Gestational diabetes not tied to increase risk of breast cancer, reveals large Danish study

Women who develop gestational diabetes are not more likely to go on to be diagnosed with breast cancer, according to a study of almost three-quarters of a million mothers to be presented at this year’s Annual Meeting of the European Association for the Study of Diabetes (EASD) (Madrid, 9-13 September).

Gestational diabetes, a type of diabetes that can develop during pregnancy, affects 14% of pregnant women globally and is becoming more common, with those who are living with obesity, have a family history of diabetes and/or older at greater risk. Race and ethnicity can also affect risk.

It usually goes away after giving birth. However, women who have had it are more likely to develop type 2 diabetes in the years to come. Gestational diabetes is also associated with higher risk of developing cardiovascular disease, metabolic syndrome, chronic kidney disease and mental health conditions, including post-natal depression.

Insulin resistance, where the body’s cells don’t respond properly to insulin and can’t easily take up glucose from blood, causing blood sugar levels to rise, is a key feature of gestational diabetes and has also been linked to breast cancer.

Some studies have found that gestational diabetes is associated with a higher risk of being subsequently diagnosed with breast cancer. But other research has concluded that the risk of breast cancer is lower – or that there is no link at all.

Study leader Maria Hornstrup Christensen, of the Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark, says: “Breast cancer is the most common cancer, as well as the leading cause of cancer deaths in women worldwide. It also has a very high treatment cost compared with other cancer types.

“If we know who is more likely to develop breast cancer, we might be able to detect it earlier when it is easier to treat, reducing deaths and treatment costs and the psychological and physical toll on women.”

To find out more, Dr Christensen and colleagues used birth, patient and other national registers to obtain information on all women who gave birth in Denmark over a 22-year-period.

After those with pre-existing diabetes or breast cancer were excluded, 708,121 women who had given birth between 1997 and 2018 were included in the analysis.

24,140 (3.4%) of the women were diagnosed with gestational diabetes in one or more pregnancy. Median age at pregnancy was 28 years in both those with and without gestational diabetes.

The women were followed for a median of 11.9 years, during which 7,609 were diagnosed with breast cancer.

The women who had gestational diabetes were no more likely to go to develop breast cancer than those without gestational diabetes. This was seen with regard to breast cancer overall, premenopausal breast cancer and postmenopausal breast cancer.

The finding held true when age, parity, ethnicity, income, occupation, education and pre-existing health problems, such as high blood pressure, were taken into account.

Analyses that factored in pre-pregnancy BMI, smoking during pregnancy and obstetric complications, such as pre-eclampsia, also failed to find an association between gestational diabetes and breast cancer.

The authors conclude that the study, one of the largest of its kind, did not find gestational diabetes to be associated with a higher risk of breast cancer.

Dr Christensen, who divides her time between research and working as a midwife who specialises in the care of women with diabetes, says: “It will be reassuring for women who have had gestational diabetes to know that they are not a higher risk of developing breast cancer.

“They do, however, need to be alert to the fact that they are at higher risk of some conditions, including type 2 diabetes.

“And all women, regardless of whether or not they have had gestational diabetes, should be breast aware and check their breasts regularly for changes.”

She adds that the women studied were predominately Caucasian and living in a country with free healthcare and free breast cancer screening and so the findings will not necessarily apply to other populations and healthcare systems.

Reference:

Gestational diabetes does not increase risk of breast cancer, large Danish study finds, Diabetologia, Meeting: Annual Meeting of the European Association for the Study of Diabetes (EASD).

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Eating more fruits & vegetables may lower BP and improve kidney and heart health in hypertension patients: Study

Doctors recommend making fruits and vegetables a foundational part of the treatment of patients with hypertension. Diets high in fruits and vegetables are found to lower blood pressure, reduce cardiovascular risk, and improve kidney health due to their base-producing effects. A new study in The American Journal of Medicine, published by Elsevier, details the findings from a five-year interventional randomized control trial.

Despite ongoing efforts to improve hypertension treatment and reduce its adverse outcomes with pharmacological strategies, hypertension-related chronic kidney disease and its cardiovascular mortality are increasing. Heart disease is the number one reason that patients with chronic kidney disease die.

The Dietary Approaches to Stop Hypertension (DASH) diet that is rich in fruits and vegetables reduces blood pressure and is the recommended first-line treatment for primary hypertension. Nevertheless, this diet is under-prescribed, and when prescribed is under-implemented despite supportive epidemiological data. The DASH diet and others generally high in fruits and vegetables are associated with lower blood pressure, lower risk for and progression of chronic kidney disease, lower cardiovascular disease risk indicators, and lower cardiovascular disease mortality.

Lead investigator of the study Donald E. Wesson, MD, MBA, Department of Internal Medicine, Dell Medical School – The University of Texas at Austin, says, “As a nephrologist (kidney doctor), my acid-base laboratory studies ways by which the kidney removes acid from the blood and puts it into the urine. Our animal studies showed years ago that mechanisms used by kidneys to remove acid from the blood can cause kidney injury if the animals were chronically (long term) exposed to an acid-producing diet. Our patient studies showed similar findings: that is, an acid-producing diet (one high in animal products) was kidney-harmful, and one that is base-producing (one high in fruits and vegetables) is kidney-healthy. Other investigators showed that a diet high in fruits and vegetables is heart-healthy. We hypothesized that one way that fruits and vegetables are both kidney- and heart-healthy is that they reduce the amount of acid in the diet and therefore the amount of acid that kidneys have to remove from the body.”

To test this hypothesis, a study was designed in which participants with hypertension, but not diabetes, and very high levels of urine albumin excretion (macroalbuminuria) were selected. Patients with macroalbuminuria have chronic kidney disease, a high risk for the worsening of their kidney disease with time, and a high risk to subsequently develop cardiovascular diseases. In a randomized control trial over a five-year period, investigators divided the cohort of 153 patients with hypertension into three groups:

• Study participants adding 2-4 cups of base-producing fruits and vegetables in addition to their usual daily food intake

• Study participants prescribed NaHCO3 (acid-reducing sodium bicarbonate, which is common baking soda) tablets in two daily doses of 4-5 650 mg tablets

• Study participants receiving standard medical care from primary care clinicians

The results of the study show that both fruits and vegetables and NaHCO3 improved kidney health, but only fruits and vegetables, and not NaHCO3, reduced blood pressure and improved indices of cardiovascular disease risk.

Co-investigator Maninder Kahlon, PhD, Department of Population Health, Dell Medical School – The University of Texas at Austin, explains, “Importantly, fruits and vegetables achieved the latter two benefits with lower doses of medication used to lower blood pressure and reduce cardiovascular disease risk. This means that one can get the kidney health benefits with either fruits and vegetables or NaHCO3, but we get the blood pressure reduction and reduced cardiovascular disease risk with fruits and vegetables, but not with NaHCO3. This supports our recommendation that fruits and vegetables should be ‘foundational’ treatment for patients with hypertension, because we accomplish all three goals (kidney health, lower blood pressure, and reduced cardiovascular disease risk) with fruits and vegetables, and we can do so with lower medication doses.

The research team emphasizes “foundational” because many clinicians begin hypertension treatment with drugs and then add diet strategies if blood pressure is not properly controlled. The findings from its studies support the opposite: treatment should begin with fruits and vegetables and then add drugs as needed.

Dr. Wesson concludes, “Dietary interventions for chronic disease management are often not recommended and even less often executed because of the many challenges to get patients to implement them. Nevertheless, they are effective, and in this instance, kidney and cardiovascular protective. We must increase our efforts to incorporate them into patient management and more broadly, make healthy diets more accessible to populations at increased risk for kidney and cardiovascular disease.”

The researchers also advise patients with hypertension to ask their clinician to measure a urine albumin-to-creatinine ratio (UACR) to determine if they have underlying kidney disease and an increased risk for subsequent cardiovascular disease.

Reference:

Nimrit Goraya, Nicolaos E. Madias, Jan Simoni, Maninder Kahlon, Nazan Aksan, Donald E. Wesson, Kidney and Cardiovascular Protection Using Dietary Acid Reduction in Primary Hypertension: A Five-Year, Interventional, Randomized, Control Trial, The American Journal of Medicine, https://doi.org/10.1016/j.amjmed.2024.06.006.

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Study Reveals Higher Risks of Severe Maternal and Perinatal Outcomes in Women with Epilepsy

Sweden: A recent multinational study comprising 4 511 267 pregnancies revealed a considerably higher risk of severe maternal and perinatal outcomes and an increased risk of death during pregnancy and postpartum in women with epilepsy.

Maternal epilepsy and the use of antiseizure medication (ASM) during pregnancy were linked to higher rates of maternal health complications as well as increased perinatal mortality and morbidity, the researchers wrote in JAMA Neurology.

Previous studies have shown that maternal epilepsy is associated with negative pregnancy and neonatal outcomes. Gaining a deeper understanding of this condition and its associated risks at delivery could help mitigate these adverse effects. Considering this, Neda Razaz, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden, and colleagues aimed to determine the risk of severe maternal and perinatal morbidity and mortality among women with epilepsy.

For this purpose, the researchers conducted a prospective population-based register study in Denmark, Finland, Iceland, Norway, and Sweden from 1996 to 2017, with data analysis completed between August 2022 and November 2023. The study included all singleton births at 22 weeks gestation or longer, excluding those with missing or invalid birth weight or gestational length data. A total of 4,511,267 deliveries were identified, comprising 4,475,984 births to women without epilepsy and 35,283 to mothers with epilepsy.

The study examined maternal epilepsy diagnoses recorded before childbirth and prenatal exposure to antiseizure medication (ASM), defined as any maternal prescription filled from conception to childbirth. The main outcomes assessed were severe maternal morbidity and mortality during pregnancy or within 42 days postpartum, as well as severe neonatal morbidity (such as neonatal convulsions) and perinatal mortality (including stillbirths and deaths within the first 28 days of life).

The following were the key findings of the study:

  • The mean age at delivery for women in the epilepsy cohort was 29.9 years. The rate of composite severe maternal morbidity and mortality was also higher in women with epilepsy compared with those without epilepsy (36.9 vs 25.4 per 1000 deliveries).
  • Women with epilepsy also had a significantly higher risk of death (0.23 deaths per 1000 deliveries) compared with women without epilepsy (0.05 deaths per 1000 deliveries), with an aOR of 3.86.
  • Maternal epilepsy was associated with increased odds of severe preeclampsia, embolism, disseminated intravascular coagulation or shock, cerebrovascular events, and severe mental health conditions.
  • Fetuses and infants of women with epilepsy were at elevated odds of mortality (aOR, 1.20) and severe neonatal morbidity (aOR, 1.48).
  • In analyses restricted to women with epilepsy, women exposed to ASM compared with those unexposed had higher odds of severe maternal morbidity (aOR,1.24), and their neonates had increased odds of mortality and severe morbidity (aOR, 1.37).

“The findings suggest that, although most women with epilepsy experience uncomplicated pregnancies, there is an urgent need for improved counseling, perinatal support, and access to specialized care to ensure safe deliveries for all women with epilepsy,” the researchers concluded.

Reference:

Razaz N, Igland J, Bjørk M, et al. Risk of Perinatal and Maternal Morbidity and Mortality Among Pregnant Women With Epilepsy. JAMA Neurol. Published online August 05, 2024. doi:10.1001/jamaneurol.2024.2375

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Oil Pulling for Oral Health: To Swish or Not to Swish?

After scrolling social media, you might be tempted to ditch your typical oral care regimen in favor of melted coconut oil, or other similar oils, for a practice known as oil pulling. A method of traditional Ayurvedic medicine native to India, oil pulling involves swishing oil in your mouth for about 10-15 minutes before spitting it out, and proponents of the process have touted various oral health benefits.

Y. Natalie Jeong, professor and chair of the Department of Periodontology at Tufts University School of Dental Medicine, explains the claims and what really needs to be done to take care of your teeth and gums.

Are there benefits to oil pulling for oral health?

Supporters of oil pulling believe it cleanses the mouth naturally without chemicals, enhancing dental hygiene. Additionally, some claims suggest it detoxifies the body, improves skin health, and alleviates symptoms of migraines and allergies.

Is there evidence to support these benefits?

Currently, there is no robust scientific evidence to confirm that oil pulling effectively reduces cavities, whitens teeth, or improves overall oral health. This doesn’t necessarily mean it is ineffective; rather, it indicates that its efficacy has not been scientifically established through sufficient, well-designed research. Challenges such as small sample sizes, lack of control groups, and uncontrolled variables contribute to this lack of definitive evidence. Consequently, the American Dental Association does not endorse oil pulling as a dental hygiene practice.

While oil pulling might help remove loose debris around the gums and teeth through its swishing action, it is less effective than brushing and flossing. Once a biofilm or plaque has formed, oil pulling is no more effective than rinsing with water, as it cannot disrupt plaque like mechanical methods such as brushing or flossing can

Can oil pulling be harmful to your oral health?

Oil pulling is generally considered safe and unlikely to cause harm directly. However, there is a risk if individuals become overly reliant on its perceived benefits and neglect established oral hygiene practices, such as brushing, flossing, and avoiding smoking. Completely substituting traditional dental care with oil pulling can pose significant risks to oral health. Additionally, accidentally swallowing large amounts of oil during the process could lead to digestive issues like an upset stomach or diarrhea.

What do you tell your patients about oil pulling?

I generally do not recommend oil pulling as there is no solid scientific evidence supporting its effectiveness. There are other, more effective methods proven to enhance oral health, such as:

Brushing your teeth: Brushing after meals helps remove food debris and plaque trapped between your teeth and gums. Remember to brush your tongue as well, as bacteria can thrive there.

Flossing: Flossing at least once a day helps remove food particles and plaque from between the teeth and along the gum line where your toothbrush can’t reach.

While I wouldn’t discourage those who want to from using oil pulling as a pre-brushing rinse, it’s important to follow it with brushing and flossing. Adding oil pulling to your routine is unlikely to cause harm, but it should not be expected to provide significant benefits.

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Insufficient evidence to recommend low-dose CT screening in never smokers lung cancer screening, finds research

Lung cancer remains the leading cause of cancer-related deaths worldwide. Detecting this disease in its early stages significantly improves survival rates, making low-dose CT screening an essential component in the fight against lung cancer. Recent studies, particularly from Asia, have sparked a debate on whether these screening benefits extend to non-smokers and those with minimal smoking histories.

However, according to an article published in the Journal of Thoracic Oncology, there is currently insufficient evidence to support lung cancer screening for those who never smoked with or without a family history of lung cancer. JTO is the official journal of the International Association for the Study of Lung Cancer.

The article “Screening Low-Risk Individuals for Lung Cancer: The Need May Be Present, but the Evidence of Benefit Is Not,” is written by a group of lung cancer researchers and public health professionals led by Gerard A. Silvestri, MD, MS, the Hillenbrand Professor of Thoracic Oncology at the Medical University of South Carolina, Charleston, S.C.

Silvestri and his colleagues note that The Early Detection Program for Lung Cancer in Taiwan revealed that the cancer detection rate for those screened with low-radiation dose computed tomography was more than twofold higher in light- or never-smokers with a family history of lung cancer compared with high-risk persons with more than 30 pack-years exposure and meeting U.S. Preventative Services Task Force criteria. In addition, more than 90% of the cancers detected in those with a family history were in early stage. On the basis of those findings, the Taiwan researchers concluded that screening first-degree relatives of those with a family history of lung cancer, irrespective of smoking history, would lead to a decrease in lung cancer mortality.

However, Silvestri writes: “…the findings in this cohort and others like it represent substantial over-diagnosis and that the harms associated with screening a population that has a low likelihood of developing lethal cancers have not been thoroughly considered.”

According to the article, over-diagnosis can lead to unnecessary treatments and procedures, posing risks to individuals who might never have developed life-threatening cancer. False positives are also a significant concern, resulting in anxiety, additional tests, and invasive procedures.

“Ultimately, we believe that there is a need to more discriminately identify those low-risk individuals who may develop a lethal lung cancer as opposed to an indolent one. What cannot currently be advocated for is screening a population where the risk of harm to the many could outweigh the risk of benefit to the few,” according to the article.

“We need to carefully weigh the potential benefits against the risks of harm in these populations,” Dr. Silvestri stated. “Extending screening without robust evidence could lead to more harm than good.”

Given these complexities, the article’s authors advocate for more rigorous research, including randomized controlled trials, which have never been performed in those who have never smoked with or without a family history of lung cancer, to better understand the benefits and harms of screening in this group. Furthermore, no randomized trials for this population have ever been undertaken in Asia where it appears that the biology of lung cancer is different than that observed in western societies.

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Alzheimer’s Diagnosis Improved with Highly Accurate Blood Biomarkers: JAMA

Sweden: A study published in JAMA revealed that blood biomarkers for amyloid beta (Aβ) and tau protein are highly effective in diagnosing Alzheimer’s disease (AD) in patients with cognitive symptoms seen in primary and secondary care settings.

The APS2 blood test demonstrated high diagnostic accuracy for identifying Alzheimer’s disease in individuals with cognitive symptoms in primary and secondary care settings, outperforming traditional clinical evaluations that do not utilize Alzheimer’s disease biomarkers, the study stated. 

Dementia specialists achieved a diagnostic accuracy of 73% for clinical Alzheimer’s disease, compared to 91% when using the APS2 test. Primary care physicians had a diagnostic accuracy of 61% without the APS2, which improved to 91% with its use, the researchers reported. 

One in five women and one in ten men develop dementia due to Alzheimer’s disease. Individuals with cognitive symptoms are initially seen in primary care, with only a few being referred to secondary care. In specialized clinics, symptomatic Alzheimer’s disease is misdiagnosed in 25% to 35% of patients, with the likelihood of higher misdiagnosis rates in primary care. Diagnostic tests, often only available at specialized clinics, such as positron emission tomography (PET) or cerebrospinal fluid analysis to assess Alzheimer’s disease biomarkers, help reduce the rate of misdiagnosis.

Sebastian Palmqvist, MD, PhD et. al. aimed to evaluate an accessible Alzheimer’s disease blood test in both primary and secondary care settings using predefined biomarker cutoff values.

For the study, 1,213 patients undergoing clinical evaluation for cognitive symptoms were examined between February 2020 and January 2024 in Sweden. The biomarker cutoff values, established in an independent cohort, were applied to a primary care cohort (n = 307) and a secondary care cohort (n = 300); each patient had one plasma sample analyzed in a single batch per cohort. The blood test was then prospectively evaluated in the primary care cohort (n = 208) and the secondary care cohort (n = 398); one plasma sample per patient was sent for analysis within two weeks of collection.

The key findings of the research are as follows:

  • Cognitive conditions among the patients included 23% with subjective cognitive decline, 44% with mild cognitive impairment, and 33% with dementia.
  • Alzheimer’s disease pathology was found in 50% of patients in both primary and secondary care assessments.
  • In the primary care cohort, 307 patients were initially assessed, and 208 were evaluated prospectively; in the secondary care cohort, 300 were initially assessed, and 398 were evaluated prospectively.
  • When plasma samples were analyzed in a single batch for the primary care cohort, the AUC was 0.97, with a PPV of 91% and an NPV of 92%; in the secondary care cohort, the AUC was 0.96, with a PPV of 88% and an NPV of 87%.
  • In the prospective analysis (biweekly) of the primary care cohort, the AUC was 0.96, with a PPV of 88% and an NPV of 90%; in the secondary care cohort, the AUC was 0.97, with a PPV of 91% and an NPV of 91%.
  • Diagnostic accuracy across all cohorts ranged from 88% to 92%.
  • Primary care physicians had a diagnostic accuracy of 61% using standard clinical methods versus 91% using the APS2.
  • Dementia specialists had a diagnostic accuracy of 73% using standard clinical methods versus 91% using the APS2.
  • Overall, the diagnostic accuracy using APS2 (90%) was comparable to using the percentage of p-tau217 alone (90%).

The researchers concluded that both the APS2 and the percentage of p-tau217 alone exhibited high diagnostic accuracy for identifying Alzheimer’s disease in individuals with cognitive symptoms in both primary and secondary care settings using predefined cutoff values.

Reference:

Palmqvist S, Tideman P, Mattsson-Carlgren N, et al. Blood Biomarkers to Detect Alzheimer Disease in Primary Care and Secondary Care. JAMA. Published online July 28, 2024. doi:10.1001/jama.2024.13855

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Preoperative Iron Infusions Work Better Than Blood Transfusions for Some Anemic Patients, suggests study

In a rigorous medical records study covering tens of thousands of patients, Johns Hopkins Medicine researchers conclude that some patients with preoperative anemia have better outcomes if they get iron infusions before surgery rather than standard red blood cell transfusions.

The findings, published in Anesthesia & Analgesia, contribute to mounting evidence that such iron infusions, which boost the production of a person’s own red blood cells, are better than relying on someone else’s blood.

“Anemia is incredibly common, especially in surgical patients, and until recently the default treatment has been blood transfusions prior to the procedure,” says Steven Frank, M.D., professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine. “However, our retrospective study showed a benefit of iron infusions over preoperative blood transfusions in decreasing morbidity and mortality, increasing hemoglobin and decreasing the need for blood transfusions.”

Iron is a mineral that the human body needs to make hemoglobin, a protein in red blood cells that carries oxygen to organs throughout the body. If there is insufficient iron in a patient’s blood, the person becomes anemic, meaning there are not enough healthy red blood cells to deliver enough oxygen. This is particularly concerning for patients undergoing surgery because there is almost always some amount of blood loss during any procedure.

While blood transfusions work, they also carry risks, including blood clots, hospital-acquired infections, allergic reactions and pulmonary complications. It can be difficult to find a donor match if a patient has certain antibodies or a condition such as sickle cell disease. As a result, physicians have long sought strategies to minimize the use of transfusions.

In the new study, the Johns Hopkins Medicine research team used data from the TriNetX Research Network database, a global network of health care organizations that pool de-identified patient information. The team’s analysis used such information gathered between 2003 and 2023 on 154,358 patients over 18 years old with a diagnosis of iron-deficient anemia prior to surgery.

The data were sorted into groups of patients who were treated with iron preoperatively but not with a blood transfusion, and patients who received a preoperative blood transfusion but no iron infusion. These infusions happened several weeks before a scheduled surgical procedure. Researchers then compared postoperative complication rates including respiratory problems, kidney issues, blood clots, infections and death rates.

From this review, researchers found a 37% reduction in mortality and a 24% reduction in morbidity (complications) in patients who were treated with iron infusions compared with those treated with blood transfusions. This finding means that patients receiving iron infusions may recover more quickly and fully from their surgical procedures without any added complications that may arise from a blood transfusion.

“The Joint Commission and the American Medical Association named blood transfusion as the No. 1 overused procedure in 2012. For perspective, also on the list was antibiotic use to treat the common cold,” says Frank. “Research shows reducing blood transfusions can improve patient outcomes, and providing patients with preoperative iron infusions is an easy way to do so.”

The researchers say they hope the new study will encourage more widespread use of preoperative iron infusions in surgical patients. They also hope to examine if oral iron supplements garner the same outcomes as infusions.

Treating preoperative anemia is one of several methods used in a comprehensive patient blood management program. Such a program, like the one at Johns Hopkins, can save blood and money while resulting in the same or better patient outcomes. In another recent publication, the researchers reported a substantial return on investment for their blood management program. They found that for every dollar spent to support the program, 7.5 dollars were saved or generated in return.

Simple things, like keeping patients warm and maintaining a lower blood pressure during surgery, or giving medications such as tranexamic acid, can reduce bleeding. “In addition to treating preoperative anemia,” Frank says, “keeping the blood in the patient during surgery is one of the primary goals in any patient blood management program.” Such programs, by reducing unnecessary transfusions, promote high-value practice by improving outcomes and reducing costs.

Reference:

Choi, Una E. BA*; Nicholson, Ryan C. BS*; Thomas, Ananda J. BA*; Crowe, Elizabeth P. MD, PhD†; Ulatowski, John A. MD, PhD, MBA*; Resar, Linda M.S. MD‡; Hensley, Nadia B. MD*; Frank, Steven M. MD*. A Propensity-Matched Cohort Study of Intravenous Iron versus Red Cell Transfusions for Preoperative Iron-Deficiency Anemia. Anesthesia & Analgesia ():10.1213/ANE.0000000000006974, July 22, 2024. | DOI: 10.1213/ANE.0000000000006974.

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Amyloid probability score 2 blood test helps identify Alzheimer disease: JAMA

A new study by Sebastian Palmqvist and team showed that when used in conjunction with established cutoff values, the amyloid probability score 2 (APS2) and proportion of p-tau217 demonstrated good diagnostic accuracy for diagnosing Alzheimer disease (AD) in patients expressing cognitive symptoms in primary and secondary care. The findings of this study were published in the Journal of American Medical Association.

Due to Alzheimer’s disease, 1 in 5 women and 1 in 10 males have dementia. The majority of people with cognitive symptoms are referred to tertiary care after initially being examined in primary care. Between 25% and 35% of individuals receiving treatment at specialist clinics and probably even more people receiving general care receive a false diagnosis of symptomatic Alzheimer’s disease. For the treatment of people with early symptomatic Alzheimer disease, two anti-amyloid immunotherapies have been licensed, and further medicines are probably in the works. To diagnose Alzheimer’s disease, primary care doctors do not have access to easily obtainable biomarker tools and so this study prospectively assessed a clinically accessible AD blood test in primary and secondary care using the predetermined biomarker cutoff values.

From February 2020 to January 2024, 1213 individuals in Sweden had clinical examinations for cognitive problems. The biomarker cutoff values were determined in an independent cohort and matched to a primary care cohort and a secondary care cohort. The plasma sample of each patient was tested prospectively in a separate batch for each cohort. Each patient provided one plasma sample for examination within two weeks after collection. The main result was AD pathology and AD in clinical terms was the secondary endpoint. The calculations were made to determine the diagnostic accuracy, area under the curve (AUC), negative predictive value (NPV) and positive predictive value (PPV).

In both primary and secondary care, the APS2 demonstrated a high degree of diagnostic accuracy (range, 88%-92%) in identifying Alzheimer disease pathology. When employing the APS2, primary care doctors had a diagnosis accuracy of 61% vs. 91%, whereas dementia experts detected clinical Alzheimer disease with a diagnostic accuracy of 73% vs. 91%. Overall, using predetermined threshold values, the APS2 and proportion of p-tau217 alone demonstrated a good diagnostic accuracy for detecting Alzheimer disease in persons with cognitive symptoms in primary and secondary care settings.

Reference:

Palmqvist, S., Tideman, P., Mattsson-Carlgren, N., Schindler, S. E., Smith, R., Ossenkoppele, R., Calling, S., West, T., Monane, M., Verghese, P. B., Braunstein, J. B., Blennow, K., Janelidze, S., Stomrud, E., Salvadó, G., & Hansson, O. (2024). Blood Biomarkers to Detect Alzheimer Disease in Primary Care and Secondary Care. In JAMA. American Medical Association (AMA). https://doi.org/10.1001/jama.2024.13855

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Vitamin D supplementation might effectively reduce symptoms of dry eye disease, suggests study

A new study published in the recent issue of Contact Lens and Anterior Eye journal found that supplementing with vitamin D (VD) may be a useful adjuvant therapy to reduce the symptoms and indicators of dry eye.

DED is a prevalent ocular illness that affects 5 to 50% of people globally, according to estimates. Common ocular discomfort symptoms in DED include dryness, redness, a feeling of a foreign body, heaviness, light sensitivity, pain, discharge, itching, and eye strain. Also, the vitamin that has immunomodulatory and anti-inflammatory properties is vitamin D which was demonstrated by numerous studies to have a correlation between VD insufficiency and both the incidence and severity of dry eye disease (DED). In this meta-analysis, Zeying Chen and colleagues examined the symptoms and indicators of DED patients both before and after using VD supplements.

The effectiveness of VD supplement in patients with DED published up to January 2023 was searched using four clinical trials registry websites (ISRCTN, ICTRP, CT, GCP, ICH) and ten databases (Cochrane, PubMed, Web of science, Embase, Ovid, CNKI, Scopus, CSTJ, SinomedWanfang). There were 8 investigations in all, comprising a total of 439 patients. In order to determine standard mean differences (SMD) for the Schirmer’s test (SH test), corneal fluorescein staining scores (CFSS, Oxford Scale, 0–5), tear film break-up time (TBUT), ocular surface disease index (OSDI), lid hyperemia, and visual analogue pain scale (VAS), two reviewers independently evaluated the quality of the literature and extracted data.

The key finding of this study was that VD supplementation was found to be effective in reducing lid hyperemia (SMD −0.71, 95% CI −1.09, −0.32, p = 0.000), OSDI (SMD −1.10, 95% CI −1.45, −0.74, p = 0.000), and tear production (SMD 1.43, 95% CI 0.81, 2.05, p = 0.000) as well as tear film stability (SMD 1.19, 95% CI 0.83, 1.55, p = 0.000).

Overall, this meta-analysis suggests that VD supplementation is an effective way to reduce several of the symptoms of DED, including lid hyperemia, TBUT, and SH test. Additionally, the subjective DED symptom score, OSDI, improved. The subgroup analysis revealed that the oral version significantly improved when compared to the buccal spray and intramuscular injection.

Reference:

Chen, Z., Zhang, C., Jiang, J., Ouyang, J., Zhang, D., Chen, T., Chu, Y., & Hu, K. (2024). The efficacy of vitamin D supplementation in dry eye disease: A systematic review and meta-analysis. In Contact Lens and Anterior Eye (p. 102169). Elsevier BV. https://doi.org/10.1016/j.clae.2024.102169

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Individuals with osteoarthritis commonly prescribed NSAIDs despite having contraindications: Study

Osteoarthritis affects 600 million people worldwide, making it a leading cause of disability. With no disease-modifying treatments available or on the horizon, oral non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used treatments to relieve OA pain and are recommended by the majority of clinical practice guidelines. However, NSAIDs are not risk-free and are associated with more emergency hospital admissions than any other class of medicine due to their widespread use. The risk of adverse events further increases among older adults and those with comorbidities.

A new study from Boston University Chobanian & Avedisian School of Medicine, has

found that people with newly diagnosed OA (knee or hip) with contraindications to or precautions for NSAIDs use continue to be prescribed these drugs. Additionally they had higher use of opioids and slightly lower physical therapy (PT) use within the first year of OA diagnosis, both of which are not consistent with treatment guidelines for OA.

“We found individuals with contraindications to NSAIDs were still commonly prescribed them, placing them at risk for NSAID-related adverse events,” explains corresponding author Tuhina Neogi, MD, PhD, the Alan S. Cohen Professor of Rheumatology and professor of medicine at the school. “Additionally, they were not more likely to receive safer alternatives like PT despite its widespread recommendation as first-line intervention.”

The researchers used population-based register data to identify adults residing in Sweden (between 2004-13) without a previous knee or hip OA diagnosis. Among this group, between 2014-18, they identified people with knee or hip OA diagnosis and presence of contraindications to or precautions for oral NSAIDs at the time of OA diagnosis. They then estimated the risk of: 1) regular oral NSAID use; 2) regular opioid use; 3) PT during the first year after diagnosis among those with versus without contraindications or precautions.

Despite having contraindications to NSAIDs, 21% of those in the study were regular users of NSAIDs within the first year of their OA diagnosis. Similarly, 21% of those with precautions for using NSAIDs were also regular users. They also found a higher proportion of persons with contraindications were regular users of opioids than those without a contraindication or precaution, while a slightly lower proportion received PT.

According to the researchers, the lower use of PT use is particularly concerning given that PT and exercise are considered first-line therapy for knee and hip OA by many professional societies. “While PT use within the first year was relatively high in this cohort, likely reflecting the Swedish healthcare system (in which PT is a covered service with minor co-pay from the patient), it is concerning that in a system in which PT services are available and covered that those with NSAID contraindications are still less likely to undergo a PT visit,” added Neogi, who also is chief of rheumatology at Boston Medical Center.

Neogi stresses that more options for effective and safe management of OA symptoms are urgently needed, and greater work is required in narrowing and ultimately closing the evidence-knowledge-practice gap.

Reference:

Tuhina Neogi, Andrea Dell’isola, Martin Englund, Aleksandra Turkiewicz, Frequent Use of Prescription NSAIDs among People with Knee or Hip Osteoarthritis Despite Contraindications to or Precautions with NSAIDs, Osteoarthritis and Cartilage, https://doi.org/10.1016/j.joca.2024.07.010.

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