Advances in breast cancer detection and treatment over the past decades have led to an increase in the number of women diagnosed at earlier stages and successfully treated, ushering in a new era of survivorship.

According to the American Cancer Society, there are currently roughly four million breast cancer survivors in the United States, including those still receiving treatment. The mortality rates for women with breast cancer have been decreasing since 1989, with an overall decline of 42% through 2021.

As the population of breast cancer survivors continues to grow, developing and delivering comprehensive survivorship care is crucial, Thelma Brown told attendees at the American Society of Clinical Oncology (ASCO) 2024 annual meeting. Ms. Brown’s talk was part of an educational session focused on addressing issues among early breast cancer survivors, evolving practices in breast cancer surveillance, and mitigating recurrence risk.

The challenges following breast cancer diagnosis and treatment can be both visible and invisible, said Ms. Brown, a patient advocate and member of the Breast Cancer Working Group at the University of Alabama at Birmingham.

Up to 90% of early breast cancer survivors experience long-term effects from treatment, which often include fatigue, loss of mobility, chronic pain, peripheral neuropathy, lymphedema, and infertility.

Survivors face an elevated risk for depression, anxiety, and fear of recurrence. “Fear of recurrence is a big issue, and it’s almost universal,” she noted.

Cancer treatment is also costly, leading to financial toxicity for many patients, which also “affects adherence to treatment and overall family well-being,” Ms. Brown explained. Survivors may struggle to access financial assistance due to complex eligibility requirements and a lack of awareness about available resources. 

There is a need for holistic and coordinated survivorship care that includes management of long-term effects and surveillance for recurrence to help breast cancer survivors to transition from merely surviving to thriving, said Ms. Brown.
 

Surveilling and Mitigating Recurrence

Surveillance in patients with breast cancer post treatment remains a debated area, particularly when it comes to detecting distant recurrences, David Cescon, MD, PhD, with Princess Margaret Cancer Center, University Health Network, Toronto, said in his talk.

While breast imaging standards are well established, systemic surveillance through imaging and laboratory tests for asymptomatic patients lacks consensus and uniform guidelines, he explained.

Several clinical trials conducted from the late 1980s to the early 2000s showed no survival benefit from intensive surveillance strategies, including imaging and laboratory tests, compared to routine clinical follow-up. Some studies even demonstrated a trend toward harm, given the number of false positives.

These studies formed the basis for guidelines that discourage surveillance among asymptomatic survivors. Currently, no major guideline organization — the National Comprehensive Cancer Network, ASCO, and the European Society for Medical Oncology — recommends routine (nonbreast) radiologic surveillance or laboratory tests for detecting asymptomatic distant breast cancer recurrence, Dr. Cescon said.

Yet, that may change in the coming years, he told attendees.

Ongoing prospective studies will hopefully generate high-quality evidence on the effectiveness of modern surveillance techniques, particularly detection of circulating tumor DNA (ctDNA) and its effect on survival and quality of life, said Dr. Cescon.

These liquid biopsy assays have shown promise in identifying minimal residual disease before radiographic recurrence, he explained. Retrospective studies suggest high prognostic value, with nearly all patients with detectable ctDNA post therapy experiencing recurrence. 

He cautioned, however, that while sensitive ctDNA tests exist and have clinical validity in identifying minimal residual disease, “their clinical utility has not yet been demonstrated,” Dr. Cescon said, adding that any surveillance strategy must consider the psychological effect of frequent testing and the potential for false positives or negatives.

The ultimate goal is preventing disease recurrence, said Neil M. Iyengar, MD, with Memorial Sloan Kettering Cancer Center in New York, in his talk on mitigating recurrence risk. 

Lifestyle modifications are an important targeted intervention for patients entering the survivorship phase, with a “robust level of evidence” supporting their use to mitigate adverse effects associated with cancer therapy and improve quality of life, he told attendees. Most notably, smoking cessation, healthy dietary patterns, physical activity, and reduced alcohol have been associated with improvements in breast cancer outcomes.

Going forward, it will be important to “understand the antitumor potential of lifestyle modification and how we can wield this type of intervention as a precision tool to potentially enhance the effects of cancer therapy and potentially cancer biology,” said Dr. Iyengar.

Ms. Brown disclosed relationships with AstraZeneca. Dr. Cescon disclosed relationships with AstraZeneca, Gilead Sciences, Daiichi Sankyo Europe GmbH, Eisai, GlaxoSmithKline, and other companies. Dr. Iyengar disclosed relationships with Curio Science, DAVA Oncology, Novartis, Pfizer, and others.

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

Advances in breast cancer detection and treatment over the past decades have led to an increase in the number of women diagnosed at earlier stages and successfully treated, ushering in a new era of survivorship.

According to the American Cancer Society, there are currently roughly four million breast cancer survivors in the United States, including those still receiving treatment. The mortality rates for women with breast cancer have been decreasing since 1989, with an overall decline of 42% through 2021.

As the population of breast cancer survivors continues to grow, developing and delivering comprehensive survivorship care is crucial, Thelma Brown told attendees at the American Society of Clinical Oncology (ASCO) 2024 annual meeting. Ms. Brown’s talk was part of an educational session focused on addressing issues among early breast cancer survivors, evolving practices in breast cancer surveillance, and mitigating recurrence risk.

The challenges following breast cancer diagnosis and treatment can be both visible and invisible, said Ms. Brown, a patient advocate and member of the Breast Cancer Working Group at the University of Alabama at Birmingham.

Up to 90% of early breast cancer survivors experience long-term effects from treatment, which often include fatigue, loss of mobility, chronic pain, peripheral neuropathy, lymphedema, and infertility.

Survivors face an elevated risk for depression, anxiety, and fear of recurrence. “Fear of recurrence is a big issue, and it’s almost universal,” she noted.

Cancer treatment is also costly, leading to financial toxicity for many patients, which also “affects adherence to treatment and overall family well-being,” Ms. Brown explained. Survivors may struggle to access financial assistance due to complex eligibility requirements and a lack of awareness about available resources. 

There is a need for holistic and coordinated survivorship care that includes management of long-term effects and surveillance for recurrence to help breast cancer survivors to transition from merely surviving to thriving, said Ms. Brown.
 

Surveilling and Mitigating Recurrence

Surveillance in patients with breast cancer post treatment remains a debated area, particularly when it comes to detecting distant recurrences, David Cescon, MD, PhD, with Princess Margaret Cancer Center, University Health Network, Toronto, said in his talk.

While breast imaging standards are well established, systemic surveillance through imaging and laboratory tests for asymptomatic patients lacks consensus and uniform guidelines, he explained.

Several clinical trials conducted from the late 1980s to the early 2000s showed no survival benefit from intensive surveillance strategies, including imaging and laboratory tests, compared to routine clinical follow-up. Some studies even demonstrated a trend toward harm, given the number of false positives.

These studies formed the basis for guidelines that discourage surveillance among asymptomatic survivors. Currently, no major guideline organization — the National Comprehensive Cancer Network, ASCO, and the European Society for Medical Oncology — recommends routine (nonbreast) radiologic surveillance or laboratory tests for detecting asymptomatic distant breast cancer recurrence, Dr. Cescon said.

Yet, that may change in the coming years, he told attendees.

Ongoing prospective studies will hopefully generate high-quality evidence on the effectiveness of modern surveillance techniques, particularly detection of circulating tumor DNA (ctDNA) and its effect on survival and quality of life, said Dr. Cescon.

These liquid biopsy assays have shown promise in identifying minimal residual disease before radiographic recurrence, he explained. Retrospective studies suggest high prognostic value, with nearly all patients with detectable ctDNA post therapy experiencing recurrence. 

He cautioned, however, that while sensitive ctDNA tests exist and have clinical validity in identifying minimal residual disease, “their clinical utility has not yet been demonstrated,” Dr. Cescon said, adding that any surveillance strategy must consider the psychological effect of frequent testing and the potential for false positives or negatives.

The ultimate goal is preventing disease recurrence, said Neil M. Iyengar, MD, with Memorial Sloan Kettering Cancer Center in New York, in his talk on mitigating recurrence risk. 

Lifestyle modifications are an important targeted intervention for patients entering the survivorship phase, with a “robust level of evidence” supporting their use to mitigate adverse effects associated with cancer therapy and improve quality of life, he told attendees. Most notably, smoking cessation, healthy dietary patterns, physical activity, and reduced alcohol have been associated with improvements in breast cancer outcomes.

Going forward, it will be important to “understand the antitumor potential of lifestyle modification and how we can wield this type of intervention as a precision tool to potentially enhance the effects of cancer therapy and potentially cancer biology,” said Dr. Iyengar.

Ms. Brown disclosed relationships with AstraZeneca. Dr. Cescon disclosed relationships with AstraZeneca, Gilead Sciences, Daiichi Sankyo Europe GmbH, Eisai, GlaxoSmithKline, and other companies. Dr. Iyengar disclosed relationships with Curio Science, DAVA Oncology, Novartis, Pfizer, and others.

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

Advances in breast cancer detection and treatment over the past decades have led to an increase in the number of women diagnosed at earlier stages and successfully treated, ushering in a new era of survivorship.

According to the American Cancer Society, there are currently roughly four million breast cancer survivors in the United States, including those still receiving treatment. The mortality rates for women with breast cancer have been decreasing since 1989, with an overall decline of 42% through 2021.

As the population of breast cancer survivors continues to grow, developing and delivering comprehensive survivorship care is crucial, Thelma Brown told attendees at the American Society of Clinical Oncology (ASCO) 2024 annual meeting. Ms. Brown’s talk was part of an educational session focused on addressing issues among early breast cancer survivors, evolving practices in breast cancer surveillance, and mitigating recurrence risk.

The challenges following breast cancer diagnosis and treatment can be both visible and invisible, said Ms. Brown, a patient advocate and member of the Breast Cancer Working Group at the University of Alabama at Birmingham.

Up to 90% of early breast cancer survivors experience long-term effects from treatment, which often include fatigue, loss of mobility, chronic pain, peripheral neuropathy, lymphedema, and infertility.

Survivors face an elevated risk for depression, anxiety, and fear of recurrence. “Fear of recurrence is a big issue, and it’s almost universal,” she noted.

Cancer treatment is also costly, leading to financial toxicity for many patients, which also “affects adherence to treatment and overall family well-being,” Ms. Brown explained. Survivors may struggle to access financial assistance due to complex eligibility requirements and a lack of awareness about available resources. 

There is a need for holistic and coordinated survivorship care that includes management of long-term effects and surveillance for recurrence to help breast cancer survivors to transition from merely surviving to thriving, said Ms. Brown.
 

Surveilling and Mitigating Recurrence

Surveillance in patients with breast cancer post treatment remains a debated area, particularly when it comes to detecting distant recurrences, David Cescon, MD, PhD, with Princess Margaret Cancer Center, University Health Network, Toronto, said in his talk.

While breast imaging standards are well established, systemic surveillance through imaging and laboratory tests for asymptomatic patients lacks consensus and uniform guidelines, he explained.

Several clinical trials conducted from the late 1980s to the early 2000s showed no survival benefit from intensive surveillance strategies, including imaging and laboratory tests, compared to routine clinical follow-up. Some studies even demonstrated a trend toward harm, given the number of false positives.

These studies formed the basis for guidelines that discourage surveillance among asymptomatic survivors. Currently, no major guideline organization — the National Comprehensive Cancer Network, ASCO, and the European Society for Medical Oncology — recommends routine (nonbreast) radiologic surveillance or laboratory tests for detecting asymptomatic distant breast cancer recurrence, Dr. Cescon said.

Yet, that may change in the coming years, he told attendees.

Ongoing prospective studies will hopefully generate high-quality evidence on the effectiveness of modern surveillance techniques, particularly detection of circulating tumor DNA (ctDNA) and its effect on survival and quality of life, said Dr. Cescon.

These liquid biopsy assays have shown promise in identifying minimal residual disease before radiographic recurrence, he explained. Retrospective studies suggest high prognostic value, with nearly all patients with detectable ctDNA post therapy experiencing recurrence. 

He cautioned, however, that while sensitive ctDNA tests exist and have clinical validity in identifying minimal residual disease, “their clinical utility has not yet been demonstrated,” Dr. Cescon said, adding that any surveillance strategy must consider the psychological effect of frequent testing and the potential for false positives or negatives.

The ultimate goal is preventing disease recurrence, said Neil M. Iyengar, MD, with Memorial Sloan Kettering Cancer Center in New York, in his talk on mitigating recurrence risk. 

Lifestyle modifications are an important targeted intervention for patients entering the survivorship phase, with a “robust level of evidence” supporting their use to mitigate adverse effects associated with cancer therapy and improve quality of life, he told attendees. Most notably, smoking cessation, healthy dietary patterns, physical activity, and reduced alcohol have been associated with improvements in breast cancer outcomes.

Going forward, it will be important to “understand the antitumor potential of lifestyle modification and how we can wield this type of intervention as a precision tool to potentially enhance the effects of cancer therapy and potentially cancer biology,” said Dr. Iyengar.

Ms. Brown disclosed relationships with AstraZeneca. Dr. Cescon disclosed relationships with AstraZeneca, Gilead Sciences, Daiichi Sankyo Europe GmbH, Eisai, GlaxoSmithKline, and other companies. Dr. Iyengar disclosed relationships with Curio Science, DAVA Oncology, Novartis, Pfizer, and others.

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

Rumination syndrome is a well-recognized functional disorder characterized by the regurgitation of food or liquid in the absence of retching or nausea.

Evidence suggests that the prevalence of rumination syndrome is increasing. In a 2022 health survey study conducted across 26 countries — the largest epidemiologic study to date on rumination syndrome — investigators reported that it had a global prevalence of 3.1% in adults. This was higher than reported in most prior country-specific studies. More recently, a systematic review and meta-analysis from 2024 reported the pooled prevalence of rumination syndrome as 3.7% in adults and 0.4% in children. Both reports noted that female gender, anxiety, and depression were independent risk factors associated with rumination syndrome.

Recognition of this disorder is crucial in order for clinicians to better diagnose and manage it in their patients.
 

Making the Diagnosis

The diagnosis of rumination syndrome is currently based on the Rome IV consensus criteria, which were last updated in 2016. These include three diagnostic criteria essential to remember as discriminant for rumination syndrome:

• Regurgitation is the effortless return of gastric contents (recognizable food) retrograde back into the esophagus and/or mouth.
• This is not preceded by retching and not associated with nausea.
• These symptoms must have started at least 6 months before evaluation, been evident over the past 3 months, and occurred at least two to three times per month.

Although this diagnosis will be highly suspected after taking an astute clinical history, you will still need to rule out the presence of underlying organic disease.

Nearly one quarter of patients with eating disorders — which commonly accompany gastrointestinal disorders — will not have been diagnosed by the time they visit with a gastroenterologist. Therefore, gastroenterologists should be vigilant in screening for eating disorders. Notably, severe weight loss, malnutrition, electrolyte abnormalities, and dental erosions (due to acid etching) are uncommon in rumination syndrome. If such symptoms are present, it increases the possibility of an underlying eating disorder rather than primary regurgitation.

Previously, there were no published, validated questionnaires to assess the diagnosis or symptomatic response to therapies for rumination syndrome. This has recently changed with the development of a novel eight-point questionnaire that assesses frequency, severity, type of regurgitant, timing of regurgitation in relation to the meal, weight loss, and use of and response to proton pump inhibitors.

This questionnaire was recently implemented in five patients diagnosed with rumination syndrome. Albeit an extremely small trial, it nonetheless showed clinical improvement in scores associated with therapeutic intervention. Further evaluation of this tool is needed.

The diagnosis of rumination syndrome can be confirmed using impedance manometry in persons with evidence of reflux extending to the proximal esophagus, which is associated with an intragastric pressure > 30 mmHg in adults or > 25 mmHg in children. 

Gastric emptying studies are typically not required to make a diagnosis unless the clinical symptoms are atypical and an alternative motility disorder is suspected. Endoscopy is performed to rule out a mechanical disorder.
 

Histopathologic Evidence

New data indicate that there may be specific histologic changes associated with rumination syndrome. A 2023 meta-analysis reported that patients with rumination syndrome had duodenal histologic evidence of increased lymphocytes and eosinophils, which have been associated with epithelial barrier dysfunction, microbial changes, and systemic immune activation in eosinophilic duodenitis.

If these histologic changes are validated, they may suggest future novel diagnostic and treatment approaches, at least for a subset of people with rumination syndrome.
 

Best Available Treatments

The first-line therapeutic treatment for rumination syndrome is diaphragmatic breathing.

I recommended using diaphragmatic breathing for this indication in a previous commentary, in which I noted that it can essentially serve as yoga for the diaphragm and abdominal muscles and advised patients to focus on breathing “through” their belly button.

Patients are instructed to breath in through their nose for 4-6 seconds, hold their breath for 2-3 seconds, and then breath out slowly against pursed lips. They can be supine or upright but should sense their abdominal muscles expand with inhaling, not move their chest wall, and completely relax their abdominal muscles upon exhaling.

Although there is no standard frequency or duration for diaphragmatic breathing, I routinely recommend patients try it after each meal for 10-15 minutes and, if possible, more during the day and in times of stress or anxiety.

Cognitive-behavioral therapies have been shown to be effective alternatives to diaphragmatic breathing.

There is some evidence that hypnosis and biofeedback-guided control of abdominothoracic muscle activity can also be effective options in treating rumination syndrome.

Robust data on pharmacologic treatments for rumination syndrome are lacking, with the exception of a randomized crossover study of baclofen. In this study, baclofen (10 mg three times daily) was significantly more effective than placebo (P = .04) in reducing regurgitation events. Investigators theorized that baclofen counteracts transient lower esophageal sphincter (LES) relaxations by increasing basal LES pressure, thereby potentially reducing regurgitation episodes. The most notable treatment side effects were somnolence, confusion, and dizziness, which may limit its extended use.
 

A Potentially Reversible Habit

Rumination syndrome is considered an acquired habit and, therefore, should be reversible.

Although there is no recent evidence in the literature that rumination syndrome contributes to a reduced survival rate, older data suggested adult mortality rates of 12%-20% (mostly in patients who were institutionalized). Additionally, rumination syndrome has been shown to diminish quality of life.

The best approach to improving the clinical outcomes of patients with rumination syndrome is to enlist a collaborative interprofessional team that includes physicians, behavioral therapists, and nurses to coordinate and optimize existing treatment strategies.

David A. Johnson, MD, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease. He has disclosed the following relevant financial relationships: advisor to ISOTHRIVE and Johnson & Johnson.

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

Rumination syndrome is a well-recognized functional disorder characterized by the regurgitation of food or liquid in the absence of retching or nausea.

Evidence suggests that the prevalence of rumination syndrome is increasing. In a 2022 health survey study conducted across 26 countries — the largest epidemiologic study to date on rumination syndrome — investigators reported that it had a global prevalence of 3.1% in adults. This was higher than reported in most prior country-specific studies. More recently, a systematic review and meta-analysis from 2024 reported the pooled prevalence of rumination syndrome as 3.7% in adults and 0.4% in children. Both reports noted that female gender, anxiety, and depression were independent risk factors associated with rumination syndrome.

Recognition of this disorder is crucial in order for clinicians to better diagnose and manage it in their patients.
 

Making the Diagnosis

The diagnosis of rumination syndrome is currently based on the Rome IV consensus criteria, which were last updated in 2016. These include three diagnostic criteria essential to remember as discriminant for rumination syndrome:

• Regurgitation is the effortless return of gastric contents (recognizable food) retrograde back into the esophagus and/or mouth.
• This is not preceded by retching and not associated with nausea.
• These symptoms must have started at least 6 months before evaluation, been evident over the past 3 months, and occurred at least two to three times per month.

Although this diagnosis will be highly suspected after taking an astute clinical history, you will still need to rule out the presence of underlying organic disease.

Nearly one quarter of patients with eating disorders — which commonly accompany gastrointestinal disorders — will not have been diagnosed by the time they visit with a gastroenterologist. Therefore, gastroenterologists should be vigilant in screening for eating disorders. Notably, severe weight loss, malnutrition, electrolyte abnormalities, and dental erosions (due to acid etching) are uncommon in rumination syndrome. If such symptoms are present, it increases the possibility of an underlying eating disorder rather than primary regurgitation.

Previously, there were no published, validated questionnaires to assess the diagnosis or symptomatic response to therapies for rumination syndrome. This has recently changed with the development of a novel eight-point questionnaire that assesses frequency, severity, type of regurgitant, timing of regurgitation in relation to the meal, weight loss, and use of and response to proton pump inhibitors.

This questionnaire was recently implemented in five patients diagnosed with rumination syndrome. Albeit an extremely small trial, it nonetheless showed clinical improvement in scores associated with therapeutic intervention. Further evaluation of this tool is needed.

The diagnosis of rumination syndrome can be confirmed using impedance manometry in persons with evidence of reflux extending to the proximal esophagus, which is associated with an intragastric pressure > 30 mmHg in adults or > 25 mmHg in children. 

Gastric emptying studies are typically not required to make a diagnosis unless the clinical symptoms are atypical and an alternative motility disorder is suspected. Endoscopy is performed to rule out a mechanical disorder.
 

Histopathologic Evidence

New data indicate that there may be specific histologic changes associated with rumination syndrome. A 2023 meta-analysis reported that patients with rumination syndrome had duodenal histologic evidence of increased lymphocytes and eosinophils, which have been associated with epithelial barrier dysfunction, microbial changes, and systemic immune activation in eosinophilic duodenitis.

If these histologic changes are validated, they may suggest future novel diagnostic and treatment approaches, at least for a subset of people with rumination syndrome.
 

Best Available Treatments

The first-line therapeutic treatment for rumination syndrome is diaphragmatic breathing.

I recommended using diaphragmatic breathing for this indication in a previous commentary, in which I noted that it can essentially serve as yoga for the diaphragm and abdominal muscles and advised patients to focus on breathing “through” their belly button.

Patients are instructed to breath in through their nose for 4-6 seconds, hold their breath for 2-3 seconds, and then breath out slowly against pursed lips. They can be supine or upright but should sense their abdominal muscles expand with inhaling, not move their chest wall, and completely relax their abdominal muscles upon exhaling.

Although there is no standard frequency or duration for diaphragmatic breathing, I routinely recommend patients try it after each meal for 10-15 minutes and, if possible, more during the day and in times of stress or anxiety.

Cognitive-behavioral therapies have been shown to be effective alternatives to diaphragmatic breathing.

There is some evidence that hypnosis and biofeedback-guided control of abdominothoracic muscle activity can also be effective options in treating rumination syndrome.

Robust data on pharmacologic treatments for rumination syndrome are lacking, with the exception of a randomized crossover study of baclofen. In this study, baclofen (10 mg three times daily) was significantly more effective than placebo (P = .04) in reducing regurgitation events. Investigators theorized that baclofen counteracts transient lower esophageal sphincter (LES) relaxations by increasing basal LES pressure, thereby potentially reducing regurgitation episodes. The most notable treatment side effects were somnolence, confusion, and dizziness, which may limit its extended use.
 

A Potentially Reversible Habit

Rumination syndrome is considered an acquired habit and, therefore, should be reversible.

Although there is no recent evidence in the literature that rumination syndrome contributes to a reduced survival rate, older data suggested adult mortality rates of 12%-20% (mostly in patients who were institutionalized). Additionally, rumination syndrome has been shown to diminish quality of life.

The best approach to improving the clinical outcomes of patients with rumination syndrome is to enlist a collaborative interprofessional team that includes physicians, behavioral therapists, and nurses to coordinate and optimize existing treatment strategies.

David A. Johnson, MD, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease. He has disclosed the following relevant financial relationships: advisor to ISOTHRIVE and Johnson & Johnson.

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

Rumination syndrome is a well-recognized functional disorder characterized by the regurgitation of food or liquid in the absence of retching or nausea.

Evidence suggests that the prevalence of rumination syndrome is increasing. In a 2022 health survey study conducted across 26 countries — the largest epidemiologic study to date on rumination syndrome — investigators reported that it had a global prevalence of 3.1% in adults. This was higher than reported in most prior country-specific studies. More recently, a systematic review and meta-analysis from 2024 reported the pooled prevalence of rumination syndrome as 3.7% in adults and 0.4% in children. Both reports noted that female gender, anxiety, and depression were independent risk factors associated with rumination syndrome.

Recognition of this disorder is crucial in order for clinicians to better diagnose and manage it in their patients.
 

Making the Diagnosis

The diagnosis of rumination syndrome is currently based on the Rome IV consensus criteria, which were last updated in 2016. These include three diagnostic criteria essential to remember as discriminant for rumination syndrome:

• Regurgitation is the effortless return of gastric contents (recognizable food) retrograde back into the esophagus and/or mouth.
• This is not preceded by retching and not associated with nausea.
• These symptoms must have started at least 6 months before evaluation, been evident over the past 3 months, and occurred at least two to three times per month.

Although this diagnosis will be highly suspected after taking an astute clinical history, you will still need to rule out the presence of underlying organic disease.

Nearly one quarter of patients with eating disorders — which commonly accompany gastrointestinal disorders — will not have been diagnosed by the time they visit with a gastroenterologist. Therefore, gastroenterologists should be vigilant in screening for eating disorders. Notably, severe weight loss, malnutrition, electrolyte abnormalities, and dental erosions (due to acid etching) are uncommon in rumination syndrome. If such symptoms are present, it increases the possibility of an underlying eating disorder rather than primary regurgitation.

Previously, there were no published, validated questionnaires to assess the diagnosis or symptomatic response to therapies for rumination syndrome. This has recently changed with the development of a novel eight-point questionnaire that assesses frequency, severity, type of regurgitant, timing of regurgitation in relation to the meal, weight loss, and use of and response to proton pump inhibitors.

This questionnaire was recently implemented in five patients diagnosed with rumination syndrome. Albeit an extremely small trial, it nonetheless showed clinical improvement in scores associated with therapeutic intervention. Further evaluation of this tool is needed.

The diagnosis of rumination syndrome can be confirmed using impedance manometry in persons with evidence of reflux extending to the proximal esophagus, which is associated with an intragastric pressure > 30 mmHg in adults or > 25 mmHg in children. 

Gastric emptying studies are typically not required to make a diagnosis unless the clinical symptoms are atypical and an alternative motility disorder is suspected. Endoscopy is performed to rule out a mechanical disorder.
 

Histopathologic Evidence

New data indicate that there may be specific histologic changes associated with rumination syndrome. A 2023 meta-analysis reported that patients with rumination syndrome had duodenal histologic evidence of increased lymphocytes and eosinophils, which have been associated with epithelial barrier dysfunction, microbial changes, and systemic immune activation in eosinophilic duodenitis.

If these histologic changes are validated, they may suggest future novel diagnostic and treatment approaches, at least for a subset of people with rumination syndrome.
 

Best Available Treatments

The first-line therapeutic treatment for rumination syndrome is diaphragmatic breathing.

I recommended using diaphragmatic breathing for this indication in a previous commentary, in which I noted that it can essentially serve as yoga for the diaphragm and abdominal muscles and advised patients to focus on breathing “through” their belly button.

Patients are instructed to breath in through their nose for 4-6 seconds, hold their breath for 2-3 seconds, and then breath out slowly against pursed lips. They can be supine or upright but should sense their abdominal muscles expand with inhaling, not move their chest wall, and completely relax their abdominal muscles upon exhaling.

Although there is no standard frequency or duration for diaphragmatic breathing, I routinely recommend patients try it after each meal for 10-15 minutes and, if possible, more during the day and in times of stress or anxiety.

Cognitive-behavioral therapies have been shown to be effective alternatives to diaphragmatic breathing.

There is some evidence that hypnosis and biofeedback-guided control of abdominothoracic muscle activity can also be effective options in treating rumination syndrome.

Robust data on pharmacologic treatments for rumination syndrome are lacking, with the exception of a randomized crossover study of baclofen. In this study, baclofen (10 mg three times daily) was significantly more effective than placebo (P = .04) in reducing regurgitation events. Investigators theorized that baclofen counteracts transient lower esophageal sphincter (LES) relaxations by increasing basal LES pressure, thereby potentially reducing regurgitation episodes. The most notable treatment side effects were somnolence, confusion, and dizziness, which may limit its extended use.
 

A Potentially Reversible Habit

Rumination syndrome is considered an acquired habit and, therefore, should be reversible.

Although there is no recent evidence in the literature that rumination syndrome contributes to a reduced survival rate, older data suggested adult mortality rates of 12%-20% (mostly in patients who were institutionalized). Additionally, rumination syndrome has been shown to diminish quality of life.

The best approach to improving the clinical outcomes of patients with rumination syndrome is to enlist a collaborative interprofessional team that includes physicians, behavioral therapists, and nurses to coordinate and optimize existing treatment strategies.

David A. Johnson, MD, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease. He has disclosed the following relevant financial relationships: advisor to ISOTHRIVE and Johnson & Johnson.

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

HOUSTON — Sleep may have a role in driving down rates of loneliness, especially among younger adults.

A study of nearly 2300 participants showed that better sleep health is associated with significantly lower levels of loneliness across ages and that the association is particularly strong in younger individuals.

The US Surgeon General has identified loneliness as “a major public health concern, linked to high rates of negative physical and mental health outcomes,” lead researcher Joseph Dzierzewski, PhD, vice president for research and scientific affairs at the National Sleep Foundation, told this news organization.

“Loneliness is an urgent public health crisis, and there is a pressing need for providers to better understand and treat it,” Dr. Dzierzewski said in a statement.

“Better sleep health might be connected to lower feelings of loneliness by empowering people to engage in social activities, reducing feelings of negative emotions and increasing the likelihood that people interpret interactions in a positive way,” he added.

The findings were presented at SLEEP 2024: 38th Annual Meeting of the Associated Professional Sleep Societies and recently published in an online supplement of the journal Sleep.
 

Rested, Connected

An American Psychiatric Association poll conducted earlier this year showed 30% of US adults reported feelings of loneliness at least once a week over the past year, and 10% reported feeling lonely every day.

Younger people are more likely to report feeling lonely, with 30% of Americans, aged 18-34 years, feeling lonely every day or several times a week.

While there is growing research identifying a relationship between loneliness and poor sleep in different age groups, few studies have explored ties between social and emotional loneliness and sleep health across the adult lifespan.

In the current study led by Dr. Dzierzewski, 2297 adults (mean age, 44 years; 51% male) completed a validated sleep health questionnaire and loneliness scale.

Linear regression analyses were used to examine the direct associations between sleep health, age, and loneliness. Moderation analyses tested whether the link between sleep health and loneliness differed by age.

On average, the total sleep score was 7.7 (range, 0-12), with higher scores indicating better multidimensional sleep health, and total loneliness scale score was 8.9 (out of 11), indicating moderate levels of loneliness.

Better sleep health and younger age were associated with significantly lower loneliness total scores and social and emotional loneliness subscale scores (all P < .001).

Age significantly moderated the association between sleep health and total (P < .001) and emotional loneliness scores (P < .001) but did not moderate the association between sleep health and social loneliness (P = .034). Better sleep health was associated with lower loneliness across ages, and this association was stronger at younger ages.

“Why younger adults might experience more sleep-related benefits to loneliness than older adults is unknown and intriguing — certainly worth further investigation,” Dr. Dzierzewski said in a conference statement.
 

Untapped Avenue

Promoting sleep health may be an “untapped avenue” to support efforts and programs that aim to reduce loneliness and increase engagement in all age groups but especially in younger ages, the researchers noted.

Future research should consider monitoring sleep health in programs or interventions that address loneliness, they added.

“Healthcare providers should be aware of the important link between sleep health and loneliness as both sleep and social connections are essential to health and well-being. When sitting across from patients, asking about both sleep health and loneliness might yield important insights into avenues for health promotion,” said Dr. Dzierzewski.

Michael Breus, PhD, clinical psychologist and founder of SleepDoctor.com, who wasn’t involved in the study, is not surprised by the results.

It makes sense that better sleep would lead to less feelings of loneliness, he told this news organization.

Research has shown that when someone is not sleeping well, they “give others a sense of unhappiness, which socially deflects new encounters or even encounters with friends. So social awareness and social initiation would appear to both be affected by sleep quality, therefore potentially leading, at least in part, to loneliness,” he said.

Support for the study was provided by the National Institute on Aging. Dr. Dzierzewski and Dr. Breus had no relevant disclosures.

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

HOUSTON — Sleep may have a role in driving down rates of loneliness, especially among younger adults.

A study of nearly 2300 participants showed that better sleep health is associated with significantly lower levels of loneliness across ages and that the association is particularly strong in younger individuals.

The US Surgeon General has identified loneliness as “a major public health concern, linked to high rates of negative physical and mental health outcomes,” lead researcher Joseph Dzierzewski, PhD, vice president for research and scientific affairs at the National Sleep Foundation, told this news organization.

“Loneliness is an urgent public health crisis, and there is a pressing need for providers to better understand and treat it,” Dr. Dzierzewski said in a statement.

“Better sleep health might be connected to lower feelings of loneliness by empowering people to engage in social activities, reducing feelings of negative emotions and increasing the likelihood that people interpret interactions in a positive way,” he added.

The findings were presented at SLEEP 2024: 38th Annual Meeting of the Associated Professional Sleep Societies and recently published in an online supplement of the journal Sleep.
 

Rested, Connected

An American Psychiatric Association poll conducted earlier this year showed 30% of US adults reported feelings of loneliness at least once a week over the past year, and 10% reported feeling lonely every day.

Younger people are more likely to report feeling lonely, with 30% of Americans, aged 18-34 years, feeling lonely every day or several times a week.

While there is growing research identifying a relationship between loneliness and poor sleep in different age groups, few studies have explored ties between social and emotional loneliness and sleep health across the adult lifespan.

In the current study led by Dr. Dzierzewski, 2297 adults (mean age, 44 years; 51% male) completed a validated sleep health questionnaire and loneliness scale.

Linear regression analyses were used to examine the direct associations between sleep health, age, and loneliness. Moderation analyses tested whether the link between sleep health and loneliness differed by age.

On average, the total sleep score was 7.7 (range, 0-12), with higher scores indicating better multidimensional sleep health, and total loneliness scale score was 8.9 (out of 11), indicating moderate levels of loneliness.

Better sleep health and younger age were associated with significantly lower loneliness total scores and social and emotional loneliness subscale scores (all P < .001).

Age significantly moderated the association between sleep health and total (P < .001) and emotional loneliness scores (P < .001) but did not moderate the association between sleep health and social loneliness (P = .034). Better sleep health was associated with lower loneliness across ages, and this association was stronger at younger ages.

“Why younger adults might experience more sleep-related benefits to loneliness than older adults is unknown and intriguing — certainly worth further investigation,” Dr. Dzierzewski said in a conference statement.
 

Untapped Avenue

Promoting sleep health may be an “untapped avenue” to support efforts and programs that aim to reduce loneliness and increase engagement in all age groups but especially in younger ages, the researchers noted.

Future research should consider monitoring sleep health in programs or interventions that address loneliness, they added.

“Healthcare providers should be aware of the important link between sleep health and loneliness as both sleep and social connections are essential to health and well-being. When sitting across from patients, asking about both sleep health and loneliness might yield important insights into avenues for health promotion,” said Dr. Dzierzewski.

Michael Breus, PhD, clinical psychologist and founder of SleepDoctor.com, who wasn’t involved in the study, is not surprised by the results.

It makes sense that better sleep would lead to less feelings of loneliness, he told this news organization.

Research has shown that when someone is not sleeping well, they “give others a sense of unhappiness, which socially deflects new encounters or even encounters with friends. So social awareness and social initiation would appear to both be affected by sleep quality, therefore potentially leading, at least in part, to loneliness,” he said.

Support for the study was provided by the National Institute on Aging. Dr. Dzierzewski and Dr. Breus had no relevant disclosures.

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

HOUSTON — Sleep may have a role in driving down rates of loneliness, especially among younger adults.

A study of nearly 2300 participants showed that better sleep health is associated with significantly lower levels of loneliness across ages and that the association is particularly strong in younger individuals.

The US Surgeon General has identified loneliness as “a major public health concern, linked to high rates of negative physical and mental health outcomes,” lead researcher Joseph Dzierzewski, PhD, vice president for research and scientific affairs at the National Sleep Foundation, told this news organization.

“Loneliness is an urgent public health crisis, and there is a pressing need for providers to better understand and treat it,” Dr. Dzierzewski said in a statement.

“Better sleep health might be connected to lower feelings of loneliness by empowering people to engage in social activities, reducing feelings of negative emotions and increasing the likelihood that people interpret interactions in a positive way,” he added.

The findings were presented at SLEEP 2024: 38th Annual Meeting of the Associated Professional Sleep Societies and recently published in an online supplement of the journal Sleep.
 

Rested, Connected

An American Psychiatric Association poll conducted earlier this year showed 30% of US adults reported feelings of loneliness at least once a week over the past year, and 10% reported feeling lonely every day.

Younger people are more likely to report feeling lonely, with 30% of Americans, aged 18-34 years, feeling lonely every day or several times a week.

While there is growing research identifying a relationship between loneliness and poor sleep in different age groups, few studies have explored ties between social and emotional loneliness and sleep health across the adult lifespan.

In the current study led by Dr. Dzierzewski, 2297 adults (mean age, 44 years; 51% male) completed a validated sleep health questionnaire and loneliness scale.

Linear regression analyses were used to examine the direct associations between sleep health, age, and loneliness. Moderation analyses tested whether the link between sleep health and loneliness differed by age.

On average, the total sleep score was 7.7 (range, 0-12), with higher scores indicating better multidimensional sleep health, and total loneliness scale score was 8.9 (out of 11), indicating moderate levels of loneliness.

Better sleep health and younger age were associated with significantly lower loneliness total scores and social and emotional loneliness subscale scores (all P < .001).

Age significantly moderated the association between sleep health and total (P < .001) and emotional loneliness scores (P < .001) but did not moderate the association between sleep health and social loneliness (P = .034). Better sleep health was associated with lower loneliness across ages, and this association was stronger at younger ages.

“Why younger adults might experience more sleep-related benefits to loneliness than older adults is unknown and intriguing — certainly worth further investigation,” Dr. Dzierzewski said in a conference statement.
 

Untapped Avenue

Promoting sleep health may be an “untapped avenue” to support efforts and programs that aim to reduce loneliness and increase engagement in all age groups but especially in younger ages, the researchers noted.

Future research should consider monitoring sleep health in programs or interventions that address loneliness, they added.

“Healthcare providers should be aware of the important link between sleep health and loneliness as both sleep and social connections are essential to health and well-being. When sitting across from patients, asking about both sleep health and loneliness might yield important insights into avenues for health promotion,” said Dr. Dzierzewski.

Michael Breus, PhD, clinical psychologist and founder of SleepDoctor.com, who wasn’t involved in the study, is not surprised by the results.

It makes sense that better sleep would lead to less feelings of loneliness, he told this news organization.

Research has shown that when someone is not sleeping well, they “give others a sense of unhappiness, which socially deflects new encounters or even encounters with friends. So social awareness and social initiation would appear to both be affected by sleep quality, therefore potentially leading, at least in part, to loneliness,” he said.

Support for the study was provided by the National Institute on Aging. Dr. Dzierzewski and Dr. Breus had no relevant disclosures.

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

TOPLINE: 

The intelligent Liver Function Testing (iLFT) platform can improve diagnosis and management of chronic liver disease in a primary care setting, new data show. 

METHODOLOGY:

• At the European Association for the Study of the Liver (EASL) Congress 2024, researchers presented 5-year, real-world data of the iLFT platform from its use in NHS Tayside in Dundee, Scotland, which serves a population of 400,000. The platform has been available since 2018.
• The iLFT platform uses an automated algorithm that analyzes standard liver function test results.
• Abnormal results prompt the system to initiate further fibrosis scoring and relevant etiologic testing to determine the cause of liver dysfunction.
• The results of these tests combined with practitioner-entered clinical information produce a probable diagnosis and recommend a patient-management strategy.

TAKEAWAY: 

• Of the 26,459 iLFT tests performed between 2018 and 2023, 68.3% (18,079) required further testing beyond the initial liver function test, whereas 31.7% (8380) did not.
• Further testing generated 20,895 outcomes, of which, isolated abnormal alanine transaminase (ALT) without fibrosis was most frequent (23.7%). Abnormal ALT was found to be most likely due to metabolic dysfunction–associated steatotic liver disease (MASLD).
• Overall, half of cascaded samples had a positive etiologic diagnosis. Alcoholic liver disease (ALD) and MASLD were the most common etiologic outcomes identified.
• In addition, 20% of cascaded tests identified potentially significant liver fibrosis.
• A total of 69.9% of outcomes recommended that patients could be safely managed in primary care. The inclusion of automatic Enhanced Liver Fibrosis (ELF) testing in 2020 further reduced the requirement for referral to secondary care by 34%.

IN PRACTICE:

“Without this algorithm, the 18,000 patients who had algorithm-directed further testing would have had to go back to the [primary care practitioner] to obtain the additional tests, and the [primary care practitioner] would need to interpret them too,” said Damien Leith, MD, trainee hepatologist at Ninewells Hospital, Dundee, Scotland, who presented the findings. “iLFTs ensure the right patients get automated, appropriate follow-up testing and subsequent recommendation of referral to secondary care if necessary, and importantly iLFT helps the primary care practitioner identify the cause of chronic liver disease.” 

SOURCE:

This study was presented on June 6, 2024 at the EASL Congress 2024 (abstract OS-007-YI).

LIMITATIONS:

Limitations include the need for further refinement of the algorithm to increase the proportion of positive etiologic iLFT outcomes. More analysis is needed to optimize the cost-effectiveness of iLFT. 

DISCLOSURES:

Dr. Leith reports no relevant financial relationships.

A version of this article appeared on Medscape.com.

TOPLINE: 

The intelligent Liver Function Testing (iLFT) platform can improve diagnosis and management of chronic liver disease in a primary care setting, new data show. 

METHODOLOGY:

• At the European Association for the Study of the Liver (EASL) Congress 2024, researchers presented 5-year, real-world data of the iLFT platform from its use in NHS Tayside in Dundee, Scotland, which serves a population of 400,000. The platform has been available since 2018.
• The iLFT platform uses an automated algorithm that analyzes standard liver function test results.
• Abnormal results prompt the system to initiate further fibrosis scoring and relevant etiologic testing to determine the cause of liver dysfunction.
• The results of these tests combined with practitioner-entered clinical information produce a probable diagnosis and recommend a patient-management strategy.

TAKEAWAY: 

• Of the 26,459 iLFT tests performed between 2018 and 2023, 68.3% (18,079) required further testing beyond the initial liver function test, whereas 31.7% (8380) did not.
• Further testing generated 20,895 outcomes, of which, isolated abnormal alanine transaminase (ALT) without fibrosis was most frequent (23.7%). Abnormal ALT was found to be most likely due to metabolic dysfunction–associated steatotic liver disease (MASLD).
• Overall, half of cascaded samples had a positive etiologic diagnosis. Alcoholic liver disease (ALD) and MASLD were the most common etiologic outcomes identified.
• In addition, 20% of cascaded tests identified potentially significant liver fibrosis.
• A total of 69.9% of outcomes recommended that patients could be safely managed in primary care. The inclusion of automatic Enhanced Liver Fibrosis (ELF) testing in 2020 further reduced the requirement for referral to secondary care by 34%.

IN PRACTICE:

“Without this algorithm, the 18,000 patients who had algorithm-directed further testing would have had to go back to the [primary care practitioner] to obtain the additional tests, and the [primary care practitioner] would need to interpret them too,” said Damien Leith, MD, trainee hepatologist at Ninewells Hospital, Dundee, Scotland, who presented the findings. “iLFTs ensure the right patients get automated, appropriate follow-up testing and subsequent recommendation of referral to secondary care if necessary, and importantly iLFT helps the primary care practitioner identify the cause of chronic liver disease.” 

SOURCE:

This study was presented on June 6, 2024 at the EASL Congress 2024 (abstract OS-007-YI).

LIMITATIONS:

Limitations include the need for further refinement of the algorithm to increase the proportion of positive etiologic iLFT outcomes. More analysis is needed to optimize the cost-effectiveness of iLFT. 

DISCLOSURES:

Dr. Leith reports no relevant financial relationships.

A version of this article appeared on Medscape.com.

TOPLINE: 

The intelligent Liver Function Testing (iLFT) platform can improve diagnosis and management of chronic liver disease in a primary care setting, new data show. 

METHODOLOGY:

• At the European Association for the Study of the Liver (EASL) Congress 2024, researchers presented 5-year, real-world data of the iLFT platform from its use in NHS Tayside in Dundee, Scotland, which serves a population of 400,000. The platform has been available since 2018.
• The iLFT platform uses an automated algorithm that analyzes standard liver function test results.
• Abnormal results prompt the system to initiate further fibrosis scoring and relevant etiologic testing to determine the cause of liver dysfunction.
• The results of these tests combined with practitioner-entered clinical information produce a probable diagnosis and recommend a patient-management strategy.

TAKEAWAY: 

• Of the 26,459 iLFT tests performed between 2018 and 2023, 68.3% (18,079) required further testing beyond the initial liver function test, whereas 31.7% (8380) did not.
• Further testing generated 20,895 outcomes, of which, isolated abnormal alanine transaminase (ALT) without fibrosis was most frequent (23.7%). Abnormal ALT was found to be most likely due to metabolic dysfunction–associated steatotic liver disease (MASLD).
• Overall, half of cascaded samples had a positive etiologic diagnosis. Alcoholic liver disease (ALD) and MASLD were the most common etiologic outcomes identified.
• In addition, 20% of cascaded tests identified potentially significant liver fibrosis.
• A total of 69.9% of outcomes recommended that patients could be safely managed in primary care. The inclusion of automatic Enhanced Liver Fibrosis (ELF) testing in 2020 further reduced the requirement for referral to secondary care by 34%.

IN PRACTICE:

“Without this algorithm, the 18,000 patients who had algorithm-directed further testing would have had to go back to the [primary care practitioner] to obtain the additional tests, and the [primary care practitioner] would need to interpret them too,” said Damien Leith, MD, trainee hepatologist at Ninewells Hospital, Dundee, Scotland, who presented the findings. “iLFTs ensure the right patients get automated, appropriate follow-up testing and subsequent recommendation of referral to secondary care if necessary, and importantly iLFT helps the primary care practitioner identify the cause of chronic liver disease.” 

SOURCE:

This study was presented on June 6, 2024 at the EASL Congress 2024 (abstract OS-007-YI).

LIMITATIONS:

Limitations include the need for further refinement of the algorithm to increase the proportion of positive etiologic iLFT outcomes. More analysis is needed to optimize the cost-effectiveness of iLFT. 

DISCLOSURES:

Dr. Leith reports no relevant financial relationships.

A version of this article appeared on Medscape.com.

Key clinical point: High adherence to the carbohydrate quality index (CQI) was associated with a significant reduction in headache severity and duration in women with migraine.

Major finding: High CQI adherence was associated with low odds of moderate pain (adjusted odds ratio [aOR] 0.37; P = .01), severe pain (aOR 0.22; P = .001), and prolonged headache duration (aOR 0.54; P = .03). Moreover, there was no significant correlation between CQI and migraine disability assessment scores (P > .05).

Study details: This cross-sectional study assessed the association of CQI with headache severity, disability, and duration in 266 women with migraine using a 147-item semiquantitative food frequency questionnaire.

Disclosures: The authors did not disclose any source of funding. The authors declared no conflicts of interest.

Source: Jebraeili H, Mirzababaei A, Abaj F, Mirzaei K. The association between carbohydrate quality index and headache severity, disability and duration among women with migraine: A cross-sectional study. Nutr Neurosci. 2024 (May 28). doi: 10.1080/1028415X.2024.2310880 Source

Key clinical point: High adherence to the carbohydrate quality index (CQI) was associated with a significant reduction in headache severity and duration in women with migraine.

Major finding: High CQI adherence was associated with low odds of moderate pain (adjusted odds ratio [aOR] 0.37; P = .01), severe pain (aOR 0.22; P = .001), and prolonged headache duration (aOR 0.54; P = .03). Moreover, there was no significant correlation between CQI and migraine disability assessment scores (P > .05).

Study details: This cross-sectional study assessed the association of CQI with headache severity, disability, and duration in 266 women with migraine using a 147-item semiquantitative food frequency questionnaire.

Disclosures: The authors did not disclose any source of funding. The authors declared no conflicts of interest.

Source: Jebraeili H, Mirzababaei A, Abaj F, Mirzaei K. The association between carbohydrate quality index and headache severity, disability and duration among women with migraine: A cross-sectional study. Nutr Neurosci. 2024 (May 28). doi: 10.1080/1028415X.2024.2310880 Source

Key clinical point: High adherence to the carbohydrate quality index (CQI) was associated with a significant reduction in headache severity and duration in women with migraine.

Major finding: High CQI adherence was associated with low odds of moderate pain (adjusted odds ratio [aOR] 0.37; P = .01), severe pain (aOR 0.22; P = .001), and prolonged headache duration (aOR 0.54; P = .03). Moreover, there was no significant correlation between CQI and migraine disability assessment scores (P > .05).

Study details: This cross-sectional study assessed the association of CQI with headache severity, disability, and duration in 266 women with migraine using a 147-item semiquantitative food frequency questionnaire.

Disclosures: The authors did not disclose any source of funding. The authors declared no conflicts of interest.

Source: Jebraeili H, Mirzababaei A, Abaj F, Mirzaei K. The association between carbohydrate quality index and headache severity, disability and duration among women with migraine: A cross-sectional study. Nutr Neurosci. 2024 (May 28). doi: 10.1080/1028415X.2024.2310880 Source

Key clinical point: Calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAb) were more effective than onabotulinumtoxinA in patients with chronic migraine (CM), even in those who were difficult-to-treat (DTT) and did not respond to ≥3 preventive treatments.

Major finding: At 6 months, CGRP mAb vs onabotulinumtoxinA significantly reduced monthly migraine days (−13.0 vs −8.7 days/month; P < .001) in overall populations, with a similar reduction observed in those who were DTT (−13.0 vs −9.1 days/month; P < .001). Both treatments were well tolerated, with no treatment discontinuation being observed because of adverse events.

Study details: This multicenter, real-world study included 316 and 333 patients with CM who received ≥1 dose of CGRP mAb and onabotulinumtoxinA, respectively, and of whom 544 were DTT and had failed to respond ≥3 preventive treatments.

Disclosures: This study was funded by Taiwan National Science and Technology Council and others. Three authors declared receiving research grants, personal fees as advisors or speakers, or honoraria as speakers from various sources.

Source: Wang Y-F, Yang F-C, Chen L-A, et al. Comparative effectiveness and tolerability of calcitonin gene-related peptide (CGRP) monoclonal antibodies and onabotulinumtoxinA in chronic migraine: A multicenter, real-world study in Taiwan. Eur J Neurol. 2024 :e16372 (Jun 5). doi: 10.1111/ene.16372 Source

Key clinical point: Calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAb) were more effective than onabotulinumtoxinA in patients with chronic migraine (CM), even in those who were difficult-to-treat (DTT) and did not respond to ≥3 preventive treatments.

Major finding: At 6 months, CGRP mAb vs onabotulinumtoxinA significantly reduced monthly migraine days (−13.0 vs −8.7 days/month; P < .001) in overall populations, with a similar reduction observed in those who were DTT (−13.0 vs −9.1 days/month; P < .001). Both treatments were well tolerated, with no treatment discontinuation being observed because of adverse events.

Study details: This multicenter, real-world study included 316 and 333 patients with CM who received ≥1 dose of CGRP mAb and onabotulinumtoxinA, respectively, and of whom 544 were DTT and had failed to respond ≥3 preventive treatments.

Disclosures: This study was funded by Taiwan National Science and Technology Council and others. Three authors declared receiving research grants, personal fees as advisors or speakers, or honoraria as speakers from various sources.

Source: Wang Y-F, Yang F-C, Chen L-A, et al. Comparative effectiveness and tolerability of calcitonin gene-related peptide (CGRP) monoclonal antibodies and onabotulinumtoxinA in chronic migraine: A multicenter, real-world study in Taiwan. Eur J Neurol. 2024 :e16372 (Jun 5). doi: 10.1111/ene.16372 Source

Key clinical point: Calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAb) were more effective than onabotulinumtoxinA in patients with chronic migraine (CM), even in those who were difficult-to-treat (DTT) and did not respond to ≥3 preventive treatments.

Major finding: At 6 months, CGRP mAb vs onabotulinumtoxinA significantly reduced monthly migraine days (−13.0 vs −8.7 days/month; P < .001) in overall populations, with a similar reduction observed in those who were DTT (−13.0 vs −9.1 days/month; P < .001). Both treatments were well tolerated, with no treatment discontinuation being observed because of adverse events.

Study details: This multicenter, real-world study included 316 and 333 patients with CM who received ≥1 dose of CGRP mAb and onabotulinumtoxinA, respectively, and of whom 544 were DTT and had failed to respond ≥3 preventive treatments.

Disclosures: This study was funded by Taiwan National Science and Technology Council and others. Three authors declared receiving research grants, personal fees as advisors or speakers, or honoraria as speakers from various sources.

Source: Wang Y-F, Yang F-C, Chen L-A, et al. Comparative effectiveness and tolerability of calcitonin gene-related peptide (CGRP) monoclonal antibodies and onabotulinumtoxinA in chronic migraine: A multicenter, real-world study in Taiwan. Eur J Neurol. 2024 :e16372 (Jun 5). doi: 10.1111/ene.16372 Source

Key clinical point: Patients with migraine who switched one or multiple times among available anti-calcitonin gene-related peptide (CGRP) monoclonal antibody (mAb) treatments showed lower treatment response and higher disease burden than those who adhered to one anti-CGRP mAb treatment.

Major finding: Overall, 73.1% patients did not switch their anti-CGRP mAb, while 20.6% switched once, 5.4% switched twice, and 0.9% switched three or more times. The ≥50% response rate for monthly migraine days was 64.7% in patients who did not switch among anti-CGRP mAb, but it worsened in those who switched once (50.7%) or twice (25.0%) during their last treatment cycle.

Study details: This real-world retrospective study used data from the Neuro TransData registry and included 655 patients with migraine who received at least one anti-CGRP mAb.

Disclosures: The authors did not disclose any source of funding. The authors declared no competing interests.

Source: Hong JB, Israel-Willner H, Peikert A, et al, and the NTD Study Group. Therapeutic patterns and migraine disease burden in switchers of CGRP-targeted monoclonal antibodies — insights from the German NeuroTransData registry. J Headache Pain. 2024;25:90 (Jun 3). doi: 10.1186/s10194-024-01790-7 Source

Key clinical point: Patients with migraine who switched one or multiple times among available anti-calcitonin gene-related peptide (CGRP) monoclonal antibody (mAb) treatments showed lower treatment response and higher disease burden than those who adhered to one anti-CGRP mAb treatment.

Major finding: Overall, 73.1% patients did not switch their anti-CGRP mAb, while 20.6% switched once, 5.4% switched twice, and 0.9% switched three or more times. The ≥50% response rate for monthly migraine days was 64.7% in patients who did not switch among anti-CGRP mAb, but it worsened in those who switched once (50.7%) or twice (25.0%) during their last treatment cycle.

Study details: This real-world retrospective study used data from the Neuro TransData registry and included 655 patients with migraine who received at least one anti-CGRP mAb.

Disclosures: The authors did not disclose any source of funding. The authors declared no competing interests.

Source: Hong JB, Israel-Willner H, Peikert A, et al, and the NTD Study Group. Therapeutic patterns and migraine disease burden in switchers of CGRP-targeted monoclonal antibodies — insights from the German NeuroTransData registry. J Headache Pain. 2024;25:90 (Jun 3). doi: 10.1186/s10194-024-01790-7 Source

Key clinical point: Patients with migraine who switched one or multiple times among available anti-calcitonin gene-related peptide (CGRP) monoclonal antibody (mAb) treatments showed lower treatment response and higher disease burden than those who adhered to one anti-CGRP mAb treatment.

Major finding: Overall, 73.1% patients did not switch their anti-CGRP mAb, while 20.6% switched once, 5.4% switched twice, and 0.9% switched three or more times. The ≥50% response rate for monthly migraine days was 64.7% in patients who did not switch among anti-CGRP mAb, but it worsened in those who switched once (50.7%) or twice (25.0%) during their last treatment cycle.

Study details: This real-world retrospective study used data from the Neuro TransData registry and included 655 patients with migraine who received at least one anti-CGRP mAb.

Disclosures: The authors did not disclose any source of funding. The authors declared no competing interests.

Source: Hong JB, Israel-Willner H, Peikert A, et al, and the NTD Study Group. Therapeutic patterns and migraine disease burden in switchers of CGRP-targeted monoclonal antibodies — insights from the German NeuroTransData registry. J Headache Pain. 2024;25:90 (Jun 3). doi: 10.1186/s10194-024-01790-7 Source

Key clinical point: A meta-analysis of real-world studies provided strong evidence that erenumab was effective and safe in patients with migraine.

Major finding: At 3 months, erenumab significantly reduced monthly migraine days (mean difference [MD] −7.18 days), monthly headache days (MD −6.89 days), headache impact test-6 scores (MD −6.97), medication days (MD −6.22 days), acute monthly intake (MD −15.75), and pain intensity (MD −1.71), and the results were consistent at 6 and 12 months. The proportion change difference of any adverse event was 0.34 and 0.43 at 6 and 12 months, respectively, with constipation being the most common adverse event (0.19 and 0.20 at 6 and 12 months, respectively).

Study details: Findings are from a meta-analysis of 53 real-world studies including 6509 patients with migraine who were treated with erenumab.

Disclosures: This study was funded by the University of Castilla – La Mancha, Spain. The authors declared no conflicts of interest.

Source: Fernández-Bravo-Rodrigo J, Cavero-Redondo I, Lucerón-Lucas-Torres M, et al. Real-world effectiveness and safety of erenumab for the treatment of migraine: A systematic review and meta-analysis. Eur J Pharmacol. 2024;975:176702 (May 31). doi: 10.1016/j.ejphar.2024.17670 Source

Key clinical point: A meta-analysis of real-world studies provided strong evidence that erenumab was effective and safe in patients with migraine.

Major finding: At 3 months, erenumab significantly reduced monthly migraine days (mean difference [MD] −7.18 days), monthly headache days (MD −6.89 days), headache impact test-6 scores (MD −6.97), medication days (MD −6.22 days), acute monthly intake (MD −15.75), and pain intensity (MD −1.71), and the results were consistent at 6 and 12 months. The proportion change difference of any adverse event was 0.34 and 0.43 at 6 and 12 months, respectively, with constipation being the most common adverse event (0.19 and 0.20 at 6 and 12 months, respectively).

Study details: Findings are from a meta-analysis of 53 real-world studies including 6509 patients with migraine who were treated with erenumab.

Disclosures: This study was funded by the University of Castilla – La Mancha, Spain. The authors declared no conflicts of interest.

Source: Fernández-Bravo-Rodrigo J, Cavero-Redondo I, Lucerón-Lucas-Torres M, et al. Real-world effectiveness and safety of erenumab for the treatment of migraine: A systematic review and meta-analysis. Eur J Pharmacol. 2024;975:176702 (May 31). doi: 10.1016/j.ejphar.2024.17670 Source

Key clinical point: A meta-analysis of real-world studies provided strong evidence that erenumab was effective and safe in patients with migraine.

Major finding: At 3 months, erenumab significantly reduced monthly migraine days (mean difference [MD] −7.18 days), monthly headache days (MD −6.89 days), headache impact test-6 scores (MD −6.97), medication days (MD −6.22 days), acute monthly intake (MD −15.75), and pain intensity (MD −1.71), and the results were consistent at 6 and 12 months. The proportion change difference of any adverse event was 0.34 and 0.43 at 6 and 12 months, respectively, with constipation being the most common adverse event (0.19 and 0.20 at 6 and 12 months, respectively).

Study details: Findings are from a meta-analysis of 53 real-world studies including 6509 patients with migraine who were treated with erenumab.

Disclosures: This study was funded by the University of Castilla – La Mancha, Spain. The authors declared no conflicts of interest.

Source: Fernández-Bravo-Rodrigo J, Cavero-Redondo I, Lucerón-Lucas-Torres M, et al. Real-world effectiveness and safety of erenumab for the treatment of migraine: A systematic review and meta-analysis. Eur J Pharmacol. 2024;975:176702 (May 31). doi: 10.1016/j.ejphar.2024.17670 Source

Key clinical point: Migraine, migraine with aura (MA), and migraine without aura (MO) were not associated with a higher risk for atrial fibrillation (AF), with migraine and its subtypes serving as a protective factor for AF in individuals age ≥ 55 years with migraine.

Major finding: No significant association was found between migraine (adjusted hazard ratio [aHR] 0.76; 95% CI 0.48-1.18), MA (aHR 1.00; 95% CI 0.59-1.70), or MO (aHR 0.50; 95% CI 0.23-1.06) and the risk for AF. However, among patients age ≥ 55 years, the risk for AF was significantly lower in those with migraine (aHR 0.53; 95% CI 0.39-0.73), MA (aHR 0.58; 95% CI 0.38-0.87), or MO (aHR 0.48; 95% CI 0.30-0.78) than in those without headache.

Study details: This prospective, population-based 9-year follow-up study included 39,340 individuals (age ≥ 20 years) without AF who answered the headache questionnaire during the Trøndelag Health Study; of these, 1524 (3.8%) developed AF.

Disclosures: This study did not receive any specific funding from any sources. The authors declared no conflicts of interest.

Source: Giri S, Tronvik E, Dalen H, et al. Migraine and risk of atrial fibrillation: A 9-year follow-up based on the Trøndelag Health Study. Cephalalgia. 2024 (May 29). doi: 10.1177/03331024241254517 Source

Key clinical point: Migraine, migraine with aura (MA), and migraine without aura (MO) were not associated with a higher risk for atrial fibrillation (AF), with migraine and its subtypes serving as a protective factor for AF in individuals age ≥ 55 years with migraine.

Major finding: No significant association was found between migraine (adjusted hazard ratio [aHR] 0.76; 95% CI 0.48-1.18), MA (aHR 1.00; 95% CI 0.59-1.70), or MO (aHR 0.50; 95% CI 0.23-1.06) and the risk for AF. However, among patients age ≥ 55 years, the risk for AF was significantly lower in those with migraine (aHR 0.53; 95% CI 0.39-0.73), MA (aHR 0.58; 95% CI 0.38-0.87), or MO (aHR 0.48; 95% CI 0.30-0.78) than in those without headache.

Study details: This prospective, population-based 9-year follow-up study included 39,340 individuals (age ≥ 20 years) without AF who answered the headache questionnaire during the Trøndelag Health Study; of these, 1524 (3.8%) developed AF.

Disclosures: This study did not receive any specific funding from any sources. The authors declared no conflicts of interest.

Source: Giri S, Tronvik E, Dalen H, et al. Migraine and risk of atrial fibrillation: A 9-year follow-up based on the Trøndelag Health Study. Cephalalgia. 2024 (May 29). doi: 10.1177/03331024241254517 Source

Key clinical point: Migraine, migraine with aura (MA), and migraine without aura (MO) were not associated with a higher risk for atrial fibrillation (AF), with migraine and its subtypes serving as a protective factor for AF in individuals age ≥ 55 years with migraine.

Major finding: No significant association was found between migraine (adjusted hazard ratio [aHR] 0.76; 95% CI 0.48-1.18), MA (aHR 1.00; 95% CI 0.59-1.70), or MO (aHR 0.50; 95% CI 0.23-1.06) and the risk for AF. However, among patients age ≥ 55 years, the risk for AF was significantly lower in those with migraine (aHR 0.53; 95% CI 0.39-0.73), MA (aHR 0.58; 95% CI 0.38-0.87), or MO (aHR 0.48; 95% CI 0.30-0.78) than in those without headache.

Study details: This prospective, population-based 9-year follow-up study included 39,340 individuals (age ≥ 20 years) without AF who answered the headache questionnaire during the Trøndelag Health Study; of these, 1524 (3.8%) developed AF.

Disclosures: This study did not receive any specific funding from any sources. The authors declared no conflicts of interest.

Source: Giri S, Tronvik E, Dalen H, et al. Migraine and risk of atrial fibrillation: A 9-year follow-up based on the Trøndelag Health Study. Cephalalgia. 2024 (May 29). doi: 10.1177/03331024241254517 Source

Key clinical point: Anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAb) were well tolerated and effective in treating high-frequency episodic or chronic migraine, with factors such as unilateral pain, fewer migraine days, and lower disability associated with good and excellent responses to anti-CGRP mAb treatment.

Major finding: At 6 months, 56.5% and 26.7% patients receiving anti-CGRP mAb showed good and excellent responses (≥50% vs ≥75% reduction in monthly headache days), respectively. The presence of unilateral pain, fewer monthly migraine days, and a low Migraine Disability Assessment Score were independent predictors of good (area under the curve [AUC] 0.648; 95% CI 0.616-0.680) and excellent (AUC 0.691; 95% CI 0.651-0.731) responses to anti-CGRP mAb treatment.

Study details: This prospective multicenter real-world study included 4963 patients with high-frequency episodic or chronic migraine who received anti-CGRP mAb treatment with a 6-month follow-up.

Disclosures: This study did not receive specific funding from any sources. Several authors declared receiving speaker honoraria, travel grants, or honoraria from or having other ties with various sources.

Source: Caronna E, Gallardo VJ, Egeo G, et al, for the EUREkA study group. Redefining migraine prevention: Early treatment with anti-CGRP monoclonal antibodies enhances response in the real world. J Neurol Neurosurg Psychiatry. 2024 (May 22). doi: 10.1136/jnnp-2023-333295 Source

Key clinical point: Anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAb) were well tolerated and effective in treating high-frequency episodic or chronic migraine, with factors such as unilateral pain, fewer migraine days, and lower disability associated with good and excellent responses to anti-CGRP mAb treatment.

Major finding: At 6 months, 56.5% and 26.7% patients receiving anti-CGRP mAb showed good and excellent responses (≥50% vs ≥75% reduction in monthly headache days), respectively. The presence of unilateral pain, fewer monthly migraine days, and a low Migraine Disability Assessment Score were independent predictors of good (area under the curve [AUC] 0.648; 95% CI 0.616-0.680) and excellent (AUC 0.691; 95% CI 0.651-0.731) responses to anti-CGRP mAb treatment.

Study details: This prospective multicenter real-world study included 4963 patients with high-frequency episodic or chronic migraine who received anti-CGRP mAb treatment with a 6-month follow-up.

Disclosures: This study did not receive specific funding from any sources. Several authors declared receiving speaker honoraria, travel grants, or honoraria from or having other ties with various sources.

Source: Caronna E, Gallardo VJ, Egeo G, et al, for the EUREkA study group. Redefining migraine prevention: Early treatment with anti-CGRP monoclonal antibodies enhances response in the real world. J Neurol Neurosurg Psychiatry. 2024 (May 22). doi: 10.1136/jnnp-2023-333295 Source

Key clinical point: Anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAb) were well tolerated and effective in treating high-frequency episodic or chronic migraine, with factors such as unilateral pain, fewer migraine days, and lower disability associated with good and excellent responses to anti-CGRP mAb treatment.

Major finding: At 6 months, 56.5% and 26.7% patients receiving anti-CGRP mAb showed good and excellent responses (≥50% vs ≥75% reduction in monthly headache days), respectively. The presence of unilateral pain, fewer monthly migraine days, and a low Migraine Disability Assessment Score were independent predictors of good (area under the curve [AUC] 0.648; 95% CI 0.616-0.680) and excellent (AUC 0.691; 95% CI 0.651-0.731) responses to anti-CGRP mAb treatment.

Study details: This prospective multicenter real-world study included 4963 patients with high-frequency episodic or chronic migraine who received anti-CGRP mAb treatment with a 6-month follow-up.

Disclosures: This study did not receive specific funding from any sources. Several authors declared receiving speaker honoraria, travel grants, or honoraria from or having other ties with various sources.

Source: Caronna E, Gallardo VJ, Egeo G, et al, for the EUREkA study group. Redefining migraine prevention: Early treatment with anti-CGRP monoclonal antibodies enhances response in the real world. J Neurol Neurosurg Psychiatry. 2024 (May 22). doi: 10.1136/jnnp-2023-333295 Source