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Displaying 251 - 260 of 378 in Annals of Internal Medicine
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Comparative Effectiveness of Glucagon-like Peptide-1 Receptor Agonists Versus Oral Agents for Insulin Discontinuation in Type 2 Diabetes: A Target Trial Emulation: Annals of Internal Medicine: Vol 179, No 8
Background: Addition of glucagon-like peptide-1 receptor agonists (GLP-1RAs) to basal insulin can decrease insulin requirements, but whether it permits insulin discontinuation is unclear. Objective: To compare rates of insulin discontinuation among patients with type 2 diabetes (T2D) receiving basal insulin who initiated treatment with a GLP-1RA, sodium–glucose cotransporter-2 inhibitor (SGLT-2i), or dipeptidyl peptidase-4 inhibitor (DPP-4i) between 2020 and 2022. Design: Target trial emulation. Setting: U.S. Veterans Health Administration electronic health record (EHR) data. Participants: Veterans with T2D receiving basal insulin. Measurements: Insulin discontinuation, defined as the first gap in insulin prescription fills of 12 months or more over 3 years of follow-up. Results: Among 8869 matched sets of GLP-1RA (76.6% semaglutide, 15.2% dulaglutide, 7.9% liraglutide, and 0.3% exenatide), SGLT-2i (99.7% empagliflozin), and DPP-4i (95.9% alogliptin) initiators, 63% were 65 years or older, 93% were male, 70% were White, and 48% had a hemoglobin A1c (HbA1c) level of 9% or more. Over 3 years of follow-up, 1480 (16.7%) GLP-1RA initiators compared with 1585 (17.9%) SGLT-2i initiators and 1517 (17.1%) DPP-4i initiators discontinued insulin therapy in the intention-to-treat analysis (risk ratio, 0.93 [95% CI, 0.86 to 1.01] and 0.98 [CI, 0.87 to 1.09] for the GLP-1RA arm compared with the SGLT-2i and DPP-4i arms, respectively). Results were not substantively different in a modified per protocol analysis. None of the subgroups showed a comparative advantage of GLP-1RAs with respect to insulin discontinuation over SGLT-2is or DPP-4is. Limitation: Possible residual confounding; misclassification of exposure and outcome using EHRs may bias associations toward the null. Conclusion: Among veterans with T2D receiving basal insulin therapy, addition of GLP-1RA did not increase the chances of stopping insulin therapy compared with SGLT-2i or DPP-4i therapy. Primary Funding Source: U.S. Department of Veterans Affairs.
GLP-1RAs increase risk for cholelithiasis and GERD but not other GI or biliary adverse events vs. placebo
Clinical Impact Ratings GIM/FP/GP: 6 out of 7 Endocrinology: 6 out of 7 Gastroenterology: 6 out of 7
How Would You Manage This Patient With Idiopathic Acute Pancreatitis? Grand Rounds Discussion From Beth Israel Deaconess Medical Center
Acute pancreatitis is among the most frequent gastroenterologic reasons for hospitalization in the United States. This condition is associated with significant morbidity, including recurrent acute pancreatitis and chronic pancreatitis. Although most patient cases are due to biliary disease and ethanol, approximately 18% are idiopathic. Diagnostic and management options for idiopathic acute pancreatitis include genetic testing for a number of associated mutations and cholecystectomy to treat subclinical or undetected biliary disease. Endoscopic retrograde cholangiopancreatography, often with concomitant endoscopic sphincterotomy, is also sometimes considered in the management of idiopathic recurrent acute pancreatitis, although the role of this invasive procedure is generally limited. Here, 2 pancreatologists and coauthors of a recent American College of Gastroenterology guideline on the management of acute pancreatitis discuss issues related to genetic testing, cholecystectomy, and endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy for patients with acute idiopathic pancreatitis in general, and for a young woman recently diagnosed with this condition.
Low-Volume Polyethylene Glycol for Bowel Preparation in Hospitalized Adults: A Multicenter Randomized Trial: Annals of Internal Medicine: Vol 179, No 6
Background: Adequate bowel preparation is essential for high-quality colonoscopy but remains challenging in hospitalized patients, and comparative data on preparation volume are limited. Objective: To compare the efficacy, tolerability, and safety of very low-volume (1-liter [1L]), low-volume (2-liter [2L]), and high-volume (4-liter [4L]) polyethylene glycol (PEG) regimens for inpatient colonoscopy preparation. Design: Multicenter, randomized controlled, endoscopist-blinded trial. (EudraCT: 2019–002799–15; ClinicalTrials.gov: NCT04708366) Setting: Community and academic hospitals in Italy. Patients: Hospitalized adults undergoing elective colonoscopy. Intervention: Patients were randomly assigned (1:1:1) to split-dose 1L PEG-ascorbate, 2L PEG-ascorbate, or 4L PEG. Measurements: Primary end point was adequate bowel cleansing (Boston Bowel Preparation Scale [BBPS] score ≥6 with all segments ≥2). Secondary end points included high-quality cleansing (BBPS score, 8 to 9), high-quality right-colon cleansing (BBPS score, 3), and willingness to repeat. Results: Among 665 randomly assigned patients (1L, n = 228; 2L, n = 218; 4L, n = 219), adequate overall cleansing occurred in 82.0%, 78.0%, and 78.5% (absolute difference between the 1L and 2L groups [Δ1L–2L], 4.0 percentage points [95% CI, −3.4 to 11.4 percentage points]; absolute difference between the 1L and 4L groups [Δ1L–4L], 3.5 percentage points [CI, −3.9 to 10.9 percentage points]). High-quality overall cleansing occurred in 46.9%, 35.3%, and 37.4% (Δ1L–2L, 11.6 percentage points [CI, 2.5 to 20.5 percentage points]; Δ1L–4L, 9.5 percentage points [CI, 0.3 to 18.5 percentage points]). High-quality right-colon cleansing occurred in 40.6%, 29.5%, and 31.6% (Δ1L–2L, 11.2 percentage points [CI, 2.1 to 20.0 percentage points]; Δ1L–4L, 9.0 percentage points [CI, 0.0 to 17.9 percentage points]). Tolerability was good across regimens, with the highest willingness to repeat in the 1L group (84.2%), despite more frequent vomiting and thirst. Limitation: Patients requiring urgent colonoscopy for active gastrointestinal bleeding and those with severe/unstable comorbid conditions were excluded. Conclusion: In hospitalized adults undergoing elective colonoscopy, 1L PEG-ascorbate yielded higher rates of high-quality cleansing, including right colon, than 2L PEG-ascorbate and 4L PEG, with similar rates of adequate cleansing and high willingness to repeat. Primary Funding Source: Norgine Srl.
Iron Deficiency Anemia
Iron deficiency anemia (IDA) is caused by iron deficiency, a common yet underrecognized clinical entity. Populations at greatest risk include children, menstruating and pregnant persons, and people of low socioeconomic status. Timely diagnosis and management of iron deficiency are key to preventing IDA and require thorough assessment of the underlying cause and appropriate iron repletion through either oral or parenteral therapy. Blood transfusion does not provide adequate elemental iron but is sometimes indicated along with iron therapy in patients with cardiovascular compromise, active bleeding, or severe anemia where more rapid correction is warranted. Alternative causes of anemia can be differentiated by red blood cell morphology and reticulocyte count and should be considered if anemia persists despite adequate repletion of iron stores.
Comparative Effectiveness of Carvedilol Versus Other Nonselective β-Blockers in Cirrhosis
Background: In cirrhosis, nonselective β-blockers (NSBBs; carvedilol, nadolol, and propranolol) reduce hepatic portal pressure and have demonstrated benefit versus placebo for preventing decompensation. Although carvedilol has emerged as the preferred NSBB, direct evidence remains limited about its effectiveness for preventing decompensation and death versus other NSBBs. Objective: To compare the effectiveness of carvedilol versus nadolol versus propranolol in cirrhosis. Design: Database cohort study. Setting: A U.S. administrative claims database, Optum Clinformatics Data Mart (2013 to 2025). Participants: Adults with cirrhosis initiating carvedilol, nadolol, or propranolol. Measurements: The primary outcome was a composite of hospitalization for major decompensation (ascites, spontaneous bacterial peritonitis [SBP], hepatorenal syndrome [HRS], hepatic encephalopathy, or variceal hemorrhage). Absolute risk differences (RDs) and risk ratios (RRs) at 6 months of follow-up were estimated using inverse probability of treatment weighting accounting for 129 preexposure covariates. Results: Carvedilol initiators had meaningfully lower 6-month risk for major decompensation events compared with nadolol (RD, −3.69 percentage points [95% CI, −5.33 to −2.09 percentage points]; RR, 0.80 [CI, 0.72 to 0.88]) or propranolol (RD, −2.88 percentage points [CI, −4.29 to −1.49 percentage points]; RR, 0.83 [CI, 0.76 to 0.90]). This included substantially lower 6-month risk for specific decompensation events with carvedilol compared with nadolol or propranolol, including reduced risk for variceal hemorrhage (RDs, −3.51 percentage points [CI, −4.79 to −2.20 percentage points] and −1.65 percentage points [CI, −2.71 to −0.59 percentage points], respectively) and ascites, SBP, or HRS (RDs, −3.05 percentage points [CI, −4.52 to −1.75 percentage points] and −1.58 percentage points [CI, −2.77 to −0.44 percentage points], respectively). Limitation: Nonrandomized treatment selection. Conclusion: Among U.S. patients with cirrhosis, carvedilol initiation—as opposed to nadolol or propranolol—was associated with meaningfully lower rates of major decompensation events. Primary Funding Source: National Institutes of Health.
Physicians Are Not Providers: The Ethical Significance of Names in Health Care: A Policy Paper From the American College of Physicians
More than 25 years ago, Pellegrino and Relman noted the increasing commercialization of the learned professions, anticipating what many physicians are increasingly experiencing today: an impairment of their ability to practice in accordance with standards of medical ethics and professionalism. These hurdles to the physician’s ability to do right by the patient contribute to what leaders in medicine and the American College of Physicians have called deprofessionalization. An example is the use of the term provider to describe physicians and other health professionals. The use of this terminology has been reviewed in medical journal articles but has not been adequately explored as a matter of ethics and professionalism. Through that lens, this paper examines the trends, significance, and implications for patients, physicians, and health care of the use of the term provider.
In primary CDI, fecal microbiota transplantation was noninferior to vancomycin for clinical cure at 14 d without recurrence at 60 d
Clinical Impact Ratings GIM/FP/GP: 6 out of 7 Gastroenterology: 5 out of 7 Infectious Disease: 6 out of 7
The Legal and Ethical Framework for Artificial Intelligence in Gastrointestinal Endoscopy: A World Endoscopy Organization International Consensus Statement
The OperA (Optimising Colorectal Cancer Prevention through Personalized Treatment with Artificial Intelligence) project aims to transform colorectal cancer care through artificial intelligence (AI) innovations. Recognizing that legal and ethical challenges remain key obstacles to clinical integration, this Delphi study sought to identify and prioritize such concerns in the context of gastrointestinal (GI) endoscopy. Fourteen international experts participated in a 2-round Delphi process. In round 1, the steering committee, with feedback from participants, proposed legal and ethical issues pertaining to AI in endoscopy. Round 2 involved iterative rating and refinement of these issues to achieve consensus on their importance. Consensus was reached on 10 key statements spanning 3 thematic domains: data governance, medicolegal implications, and equity and bias. Experts emphasized the need for robust data protection, transparent algorithmic development, and institutional clarity on data ownership. Liability concerns related to AI-assisted diagnosis and automated reporting were highlighted, alongside calls for guidance from legal and professional bodies. Finally, participants underscored the importance of demographic diversity in training data sets and transparent reporting practices to mitigate bias and ensure equitable AI deployment. As AI tools become increasingly integrated into the clinical practice of gastroenterology, addressing legal, ethical, and equity-related challenges is essential. This expert consensus provides a foundation for developing guidelines and regulatory frameworks to support responsible AI adoption in GI endoscopy.
In MASH with moderate or advanced liver fibrosis, weekly semaglutide improved histologic steatohepatitis and fibrosis at 72 wk
Clinical Impact Ratings GIM/FP/GP: 6 out of 7 Gastroenterology: 5 out of 7