Meta-Analysis Finds L-Carnitine Supplementation Reduces CV Risk Factors in Diabetic and Glucose Intolerant Patients

Iran: A recent systematic review and dose-response meta-analysis has examined the impact of L-carnitine supplementation on cardiovascular risk factors in individuals with impaired glucose tolerance and diabetes.

This meta-analysis revealed that L-carnitine supplementation significantly reduces levels of triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), fasting blood glucose (FBG), HbA1c, HOMA-IR, C-reactive protein (CRP), tumor necrosis factor-alpha (TNF-α), as well as weight, body mass index (BMI), body fat percentage (BFP), and leptin in patients with diabetes and impaired glucose tolerance. However, no significant effects were observed on total cholesterol (TC), high-density lipoprotein (HDL), serum insulin, systolic blood pressure (SBP), diastolic blood pressure (DBP), apolipoprotein A (apo A), or apolipoprotein B (apo B) in these patients.

The findings were published online in Diabetology & Metabolic Syndrome on July 31, 2024.

L-carnitine is often touted for its potential benefits in enhancing exercise performance and weight management. However, its effects on cardiovascular health, particularly in diabetic and pre-diabetic populations, have been less clear. Therefore, Rezvan Gheysari, Shohada-E-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran, and colleagues aimed to assess the effect of L-carnitine supplementation on CVD risk factors.

For this purpose, the researchers conducted a systematic literature search in PubMed, Web of Science, and Scopus until October 2022. The primary outcomes assessed included lipid profiles, insulin resistance, anthropometric measurements, leptin, serum glucose levels, blood pressure, and inflammatory markers. A random-effects model was used to calculate the pooled weighted mean difference (WMD).

The researchers reported the following findings:

  • The study included 21 RCTs (n = 2900) with 21 effect sizes.
  • L-carnitine supplementation had a significant effect on TG (WMD = − 13.50 mg/dl), LDL (WMD = − 12.66 mg/dl), HbA1c (WMD = -0.37%), FBG (WMD = − 6.24 mg/dl), HOMA-IR (WMD = -0.72), CRP (WMD = − 0.07 mg/dl), TNF-α (WMD = − 1.39 pg/ml), weight (WMD = − 1.58 kg), BFP (WMD = − 1.83), BMI (WMD = − 0.28 kg/m2), and leptin (WMD = − 2.21 ng/ml) in intervention, compared to the placebo group, in the pooled analysis.

The analysis also indicated that the optimal duration for L-carnitine supplementation to effectively reduce FBG, HbA1c, and HOMA-IR was approximately 50 weeks after initiation. It was noted that longer durations of supplementation (≥ 25 weeks) had a diminishing impact on weight.

“Given the significant risk of bias present in the majority of the included trials, further well-designed and comprehensive RCTs with larger sample sizes and robust analytical methods are needed to more accurately determine the influence of L-carnitine on cardiovascular disease (CVD) risk factors in individuals with diabetes and glucose intolerance,” the researchers concluded.

Reference:

Gheysari, R., Nikbaf-Shandiz, M., Hosseini, A.M. et al. The effects of L-carnitine supplementation on cardiovascular risk factors in participants with impaired glucose tolerance and diabetes: a systematic review and dose–response meta-analysis. Diabetol Metab Syndr 16, 185 (2024). https://doi.org/10.1186/s13098-024-01415-8

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ECV mapping, in systemic AL amyloidosis an independent predictor of prognosis: JAMA

UK: In a recent study published in JAMA Cardiology, researchers have unveiled new insights into managing systemic immunoglobulin AL amyloidosis, particularly emphasizing the role of extracellular volume (ECV) mapping as a crucial tool for predicting patient outcomes. This revelation marks a significant shift in how clinicians approach treatment for this rare but severe condition characterized by the deposition of amyloid proteins in organs, most critically the heart.

The researchers revealed that ECV mapping reshapes the understanding of hematological responses linked to improved outcomes and holds the promise of guiding more effective treatment strategies. ECV mapping is a technique used to assess the volume of extracellular space in cardiac tissues.

The cohort study encompassed 560 newly diagnosed systemic AL amyloidosis patients who underwent cardiac magnetic resonance (CMR) imaging with ECV mapping before starting chemotherapy. Among various methods for assessing cardiac involvement, ECV mapping emerged as the sole independent prognostic indicator.

“It offered valuable insights into how the depth and speed of hematological response correlate with patient outcomes, highlighting that a swift and substantial hematological response is particularly crucial for those with elevated ECV levels,” the researchers wrote.

Systemic light-chain (AL) amyloidosis, a condition resulting from the abnormal accumulation of light-chain amyloid proteins, often leads to severe cardiac complications. Traditionally, treatment strategies have focused primarily on the reduction of amyloid-producing plasma cells and the overall control of disease progression. The key determinant of survival in systemic AL amyloidosis is cardiac amyloid infiltration. Current guidelines advise early therapy modification for patients showing nonoptimal or suboptimal responses, irrespective of the degree of cardiac amyloid infiltration.

Against the above background, Aldostefano Porcari, University College London, Royal Free Hospital, London, United Kingdom, and colleagues aimed to evaluate the differences between serum biomarkers, echocardiography, and CMR with ECV mapping in characterizing cardiac amyloid, the independent prognostic role of these approaches, and the ECV mapping’s role to guide treatment strategies.

From 2015 to 2021, consecutive patients newly diagnosed with systemic AL amyloidosis underwent echocardiography, cardiac biomarker assessments, and cardiac magnetic resonance (CMR) imaging with ECV mapping at the time of diagnosis.

The primary outcomes of the study included all-cause mortality and hematological response, categorized into no response (NR), partial response (PR), very good partial response (VGPR), and complete response (CR) based on validated criteria. Secondary outcomes focused on the depth and speed of the hematological response, as well as overall survival with ECV levels.

The following were the key findings of the study:

  • Of 560 patients with AL amyloidosis, the median age was 68 years; 61.8% were males.
  • Over a median of 40.5 months, ECV was independently associated with mortality.
  • In the landmark analysis at one month, long-term survival was independent of the achieved hematological response in ECV less than 0.30% and ECV of 0.31% to 0.40%, while it was dependent on the depth of the hematological response in ECV greater than 0.40%.
  • In the landmark analysis at six months, survival was independent of the achieved hematological response in ECV less than 0.30% and dependent on achieving at least PR in ECV of 0.31% to 0.40%.
  • Survival was dependent on achieving CR in ECV of 0.41% to 0.50% and ECV greater than 0.50%.
  • Achieving a deep hematological response at one month was associated with better survival than six months in patients with ECV greater than 0.40% but not with ECV less than 0.40%.

This study demonstrated that CMR with ECV mapping provides a significant advantage by precisely assessing the presence and extent of cardiac amyloid infiltration, surpassing the accuracy of serum cardiac biomarkers and echocardiography.

“ECV mapping not only independently predicts overall survival in systemic AL amyloidosis but also helps delineate hematological responses that correlate with improved long-term survival based on the degree and severity of cardiac amyloid infiltration,” the researchers concluded.

Reference:

Porcari A, Masi A, Martinez-Naharro A, et al. Redefining Cardiac Involvement and Targets of Treatment in Systemic Immunoglobulin AL Amyloidosis. JAMA Cardiol. Published online August 21, 2024. doi:10.1001/jamacardio.2024.2555

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3D body volume scanner may use AI to help predict metabolic syndrome risk, claims research

Mayo Clinic researchers are using artificial intelligence (AI) with an advanced 3D body-volume scanner-originally developed for the clothing industry – to help doctors predict metabolic syndrome risk and severity. The combination of tools offers doctors a more precise alternative to other measures of disease risk like body mass index (BMI) and waist-to-hip ratio, according to findings published in theEuropean Heart Journal – Digital Health.

Metabolic syndrome can lead to heart attack, stroke and other serious health issues and affects over a third of the U.S. population and a quarter of people globally. The condition lacks widely accepted screening strategies. However, researchers found that using a 3D body volume scanner combined with imaging technology and Mayo Clinic-developed algorithms may help clinicians offer a more accurate method for identifying people who have the syndrome, as well as those at risk for developing it.

The effects of metabolic disease create hardship for patients. In addition to heart attack and stroke, people with metabolic syndrome are more likely to develop diabetes, cognitive disease and liver disease. Metabolic syndrome is diagnosed clinically when at least three of these five conditions are present: abdominal obesity, high blood pressure, high triglycerides, low HDL cholesterol and high fasting blood sugar.

“There is a need for a reliable, repeatable measure of metabolic syndrome risk and severity,” says Betsy Medina Inojosa, M.D., a research fellow at Mayo Clinic and first author of the study. “Body mass index measurements and bioimpedance scales that measure body fat and muscle are inaccurate for many people, and other types of scans are not widely available. Our research shows that this AI model may also be a tool to guide clinicians and patients to take action and seek outcomes that are a better fit for their metabolic health.”

To develop the tool, researchers trained and validated an AI model on 1,280 volunteer subjects who underwent an evaluation that included 3D body-volume scans, standardized clinical questionnaires, blood tests and traditional body shape measurements. An extra 133 volunteers had front- and side-view images taken via a mobile app from Select Research called myBVI to further test the tool’s ability to evaluate whether they had metabolic syndrome, and if so, how severe it was.

People with metabolic syndrome typically have apple-shaped bodies, meaning they carry a lot of their weight around the abdomen. The diagnosis of metabolic syndrome revolves around laboratory tests, blood pressure and body shape measurements, but there are no widely accepted routine screening strategies because these measurements are not always available or reproducible in the same way.

“This small study finds that digitally measuring a patient’s body volume index with 3D imaging provides a highly accurate measurement of shapes and volumes in critical regions where unhealthy visceral fat is deposited, such as the abdomen and chest,” says Francisco Lopez-Jimenez, M.D., director of Preventive Cardiology at Mayo Clinic in Rochester and senior author of the study. “The scans also record the volume of hips, buttocks and legs – a measure related to muscle mass and ‘healthy’ fat. The 3D information about body volume in these key regions, whether from the large, stationary 3D scanner or from the mobile app, accurately flagged the presence and severity of metabolic syndrome using imaging instead of invasive tests. Looking ahead, the next steps will be to broaden the sample of research subjects to include more diversity.”

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IV USG-guided shockwave lithotripsy effective for radiolucent ureteral stones, reveals study

A recent retrospective study found that intravenous urography-assisted fluoroscopy-guided shockwave lithotripsy (SWL) helps in the effective treatment of radiolucent ureteral stones when compared to standard fluoroscopy-guided SWL. The findings were published in the recent issue of Asian Journal of Urology.

The study included a total of 734 patients who underwent SWL were divided into two groups. In this, 98 patients received the IVU protocol (Group I) and 636 underwent the standard non-IVU protocol (Group N). The primary measure of success was the stone-free rate within 30 days post-treatment which was defined as no residual stones detected without requiring additional interventions.

This extensive analysis revealed that 37.8% of patients in Group I were stone-free within one session and 30 days when compared to 31.7% in Group N. Group I showed a slightly higher success rate, while the difference was not statistically significant (p=0.20). This indicated that the use of IVU does not significantly improve the effectiveness of SWL for radiolucent stones when compared to standard treatment for radiopaque stones.

Also, the study examined secondary outcomes like the rate of conversion to ureteroscopy which is a more invasive procedure and the complication rate. Both groups showed similar results, with no significant differences in the conversion rate (p=0.26) and complication rate (p=0.70). Only one patient underwent a complication related to the contrast medium used in IVU by developing minor skin redness.

A propensity score matching analysis was performed to ensure the comparability of the groups which resulted in 88 matched pairs. This analysis reinforced the initial findings where 35.2% of patients in Group I and 37.5% in Group N achieved stone-free status within one session and 30 days (p=0.88).

The study concludes that radiolucent stones can be effectively and safely treated with SWL not regarding the utilization of IVU. This finding is significant for clinical practice where the standard SWL procedure is just as effective for radiolucent stones as for radiopaque stones by potentially simplifying the treatment protocol for different types of ureteral stones. Overall, the findings of this study provide crucial insights in to this aspect  Further research and prospective studies are imperative to explore long-term outcomes and the cost-effectiveness of IVU-assisted SWL to refine treatment guidelines by ensuring optimal patient care in urology.

Source:

Somiya, S., Koterazawa, S., Ito, K., Haitani, T., Makino, Y., Arakaki, R., Kawase, N., Higashi, Y., Yamada, H., & Kanno, T. (2024). Clinical outcome of intravenous urography-assisted shockwave lithotripsy for radiolucent ureteral stones. In Asian Journal of Urology. Elsevier BV. https://doi.org/10.1016/j.ajur.2024.03.002

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Study Finds Perineural Dexamethasone May Delay Nerve Recovery After Surgery, Urges Caution for High-Risk Patients

China: A recent randomized controlled trial has brought new insights into the use of perineural dexamethasone for managing nerve injury and recovery following surgery. The study, published in Heliyon, suggests that while dexamethasone is commonly used to reduce inflammation, its impact on nerve function recovery may be more complex than previously thought.

“Perineural dexamethasone could hinder nerve function recovery, indicating the need for caution, especially in patients with pre-existing nerve damage or diabetes,” the researchers wrote.

Perineural dexamethasone, a corticosteroid administered near nerves to alleviate inflammation and pain, is often used in surgical settings to enhance recovery and minimize postoperative discomfort. Although many studies have explored how perineural dexamethasone affects nerve block duration, its potential effects on postoperative nerve injury have not been thoroughly investigated. Considering this, Yunke Dai, Department of Anesthesiology, Clinical Medical College and the First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China, and colleagues aimed to clarify the impact of perineural dexamethasone on nerve injury and the recovery of nerve function following surgery.

The study, a prospective randomized double-blinded trial, was conducted at The First Affiliated Hospital of Chengdu Medical College in Chengdu, China, from June 14 to December 30, 2022. It involved patients aged 18 to 80 years, classified as ASA I or II, who were scheduled for elective orthopedic, burn, or plastic surgery. Participants were randomly assigned to receive either perineural dexamethasone (D group) or no dexamethasone (ND group).

The primary outcomes measured were the incidence and recovery of nerve injury, while secondary outcomes included postoperative pain scores, analgesic consumption, and adverse events.

The researchers reported the following findings:

  • Initial postoperative nerve injury rates were similar between groups (D: 30.4 %, ND: 33.3 %).
  • At 12 weeks post-discharge, significantly more patients in the ND group recovered from nerve deficits (78.8 % versus 60.3 %; OR = 2.45).
  • There were no significant differences in postoperative hyperglycemia or surgical site infection rates.

The study revealed that perineural dexamethasone did not increase the initial risk of postoperative nerve injury but seemed to delay recovery from nerve injury symptoms. The researchers suggest weighing the advantages of prolonged analgesia and reduced postoperative nausea against this potential delay. Diabetes and tourniquet use were identified as significant risk factors, necessitating extra caution in these patients.

“These findings underscore the need for careful use of dexamethasone in high-risk individuals. Future research should focus on optimizing dosing, exploring alternative administration methods, and conducting longer-term studies to better understand the impact of dexamethasone on nerve recovery,” the researchers concluded.

Reference:

Zhu, N., Xiang, B., Shi, J., Yang, P., Dai, Y., & Wang, S. (2024). The effect of perineural dexamethasone on nerve injury and recovery of nerve function after surgery: A randomized controlled trial. Heliyon, 10(16), e35612. https://doi.org/10.1016/j.heliyon.2024.e35612

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High-dose and adjuvanted flu vaccines provided better protection for seniors, claims study

High-dose and adjuvanted influenza (flu) vaccines boosted protection against flu symptoms and hospitalization for people 65 years and older during the 2022-2023 flu season compared to the standard flu vaccine. The study Comparative effectiveness of licensed influenza vaccines in preventing influenza-related medical encounters and hospitalizations in the 2022-2023 influenza season among adults ≥65 years of age was published on in Clinical Infectious Diseases.

“Our research showed that there were advantages for older people to receive high-dose or adjuvanted flu vaccines over the standard vaccine,” said Jennifer Ku, PhD, MPH, an infectious disease epidemiologist with the Kaiser Permanente Southern California Department of Research & Evaluation. “While seasonal variation exists, it is expected that seniors will continue to benefit from flu vaccines that are stronger than the traditional standard-dose vaccines.”

Vaccination is the best way to prevent flu and reduce the severity of flu symptoms. Typically, flu vaccines are made by incubating the viruses in chicken eggs. To improve flu vaccine performance and its production, high-dose, adjuvanted, and recombinant vaccines became available. High-dose vaccine is four times higher-dose than regular flu vaccines, while adjuvanted vaccines have an additional ingredient to boost the immune system. Recombinant vaccines are produced using recombinant technology that does not rely on eggs in the manufacturing process; they were not widely administered within Kaiser Permanente in Southern California and so were not included in this study.

In 2022, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) made a recommendation to use high-dose, adjuvanted, or recombinant vaccines over standard dose vaccines for adults aged 65 years and older. Individuals in this age group are at increased risk for severe illness, hospitalization, and death due to flu.

The study included nearly a half-million people aged 65 years and older who received one or more doses of flu vaccine during the 2022-2023 flu season.

• As compared to standard dose flu vaccine, the vaccine effectiveness of high-dose and adjuvanted flu vaccine against hospitalization for flu was estimated as 25% and 62%, respectively.

• As compared to standard dose flu vaccine, the vaccine effectiveness of high-dose and adjuvanted flu vaccine against health care visits for flu was estimated at 9% and 17%, respectively.

“This was the first real-world study to compare high-dose and adjuvanted flu vaccines to the more traditional standard-dose egg-based vaccines after the preferential recommendation was made by ACIP.” said the senior author on the paper, Hung Fu Tseng, PhD, MPH, a senior scientist with the Department of Research & Evaluation. “Our study findings support ACIP’s recommendation to vaccinate seniors with high-dose and adjuvanted flu vaccines.”

Reference:

Jennifer H Ku, Emily Rayens, Lina S Sy, Lei Qian, Bradley K Ackerson, Yi Luo, Julia E Tubert, Gina S Lee, Punam P Modha, Yoonyoung Park, Comparative Effectiveness of Licensed Influenza Vaccines in Preventing Influenza-related Medical Encounters and Hospitalizations in the 2022–2023 Influenza Season Among Adults ≥65 Years of Age, Clinical Infectious Diseases, https://doi.org/10.1093/cid/ciae375.

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Multiple treatment modalities including occlusal devices, sleep hygiene, and muscle relaxation may achieve better control of bruxism: Study

Multiple treatment modalities including occlusal devices, sleep hygiene, and muscle relaxation may achieve better control of bruxism suggests a study published in the Journal of Prosthodontics.

The objective was the comparison of an occlusal device (OD), and sleep hygiene and progressive muscle relaxation (SH & PMR) on perceived stress and sleep bruxism activity (burst/episode and episode/hour) in participants with sleep bruxism. Sixty-six participants with self-reported sleep bruxism were selected and randomly allocated into two groups: OD group or SH & PMR group. Assessment of perceived stress and sleep bruxism activity were the primary outcomes. The Perceived Stress Scale-10 (PSS-10 scale) was used to measure perceived stress and bruxism episodes/hour and bursts/episode recorded by electromyography of masseter and temporalis. These outcomes were assessed at baseline, 1 month, 6 months, and 1 year. The paired t-test assessed changes in PSS-10 scores and sleep bruxism activity within the same group over different time points (baseline, 1 month, 6 months, and 1 year). The unpaired t-test compared scores between two groups (OD and SH & PMR) at each time point to evaluate intervention differences. The chi-square test compared gender distribution between both groups. Results: PSS-10 scores were found to decrease with the OD at 1 month and 6 months compared to baseline and SH & PMR at all subsequent follow-ups. This decrease was not statistically significant (p > 0.05) between the OD and SH & PMR groups at all follow-ups. OD and SH & PMR significantly reduced bruxism episodes/hour and bursts/episode at all follow-ups (p < 0.05). There were no adverse effects related to any intervention. The OD and SH & PMR both effectively reduced PSS-10 scores over 6 months and significantly decreased bruxism episodes and bursts per episode. Both methods are safe and effective for managing sleep bruxism and reducing stress.

Reference:

Tandon A, Singh BP, Shanker R, Agrawal KK, Mahour P, Tripathi SK. Efficacy of occlusal splint versus sleep hygiene and progressive muscle relaxation on perceived stress and sleep bruxism: A randomized clinical trial. J Prosthodont. 2024; 1–8. https://doi.org/10.1111/jopr.13917

Keywords:

Multiple, treatment, modalities, occlusal devices, sleep hygiene, muscle relaxation, achieve, better control, bruxism, study, Tandon A, Singh BP, Shanker R, Agrawal KK, Mahour P, Tripathi SK

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Endoscopic treatment approaches for inflammatory bowel diseases: old friends and new weapons

Inflammatory bowel diseases (IBD), comprising Crohn’s disease (CD) and ulcerative colitis (UC), are chronic inflammatory conditions affecting the gastrointestinal tract. These diseases can lead to various complications, including strictures, fistulas, and abscesses, significantly impacting patients’ quality of life. Endoscopy plays a crucial role in diagnosing IBD, assessing disease activity, and monitoring treatment response. In recent years, advances in operative endoscopy have introduced novel strategies for managing IBD-related complications, particularly strictures and dysplastic lesions. This review summarizes the current endoscopic treatment approaches for IBD, highlighting their advantages and disadvantages.

Inflammatory Bowel Diseases and Their Complications

CD and UC are characterized by inflammation of the gastrointestinal tract, which can lead to irreversible structural damage. CD often presents with strictures, while UC affects gut integrity and increases the risk of colorectal cancer (CRC). Fibrotic strictures in CD and UC pose significant challenges for clinicians and often require surgical intervention. However, modern medical therapies have improved the natural history of IBD, particularly when initiated early.

Endoscopic Treatment Approaches

1. Strictures in IBD

Strictures in IBD are complex and can result from a combination of fibrosis and inflammation. The management of these strictures requires a tailored approach considering factors such as etiology, number, degree, shape, length, location, and associated conditions. Cross-sectional imaging modalities like ultrasound, CT, and MRI are valuable tools for diagnosing strictures and differentiating between fibrotic and inflammatory strictures. Anti-inflammatory medical therapy can reduce wall edema and intestinal wall thickness, while mechanical therapies, including endoscopic balloon dilation (EBD) and surgery, are primarily required for fibrotic strictures.

a. Endoscopic Balloon Dilation (EBD)

EBD is an effective technique for treating CD-related strictures, particularly those localized in the small bowel, ileocolonic, or colonic regions. EBD is best suited for accessible, short, and anastomotic strictures, with through-the-scope balloon catheters preferred due to their safety and ease of use. The dilation process involves inserting a balloon catheter through the stricture and inflating it under X-ray guidance, with the endoscopist determining the appropriate dilation diameter. Retrograde dilation is used for passable strictures, while anterograde dilation with wire-guided balloons is employed for non-passable strictures.

EBD offers short-term symptomatic improvement in the majority of patients, with a significant proportion avoiding surgery for extended periods. However, symptomatic recurrence is common, and the optimal technical details of EBD, such as balloon size and duration of insufflation, remain undefined.

2. Management of Dysplastic Lesions

Dysplastic lesions in IBD patients, which may precede CRC, can be managed endoscopically. Techniques like endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) offer minimally invasive options for resecting dysplastic tissue. These techniques require expertise and careful patient selection, as they can be technically challenging and associated with complications. Nevertheless, they represent important tools in the management of dysplastic lesions in IBD.

Advantages and Disadvantages of Endoscopic Approaches

Advantages:

  • Minimally invasive, reducing surgery-related morbidity and mortality.
  • Preserves bowel anatomy and function.
  • Repeatable and can be performed as needed.
  • Can be used to assess disease activity and progression.

Disadvantages:

  • Technical challenges, particularly with complex strictures and dysplastic lesions.
  • Risk of complications, including bleeding, perforation, and recurrence.
  • Limited long-term data on efficacy and durability of endoscopic treatments.

Conclusions

Endoscopic treatment approaches have emerged as important tools in the management of IBD-related strictures and dysplastic lesions. While these techniques offer minimally invasive options, they also require expertise and careful patient selection. Future research is needed to refine technical details, optimize treatment strategies, and improve long-term outcomes. Endoscopic management of IBD should be approached by a multidisciplinary team involving gastroenterologists, radiologists, and colorectal surgeons, ensuring a patient-tailored approach that balances risks and benefits.

Reference:

Alberto Barchi, Sarah Bencardino, Ernesto Fasulo, Ferdinando D’Amico, Alessandra Zilli, Gionata Fiorino, Tommaso Lorenzo Parigi, Endoscopic Treatment Approaches for Inflammatory Bowel Diseases: Old Friends and New Weapons, Journal of Translational Gastroenterology, doi: 10.14218/JTG.2023.00096.

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Both conventional and minimal nipple-sparing mastectomy equally safe for breast cancer treatment: JAMA

A new study published in the Journal of American Medical Association found that the comparable complication rates of minimum access nipple-sparing mastectomy (M-NSM) and conventional nipple-sparing mastectomy (C-NSM) show that both techniques were equally safe.

Although formerly limited to open procedures, the frequency of nipple-sparing mastectomy (NSM) for breast cancer has been steadily rising with the use of endoscopic and robotic surgical equipment. Studies on postoperative problems and the advantages and disadvantages of minimum access NSM (M-NSM) in comparison to conventional NSM (C-NSM) are, nevertheless, scarce. Joo Heung Kim and colleagues carried out this investigation to look at the variations in postoperative complications between C-NSM and M-NSM.

In this retrospective multicenter cohort analysis, a total of 1583 female patients with breast cancer who were 19 years of age or older and had undergone NSM at 21 Korean university hospitals between January 2018 and December 2020 were enrolled. Patients with inflammatory breast cancer, breast cancer that had spread to the chest wall or skin, metastatic breast cancer, breast cancer with insufficient medical records, and mastectomy without preservation of the nipple-areolar complex (NAC) were excluded. The primary results and measures of this study were 3 months following surgery, postoperative complications, and clinicopathological variables were evaluated. The variables linked to problems were found by statistical studies, such as logistic regression.

A total of 227 people underwent M-NSM and 1356 people underwent C-NSM. Regarding the immediate and long-term postoperative problems, there was no discernible difference between the two groups. After C-NSM, the long-term prevalence of glandular-areolar complex necrosis was higher than that of M-NSM. Following M-NSM, wound infections happened more often. After C-NSM, the postoperative seroma was more common. Areolar or nipple necrosis was much more likely to occur in cases with mild or severe breast ptosis. In contrast, there was a decreased incidence of necrosis when axillary, anterior, or midaxillary incisions were used. When comparing direct-to-implant breast reconstruction to other breast reconstructions, necrosis happened far less frequently.

Overall, the frequency and extent of postoperative problems did not significantly differ between C-NSM and M-NSM, according to this study. Given their comparable rates of complications, C-NSM and M-NSM seem like about as safe of alternatives. As a result, the surgical strategy used should take the preferences and unique requirements of patients into consideration.

Reference:

Kim, J. H., Ryu, J. M., Bae, S. J., Ko, B. S., Choi, J. E., Kim, K. S., Cha, C., Choi, Y. J., Lee, H. Y., Nam, S. E., Kim, Z., Kang, Y.-J., Lee, M. H., Lee, J. E., Park, E., Shin, H. J., Kim, M. K., Choi, H. J., Kwon, S. U., … Kim, J. Y. (2024). Minimal Access vs Conventional Nipple-Sparing Mastectomy. In JAMA Surgery. American Medical Association (AMA). https://doi.org/10.1001/jamasurg.2024.2977

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Hormone therapy for breast cancer linked with lower dementia risk: Study

Hormone modulating therapy (HMT) used for the treatment of breast cancer was associated with a 7% lower risk of developing Alzheimer’s disease and related dementias later in life, according to a new study published in JAMA Network Open.

The study, which is one of the largest of its kind, found that although HMT was linked with protection against the development of dementia overall, the association decreased with age and varied by race.

“Our findings emphasize the importance of being cognizant of individual patient factors when we prescribe medications or develop treatment plans for breast cancer,” said senior author Francesmary Modugno, Ph.D. M.P.H., professor of obstetrics, gynecology and reproductive sciences at the University of Pittsburgh and member of Magee-Womens Research Institute and UPMC Hillman Cancer Center. “It’s not one-size-fits-all. We need to think about each individual patient to optimize outcomes and minimize risks.”

About two-thirds of breast cancer patients have tumors that are hormone receptor positive, meaning that they grow in response to estrogen or progesterone. For these patients, HMT can impede tumor growth by blocking hormones from attaching to these receptors. While use of HMT is linked with increased survival, there is conflicting evidence about whether it increases or decreases the risk of developing Alzheimer’s disease and related dementias (ADRD), debilitating conditions that are characterized by memory loss, changes in mood or behavior, and difficulties with thinking, problem-solving and reasoning.

To improve understanding about the risk of ADRD following HMT in breast cancer patients, Modugno, teamed up with lead author Chao Cai, Ph.D., assistant professor at the University of South Carolina College of Pharmacy. They used a federal database of people aged 65 and older to identify women who were diagnosed with breast cancer between 2007 and 2009 and who did not have a previous ADRD diagnosis or history of using HMT before their breast cancer diagnosis.

Of 18,808 patients who fit the criteria, 66% had received HMT within three years of their diagnosis and 34% had not. During an average of 12 years of follow-up, 24% of HMT users and 28% of non-HMT users developed ADRD.

To calculate the risk of developing ADRD, the researchers accounted for the risk of death associated with increased age and duration of exposure to HMT. They found that while HMT use was associated with an overall decrease in the relative risk of developing ADRD, the protective effect of HMT was most pronounced in patients aged 65 through 69 and diminished with age. Notably, when patients aged over 80, there was an increased risk of ADRD in HMT users.

“Our study suggests that younger women may benefit more from HMT in terms of reduced risk of developing Alzheimer’s disease and other types of dementia,” said Cai. “The benefits of HMT decreased for women aged 75 and older, particularly in those who identified as white. This suggests that the timing of HMT initiation is crucial and treatment plans should be tailored to a patient’s age.”

Black women aged 65 through 74 who used HMT had a 24% reduction in relative risk of developing ADRD, which dropped to 19% after age 75. White women aged 65 through 74 had an 11% reduction in risk of ADRD with HMT use, but this beneficial association disappeared after age 75.

“Black women have higher rates of breast cancer and tend to have higher lifetime stress due to structural racism and other societal factors, which are associated with worse outcomes,” said Modugno. “We don’t know the mechanisms behind the racial disparities we saw with HMT and risk of ADRD, but it’s possible that these factors could contribute. It deserves further investigation.”

“These findings emphasize the importance of being cognizant of individual patient factors when we prescribe medications or develop treatment plans for breast cancer,” Modugno said. “It’s not one-size-fits-all. We need to think about each individual patient to optimize outcomes and minimize risks.”

There are three main types of HMT: selective estrogen receptor modulators, aromatase inhibitors and selective estrogen receptor degraders. The analysis found that risk of developing ADRD varied by HMT type.

According to Cai, estrogen has neuroprotective effects, so these therapies could influence ADRD risk by mimicking estrogen, influencing estrogen production or modulating estrogen receptor levels. HMT might also affect clearance of a protein called beta-amyloid, stability of tau protein and vascular health, all of which are closely linked to brain health and ADRD risk.

“The relationship between HMT for breast cancer and dementia risk is complex and influenced by multiple factors,” explained Cai. “Ongoing research is needed to further understand the mechanisms behind this association and provide clearer guidance on the use of HMT.”

A limitation of the study was that it only included patients over 65. In the future, Cai and Modugno will include younger women who haven’t reached menopause yet to further understand the link between HMT and dementia risk.

Reference:

Cai C, Strickland K, Knudsen S, Tucker SB, Chidrala CS, Modugno F. Alzheimer Disease and Related Dementia Following Hormone-Modulating Therapy in Patients With Breast Cancer. JAMA Netw Open. 2024;7(7):e2422493. doi:10.1001/jamanetworkopen.2024.22493

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