A single negative colonoscopy associated with long-lasting and significantly reduced cancer incidenceby American College of Physicians
Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.
1. A single negative colonoscopy associated with long-lasting and significantly reduced cancer incidence and mortality
Study findings suggest that CRC screening interval might safely be extended
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Having a single negative high-quality screening colonoscopy was associated with reduced colorectal cancer (CRC) incidence and mortality (by 84 percent and 90 percent, respectively) for up to 17.4 years. These findings suggest that the currently recommended 10-year screening interval could safely be extended. Findings from an observational study are published in Annals of Internal Medicine.
Current guidelines recommend a 10-year interval between negative screening colonoscopies for average-risk adults. This recommendation is based on estimates of time between adenoma and carcinoma, as well as extrapolations from studies assessing colonoscopy sensitivity. A lack of long-term data makes it challenging to determine the optimal screening interval following a normal colonoscopy.
Researchers from The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland studied a screening registry for 165,887 individuals to assess the long-term risk for CRC and death from CRC after high- and low-quality single negative screening colonoscopy. The researchers found that a single negative screening colonoscopy was associated with a significantly reduced CRC incidence and mortality over more than 17 years of follow-up, but only high-quality colonoscopy provided a profound and stable reduction in both CRC incidence and mortality throughout follow-up period. High quality was key for the profound long-term efficacy of screening colonoscopy in the proximal colon, and among women. The researchers point out that these findings are of paramount importance, because previous reports have questioned the efficacy of colonoscopy in the proximal colon and of screening sigmoidoscopy in women. These findings suggest that the currently recommended 10-year interval for screening colonoscopy is safe and could potentially be extended.
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2. Aldosterone production is a common and unrecognized cause of high blood pressure
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Findings from a cross-sectional study published in Annals of Internal Medicine implicate the hormone aldosterone as a common and unrecognized contributor to hypertension.
Hypertension affects more than 1.5 billion people worldwide and is arguably the leading preventable cause of heart disease and stroke. Primary aldosteronism is a condition where the adrenal glands produce too much of the hormone aldosterone, which causes high blood pressure and cardiovascular disease. Primary aldosteronism has traditionally been considered to be an uncommon cause of hypertension, however, the findings of this study show that it is much more common than previously recognized.
Researchers from four academic medical centers (including Brigham and Women's Hospital, University of Alabama, University of Virginia, and University of Utah) studied patients with normotension (n = 289), stage 1 hypertension (n = 115), stage 2 hypertension (n = 203), and resistant hypertension (n = 408) to determine the prevalence of excess aldosterone production and primary aldosteronism. They found that there was a continuum of excess aldosterone production that paralleled the severity of blood pressure. Importantly, most of this excess aldosterone production would have not been recognized by currently recommended diagnostic approaches. According to the authors, this finding supports the need to redefine primary aldosteronism from a rare disease to, instead, a common syndrome that manifests across a broad severity spectrum and may be a primary cause of hypertension. Since generic medications that block the deleterious effects of aldosterone already exist and are easily available, these findings suggest that using these drugs more frequently to treat hypertension may be an effective way to lower the risk of cardiovascular disease.
The author of an accompanying editorial, Professor John Funder, who currently chairs the international guidelines for the diagnosis and management of primary aldosteronism, called the study a "game changer" and indicated that these findings should trigger a "radical reconstruction" of current clinical practice and guideline recommendations.
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3. Liraglutide provides excellent glucose control in patients with type 2 diabetes and cirrhosis, but should we optimize the prevention of variceal bleeding?
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The glucagon-like peptide-1 (GLP-1) agonist drug, liraglutide, seems to provide excellent glucose control in patients with type 2 diabetes who are also taking a beta-blocker, specifically propranolol, to prevent bleeding from esophageal varices due to cirrhosis, but it seems to hamper the pharmacological effects of beta-blockers. A case report is published in Annals of Internal Medicine.
When using beta-blockers to prevent bleeding from esophageal varices, clinicians use the resting heart rate as a guide, as these therapies lower heart rate. GLP-1s are used to treat diabetes because they lower blood glucose levels and are especially useful when the patient is obese and has nonalcoholic fatty liver disease, but they are known to increase heart rate, although not significantly. No data are available on the concomitant treatment with GLP-1 analogues and β-blockers in patients with cirrhosis and diabetes.
Researchers from University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy studied 18 consecutive patients with cirrhosis who were receiving propranolol to prevent variceal bleeding while also receiving liraglutide for uncontrolled type 2 diabetes. Liraglutide provided optimal control of blood glucose, HbA1c and body weight, but the researchers observed a lack of optimal effect of beta-blockers on heart rate after starting a GLP-1 receptor agonist. However, in this small cohort no increase in bleeding rate was observed. The researchers propose a mechanistic molecular explanation of how a GLP-1 receptor agonist might prevent beta-adrenergic receptor blockade.
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