News

TOPLINE:

In patients with pulmonary oligometastases from colorectal cancer (CRC), both stereotactic body radiotherapy (SBRT) and surgery led to similar overall survival rates at 5 years. However, those who received surgery had significantly better progression-free and disease-free survival rates, as well as a longer time to intrathoracic progression.
 

METHODOLOGY:

• SBRT has been shown to provide effective local control and improve short-term survival for patients with pulmonary oligometastases from CRC and has become an alternative for these patients who are ineligible or reluctant to undergo surgery. It’s unclear, however, whether SBRT should be prioritized over surgery in patients with CRC pulmonary metastases, largely because of a lack of prospective data.
• In the current analysis, researchers compared outcomes among 335 patients (median age, 61 years) with lung metastases from CRC who underwent surgery or SBRT, using data from the Peking University Cancer Hospital and Institute between March 2011 and September 2022.
• A total of 251 patients were included in the final analysis after propensity score matching, 173 (68.9%) underwent surgery and 78 (31.1%) received SBRT. The median follow-up was 61.6 months in the surgery group and 54.4 months in the SBRT group.
• The study outcomes were freedom from intrathoracic progression, progression-free survival, and overall survival.

TAKEAWAY:

• At 5 years, rates of freedom from intrathoracic progression were more than twofold higher in the surgery group than in the SBRT group (53% vs 23.4%; hazard ratio [HR], 0.46; P < .001). Progression-free survival rates were also more than twofold higher in the surgery group vs the SBRT group (43.8% vs 18.5%; HR, 0.47; P < .001), respectively. In the SBRT group, a higher percentage of patients had a disease-free interval of less than 12 months compared with the surgery group, with rates of 48.7% and 32.9%, respectively (P = 0.025). 
• Overall survival, however, was not significantly different between the two groups at 5 years (72.5% in the surgery group vs 63.7% in the SBRT group; P = .260). The number of pulmonary metastases (HR, 1.87; 95% CI, 1.11-3.14, P = .019 and tumor size (HR, 1.03; 95% CI, 1.00-1.05, P = .023) were significant prognostic factors for overall survival.
• Local recurrence was more prevalent after SBRT (33.3%) than surgery (16.9%), while new intrathoracic tumors occurred more frequently after surgery than SBRT (71.8% vs 43.1%). Repeated local treatments were common among patients with intrathoracic progression, which might have contributed to favorable survival outcomes in both groups.
• Both treatments were well-tolerated with no treatment-related mortality or grade ≥ 3 toxicities. In the surgery group, 14 patients experienced complications, including atrial fibrillation (n = 4) and prolonged air leaks (n = 7). In the SBRT group, radiation pneumonitis was the most common adverse event (n = 21).

IN PRACTICE:

SBRT yielded overall survival benefits similar to surgery despite a “higher likelihood of prior extrapulmonary metastases, a shorter disease-free interval, and a greater number of metastatic lesions,” the authors wrote. Still, SBRT should be regarded as an “effective alternative in cases in which surgical intervention is either unviable or declined by the patient,” the authors concluded.
 

SOURCE:

The study was co-led by Yaqi Wang and Xin Dong, Peking University Cancer Hospital & Institute, Beijing, China, and was published online in the International Journal of Radiation Oncology, Biology, Physics.
 

LIMITATIONS:

This single-center retrospective study had an inherent selection bias. The lack of balanced sample sizes of the surgery and SBRT groups might have affected the robustness of the statistical analyses. Detailed data on adverse events were not available.
 

DISCLOSURES:

The study was supported by grants from the National Natural Science Foundation of China, Beijing Natural Science Foundation, and Beijing Municipal Administration of Hospital’s Ascent Plan. The authors did not declare any conflicts of interest.

This article was created 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.

TOPLINE:

In patients with pulmonary oligometastases from colorectal cancer (CRC), both stereotactic body radiotherapy (SBRT) and surgery led to similar overall survival rates at 5 years. However, those who received surgery had significantly better progression-free and disease-free survival rates, as well as a longer time to intrathoracic progression.
 

METHODOLOGY:

• SBRT has been shown to provide effective local control and improve short-term survival for patients with pulmonary oligometastases from CRC and has become an alternative for these patients who are ineligible or reluctant to undergo surgery. It’s unclear, however, whether SBRT should be prioritized over surgery in patients with CRC pulmonary metastases, largely because of a lack of prospective data.
• In the current analysis, researchers compared outcomes among 335 patients (median age, 61 years) with lung metastases from CRC who underwent surgery or SBRT, using data from the Peking University Cancer Hospital and Institute between March 2011 and September 2022.
• A total of 251 patients were included in the final analysis after propensity score matching, 173 (68.9%) underwent surgery and 78 (31.1%) received SBRT. The median follow-up was 61.6 months in the surgery group and 54.4 months in the SBRT group.
• The study outcomes were freedom from intrathoracic progression, progression-free survival, and overall survival.

TAKEAWAY:

• At 5 years, rates of freedom from intrathoracic progression were more than twofold higher in the surgery group than in the SBRT group (53% vs 23.4%; hazard ratio [HR], 0.46; P < .001). Progression-free survival rates were also more than twofold higher in the surgery group vs the SBRT group (43.8% vs 18.5%; HR, 0.47; P < .001), respectively. In the SBRT group, a higher percentage of patients had a disease-free interval of less than 12 months compared with the surgery group, with rates of 48.7% and 32.9%, respectively (P = 0.025). 
• Overall survival, however, was not significantly different between the two groups at 5 years (72.5% in the surgery group vs 63.7% in the SBRT group; P = .260). The number of pulmonary metastases (HR, 1.87; 95% CI, 1.11-3.14, P = .019 and tumor size (HR, 1.03; 95% CI, 1.00-1.05, P = .023) were significant prognostic factors for overall survival.
• Local recurrence was more prevalent after SBRT (33.3%) than surgery (16.9%), while new intrathoracic tumors occurred more frequently after surgery than SBRT (71.8% vs 43.1%). Repeated local treatments were common among patients with intrathoracic progression, which might have contributed to favorable survival outcomes in both groups.
• Both treatments were well-tolerated with no treatment-related mortality or grade ≥ 3 toxicities. In the surgery group, 14 patients experienced complications, including atrial fibrillation (n = 4) and prolonged air leaks (n = 7). In the SBRT group, radiation pneumonitis was the most common adverse event (n = 21).

IN PRACTICE:

SBRT yielded overall survival benefits similar to surgery despite a “higher likelihood of prior extrapulmonary metastases, a shorter disease-free interval, and a greater number of metastatic lesions,” the authors wrote. Still, SBRT should be regarded as an “effective alternative in cases in which surgical intervention is either unviable or declined by the patient,” the authors concluded.
 

SOURCE:

The study was co-led by Yaqi Wang and Xin Dong, Peking University Cancer Hospital & Institute, Beijing, China, and was published online in the International Journal of Radiation Oncology, Biology, Physics.
 

LIMITATIONS:

This single-center retrospective study had an inherent selection bias. The lack of balanced sample sizes of the surgery and SBRT groups might have affected the robustness of the statistical analyses. Detailed data on adverse events were not available.
 

DISCLOSURES:

The study was supported by grants from the National Natural Science Foundation of China, Beijing Natural Science Foundation, and Beijing Municipal Administration of Hospital’s Ascent Plan. The authors did not declare any conflicts of interest.

This article was created 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.

TOPLINE:

In patients with pulmonary oligometastases from colorectal cancer (CRC), both stereotactic body radiotherapy (SBRT) and surgery led to similar overall survival rates at 5 years. However, those who received surgery had significantly better progression-free and disease-free survival rates, as well as a longer time to intrathoracic progression.
 

METHODOLOGY:

• SBRT has been shown to provide effective local control and improve short-term survival for patients with pulmonary oligometastases from CRC and has become an alternative for these patients who are ineligible or reluctant to undergo surgery. It’s unclear, however, whether SBRT should be prioritized over surgery in patients with CRC pulmonary metastases, largely because of a lack of prospective data.
• In the current analysis, researchers compared outcomes among 335 patients (median age, 61 years) with lung metastases from CRC who underwent surgery or SBRT, using data from the Peking University Cancer Hospital and Institute between March 2011 and September 2022.
• A total of 251 patients were included in the final analysis after propensity score matching, 173 (68.9%) underwent surgery and 78 (31.1%) received SBRT. The median follow-up was 61.6 months in the surgery group and 54.4 months in the SBRT group.
• The study outcomes were freedom from intrathoracic progression, progression-free survival, and overall survival.

TAKEAWAY:

• At 5 years, rates of freedom from intrathoracic progression were more than twofold higher in the surgery group than in the SBRT group (53% vs 23.4%; hazard ratio [HR], 0.46; P < .001). Progression-free survival rates were also more than twofold higher in the surgery group vs the SBRT group (43.8% vs 18.5%; HR, 0.47; P < .001), respectively. In the SBRT group, a higher percentage of patients had a disease-free interval of less than 12 months compared with the surgery group, with rates of 48.7% and 32.9%, respectively (P = 0.025). 
• Overall survival, however, was not significantly different between the two groups at 5 years (72.5% in the surgery group vs 63.7% in the SBRT group; P = .260). The number of pulmonary metastases (HR, 1.87; 95% CI, 1.11-3.14, P = .019 and tumor size (HR, 1.03; 95% CI, 1.00-1.05, P = .023) were significant prognostic factors for overall survival.
• Local recurrence was more prevalent after SBRT (33.3%) than surgery (16.9%), while new intrathoracic tumors occurred more frequently after surgery than SBRT (71.8% vs 43.1%). Repeated local treatments were common among patients with intrathoracic progression, which might have contributed to favorable survival outcomes in both groups.
• Both treatments were well-tolerated with no treatment-related mortality or grade ≥ 3 toxicities. In the surgery group, 14 patients experienced complications, including atrial fibrillation (n = 4) and prolonged air leaks (n = 7). In the SBRT group, radiation pneumonitis was the most common adverse event (n = 21).

IN PRACTICE:

SBRT yielded overall survival benefits similar to surgery despite a “higher likelihood of prior extrapulmonary metastases, a shorter disease-free interval, and a greater number of metastatic lesions,” the authors wrote. Still, SBRT should be regarded as an “effective alternative in cases in which surgical intervention is either unviable or declined by the patient,” the authors concluded.
 

SOURCE:

The study was co-led by Yaqi Wang and Xin Dong, Peking University Cancer Hospital & Institute, Beijing, China, and was published online in the International Journal of Radiation Oncology, Biology, Physics.
 

LIMITATIONS:

This single-center retrospective study had an inherent selection bias. The lack of balanced sample sizes of the surgery and SBRT groups might have affected the robustness of the statistical analyses. Detailed data on adverse events were not available.
 

DISCLOSURES:

The study was supported by grants from the National Natural Science Foundation of China, Beijing Natural Science Foundation, and Beijing Municipal Administration of Hospital’s Ascent Plan. The authors did not declare any conflicts of interest.

This article was created 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.

This transcript has been edited for clarity. 

Akshay B. Jain, MD: I’m Dr. Akshay Jain, an endocrinologist from Vancouver, and I’m joined by Dr. James Kim, a primary care physician from Calgary, Canada. 

Both Dr. Kim and I attended ADA 2024. We went over all our learnings and decided that there was a whole heap of clinical pearls that we learned from the conference. We thought it would be awesome if we could share our learnings with all of you, both from a primary care lens and from an endocrinology perspective.

One study Dr. Kim and I learned about, and we think has some definite nuances in management of people living with diabetes, regards inhaled insulin. When we have patients in our clinic who have perhaps failed multiple oral agents or have very high blood sugars, we obviously want to consider starting them on insulin for type 2 diabetes.

Sometimes there is a significant barrier, which is related to the needles. There’s an actual term for this: trypanophobia — a fear of needles. For the longest time, people have not wanted to take insulin or injectables because there’s only one way of administering it, which is subcutaneous.

Enter now inhaled insulin. We saw studies at the ADA 2024 conference that looked at a new inhaled insulin called Afrezza. Afrezza essentially is a short-acting insulin, so it’s kind of like a prandial insulin derivative, where it can be inhaled by an individual and it will work for mealtime control of blood sugars.

Dr. Kim, in your practice, how often do you see people not wanting to take shots, and has this been a big barrier for you in starting insulin? 

James W. Kim, MBBCh, PgDip, MScCH: Thank you for having me. To answer your question, absolutely I encounter this on a weekly basis — and I’m not even an endocrinologist. I just have an interest in diabetes. There are a number of patients that I think will benefit massively with insulin but they’re needle-phobic. You taught me that word, but I can never pronounce it, so my apologies for not remembering that phobia. I’m just going to call it needle phobia because I’m a simple-minded person.

The needle phobia is massive. I think there’s a definite fear of the needle, but there’s also a fear of failure. As soon as an injection is mentioned, many patients feel they failed miserably. There’s an emotional roller coaster that happens.

I’m sure, Dr. Jain, you have seen many patients, especially from Asia, who would say: “Oh, my auntie got on insulin and 3 months later, she got a kidney transplant.” “My uncle started on insulin and he unfortunately passed away a couple of months later.” Unfortunately, they’re blaming many of those things on insulin.

I also have a number of patients who said they were on insulin before many years ago, and they experienced some severe hypoglycemic events, and they don’t want to get on the insulin ever again. This is unfortunate because you know that if those patients, those aunties and uncles, were on insulin long before, maybe we could have saved their legs and kidneys, and potentially death.

Now we have advanced so much with insulin that hypoglycemia does occur, but much less than before. We still have many barriers when it comes to insulin initiations. Therefore, having this idea of inhaled insulin is fantastic, and I think we can get many more patients on insulin — the medication they actually need.

Dr. Jain: Absolutely. From the studies on inhaled insulin at ADA 2024, the key thing I found very interesting, regarding the pharmacokinetics of the insulin, was that it’s working very quickly. It starts working within minutes of administering it.

Additionally, it lasts in the body only for a shorter duration of time, compared with other injectable short-acting insulins, so it lasts in the body. The active insulin time is roughly about 2 hours or so, based on the studies, which in my mind opens up a whole world of possibilities because it means that people can take another correctional insulin if the blood sugars are still high after taking their first inhaled dose. You can take another dose subsequently without worrying about stacking of insulin. 

Many of us are familiar with this term, which is if you take two shots of short-acting insulin too close to each other, the insulin doses might add up and there can be a big drop in the blood sugars; it’s called stacking of insulin. This can be potentially avoided. 

Similarly, if you take your dinnertime inhaled insulin and the sugars are still high around bedtime, you could take a smaller dose of the inhaled insulin and not worry about middle-of-the-night hypoglycemia because the effect of the insulin would be only for a little while.

That’s one key learning that I found very helpful. The other important thing that I found was that this is not for everyone, so there are some restrictions. Essentially, the contraindication is that people who have asthma or COPD cannot be prescribed an inhaled insulin.

What are your thoughts, Dr. Kim, based on this for your practice in primary care? 

Dr. Kim: It is very fascinating, for sure. I cannot wait to get hold of this insulin. I can already think of some patients who may benefit. You’ve mentioned the asthma and COPD patients, and that makes more sense because there is an actual airway problem.

I also wonder what will happen to patients who have restrictive airway disease, where asthma and COPD fall under obstructive airway disease. What if they have obesity, where it’s really pressing into the diaphragm, and where they may not be able to take the deep breath in? How will they react?

What about someone who’s got a cold, someone who has postnasal drip, or someone who tends to cough frequently? What about egg allergies? There are many question marks around this insulin before initiating these medications. There is excitement, but there are also many questions at the same time.

Dr. Jain: I think these are very important, practical considerations that we’ll uncover as we start using more of this in clinical practice. The other important thing to note is that the presenters told us it’s important to monitor pulmonary function tests. It’s important to get a baseline pulmonary function test, and then we have to do another one in 6 months, followed by annually thereafter.

If, at any point of time, the FEV1 drops by 20% or more, then that would be an indication for discontinuation of the inhaled insulin. The pulmonary function test does not need to be one of those fancier ones. The study group would just do office spirometries. I’m wondering, Dr. Kim, in primary care, do you think this could potentially be a rate-limiting factor?

Dr. Kim: In Alberta, where I reside, no. Spirometry is very easily accessible in the province. For example, in Calgary alone, we have a population of about 1.3 million people. We have over 13 or 15 companies that can do this spirometry. We can get these things done literally within a week or 2.

However, I am aware that, in other provinces in Canada, it can definitely be a huge rate-limiting factor. Not everyone has the office-based spirometry, and definitely not within the primary care office. It has to be referred out to these private companies, most likely, and some of the rural areas will have to rely on the provincial hospitals, where the access can be even more challenging. 

On the day of the actual spirometry, if the person has a cough or is not feeling well, it’s going to be a problem because you don’t want the spirometry to be infected with a whole bunch of viruses. You’ll have to cancel that and it can be a bit of an issue.

Dr. Jain: Many of our viewers are from the United States and other parts of the world, and spirometry is quite easily accessible in most places. As an endocrinologist, I must confess that it’s been a long time since I’ve even ordered a spirometry or any clinical form of pulmonary function test. Once I start using the inhaled insulin, I’ll need to start brushing up on my pulmonary function test knowledge. 

I think these are exciting times. At least we’ve got something to offer to people who would have otherwise not taken any insulin at all. There’s certainly that hope that now there’s a different way to administer this, and hopefully it can only get better from here on.
 

Dr. Jain is a clinical instructor, Department of Endocrinology, University of British Columbia, Vancouver. Dr. Kim is a clinical assistant professor, Department of Family Medicine, University of Calgary in Alberta. Both disclosed conflicts of interest with numerous pharmaceutical companies.

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

This transcript has been edited for clarity. 

Akshay B. Jain, MD: I’m Dr. Akshay Jain, an endocrinologist from Vancouver, and I’m joined by Dr. James Kim, a primary care physician from Calgary, Canada. 

Both Dr. Kim and I attended ADA 2024. We went over all our learnings and decided that there was a whole heap of clinical pearls that we learned from the conference. We thought it would be awesome if we could share our learnings with all of you, both from a primary care lens and from an endocrinology perspective.

One study Dr. Kim and I learned about, and we think has some definite nuances in management of people living with diabetes, regards inhaled insulin. When we have patients in our clinic who have perhaps failed multiple oral agents or have very high blood sugars, we obviously want to consider starting them on insulin for type 2 diabetes.

Sometimes there is a significant barrier, which is related to the needles. There’s an actual term for this: trypanophobia — a fear of needles. For the longest time, people have not wanted to take insulin or injectables because there’s only one way of administering it, which is subcutaneous.

Enter now inhaled insulin. We saw studies at the ADA 2024 conference that looked at a new inhaled insulin called Afrezza. Afrezza essentially is a short-acting insulin, so it’s kind of like a prandial insulin derivative, where it can be inhaled by an individual and it will work for mealtime control of blood sugars.

Dr. Kim, in your practice, how often do you see people not wanting to take shots, and has this been a big barrier for you in starting insulin? 

James W. Kim, MBBCh, PgDip, MScCH: Thank you for having me. To answer your question, absolutely I encounter this on a weekly basis — and I’m not even an endocrinologist. I just have an interest in diabetes. There are a number of patients that I think will benefit massively with insulin but they’re needle-phobic. You taught me that word, but I can never pronounce it, so my apologies for not remembering that phobia. I’m just going to call it needle phobia because I’m a simple-minded person.

The needle phobia is massive. I think there’s a definite fear of the needle, but there’s also a fear of failure. As soon as an injection is mentioned, many patients feel they failed miserably. There’s an emotional roller coaster that happens.

I’m sure, Dr. Jain, you have seen many patients, especially from Asia, who would say: “Oh, my auntie got on insulin and 3 months later, she got a kidney transplant.” “My uncle started on insulin and he unfortunately passed away a couple of months later.” Unfortunately, they’re blaming many of those things on insulin.

I also have a number of patients who said they were on insulin before many years ago, and they experienced some severe hypoglycemic events, and they don’t want to get on the insulin ever again. This is unfortunate because you know that if those patients, those aunties and uncles, were on insulin long before, maybe we could have saved their legs and kidneys, and potentially death.

Now we have advanced so much with insulin that hypoglycemia does occur, but much less than before. We still have many barriers when it comes to insulin initiations. Therefore, having this idea of inhaled insulin is fantastic, and I think we can get many more patients on insulin — the medication they actually need.

Dr. Jain: Absolutely. From the studies on inhaled insulin at ADA 2024, the key thing I found very interesting, regarding the pharmacokinetics of the insulin, was that it’s working very quickly. It starts working within minutes of administering it.

Additionally, it lasts in the body only for a shorter duration of time, compared with other injectable short-acting insulins, so it lasts in the body. The active insulin time is roughly about 2 hours or so, based on the studies, which in my mind opens up a whole world of possibilities because it means that people can take another correctional insulin if the blood sugars are still high after taking their first inhaled dose. You can take another dose subsequently without worrying about stacking of insulin. 

Many of us are familiar with this term, which is if you take two shots of short-acting insulin too close to each other, the insulin doses might add up and there can be a big drop in the blood sugars; it’s called stacking of insulin. This can be potentially avoided. 

Similarly, if you take your dinnertime inhaled insulin and the sugars are still high around bedtime, you could take a smaller dose of the inhaled insulin and not worry about middle-of-the-night hypoglycemia because the effect of the insulin would be only for a little while.

That’s one key learning that I found very helpful. The other important thing that I found was that this is not for everyone, so there are some restrictions. Essentially, the contraindication is that people who have asthma or COPD cannot be prescribed an inhaled insulin.

What are your thoughts, Dr. Kim, based on this for your practice in primary care? 

Dr. Kim: It is very fascinating, for sure. I cannot wait to get hold of this insulin. I can already think of some patients who may benefit. You’ve mentioned the asthma and COPD patients, and that makes more sense because there is an actual airway problem.

I also wonder what will happen to patients who have restrictive airway disease, where asthma and COPD fall under obstructive airway disease. What if they have obesity, where it’s really pressing into the diaphragm, and where they may not be able to take the deep breath in? How will they react?

What about someone who’s got a cold, someone who has postnasal drip, or someone who tends to cough frequently? What about egg allergies? There are many question marks around this insulin before initiating these medications. There is excitement, but there are also many questions at the same time.

Dr. Jain: I think these are very important, practical considerations that we’ll uncover as we start using more of this in clinical practice. The other important thing to note is that the presenters told us it’s important to monitor pulmonary function tests. It’s important to get a baseline pulmonary function test, and then we have to do another one in 6 months, followed by annually thereafter.

If, at any point of time, the FEV1 drops by 20% or more, then that would be an indication for discontinuation of the inhaled insulin. The pulmonary function test does not need to be one of those fancier ones. The study group would just do office spirometries. I’m wondering, Dr. Kim, in primary care, do you think this could potentially be a rate-limiting factor?

Dr. Kim: In Alberta, where I reside, no. Spirometry is very easily accessible in the province. For example, in Calgary alone, we have a population of about 1.3 million people. We have over 13 or 15 companies that can do this spirometry. We can get these things done literally within a week or 2.

However, I am aware that, in other provinces in Canada, it can definitely be a huge rate-limiting factor. Not everyone has the office-based spirometry, and definitely not within the primary care office. It has to be referred out to these private companies, most likely, and some of the rural areas will have to rely on the provincial hospitals, where the access can be even more challenging. 

On the day of the actual spirometry, if the person has a cough or is not feeling well, it’s going to be a problem because you don’t want the spirometry to be infected with a whole bunch of viruses. You’ll have to cancel that and it can be a bit of an issue.

Dr. Jain: Many of our viewers are from the United States and other parts of the world, and spirometry is quite easily accessible in most places. As an endocrinologist, I must confess that it’s been a long time since I’ve even ordered a spirometry or any clinical form of pulmonary function test. Once I start using the inhaled insulin, I’ll need to start brushing up on my pulmonary function test knowledge. 

I think these are exciting times. At least we’ve got something to offer to people who would have otherwise not taken any insulin at all. There’s certainly that hope that now there’s a different way to administer this, and hopefully it can only get better from here on.
 

Dr. Jain is a clinical instructor, Department of Endocrinology, University of British Columbia, Vancouver. Dr. Kim is a clinical assistant professor, Department of Family Medicine, University of Calgary in Alberta. Both disclosed conflicts of interest with numerous pharmaceutical companies.

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

This transcript has been edited for clarity. 

Akshay B. Jain, MD: I’m Dr. Akshay Jain, an endocrinologist from Vancouver, and I’m joined by Dr. James Kim, a primary care physician from Calgary, Canada. 

Both Dr. Kim and I attended ADA 2024. We went over all our learnings and decided that there was a whole heap of clinical pearls that we learned from the conference. We thought it would be awesome if we could share our learnings with all of you, both from a primary care lens and from an endocrinology perspective.

One study Dr. Kim and I learned about, and we think has some definite nuances in management of people living with diabetes, regards inhaled insulin. When we have patients in our clinic who have perhaps failed multiple oral agents or have very high blood sugars, we obviously want to consider starting them on insulin for type 2 diabetes.

Sometimes there is a significant barrier, which is related to the needles. There’s an actual term for this: trypanophobia — a fear of needles. For the longest time, people have not wanted to take insulin or injectables because there’s only one way of administering it, which is subcutaneous.

Enter now inhaled insulin. We saw studies at the ADA 2024 conference that looked at a new inhaled insulin called Afrezza. Afrezza essentially is a short-acting insulin, so it’s kind of like a prandial insulin derivative, where it can be inhaled by an individual and it will work for mealtime control of blood sugars.

Dr. Kim, in your practice, how often do you see people not wanting to take shots, and has this been a big barrier for you in starting insulin? 

James W. Kim, MBBCh, PgDip, MScCH: Thank you for having me. To answer your question, absolutely I encounter this on a weekly basis — and I’m not even an endocrinologist. I just have an interest in diabetes. There are a number of patients that I think will benefit massively with insulin but they’re needle-phobic. You taught me that word, but I can never pronounce it, so my apologies for not remembering that phobia. I’m just going to call it needle phobia because I’m a simple-minded person.

The needle phobia is massive. I think there’s a definite fear of the needle, but there’s also a fear of failure. As soon as an injection is mentioned, many patients feel they failed miserably. There’s an emotional roller coaster that happens.

I’m sure, Dr. Jain, you have seen many patients, especially from Asia, who would say: “Oh, my auntie got on insulin and 3 months later, she got a kidney transplant.” “My uncle started on insulin and he unfortunately passed away a couple of months later.” Unfortunately, they’re blaming many of those things on insulin.

I also have a number of patients who said they were on insulin before many years ago, and they experienced some severe hypoglycemic events, and they don’t want to get on the insulin ever again. This is unfortunate because you know that if those patients, those aunties and uncles, were on insulin long before, maybe we could have saved their legs and kidneys, and potentially death.

Now we have advanced so much with insulin that hypoglycemia does occur, but much less than before. We still have many barriers when it comes to insulin initiations. Therefore, having this idea of inhaled insulin is fantastic, and I think we can get many more patients on insulin — the medication they actually need.

Dr. Jain: Absolutely. From the studies on inhaled insulin at ADA 2024, the key thing I found very interesting, regarding the pharmacokinetics of the insulin, was that it’s working very quickly. It starts working within minutes of administering it.

Additionally, it lasts in the body only for a shorter duration of time, compared with other injectable short-acting insulins, so it lasts in the body. The active insulin time is roughly about 2 hours or so, based on the studies, which in my mind opens up a whole world of possibilities because it means that people can take another correctional insulin if the blood sugars are still high after taking their first inhaled dose. You can take another dose subsequently without worrying about stacking of insulin. 

Many of us are familiar with this term, which is if you take two shots of short-acting insulin too close to each other, the insulin doses might add up and there can be a big drop in the blood sugars; it’s called stacking of insulin. This can be potentially avoided. 

Similarly, if you take your dinnertime inhaled insulin and the sugars are still high around bedtime, you could take a smaller dose of the inhaled insulin and not worry about middle-of-the-night hypoglycemia because the effect of the insulin would be only for a little while.

That’s one key learning that I found very helpful. The other important thing that I found was that this is not for everyone, so there are some restrictions. Essentially, the contraindication is that people who have asthma or COPD cannot be prescribed an inhaled insulin.

What are your thoughts, Dr. Kim, based on this for your practice in primary care? 

Dr. Kim: It is very fascinating, for sure. I cannot wait to get hold of this insulin. I can already think of some patients who may benefit. You’ve mentioned the asthma and COPD patients, and that makes more sense because there is an actual airway problem.

I also wonder what will happen to patients who have restrictive airway disease, where asthma and COPD fall under obstructive airway disease. What if they have obesity, where it’s really pressing into the diaphragm, and where they may not be able to take the deep breath in? How will they react?

What about someone who’s got a cold, someone who has postnasal drip, or someone who tends to cough frequently? What about egg allergies? There are many question marks around this insulin before initiating these medications. There is excitement, but there are also many questions at the same time.

Dr. Jain: I think these are very important, practical considerations that we’ll uncover as we start using more of this in clinical practice. The other important thing to note is that the presenters told us it’s important to monitor pulmonary function tests. It’s important to get a baseline pulmonary function test, and then we have to do another one in 6 months, followed by annually thereafter.

If, at any point of time, the FEV1 drops by 20% or more, then that would be an indication for discontinuation of the inhaled insulin. The pulmonary function test does not need to be one of those fancier ones. The study group would just do office spirometries. I’m wondering, Dr. Kim, in primary care, do you think this could potentially be a rate-limiting factor?

Dr. Kim: In Alberta, where I reside, no. Spirometry is very easily accessible in the province. For example, in Calgary alone, we have a population of about 1.3 million people. We have over 13 or 15 companies that can do this spirometry. We can get these things done literally within a week or 2.

However, I am aware that, in other provinces in Canada, it can definitely be a huge rate-limiting factor. Not everyone has the office-based spirometry, and definitely not within the primary care office. It has to be referred out to these private companies, most likely, and some of the rural areas will have to rely on the provincial hospitals, where the access can be even more challenging. 

On the day of the actual spirometry, if the person has a cough or is not feeling well, it’s going to be a problem because you don’t want the spirometry to be infected with a whole bunch of viruses. You’ll have to cancel that and it can be a bit of an issue.

Dr. Jain: Many of our viewers are from the United States and other parts of the world, and spirometry is quite easily accessible in most places. As an endocrinologist, I must confess that it’s been a long time since I’ve even ordered a spirometry or any clinical form of pulmonary function test. Once I start using the inhaled insulin, I’ll need to start brushing up on my pulmonary function test knowledge. 

I think these are exciting times. At least we’ve got something to offer to people who would have otherwise not taken any insulin at all. There’s certainly that hope that now there’s a different way to administer this, and hopefully it can only get better from here on.
 

Dr. Jain is a clinical instructor, Department of Endocrinology, University of British Columbia, Vancouver. Dr. Kim is a clinical assistant professor, Department of Family Medicine, University of Calgary in Alberta. Both disclosed conflicts of interest with numerous pharmaceutical companies.

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

This transcript has been edited for clarity.

In my job, I spend 99% of my time thinking about ethical issues that arise in the care of human beings. That is the focus of our medical school, and that’s what we do. 

However, there are behaviors that are emerging with respect to pets that bear on human health and require the attention of doctors and nurses who deal with people who are pet owners.

Recently, there has been a great increase in the number of pet owners who are saying, “I’m not going to vaccinate my pets.” As horrible as this sounds, what’s happening is vaccine hesitancy about vaccines used in humans is extending through some people to their pets. 

The number of people who say they don’t trust things like rabies vaccine to be effective or safe for their pet animals is 40%, at least in surveys, and the American Veterinary Medical Association reports that 15%-18% of pet owners are not, in fact, vaccinating their pets against rabies.

Rabies, as I hope everybody knows, is one horrible disease. Even the treatment of it, should you get bitten by a rabid animal, is no fun, expensive, and hopefully something that can be administered quickly. It’s not always the case. Worldwide, at least 70,000 people die from rabies every year.

Obviously, there are many countries that are so terrified of rabies, they won’t let you bring pets in without quarantining them, say, England, for at least 6 months to a year, I believe, because they don’t want rabies getting into their country. They’re very strict about the movement of pets.

It is inexcusable for people, first, not to give their pets vaccines that prevent them getting distemper, parvovirus, or many other diseases that harm the pet. It’s also inexcusable to shorten your pet’s life or ask your patients to care for pets who get sick from many of these diseases that are vaccine preventable.

Worst of all, it’s inexcusable for any pet owner not to give a rabies vaccine to their pets. Were it up to me, I’d say you have to license your pet, and as part of that, you must mandate rabies vaccines for your dogs, cats, and other pets. 

We know what happens when people encounter wild animals like raccoons and rabbits. It is not a good situation. Your pets can easily encounter a rabid animal and then put themselves in a position where they can harm their human owners. 

We have an efficacious, safe treatment. If you’re dealing with someone, it might make sense to ask them, “Do you own a pet? Are you vaccinating?” It may not be something you’d ever thought about, but what we don’t need is rabies back in a bigger way in the United States than it’s been in the past.

I think, as a matter of prudence and public health, maybe firing up that question, “Got a pet in the house and are you vaccinating,” could be part of taking a good history.

 

Dr. Caplan is director of the division of medical ethics at New York University Langone Medical Center, New York City. He disclosed conflicts of interest with Johnson & Johnson and Medscape.

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

This transcript has been edited for clarity.

In my job, I spend 99% of my time thinking about ethical issues that arise in the care of human beings. That is the focus of our medical school, and that’s what we do. 

However, there are behaviors that are emerging with respect to pets that bear on human health and require the attention of doctors and nurses who deal with people who are pet owners.

Recently, there has been a great increase in the number of pet owners who are saying, “I’m not going to vaccinate my pets.” As horrible as this sounds, what’s happening is vaccine hesitancy about vaccines used in humans is extending through some people to their pets. 

The number of people who say they don’t trust things like rabies vaccine to be effective or safe for their pet animals is 40%, at least in surveys, and the American Veterinary Medical Association reports that 15%-18% of pet owners are not, in fact, vaccinating their pets against rabies.

Rabies, as I hope everybody knows, is one horrible disease. Even the treatment of it, should you get bitten by a rabid animal, is no fun, expensive, and hopefully something that can be administered quickly. It’s not always the case. Worldwide, at least 70,000 people die from rabies every year.

Obviously, there are many countries that are so terrified of rabies, they won’t let you bring pets in without quarantining them, say, England, for at least 6 months to a year, I believe, because they don’t want rabies getting into their country. They’re very strict about the movement of pets.

It is inexcusable for people, first, not to give their pets vaccines that prevent them getting distemper, parvovirus, or many other diseases that harm the pet. It’s also inexcusable to shorten your pet’s life or ask your patients to care for pets who get sick from many of these diseases that are vaccine preventable.

Worst of all, it’s inexcusable for any pet owner not to give a rabies vaccine to their pets. Were it up to me, I’d say you have to license your pet, and as part of that, you must mandate rabies vaccines for your dogs, cats, and other pets. 

We know what happens when people encounter wild animals like raccoons and rabbits. It is not a good situation. Your pets can easily encounter a rabid animal and then put themselves in a position where they can harm their human owners. 

We have an efficacious, safe treatment. If you’re dealing with someone, it might make sense to ask them, “Do you own a pet? Are you vaccinating?” It may not be something you’d ever thought about, but what we don’t need is rabies back in a bigger way in the United States than it’s been in the past.

I think, as a matter of prudence and public health, maybe firing up that question, “Got a pet in the house and are you vaccinating,” could be part of taking a good history.

 

Dr. Caplan is director of the division of medical ethics at New York University Langone Medical Center, New York City. He disclosed conflicts of interest with Johnson & Johnson and Medscape.

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

This transcript has been edited for clarity.

In my job, I spend 99% of my time thinking about ethical issues that arise in the care of human beings. That is the focus of our medical school, and that’s what we do. 

However, there are behaviors that are emerging with respect to pets that bear on human health and require the attention of doctors and nurses who deal with people who are pet owners.

Recently, there has been a great increase in the number of pet owners who are saying, “I’m not going to vaccinate my pets.” As horrible as this sounds, what’s happening is vaccine hesitancy about vaccines used in humans is extending through some people to their pets. 

The number of people who say they don’t trust things like rabies vaccine to be effective or safe for their pet animals is 40%, at least in surveys, and the American Veterinary Medical Association reports that 15%-18% of pet owners are not, in fact, vaccinating their pets against rabies.

Rabies, as I hope everybody knows, is one horrible disease. Even the treatment of it, should you get bitten by a rabid animal, is no fun, expensive, and hopefully something that can be administered quickly. It’s not always the case. Worldwide, at least 70,000 people die from rabies every year.

Obviously, there are many countries that are so terrified of rabies, they won’t let you bring pets in without quarantining them, say, England, for at least 6 months to a year, I believe, because they don’t want rabies getting into their country. They’re very strict about the movement of pets.

It is inexcusable for people, first, not to give their pets vaccines that prevent them getting distemper, parvovirus, or many other diseases that harm the pet. It’s also inexcusable to shorten your pet’s life or ask your patients to care for pets who get sick from many of these diseases that are vaccine preventable.

Worst of all, it’s inexcusable for any pet owner not to give a rabies vaccine to their pets. Were it up to me, I’d say you have to license your pet, and as part of that, you must mandate rabies vaccines for your dogs, cats, and other pets. 

We know what happens when people encounter wild animals like raccoons and rabbits. It is not a good situation. Your pets can easily encounter a rabid animal and then put themselves in a position where they can harm their human owners. 

We have an efficacious, safe treatment. If you’re dealing with someone, it might make sense to ask them, “Do you own a pet? Are you vaccinating?” It may not be something you’d ever thought about, but what we don’t need is rabies back in a bigger way in the United States than it’s been in the past.

I think, as a matter of prudence and public health, maybe firing up that question, “Got a pet in the house and are you vaccinating,” could be part of taking a good history.

 

Dr. Caplan is director of the division of medical ethics at New York University Langone Medical Center, New York City. He disclosed conflicts of interest with Johnson & Johnson and Medscape.

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

TOPLINE:

When starting a regular exercise program, the skeletal muscle of sedentary men and women with overweight and obesity differs in burning sugar and fatty acids, but regular training can lessen these differences and promote similar positive metabolic changes in both biological sexes.

METHODOLOGY:

• By stimulating skeletal muscle, exercise can help prevent muscle loss associated with weight loss and improve insulin sensitivity and glucose control in type 2 diabetes, but biological sex-based differences have been reported for many measures.
• This study of sedentary men and women evaluated the molecular differences in skeletal muscle in response to a training program.
• Researchers collected muscle biopsies from 16 women and nine men with overweight or obesity (average age, 30 years) at three time points — baseline, after the first exercise session, and after the last session at the end of training.
• Training involved 1 hour of moderate to intense endurance exercise under supervision (30 minutes cycling on an ergometer and 30 minutes walking on a treadmill) thrice a week for 8 weeks.
• The biopsies were profiled for patterns of three sets of omics data — DNA methylation for insight into genes switched on and off (epigenomics), RNA molecules transcribed from genes (transcriptomics), and proteins (proteomics).

TAKEAWAY:

• At baseline, sex-specific differences were observed most tellingly in 120 proteins and also in DNA methylation sites of 16,012 genes and in 1366 RNA transcripts.
• Men displayed a higher abundance of glycolysis-related proteins and other fast-twitch fiber–type proteins, which are involved in the processing of glucose, while women showed more proteins responsible for regulating fatty acid metabolism.
• The response to the first exercise session differed between men and women, with the cellular stress response upregulated predominantly in men.
• The 8-week exercise training mitigated these sex-specific differences in the skeletal muscle, leading to an upregulation of mitochondrial proteins responsible for substrate oxidation and ATP generation in both men and women.

IN PRACTICE:

“This is important because the increased capacity after exercise to use glucose and lipids for energy production is generally regarded as key to prevent type 2 diabetes,” study leader Professor Cora Weigert from the University of Tübingen, Germany, said in a news release from the meeting organizers. “While initial response of skeletal muscles to exercise differs between females and males, repeated exercise appears to cancel out these differences and trigger beneficial metabolic changes in both sexes,” she added.

SOURCE:

The study was led by Simon I. Dreher, PhD, Institute for Clinical Chemistry and Pathobiochemistry, Department for Diagnostic Laboratory Medicine, Tübingen, Germany. It was published on August 15, 2024, as an early release from the annual meeting of the European Association for the Study of Diabetes 2024, Madrid, September 9-13.

LIMITATIONS:

This abstract did not discuss any limitations.

DISCLOSURES:

The authors did not disclose any funding information. The authors declared no relevant conflicts of interest.

This article was created 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.

TOPLINE:

When starting a regular exercise program, the skeletal muscle of sedentary men and women with overweight and obesity differs in burning sugar and fatty acids, but regular training can lessen these differences and promote similar positive metabolic changes in both biological sexes.

METHODOLOGY:

• By stimulating skeletal muscle, exercise can help prevent muscle loss associated with weight loss and improve insulin sensitivity and glucose control in type 2 diabetes, but biological sex-based differences have been reported for many measures.
• This study of sedentary men and women evaluated the molecular differences in skeletal muscle in response to a training program.
• Researchers collected muscle biopsies from 16 women and nine men with overweight or obesity (average age, 30 years) at three time points — baseline, after the first exercise session, and after the last session at the end of training.
• Training involved 1 hour of moderate to intense endurance exercise under supervision (30 minutes cycling on an ergometer and 30 minutes walking on a treadmill) thrice a week for 8 weeks.
• The biopsies were profiled for patterns of three sets of omics data — DNA methylation for insight into genes switched on and off (epigenomics), RNA molecules transcribed from genes (transcriptomics), and proteins (proteomics).

TAKEAWAY:

• At baseline, sex-specific differences were observed most tellingly in 120 proteins and also in DNA methylation sites of 16,012 genes and in 1366 RNA transcripts.
• Men displayed a higher abundance of glycolysis-related proteins and other fast-twitch fiber–type proteins, which are involved in the processing of glucose, while women showed more proteins responsible for regulating fatty acid metabolism.
• The response to the first exercise session differed between men and women, with the cellular stress response upregulated predominantly in men.
• The 8-week exercise training mitigated these sex-specific differences in the skeletal muscle, leading to an upregulation of mitochondrial proteins responsible for substrate oxidation and ATP generation in both men and women.

IN PRACTICE:

“This is important because the increased capacity after exercise to use glucose and lipids for energy production is generally regarded as key to prevent type 2 diabetes,” study leader Professor Cora Weigert from the University of Tübingen, Germany, said in a news release from the meeting organizers. “While initial response of skeletal muscles to exercise differs between females and males, repeated exercise appears to cancel out these differences and trigger beneficial metabolic changes in both sexes,” she added.

SOURCE:

The study was led by Simon I. Dreher, PhD, Institute for Clinical Chemistry and Pathobiochemistry, Department for Diagnostic Laboratory Medicine, Tübingen, Germany. It was published on August 15, 2024, as an early release from the annual meeting of the European Association for the Study of Diabetes 2024, Madrid, September 9-13.

LIMITATIONS:

This abstract did not discuss any limitations.

DISCLOSURES:

The authors did not disclose any funding information. The authors declared no relevant conflicts of interest.

This article was created 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.

TOPLINE:

When starting a regular exercise program, the skeletal muscle of sedentary men and women with overweight and obesity differs in burning sugar and fatty acids, but regular training can lessen these differences and promote similar positive metabolic changes in both biological sexes.

METHODOLOGY:

• By stimulating skeletal muscle, exercise can help prevent muscle loss associated with weight loss and improve insulin sensitivity and glucose control in type 2 diabetes, but biological sex-based differences have been reported for many measures.
• This study of sedentary men and women evaluated the molecular differences in skeletal muscle in response to a training program.
• Researchers collected muscle biopsies from 16 women and nine men with overweight or obesity (average age, 30 years) at three time points — baseline, after the first exercise session, and after the last session at the end of training.
• Training involved 1 hour of moderate to intense endurance exercise under supervision (30 minutes cycling on an ergometer and 30 minutes walking on a treadmill) thrice a week for 8 weeks.
• The biopsies were profiled for patterns of three sets of omics data — DNA methylation for insight into genes switched on and off (epigenomics), RNA molecules transcribed from genes (transcriptomics), and proteins (proteomics).

TAKEAWAY:

• At baseline, sex-specific differences were observed most tellingly in 120 proteins and also in DNA methylation sites of 16,012 genes and in 1366 RNA transcripts.
• Men displayed a higher abundance of glycolysis-related proteins and other fast-twitch fiber–type proteins, which are involved in the processing of glucose, while women showed more proteins responsible for regulating fatty acid metabolism.
• The response to the first exercise session differed between men and women, with the cellular stress response upregulated predominantly in men.
• The 8-week exercise training mitigated these sex-specific differences in the skeletal muscle, leading to an upregulation of mitochondrial proteins responsible for substrate oxidation and ATP generation in both men and women.

IN PRACTICE:

“This is important because the increased capacity after exercise to use glucose and lipids for energy production is generally regarded as key to prevent type 2 diabetes,” study leader Professor Cora Weigert from the University of Tübingen, Germany, said in a news release from the meeting organizers. “While initial response of skeletal muscles to exercise differs between females and males, repeated exercise appears to cancel out these differences and trigger beneficial metabolic changes in both sexes,” she added.

SOURCE:

The study was led by Simon I. Dreher, PhD, Institute for Clinical Chemistry and Pathobiochemistry, Department for Diagnostic Laboratory Medicine, Tübingen, Germany. It was published on August 15, 2024, as an early release from the annual meeting of the European Association for the Study of Diabetes 2024, Madrid, September 9-13.

LIMITATIONS:

This abstract did not discuss any limitations.

DISCLOSURES:

The authors did not disclose any funding information. The authors declared no relevant conflicts of interest.

This article was created 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.

TOPLINE:

High-dose psilocybin is associated with greater relief from depressive symptoms than placebo or escitalopram, with no increased risk for severe adverse events, a new meta-analysis suggests.
 

METHODOLOGY:

• Researchers conducted a network meta-analysis to evaluate the comparative effectiveness of oral monotherapy with psychedelics versus escitalopram in patients with clinically diagnosed depression.
• The meta-analysis included 811 participants (mean age, 42.49 years; 54.2% women) with clinically diagnosed depression across 15 psychedelic trials and 1968 participants (mean age, 39.35 years; 62.5% women) across five escitalopram trials.
• Trials evaluated oral monotherapy with psychedelics (psilocybin, lysergic acid diethylamide, 3,4-methylenedioxymethamphetamine [MDMA], and ayahuasca), fixed-dose escitalopram (up to 20 mg/d) versus placebo, and psychedelic versus escitalopram monotherapy.
• The primary outcome was a change in depressive symptoms from baseline.

TAKEAWAY:

• Placebo responses in antidepressant trials (mean difference, 3.79; 95% CI, 0.77-6.80) and extremely low-dose psilocybin (mean difference, 3.96; 95% CI, 0.61-7.17) were better than those in psychedelic trials.
• High-dose psilocybin (20 mg or more) performed better than placebo in the antidepressant trials (mean difference, > 3). However, when comparing high-dose psilocybin with the placebo used in antidepressant trials, the effect size was smaller. The standardized mean difference dropped from 0.88 to 0.31, indicating that the effect of high-dose psilocybin was similar to that of current antidepressants.
• High-dose psilocybin was associated with a greater response than escitalopram at 10 mg (4.66; 95% CI, 1.36-7.74) and 20 mg (4.69; 95% CI, 1.64-7.54).
• No interventions were associated with an increased risk for all-cause discontinuation or severe adverse events.

IN PRACTICE:

“Taken together, our study findings suggest that among psychedelic treatments, high-dose psilocybin is more likely to reach the minimal important difference for depressive symptoms in studies with adequate blinding design, while the effect size of psilocybin was similar to that of current antidepressant drugs, showing a mean standardized mean difference of 0.3,” the authors wrote.

SOURCE:

The study was led by Tien-Wei Hsu, MD, I-Shou University and Kaohsiung Medical University, Kaohsiung City, Taiwan. It was published online in The BMJ. 

LIMITATIONS:

The study did not assess long-term effects of the interventions. Participants in the MDMA trials were primarily diagnosed with posttraumatic stress disorder, which may not be representative of the general population with depressive symptoms. Moreover, the sample size of the psychedelic trials was small. Using extremely low-dose psychedelics as a reference group may have eliminated some pharmacologic effects as these doses cannot be considered a placebo.

DISCLOSURES:

The study was supported by grants from the National Science and Technology Council. The authors declared no financial relationships with any organizations outside the submitted work in the past 3 years. Full disclosures are available in the original article.

This article was created 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.

TOPLINE:

High-dose psilocybin is associated with greater relief from depressive symptoms than placebo or escitalopram, with no increased risk for severe adverse events, a new meta-analysis suggests.
 

METHODOLOGY:

• Researchers conducted a network meta-analysis to evaluate the comparative effectiveness of oral monotherapy with psychedelics versus escitalopram in patients with clinically diagnosed depression.
• The meta-analysis included 811 participants (mean age, 42.49 years; 54.2% women) with clinically diagnosed depression across 15 psychedelic trials and 1968 participants (mean age, 39.35 years; 62.5% women) across five escitalopram trials.
• Trials evaluated oral monotherapy with psychedelics (psilocybin, lysergic acid diethylamide, 3,4-methylenedioxymethamphetamine [MDMA], and ayahuasca), fixed-dose escitalopram (up to 20 mg/d) versus placebo, and psychedelic versus escitalopram monotherapy.
• The primary outcome was a change in depressive symptoms from baseline.

TAKEAWAY:

• Placebo responses in antidepressant trials (mean difference, 3.79; 95% CI, 0.77-6.80) and extremely low-dose psilocybin (mean difference, 3.96; 95% CI, 0.61-7.17) were better than those in psychedelic trials.
• High-dose psilocybin (20 mg or more) performed better than placebo in the antidepressant trials (mean difference, > 3). However, when comparing high-dose psilocybin with the placebo used in antidepressant trials, the effect size was smaller. The standardized mean difference dropped from 0.88 to 0.31, indicating that the effect of high-dose psilocybin was similar to that of current antidepressants.
• High-dose psilocybin was associated with a greater response than escitalopram at 10 mg (4.66; 95% CI, 1.36-7.74) and 20 mg (4.69; 95% CI, 1.64-7.54).
• No interventions were associated with an increased risk for all-cause discontinuation or severe adverse events.

IN PRACTICE:

“Taken together, our study findings suggest that among psychedelic treatments, high-dose psilocybin is more likely to reach the minimal important difference for depressive symptoms in studies with adequate blinding design, while the effect size of psilocybin was similar to that of current antidepressant drugs, showing a mean standardized mean difference of 0.3,” the authors wrote.

SOURCE:

The study was led by Tien-Wei Hsu, MD, I-Shou University and Kaohsiung Medical University, Kaohsiung City, Taiwan. It was published online in The BMJ. 

LIMITATIONS:

The study did not assess long-term effects of the interventions. Participants in the MDMA trials were primarily diagnosed with posttraumatic stress disorder, which may not be representative of the general population with depressive symptoms. Moreover, the sample size of the psychedelic trials was small. Using extremely low-dose psychedelics as a reference group may have eliminated some pharmacologic effects as these doses cannot be considered a placebo.

DISCLOSURES:

The study was supported by grants from the National Science and Technology Council. The authors declared no financial relationships with any organizations outside the submitted work in the past 3 years. Full disclosures are available in the original article.

This article was created 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.

TOPLINE:

High-dose psilocybin is associated with greater relief from depressive symptoms than placebo or escitalopram, with no increased risk for severe adverse events, a new meta-analysis suggests.
 

METHODOLOGY:

• Researchers conducted a network meta-analysis to evaluate the comparative effectiveness of oral monotherapy with psychedelics versus escitalopram in patients with clinically diagnosed depression.
• The meta-analysis included 811 participants (mean age, 42.49 years; 54.2% women) with clinically diagnosed depression across 15 psychedelic trials and 1968 participants (mean age, 39.35 years; 62.5% women) across five escitalopram trials.
• Trials evaluated oral monotherapy with psychedelics (psilocybin, lysergic acid diethylamide, 3,4-methylenedioxymethamphetamine [MDMA], and ayahuasca), fixed-dose escitalopram (up to 20 mg/d) versus placebo, and psychedelic versus escitalopram monotherapy.
• The primary outcome was a change in depressive symptoms from baseline.

TAKEAWAY:

• Placebo responses in antidepressant trials (mean difference, 3.79; 95% CI, 0.77-6.80) and extremely low-dose psilocybin (mean difference, 3.96; 95% CI, 0.61-7.17) were better than those in psychedelic trials.
• High-dose psilocybin (20 mg or more) performed better than placebo in the antidepressant trials (mean difference, > 3). However, when comparing high-dose psilocybin with the placebo used in antidepressant trials, the effect size was smaller. The standardized mean difference dropped from 0.88 to 0.31, indicating that the effect of high-dose psilocybin was similar to that of current antidepressants.
• High-dose psilocybin was associated with a greater response than escitalopram at 10 mg (4.66; 95% CI, 1.36-7.74) and 20 mg (4.69; 95% CI, 1.64-7.54).
• No interventions were associated with an increased risk for all-cause discontinuation or severe adverse events.

IN PRACTICE:

“Taken together, our study findings suggest that among psychedelic treatments, high-dose psilocybin is more likely to reach the minimal important difference for depressive symptoms in studies with adequate blinding design, while the effect size of psilocybin was similar to that of current antidepressant drugs, showing a mean standardized mean difference of 0.3,” the authors wrote.

SOURCE:

The study was led by Tien-Wei Hsu, MD, I-Shou University and Kaohsiung Medical University, Kaohsiung City, Taiwan. It was published online in The BMJ. 

LIMITATIONS:

The study did not assess long-term effects of the interventions. Participants in the MDMA trials were primarily diagnosed with posttraumatic stress disorder, which may not be representative of the general population with depressive symptoms. Moreover, the sample size of the psychedelic trials was small. Using extremely low-dose psychedelics as a reference group may have eliminated some pharmacologic effects as these doses cannot be considered a placebo.

DISCLOSURES:

The study was supported by grants from the National Science and Technology Council. The authors declared no financial relationships with any organizations outside the submitted work in the past 3 years. Full disclosures are available in the original article.

This article was created 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.

Certain extraintestinal manifestations (EIMs) in inflammatory bowel disease (IBD) have distinct clinical, serologic, and genetic associations that reveal underlying mechanisms and indicate targets for new or existing drugs, according to a recent study.

For instance, antinuclear cytoplastic antibody is associated with primary sclerosing cholangitis (PSC) in Crohn’s disease, and CPEB4 genetic variation is associated with skin manifestations.

“Up to 40% of people with IBD suffer with symptoms from inflammation that occurs outside the gut, particularly affecting the liver, skin, and joints. These symptoms can often have a bigger impact on quality of life than the gut inflammation itself and can actually be life-threatening,” said senior author Dermot McGovern, MD, PhD, AGAF, director of translational medicine at the F. Widjaja Foundation Inflammatory Bowel Disease and Immunobiology Research Institute at Cedars-Sinai Medical Center, Los Angeles.

Cedars-Sinai Medical Center

“With the advances in therapies for IBD, including availability of gut-selective agents, treatment choices often incorporate whether a patient has one of these manifestations or not,” he said. “We need to understand who is at increased risk of these and why.”

The study was published in Gastroenterology .
 

Analyzing Associations

Dr. McGovern and colleagues analyzed data for 12,083 unrelated European ancestry IBD cases with presence or absence of EIMs across four cohorts in the Cedars-Sinai Medical Center IBD Research Repository, National Institute for Diabetes and Digestive and Kidney Diseases IBD Genetics Consortium, Sinai Helmsley Alliance for Research Excellence Consortium, and Risk Stratification and Identification of Immunogenetic and Microbial Markers of Rapid Disease Progression in Children with Crohn’s Disease.

In particular, the researchers looked at EIM phenotypes such as ankylosing spondylitis and sacroiliitis, PSC, peripheral arthritis, and skin and ocular manifestations. They analyzed clinical and serologic parameters through regression analyses using a mixed-effects model, as well as within-case logistic regression for genetic associations.

Overall, 14% of patients had at least one EIM. Contrary to previous reports, only 2% had multiple EIMs, and most co-occurrences were negatively correlated. Nearly all EIMs were more common in Crohn’s disease, except for PSC, which was more common in ulcerative colitis.

In general, EIMs occurred more often in women, particularly with Crohn’s disease and colonic disease location, and in patients who required surgery. Jewish ancestry was associated with psoriasis and overall skin manifestations.

Smoking increased the risk for multiple EIMs, except for PSC, where there appeared to be a “protective” effect. Older age at diagnosis and a family history of IBD were associated with increased risk for certain EIMs as well.

In addition, the research team noted multiple serologic associations, such as immunoglobulin (Ig) G and IgA, perinuclear antinuclear cytoplastic antibodies, and anti–Pseudomonas fluorescens–associated sequences with any EIM, as well as particular associations with PSC, such as anti-Saccharomyces cerevisiae antibodies and anti-flagellin.

There were also genome-wide significant associations within the major histocompatibility complex and CPEB4. Genetic associations implicated tumor necrosis factor, Janus kinase-signal transducer and activator of transcription, and interleukin 6 as potential targets for EIMs.

“We are working with colleagues across the world to increase the sample size, as we believe there is more to find,” Dr. McGovern said. “Importantly, this includes non-European ancestry subjects, as there is an urgent need to increase the diversity of populations we study so advances in clinical care are available to all communities.”
 

Considering Target Therapies

As medicine becomes more specialized, physicians should remember to consider the whole patient while choosing treatment strategies.

“Sometimes doctors wear blinders to the whole person, and it’s important to be aware of a holistic approach, where a gastroenterologist also asks about potential joint inflammation or a rheumatologist asks about bowel inflammation,” said David Rubin, MD, AGAF, chief of the Section of Gastroenterology, Hepatology and Nutrition at the University of Chicago Medicine, Chicago.

Dr. Rubin, who wasn’t involved with this study, has researched and published on EIMs in IBD. He and colleagues analyzed the prevalence, pathophysiology, and clinical presentation of EIMs to better understand possibilities for disease management.

A version of this article appeared on Medscape.com.

Certain extraintestinal manifestations (EIMs) in inflammatory bowel disease (IBD) have distinct clinical, serologic, and genetic associations that reveal underlying mechanisms and indicate targets for new or existing drugs, according to a recent study.

For instance, antinuclear cytoplastic antibody is associated with primary sclerosing cholangitis (PSC) in Crohn’s disease, and CPEB4 genetic variation is associated with skin manifestations.

“Up to 40% of people with IBD suffer with symptoms from inflammation that occurs outside the gut, particularly affecting the liver, skin, and joints. These symptoms can often have a bigger impact on quality of life than the gut inflammation itself and can actually be life-threatening,” said senior author Dermot McGovern, MD, PhD, AGAF, director of translational medicine at the F. Widjaja Foundation Inflammatory Bowel Disease and Immunobiology Research Institute at Cedars-Sinai Medical Center, Los Angeles.

Cedars-Sinai Medical Center

“With the advances in therapies for IBD, including availability of gut-selective agents, treatment choices often incorporate whether a patient has one of these manifestations or not,” he said. “We need to understand who is at increased risk of these and why.”

The study was published in Gastroenterology .
 

Analyzing Associations

Dr. McGovern and colleagues analyzed data for 12,083 unrelated European ancestry IBD cases with presence or absence of EIMs across four cohorts in the Cedars-Sinai Medical Center IBD Research Repository, National Institute for Diabetes and Digestive and Kidney Diseases IBD Genetics Consortium, Sinai Helmsley Alliance for Research Excellence Consortium, and Risk Stratification and Identification of Immunogenetic and Microbial Markers of Rapid Disease Progression in Children with Crohn’s Disease.

In particular, the researchers looked at EIM phenotypes such as ankylosing spondylitis and sacroiliitis, PSC, peripheral arthritis, and skin and ocular manifestations. They analyzed clinical and serologic parameters through regression analyses using a mixed-effects model, as well as within-case logistic regression for genetic associations.

Overall, 14% of patients had at least one EIM. Contrary to previous reports, only 2% had multiple EIMs, and most co-occurrences were negatively correlated. Nearly all EIMs were more common in Crohn’s disease, except for PSC, which was more common in ulcerative colitis.

In general, EIMs occurred more often in women, particularly with Crohn’s disease and colonic disease location, and in patients who required surgery. Jewish ancestry was associated with psoriasis and overall skin manifestations.

Smoking increased the risk for multiple EIMs, except for PSC, where there appeared to be a “protective” effect. Older age at diagnosis and a family history of IBD were associated with increased risk for certain EIMs as well.

In addition, the research team noted multiple serologic associations, such as immunoglobulin (Ig) G and IgA, perinuclear antinuclear cytoplastic antibodies, and anti–Pseudomonas fluorescens–associated sequences with any EIM, as well as particular associations with PSC, such as anti-Saccharomyces cerevisiae antibodies and anti-flagellin.

There were also genome-wide significant associations within the major histocompatibility complex and CPEB4. Genetic associations implicated tumor necrosis factor, Janus kinase-signal transducer and activator of transcription, and interleukin 6 as potential targets for EIMs.

“We are working with colleagues across the world to increase the sample size, as we believe there is more to find,” Dr. McGovern said. “Importantly, this includes non-European ancestry subjects, as there is an urgent need to increase the diversity of populations we study so advances in clinical care are available to all communities.”
 

Considering Target Therapies

As medicine becomes more specialized, physicians should remember to consider the whole patient while choosing treatment strategies.

“Sometimes doctors wear blinders to the whole person, and it’s important to be aware of a holistic approach, where a gastroenterologist also asks about potential joint inflammation or a rheumatologist asks about bowel inflammation,” said David Rubin, MD, AGAF, chief of the Section of Gastroenterology, Hepatology and Nutrition at the University of Chicago Medicine, Chicago.

Dr. Rubin, who wasn’t involved with this study, has researched and published on EIMs in IBD. He and colleagues analyzed the prevalence, pathophysiology, and clinical presentation of EIMs to better understand possibilities for disease management.

A version of this article appeared on Medscape.com.

Certain extraintestinal manifestations (EIMs) in inflammatory bowel disease (IBD) have distinct clinical, serologic, and genetic associations that reveal underlying mechanisms and indicate targets for new or existing drugs, according to a recent study.

For instance, antinuclear cytoplastic antibody is associated with primary sclerosing cholangitis (PSC) in Crohn’s disease, and CPEB4 genetic variation is associated with skin manifestations.

“Up to 40% of people with IBD suffer with symptoms from inflammation that occurs outside the gut, particularly affecting the liver, skin, and joints. These symptoms can often have a bigger impact on quality of life than the gut inflammation itself and can actually be life-threatening,” said senior author Dermot McGovern, MD, PhD, AGAF, director of translational medicine at the F. Widjaja Foundation Inflammatory Bowel Disease and Immunobiology Research Institute at Cedars-Sinai Medical Center, Los Angeles.

Cedars-Sinai Medical Center

“With the advances in therapies for IBD, including availability of gut-selective agents, treatment choices often incorporate whether a patient has one of these manifestations or not,” he said. “We need to understand who is at increased risk of these and why.”

The study was published in Gastroenterology .
 

Analyzing Associations

Dr. McGovern and colleagues analyzed data for 12,083 unrelated European ancestry IBD cases with presence or absence of EIMs across four cohorts in the Cedars-Sinai Medical Center IBD Research Repository, National Institute for Diabetes and Digestive and Kidney Diseases IBD Genetics Consortium, Sinai Helmsley Alliance for Research Excellence Consortium, and Risk Stratification and Identification of Immunogenetic and Microbial Markers of Rapid Disease Progression in Children with Crohn’s Disease.

In particular, the researchers looked at EIM phenotypes such as ankylosing spondylitis and sacroiliitis, PSC, peripheral arthritis, and skin and ocular manifestations. They analyzed clinical and serologic parameters through regression analyses using a mixed-effects model, as well as within-case logistic regression for genetic associations.

Overall, 14% of patients had at least one EIM. Contrary to previous reports, only 2% had multiple EIMs, and most co-occurrences were negatively correlated. Nearly all EIMs were more common in Crohn’s disease, except for PSC, which was more common in ulcerative colitis.

In general, EIMs occurred more often in women, particularly with Crohn’s disease and colonic disease location, and in patients who required surgery. Jewish ancestry was associated with psoriasis and overall skin manifestations.

Smoking increased the risk for multiple EIMs, except for PSC, where there appeared to be a “protective” effect. Older age at diagnosis and a family history of IBD were associated with increased risk for certain EIMs as well.

In addition, the research team noted multiple serologic associations, such as immunoglobulin (Ig) G and IgA, perinuclear antinuclear cytoplastic antibodies, and anti–Pseudomonas fluorescens–associated sequences with any EIM, as well as particular associations with PSC, such as anti-Saccharomyces cerevisiae antibodies and anti-flagellin.

There were also genome-wide significant associations within the major histocompatibility complex and CPEB4. Genetic associations implicated tumor necrosis factor, Janus kinase-signal transducer and activator of transcription, and interleukin 6 as potential targets for EIMs.

“We are working with colleagues across the world to increase the sample size, as we believe there is more to find,” Dr. McGovern said. “Importantly, this includes non-European ancestry subjects, as there is an urgent need to increase the diversity of populations we study so advances in clinical care are available to all communities.”
 

Considering Target Therapies

As medicine becomes more specialized, physicians should remember to consider the whole patient while choosing treatment strategies.

“Sometimes doctors wear blinders to the whole person, and it’s important to be aware of a holistic approach, where a gastroenterologist also asks about potential joint inflammation or a rheumatologist asks about bowel inflammation,” said David Rubin, MD, AGAF, chief of the Section of Gastroenterology, Hepatology and Nutrition at the University of Chicago Medicine, Chicago.

Dr. Rubin, who wasn’t involved with this study, has researched and published on EIMs in IBD. He and colleagues analyzed the prevalence, pathophysiology, and clinical presentation of EIMs to better understand possibilities for disease management.

A version of this article appeared on Medscape.com.

TOPLINE:

Intermittent energy restriction (IER) and continuous energy restriction (CER) reduced body mass index (BMI) in adolescents with obesity after 52 weeks, with no major differences found in body composition or cardiometabolic outcomes.

METHODOLOGY:

• Researchers conducted a 52-week randomized clinical trial at two pediatric centers in Australia that involved 141 adolescents aged 13-17 years with obesity and at least one associated complication.
• Participants were divided into two groups: IER and CER, with three phases: Very low-energy diet (weeks 0-4), intensive intervention (weeks 5-16), and continued intervention/maintenance (weeks 17-52).
• Interventions included a very low-energy diet of 3350 kJ/d (800 kcal/d) for the first 4 weeks, followed by either IER intervention (2500-2950 kJ [600-700 kcal 3 days/wk]) or a daily CER intervention (6000-8000 kJ/d based on age; 1430-1670 kcal/d for teens aged 13-14 years and 1670-1900 kcal/d for teens aged 15-17 years).
• Participants were provided with multivitamins and met with dietitians regularly, with additional support via telephone, text message, or email.

TAKEAWAY:

• Teens in both the IER and CER groups showed a 0.28 reduction in BMI z-scores at 52 weeks with no significant differences between the two.
• The researchers observed no differences in body composition or cardiometabolic outcomes between the IER and CER groups.
• The occurrence of insulin resistance was reduced in both groups at week 16, but this effect was maintained only in the CER group at week 52.
• The study found no significant differences in the occurrence of dyslipidemia or impaired hepatic function between the IER and CER groups.

IN PRACTICE:

“These findings suggest that for adolescents with obesity-associated complications, IER can be incorporated into a behavioral weight management program, providing an option in addition to CER and offering participants more choice,” the authors of the study wrote.

SOURCE:

The study was led by Natalie B. Lister, PhD, of the University of Sydney in Australia and was published online in JAMA Pediatrics.

LIMITATIONS:

The COVID-19 pandemic and subsequent lockdowns limited the sample size. Some dietitian visits were conducted via telehealth.

DISCLOSURES:

Dr. Lister received grants from the National Health and Medical Research Council of Australia. A coauthor, Louise A. Baur, MBBS, PhD, received speakers’ fees from Novo Nordisk and served as a member of the Eli Lilly Advisory Committee.

This article was created 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.

TOPLINE:

Intermittent energy restriction (IER) and continuous energy restriction (CER) reduced body mass index (BMI) in adolescents with obesity after 52 weeks, with no major differences found in body composition or cardiometabolic outcomes.

METHODOLOGY:

• Researchers conducted a 52-week randomized clinical trial at two pediatric centers in Australia that involved 141 adolescents aged 13-17 years with obesity and at least one associated complication.
• Participants were divided into two groups: IER and CER, with three phases: Very low-energy diet (weeks 0-4), intensive intervention (weeks 5-16), and continued intervention/maintenance (weeks 17-52).
• Interventions included a very low-energy diet of 3350 kJ/d (800 kcal/d) for the first 4 weeks, followed by either IER intervention (2500-2950 kJ [600-700 kcal 3 days/wk]) or a daily CER intervention (6000-8000 kJ/d based on age; 1430-1670 kcal/d for teens aged 13-14 years and 1670-1900 kcal/d for teens aged 15-17 years).
• Participants were provided with multivitamins and met with dietitians regularly, with additional support via telephone, text message, or email.

TAKEAWAY:

• Teens in both the IER and CER groups showed a 0.28 reduction in BMI z-scores at 52 weeks with no significant differences between the two.
• The researchers observed no differences in body composition or cardiometabolic outcomes between the IER and CER groups.
• The occurrence of insulin resistance was reduced in both groups at week 16, but this effect was maintained only in the CER group at week 52.
• The study found no significant differences in the occurrence of dyslipidemia or impaired hepatic function between the IER and CER groups.

IN PRACTICE:

“These findings suggest that for adolescents with obesity-associated complications, IER can be incorporated into a behavioral weight management program, providing an option in addition to CER and offering participants more choice,” the authors of the study wrote.

SOURCE:

The study was led by Natalie B. Lister, PhD, of the University of Sydney in Australia and was published online in JAMA Pediatrics.

LIMITATIONS:

The COVID-19 pandemic and subsequent lockdowns limited the sample size. Some dietitian visits were conducted via telehealth.

DISCLOSURES:

Dr. Lister received grants from the National Health and Medical Research Council of Australia. A coauthor, Louise A. Baur, MBBS, PhD, received speakers’ fees from Novo Nordisk and served as a member of the Eli Lilly Advisory Committee.

This article was created 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.

TOPLINE:

Intermittent energy restriction (IER) and continuous energy restriction (CER) reduced body mass index (BMI) in adolescents with obesity after 52 weeks, with no major differences found in body composition or cardiometabolic outcomes.

METHODOLOGY:

• Researchers conducted a 52-week randomized clinical trial at two pediatric centers in Australia that involved 141 adolescents aged 13-17 years with obesity and at least one associated complication.
• Participants were divided into two groups: IER and CER, with three phases: Very low-energy diet (weeks 0-4), intensive intervention (weeks 5-16), and continued intervention/maintenance (weeks 17-52).
• Interventions included a very low-energy diet of 3350 kJ/d (800 kcal/d) for the first 4 weeks, followed by either IER intervention (2500-2950 kJ [600-700 kcal 3 days/wk]) or a daily CER intervention (6000-8000 kJ/d based on age; 1430-1670 kcal/d for teens aged 13-14 years and 1670-1900 kcal/d for teens aged 15-17 years).
• Participants were provided with multivitamins and met with dietitians regularly, with additional support via telephone, text message, or email.

TAKEAWAY:

• Teens in both the IER and CER groups showed a 0.28 reduction in BMI z-scores at 52 weeks with no significant differences between the two.
• The researchers observed no differences in body composition or cardiometabolic outcomes between the IER and CER groups.
• The occurrence of insulin resistance was reduced in both groups at week 16, but this effect was maintained only in the CER group at week 52.
• The study found no significant differences in the occurrence of dyslipidemia or impaired hepatic function between the IER and CER groups.

IN PRACTICE:

“These findings suggest that for adolescents with obesity-associated complications, IER can be incorporated into a behavioral weight management program, providing an option in addition to CER and offering participants more choice,” the authors of the study wrote.

SOURCE:

The study was led by Natalie B. Lister, PhD, of the University of Sydney in Australia and was published online in JAMA Pediatrics.

LIMITATIONS:

The COVID-19 pandemic and subsequent lockdowns limited the sample size. Some dietitian visits were conducted via telehealth.

DISCLOSURES:

Dr. Lister received grants from the National Health and Medical Research Council of Australia. A coauthor, Louise A. Baur, MBBS, PhD, received speakers’ fees from Novo Nordisk and served as a member of the Eli Lilly Advisory Committee.

This article was created 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.

A medical student’s life is an endless cycle of classes, exams, clinical rotations, and residency preparation. While students typically have little free time, some still manage to build a mega social media presence. On TikTok and Instagram, among other sites, they share medical school experiences and lessons learned in the classroom and advocate for causes such as increased diversity and gender rights in the medical field.

This news organization caught up with a few social media influencers with a large online following to learn how medical students can effectively use social media to build a professional brand and network. Most of the students interviewed said that their social media platforms offered an opportunity to educate others about significant medical developments, feel part of a community with a like-minded audience, and network with doctors who may lead them to a future residency or career path.

Many med students said that they built their large audiences by creating a platform for people of their ethnic background, nationality, race, gender, or simply what others weren’t already talking about. They said they saw a niche in social media that was missing or others hadn’t tackled in the same way.

When Joel Bervell began med school in 2020, he questioned some of the lessons he learned about how race is used in medical practice, which didn’t make sense to him. So, he began his own research. He had about 2000 followers on Instagram at the time.

Mr. Bervell read a new study about pulse oximeters and how they often produce misleading readings on patients with dark skin.

He wondered why he hadn’t learned this in medical school, so he posted it on TikTok. Within 24 hours, about 500,000 people viewed it. Most of the comments were from doctors, nurses, and physician assistants who said they weren’t aware of the disparity.

While his initial posts detailed his journey to medical school and a day-in-the-life of a medical student, he transitioned to posts primarily about race, health equity, and what he perceives as racial bias in medicine.

Now, the fourth-year Ghanaian-American student at the Elson S. Floyd College of Medicine at Washington State University Spokane has close to 1.2 million followers on Instagram and TikTok combined. He frequently visits the White House to advise on social media’s influence on healthcare and has appeared on the Kelly Clarkson Show, Good Morning America, CNN, and ABC, among others.

He said he also uses social media to translate complex medical information for a general audience, many of whom access health information online so they can manage their own healthcare. He sees his social media work as an extension of his medical education, allowing him to delve deeper into subjects and report on them as if he were publishing research in a medical journal.

“When I came to medical school, yes, I wanted to be a doctor. But I also wanted to impact people.” Social media allows him to educate many more people than individual patients, the 29-year-old told this news organization.
 

Inspiring Minorities

Tabhata Paulet, 27, started her TikTok presence as a premed student in 2021. She aimed to provide free resources to help low-income, first-generation Latinx students like herself study for standardized exams.

“I always looked online for guidance and resources, and the medical influencers did not share a similar background. So, I shared my story and what I had to do as a first-generation and first person in my family to become a physician. I did not have access to the same resources as my peers,” said Ms. Paulet, who was born in Peru and came to New Jersey as a child.

Students who are Hispanic, Latinx, or of Spanish origin made up 6.8% of total medical school enrollment in 2023-2024, up slightly from 6.7% in 2022-2023, according to the Association of American Medical Colleges (AAMC).

Ms. Paulet’s online presence grew when she began documenting her experiences as a first-year medical student, bridging the language barrier for Spanish-speaking patients so they could understand their diagnosis and treatment. She often posts about health disparity and barriers to care for underserved communities.

Most of her nearly 22,000 followers are Hispanic, said the now fourth-year student at Rutgers New Jersey Medical School in Newark, New Jersey. “I talk a lot about my interesting Spanish-speaking patients ... and how sometimes speaking their native language truly makes a difference in their care.”

She believes that she serves an important role in social media. “It can be very inspirational for those who come after you [in med school] to see someone from a similar culture and upbringing.”
 

Creating a Community

It was during a therapy session 4 years ago that Jeremy “JP” Scott decided to share Instagram posts about his experiences as a nontraditional medical student. The 37-year-old was studying at Ross University School of Medicine in Barbados and was feeling lonely as an international medical student training to be a doctor as a second career.

Before starting med school, Mr. Scott was an adjunct professor and lab supervisor at the University of Hartford Biology Department, West Hartford, Connecticut, and then a research assistant and lab manager at the Wistar Institute in Philadelphia.

Although he wanted to follow his mother’s path to becoming a doctor, it was more difficult than he envisioned, said the fourth-year student who completed clinical rotations in the United States and is now applying for residencies.

“I talked about how medical school is not what it appears to be ... There are a lot of challenges we are going through,” especially as people of color, he said.

Mr. Scott believes social media helps people feel included and less alone. He said many of his followers are med students and physicians.

His posts often focus on LGBTQIA+ pride and being a minority as a Black man in medicine.

“The pandemic spurred a lot of us. We had a racial reckoning in our country at the time. It inspired us to talk as Black creators and Black medical students.”

Black or African American medical students made up 8.5% of total med school enrollment in 2023-2024, a slight increase from 2022 to 2023, according to AAMC figures. Black men represented 7% of total enrollment in 2023-2024, while Black women represented 9.8%.

After only a handful of online posts in which Mr. Scott candidly discussed his mental health struggles and relationships, he attracted the attention of several medical apparel companies, including the popular FIGS scrubs. He’s now an ambassador for the company, which supports him and his content.

“My association with FIGS has helped attract a wider online audience, increasing my presence.” Today, he has 14,000 Instagram followers. “It opened up so many opportunities,” Mr. Scott said. One example is working with the national LGBTQIA+ community.

“The goal was never to be a social media influencer, to gain sponsorships or photo opportunities,” he said.

“My job, first, is as a medical student. Everything else is second. I am not trying to be a professional social media personality. I’m trying to be an actual physician.” He also tries to separate JP “social media” from Jeremy, the medical student.

“On Instagram, anyone can pull it up and see what you’re doing. The last thing I want is for them to think that I’m not serious about what I’m doing, that I’m not here to learn and become a doctor.”
 

Benefits and Drawbacks

Ms. Paulet said her social media following helped her connect with leaders in the Latinx medical community, including an obstetrics anesthesiologist, her intended specialty. “I don’t think I’d be able to do that without a social media platform.”

Her online activity also propelled her from regional to national leadership in the Latino Medical Student Association (LMSA). She now also runs their Instagram page, which has 14,000 followers.

Mr. Bervell believes social media is a great way to network. He’s connected with people he wouldn’t have met otherwise, including physicians. “I think it will help me get into a residency,” he said. “It allows people to know who you are ... They will be able to tell in a few videos the type of doctor I want to be.”

On the other hand, Mr. Bervell is aware of the negative impacts of social media on mental health. “You can get lost in social media.” For that reason, he often tries to disconnect. “I can go days without my phone.”

Posting on social media can be time-consuming, Mr. Bervell admitted. He said he spent about 2 hours a day researching, editing, and posting on TikTok when he first started building his following. Now, he spends about 2-3 hours a week creating videos. “I don’t post every day anymore. I don’t have the time.”

When she started building her TikTok presence, Ms. Paulet said she devoted 15 hours a week to the endeavor, but now she spends 10-12 hours a week posting online, including on LMSA’s Instagram page. “Whenever you are done with an exam or have a study break, this is something fun to do.” She also says you never know who you’re going to inspire when you put yourself out there.

“Talk about your journey, rotations, or your experience in your first or second year of medical school. Talk about milestones like board exams.”
 

Word to the Wise

Some students may be concerned that their posts might affect a potential residency program. But the medical students interviewed say they want to find programs that align with their values and accept them for who they are.

Mr. Scott said he’s not worried about someone not liking him because of who he is. “I am Black and openly gay. If it’s a problem, I don’t need to work with you or your institution.”

Mr. Bervell stressed that medical students should stay professional online. “I reach 5-10 million people a month, and I have to think: Would I want them to see this? You have to know at all times that someone is watching. I’m very careful about how I post. I script out every video.”

Mr. Scott agreed. He advises those interested in becoming medical influencers to know what they can’t post online. For example, to ensure safety and privacy, Mr. Scott doesn’t take photos in the hospital, show his medical badge, or post patient information. “You want to be respectful of your future medical profession,” he said.

“If it’s something my mother would be ashamed of, I don’t need to post about it.”
 

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

A medical student’s life is an endless cycle of classes, exams, clinical rotations, and residency preparation. While students typically have little free time, some still manage to build a mega social media presence. On TikTok and Instagram, among other sites, they share medical school experiences and lessons learned in the classroom and advocate for causes such as increased diversity and gender rights in the medical field.

This news organization caught up with a few social media influencers with a large online following to learn how medical students can effectively use social media to build a professional brand and network. Most of the students interviewed said that their social media platforms offered an opportunity to educate others about significant medical developments, feel part of a community with a like-minded audience, and network with doctors who may lead them to a future residency or career path.

Many med students said that they built their large audiences by creating a platform for people of their ethnic background, nationality, race, gender, or simply what others weren’t already talking about. They said they saw a niche in social media that was missing or others hadn’t tackled in the same way.

When Joel Bervell began med school in 2020, he questioned some of the lessons he learned about how race is used in medical practice, which didn’t make sense to him. So, he began his own research. He had about 2000 followers on Instagram at the time.

Mr. Bervell read a new study about pulse oximeters and how they often produce misleading readings on patients with dark skin.

He wondered why he hadn’t learned this in medical school, so he posted it on TikTok. Within 24 hours, about 500,000 people viewed it. Most of the comments were from doctors, nurses, and physician assistants who said they weren’t aware of the disparity.

While his initial posts detailed his journey to medical school and a day-in-the-life of a medical student, he transitioned to posts primarily about race, health equity, and what he perceives as racial bias in medicine.

Now, the fourth-year Ghanaian-American student at the Elson S. Floyd College of Medicine at Washington State University Spokane has close to 1.2 million followers on Instagram and TikTok combined. He frequently visits the White House to advise on social media’s influence on healthcare and has appeared on the Kelly Clarkson Show, Good Morning America, CNN, and ABC, among others.

He said he also uses social media to translate complex medical information for a general audience, many of whom access health information online so they can manage their own healthcare. He sees his social media work as an extension of his medical education, allowing him to delve deeper into subjects and report on them as if he were publishing research in a medical journal.

“When I came to medical school, yes, I wanted to be a doctor. But I also wanted to impact people.” Social media allows him to educate many more people than individual patients, the 29-year-old told this news organization.
 

Inspiring Minorities

Tabhata Paulet, 27, started her TikTok presence as a premed student in 2021. She aimed to provide free resources to help low-income, first-generation Latinx students like herself study for standardized exams.

“I always looked online for guidance and resources, and the medical influencers did not share a similar background. So, I shared my story and what I had to do as a first-generation and first person in my family to become a physician. I did not have access to the same resources as my peers,” said Ms. Paulet, who was born in Peru and came to New Jersey as a child.

Students who are Hispanic, Latinx, or of Spanish origin made up 6.8% of total medical school enrollment in 2023-2024, up slightly from 6.7% in 2022-2023, according to the Association of American Medical Colleges (AAMC).

Ms. Paulet’s online presence grew when she began documenting her experiences as a first-year medical student, bridging the language barrier for Spanish-speaking patients so they could understand their diagnosis and treatment. She often posts about health disparity and barriers to care for underserved communities.

Most of her nearly 22,000 followers are Hispanic, said the now fourth-year student at Rutgers New Jersey Medical School in Newark, New Jersey. “I talk a lot about my interesting Spanish-speaking patients ... and how sometimes speaking their native language truly makes a difference in their care.”

She believes that she serves an important role in social media. “It can be very inspirational for those who come after you [in med school] to see someone from a similar culture and upbringing.”
 

Creating a Community

It was during a therapy session 4 years ago that Jeremy “JP” Scott decided to share Instagram posts about his experiences as a nontraditional medical student. The 37-year-old was studying at Ross University School of Medicine in Barbados and was feeling lonely as an international medical student training to be a doctor as a second career.

Before starting med school, Mr. Scott was an adjunct professor and lab supervisor at the University of Hartford Biology Department, West Hartford, Connecticut, and then a research assistant and lab manager at the Wistar Institute in Philadelphia.

Although he wanted to follow his mother’s path to becoming a doctor, it was more difficult than he envisioned, said the fourth-year student who completed clinical rotations in the United States and is now applying for residencies.

“I talked about how medical school is not what it appears to be ... There are a lot of challenges we are going through,” especially as people of color, he said.

Mr. Scott believes social media helps people feel included and less alone. He said many of his followers are med students and physicians.

His posts often focus on LGBTQIA+ pride and being a minority as a Black man in medicine.

“The pandemic spurred a lot of us. We had a racial reckoning in our country at the time. It inspired us to talk as Black creators and Black medical students.”

Black or African American medical students made up 8.5% of total med school enrollment in 2023-2024, a slight increase from 2022 to 2023, according to AAMC figures. Black men represented 7% of total enrollment in 2023-2024, while Black women represented 9.8%.

After only a handful of online posts in which Mr. Scott candidly discussed his mental health struggles and relationships, he attracted the attention of several medical apparel companies, including the popular FIGS scrubs. He’s now an ambassador for the company, which supports him and his content.

“My association with FIGS has helped attract a wider online audience, increasing my presence.” Today, he has 14,000 Instagram followers. “It opened up so many opportunities,” Mr. Scott said. One example is working with the national LGBTQIA+ community.

“The goal was never to be a social media influencer, to gain sponsorships or photo opportunities,” he said.

“My job, first, is as a medical student. Everything else is second. I am not trying to be a professional social media personality. I’m trying to be an actual physician.” He also tries to separate JP “social media” from Jeremy, the medical student.

“On Instagram, anyone can pull it up and see what you’re doing. The last thing I want is for them to think that I’m not serious about what I’m doing, that I’m not here to learn and become a doctor.”
 

Benefits and Drawbacks

Ms. Paulet said her social media following helped her connect with leaders in the Latinx medical community, including an obstetrics anesthesiologist, her intended specialty. “I don’t think I’d be able to do that without a social media platform.”

Her online activity also propelled her from regional to national leadership in the Latino Medical Student Association (LMSA). She now also runs their Instagram page, which has 14,000 followers.

Mr. Bervell believes social media is a great way to network. He’s connected with people he wouldn’t have met otherwise, including physicians. “I think it will help me get into a residency,” he said. “It allows people to know who you are ... They will be able to tell in a few videos the type of doctor I want to be.”

On the other hand, Mr. Bervell is aware of the negative impacts of social media on mental health. “You can get lost in social media.” For that reason, he often tries to disconnect. “I can go days without my phone.”

Posting on social media can be time-consuming, Mr. Bervell admitted. He said he spent about 2 hours a day researching, editing, and posting on TikTok when he first started building his following. Now, he spends about 2-3 hours a week creating videos. “I don’t post every day anymore. I don’t have the time.”

When she started building her TikTok presence, Ms. Paulet said she devoted 15 hours a week to the endeavor, but now she spends 10-12 hours a week posting online, including on LMSA’s Instagram page. “Whenever you are done with an exam or have a study break, this is something fun to do.” She also says you never know who you’re going to inspire when you put yourself out there.

“Talk about your journey, rotations, or your experience in your first or second year of medical school. Talk about milestones like board exams.”
 

Word to the Wise

Some students may be concerned that their posts might affect a potential residency program. But the medical students interviewed say they want to find programs that align with their values and accept them for who they are.

Mr. Scott said he’s not worried about someone not liking him because of who he is. “I am Black and openly gay. If it’s a problem, I don’t need to work with you or your institution.”

Mr. Bervell stressed that medical students should stay professional online. “I reach 5-10 million people a month, and I have to think: Would I want them to see this? You have to know at all times that someone is watching. I’m very careful about how I post. I script out every video.”

Mr. Scott agreed. He advises those interested in becoming medical influencers to know what they can’t post online. For example, to ensure safety and privacy, Mr. Scott doesn’t take photos in the hospital, show his medical badge, or post patient information. “You want to be respectful of your future medical profession,” he said.

“If it’s something my mother would be ashamed of, I don’t need to post about it.”
 

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

A medical student’s life is an endless cycle of classes, exams, clinical rotations, and residency preparation. While students typically have little free time, some still manage to build a mega social media presence. On TikTok and Instagram, among other sites, they share medical school experiences and lessons learned in the classroom and advocate for causes such as increased diversity and gender rights in the medical field.

This news organization caught up with a few social media influencers with a large online following to learn how medical students can effectively use social media to build a professional brand and network. Most of the students interviewed said that their social media platforms offered an opportunity to educate others about significant medical developments, feel part of a community with a like-minded audience, and network with doctors who may lead them to a future residency or career path.

Many med students said that they built their large audiences by creating a platform for people of their ethnic background, nationality, race, gender, or simply what others weren’t already talking about. They said they saw a niche in social media that was missing or others hadn’t tackled in the same way.

When Joel Bervell began med school in 2020, he questioned some of the lessons he learned about how race is used in medical practice, which didn’t make sense to him. So, he began his own research. He had about 2000 followers on Instagram at the time.

Mr. Bervell read a new study about pulse oximeters and how they often produce misleading readings on patients with dark skin.

He wondered why he hadn’t learned this in medical school, so he posted it on TikTok. Within 24 hours, about 500,000 people viewed it. Most of the comments were from doctors, nurses, and physician assistants who said they weren’t aware of the disparity.

While his initial posts detailed his journey to medical school and a day-in-the-life of a medical student, he transitioned to posts primarily about race, health equity, and what he perceives as racial bias in medicine.

Now, the fourth-year Ghanaian-American student at the Elson S. Floyd College of Medicine at Washington State University Spokane has close to 1.2 million followers on Instagram and TikTok combined. He frequently visits the White House to advise on social media’s influence on healthcare and has appeared on the Kelly Clarkson Show, Good Morning America, CNN, and ABC, among others.

He said he also uses social media to translate complex medical information for a general audience, many of whom access health information online so they can manage their own healthcare. He sees his social media work as an extension of his medical education, allowing him to delve deeper into subjects and report on them as if he were publishing research in a medical journal.

“When I came to medical school, yes, I wanted to be a doctor. But I also wanted to impact people.” Social media allows him to educate many more people than individual patients, the 29-year-old told this news organization.
 

Inspiring Minorities

Tabhata Paulet, 27, started her TikTok presence as a premed student in 2021. She aimed to provide free resources to help low-income, first-generation Latinx students like herself study for standardized exams.

“I always looked online for guidance and resources, and the medical influencers did not share a similar background. So, I shared my story and what I had to do as a first-generation and first person in my family to become a physician. I did not have access to the same resources as my peers,” said Ms. Paulet, who was born in Peru and came to New Jersey as a child.

Students who are Hispanic, Latinx, or of Spanish origin made up 6.8% of total medical school enrollment in 2023-2024, up slightly from 6.7% in 2022-2023, according to the Association of American Medical Colleges (AAMC).

Ms. Paulet’s online presence grew when she began documenting her experiences as a first-year medical student, bridging the language barrier for Spanish-speaking patients so they could understand their diagnosis and treatment. She often posts about health disparity and barriers to care for underserved communities.

Most of her nearly 22,000 followers are Hispanic, said the now fourth-year student at Rutgers New Jersey Medical School in Newark, New Jersey. “I talk a lot about my interesting Spanish-speaking patients ... and how sometimes speaking their native language truly makes a difference in their care.”

She believes that she serves an important role in social media. “It can be very inspirational for those who come after you [in med school] to see someone from a similar culture and upbringing.”
 

Creating a Community

It was during a therapy session 4 years ago that Jeremy “JP” Scott decided to share Instagram posts about his experiences as a nontraditional medical student. The 37-year-old was studying at Ross University School of Medicine in Barbados and was feeling lonely as an international medical student training to be a doctor as a second career.

Before starting med school, Mr. Scott was an adjunct professor and lab supervisor at the University of Hartford Biology Department, West Hartford, Connecticut, and then a research assistant and lab manager at the Wistar Institute in Philadelphia.

Although he wanted to follow his mother’s path to becoming a doctor, it was more difficult than he envisioned, said the fourth-year student who completed clinical rotations in the United States and is now applying for residencies.

“I talked about how medical school is not what it appears to be ... There are a lot of challenges we are going through,” especially as people of color, he said.

Mr. Scott believes social media helps people feel included and less alone. He said many of his followers are med students and physicians.

His posts often focus on LGBTQIA+ pride and being a minority as a Black man in medicine.

“The pandemic spurred a lot of us. We had a racial reckoning in our country at the time. It inspired us to talk as Black creators and Black medical students.”

Black or African American medical students made up 8.5% of total med school enrollment in 2023-2024, a slight increase from 2022 to 2023, according to AAMC figures. Black men represented 7% of total enrollment in 2023-2024, while Black women represented 9.8%.

After only a handful of online posts in which Mr. Scott candidly discussed his mental health struggles and relationships, he attracted the attention of several medical apparel companies, including the popular FIGS scrubs. He’s now an ambassador for the company, which supports him and his content.

“My association with FIGS has helped attract a wider online audience, increasing my presence.” Today, he has 14,000 Instagram followers. “It opened up so many opportunities,” Mr. Scott said. One example is working with the national LGBTQIA+ community.

“The goal was never to be a social media influencer, to gain sponsorships or photo opportunities,” he said.

“My job, first, is as a medical student. Everything else is second. I am not trying to be a professional social media personality. I’m trying to be an actual physician.” He also tries to separate JP “social media” from Jeremy, the medical student.

“On Instagram, anyone can pull it up and see what you’re doing. The last thing I want is for them to think that I’m not serious about what I’m doing, that I’m not here to learn and become a doctor.”
 

Benefits and Drawbacks

Ms. Paulet said her social media following helped her connect with leaders in the Latinx medical community, including an obstetrics anesthesiologist, her intended specialty. “I don’t think I’d be able to do that without a social media platform.”

Her online activity also propelled her from regional to national leadership in the Latino Medical Student Association (LMSA). She now also runs their Instagram page, which has 14,000 followers.

Mr. Bervell believes social media is a great way to network. He’s connected with people he wouldn’t have met otherwise, including physicians. “I think it will help me get into a residency,” he said. “It allows people to know who you are ... They will be able to tell in a few videos the type of doctor I want to be.”

On the other hand, Mr. Bervell is aware of the negative impacts of social media on mental health. “You can get lost in social media.” For that reason, he often tries to disconnect. “I can go days without my phone.”

Posting on social media can be time-consuming, Mr. Bervell admitted. He said he spent about 2 hours a day researching, editing, and posting on TikTok when he first started building his following. Now, he spends about 2-3 hours a week creating videos. “I don’t post every day anymore. I don’t have the time.”

When she started building her TikTok presence, Ms. Paulet said she devoted 15 hours a week to the endeavor, but now she spends 10-12 hours a week posting online, including on LMSA’s Instagram page. “Whenever you are done with an exam or have a study break, this is something fun to do.” She also says you never know who you’re going to inspire when you put yourself out there.

“Talk about your journey, rotations, or your experience in your first or second year of medical school. Talk about milestones like board exams.”
 

Word to the Wise

Some students may be concerned that their posts might affect a potential residency program. But the medical students interviewed say they want to find programs that align with their values and accept them for who they are.

Mr. Scott said he’s not worried about someone not liking him because of who he is. “I am Black and openly gay. If it’s a problem, I don’t need to work with you or your institution.”

Mr. Bervell stressed that medical students should stay professional online. “I reach 5-10 million people a month, and I have to think: Would I want them to see this? You have to know at all times that someone is watching. I’m very careful about how I post. I script out every video.”

Mr. Scott agreed. He advises those interested in becoming medical influencers to know what they can’t post online. For example, to ensure safety and privacy, Mr. Scott doesn’t take photos in the hospital, show his medical badge, or post patient information. “You want to be respectful of your future medical profession,” he said.

“If it’s something my mother would be ashamed of, I don’t need to post about it.”
 

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

Prophylactic placement of balloon catheters or sheaths prior to planned cesarean delivery may reduce blood loss in women with placenta accreta spectrum disorder, according to a new systematic review of more than 5,000 individuals.

Placenta accreta spectrum disorder occurs when the endometrial-myometrial interface of the uterus is damaged, wrote Lisanne R. Bonsen, MD, of Leiden University Medical Center, the Netherlands, and colleagues. As a result, the placenta fails to detach at the time of birth and can result in life-threatening postpartum hemorrhage, the researchers said.

The greater the depth of placental invasiveness, the more severe the maternal outcomes, the researchers noted. Previous cesarean delivery is the primary risk factor for placenta accreta spectrum disorder, and the incidence has increased along with the increased rates of cesarean delivery on a global level, they explained.

More research is needed on intrapartum strategies to improve maternal outcomes, and prophylactic radiologic intervention to reduce perioperative blood loss has been explored, the researchers wrote. However, placenta accreta spectrum disorder remains relatively rare in most pregnancy settings, and data on the effect of prophylactic radiologic interventions to reduce bleeding in this high-risk population are limited they said.

In the review published in Obstetrics & Gynecology, the researchers analyzed data from 50 studies of prophylactic radiologic interventions (48 observational studies and 2 randomized, controlled trials) including 5,962 women.

The primary outcome was perioperative blood loss; secondary outcomes included the number of red blood cells transferred within 24 hours after delivery, maternal mortality, adverse events related to the interventions, and surgical complications.

Blood loss was significantly lower in the intervention groups compared with the control groups for patients who underwent distal balloon occlusion (30 studies), proximal balloon occlusion (14 studies), or uterine artery embolization (5 studies), with mean differences in blood loss of 406 mL, 1,041 mL, and 936 mL, respectively.

Results were similar with lower blood loss for intervention patients compared with controls in subgroup analyses of different types of placenta accreta spectrum disorder and those with placenta accreta spectrum disorder confirmed post partum.

Across the 35 studies that included data on blood transfusions, women who underwent any prophylactic radiologic intervention averaged fewer red blood cell units transferred than women who had no radiologic intervention, with a mean difference of 1.13, 1.90, and 1.86 units for distal prophylactic balloon occlusion, proximal prophylactic balloon occlusion, and prophylactic uterine artery embolization, respectively.

Data on adverse events related to the interventions were limited, but noted in approximately 2% of patients who underwent distal or proximal prophylactic balloon occlusion, and 45% of patients who underwent prophylactic uterine artery embolization. One maternal death was reported and attributed to diffuse intravascular coagulation. Three cardiac arrests occurred in control patients across different studies and all were successfully resuscitated.

Most of the studies did not report data on the researchers’ predefined secondary outcomes, including shock, transfer to a higher level of care, coagulopathy, organ dysfunction, and patient-reported outcomes.
 

What Works Best

“Our main analysis reveals differences in outcomes among the three interventions, with proximal balloon occlusion demonstrating the strongest effect,” the researchers wrote. “Our results show a blood loss reduction of 406 mL by distal prophylactic balloon occlusion. An explanation for the differences between the results of prophylactic balloon occlusion–distal and prophylactic balloon occlusion–proximal could be that implementing occlusion at a distal level may be less effective because of bleeding from the collateral circulation,” they said.

The findings were limited by several factors including the observational design of most of the studies, variation in measurements of blood loss among studies and in inclusion criteria, and insufficient adverse event data to draw conclusions about safety, the researchers noted. More research is needed to examine efficacy and safety of the interventions according to different sensitivities of placenta accreta spectrum disorder, they added.

Results Support Judicious Intervention

“Although previous studies showed mixed results, our meta-analysis demonstrated that prophylactic radiologic interventions, particularly balloon occlusion (both distal and proximal), were associated with reduced perioperative blood loss and less red blood cell unit transfusion; this was most pronounced in women with confirmed placenta percreta,” Bonsen said in an interview. However, the heterogeneity across the included studies prevents generalizations about the overall effects of the interventions across different severities of placenta accreta spectrum disorder, she said.*

Despite these limitations, the overview of the currently available evidence provides insights for clinical decision making, said Bonsen. “Our study highlights that, if we were to be certain of the diagnosis of placenta accreta spectrum disorder antepartum, prophylactic radiologic intervention could help reduce peripartum blood loss,” she said.

Risks vs Benefits

“Given the challenges in performing randomized surgical trials in a pregnant patient population with an uncommon disorder, this level of evidence provides important data to assist with clinical decision making in patients with placenta accreta spectrum disorder,” despite the limitations of the observational studies, wrote Jocelyn S. Chapman, MD, and Arianna M. Cassidy, MD, both affiliated with the Multidisciplinary Approach to Placenta Accreta Spectrum Disorder Service (MAPS) at the University of California, San Francisco, in an accompanying editorial.

Previous research has shown an increased risk of severe maternal morbidity among women with placenta accreta spectrum disorder and previous intervention strategies have involved protocols, surgical techniques, and management strategies, they wrote.

Uterine artery embolization after cesarean delivery also has been associated with reduced hemorrhage and no adverse events, but this procedure was not included in the studies reviewed and is best conducted in a delivery setup not available in many hospital systems, the editorialists noted.

The current study illustrates the value of prophylactic balloon occlusion and placement of vascular sheaths to reduce blood loss and blood transfusion, but the risk of thrombosis and lumbosacral pain must be considered, they said. These risks may be a reasonable trade-off to avoid severe blood loss and ICU care, and to preserve the uterus, Chapman and Cassidy added.

“However, we would urge continued critical appraisal of each placenta accreta spectrum disorder case with a multidisciplinary team to evaluate the available evidence-based strategies most likely to mitigate clinically relevant complications while minimizing the introduction of new ones,” the editorialists concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Chapman and Dr. Cassidy had no financial conflicts to disclose.

*This story was updated on August 28, 2024.

Prophylactic placement of balloon catheters or sheaths prior to planned cesarean delivery may reduce blood loss in women with placenta accreta spectrum disorder, according to a new systematic review of more than 5,000 individuals.

Placenta accreta spectrum disorder occurs when the endometrial-myometrial interface of the uterus is damaged, wrote Lisanne R. Bonsen, MD, of Leiden University Medical Center, the Netherlands, and colleagues. As a result, the placenta fails to detach at the time of birth and can result in life-threatening postpartum hemorrhage, the researchers said.

The greater the depth of placental invasiveness, the more severe the maternal outcomes, the researchers noted. Previous cesarean delivery is the primary risk factor for placenta accreta spectrum disorder, and the incidence has increased along with the increased rates of cesarean delivery on a global level, they explained.

More research is needed on intrapartum strategies to improve maternal outcomes, and prophylactic radiologic intervention to reduce perioperative blood loss has been explored, the researchers wrote. However, placenta accreta spectrum disorder remains relatively rare in most pregnancy settings, and data on the effect of prophylactic radiologic interventions to reduce bleeding in this high-risk population are limited they said.

In the review published in Obstetrics & Gynecology, the researchers analyzed data from 50 studies of prophylactic radiologic interventions (48 observational studies and 2 randomized, controlled trials) including 5,962 women.

The primary outcome was perioperative blood loss; secondary outcomes included the number of red blood cells transferred within 24 hours after delivery, maternal mortality, adverse events related to the interventions, and surgical complications.

Blood loss was significantly lower in the intervention groups compared with the control groups for patients who underwent distal balloon occlusion (30 studies), proximal balloon occlusion (14 studies), or uterine artery embolization (5 studies), with mean differences in blood loss of 406 mL, 1,041 mL, and 936 mL, respectively.

Results were similar with lower blood loss for intervention patients compared with controls in subgroup analyses of different types of placenta accreta spectrum disorder and those with placenta accreta spectrum disorder confirmed post partum.

Across the 35 studies that included data on blood transfusions, women who underwent any prophylactic radiologic intervention averaged fewer red blood cell units transferred than women who had no radiologic intervention, with a mean difference of 1.13, 1.90, and 1.86 units for distal prophylactic balloon occlusion, proximal prophylactic balloon occlusion, and prophylactic uterine artery embolization, respectively.

Data on adverse events related to the interventions were limited, but noted in approximately 2% of patients who underwent distal or proximal prophylactic balloon occlusion, and 45% of patients who underwent prophylactic uterine artery embolization. One maternal death was reported and attributed to diffuse intravascular coagulation. Three cardiac arrests occurred in control patients across different studies and all were successfully resuscitated.

Most of the studies did not report data on the researchers’ predefined secondary outcomes, including shock, transfer to a higher level of care, coagulopathy, organ dysfunction, and patient-reported outcomes.
 

What Works Best

“Our main analysis reveals differences in outcomes among the three interventions, with proximal balloon occlusion demonstrating the strongest effect,” the researchers wrote. “Our results show a blood loss reduction of 406 mL by distal prophylactic balloon occlusion. An explanation for the differences between the results of prophylactic balloon occlusion–distal and prophylactic balloon occlusion–proximal could be that implementing occlusion at a distal level may be less effective because of bleeding from the collateral circulation,” they said.

The findings were limited by several factors including the observational design of most of the studies, variation in measurements of blood loss among studies and in inclusion criteria, and insufficient adverse event data to draw conclusions about safety, the researchers noted. More research is needed to examine efficacy and safety of the interventions according to different sensitivities of placenta accreta spectrum disorder, they added.

Results Support Judicious Intervention

“Although previous studies showed mixed results, our meta-analysis demonstrated that prophylactic radiologic interventions, particularly balloon occlusion (both distal and proximal), were associated with reduced perioperative blood loss and less red blood cell unit transfusion; this was most pronounced in women with confirmed placenta percreta,” Bonsen said in an interview. However, the heterogeneity across the included studies prevents generalizations about the overall effects of the interventions across different severities of placenta accreta spectrum disorder, she said.*

Despite these limitations, the overview of the currently available evidence provides insights for clinical decision making, said Bonsen. “Our study highlights that, if we were to be certain of the diagnosis of placenta accreta spectrum disorder antepartum, prophylactic radiologic intervention could help reduce peripartum blood loss,” she said.

Risks vs Benefits

“Given the challenges in performing randomized surgical trials in a pregnant patient population with an uncommon disorder, this level of evidence provides important data to assist with clinical decision making in patients with placenta accreta spectrum disorder,” despite the limitations of the observational studies, wrote Jocelyn S. Chapman, MD, and Arianna M. Cassidy, MD, both affiliated with the Multidisciplinary Approach to Placenta Accreta Spectrum Disorder Service (MAPS) at the University of California, San Francisco, in an accompanying editorial.

Previous research has shown an increased risk of severe maternal morbidity among women with placenta accreta spectrum disorder and previous intervention strategies have involved protocols, surgical techniques, and management strategies, they wrote.

Uterine artery embolization after cesarean delivery also has been associated with reduced hemorrhage and no adverse events, but this procedure was not included in the studies reviewed and is best conducted in a delivery setup not available in many hospital systems, the editorialists noted.

The current study illustrates the value of prophylactic balloon occlusion and placement of vascular sheaths to reduce blood loss and blood transfusion, but the risk of thrombosis and lumbosacral pain must be considered, they said. These risks may be a reasonable trade-off to avoid severe blood loss and ICU care, and to preserve the uterus, Chapman and Cassidy added.

“However, we would urge continued critical appraisal of each placenta accreta spectrum disorder case with a multidisciplinary team to evaluate the available evidence-based strategies most likely to mitigate clinically relevant complications while minimizing the introduction of new ones,” the editorialists concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Chapman and Dr. Cassidy had no financial conflicts to disclose.

*This story was updated on August 28, 2024.

Prophylactic placement of balloon catheters or sheaths prior to planned cesarean delivery may reduce blood loss in women with placenta accreta spectrum disorder, according to a new systematic review of more than 5,000 individuals.

Placenta accreta spectrum disorder occurs when the endometrial-myometrial interface of the uterus is damaged, wrote Lisanne R. Bonsen, MD, of Leiden University Medical Center, the Netherlands, and colleagues. As a result, the placenta fails to detach at the time of birth and can result in life-threatening postpartum hemorrhage, the researchers said.

The greater the depth of placental invasiveness, the more severe the maternal outcomes, the researchers noted. Previous cesarean delivery is the primary risk factor for placenta accreta spectrum disorder, and the incidence has increased along with the increased rates of cesarean delivery on a global level, they explained.

More research is needed on intrapartum strategies to improve maternal outcomes, and prophylactic radiologic intervention to reduce perioperative blood loss has been explored, the researchers wrote. However, placenta accreta spectrum disorder remains relatively rare in most pregnancy settings, and data on the effect of prophylactic radiologic interventions to reduce bleeding in this high-risk population are limited they said.

In the review published in Obstetrics & Gynecology, the researchers analyzed data from 50 studies of prophylactic radiologic interventions (48 observational studies and 2 randomized, controlled trials) including 5,962 women.

The primary outcome was perioperative blood loss; secondary outcomes included the number of red blood cells transferred within 24 hours after delivery, maternal mortality, adverse events related to the interventions, and surgical complications.

Blood loss was significantly lower in the intervention groups compared with the control groups for patients who underwent distal balloon occlusion (30 studies), proximal balloon occlusion (14 studies), or uterine artery embolization (5 studies), with mean differences in blood loss of 406 mL, 1,041 mL, and 936 mL, respectively.

Results were similar with lower blood loss for intervention patients compared with controls in subgroup analyses of different types of placenta accreta spectrum disorder and those with placenta accreta spectrum disorder confirmed post partum.

Across the 35 studies that included data on blood transfusions, women who underwent any prophylactic radiologic intervention averaged fewer red blood cell units transferred than women who had no radiologic intervention, with a mean difference of 1.13, 1.90, and 1.86 units for distal prophylactic balloon occlusion, proximal prophylactic balloon occlusion, and prophylactic uterine artery embolization, respectively.

Data on adverse events related to the interventions were limited, but noted in approximately 2% of patients who underwent distal or proximal prophylactic balloon occlusion, and 45% of patients who underwent prophylactic uterine artery embolization. One maternal death was reported and attributed to diffuse intravascular coagulation. Three cardiac arrests occurred in control patients across different studies and all were successfully resuscitated.

Most of the studies did not report data on the researchers’ predefined secondary outcomes, including shock, transfer to a higher level of care, coagulopathy, organ dysfunction, and patient-reported outcomes.
 

What Works Best

“Our main analysis reveals differences in outcomes among the three interventions, with proximal balloon occlusion demonstrating the strongest effect,” the researchers wrote. “Our results show a blood loss reduction of 406 mL by distal prophylactic balloon occlusion. An explanation for the differences between the results of prophylactic balloon occlusion–distal and prophylactic balloon occlusion–proximal could be that implementing occlusion at a distal level may be less effective because of bleeding from the collateral circulation,” they said.

The findings were limited by several factors including the observational design of most of the studies, variation in measurements of blood loss among studies and in inclusion criteria, and insufficient adverse event data to draw conclusions about safety, the researchers noted. More research is needed to examine efficacy and safety of the interventions according to different sensitivities of placenta accreta spectrum disorder, they added.

Results Support Judicious Intervention

“Although previous studies showed mixed results, our meta-analysis demonstrated that prophylactic radiologic interventions, particularly balloon occlusion (both distal and proximal), were associated with reduced perioperative blood loss and less red blood cell unit transfusion; this was most pronounced in women with confirmed placenta percreta,” Bonsen said in an interview. However, the heterogeneity across the included studies prevents generalizations about the overall effects of the interventions across different severities of placenta accreta spectrum disorder, she said.*

Despite these limitations, the overview of the currently available evidence provides insights for clinical decision making, said Bonsen. “Our study highlights that, if we were to be certain of the diagnosis of placenta accreta spectrum disorder antepartum, prophylactic radiologic intervention could help reduce peripartum blood loss,” she said.

Risks vs Benefits

“Given the challenges in performing randomized surgical trials in a pregnant patient population with an uncommon disorder, this level of evidence provides important data to assist with clinical decision making in patients with placenta accreta spectrum disorder,” despite the limitations of the observational studies, wrote Jocelyn S. Chapman, MD, and Arianna M. Cassidy, MD, both affiliated with the Multidisciplinary Approach to Placenta Accreta Spectrum Disorder Service (MAPS) at the University of California, San Francisco, in an accompanying editorial.

Previous research has shown an increased risk of severe maternal morbidity among women with placenta accreta spectrum disorder and previous intervention strategies have involved protocols, surgical techniques, and management strategies, they wrote.

Uterine artery embolization after cesarean delivery also has been associated with reduced hemorrhage and no adverse events, but this procedure was not included in the studies reviewed and is best conducted in a delivery setup not available in many hospital systems, the editorialists noted.

The current study illustrates the value of prophylactic balloon occlusion and placement of vascular sheaths to reduce blood loss and blood transfusion, but the risk of thrombosis and lumbosacral pain must be considered, they said. These risks may be a reasonable trade-off to avoid severe blood loss and ICU care, and to preserve the uterus, Chapman and Cassidy added.

“However, we would urge continued critical appraisal of each placenta accreta spectrum disorder case with a multidisciplinary team to evaluate the available evidence-based strategies most likely to mitigate clinically relevant complications while minimizing the introduction of new ones,” the editorialists concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Chapman and Dr. Cassidy had no financial conflicts to disclose.

*This story was updated on August 28, 2024.