User login
MDedge conference coverage features onsite reporting of the latest study results and expert perspectives from leading researchers.
What Does Health Equity in Dermatology Look Like?
SAN DIEGO —.
It also means embracing diversity, which she defined as diversity of thinking. “If you look at the literature, diversity in higher education and health profession training settings is associated with better educational outcomes for all students,” Dr. Treadwell, professor emeritus of dermatology and pediatrics at Indiana University School of Medicine, Indianapolis, said in a presentation on health equity during the plenary session at the annual meeting of the American Academy of Dermatology. “Each person brings a variety of experiences and perspectives. This provides a wide range of opinions and different ways to look at things. Racial and ethnic minority providers can help health organization reduce cultural and linguistic barriers and improve cultural competence.”
Such efforts matter, she continued, because according to the United States Census, Black individuals make up 13.6% of the population, while Latinx individuals represent 19.1% of the population. “So, melanin matters,” she said. “If you look at a dermatology textbook, a high percentage [of cases] are identified as Caucasian individuals, which results in an overrepresentation of Caucasians in photographs. That can result in delayed or missed diagnoses [in different skin types]. If you are contributing to cases in textbooks, make sure you have a variety of different skin types so that individuals who are referring to the textbooks will be more equipped.”
Practicing dermatologists can support diversity by offering opportunities to underrepresented in medicine (URM) students, “African-American students, Hispanic students, and Native American students,” said Dr. Treadwell, who was chief of pediatric dermatology at Riley Hospital for Children in Indianapolis from 1987 to 2004. “You also want to be encouraging,” she said.
Dermatologists can also support diversity by providing precepting opportunities, “because many [medical] students may not have connections and networks. Providing those opportunities is important,” she said. Another way to help is to be a mentor to young dermatologists. “I certainly have had mentors in my career who have been very helpful,” she said. “They’ve given me advice about things I was not familiar with.”
Dr. Treadwell suggested the Skin of Color Society as an organization that can assist with networking, mentoring, and research efforts. She also cited the Society for Pediatric Dermatology’s Equity, Diversity, and Inclusion Committee, formed in 2020. One of its initiatives was assembling a special issue of Pediatric Dermatology dedicated to DEI issues, which was published in November 2021.
Dr. Treadwell concluded her presentation by encouraging dermatologists to find ways to care for uninsured or underinsured patients, particularly those with skin of color. This might involve work at a county hospital “to provide access, to serve the patients ... and helping to decrease some the issues in terms of health equity,” she said.
Dr. Treadwell reported having no relevant disclosures. At the plenary session, she presented the John Kenney Jr., MD Lifetime Achievement Award and Lectureship.
SAN DIEGO —.
It also means embracing diversity, which she defined as diversity of thinking. “If you look at the literature, diversity in higher education and health profession training settings is associated with better educational outcomes for all students,” Dr. Treadwell, professor emeritus of dermatology and pediatrics at Indiana University School of Medicine, Indianapolis, said in a presentation on health equity during the plenary session at the annual meeting of the American Academy of Dermatology. “Each person brings a variety of experiences and perspectives. This provides a wide range of opinions and different ways to look at things. Racial and ethnic minority providers can help health organization reduce cultural and linguistic barriers and improve cultural competence.”
Such efforts matter, she continued, because according to the United States Census, Black individuals make up 13.6% of the population, while Latinx individuals represent 19.1% of the population. “So, melanin matters,” she said. “If you look at a dermatology textbook, a high percentage [of cases] are identified as Caucasian individuals, which results in an overrepresentation of Caucasians in photographs. That can result in delayed or missed diagnoses [in different skin types]. If you are contributing to cases in textbooks, make sure you have a variety of different skin types so that individuals who are referring to the textbooks will be more equipped.”
Practicing dermatologists can support diversity by offering opportunities to underrepresented in medicine (URM) students, “African-American students, Hispanic students, and Native American students,” said Dr. Treadwell, who was chief of pediatric dermatology at Riley Hospital for Children in Indianapolis from 1987 to 2004. “You also want to be encouraging,” she said.
Dermatologists can also support diversity by providing precepting opportunities, “because many [medical] students may not have connections and networks. Providing those opportunities is important,” she said. Another way to help is to be a mentor to young dermatologists. “I certainly have had mentors in my career who have been very helpful,” she said. “They’ve given me advice about things I was not familiar with.”
Dr. Treadwell suggested the Skin of Color Society as an organization that can assist with networking, mentoring, and research efforts. She also cited the Society for Pediatric Dermatology’s Equity, Diversity, and Inclusion Committee, formed in 2020. One of its initiatives was assembling a special issue of Pediatric Dermatology dedicated to DEI issues, which was published in November 2021.
Dr. Treadwell concluded her presentation by encouraging dermatologists to find ways to care for uninsured or underinsured patients, particularly those with skin of color. This might involve work at a county hospital “to provide access, to serve the patients ... and helping to decrease some the issues in terms of health equity,” she said.
Dr. Treadwell reported having no relevant disclosures. At the plenary session, she presented the John Kenney Jr., MD Lifetime Achievement Award and Lectureship.
SAN DIEGO —.
It also means embracing diversity, which she defined as diversity of thinking. “If you look at the literature, diversity in higher education and health profession training settings is associated with better educational outcomes for all students,” Dr. Treadwell, professor emeritus of dermatology and pediatrics at Indiana University School of Medicine, Indianapolis, said in a presentation on health equity during the plenary session at the annual meeting of the American Academy of Dermatology. “Each person brings a variety of experiences and perspectives. This provides a wide range of opinions and different ways to look at things. Racial and ethnic minority providers can help health organization reduce cultural and linguistic barriers and improve cultural competence.”
Such efforts matter, she continued, because according to the United States Census, Black individuals make up 13.6% of the population, while Latinx individuals represent 19.1% of the population. “So, melanin matters,” she said. “If you look at a dermatology textbook, a high percentage [of cases] are identified as Caucasian individuals, which results in an overrepresentation of Caucasians in photographs. That can result in delayed or missed diagnoses [in different skin types]. If you are contributing to cases in textbooks, make sure you have a variety of different skin types so that individuals who are referring to the textbooks will be more equipped.”
Practicing dermatologists can support diversity by offering opportunities to underrepresented in medicine (URM) students, “African-American students, Hispanic students, and Native American students,” said Dr. Treadwell, who was chief of pediatric dermatology at Riley Hospital for Children in Indianapolis from 1987 to 2004. “You also want to be encouraging,” she said.
Dermatologists can also support diversity by providing precepting opportunities, “because many [medical] students may not have connections and networks. Providing those opportunities is important,” she said. Another way to help is to be a mentor to young dermatologists. “I certainly have had mentors in my career who have been very helpful,” she said. “They’ve given me advice about things I was not familiar with.”
Dr. Treadwell suggested the Skin of Color Society as an organization that can assist with networking, mentoring, and research efforts. She also cited the Society for Pediatric Dermatology’s Equity, Diversity, and Inclusion Committee, formed in 2020. One of its initiatives was assembling a special issue of Pediatric Dermatology dedicated to DEI issues, which was published in November 2021.
Dr. Treadwell concluded her presentation by encouraging dermatologists to find ways to care for uninsured or underinsured patients, particularly those with skin of color. This might involve work at a county hospital “to provide access, to serve the patients ... and helping to decrease some the issues in terms of health equity,” she said.
Dr. Treadwell reported having no relevant disclosures. At the plenary session, she presented the John Kenney Jr., MD Lifetime Achievement Award and Lectureship.
FROM AAD 2024
Certain Pesticides Linked With Risk for Pancreatic Cancer
One of them, a case-control study, showed an elevated risk in individuals whose adipose tissue contained substances that are now banned.
“The association between pesticides and pancreatic cancer exists. It is of low magnitude but robust, concerning cumulative pesticides and three substances: Mancozeb, glyphosate, and sulfur in spray form,” said Mathias Brugel, MD, hospital practitioner at Basque Coast Hospital Center in Bayonne, France, during his presentation.
Regarding the four other liposoluble substances associated with an increased risk for pancreatic cancer in the second study, “their use has been banned since the 1990s, but they are still present in soils and in the air,” Dr. Brugel told this news organization.
For example, in Reims, France, the assessment of air quality by ATMO Grand Est revealed the presence of banned pesticides in the air, he added. However, Dr. Brugel stressed that a cause-effect relationship between pesticide exposure and the risk for pancreatic cancer cannot be established with these studies.
Incidence Rising Constantly
The incidence of pancreatic adenocarcinoma has been increasing steadily for more than 30 years. In France, nearly 16,000 new cases were reported in 2023, which represented an annual increase of about 2%. According to the National Cancer Institute, “pancreatic adenocarcinoma could become the second leading cause of cancer mortality by 2030.”
“This increase in incidence is particularly strong in France compared with other Western countries. The causes are still poorly understood. One might wonder whether environmental factors like pesticides are involved,” said Dr. Brugel.
Known to have a mechanism of action favoring oncogenesis, pesticides are suspected of being responsible for the rise in certain cancers, especially given their extensive use in France. In total, around 300 substances are authorized, and 65,000 tons are applied each year, making France the largest consumer of pesticides in Europe.
“Contamination is ubiquitous, meaning they are found in soil, water, air, and in individuals,” said Dr. Brugel. According to a study by the Institute for Scientific Expertise Research, pesticide residues were detected in 64% of hair samples taken from French volunteers.
The literature increasingly reported data suggesting a link between pesticide exposure and the development of certain diseases like cancer. A 2021 document by Inserm notably confirmed the strong presumption of a link between occupational pesticide exposure and pathologies such as non-Hodgkin’s lymphoma and prostate cancer.
High-Incidence Zones
To explore the link between pesticide exposure and pancreatic cancer, Dr. Brugel and his colleagues conducted the EcoPESTIPAC and PESTIPAC studies, the results of which were presented at this year’s conference.
In EcoPESTIPAC, researchers conducted a national ecological regression by dividing the entire French territory into 5529 spatial units. The number of pancreatic cancer cases per spatial unit per year (disease-mapping) was determined using the National Health Data System.
Nine chemicals, including glyphosate, were included, thus covering half of pesticide purchases in France. The cumulative quantity of pesticides, regardless of molecule, was also examined. Pesticide exposure was estimated by the median ratio between pesticide purchase and agricultural area per spatial unit over an 11-year period from early 2011 to the end of 2021.
Mor than 134,000 cases of pancreatic cancer were reported during this period. The analysis revealed three high-incidence zones located around Paris, in central France, and in the Mediterranean basin, while spatial units in the western region showed the lowest incidences.
The heterogeneous distribution of the disease suggests the involvement of risk factors, said Dr. Brugel. After adjusting for confounding factors such as smoking, the study showed an increased risk for pancreatic cancer associated with the cumulative quantity of pesticides and three specific substances: Sulfur in spray form, mancozeb, and glyphosate.
Risk Increases
A dose-response relationship was evident. For an increase in pesticide use of 2.5 kg/hectare over 11 years, the risk for pancreatic adenocarcinoma increased from 0.9% to 1.4%. “The increase is relatively small, but one must not forget that this risk applies to all of France,” said Dr. Brugel. Indeed, the risk appeared homogeneous across the entire territory.
This was the first study to explore this link at the national level. Although the association between the four identified factors and pancreatic risk was robust, the study had some limitations. It relied on the quantities of pesticides purchased to estimate the quantities used, Dr. Brugel pointed out.
The second study, PESTIPAC, was a case-control study conducted at the Reims University Hospital to explore the association between pancreatic adenocarcinoma and concentrations of organochlorine pesticides in fat and urine.
The study included 26 patients with pancreatic cancer who had abdominal surgery that allowed for adipose tissue sampling (minimum 10 g). Urine was collected in the morning on an empty stomach.
A control group was formed by including 26 other patients who underwent surgery for a benign abdominal condition such as gallstones or hernia, thus allowing for the same sampling. Individuals in both groups were matched for age and body mass index, two risk factors for pancreatic cancer.
Banned Substances
In total, 345 substances were searched for using chromatography and mass spectrometry. Analyses revealed the presence of five banned substances in all patients, while nine substances were found in half of the samples.
“Contamination is very widespread, both in patients with pancreatic cancer and in the controls,” said Dr. Brugel. Consequently, for this study, between-group comparisons of substances present in all individuals could not be performed.
After adjustment, an association with an increased risk for pancreatic cancer was nonetheless observed with four liposoluble substances: 4,4-DDE, mirex or perchlordecone, trans-nonachlor, and cis-nonachlor. All four substances are herbicides that have been banned for at least 30 years.
The study also aimed to assess the effect of pesticide presence in the body on survival after pancreatic cancer. The results showed no significant difference for overall survival or progression-free survival.
“Pesticides are a credible candidate to explain the increase in the incidence of pancreatic adenocarcinoma,” said Dr. Brugel. However, “if associations between pancreatic cancer and pesticides exist, they remain poorly understood, and it is difficult to establish clear causality.”
Further large-scale studies will be needed to confirm these associations. An evaluation of the general population’s exposure to banned substances also appears justified, according to the researchers.
This story was translated from the Medscape French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
One of them, a case-control study, showed an elevated risk in individuals whose adipose tissue contained substances that are now banned.
“The association between pesticides and pancreatic cancer exists. It is of low magnitude but robust, concerning cumulative pesticides and three substances: Mancozeb, glyphosate, and sulfur in spray form,” said Mathias Brugel, MD, hospital practitioner at Basque Coast Hospital Center in Bayonne, France, during his presentation.
Regarding the four other liposoluble substances associated with an increased risk for pancreatic cancer in the second study, “their use has been banned since the 1990s, but they are still present in soils and in the air,” Dr. Brugel told this news organization.
For example, in Reims, France, the assessment of air quality by ATMO Grand Est revealed the presence of banned pesticides in the air, he added. However, Dr. Brugel stressed that a cause-effect relationship between pesticide exposure and the risk for pancreatic cancer cannot be established with these studies.
Incidence Rising Constantly
The incidence of pancreatic adenocarcinoma has been increasing steadily for more than 30 years. In France, nearly 16,000 new cases were reported in 2023, which represented an annual increase of about 2%. According to the National Cancer Institute, “pancreatic adenocarcinoma could become the second leading cause of cancer mortality by 2030.”
“This increase in incidence is particularly strong in France compared with other Western countries. The causes are still poorly understood. One might wonder whether environmental factors like pesticides are involved,” said Dr. Brugel.
Known to have a mechanism of action favoring oncogenesis, pesticides are suspected of being responsible for the rise in certain cancers, especially given their extensive use in France. In total, around 300 substances are authorized, and 65,000 tons are applied each year, making France the largest consumer of pesticides in Europe.
“Contamination is ubiquitous, meaning they are found in soil, water, air, and in individuals,” said Dr. Brugel. According to a study by the Institute for Scientific Expertise Research, pesticide residues were detected in 64% of hair samples taken from French volunteers.
The literature increasingly reported data suggesting a link between pesticide exposure and the development of certain diseases like cancer. A 2021 document by Inserm notably confirmed the strong presumption of a link between occupational pesticide exposure and pathologies such as non-Hodgkin’s lymphoma and prostate cancer.
High-Incidence Zones
To explore the link between pesticide exposure and pancreatic cancer, Dr. Brugel and his colleagues conducted the EcoPESTIPAC and PESTIPAC studies, the results of which were presented at this year’s conference.
In EcoPESTIPAC, researchers conducted a national ecological regression by dividing the entire French territory into 5529 spatial units. The number of pancreatic cancer cases per spatial unit per year (disease-mapping) was determined using the National Health Data System.
Nine chemicals, including glyphosate, were included, thus covering half of pesticide purchases in France. The cumulative quantity of pesticides, regardless of molecule, was also examined. Pesticide exposure was estimated by the median ratio between pesticide purchase and agricultural area per spatial unit over an 11-year period from early 2011 to the end of 2021.
Mor than 134,000 cases of pancreatic cancer were reported during this period. The analysis revealed three high-incidence zones located around Paris, in central France, and in the Mediterranean basin, while spatial units in the western region showed the lowest incidences.
The heterogeneous distribution of the disease suggests the involvement of risk factors, said Dr. Brugel. After adjusting for confounding factors such as smoking, the study showed an increased risk for pancreatic cancer associated with the cumulative quantity of pesticides and three specific substances: Sulfur in spray form, mancozeb, and glyphosate.
Risk Increases
A dose-response relationship was evident. For an increase in pesticide use of 2.5 kg/hectare over 11 years, the risk for pancreatic adenocarcinoma increased from 0.9% to 1.4%. “The increase is relatively small, but one must not forget that this risk applies to all of France,” said Dr. Brugel. Indeed, the risk appeared homogeneous across the entire territory.
This was the first study to explore this link at the national level. Although the association between the four identified factors and pancreatic risk was robust, the study had some limitations. It relied on the quantities of pesticides purchased to estimate the quantities used, Dr. Brugel pointed out.
The second study, PESTIPAC, was a case-control study conducted at the Reims University Hospital to explore the association between pancreatic adenocarcinoma and concentrations of organochlorine pesticides in fat and urine.
The study included 26 patients with pancreatic cancer who had abdominal surgery that allowed for adipose tissue sampling (minimum 10 g). Urine was collected in the morning on an empty stomach.
A control group was formed by including 26 other patients who underwent surgery for a benign abdominal condition such as gallstones or hernia, thus allowing for the same sampling. Individuals in both groups were matched for age and body mass index, two risk factors for pancreatic cancer.
Banned Substances
In total, 345 substances were searched for using chromatography and mass spectrometry. Analyses revealed the presence of five banned substances in all patients, while nine substances were found in half of the samples.
“Contamination is very widespread, both in patients with pancreatic cancer and in the controls,” said Dr. Brugel. Consequently, for this study, between-group comparisons of substances present in all individuals could not be performed.
After adjustment, an association with an increased risk for pancreatic cancer was nonetheless observed with four liposoluble substances: 4,4-DDE, mirex or perchlordecone, trans-nonachlor, and cis-nonachlor. All four substances are herbicides that have been banned for at least 30 years.
The study also aimed to assess the effect of pesticide presence in the body on survival after pancreatic cancer. The results showed no significant difference for overall survival or progression-free survival.
“Pesticides are a credible candidate to explain the increase in the incidence of pancreatic adenocarcinoma,” said Dr. Brugel. However, “if associations between pancreatic cancer and pesticides exist, they remain poorly understood, and it is difficult to establish clear causality.”
Further large-scale studies will be needed to confirm these associations. An evaluation of the general population’s exposure to banned substances also appears justified, according to the researchers.
This story was translated from the Medscape French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
One of them, a case-control study, showed an elevated risk in individuals whose adipose tissue contained substances that are now banned.
“The association between pesticides and pancreatic cancer exists. It is of low magnitude but robust, concerning cumulative pesticides and three substances: Mancozeb, glyphosate, and sulfur in spray form,” said Mathias Brugel, MD, hospital practitioner at Basque Coast Hospital Center in Bayonne, France, during his presentation.
Regarding the four other liposoluble substances associated with an increased risk for pancreatic cancer in the second study, “their use has been banned since the 1990s, but they are still present in soils and in the air,” Dr. Brugel told this news organization.
For example, in Reims, France, the assessment of air quality by ATMO Grand Est revealed the presence of banned pesticides in the air, he added. However, Dr. Brugel stressed that a cause-effect relationship between pesticide exposure and the risk for pancreatic cancer cannot be established with these studies.
Incidence Rising Constantly
The incidence of pancreatic adenocarcinoma has been increasing steadily for more than 30 years. In France, nearly 16,000 new cases were reported in 2023, which represented an annual increase of about 2%. According to the National Cancer Institute, “pancreatic adenocarcinoma could become the second leading cause of cancer mortality by 2030.”
“This increase in incidence is particularly strong in France compared with other Western countries. The causes are still poorly understood. One might wonder whether environmental factors like pesticides are involved,” said Dr. Brugel.
Known to have a mechanism of action favoring oncogenesis, pesticides are suspected of being responsible for the rise in certain cancers, especially given their extensive use in France. In total, around 300 substances are authorized, and 65,000 tons are applied each year, making France the largest consumer of pesticides in Europe.
“Contamination is ubiquitous, meaning they are found in soil, water, air, and in individuals,” said Dr. Brugel. According to a study by the Institute for Scientific Expertise Research, pesticide residues were detected in 64% of hair samples taken from French volunteers.
The literature increasingly reported data suggesting a link between pesticide exposure and the development of certain diseases like cancer. A 2021 document by Inserm notably confirmed the strong presumption of a link between occupational pesticide exposure and pathologies such as non-Hodgkin’s lymphoma and prostate cancer.
High-Incidence Zones
To explore the link between pesticide exposure and pancreatic cancer, Dr. Brugel and his colleagues conducted the EcoPESTIPAC and PESTIPAC studies, the results of which were presented at this year’s conference.
In EcoPESTIPAC, researchers conducted a national ecological regression by dividing the entire French territory into 5529 spatial units. The number of pancreatic cancer cases per spatial unit per year (disease-mapping) was determined using the National Health Data System.
Nine chemicals, including glyphosate, were included, thus covering half of pesticide purchases in France. The cumulative quantity of pesticides, regardless of molecule, was also examined. Pesticide exposure was estimated by the median ratio between pesticide purchase and agricultural area per spatial unit over an 11-year period from early 2011 to the end of 2021.
Mor than 134,000 cases of pancreatic cancer were reported during this period. The analysis revealed three high-incidence zones located around Paris, in central France, and in the Mediterranean basin, while spatial units in the western region showed the lowest incidences.
The heterogeneous distribution of the disease suggests the involvement of risk factors, said Dr. Brugel. After adjusting for confounding factors such as smoking, the study showed an increased risk for pancreatic cancer associated with the cumulative quantity of pesticides and three specific substances: Sulfur in spray form, mancozeb, and glyphosate.
Risk Increases
A dose-response relationship was evident. For an increase in pesticide use of 2.5 kg/hectare over 11 years, the risk for pancreatic adenocarcinoma increased from 0.9% to 1.4%. “The increase is relatively small, but one must not forget that this risk applies to all of France,” said Dr. Brugel. Indeed, the risk appeared homogeneous across the entire territory.
This was the first study to explore this link at the national level. Although the association between the four identified factors and pancreatic risk was robust, the study had some limitations. It relied on the quantities of pesticides purchased to estimate the quantities used, Dr. Brugel pointed out.
The second study, PESTIPAC, was a case-control study conducted at the Reims University Hospital to explore the association between pancreatic adenocarcinoma and concentrations of organochlorine pesticides in fat and urine.
The study included 26 patients with pancreatic cancer who had abdominal surgery that allowed for adipose tissue sampling (minimum 10 g). Urine was collected in the morning on an empty stomach.
A control group was formed by including 26 other patients who underwent surgery for a benign abdominal condition such as gallstones or hernia, thus allowing for the same sampling. Individuals in both groups were matched for age and body mass index, two risk factors for pancreatic cancer.
Banned Substances
In total, 345 substances were searched for using chromatography and mass spectrometry. Analyses revealed the presence of five banned substances in all patients, while nine substances were found in half of the samples.
“Contamination is very widespread, both in patients with pancreatic cancer and in the controls,” said Dr. Brugel. Consequently, for this study, between-group comparisons of substances present in all individuals could not be performed.
After adjustment, an association with an increased risk for pancreatic cancer was nonetheless observed with four liposoluble substances: 4,4-DDE, mirex or perchlordecone, trans-nonachlor, and cis-nonachlor. All four substances are herbicides that have been banned for at least 30 years.
The study also aimed to assess the effect of pesticide presence in the body on survival after pancreatic cancer. The results showed no significant difference for overall survival or progression-free survival.
“Pesticides are a credible candidate to explain the increase in the incidence of pancreatic adenocarcinoma,” said Dr. Brugel. However, “if associations between pancreatic cancer and pesticides exist, they remain poorly understood, and it is difficult to establish clear causality.”
Further large-scale studies will be needed to confirm these associations. An evaluation of the general population’s exposure to banned substances also appears justified, according to the researchers.
This story was translated from the Medscape French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
Clinical Characteristics of Chronic Nonbacterial Osteomyelitis Can Predict Therapy Needs Over Time
CORRECTED April 7, 2024 // An earlier version of this article misstated the clinical factors of children with CNO that were significantly associated with the need for second-line treatment, as well as the scope of assessments of aspects of disease involvement and their relationship to total number of days on NSAID monotherapy and the odds of needing a second-line treatment.
Children with chronic nonbacterial osteomyelitis (CNO) who had symmetric bone lesions or multiple affected body regions were more likely to need second-line treatment than were patients without these features, according to findings presented at the annual scientific meeting of the Childhood Arthritis and Rheumatology Research Alliance.
CNO is an auto-inflammatory condition that results in sterile inflammatory bone lesions and most commonly affects the long bones of people who are skeletally immature. After a first-line treatment of nonsteroidal anti-inflammatory drugs (NSAIDs), second-line treatments per CARRA guidelines typically include methotrexate or sulfasalazine, tumor necrosis factor (TNF)–alpha inhibitors, and bisphosphonates.
“Since it’s common for there to be long delays before diagnosis of CNO, it is important to start an effective treatment promptly,” Katherine D. Nowicki, MD, of Children’s Hospital Colorado, Aurora, told attendees. “While we have guidance on which treatments to use, it remains unclear which patients are most likely to respond to NSAIDs and which patients will require a second-line treatment.”
Findings Helpful for Counseling
Melissa S. Oliver, MD, MS, assistant professor of clinical pediatrics in rheumatology at Riley Children’s Health at Indiana University Health, Indianapolis, who was not involved in the research, said the findings of this study are helpful in “counseling families and patients at that initial visit and having a lower threshold to start a second-line agent if NSAID monotherapy is not working well.”
There are no clinical trials on patients with CNO, Dr. Oliver said, so very little data exist for guiding clinicians on the best therapy to use and how long to keep patients on therapy while minimizing risk for flare when coming off therapy.
A key clinical takeaway for clinicians is being able to tell patients with unifocal disease that they may not need to be on NSAIDs for a long period and can still do well, Dr. Oliver said. For patients with multifocal disease with symmetric bone lesions or multiple regions involved with CNO, “pediatric rheumatologists should have a lower threshold to start a second-line therapy for these patients,” she said.
To better understand how different clinical characteristics predict treatment needs, the researchers conducted a retrospective chart review of 234 patients who received a CNO diagnosis before age 18 and who established care in the Children’s Hospital Colorado’s CNO multidisciplinary clinic between January 2005 and July 2021. After excluding 70 patients, primarily due to inadequate follow-up for assessing treatment response, the researchers included 164 patients whose records they reviewed through January 2022.
The researchers assessed how multiple aspects of disease involvement, including unifocal or multifocal at diagnosis, ever having symmetric bone lesions, number of regions ever affected by CNO, complications, and disease activity at most recent follow-up, to determine their relationship to the total number of days on NSAID monotherapy and the odds of needing a second-line treatment.
Among the 164 patients in the study, 32 had a short course of NSAIDs (3-7 months), 62 had a long course of NSAIDs (7 or more months), and 70 received second-line treatment.
Findings From Largest Single-Center Cohort in North America
Their topline findings revealed that patients with unifocal disease at diagnosis required 47% fewer total days of NSAID monotherapy treatment than those with multifocal disease at diagnosis, Dr. Nowicki told attendees. Having symmetric bone lesions increased the likelihood of needing a second-line therapy by 6.86 times compared with those without symmetric bone lesions, and for each additional region affected by CNO, the odds of needing a second-line therapy increased by a factor of 1.94, she said.
There were no significant differences in patient ages or sex or in mean interval from symptom onset to treatment onset across treatment groups. However, patients who received second-line treatment did have a significantly longer average time from symptom onset to diagnosis (324 days) than those who had a short course (119 days) or long course (270 days) of NSAIDs (P = .023). Mean follow-up was also significantly longer for patients with second-line treatment (3.8 years) or long-course NSAIDs (2.7 years) than for those with short-course NSAIDs (1.2 years; P < .001).
Mean erythrocyte sedimentation rate or C-reactive protein did not differ across treatment groups nor did presence of a CNO lesion on x-rays at presentation. But significantly more patients in the second-line group had a biopsy (94%) than in the long-course (74%) or short-course (69%) NSAID groups (P = .0025). They were also more likely to have one or more whole-body MRIs. Most of the patients on short-course (88%) and long-course (82%) NSAIDs did not undergo a whole-body MRI, whereas most patients (59%) on a second-line treatment underwent at least one and 24% underwent three or more MRIs (P < .001).
More patients on short-course NSAIDs had unifocal disease at diagnosis (72%) than those on long-course NSAIDs (47%) or a second-line treatment (41%; P = .015). Patients on a second-line treatment were also more likely to have symmetric involvement in the same bone (73% vs 16% short-course and 23% long-course NSAIDs) and to have more regions of the body affected (P < .001).
There were significant differences in mean days on NSAID monotherapy and number of NSAIDs trialed. Patients on a second-line treatment had a mean 441 days of NSAID monotherapy compared with 175 days for patients on short-course NSAIDs and 725 for patients on long-course NSAIDs (P < .001). Nearly all the short-course patients (94%) trialed a single NSAID, while more than half the long-course and second-line patients trialed two or more (P < .001).
None of the patients on short-course NSAIDs had complications. More patients on second-line treatments had vertebral height loss (20%) or amplified pain (14%) than long-course patients (13% and 5%, respectively; P = .02).
At the study’s end date, nearly all the patients on short-course NSAIDs were in remission (94%) compared with 71% of patients on long-course NSAIDs and only half of patients (51%) on the second-line treatment (P < .001). None of the patients on short-course NSAIDs had active disease compared with 11% of patients on long-course NSAIDs and 20% of patients on second-line treatments (P = .02).
This study included the largest single-center cohort of patients with CNO in North America, all treated at a multidisciplinary clinic with a protocolized treatment approach, but it remains limited by its retrospective nature and the missing data for 70 patients, Dr. Nowicki said. She noted that whole-body MRI was not systematically performed on all patients, so it was possible patients without a whole-body MRI had undetected asymptomatic lesions.
Despite these limitations, Dr. Oliver said retrospective studies like these can help pediatric rheumatologists get an idea of reasonable therapies to start, how long to keep patients on them, and when to escalate to the next step.
“I hope one day our CNO research will be able to tell us about which is the optimal second-line therapy for patients, such as bisphosphonates vs TNF inhibitors vs DMARDs [disease-modifying antirheumatic drugs],” Dr. Oliver said.
Dr. Nowicki and Dr. Oliver reported no disclosures. Information on study funding was not provided.
A version of this article appeared on Medscape.com .
CORRECTED April 7, 2024 // An earlier version of this article misstated the clinical factors of children with CNO that were significantly associated with the need for second-line treatment, as well as the scope of assessments of aspects of disease involvement and their relationship to total number of days on NSAID monotherapy and the odds of needing a second-line treatment.
Children with chronic nonbacterial osteomyelitis (CNO) who had symmetric bone lesions or multiple affected body regions were more likely to need second-line treatment than were patients without these features, according to findings presented at the annual scientific meeting of the Childhood Arthritis and Rheumatology Research Alliance.
CNO is an auto-inflammatory condition that results in sterile inflammatory bone lesions and most commonly affects the long bones of people who are skeletally immature. After a first-line treatment of nonsteroidal anti-inflammatory drugs (NSAIDs), second-line treatments per CARRA guidelines typically include methotrexate or sulfasalazine, tumor necrosis factor (TNF)–alpha inhibitors, and bisphosphonates.
“Since it’s common for there to be long delays before diagnosis of CNO, it is important to start an effective treatment promptly,” Katherine D. Nowicki, MD, of Children’s Hospital Colorado, Aurora, told attendees. “While we have guidance on which treatments to use, it remains unclear which patients are most likely to respond to NSAIDs and which patients will require a second-line treatment.”
Findings Helpful for Counseling
Melissa S. Oliver, MD, MS, assistant professor of clinical pediatrics in rheumatology at Riley Children’s Health at Indiana University Health, Indianapolis, who was not involved in the research, said the findings of this study are helpful in “counseling families and patients at that initial visit and having a lower threshold to start a second-line agent if NSAID monotherapy is not working well.”
There are no clinical trials on patients with CNO, Dr. Oliver said, so very little data exist for guiding clinicians on the best therapy to use and how long to keep patients on therapy while minimizing risk for flare when coming off therapy.
A key clinical takeaway for clinicians is being able to tell patients with unifocal disease that they may not need to be on NSAIDs for a long period and can still do well, Dr. Oliver said. For patients with multifocal disease with symmetric bone lesions or multiple regions involved with CNO, “pediatric rheumatologists should have a lower threshold to start a second-line therapy for these patients,” she said.
To better understand how different clinical characteristics predict treatment needs, the researchers conducted a retrospective chart review of 234 patients who received a CNO diagnosis before age 18 and who established care in the Children’s Hospital Colorado’s CNO multidisciplinary clinic between January 2005 and July 2021. After excluding 70 patients, primarily due to inadequate follow-up for assessing treatment response, the researchers included 164 patients whose records they reviewed through January 2022.
The researchers assessed how multiple aspects of disease involvement, including unifocal or multifocal at diagnosis, ever having symmetric bone lesions, number of regions ever affected by CNO, complications, and disease activity at most recent follow-up, to determine their relationship to the total number of days on NSAID monotherapy and the odds of needing a second-line treatment.
Among the 164 patients in the study, 32 had a short course of NSAIDs (3-7 months), 62 had a long course of NSAIDs (7 or more months), and 70 received second-line treatment.
Findings From Largest Single-Center Cohort in North America
Their topline findings revealed that patients with unifocal disease at diagnosis required 47% fewer total days of NSAID monotherapy treatment than those with multifocal disease at diagnosis, Dr. Nowicki told attendees. Having symmetric bone lesions increased the likelihood of needing a second-line therapy by 6.86 times compared with those without symmetric bone lesions, and for each additional region affected by CNO, the odds of needing a second-line therapy increased by a factor of 1.94, she said.
There were no significant differences in patient ages or sex or in mean interval from symptom onset to treatment onset across treatment groups. However, patients who received second-line treatment did have a significantly longer average time from symptom onset to diagnosis (324 days) than those who had a short course (119 days) or long course (270 days) of NSAIDs (P = .023). Mean follow-up was also significantly longer for patients with second-line treatment (3.8 years) or long-course NSAIDs (2.7 years) than for those with short-course NSAIDs (1.2 years; P < .001).
Mean erythrocyte sedimentation rate or C-reactive protein did not differ across treatment groups nor did presence of a CNO lesion on x-rays at presentation. But significantly more patients in the second-line group had a biopsy (94%) than in the long-course (74%) or short-course (69%) NSAID groups (P = .0025). They were also more likely to have one or more whole-body MRIs. Most of the patients on short-course (88%) and long-course (82%) NSAIDs did not undergo a whole-body MRI, whereas most patients (59%) on a second-line treatment underwent at least one and 24% underwent three or more MRIs (P < .001).
More patients on short-course NSAIDs had unifocal disease at diagnosis (72%) than those on long-course NSAIDs (47%) or a second-line treatment (41%; P = .015). Patients on a second-line treatment were also more likely to have symmetric involvement in the same bone (73% vs 16% short-course and 23% long-course NSAIDs) and to have more regions of the body affected (P < .001).
There were significant differences in mean days on NSAID monotherapy and number of NSAIDs trialed. Patients on a second-line treatment had a mean 441 days of NSAID monotherapy compared with 175 days for patients on short-course NSAIDs and 725 for patients on long-course NSAIDs (P < .001). Nearly all the short-course patients (94%) trialed a single NSAID, while more than half the long-course and second-line patients trialed two or more (P < .001).
None of the patients on short-course NSAIDs had complications. More patients on second-line treatments had vertebral height loss (20%) or amplified pain (14%) than long-course patients (13% and 5%, respectively; P = .02).
At the study’s end date, nearly all the patients on short-course NSAIDs were in remission (94%) compared with 71% of patients on long-course NSAIDs and only half of patients (51%) on the second-line treatment (P < .001). None of the patients on short-course NSAIDs had active disease compared with 11% of patients on long-course NSAIDs and 20% of patients on second-line treatments (P = .02).
This study included the largest single-center cohort of patients with CNO in North America, all treated at a multidisciplinary clinic with a protocolized treatment approach, but it remains limited by its retrospective nature and the missing data for 70 patients, Dr. Nowicki said. She noted that whole-body MRI was not systematically performed on all patients, so it was possible patients without a whole-body MRI had undetected asymptomatic lesions.
Despite these limitations, Dr. Oliver said retrospective studies like these can help pediatric rheumatologists get an idea of reasonable therapies to start, how long to keep patients on them, and when to escalate to the next step.
“I hope one day our CNO research will be able to tell us about which is the optimal second-line therapy for patients, such as bisphosphonates vs TNF inhibitors vs DMARDs [disease-modifying antirheumatic drugs],” Dr. Oliver said.
Dr. Nowicki and Dr. Oliver reported no disclosures. Information on study funding was not provided.
A version of this article appeared on Medscape.com .
CORRECTED April 7, 2024 // An earlier version of this article misstated the clinical factors of children with CNO that were significantly associated with the need for second-line treatment, as well as the scope of assessments of aspects of disease involvement and their relationship to total number of days on NSAID monotherapy and the odds of needing a second-line treatment.
Children with chronic nonbacterial osteomyelitis (CNO) who had symmetric bone lesions or multiple affected body regions were more likely to need second-line treatment than were patients without these features, according to findings presented at the annual scientific meeting of the Childhood Arthritis and Rheumatology Research Alliance.
CNO is an auto-inflammatory condition that results in sterile inflammatory bone lesions and most commonly affects the long bones of people who are skeletally immature. After a first-line treatment of nonsteroidal anti-inflammatory drugs (NSAIDs), second-line treatments per CARRA guidelines typically include methotrexate or sulfasalazine, tumor necrosis factor (TNF)–alpha inhibitors, and bisphosphonates.
“Since it’s common for there to be long delays before diagnosis of CNO, it is important to start an effective treatment promptly,” Katherine D. Nowicki, MD, of Children’s Hospital Colorado, Aurora, told attendees. “While we have guidance on which treatments to use, it remains unclear which patients are most likely to respond to NSAIDs and which patients will require a second-line treatment.”
Findings Helpful for Counseling
Melissa S. Oliver, MD, MS, assistant professor of clinical pediatrics in rheumatology at Riley Children’s Health at Indiana University Health, Indianapolis, who was not involved in the research, said the findings of this study are helpful in “counseling families and patients at that initial visit and having a lower threshold to start a second-line agent if NSAID monotherapy is not working well.”
There are no clinical trials on patients with CNO, Dr. Oliver said, so very little data exist for guiding clinicians on the best therapy to use and how long to keep patients on therapy while minimizing risk for flare when coming off therapy.
A key clinical takeaway for clinicians is being able to tell patients with unifocal disease that they may not need to be on NSAIDs for a long period and can still do well, Dr. Oliver said. For patients with multifocal disease with symmetric bone lesions or multiple regions involved with CNO, “pediatric rheumatologists should have a lower threshold to start a second-line therapy for these patients,” she said.
To better understand how different clinical characteristics predict treatment needs, the researchers conducted a retrospective chart review of 234 patients who received a CNO diagnosis before age 18 and who established care in the Children’s Hospital Colorado’s CNO multidisciplinary clinic between January 2005 and July 2021. After excluding 70 patients, primarily due to inadequate follow-up for assessing treatment response, the researchers included 164 patients whose records they reviewed through January 2022.
The researchers assessed how multiple aspects of disease involvement, including unifocal or multifocal at diagnosis, ever having symmetric bone lesions, number of regions ever affected by CNO, complications, and disease activity at most recent follow-up, to determine their relationship to the total number of days on NSAID monotherapy and the odds of needing a second-line treatment.
Among the 164 patients in the study, 32 had a short course of NSAIDs (3-7 months), 62 had a long course of NSAIDs (7 or more months), and 70 received second-line treatment.
Findings From Largest Single-Center Cohort in North America
Their topline findings revealed that patients with unifocal disease at diagnosis required 47% fewer total days of NSAID monotherapy treatment than those with multifocal disease at diagnosis, Dr. Nowicki told attendees. Having symmetric bone lesions increased the likelihood of needing a second-line therapy by 6.86 times compared with those without symmetric bone lesions, and for each additional region affected by CNO, the odds of needing a second-line therapy increased by a factor of 1.94, she said.
There were no significant differences in patient ages or sex or in mean interval from symptom onset to treatment onset across treatment groups. However, patients who received second-line treatment did have a significantly longer average time from symptom onset to diagnosis (324 days) than those who had a short course (119 days) or long course (270 days) of NSAIDs (P = .023). Mean follow-up was also significantly longer for patients with second-line treatment (3.8 years) or long-course NSAIDs (2.7 years) than for those with short-course NSAIDs (1.2 years; P < .001).
Mean erythrocyte sedimentation rate or C-reactive protein did not differ across treatment groups nor did presence of a CNO lesion on x-rays at presentation. But significantly more patients in the second-line group had a biopsy (94%) than in the long-course (74%) or short-course (69%) NSAID groups (P = .0025). They were also more likely to have one or more whole-body MRIs. Most of the patients on short-course (88%) and long-course (82%) NSAIDs did not undergo a whole-body MRI, whereas most patients (59%) on a second-line treatment underwent at least one and 24% underwent three or more MRIs (P < .001).
More patients on short-course NSAIDs had unifocal disease at diagnosis (72%) than those on long-course NSAIDs (47%) or a second-line treatment (41%; P = .015). Patients on a second-line treatment were also more likely to have symmetric involvement in the same bone (73% vs 16% short-course and 23% long-course NSAIDs) and to have more regions of the body affected (P < .001).
There were significant differences in mean days on NSAID monotherapy and number of NSAIDs trialed. Patients on a second-line treatment had a mean 441 days of NSAID monotherapy compared with 175 days for patients on short-course NSAIDs and 725 for patients on long-course NSAIDs (P < .001). Nearly all the short-course patients (94%) trialed a single NSAID, while more than half the long-course and second-line patients trialed two or more (P < .001).
None of the patients on short-course NSAIDs had complications. More patients on second-line treatments had vertebral height loss (20%) or amplified pain (14%) than long-course patients (13% and 5%, respectively; P = .02).
At the study’s end date, nearly all the patients on short-course NSAIDs were in remission (94%) compared with 71% of patients on long-course NSAIDs and only half of patients (51%) on the second-line treatment (P < .001). None of the patients on short-course NSAIDs had active disease compared with 11% of patients on long-course NSAIDs and 20% of patients on second-line treatments (P = .02).
This study included the largest single-center cohort of patients with CNO in North America, all treated at a multidisciplinary clinic with a protocolized treatment approach, but it remains limited by its retrospective nature and the missing data for 70 patients, Dr. Nowicki said. She noted that whole-body MRI was not systematically performed on all patients, so it was possible patients without a whole-body MRI had undetected asymptomatic lesions.
Despite these limitations, Dr. Oliver said retrospective studies like these can help pediatric rheumatologists get an idea of reasonable therapies to start, how long to keep patients on them, and when to escalate to the next step.
“I hope one day our CNO research will be able to tell us about which is the optimal second-line therapy for patients, such as bisphosphonates vs TNF inhibitors vs DMARDs [disease-modifying antirheumatic drugs],” Dr. Oliver said.
Dr. Nowicki and Dr. Oliver reported no disclosures. Information on study funding was not provided.
A version of this article appeared on Medscape.com .
FROM CARRA 2024
How Does Diet Affect Gastroesophageal Reflux Disease?
What dietary recommendations are appropriate for gastroesophageal reflux disease (GERD)? While 85% of patients identify at least one food associated with reflux symptoms, misconceptions about diet in GERD are widespread. The issue was discussed during a dedicated session at the Francophone Days of Hepatology, Gastroenterology, and Digestive Oncology.
GERD occurs when the contents, especially acid, of the stomach back up into the esophagus, leading to symptoms or lesions of the esophageal mucosa.
In addition to proton pump inhibitors, several hygienic-dietary rules are integrated into the therapeutic management of GERD. Some, such as elevating the head of the bed and allowing a 2- to 3-hour gap between meals and bedtime, have proven effective.
Diet and obesity also play a role in the onset of GERD symptoms. Thus, hygienic-dietary rules are an integral part of current recommendations.
“Weight loss is effective in reducing reflux symptoms and should be recommended,” stated Frank Zerbib, MD, head of Hepatology, Gastroenterology, and Digestive Oncology at University Hospital of Bordeaux in France, during the presentation.
Furthermore, most patients with GERD identify foods that may trigger their symptoms, even if there is no evidence to support this in the literature. However, it has been shown that reducing the consumption of these foods is effective.
Caloric Intake and Lipid Content
Meal intake affects esophagogastric physiology in several ways: It reduces the tone of the lower esophageal sphincter (LES) and increases the number of transient LES relaxations (TLESRs), which are induced by distension and relaxation of the proximal stomach. These effects are mediated by vagal afferent stimulation and the stretching of the mechanoreceptors of the fundic wall. They are influenced by neuropeptide effects such as cholecystokinin (CCK), which is released in the presence of lipids in the duodenal lumen. Hence, the importance of caloric intake and lipid content, even though it is difficult to distinguish their respective effects.
A high-calorie meal slows gastric emptying, thus prolonging gastric distension, reducing LES tone, and promoting the onset of TLESRs. Several studies have emphasized that at equivalent caloric intake, lipid composition has no impact on LES tone and the number of TLESRs in healthy patients or those with GERD. However, with equivalent caloric intake, and thus equivalent acid exposure, the presence of lipids in the meal increases the perception of reflux. This “reflux hypersensitivity” effect induced by lipids is caused by the endogenous release of CCK and its action on vagal afferents. This effect also is observed in the perception of functional dyspepsia symptoms.
Several studies have established a correlation between saturated fat consumption and the presence of GERD symptoms.
The Role of Carbohydrates
While the protein component of a meal has little impact on esophagogastric physiology, carbohydrates produce effects on esophagogastric motility that are mediated by their fermentation products, especially short-chain fatty acids (SCFAs), which are synthesized in the colon. Colonic perfusion of these SCFAs leads to fundus relaxation, reduced LES tone, and increased TLESRs. Moreover, in patients with GERD, adding prebiotics (fructo-oligosaccharide) to the meal content increases the number of TLESRs, acid reflux, and symptoms by amplifying colonic fermentation and SCFA production.
Several studies have evaluated low-carbohydrate diets in GERD. A small study of eight patients with morbid obesity on a very low–carbohydrate diet observed benefits on symptoms and esophageal acid exposure in pH probe testing.
A randomized French study of 31 patients with refractory GERD found no significant difference between a low fermentable oligo-, di-, monosaccharides, and polyols diet and usual dietary advice.
A recent American study of 95 veterans found an improvement in pH in the group reducing simple sugars but symptomatic improvement in all groups reducing sugar consumption in general.
Therefore, based on all these data, according to Dr. Zerbib, “high-calorie meals, rich in fats or carbohydrates, promote the onset of reflux episodes and their perception. Diets low in fats and carbohydrates should be recommended.”
Questionable Studies
Certain foods can reduce LES pressure, such as coffee (excluding decaf), chocolate, and white wine. Moreover, white wine, beer, and chocolate have been associated with increased esophageal acid exposure. No significant effects on LES pressure or reflux have been observed with the consumption of citrus fruits or spicy foods. These conclusions, however, are based on older studies and subject to methodological criticisms.
Population studies on tea and coffee yield conflicting results. A recent study of 48,000 nurses without documented GERD found that consumption of tea, coffee, or sodas increased the risk for reflux symptoms by about 30% at least once per week, while water, milk, or fruit juice had no effect. Furthermore, the consumption of carbonated beverages also does not seem to increase the risk for GERD.
Regarding alcohol consumption as a risk factor for GERD, epidemiological data do not allow for a definitive conclusion. Most studies have not found a significant link, a finding confirmed by a recent meta-analysis of 24 publications.
Obesity contributes to GERD by promoting increased abdominal pressure and constraints on the esophagogastric junction. A high-resolution manometry study provided robust evidence for this mechanism. Generally, the relative risk for symptomatic GERD with obesity is 2-3 compared with normal body mass index (BMI), with a linear increase according to BMI.
Dr. Zerbib reported no relevant financial conflicts related to his presentation.
This story was translated from the Medscape French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
What dietary recommendations are appropriate for gastroesophageal reflux disease (GERD)? While 85% of patients identify at least one food associated with reflux symptoms, misconceptions about diet in GERD are widespread. The issue was discussed during a dedicated session at the Francophone Days of Hepatology, Gastroenterology, and Digestive Oncology.
GERD occurs when the contents, especially acid, of the stomach back up into the esophagus, leading to symptoms or lesions of the esophageal mucosa.
In addition to proton pump inhibitors, several hygienic-dietary rules are integrated into the therapeutic management of GERD. Some, such as elevating the head of the bed and allowing a 2- to 3-hour gap between meals and bedtime, have proven effective.
Diet and obesity also play a role in the onset of GERD symptoms. Thus, hygienic-dietary rules are an integral part of current recommendations.
“Weight loss is effective in reducing reflux symptoms and should be recommended,” stated Frank Zerbib, MD, head of Hepatology, Gastroenterology, and Digestive Oncology at University Hospital of Bordeaux in France, during the presentation.
Furthermore, most patients with GERD identify foods that may trigger their symptoms, even if there is no evidence to support this in the literature. However, it has been shown that reducing the consumption of these foods is effective.
Caloric Intake and Lipid Content
Meal intake affects esophagogastric physiology in several ways: It reduces the tone of the lower esophageal sphincter (LES) and increases the number of transient LES relaxations (TLESRs), which are induced by distension and relaxation of the proximal stomach. These effects are mediated by vagal afferent stimulation and the stretching of the mechanoreceptors of the fundic wall. They are influenced by neuropeptide effects such as cholecystokinin (CCK), which is released in the presence of lipids in the duodenal lumen. Hence, the importance of caloric intake and lipid content, even though it is difficult to distinguish their respective effects.
A high-calorie meal slows gastric emptying, thus prolonging gastric distension, reducing LES tone, and promoting the onset of TLESRs. Several studies have emphasized that at equivalent caloric intake, lipid composition has no impact on LES tone and the number of TLESRs in healthy patients or those with GERD. However, with equivalent caloric intake, and thus equivalent acid exposure, the presence of lipids in the meal increases the perception of reflux. This “reflux hypersensitivity” effect induced by lipids is caused by the endogenous release of CCK and its action on vagal afferents. This effect also is observed in the perception of functional dyspepsia symptoms.
Several studies have established a correlation between saturated fat consumption and the presence of GERD symptoms.
The Role of Carbohydrates
While the protein component of a meal has little impact on esophagogastric physiology, carbohydrates produce effects on esophagogastric motility that are mediated by their fermentation products, especially short-chain fatty acids (SCFAs), which are synthesized in the colon. Colonic perfusion of these SCFAs leads to fundus relaxation, reduced LES tone, and increased TLESRs. Moreover, in patients with GERD, adding prebiotics (fructo-oligosaccharide) to the meal content increases the number of TLESRs, acid reflux, and symptoms by amplifying colonic fermentation and SCFA production.
Several studies have evaluated low-carbohydrate diets in GERD. A small study of eight patients with morbid obesity on a very low–carbohydrate diet observed benefits on symptoms and esophageal acid exposure in pH probe testing.
A randomized French study of 31 patients with refractory GERD found no significant difference between a low fermentable oligo-, di-, monosaccharides, and polyols diet and usual dietary advice.
A recent American study of 95 veterans found an improvement in pH in the group reducing simple sugars but symptomatic improvement in all groups reducing sugar consumption in general.
Therefore, based on all these data, according to Dr. Zerbib, “high-calorie meals, rich in fats or carbohydrates, promote the onset of reflux episodes and their perception. Diets low in fats and carbohydrates should be recommended.”
Questionable Studies
Certain foods can reduce LES pressure, such as coffee (excluding decaf), chocolate, and white wine. Moreover, white wine, beer, and chocolate have been associated with increased esophageal acid exposure. No significant effects on LES pressure or reflux have been observed with the consumption of citrus fruits or spicy foods. These conclusions, however, are based on older studies and subject to methodological criticisms.
Population studies on tea and coffee yield conflicting results. A recent study of 48,000 nurses without documented GERD found that consumption of tea, coffee, or sodas increased the risk for reflux symptoms by about 30% at least once per week, while water, milk, or fruit juice had no effect. Furthermore, the consumption of carbonated beverages also does not seem to increase the risk for GERD.
Regarding alcohol consumption as a risk factor for GERD, epidemiological data do not allow for a definitive conclusion. Most studies have not found a significant link, a finding confirmed by a recent meta-analysis of 24 publications.
Obesity contributes to GERD by promoting increased abdominal pressure and constraints on the esophagogastric junction. A high-resolution manometry study provided robust evidence for this mechanism. Generally, the relative risk for symptomatic GERD with obesity is 2-3 compared with normal body mass index (BMI), with a linear increase according to BMI.
Dr. Zerbib reported no relevant financial conflicts related to his presentation.
This story was translated from the Medscape French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
What dietary recommendations are appropriate for gastroesophageal reflux disease (GERD)? While 85% of patients identify at least one food associated with reflux symptoms, misconceptions about diet in GERD are widespread. The issue was discussed during a dedicated session at the Francophone Days of Hepatology, Gastroenterology, and Digestive Oncology.
GERD occurs when the contents, especially acid, of the stomach back up into the esophagus, leading to symptoms or lesions of the esophageal mucosa.
In addition to proton pump inhibitors, several hygienic-dietary rules are integrated into the therapeutic management of GERD. Some, such as elevating the head of the bed and allowing a 2- to 3-hour gap between meals and bedtime, have proven effective.
Diet and obesity also play a role in the onset of GERD symptoms. Thus, hygienic-dietary rules are an integral part of current recommendations.
“Weight loss is effective in reducing reflux symptoms and should be recommended,” stated Frank Zerbib, MD, head of Hepatology, Gastroenterology, and Digestive Oncology at University Hospital of Bordeaux in France, during the presentation.
Furthermore, most patients with GERD identify foods that may trigger their symptoms, even if there is no evidence to support this in the literature. However, it has been shown that reducing the consumption of these foods is effective.
Caloric Intake and Lipid Content
Meal intake affects esophagogastric physiology in several ways: It reduces the tone of the lower esophageal sphincter (LES) and increases the number of transient LES relaxations (TLESRs), which are induced by distension and relaxation of the proximal stomach. These effects are mediated by vagal afferent stimulation and the stretching of the mechanoreceptors of the fundic wall. They are influenced by neuropeptide effects such as cholecystokinin (CCK), which is released in the presence of lipids in the duodenal lumen. Hence, the importance of caloric intake and lipid content, even though it is difficult to distinguish their respective effects.
A high-calorie meal slows gastric emptying, thus prolonging gastric distension, reducing LES tone, and promoting the onset of TLESRs. Several studies have emphasized that at equivalent caloric intake, lipid composition has no impact on LES tone and the number of TLESRs in healthy patients or those with GERD. However, with equivalent caloric intake, and thus equivalent acid exposure, the presence of lipids in the meal increases the perception of reflux. This “reflux hypersensitivity” effect induced by lipids is caused by the endogenous release of CCK and its action on vagal afferents. This effect also is observed in the perception of functional dyspepsia symptoms.
Several studies have established a correlation between saturated fat consumption and the presence of GERD symptoms.
The Role of Carbohydrates
While the protein component of a meal has little impact on esophagogastric physiology, carbohydrates produce effects on esophagogastric motility that are mediated by their fermentation products, especially short-chain fatty acids (SCFAs), which are synthesized in the colon. Colonic perfusion of these SCFAs leads to fundus relaxation, reduced LES tone, and increased TLESRs. Moreover, in patients with GERD, adding prebiotics (fructo-oligosaccharide) to the meal content increases the number of TLESRs, acid reflux, and symptoms by amplifying colonic fermentation and SCFA production.
Several studies have evaluated low-carbohydrate diets in GERD. A small study of eight patients with morbid obesity on a very low–carbohydrate diet observed benefits on symptoms and esophageal acid exposure in pH probe testing.
A randomized French study of 31 patients with refractory GERD found no significant difference between a low fermentable oligo-, di-, monosaccharides, and polyols diet and usual dietary advice.
A recent American study of 95 veterans found an improvement in pH in the group reducing simple sugars but symptomatic improvement in all groups reducing sugar consumption in general.
Therefore, based on all these data, according to Dr. Zerbib, “high-calorie meals, rich in fats or carbohydrates, promote the onset of reflux episodes and their perception. Diets low in fats and carbohydrates should be recommended.”
Questionable Studies
Certain foods can reduce LES pressure, such as coffee (excluding decaf), chocolate, and white wine. Moreover, white wine, beer, and chocolate have been associated with increased esophageal acid exposure. No significant effects on LES pressure or reflux have been observed with the consumption of citrus fruits or spicy foods. These conclusions, however, are based on older studies and subject to methodological criticisms.
Population studies on tea and coffee yield conflicting results. A recent study of 48,000 nurses without documented GERD found that consumption of tea, coffee, or sodas increased the risk for reflux symptoms by about 30% at least once per week, while water, milk, or fruit juice had no effect. Furthermore, the consumption of carbonated beverages also does not seem to increase the risk for GERD.
Regarding alcohol consumption as a risk factor for GERD, epidemiological data do not allow for a definitive conclusion. Most studies have not found a significant link, a finding confirmed by a recent meta-analysis of 24 publications.
Obesity contributes to GERD by promoting increased abdominal pressure and constraints on the esophagogastric junction. A high-resolution manometry study provided robust evidence for this mechanism. Generally, the relative risk for symptomatic GERD with obesity is 2-3 compared with normal body mass index (BMI), with a linear increase according to BMI.
Dr. Zerbib reported no relevant financial conflicts related to his presentation.
This story was translated from the Medscape French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
Overlord or Underachiever: AI Poised to Disrupt Eye Care
You can’t spell “ophthalmologist” without artificial intelligence (AI) — a fact that might have many eye specialists looking warily over their shoulders. But should they be concerned, or is it time to embrace the new technology?
Ophthalmologists, like most other medical specialists, might be looking warily over their shoulders as AI continues to evolve. But should they be concerned, or is it time to embrace the new technology?
Two recent studies have demonstrated the ability of AI to match ophthalmologists’ answers to patients’ questions about eye disease, and the technology is poised to assist ophthalmologists in managing patient workflow and overcome shortages in the ophthalmic workforce, attendees at the American Glaucoma Society meeting presented on March 2, 2024, in Huntington Beach, California, were told.
A study at the Icahn School of Medicine at Mount Sinai in New York City found chatbots matched the proficiency of fellowship-trained ophthalmologists in diagnostic accuracy and completeness in handling questions about eye disease and real patient cases. Another study found a similar result in handling 200 eye care questions from an online chat forum, Robert Chang, MD, co-author of the second study and a glaucoma specialist and associate professor of ophthalmology at Stanford University in Stanford, California, reported.
“Using prompt engineering of ChatGPT, replies to patient online forum questions are becoming so realistic that specialist physicians are having difficulty telling the difference between human- and machine-generated responses,” Dr. Chang said.
The study used questions patients submitted to an online medical forum that received responses from ophthalmologists, then presented those responses plus answers generated by ChatGPT to a panel of eight ophthalmologists and asked them to distinguish between the two. “The accuracy of judging whether you could tell if it was written by AI or a human was about 61%,” Dr. Chang reported. “So most of the time you could not tell the difference.”
The study reported that of 800 evaluations of chatbot-written answers, ophthalmologists rated 21% of them as human-written, while they marked 64.6% of human-written answers as AI-written. The study also found that the likelihood of chatbot answers containing incorrect or inappropriate material was comparable with human answers: Less than 1% for both.
Dr. Chang also referenced a similar, more recent study from the Icahn School of Medicine in which 15 clinicians reviewed answers to patient questions by fellowship-trained glaucoma and retina specialists and those generated by ChatGPT-4, the chatbot model released by OpenAI in the spring of 2023. The study used a statistical tool to evaluate the combined question-case mean rank for accuracy, which was 506.2 for ChatGPT and 403.4 for glaucoma specialists based on 831 question cases. The mean rank for completeness was 528.3 and 398.7, respectively, based on 828 question cases (P < .001).
“The specialists themselves didn’t rate their answers as good as they rated the chatbot answers,” Dr. Chang said. “So it’s really showing that what we can come up with generative AI so human-like that it’s difficult for us to tell the difference on accuracy and completeness.”
‘Getting Close’
However, he noted that chatbots still have some kinks to work out with factual errors, difficulty referencing reliable sources, and hallucinations — fabricated material that may not be accurate. “We’re not quite there yet, but it’s getting close,” Dr. Chang added.
Dr. Chang noted that his clinic at Stanford is testing an AI platform to perform virtual scribing of patient encounters in real time. “That can save a lot of time on documentation,” he said. “I think this is a direction moving forward to increase our productivity because as we know, we all have workforce problems whether it’s the doctors or having enough technicians.”
Chatbots also are being tested for scheduling and generating letters. “Because of the unique needs of each ophthalmologist, AI agents that augment the existing workforce on specific administrative tasks will be the most likely early use case rather than autonomous disease screening or clinical decision support tools, which will take longer to validate prospectively in specific cohorts,” he said.
“Any AI today still has a long way to go before it can ingest and verify all the data for independent decision-making and be validated for fairness and generalizability,” Dr. Chang added. “It is much easier to have ‘low-level thinking’, repetitive tasks be taken care of by algorithms first.”
Dr. Chang “made a convincing case for embracing currently feasible applications of AI, highlighting the potential benefits of leveraging LLMs such as ChatGPT to enhance clinical productivity,” said Thasarat Vajaranant, MD, MHA, director of the glaucoma service and of data sourcing and strategy for the AI Ophthalmology Center at Illinois Eye and Ear Infirmary and the University of Illinois Chicago.
“With the growing demands of an aging population and workforce shortages in ophthalmology, AI-driven solutions offer promise in various areas, including telemedicine triage, organizing clinical notes, assisting in assessments and treatment planning, and virtual scribing,” Dr. Vajaranant said. “Rather than fearing this technology, we should approach its integration with caution.”
Dr. Chang disclosed relationships with Alcon, Genentech/Roche, Itnalight, Verana Health, Sight Sciences, Ocular Therapeutix, Glaukos, Carl Zeiss Meditec, and Apple. Dr. Vajaranant had no relevant disclosures.
A version of this article first appeared on Medscape.com.
You can’t spell “ophthalmologist” without artificial intelligence (AI) — a fact that might have many eye specialists looking warily over their shoulders. But should they be concerned, or is it time to embrace the new technology?
Ophthalmologists, like most other medical specialists, might be looking warily over their shoulders as AI continues to evolve. But should they be concerned, or is it time to embrace the new technology?
Two recent studies have demonstrated the ability of AI to match ophthalmologists’ answers to patients’ questions about eye disease, and the technology is poised to assist ophthalmologists in managing patient workflow and overcome shortages in the ophthalmic workforce, attendees at the American Glaucoma Society meeting presented on March 2, 2024, in Huntington Beach, California, were told.
A study at the Icahn School of Medicine at Mount Sinai in New York City found chatbots matched the proficiency of fellowship-trained ophthalmologists in diagnostic accuracy and completeness in handling questions about eye disease and real patient cases. Another study found a similar result in handling 200 eye care questions from an online chat forum, Robert Chang, MD, co-author of the second study and a glaucoma specialist and associate professor of ophthalmology at Stanford University in Stanford, California, reported.
“Using prompt engineering of ChatGPT, replies to patient online forum questions are becoming so realistic that specialist physicians are having difficulty telling the difference between human- and machine-generated responses,” Dr. Chang said.
The study used questions patients submitted to an online medical forum that received responses from ophthalmologists, then presented those responses plus answers generated by ChatGPT to a panel of eight ophthalmologists and asked them to distinguish between the two. “The accuracy of judging whether you could tell if it was written by AI or a human was about 61%,” Dr. Chang reported. “So most of the time you could not tell the difference.”
The study reported that of 800 evaluations of chatbot-written answers, ophthalmologists rated 21% of them as human-written, while they marked 64.6% of human-written answers as AI-written. The study also found that the likelihood of chatbot answers containing incorrect or inappropriate material was comparable with human answers: Less than 1% for both.
Dr. Chang also referenced a similar, more recent study from the Icahn School of Medicine in which 15 clinicians reviewed answers to patient questions by fellowship-trained glaucoma and retina specialists and those generated by ChatGPT-4, the chatbot model released by OpenAI in the spring of 2023. The study used a statistical tool to evaluate the combined question-case mean rank for accuracy, which was 506.2 for ChatGPT and 403.4 for glaucoma specialists based on 831 question cases. The mean rank for completeness was 528.3 and 398.7, respectively, based on 828 question cases (P < .001).
“The specialists themselves didn’t rate their answers as good as they rated the chatbot answers,” Dr. Chang said. “So it’s really showing that what we can come up with generative AI so human-like that it’s difficult for us to tell the difference on accuracy and completeness.”
‘Getting Close’
However, he noted that chatbots still have some kinks to work out with factual errors, difficulty referencing reliable sources, and hallucinations — fabricated material that may not be accurate. “We’re not quite there yet, but it’s getting close,” Dr. Chang added.
Dr. Chang noted that his clinic at Stanford is testing an AI platform to perform virtual scribing of patient encounters in real time. “That can save a lot of time on documentation,” he said. “I think this is a direction moving forward to increase our productivity because as we know, we all have workforce problems whether it’s the doctors or having enough technicians.”
Chatbots also are being tested for scheduling and generating letters. “Because of the unique needs of each ophthalmologist, AI agents that augment the existing workforce on specific administrative tasks will be the most likely early use case rather than autonomous disease screening or clinical decision support tools, which will take longer to validate prospectively in specific cohorts,” he said.
“Any AI today still has a long way to go before it can ingest and verify all the data for independent decision-making and be validated for fairness and generalizability,” Dr. Chang added. “It is much easier to have ‘low-level thinking’, repetitive tasks be taken care of by algorithms first.”
Dr. Chang “made a convincing case for embracing currently feasible applications of AI, highlighting the potential benefits of leveraging LLMs such as ChatGPT to enhance clinical productivity,” said Thasarat Vajaranant, MD, MHA, director of the glaucoma service and of data sourcing and strategy for the AI Ophthalmology Center at Illinois Eye and Ear Infirmary and the University of Illinois Chicago.
“With the growing demands of an aging population and workforce shortages in ophthalmology, AI-driven solutions offer promise in various areas, including telemedicine triage, organizing clinical notes, assisting in assessments and treatment planning, and virtual scribing,” Dr. Vajaranant said. “Rather than fearing this technology, we should approach its integration with caution.”
Dr. Chang disclosed relationships with Alcon, Genentech/Roche, Itnalight, Verana Health, Sight Sciences, Ocular Therapeutix, Glaukos, Carl Zeiss Meditec, and Apple. Dr. Vajaranant had no relevant disclosures.
A version of this article first appeared on Medscape.com.
You can’t spell “ophthalmologist” without artificial intelligence (AI) — a fact that might have many eye specialists looking warily over their shoulders. But should they be concerned, or is it time to embrace the new technology?
Ophthalmologists, like most other medical specialists, might be looking warily over their shoulders as AI continues to evolve. But should they be concerned, or is it time to embrace the new technology?
Two recent studies have demonstrated the ability of AI to match ophthalmologists’ answers to patients’ questions about eye disease, and the technology is poised to assist ophthalmologists in managing patient workflow and overcome shortages in the ophthalmic workforce, attendees at the American Glaucoma Society meeting presented on March 2, 2024, in Huntington Beach, California, were told.
A study at the Icahn School of Medicine at Mount Sinai in New York City found chatbots matched the proficiency of fellowship-trained ophthalmologists in diagnostic accuracy and completeness in handling questions about eye disease and real patient cases. Another study found a similar result in handling 200 eye care questions from an online chat forum, Robert Chang, MD, co-author of the second study and a glaucoma specialist and associate professor of ophthalmology at Stanford University in Stanford, California, reported.
“Using prompt engineering of ChatGPT, replies to patient online forum questions are becoming so realistic that specialist physicians are having difficulty telling the difference between human- and machine-generated responses,” Dr. Chang said.
The study used questions patients submitted to an online medical forum that received responses from ophthalmologists, then presented those responses plus answers generated by ChatGPT to a panel of eight ophthalmologists and asked them to distinguish between the two. “The accuracy of judging whether you could tell if it was written by AI or a human was about 61%,” Dr. Chang reported. “So most of the time you could not tell the difference.”
The study reported that of 800 evaluations of chatbot-written answers, ophthalmologists rated 21% of them as human-written, while they marked 64.6% of human-written answers as AI-written. The study also found that the likelihood of chatbot answers containing incorrect or inappropriate material was comparable with human answers: Less than 1% for both.
Dr. Chang also referenced a similar, more recent study from the Icahn School of Medicine in which 15 clinicians reviewed answers to patient questions by fellowship-trained glaucoma and retina specialists and those generated by ChatGPT-4, the chatbot model released by OpenAI in the spring of 2023. The study used a statistical tool to evaluate the combined question-case mean rank for accuracy, which was 506.2 for ChatGPT and 403.4 for glaucoma specialists based on 831 question cases. The mean rank for completeness was 528.3 and 398.7, respectively, based on 828 question cases (P < .001).
“The specialists themselves didn’t rate their answers as good as they rated the chatbot answers,” Dr. Chang said. “So it’s really showing that what we can come up with generative AI so human-like that it’s difficult for us to tell the difference on accuracy and completeness.”
‘Getting Close’
However, he noted that chatbots still have some kinks to work out with factual errors, difficulty referencing reliable sources, and hallucinations — fabricated material that may not be accurate. “We’re not quite there yet, but it’s getting close,” Dr. Chang added.
Dr. Chang noted that his clinic at Stanford is testing an AI platform to perform virtual scribing of patient encounters in real time. “That can save a lot of time on documentation,” he said. “I think this is a direction moving forward to increase our productivity because as we know, we all have workforce problems whether it’s the doctors or having enough technicians.”
Chatbots also are being tested for scheduling and generating letters. “Because of the unique needs of each ophthalmologist, AI agents that augment the existing workforce on specific administrative tasks will be the most likely early use case rather than autonomous disease screening or clinical decision support tools, which will take longer to validate prospectively in specific cohorts,” he said.
“Any AI today still has a long way to go before it can ingest and verify all the data for independent decision-making and be validated for fairness and generalizability,” Dr. Chang added. “It is much easier to have ‘low-level thinking’, repetitive tasks be taken care of by algorithms first.”
Dr. Chang “made a convincing case for embracing currently feasible applications of AI, highlighting the potential benefits of leveraging LLMs such as ChatGPT to enhance clinical productivity,” said Thasarat Vajaranant, MD, MHA, director of the glaucoma service and of data sourcing and strategy for the AI Ophthalmology Center at Illinois Eye and Ear Infirmary and the University of Illinois Chicago.
“With the growing demands of an aging population and workforce shortages in ophthalmology, AI-driven solutions offer promise in various areas, including telemedicine triage, organizing clinical notes, assisting in assessments and treatment planning, and virtual scribing,” Dr. Vajaranant said. “Rather than fearing this technology, we should approach its integration with caution.”
Dr. Chang disclosed relationships with Alcon, Genentech/Roche, Itnalight, Verana Health, Sight Sciences, Ocular Therapeutix, Glaukos, Carl Zeiss Meditec, and Apple. Dr. Vajaranant had no relevant disclosures.
A version of this article first appeared on Medscape.com.
Money, Ethnicity, and Access Linked to Cervical Cancer Disparities
These findings come from analyses of insurance data gathered via the Cervical Cancer Geo-Analyzer tool, a publicly available online instrument designed to provide visual representation of recurrent or metastatic cervical cancer burden across metropolitan statistical areas in the United States over multiple years.
[Reporting the findings of] “this study is the first step to optimize healthcare resources allocations, advocate for policy changes that will minimize access barriers, and tailor education for modern treatment options to help reduce and improve outcomes for cervical cancer in US patients,” said Tara Castellano, MD, an author and presenter of this new research, at the Society of Gynecologic Oncology’s Annual Meeting on Women’s Cancer, held in San Diego.
Seeing Cancer Cases
Dr. Castellano and colleagues previously reported that the Geo-Analyzer tool effectively provides quantified evidence of cervical cancer disease burden and graphic representation of geographical variations across the United States for both incident and recurrent/metastatic cervical cancer.
In the current analysis, Dr. Castellano, of Louisiana State University School of Medicine in New Orleans, discussed potential factors related to cervical cancer incidence and geographic variations.
The study builds on previous studies that have shown that Black and Hispanic women have longer time to treatment and worse cervical cancer outcomes than White women.
For example, in a study published in the International Journal of Gynecologic Cancer, Marilyn Huang, MD, and colleagues from the University of Miami Miller School of Medicine, Miami, Florida, and other centers in Miami looked at time to treatment in a diverse population of 274 women starting therapy for cervical cancer.
They found that insurance type (private, public, or none) contributed to delay in treatment initiation regardless of the treatment modality, and that the patient’s language and institution of diagnosis also influenced time to treatment.
In a separate scientific poster presented at SGO 2024, Dr. Castellano and colleagues reported that, among women with newly diagnosed endometrial cancer, the median time to treatment was 7 days longer for both Hispanic and Black women, compared with non-Hispanic White women. In addition, Black women had a 7-day longer time to receiving their first therapy for advanced disease. All of these differences were statistically significant.
Dr. Castellano told this news organization that the time-to-treatment disparities in the endometrial cancer study were determined by diagnostic codes and the timing of insurance claims.
Reasons for the disparities may include more limited access to care and structural and systemic biases in the healthcare systems where the majority of Black and Hispanic patients live, she said.
Insurance Database
In the new study on cervical cancer, Dr. Castellano and her team defined cervical cancer burden as prevalent cervical cancer diagnosis per 100,000 eligible women enrolled in a commercial insurance plan, Medicaid, or Medicare Advantage. Recurrent or metastatic cancer was determined to be the proportion of patients with cervical cancer who initiated systemic therapy.
The goals of the study were to provide a visualization of geographical distribution of cervical cancer in the US, and to quantify associations between early or advanced cancers with screening rates, poverty level, race/ethnicity, and access to brachytherapy.
The administrative claims database queried for the study included information on 75,521 women (median age 53) with a first diagnosis of cervical cancer from 2015 through 2022, and 14,033 women with recurrent or metastatic malignancies (median age 59 years).
Distribution of cases was higher in the South compared with in other US regions (37% vs approximately 20% for other regions).
Looking at the association between screening rates and disease burden from 2017 through 2022, the Geo-Analyzer showed that higher screening rates were significantly associated with decreased burden of new cases only in the South, whereas higher screening rates were associated with lower recurrent/metastatic disease burden in the Midwest and South, but a higher disease burden in the West.
In all regions, there was a significant association between decreased early cancer burden in areas with high percentages of women of Asian heritage, and significantly increased burden in areas with large populations of women of Hispanic origin.
The only significant association of race/ethnicity with recurrent/metastatic burden was a decrease in the Midwest in populations with large Asian populations.
An analysis of the how poverty levels affected screening and disease burden showed that in areas with a high percentage of low-income households there were significant associations with decreased cervical cancer screening and higher burden of newly diagnosed cases.
Poverty levels were significantly associated with recurrent/metastatic cancers only in the South.
The investigators also found that the presence of one or more brachytherapy centers within a ZIP-3 region (that is, a large geographic area designated by the first 3 digits of ZIP codes rather than 5-digit city codes) was associated with a 2.7% reduction in recurrent or metastatic cervical cancer burden (P less than .001).
Demographic Marker?
Reasons for disparities are complex and may involve a combination of inadequate health literacy and social and economic circumstances, said Cesar Castro, MD, commenting on the new cervical cancer study.
He noted in an interview that “the concept that a single Pap smear is often insufficient to capture precancerous changes, and hence the need for serial testing every 3 years, can be lost on individuals who also have competing challenges securing paychecks and/or dependent care. Historical barriers such as perceptions of the underlying cause of cervical cancer, the HPV virus, being a sexually transmitted disease and hence a taboo subject, also underpin decision-making. These sentiments have also fueled resistance towards HPV vaccination in young girls and boys.”
Dr. Castro, who is Program Director for Gynecologic Oncology at the Mass General Cancer Center in Boston, pointed out that treatments for cervical cancer often involve surgery or a combination of chemotherapy and radiation, and that side effects from these interventions may be especially disruptive to the lives of women who are breadwinners or caregivers for their families.
“These are the shackles that poverty places on many Black and Hispanic women notably in under-resourced regions domestically and globally,” he said.
The study was supported by Seagen and Genmab. Dr. Castellano disclosed consulting fees from GSK and Nykode and grant support from BMS. Dr. Castro reported no relevant conflicts of interest and was not involved in either of the studies presented at the meeting.
These findings come from analyses of insurance data gathered via the Cervical Cancer Geo-Analyzer tool, a publicly available online instrument designed to provide visual representation of recurrent or metastatic cervical cancer burden across metropolitan statistical areas in the United States over multiple years.
[Reporting the findings of] “this study is the first step to optimize healthcare resources allocations, advocate for policy changes that will minimize access barriers, and tailor education for modern treatment options to help reduce and improve outcomes for cervical cancer in US patients,” said Tara Castellano, MD, an author and presenter of this new research, at the Society of Gynecologic Oncology’s Annual Meeting on Women’s Cancer, held in San Diego.
Seeing Cancer Cases
Dr. Castellano and colleagues previously reported that the Geo-Analyzer tool effectively provides quantified evidence of cervical cancer disease burden and graphic representation of geographical variations across the United States for both incident and recurrent/metastatic cervical cancer.
In the current analysis, Dr. Castellano, of Louisiana State University School of Medicine in New Orleans, discussed potential factors related to cervical cancer incidence and geographic variations.
The study builds on previous studies that have shown that Black and Hispanic women have longer time to treatment and worse cervical cancer outcomes than White women.
For example, in a study published in the International Journal of Gynecologic Cancer, Marilyn Huang, MD, and colleagues from the University of Miami Miller School of Medicine, Miami, Florida, and other centers in Miami looked at time to treatment in a diverse population of 274 women starting therapy for cervical cancer.
They found that insurance type (private, public, or none) contributed to delay in treatment initiation regardless of the treatment modality, and that the patient’s language and institution of diagnosis also influenced time to treatment.
In a separate scientific poster presented at SGO 2024, Dr. Castellano and colleagues reported that, among women with newly diagnosed endometrial cancer, the median time to treatment was 7 days longer for both Hispanic and Black women, compared with non-Hispanic White women. In addition, Black women had a 7-day longer time to receiving their first therapy for advanced disease. All of these differences were statistically significant.
Dr. Castellano told this news organization that the time-to-treatment disparities in the endometrial cancer study were determined by diagnostic codes and the timing of insurance claims.
Reasons for the disparities may include more limited access to care and structural and systemic biases in the healthcare systems where the majority of Black and Hispanic patients live, she said.
Insurance Database
In the new study on cervical cancer, Dr. Castellano and her team defined cervical cancer burden as prevalent cervical cancer diagnosis per 100,000 eligible women enrolled in a commercial insurance plan, Medicaid, or Medicare Advantage. Recurrent or metastatic cancer was determined to be the proportion of patients with cervical cancer who initiated systemic therapy.
The goals of the study were to provide a visualization of geographical distribution of cervical cancer in the US, and to quantify associations between early or advanced cancers with screening rates, poverty level, race/ethnicity, and access to brachytherapy.
The administrative claims database queried for the study included information on 75,521 women (median age 53) with a first diagnosis of cervical cancer from 2015 through 2022, and 14,033 women with recurrent or metastatic malignancies (median age 59 years).
Distribution of cases was higher in the South compared with in other US regions (37% vs approximately 20% for other regions).
Looking at the association between screening rates and disease burden from 2017 through 2022, the Geo-Analyzer showed that higher screening rates were significantly associated with decreased burden of new cases only in the South, whereas higher screening rates were associated with lower recurrent/metastatic disease burden in the Midwest and South, but a higher disease burden in the West.
In all regions, there was a significant association between decreased early cancer burden in areas with high percentages of women of Asian heritage, and significantly increased burden in areas with large populations of women of Hispanic origin.
The only significant association of race/ethnicity with recurrent/metastatic burden was a decrease in the Midwest in populations with large Asian populations.
An analysis of the how poverty levels affected screening and disease burden showed that in areas with a high percentage of low-income households there were significant associations with decreased cervical cancer screening and higher burden of newly diagnosed cases.
Poverty levels were significantly associated with recurrent/metastatic cancers only in the South.
The investigators also found that the presence of one or more brachytherapy centers within a ZIP-3 region (that is, a large geographic area designated by the first 3 digits of ZIP codes rather than 5-digit city codes) was associated with a 2.7% reduction in recurrent or metastatic cervical cancer burden (P less than .001).
Demographic Marker?
Reasons for disparities are complex and may involve a combination of inadequate health literacy and social and economic circumstances, said Cesar Castro, MD, commenting on the new cervical cancer study.
He noted in an interview that “the concept that a single Pap smear is often insufficient to capture precancerous changes, and hence the need for serial testing every 3 years, can be lost on individuals who also have competing challenges securing paychecks and/or dependent care. Historical barriers such as perceptions of the underlying cause of cervical cancer, the HPV virus, being a sexually transmitted disease and hence a taboo subject, also underpin decision-making. These sentiments have also fueled resistance towards HPV vaccination in young girls and boys.”
Dr. Castro, who is Program Director for Gynecologic Oncology at the Mass General Cancer Center in Boston, pointed out that treatments for cervical cancer often involve surgery or a combination of chemotherapy and radiation, and that side effects from these interventions may be especially disruptive to the lives of women who are breadwinners or caregivers for their families.
“These are the shackles that poverty places on many Black and Hispanic women notably in under-resourced regions domestically and globally,” he said.
The study was supported by Seagen and Genmab. Dr. Castellano disclosed consulting fees from GSK and Nykode and grant support from BMS. Dr. Castro reported no relevant conflicts of interest and was not involved in either of the studies presented at the meeting.
These findings come from analyses of insurance data gathered via the Cervical Cancer Geo-Analyzer tool, a publicly available online instrument designed to provide visual representation of recurrent or metastatic cervical cancer burden across metropolitan statistical areas in the United States over multiple years.
[Reporting the findings of] “this study is the first step to optimize healthcare resources allocations, advocate for policy changes that will minimize access barriers, and tailor education for modern treatment options to help reduce and improve outcomes for cervical cancer in US patients,” said Tara Castellano, MD, an author and presenter of this new research, at the Society of Gynecologic Oncology’s Annual Meeting on Women’s Cancer, held in San Diego.
Seeing Cancer Cases
Dr. Castellano and colleagues previously reported that the Geo-Analyzer tool effectively provides quantified evidence of cervical cancer disease burden and graphic representation of geographical variations across the United States for both incident and recurrent/metastatic cervical cancer.
In the current analysis, Dr. Castellano, of Louisiana State University School of Medicine in New Orleans, discussed potential factors related to cervical cancer incidence and geographic variations.
The study builds on previous studies that have shown that Black and Hispanic women have longer time to treatment and worse cervical cancer outcomes than White women.
For example, in a study published in the International Journal of Gynecologic Cancer, Marilyn Huang, MD, and colleagues from the University of Miami Miller School of Medicine, Miami, Florida, and other centers in Miami looked at time to treatment in a diverse population of 274 women starting therapy for cervical cancer.
They found that insurance type (private, public, or none) contributed to delay in treatment initiation regardless of the treatment modality, and that the patient’s language and institution of diagnosis also influenced time to treatment.
In a separate scientific poster presented at SGO 2024, Dr. Castellano and colleagues reported that, among women with newly diagnosed endometrial cancer, the median time to treatment was 7 days longer for both Hispanic and Black women, compared with non-Hispanic White women. In addition, Black women had a 7-day longer time to receiving their first therapy for advanced disease. All of these differences were statistically significant.
Dr. Castellano told this news organization that the time-to-treatment disparities in the endometrial cancer study were determined by diagnostic codes and the timing of insurance claims.
Reasons for the disparities may include more limited access to care and structural and systemic biases in the healthcare systems where the majority of Black and Hispanic patients live, she said.
Insurance Database
In the new study on cervical cancer, Dr. Castellano and her team defined cervical cancer burden as prevalent cervical cancer diagnosis per 100,000 eligible women enrolled in a commercial insurance plan, Medicaid, or Medicare Advantage. Recurrent or metastatic cancer was determined to be the proportion of patients with cervical cancer who initiated systemic therapy.
The goals of the study were to provide a visualization of geographical distribution of cervical cancer in the US, and to quantify associations between early or advanced cancers with screening rates, poverty level, race/ethnicity, and access to brachytherapy.
The administrative claims database queried for the study included information on 75,521 women (median age 53) with a first diagnosis of cervical cancer from 2015 through 2022, and 14,033 women with recurrent or metastatic malignancies (median age 59 years).
Distribution of cases was higher in the South compared with in other US regions (37% vs approximately 20% for other regions).
Looking at the association between screening rates and disease burden from 2017 through 2022, the Geo-Analyzer showed that higher screening rates were significantly associated with decreased burden of new cases only in the South, whereas higher screening rates were associated with lower recurrent/metastatic disease burden in the Midwest and South, but a higher disease burden in the West.
In all regions, there was a significant association between decreased early cancer burden in areas with high percentages of women of Asian heritage, and significantly increased burden in areas with large populations of women of Hispanic origin.
The only significant association of race/ethnicity with recurrent/metastatic burden was a decrease in the Midwest in populations with large Asian populations.
An analysis of the how poverty levels affected screening and disease burden showed that in areas with a high percentage of low-income households there were significant associations with decreased cervical cancer screening and higher burden of newly diagnosed cases.
Poverty levels were significantly associated with recurrent/metastatic cancers only in the South.
The investigators also found that the presence of one or more brachytherapy centers within a ZIP-3 region (that is, a large geographic area designated by the first 3 digits of ZIP codes rather than 5-digit city codes) was associated with a 2.7% reduction in recurrent or metastatic cervical cancer burden (P less than .001).
Demographic Marker?
Reasons for disparities are complex and may involve a combination of inadequate health literacy and social and economic circumstances, said Cesar Castro, MD, commenting on the new cervical cancer study.
He noted in an interview that “the concept that a single Pap smear is often insufficient to capture precancerous changes, and hence the need for serial testing every 3 years, can be lost on individuals who also have competing challenges securing paychecks and/or dependent care. Historical barriers such as perceptions of the underlying cause of cervical cancer, the HPV virus, being a sexually transmitted disease and hence a taboo subject, also underpin decision-making. These sentiments have also fueled resistance towards HPV vaccination in young girls and boys.”
Dr. Castro, who is Program Director for Gynecologic Oncology at the Mass General Cancer Center in Boston, pointed out that treatments for cervical cancer often involve surgery or a combination of chemotherapy and radiation, and that side effects from these interventions may be especially disruptive to the lives of women who are breadwinners or caregivers for their families.
“These are the shackles that poverty places on many Black and Hispanic women notably in under-resourced regions domestically and globally,” he said.
The study was supported by Seagen and Genmab. Dr. Castellano disclosed consulting fees from GSK and Nykode and grant support from BMS. Dr. Castro reported no relevant conflicts of interest and was not involved in either of the studies presented at the meeting.
FROM SGO 2024
Maternal Lifestyle Interventions Boost Babies’ Heart Health
Infants born to women with obesity showed improved measures of cardiovascular health when their mothers adopted healthier lifestyles before and during pregnancy, based on data from a systematic review presented at the annual meeting of the Society for Reproductive Investigation.
Previous research has shown that children born to mothers with a high body mass index (BMI) are more likely to die from cardiovascular disease in later life, said presenting author Samuel J. Burden, PhD, in an interview.
“Surprisingly, early signs of these heart issues can start before birth and continue into childhood,” said Dr. Burden, a research associate in the Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom.
To examine the effect of interventions such as a healthy diet and exercise in pregnant women with obesity on the heart health of their infants, Dr. Burden and colleagues reviewed data from eight randomized, controlled trials involving diet and exercise for pregnant women with obesity. Of these, two used antenatal exercise, two used diet and physical activity, and one used preconception diet and physical activity. The studies ranged in size from 18 to 404 participants. Two studies included infants younger than 2 months of age, and four studies included children aged 3-7 years.
Overall, lifestyle interventions before conception and before birth were associated with significant changes in cardiac remodeling, specifically reduced interventricular septal wall thickness.
In addition, one of three studies of cardiac diastolic function and four of five studies of systolic function showed significant improvements. The five studies of cardiac systolic function and three studies of diastolic function also showed improvement in systolic and diastolic blood pressure in infants of mothers who took part in the interventions. The studies were limited mainly by large attrition rates, the researchers wrote in their presentation. However, more studies in larger populations that also include older children could confirm the findings and inform public health strategies to promote healthy lifestyles for pregnant women, they noted.
Encourage Healthy Lifestyle Before and During Pregnancy
The evidence supports the findings from animal studies showing that an offspring’s health is influenced by maternal lifestyle before and during pregnancy, Dr. Burden said in an interview. The data suggest that healthcare providers should encourage women with a high BMI who want to become pregnant to eat healthfully and become more active as a way to enhance the future cardiovascular health of their children, he said.
The full results of the current study are soon to be published, but more work is needed, said Dr. Burden. “While we observed a protective effect from these lifestyle programs, there is a need for more extensive studies involving a larger number of women (and their children) who were part of the initial research,” he said. “Additionally, it will be crucial to track these children into adulthood to determine whether these antenatal lifestyle interventions persist in lowering the risk of future cardiovascular disease.”
Beginning healthy lifestyle programs prior to pregnancy might yield the best results for promoting infant cardiovascular health, and more prepregnancy interventions for women with obesity are needed, Dr. Burden added.
The current study adds to the growing body of evidence that the in utero environment can have lifelong effects on offspring, Joseph R. Biggio Jr, MD, system chair of maternal fetal medicine at Ochsner Health, New Orleans, Louisiana, said in an interview.
“Several studies have previously shown that the children of mothers with diabetes, hypertension, or obesity are at increased risk for developing signs of metabolic syndrome and cardiovascular changes during childhood or adolescence,” said Dr. Biggio.
The data from this systematic review support the potential value of interventions aimed at improving maternal weight gain and cardiovascular performance before and during pregnancy that may result in reduced cardiovascular remodeling and myocardial thickening in infants, he said.
The study was supported by a British Heart Foundation Special Project Grant. The researchers had no financial conflicts to disclose. Dr. Biggio had no financial conflicts to disclose.
Infants born to women with obesity showed improved measures of cardiovascular health when their mothers adopted healthier lifestyles before and during pregnancy, based on data from a systematic review presented at the annual meeting of the Society for Reproductive Investigation.
Previous research has shown that children born to mothers with a high body mass index (BMI) are more likely to die from cardiovascular disease in later life, said presenting author Samuel J. Burden, PhD, in an interview.
“Surprisingly, early signs of these heart issues can start before birth and continue into childhood,” said Dr. Burden, a research associate in the Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom.
To examine the effect of interventions such as a healthy diet and exercise in pregnant women with obesity on the heart health of their infants, Dr. Burden and colleagues reviewed data from eight randomized, controlled trials involving diet and exercise for pregnant women with obesity. Of these, two used antenatal exercise, two used diet and physical activity, and one used preconception diet and physical activity. The studies ranged in size from 18 to 404 participants. Two studies included infants younger than 2 months of age, and four studies included children aged 3-7 years.
Overall, lifestyle interventions before conception and before birth were associated with significant changes in cardiac remodeling, specifically reduced interventricular septal wall thickness.
In addition, one of three studies of cardiac diastolic function and four of five studies of systolic function showed significant improvements. The five studies of cardiac systolic function and three studies of diastolic function also showed improvement in systolic and diastolic blood pressure in infants of mothers who took part in the interventions. The studies were limited mainly by large attrition rates, the researchers wrote in their presentation. However, more studies in larger populations that also include older children could confirm the findings and inform public health strategies to promote healthy lifestyles for pregnant women, they noted.
Encourage Healthy Lifestyle Before and During Pregnancy
The evidence supports the findings from animal studies showing that an offspring’s health is influenced by maternal lifestyle before and during pregnancy, Dr. Burden said in an interview. The data suggest that healthcare providers should encourage women with a high BMI who want to become pregnant to eat healthfully and become more active as a way to enhance the future cardiovascular health of their children, he said.
The full results of the current study are soon to be published, but more work is needed, said Dr. Burden. “While we observed a protective effect from these lifestyle programs, there is a need for more extensive studies involving a larger number of women (and their children) who were part of the initial research,” he said. “Additionally, it will be crucial to track these children into adulthood to determine whether these antenatal lifestyle interventions persist in lowering the risk of future cardiovascular disease.”
Beginning healthy lifestyle programs prior to pregnancy might yield the best results for promoting infant cardiovascular health, and more prepregnancy interventions for women with obesity are needed, Dr. Burden added.
The current study adds to the growing body of evidence that the in utero environment can have lifelong effects on offspring, Joseph R. Biggio Jr, MD, system chair of maternal fetal medicine at Ochsner Health, New Orleans, Louisiana, said in an interview.
“Several studies have previously shown that the children of mothers with diabetes, hypertension, or obesity are at increased risk for developing signs of metabolic syndrome and cardiovascular changes during childhood or adolescence,” said Dr. Biggio.
The data from this systematic review support the potential value of interventions aimed at improving maternal weight gain and cardiovascular performance before and during pregnancy that may result in reduced cardiovascular remodeling and myocardial thickening in infants, he said.
The study was supported by a British Heart Foundation Special Project Grant. The researchers had no financial conflicts to disclose. Dr. Biggio had no financial conflicts to disclose.
Infants born to women with obesity showed improved measures of cardiovascular health when their mothers adopted healthier lifestyles before and during pregnancy, based on data from a systematic review presented at the annual meeting of the Society for Reproductive Investigation.
Previous research has shown that children born to mothers with a high body mass index (BMI) are more likely to die from cardiovascular disease in later life, said presenting author Samuel J. Burden, PhD, in an interview.
“Surprisingly, early signs of these heart issues can start before birth and continue into childhood,” said Dr. Burden, a research associate in the Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom.
To examine the effect of interventions such as a healthy diet and exercise in pregnant women with obesity on the heart health of their infants, Dr. Burden and colleagues reviewed data from eight randomized, controlled trials involving diet and exercise for pregnant women with obesity. Of these, two used antenatal exercise, two used diet and physical activity, and one used preconception diet and physical activity. The studies ranged in size from 18 to 404 participants. Two studies included infants younger than 2 months of age, and four studies included children aged 3-7 years.
Overall, lifestyle interventions before conception and before birth were associated with significant changes in cardiac remodeling, specifically reduced interventricular septal wall thickness.
In addition, one of three studies of cardiac diastolic function and four of five studies of systolic function showed significant improvements. The five studies of cardiac systolic function and three studies of diastolic function also showed improvement in systolic and diastolic blood pressure in infants of mothers who took part in the interventions. The studies were limited mainly by large attrition rates, the researchers wrote in their presentation. However, more studies in larger populations that also include older children could confirm the findings and inform public health strategies to promote healthy lifestyles for pregnant women, they noted.
Encourage Healthy Lifestyle Before and During Pregnancy
The evidence supports the findings from animal studies showing that an offspring’s health is influenced by maternal lifestyle before and during pregnancy, Dr. Burden said in an interview. The data suggest that healthcare providers should encourage women with a high BMI who want to become pregnant to eat healthfully and become more active as a way to enhance the future cardiovascular health of their children, he said.
The full results of the current study are soon to be published, but more work is needed, said Dr. Burden. “While we observed a protective effect from these lifestyle programs, there is a need for more extensive studies involving a larger number of women (and their children) who were part of the initial research,” he said. “Additionally, it will be crucial to track these children into adulthood to determine whether these antenatal lifestyle interventions persist in lowering the risk of future cardiovascular disease.”
Beginning healthy lifestyle programs prior to pregnancy might yield the best results for promoting infant cardiovascular health, and more prepregnancy interventions for women with obesity are needed, Dr. Burden added.
The current study adds to the growing body of evidence that the in utero environment can have lifelong effects on offspring, Joseph R. Biggio Jr, MD, system chair of maternal fetal medicine at Ochsner Health, New Orleans, Louisiana, said in an interview.
“Several studies have previously shown that the children of mothers with diabetes, hypertension, or obesity are at increased risk for developing signs of metabolic syndrome and cardiovascular changes during childhood or adolescence,” said Dr. Biggio.
The data from this systematic review support the potential value of interventions aimed at improving maternal weight gain and cardiovascular performance before and during pregnancy that may result in reduced cardiovascular remodeling and myocardial thickening in infants, he said.
The study was supported by a British Heart Foundation Special Project Grant. The researchers had no financial conflicts to disclose. Dr. Biggio had no financial conflicts to disclose.
Delaying Embryo Transfers May Benefit Patients With Endometrial Polyps
A longer time between hysteroscopic polypectomy and frozen embryo transfer may improve the odds of successful pregnancy, based on data from a new analysis presented at the annual meeting of the Society for Reproductive Investigation.
Although uterine polyps have a negative effect on pregnancy rates, data supporting a specific time interval between hysteroscopic polypectomy (HP) and frozen embryo transfer (FET) are limited, according to Audrey Messelt, MD, of Baylor College of Medicine, Houston, Texas, and colleagues.
“Hysteroscopic polypectomy is a common procedure performed before embryo transfer to optimize the receptivity of the endometrium. Currently, there is no ideal recovery time lapse between surgery and an embryo transfer,” said senior author Laura Detti, MD, professor of obstetrics and gynecology at Baylor, in an interview. “This is often the last step prior to embryo transfer, and identifying a recovery time that allows the best outcome is important.”
In a retrospective analysis, the researchers examined the effect of the time between HP and FET on pregnancy outcomes. They identified 65 patients with uterine pathology based on saline-infusion sonogram who underwent hysteroscopy and FET between June 1, 2022, and September 30, 2023.
The endometrial preparation for FET included sequential administration of oral or transdermal estradiol and intramuscular progesterone.
Overall, 46 patients were diagnosed with endometrial polyps at the time of surgery; three had endometritis, one had a uterine septum that was resected, 15 had no abnormal pathology or had normal endometrium at the time of examination. No cases of hyperplasia or malignancy were identified.
A total of 58 patients underwent FET with a single euploid embryo, four with a single untested embryo, one with a low-mosaic embryo, and two with a double-embryo transfer (one euploid and one low mosaic).
After FET, 50 patients conceived and 15 did not. Patients with ongoing pregnancies who had a history of endometrial polyps had significantly more days from surgery to FET, compared to patients with a history of polyps who failed to conceive (median 70 days vs 45 days, P = .01).
By contrast, the time between hysteroscopy and FET was similar among patients with no endometrial pathology who did and did not have ongoing pregnancies (median 45 vs 52.5 days, P = .95).
The findings were limited by the relatively small sample size and exclusion of patients with pathologies other than polyps, as well as a lack of data on age group breakdowns. However, the results suggest that patients with uterine polyps may benefit from more time between HP and FET, while patients with normal surgical findings could undergo FET sooner, the researchers concluded.
Postpolypectomy Timing May Affect Pregnancy Outcomes
“We used to think that having had the first menses from surgery would be enough recovery time for the uterine cavity, even if it was just 2 weeks,” Dr. Detti said in an interview. “This still holds true when no endometrial polyps are diagnosed in the pathological specimen; however, we learned that if endometrial polyps are removed at the time of hysteroscopy, the ideal recovery time prior to an embryo transfer should be longer,” she said.
The current study is important because approximately 15% of women are diagnosed with endometrial polyps during their reproductive years, said Mark P. Trolice, MD, professor at the University of Central Florida, Orlando, and founder/medical director of the IVF Center of Central Florida in Winter Park, in an interview.
“Abnormalities of the uterine cavity have been shown to reduce embryo implantation and increase the risk of miscarriage,” said Dr. Trolice. Although the impact of small endometrial polyps on fertility and pregnancy are uncertain, most infertility specialists recommend removal of endometrial polyps via hysteroscopic polypectomy in general and prior to IVF embryo transfer in particular, he said.
Although infertility patients are anxious to undergo embryo transfer, the current study suggests a benefit in delaying the procedure following the removal of any polyps identified during the pretransfer evaluation, Dr. Trolice said in an interview. As for additional research, “it would be helpful to know the age group breakdown of patients and if the results were consistent among all categories,” he said.
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Trolice had no financial conflicts to disclose and serves on the Editorial Advisory Board of Ob.Gyn. News.
A longer time between hysteroscopic polypectomy and frozen embryo transfer may improve the odds of successful pregnancy, based on data from a new analysis presented at the annual meeting of the Society for Reproductive Investigation.
Although uterine polyps have a negative effect on pregnancy rates, data supporting a specific time interval between hysteroscopic polypectomy (HP) and frozen embryo transfer (FET) are limited, according to Audrey Messelt, MD, of Baylor College of Medicine, Houston, Texas, and colleagues.
“Hysteroscopic polypectomy is a common procedure performed before embryo transfer to optimize the receptivity of the endometrium. Currently, there is no ideal recovery time lapse between surgery and an embryo transfer,” said senior author Laura Detti, MD, professor of obstetrics and gynecology at Baylor, in an interview. “This is often the last step prior to embryo transfer, and identifying a recovery time that allows the best outcome is important.”
In a retrospective analysis, the researchers examined the effect of the time between HP and FET on pregnancy outcomes. They identified 65 patients with uterine pathology based on saline-infusion sonogram who underwent hysteroscopy and FET between June 1, 2022, and September 30, 2023.
The endometrial preparation for FET included sequential administration of oral or transdermal estradiol and intramuscular progesterone.
Overall, 46 patients were diagnosed with endometrial polyps at the time of surgery; three had endometritis, one had a uterine septum that was resected, 15 had no abnormal pathology or had normal endometrium at the time of examination. No cases of hyperplasia or malignancy were identified.
A total of 58 patients underwent FET with a single euploid embryo, four with a single untested embryo, one with a low-mosaic embryo, and two with a double-embryo transfer (one euploid and one low mosaic).
After FET, 50 patients conceived and 15 did not. Patients with ongoing pregnancies who had a history of endometrial polyps had significantly more days from surgery to FET, compared to patients with a history of polyps who failed to conceive (median 70 days vs 45 days, P = .01).
By contrast, the time between hysteroscopy and FET was similar among patients with no endometrial pathology who did and did not have ongoing pregnancies (median 45 vs 52.5 days, P = .95).
The findings were limited by the relatively small sample size and exclusion of patients with pathologies other than polyps, as well as a lack of data on age group breakdowns. However, the results suggest that patients with uterine polyps may benefit from more time between HP and FET, while patients with normal surgical findings could undergo FET sooner, the researchers concluded.
Postpolypectomy Timing May Affect Pregnancy Outcomes
“We used to think that having had the first menses from surgery would be enough recovery time for the uterine cavity, even if it was just 2 weeks,” Dr. Detti said in an interview. “This still holds true when no endometrial polyps are diagnosed in the pathological specimen; however, we learned that if endometrial polyps are removed at the time of hysteroscopy, the ideal recovery time prior to an embryo transfer should be longer,” she said.
The current study is important because approximately 15% of women are diagnosed with endometrial polyps during their reproductive years, said Mark P. Trolice, MD, professor at the University of Central Florida, Orlando, and founder/medical director of the IVF Center of Central Florida in Winter Park, in an interview.
“Abnormalities of the uterine cavity have been shown to reduce embryo implantation and increase the risk of miscarriage,” said Dr. Trolice. Although the impact of small endometrial polyps on fertility and pregnancy are uncertain, most infertility specialists recommend removal of endometrial polyps via hysteroscopic polypectomy in general and prior to IVF embryo transfer in particular, he said.
Although infertility patients are anxious to undergo embryo transfer, the current study suggests a benefit in delaying the procedure following the removal of any polyps identified during the pretransfer evaluation, Dr. Trolice said in an interview. As for additional research, “it would be helpful to know the age group breakdown of patients and if the results were consistent among all categories,” he said.
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Trolice had no financial conflicts to disclose and serves on the Editorial Advisory Board of Ob.Gyn. News.
A longer time between hysteroscopic polypectomy and frozen embryo transfer may improve the odds of successful pregnancy, based on data from a new analysis presented at the annual meeting of the Society for Reproductive Investigation.
Although uterine polyps have a negative effect on pregnancy rates, data supporting a specific time interval between hysteroscopic polypectomy (HP) and frozen embryo transfer (FET) are limited, according to Audrey Messelt, MD, of Baylor College of Medicine, Houston, Texas, and colleagues.
“Hysteroscopic polypectomy is a common procedure performed before embryo transfer to optimize the receptivity of the endometrium. Currently, there is no ideal recovery time lapse between surgery and an embryo transfer,” said senior author Laura Detti, MD, professor of obstetrics and gynecology at Baylor, in an interview. “This is often the last step prior to embryo transfer, and identifying a recovery time that allows the best outcome is important.”
In a retrospective analysis, the researchers examined the effect of the time between HP and FET on pregnancy outcomes. They identified 65 patients with uterine pathology based on saline-infusion sonogram who underwent hysteroscopy and FET between June 1, 2022, and September 30, 2023.
The endometrial preparation for FET included sequential administration of oral or transdermal estradiol and intramuscular progesterone.
Overall, 46 patients were diagnosed with endometrial polyps at the time of surgery; three had endometritis, one had a uterine septum that was resected, 15 had no abnormal pathology or had normal endometrium at the time of examination. No cases of hyperplasia or malignancy were identified.
A total of 58 patients underwent FET with a single euploid embryo, four with a single untested embryo, one with a low-mosaic embryo, and two with a double-embryo transfer (one euploid and one low mosaic).
After FET, 50 patients conceived and 15 did not. Patients with ongoing pregnancies who had a history of endometrial polyps had significantly more days from surgery to FET, compared to patients with a history of polyps who failed to conceive (median 70 days vs 45 days, P = .01).
By contrast, the time between hysteroscopy and FET was similar among patients with no endometrial pathology who did and did not have ongoing pregnancies (median 45 vs 52.5 days, P = .95).
The findings were limited by the relatively small sample size and exclusion of patients with pathologies other than polyps, as well as a lack of data on age group breakdowns. However, the results suggest that patients with uterine polyps may benefit from more time between HP and FET, while patients with normal surgical findings could undergo FET sooner, the researchers concluded.
Postpolypectomy Timing May Affect Pregnancy Outcomes
“We used to think that having had the first menses from surgery would be enough recovery time for the uterine cavity, even if it was just 2 weeks,” Dr. Detti said in an interview. “This still holds true when no endometrial polyps are diagnosed in the pathological specimen; however, we learned that if endometrial polyps are removed at the time of hysteroscopy, the ideal recovery time prior to an embryo transfer should be longer,” she said.
The current study is important because approximately 15% of women are diagnosed with endometrial polyps during their reproductive years, said Mark P. Trolice, MD, professor at the University of Central Florida, Orlando, and founder/medical director of the IVF Center of Central Florida in Winter Park, in an interview.
“Abnormalities of the uterine cavity have been shown to reduce embryo implantation and increase the risk of miscarriage,” said Dr. Trolice. Although the impact of small endometrial polyps on fertility and pregnancy are uncertain, most infertility specialists recommend removal of endometrial polyps via hysteroscopic polypectomy in general and prior to IVF embryo transfer in particular, he said.
Although infertility patients are anxious to undergo embryo transfer, the current study suggests a benefit in delaying the procedure following the removal of any polyps identified during the pretransfer evaluation, Dr. Trolice said in an interview. As for additional research, “it would be helpful to know the age group breakdown of patients and if the results were consistent among all categories,” he said.
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Trolice had no financial conflicts to disclose and serves on the Editorial Advisory Board of Ob.Gyn. News.
‘From Interpretation to Action’: Using CGM to Manage T2D
Data derived from continuous glucose monitoring (CGM) devices can help guide nutrition management and insulin dosing in people with type 2 diabetes (T2D) in primary care settings.
At the Advanced Technologies & Treatments for Diabetes meeting, two experts from the International Diabetes Center – HealthPartners Institute, Minneapolis, offered advice for clinicians. Tara Ettestad, RN, LD, CDCES, program manager for care transformation and training at the center, shared tips for helping patients change their diet based on CGM readings. The center’s medical director Thomas Martens, MD, provided a systematic approach to using CGM to guide adjustment of insulin doses and other medications for insulin-treated patients with T2D.
CGM-Guided Nutrition: Focus on Sustainable Changes
With CGM, people with diabetes get real-time feedback about the impact of foods on their glucose levels. This can help them learn not just what they can’t eat but what they can eat, Ms. Ettestad pointed out.
“People want to know what to eat. This is the number-one question that people who are newly diagnosed with diabetes ask, and unfortunately, they typically hear what not to eat. No carbohydrates, no sugar, no white foods, no sweets. This can be really disheartening and confusing for many. We should be focusing on sustainable changes to help improve diets,” she said.
She added, “Not everyone can see a dietitian, but all clinicians can help provide evidence-based nutrition guidance.”
When guiding patients, it’s important to focus on the four “core concepts” outlined in the American Diabetes Association’s nutrition consensus report:
- Emphasize nonstarchy vegetables
- Minimize added sugars and refined grains
- Eat more whole foods, less highly processed foods
- Replace sugar-sweetened beverages with water as often as possible
With CGM, patients can see the differences in response to refined carbs (wheat, rice, and potato), sugars (sucrose, fructose, and glucose), and resistant starches (whole grains, fruits, and legumes). Typically, glucose responses are steeper and higher for the first two compared to resistant starches.
CGM can also show the effects of eating fat and protein, in that they can delay glucose responses to meals even with the same carbohydrate content, Ms. Ettestad said.
It’s important to remind patients that although one goal of using CGM is to reduce post-meal glucose spikes, eating a lot of high-saturated fat, high-calorie foods isn’t the healthful way to do it. “What’s really important when we’re using CGM to help guide nutrition is remembering nutrition quality and what can be good for glucose is not always good for our overall health,” Ms. Ettestad stressed.
She provided these further tips:
- Pick one meal at a time to focus on. Collaborate with patients to see what changes they are able and willing to make. For example, rather than entirely giving up rice or noodles at dinner, try eating less of those and adding more vegetables.
- Suggest that patients keep a food log or use a tracking app so that the source of specific glucose patterns can be identified and addressed.
- Show patients how to check their time in range (TIR) on their mobile device or reader each week so they can see big-picture results of their changes. “This can be really motivating for people to see,” she said.
- Remind people that glucose rises with meals. This seems obvious but may not be to those newly diagnosed, she pointed out.
- Educate patients on glucose targets and explain that other factors such as stress and activity can influence glucose levels.
- Focus on the positive. “What have you been learning about how your meals and beverages affect your glucose?”
- Help guide patients toward better diet quality, even when TIR is a goal, using the four core concepts.
- Encourage curiosity, such as by experimenting with portions, timing, or food order. “What if you try eating nonstarchy foods first?”
- Before adjusting a medication dose, consider asking if the patient is willing to make a nutrition change. “Every visit is an opportunity!”
Adjusting Insulin With the Help of CGM: Focus on Four Patient Subgroups
Dr. Martens noted that about a quarter of people with T2D will require insulin treatment, despite increasing use of sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 (GLP-1) receptor agonists. And even when insulin is used as a “salvage therapy” in T2D, about two thirds of those individuals still struggle to achieve an A1c below 7% with or without other glucose-lowering medications, he noted.
“So, we have this huge population with type 2 diabetes who have limited access to endocrinology, and advanced insulin delivery devices are not yet available for them. Can better use of CGM drive improvements in care?”
He pointed to MOBILE, a randomized clinical trial, which showed that CGM use resulted in significantly improved A1c at 8 months compared with fingerstick monitoring among adults with T2D taking long-acting insulin alone without premeal insulin. However, TIR was still just 59% (vs 43% with fingerstick testing), suggesting room for improvement.
“This could have been much, much better…Rapid interpretation isn’t really enough. We need to move from interpretation into action,” Dr. Martens said.
His team recently developed a program called “CGM Clinician Guided Management (CCGM)” aimed at primary care that encourages the following principles:
- Appropriate movement toward the safer “high value” noninsulin therapies, that is, GLP-1 agonists and SGLT2 inhibitors.
- Appropriate insulin titration.
- Appropriate cycle time in titration, that is, accelerating more rapidly when one dose isn’t working. “That’s the Achilles heel of primary care,” he noted.
- Quick identification of when the limits of basal insulin therapy have been reached.
- Team-based management for difficult situations and for individuals on multiple daily injections and mealtime insulin regimens. “This is a group that really struggles…in primary care settings,” he noted.
The following three steps are based on published T2D management guidelines:
- Step 1: If the patient has atherosclerotic cardiovascular disease, start with either an SGLT2 inhibitor or GLP-1 agonist. For those with congestive heart failure and/or chronic kidney disease, SGLT2 inhibitors are indicated.
- Step 2: Is the patient on sulfonylurea? Consider eliminating it before moving to CGM-based insulin titration.
- Step 3: Was there a change in therapy based on steps 1 or 2? If not, move to CGM-guided insulin titration. If yes, wait 2-4 weeks to see the impact of therapy change before moving on.
The program categorizes patients into one of four groups based on CGM data, with respective management approaches:
- Category 1: TIR > 70%, time below range (TBR) < 3%: Doing well, keep on going!
- Category 2: TIR > 70%, TBR ≥ 3%: Too much hypoglycemia, need to decrease therapy. Stop sulfonylureas, and if TBR > 10%, also decrease basal insulin dose.
- Category 3: TIR < 70%, TBR < 3%: Too much hyperglycemia — increase therapy.
- Category 4: TIR < 70%, TBR ≥ 3%: This is the toughest category. Fix or advance therapy. These patients should be either referred to a diabetes care and education specialist (formerly known as “diabetes educators”) to troubleshoot their regimens or have their therapy advanced to multiple daily injections. The hypoglycemia should be addressed first for safety, then the hyperglycemia.
“We hope that CCGM is going to be the translation of CGM data into action in primary care, where we struggle with action and inaction,” Dr. Martens said. It’s expected to be posted on the IDC website soon.
Ms. Ettestad’s employer received educational grant funds from Abbott Diabetes Care and Sanofi-Aventis Groupe. She also worked as a product trainer with Tandem Diabetes Care. She is employed by nonprofit International Diabetes Center – HealthPartners Institute and received no personal income or honoraria from these activities. Dr. Martens’ employer received funds on his behalf for research and speaking support from Dexcom, Abbott Diabetes Care, Medtronic, Insulet, Tandem, Sanofi, Lilly, and Novo Nordisk and for consulting from Sanofi and Lilly. He is employed by nonprofit HealthPartners Institute – International Diabetes Center and received no personal income or honoraria from these activities.
A version of this article first appeared on Medscape.com.
Data derived from continuous glucose monitoring (CGM) devices can help guide nutrition management and insulin dosing in people with type 2 diabetes (T2D) in primary care settings.
At the Advanced Technologies & Treatments for Diabetes meeting, two experts from the International Diabetes Center – HealthPartners Institute, Minneapolis, offered advice for clinicians. Tara Ettestad, RN, LD, CDCES, program manager for care transformation and training at the center, shared tips for helping patients change their diet based on CGM readings. The center’s medical director Thomas Martens, MD, provided a systematic approach to using CGM to guide adjustment of insulin doses and other medications for insulin-treated patients with T2D.
CGM-Guided Nutrition: Focus on Sustainable Changes
With CGM, people with diabetes get real-time feedback about the impact of foods on their glucose levels. This can help them learn not just what they can’t eat but what they can eat, Ms. Ettestad pointed out.
“People want to know what to eat. This is the number-one question that people who are newly diagnosed with diabetes ask, and unfortunately, they typically hear what not to eat. No carbohydrates, no sugar, no white foods, no sweets. This can be really disheartening and confusing for many. We should be focusing on sustainable changes to help improve diets,” she said.
She added, “Not everyone can see a dietitian, but all clinicians can help provide evidence-based nutrition guidance.”
When guiding patients, it’s important to focus on the four “core concepts” outlined in the American Diabetes Association’s nutrition consensus report:
- Emphasize nonstarchy vegetables
- Minimize added sugars and refined grains
- Eat more whole foods, less highly processed foods
- Replace sugar-sweetened beverages with water as often as possible
With CGM, patients can see the differences in response to refined carbs (wheat, rice, and potato), sugars (sucrose, fructose, and glucose), and resistant starches (whole grains, fruits, and legumes). Typically, glucose responses are steeper and higher for the first two compared to resistant starches.
CGM can also show the effects of eating fat and protein, in that they can delay glucose responses to meals even with the same carbohydrate content, Ms. Ettestad said.
It’s important to remind patients that although one goal of using CGM is to reduce post-meal glucose spikes, eating a lot of high-saturated fat, high-calorie foods isn’t the healthful way to do it. “What’s really important when we’re using CGM to help guide nutrition is remembering nutrition quality and what can be good for glucose is not always good for our overall health,” Ms. Ettestad stressed.
She provided these further tips:
- Pick one meal at a time to focus on. Collaborate with patients to see what changes they are able and willing to make. For example, rather than entirely giving up rice or noodles at dinner, try eating less of those and adding more vegetables.
- Suggest that patients keep a food log or use a tracking app so that the source of specific glucose patterns can be identified and addressed.
- Show patients how to check their time in range (TIR) on their mobile device or reader each week so they can see big-picture results of their changes. “This can be really motivating for people to see,” she said.
- Remind people that glucose rises with meals. This seems obvious but may not be to those newly diagnosed, she pointed out.
- Educate patients on glucose targets and explain that other factors such as stress and activity can influence glucose levels.
- Focus on the positive. “What have you been learning about how your meals and beverages affect your glucose?”
- Help guide patients toward better diet quality, even when TIR is a goal, using the four core concepts.
- Encourage curiosity, such as by experimenting with portions, timing, or food order. “What if you try eating nonstarchy foods first?”
- Before adjusting a medication dose, consider asking if the patient is willing to make a nutrition change. “Every visit is an opportunity!”
Adjusting Insulin With the Help of CGM: Focus on Four Patient Subgroups
Dr. Martens noted that about a quarter of people with T2D will require insulin treatment, despite increasing use of sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 (GLP-1) receptor agonists. And even when insulin is used as a “salvage therapy” in T2D, about two thirds of those individuals still struggle to achieve an A1c below 7% with or without other glucose-lowering medications, he noted.
“So, we have this huge population with type 2 diabetes who have limited access to endocrinology, and advanced insulin delivery devices are not yet available for them. Can better use of CGM drive improvements in care?”
He pointed to MOBILE, a randomized clinical trial, which showed that CGM use resulted in significantly improved A1c at 8 months compared with fingerstick monitoring among adults with T2D taking long-acting insulin alone without premeal insulin. However, TIR was still just 59% (vs 43% with fingerstick testing), suggesting room for improvement.
“This could have been much, much better…Rapid interpretation isn’t really enough. We need to move from interpretation into action,” Dr. Martens said.
His team recently developed a program called “CGM Clinician Guided Management (CCGM)” aimed at primary care that encourages the following principles:
- Appropriate movement toward the safer “high value” noninsulin therapies, that is, GLP-1 agonists and SGLT2 inhibitors.
- Appropriate insulin titration.
- Appropriate cycle time in titration, that is, accelerating more rapidly when one dose isn’t working. “That’s the Achilles heel of primary care,” he noted.
- Quick identification of when the limits of basal insulin therapy have been reached.
- Team-based management for difficult situations and for individuals on multiple daily injections and mealtime insulin regimens. “This is a group that really struggles…in primary care settings,” he noted.
The following three steps are based on published T2D management guidelines:
- Step 1: If the patient has atherosclerotic cardiovascular disease, start with either an SGLT2 inhibitor or GLP-1 agonist. For those with congestive heart failure and/or chronic kidney disease, SGLT2 inhibitors are indicated.
- Step 2: Is the patient on sulfonylurea? Consider eliminating it before moving to CGM-based insulin titration.
- Step 3: Was there a change in therapy based on steps 1 or 2? If not, move to CGM-guided insulin titration. If yes, wait 2-4 weeks to see the impact of therapy change before moving on.
The program categorizes patients into one of four groups based on CGM data, with respective management approaches:
- Category 1: TIR > 70%, time below range (TBR) < 3%: Doing well, keep on going!
- Category 2: TIR > 70%, TBR ≥ 3%: Too much hypoglycemia, need to decrease therapy. Stop sulfonylureas, and if TBR > 10%, also decrease basal insulin dose.
- Category 3: TIR < 70%, TBR < 3%: Too much hyperglycemia — increase therapy.
- Category 4: TIR < 70%, TBR ≥ 3%: This is the toughest category. Fix or advance therapy. These patients should be either referred to a diabetes care and education specialist (formerly known as “diabetes educators”) to troubleshoot their regimens or have their therapy advanced to multiple daily injections. The hypoglycemia should be addressed first for safety, then the hyperglycemia.
“We hope that CCGM is going to be the translation of CGM data into action in primary care, where we struggle with action and inaction,” Dr. Martens said. It’s expected to be posted on the IDC website soon.
Ms. Ettestad’s employer received educational grant funds from Abbott Diabetes Care and Sanofi-Aventis Groupe. She also worked as a product trainer with Tandem Diabetes Care. She is employed by nonprofit International Diabetes Center – HealthPartners Institute and received no personal income or honoraria from these activities. Dr. Martens’ employer received funds on his behalf for research and speaking support from Dexcom, Abbott Diabetes Care, Medtronic, Insulet, Tandem, Sanofi, Lilly, and Novo Nordisk and for consulting from Sanofi and Lilly. He is employed by nonprofit HealthPartners Institute – International Diabetes Center and received no personal income or honoraria from these activities.
A version of this article first appeared on Medscape.com.
Data derived from continuous glucose monitoring (CGM) devices can help guide nutrition management and insulin dosing in people with type 2 diabetes (T2D) in primary care settings.
At the Advanced Technologies & Treatments for Diabetes meeting, two experts from the International Diabetes Center – HealthPartners Institute, Minneapolis, offered advice for clinicians. Tara Ettestad, RN, LD, CDCES, program manager for care transformation and training at the center, shared tips for helping patients change their diet based on CGM readings. The center’s medical director Thomas Martens, MD, provided a systematic approach to using CGM to guide adjustment of insulin doses and other medications for insulin-treated patients with T2D.
CGM-Guided Nutrition: Focus on Sustainable Changes
With CGM, people with diabetes get real-time feedback about the impact of foods on their glucose levels. This can help them learn not just what they can’t eat but what they can eat, Ms. Ettestad pointed out.
“People want to know what to eat. This is the number-one question that people who are newly diagnosed with diabetes ask, and unfortunately, they typically hear what not to eat. No carbohydrates, no sugar, no white foods, no sweets. This can be really disheartening and confusing for many. We should be focusing on sustainable changes to help improve diets,” she said.
She added, “Not everyone can see a dietitian, but all clinicians can help provide evidence-based nutrition guidance.”
When guiding patients, it’s important to focus on the four “core concepts” outlined in the American Diabetes Association’s nutrition consensus report:
- Emphasize nonstarchy vegetables
- Minimize added sugars and refined grains
- Eat more whole foods, less highly processed foods
- Replace sugar-sweetened beverages with water as often as possible
With CGM, patients can see the differences in response to refined carbs (wheat, rice, and potato), sugars (sucrose, fructose, and glucose), and resistant starches (whole grains, fruits, and legumes). Typically, glucose responses are steeper and higher for the first two compared to resistant starches.
CGM can also show the effects of eating fat and protein, in that they can delay glucose responses to meals even with the same carbohydrate content, Ms. Ettestad said.
It’s important to remind patients that although one goal of using CGM is to reduce post-meal glucose spikes, eating a lot of high-saturated fat, high-calorie foods isn’t the healthful way to do it. “What’s really important when we’re using CGM to help guide nutrition is remembering nutrition quality and what can be good for glucose is not always good for our overall health,” Ms. Ettestad stressed.
She provided these further tips:
- Pick one meal at a time to focus on. Collaborate with patients to see what changes they are able and willing to make. For example, rather than entirely giving up rice or noodles at dinner, try eating less of those and adding more vegetables.
- Suggest that patients keep a food log or use a tracking app so that the source of specific glucose patterns can be identified and addressed.
- Show patients how to check their time in range (TIR) on their mobile device or reader each week so they can see big-picture results of their changes. “This can be really motivating for people to see,” she said.
- Remind people that glucose rises with meals. This seems obvious but may not be to those newly diagnosed, she pointed out.
- Educate patients on glucose targets and explain that other factors such as stress and activity can influence glucose levels.
- Focus on the positive. “What have you been learning about how your meals and beverages affect your glucose?”
- Help guide patients toward better diet quality, even when TIR is a goal, using the four core concepts.
- Encourage curiosity, such as by experimenting with portions, timing, or food order. “What if you try eating nonstarchy foods first?”
- Before adjusting a medication dose, consider asking if the patient is willing to make a nutrition change. “Every visit is an opportunity!”
Adjusting Insulin With the Help of CGM: Focus on Four Patient Subgroups
Dr. Martens noted that about a quarter of people with T2D will require insulin treatment, despite increasing use of sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 (GLP-1) receptor agonists. And even when insulin is used as a “salvage therapy” in T2D, about two thirds of those individuals still struggle to achieve an A1c below 7% with or without other glucose-lowering medications, he noted.
“So, we have this huge population with type 2 diabetes who have limited access to endocrinology, and advanced insulin delivery devices are not yet available for them. Can better use of CGM drive improvements in care?”
He pointed to MOBILE, a randomized clinical trial, which showed that CGM use resulted in significantly improved A1c at 8 months compared with fingerstick monitoring among adults with T2D taking long-acting insulin alone without premeal insulin. However, TIR was still just 59% (vs 43% with fingerstick testing), suggesting room for improvement.
“This could have been much, much better…Rapid interpretation isn’t really enough. We need to move from interpretation into action,” Dr. Martens said.
His team recently developed a program called “CGM Clinician Guided Management (CCGM)” aimed at primary care that encourages the following principles:
- Appropriate movement toward the safer “high value” noninsulin therapies, that is, GLP-1 agonists and SGLT2 inhibitors.
- Appropriate insulin titration.
- Appropriate cycle time in titration, that is, accelerating more rapidly when one dose isn’t working. “That’s the Achilles heel of primary care,” he noted.
- Quick identification of when the limits of basal insulin therapy have been reached.
- Team-based management for difficult situations and for individuals on multiple daily injections and mealtime insulin regimens. “This is a group that really struggles…in primary care settings,” he noted.
The following three steps are based on published T2D management guidelines:
- Step 1: If the patient has atherosclerotic cardiovascular disease, start with either an SGLT2 inhibitor or GLP-1 agonist. For those with congestive heart failure and/or chronic kidney disease, SGLT2 inhibitors are indicated.
- Step 2: Is the patient on sulfonylurea? Consider eliminating it before moving to CGM-based insulin titration.
- Step 3: Was there a change in therapy based on steps 1 or 2? If not, move to CGM-guided insulin titration. If yes, wait 2-4 weeks to see the impact of therapy change before moving on.
The program categorizes patients into one of four groups based on CGM data, with respective management approaches:
- Category 1: TIR > 70%, time below range (TBR) < 3%: Doing well, keep on going!
- Category 2: TIR > 70%, TBR ≥ 3%: Too much hypoglycemia, need to decrease therapy. Stop sulfonylureas, and if TBR > 10%, also decrease basal insulin dose.
- Category 3: TIR < 70%, TBR < 3%: Too much hyperglycemia — increase therapy.
- Category 4: TIR < 70%, TBR ≥ 3%: This is the toughest category. Fix or advance therapy. These patients should be either referred to a diabetes care and education specialist (formerly known as “diabetes educators”) to troubleshoot their regimens or have their therapy advanced to multiple daily injections. The hypoglycemia should be addressed first for safety, then the hyperglycemia.
“We hope that CCGM is going to be the translation of CGM data into action in primary care, where we struggle with action and inaction,” Dr. Martens said. It’s expected to be posted on the IDC website soon.
Ms. Ettestad’s employer received educational grant funds from Abbott Diabetes Care and Sanofi-Aventis Groupe. She also worked as a product trainer with Tandem Diabetes Care. She is employed by nonprofit International Diabetes Center – HealthPartners Institute and received no personal income or honoraria from these activities. Dr. Martens’ employer received funds on his behalf for research and speaking support from Dexcom, Abbott Diabetes Care, Medtronic, Insulet, Tandem, Sanofi, Lilly, and Novo Nordisk and for consulting from Sanofi and Lilly. He is employed by nonprofit HealthPartners Institute – International Diabetes Center and received no personal income or honoraria from these activities.
A version of this article first appeared on Medscape.com.
Think Beyond the ‘Go-Tos’ for Wart Management, Expert Advises
SAN DIEGO — When Jennifer Adams, MD, recently entered the search term “warts” on the ClinicalTrials.gov web site, nearly 240 results popped up.
“There is a lot of research activity around this topic,” Dr. Adams, vice chair of the department of dermatology at the University of Nebraska Medical Center, said at the annual meeting of the American Academy of Dermatology. “We just don’t have fantastic, well-run trials on many of the currently available treatments.”
In a 2012 Cochrane review on the topical treatment of non-genital cutaneous warts, authors drew from 85 trials involving 8,815 randomized patients. They found that most warts spontaneously resolved, and the authors determined salicylic acid to be safe and modestly beneficial. Specifically, trials of salicylic acid (SA) versus placebo showed that the former significantly increased the chance of clearance of warts at all sites (risk ratio, 1.56, 95% confidence interval [CI], 1.20-2.03). A meta-analysis of cryotherapy versus placebo for warts at all sites favored neither intervention nor control (RR, 1.45, 95% CI, 0.65-3.23).
“The authors determined that there is less evidence for cryotherapy but stated that it may work when salicylic acid does not, or in combination with salicylic acid,” Dr. Adams said. “However, salicylic acid and cryotherapy don’t do enough for our patients [with warts]. There are a lot of situations where we need to reach further into the toolbox.”
A 2021 review article listed many options for managing difficult-to-treat warts, including intralesional Candida antigen, intralesional measles-mumps-rubella (MMR), intralesional HPV vaccine, intralesional vitamin D, intralesional cidofovir, intralesional bleomycin, and intralesional 5-FU injections, and topical vitamin D, topical cidofovir, and topical bleomycin. According to Dr. Adams, clinical data exist for cidofovir and vitamin D but studies evaluated different formulations, doses, sites of administration, and limited randomized controlled trials.
“Intralesional cidofovir is more effective than the topical form, but intralesional cidofovir can be painful and both forms are expensive,” she said. “Topical vitamin D is less likely to cause dyspigmentation compared to other available treatments, so it’s a great option in skin of color, but it has been less effective compared to some of our other topical treatments.”
Newer Options Promising
On the horizon, berdazimer gel was approved in January of 2024 for the treatment of molluscum but results from trials of its use for extragenital warts are encouraging. Another promising option is topical ionic contraviral therapy (ICVT) with digoxin and furosemide combined, which inhibits cellular potassium influx. A phase 2a randomized controlled trial of 80 adults found a statistically significant reduction in the diameter of cutaneous warts among those who received ICVT compared with those who received placebo (P = .002). “It’s cheap and well tolerated,” Dr. Adams added.
Intralesional approaches to treating warts offer another alternative. A 2020 review of 43 articles concluded that intralesional treatments for warts have equal or superior efficacy to first-line salicylic acid or cryotherapy.
Dr. Adams said that she considers intralesional treatments such as vitamin D, MMR vaccine antigen, and Candida antigen for refractory, numerous, or distant site warts. “Injecting the MMR vaccine into the largest wart every 2 weeks has been found to lead to complete clearance in 60%-68% of cases in one study,” she said. “The benefit is that it’s $21 per dose, which is nice, but as with any vaccination, patients can develop flu-like symptoms as side effects.”
Use of the HPV vaccine for treating cutaneous warts remains controversial, she continued, but it seems to work better in younger patients. In one open-label study that evaluated the HPV vaccine for the treatment of multiple recalcitrant warts, with doses administered at 0. 2, and 6 months, the response rate 3 months after the third dose was 55% among those older than age 26, compared with 84% among those ages 9-26 years.
Another option, intralesional cidofovir, has been shown to be especially effective for refractory warts. “It has also been shown to work for warts in immunocompetent and immunocompromised patients,” Dr. Adams said.
In the realm of adjuvant treatments, microneedling has been found to have similar efficacy to needling, Dr. Adams said, but with minimal pain. “When we combine it with topical treatments like 5-FU, it’s even more efficacious,” she said.
One study found that combining microneedling with topical 5-FU had clearance similar to that of intralesional 5-FU or microneedling alone, but involved fewer treatment sessions and less pain in the combination group.
Autoinoculation has been used to stimulate an immune response in patients with warts, leading to clearance rates of 4% (mild clearance) to 66% (complete clearance) in one study. “We would expect this to work better in immunocompetent patients, but it’s something to keep in mind if you’re limited in the medications you can get for a patient,” Dr. Adams said. Also, results from a systematic review and meta-analysis suggest that systemic retinoids combined with intralesional immunotherapy leads to higher clearance rates and lower rates of recurrence of warts. The top performer among those tested was acitretin plus Candida antigen.
Dr. Adams advised dermatologists who try alternatives to salicylic acid and cryotherapy for warts to be “wary of a lack of high-level evidence” for their use. “They can be helpful for patients who have failed traditional therapies or have a contraindication to the usual go-tos.”
She reported having no relevant financial disclosures.
SAN DIEGO — When Jennifer Adams, MD, recently entered the search term “warts” on the ClinicalTrials.gov web site, nearly 240 results popped up.
“There is a lot of research activity around this topic,” Dr. Adams, vice chair of the department of dermatology at the University of Nebraska Medical Center, said at the annual meeting of the American Academy of Dermatology. “We just don’t have fantastic, well-run trials on many of the currently available treatments.”
In a 2012 Cochrane review on the topical treatment of non-genital cutaneous warts, authors drew from 85 trials involving 8,815 randomized patients. They found that most warts spontaneously resolved, and the authors determined salicylic acid to be safe and modestly beneficial. Specifically, trials of salicylic acid (SA) versus placebo showed that the former significantly increased the chance of clearance of warts at all sites (risk ratio, 1.56, 95% confidence interval [CI], 1.20-2.03). A meta-analysis of cryotherapy versus placebo for warts at all sites favored neither intervention nor control (RR, 1.45, 95% CI, 0.65-3.23).
“The authors determined that there is less evidence for cryotherapy but stated that it may work when salicylic acid does not, or in combination with salicylic acid,” Dr. Adams said. “However, salicylic acid and cryotherapy don’t do enough for our patients [with warts]. There are a lot of situations where we need to reach further into the toolbox.”
A 2021 review article listed many options for managing difficult-to-treat warts, including intralesional Candida antigen, intralesional measles-mumps-rubella (MMR), intralesional HPV vaccine, intralesional vitamin D, intralesional cidofovir, intralesional bleomycin, and intralesional 5-FU injections, and topical vitamin D, topical cidofovir, and topical bleomycin. According to Dr. Adams, clinical data exist for cidofovir and vitamin D but studies evaluated different formulations, doses, sites of administration, and limited randomized controlled trials.
“Intralesional cidofovir is more effective than the topical form, but intralesional cidofovir can be painful and both forms are expensive,” she said. “Topical vitamin D is less likely to cause dyspigmentation compared to other available treatments, so it’s a great option in skin of color, but it has been less effective compared to some of our other topical treatments.”
Newer Options Promising
On the horizon, berdazimer gel was approved in January of 2024 for the treatment of molluscum but results from trials of its use for extragenital warts are encouraging. Another promising option is topical ionic contraviral therapy (ICVT) with digoxin and furosemide combined, which inhibits cellular potassium influx. A phase 2a randomized controlled trial of 80 adults found a statistically significant reduction in the diameter of cutaneous warts among those who received ICVT compared with those who received placebo (P = .002). “It’s cheap and well tolerated,” Dr. Adams added.
Intralesional approaches to treating warts offer another alternative. A 2020 review of 43 articles concluded that intralesional treatments for warts have equal or superior efficacy to first-line salicylic acid or cryotherapy.
Dr. Adams said that she considers intralesional treatments such as vitamin D, MMR vaccine antigen, and Candida antigen for refractory, numerous, or distant site warts. “Injecting the MMR vaccine into the largest wart every 2 weeks has been found to lead to complete clearance in 60%-68% of cases in one study,” she said. “The benefit is that it’s $21 per dose, which is nice, but as with any vaccination, patients can develop flu-like symptoms as side effects.”
Use of the HPV vaccine for treating cutaneous warts remains controversial, she continued, but it seems to work better in younger patients. In one open-label study that evaluated the HPV vaccine for the treatment of multiple recalcitrant warts, with doses administered at 0. 2, and 6 months, the response rate 3 months after the third dose was 55% among those older than age 26, compared with 84% among those ages 9-26 years.
Another option, intralesional cidofovir, has been shown to be especially effective for refractory warts. “It has also been shown to work for warts in immunocompetent and immunocompromised patients,” Dr. Adams said.
In the realm of adjuvant treatments, microneedling has been found to have similar efficacy to needling, Dr. Adams said, but with minimal pain. “When we combine it with topical treatments like 5-FU, it’s even more efficacious,” she said.
One study found that combining microneedling with topical 5-FU had clearance similar to that of intralesional 5-FU or microneedling alone, but involved fewer treatment sessions and less pain in the combination group.
Autoinoculation has been used to stimulate an immune response in patients with warts, leading to clearance rates of 4% (mild clearance) to 66% (complete clearance) in one study. “We would expect this to work better in immunocompetent patients, but it’s something to keep in mind if you’re limited in the medications you can get for a patient,” Dr. Adams said. Also, results from a systematic review and meta-analysis suggest that systemic retinoids combined with intralesional immunotherapy leads to higher clearance rates and lower rates of recurrence of warts. The top performer among those tested was acitretin plus Candida antigen.
Dr. Adams advised dermatologists who try alternatives to salicylic acid and cryotherapy for warts to be “wary of a lack of high-level evidence” for their use. “They can be helpful for patients who have failed traditional therapies or have a contraindication to the usual go-tos.”
She reported having no relevant financial disclosures.
SAN DIEGO — When Jennifer Adams, MD, recently entered the search term “warts” on the ClinicalTrials.gov web site, nearly 240 results popped up.
“There is a lot of research activity around this topic,” Dr. Adams, vice chair of the department of dermatology at the University of Nebraska Medical Center, said at the annual meeting of the American Academy of Dermatology. “We just don’t have fantastic, well-run trials on many of the currently available treatments.”
In a 2012 Cochrane review on the topical treatment of non-genital cutaneous warts, authors drew from 85 trials involving 8,815 randomized patients. They found that most warts spontaneously resolved, and the authors determined salicylic acid to be safe and modestly beneficial. Specifically, trials of salicylic acid (SA) versus placebo showed that the former significantly increased the chance of clearance of warts at all sites (risk ratio, 1.56, 95% confidence interval [CI], 1.20-2.03). A meta-analysis of cryotherapy versus placebo for warts at all sites favored neither intervention nor control (RR, 1.45, 95% CI, 0.65-3.23).
“The authors determined that there is less evidence for cryotherapy but stated that it may work when salicylic acid does not, or in combination with salicylic acid,” Dr. Adams said. “However, salicylic acid and cryotherapy don’t do enough for our patients [with warts]. There are a lot of situations where we need to reach further into the toolbox.”
A 2021 review article listed many options for managing difficult-to-treat warts, including intralesional Candida antigen, intralesional measles-mumps-rubella (MMR), intralesional HPV vaccine, intralesional vitamin D, intralesional cidofovir, intralesional bleomycin, and intralesional 5-FU injections, and topical vitamin D, topical cidofovir, and topical bleomycin. According to Dr. Adams, clinical data exist for cidofovir and vitamin D but studies evaluated different formulations, doses, sites of administration, and limited randomized controlled trials.
“Intralesional cidofovir is more effective than the topical form, but intralesional cidofovir can be painful and both forms are expensive,” she said. “Topical vitamin D is less likely to cause dyspigmentation compared to other available treatments, so it’s a great option in skin of color, but it has been less effective compared to some of our other topical treatments.”
Newer Options Promising
On the horizon, berdazimer gel was approved in January of 2024 for the treatment of molluscum but results from trials of its use for extragenital warts are encouraging. Another promising option is topical ionic contraviral therapy (ICVT) with digoxin and furosemide combined, which inhibits cellular potassium influx. A phase 2a randomized controlled trial of 80 adults found a statistically significant reduction in the diameter of cutaneous warts among those who received ICVT compared with those who received placebo (P = .002). “It’s cheap and well tolerated,” Dr. Adams added.
Intralesional approaches to treating warts offer another alternative. A 2020 review of 43 articles concluded that intralesional treatments for warts have equal or superior efficacy to first-line salicylic acid or cryotherapy.
Dr. Adams said that she considers intralesional treatments such as vitamin D, MMR vaccine antigen, and Candida antigen for refractory, numerous, or distant site warts. “Injecting the MMR vaccine into the largest wart every 2 weeks has been found to lead to complete clearance in 60%-68% of cases in one study,” she said. “The benefit is that it’s $21 per dose, which is nice, but as with any vaccination, patients can develop flu-like symptoms as side effects.”
Use of the HPV vaccine for treating cutaneous warts remains controversial, she continued, but it seems to work better in younger patients. In one open-label study that evaluated the HPV vaccine for the treatment of multiple recalcitrant warts, with doses administered at 0. 2, and 6 months, the response rate 3 months after the third dose was 55% among those older than age 26, compared with 84% among those ages 9-26 years.
Another option, intralesional cidofovir, has been shown to be especially effective for refractory warts. “It has also been shown to work for warts in immunocompetent and immunocompromised patients,” Dr. Adams said.
In the realm of adjuvant treatments, microneedling has been found to have similar efficacy to needling, Dr. Adams said, but with minimal pain. “When we combine it with topical treatments like 5-FU, it’s even more efficacious,” she said.
One study found that combining microneedling with topical 5-FU had clearance similar to that of intralesional 5-FU or microneedling alone, but involved fewer treatment sessions and less pain in the combination group.
Autoinoculation has been used to stimulate an immune response in patients with warts, leading to clearance rates of 4% (mild clearance) to 66% (complete clearance) in one study. “We would expect this to work better in immunocompetent patients, but it’s something to keep in mind if you’re limited in the medications you can get for a patient,” Dr. Adams said. Also, results from a systematic review and meta-analysis suggest that systemic retinoids combined with intralesional immunotherapy leads to higher clearance rates and lower rates of recurrence of warts. The top performer among those tested was acitretin plus Candida antigen.
Dr. Adams advised dermatologists who try alternatives to salicylic acid and cryotherapy for warts to be “wary of a lack of high-level evidence” for their use. “They can be helpful for patients who have failed traditional therapies or have a contraindication to the usual go-tos.”
She reported having no relevant financial disclosures.
FROM AAD 2024