release reporting the results.

SOURCE:

The study was conducted by researchers at the Mayo Clinic and Meharry Medical College, Nashville. It was published in the November 2023 Mayo Clinic Proceedings.

LIMITATIONS:

This was a single-center retrospective study, and patients with LE lymphedema may be overdiagnosed with LE skin cancer because they have a greater number of examinations.

DISCLOSURES:

Dr. Alavi reports having been a consultant for AbbVie, Boehringer Ingelheim, InflaRx, Novartis, and UCB SA and an investigator for Processa Pharmaceuticals and Boehringer Ingelheim. The other authors had no disclosures.

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