I posted this link in 2019 – this nearby house continues with pretty cool lights, though they change their songs each year. There are more than 25,000 lights which are synchronized to music. Cool stuff! Here’s a 1 minute clip: Holiday Lights 2019
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Last year I posted a list of some of my favorite books. Here are a few of my favorite that I read from the past year (not in any particular preference order):
With the widespread adoption of GLP-1 RAs, there have been increasing reports of adverse effects. This systematic review/meta-analysis (with 55 randomized controlled trials involving 106,395 participants) more fully describes the likelihood of GI adverse events.
Key findings:
GLP-1RAs increased the risk of cholelithiasis (risk ratio [RR], 1.46; 95% CI, 1.09–1.97; 2 more cases per 1000) and probably increased the risk of GERD (RR, 2.19; 95% CI, 1.48–3.25; 4 more cases per 1000) compared with placebo
GLP-1RAs probably have little or no effect on the risk of other gastrointestinal or biliary events
Figures 2 & 3 use a Forest plot to look at a large number of potential adverse gastrointestinal/biliary events. For example, cholecystitis and cholangitis had increased RR at 1.17 and 1.54 respectively. However neither reached statistical significance.
My take: GLP-1 RAs definitely cause adverse gastrointestinal effects, especially nausea, vomiting, diarrhea, bloating and reduced appetite. More severe adverse effects are quite uncommon and are unlikely to influence the decision to use these medications.
“The Food and Drug Administration on Monday approved a pill version of Wegovy…The Wegovy pill, as it’s called, is first oral version of a GLP-1 drug that has been brought to market for weight loss…
In November, Novo Nordisk reached a deal with the Trump administration to sell the lowest dose of the pill for $149 a month for people who pay out of pocket, in exchange for tariff relief…
Phase 3 clinical trial results published in the New England Journal of Medicine found that people who took the highest dose of the Wegovy pill lost 16.6% of their body weight, on average, after 64 weeks, compared with 2.2% weight loss in the placebo group…
The company expects that the Wegovy pill will be available widely in January.”
This was a multicenter, retrospective, case-control study of patients hospitalized with ASUC who underwent colectomy, comparing patients treated with tofacitinib (n=41) prior to colectomy with infliximab-treated controls (n=68).
Key findings:
Compared with tofacitinib-treated patients, infliximab-treated patients had higher overall rates of overall (44 [64.7%] vs 13 [31.7%]; P = .002) and serious (19 [27.9%] vs 3 [12%]; P = .019) postoperative complications
My take: This study supports the safety of JAK inhibitor therapy for ASUC. It showed a significantly lower rate of overall postoperative complications in ASUC patients treated with tofacitinib compared with infliximab; the authors note that “these findings can likely be extrapolated to upadacitinib, a selective JAK inhibitor, given its similar mechanism of action.”
Background: “Recent seminal studies such as the ESSENCE trial have demonstrated MASH resolution with improvement in fibrosis in adult patients with biopsy-proven steatohepatitis treated with semaglutide.18 This has led to the pivotal FDA approval of semaglutide for the treatment of MASH in adults.”
Methods: 42 patients with MASLD (see study for details). 71% of patients had a therapeutic indication for T2DM and 29% for obesity. Of the GLP-1RA medications, liraglutide was most frequently prescribed (44%), followed by semaglutide (27%), dulaglutide (25%), and exenatide (4%).
Key findings:
ALT improved by a mean of 56 U/L at 6 months (p = 0.04), and by 37 U/L at en-of-treatment (p = 0.004).
GLP-1RA use was associated with significant improvements in alanine transaminase (ALT) along with other cardiometabolic biomarkers even in the absence of improvements in body mass index percentile or z-score. There were reductions in GGT, AST, triglycerides, and HbA1C
In this study, there was not a significant decline in weight. Prior studies have shown less weight loss in patients with T2DM compared to those with obesity (w/o T2DM)
My take: It is helpful to have a pediatric study that shows that GLP1-RAs are effective specifically in those with MASLD.
This article focuses on the experience of a transgender patient who recorded unfavorable remarks while under anesthesia.
An excerpt:
On the recording, the health care workers express a variety of opinions about transgender identity more generally….And in the middle of the conversation, one person suggests updating Ms. Capasso’s medical file. “Yeah, it needs to say ‘male,’” the person says.Ms. Capasso said it appeared that hospital staff had in fact changed her electronic medical records, all while she was unconscious…
Ms. Capasso insists that she was not trying to catch the medical staff speaking disrespectfully about her. She said she was motivated by curiosity and a desire to know exactly what the surgeons discovered. It may not be such an unusual impulse.
Dr. Alexander Langerman, a surgeon at Vanderbilt University Medical Center, led a medical conference in 2021 on surgical recordings.
There is often “a really strong desire by patients to know what happened to them in the operating room,” Dr. Langerman said. “And, I think, a valid right to know what happened.”
Surgery was once a relatively public event — operating rooms were called “theaters” for a reason. But infection control and malpractice litigation pulled the operating room out of public view.
“Operating rooms and surgery have become one of the most secretive environments in modern society,” said Dr. Teodor Grantcharov, a Stanford University professor who started a company that uses operating room recordings to improve patient safety and hospital efficiency.
My take: While a patient is under anesthesia, it is best to treat them in the same manner as if they were awake.
“The true test of a man’s character is what he does when no one is watching.”
This was a single center retrospective study examining children (n=202) undergoing EGD (2022-2024) to evaluate for celiac. Among those with low anti-TTG IgA titers, Group 1 (n=25) was EMA negative and Group 2 (n=100) was EMA positive.
Key findings:
The finding of discordant serology (anti-transglutaminase [anti-TG] positive and EMA negative) is infrequent (12% cases, 25 out of 202), and all patients with discordant serology had anti-TG positive at low titer (<4 times the upper limit of normality).
Group 1 (N = 25) had a mean anti-TG titer of 1.86× ULN and villous atrophy (VA) in only 8% (2/25). Group 2 (N = 100) had VA in 35% (35/100)
Percentage of patients with villous atrophy between EMA positive and EMA negative children.
Discussion Points:
The diagnosis of CD still requires performing an EGD in at least half of the cases
This “study suggests that patients with low levels of anti-TG but EMA positive antibodies should anyway receive an EGDS in the next 6 months, since in around one-third of the cases a duodenal atrophy will be detected”
In those with low anti-TG but EMA negative, ” it could be reasonable to initially follow-up patients over time with clinical and serological monitoring (in particular of anti-TG titer), postponing the EGDS to a later stage, when the disease is more advanced and the chance of finding a concomitant VA (and thus the need to start a GFD) is higher”
My take: In patients with minimal symptoms and low level anti-TG, my strategy has been to follow with serological monitoring and if repeatedly abnormal, proceed with endoscopy. This study suggests that obtaining EMA early may influence choice to proceed earlier with endoscopy.
The guideline panel agreed on 16 recommendations. This highly-detailed report provides a comprehensive, patient-centered, evidence-based approach to the pharmacologic management of adult patients with moderate-to-severely active CD. Table 1 summarizes this lengthy 53-page report. Tomorrow’s post will be the “spotlight” summary which presents the recommendations in easier to read graphic.
Key Points:
The guidelines are overall very helpful. They identify higher efficacy medications and recommend them. In addition, they support the use of combination therapy with thiopurines (which are less frequently used in pediatrics). It is interesting that the sixteenth recommendation clashes with prior expert recommendations. The sixteenth recommendation in this report makes no recommendation on using endoscopic surveillance compared to symptomatic clinical remission. Most experts advise “treat-to-target” therapy approaches.
In the discussion of this, the authors state the followiing:
“Recent position statements from an international consortium of experts have advised that longitudinal targets for the management of IBD should include not only clinical remission but also endoscopic resolution of inflammation.31 Several studies have demonstrated that patients who achieve endoscopic remission (vs those with ongoing endoscopic activity) have favorable long-term outcomes…
There are limited RCTs assessing whether there is actual benefit in systematically treating toward endoscopic remission target vs symptomatic remission targets (ie, testing whether the target has been achieved, followed by algorithmic treatment adjustment, including escalating index therapy, adding an immunomodulator, followed by switching to an alternative advanced therapy and surgery). There was significant heterogeneity among the 2 reviewed studies, both in terms of the advanced therapy used, algorithms for therapy modification, and the cadence and frequency of endoscopic monitoring that challenge interpretation. Based on the significant uncertainty of evidence with regard to improving maintenance of remission or reducing the risks of adverse events, the guideline panel could not make a recommendation in relation to selecting endoscopic targets over clinical targets.
It is worth emphasizing that in both of the included trials, the majority of individuals in the endoscopic healing arms were not able to meet the goal of endoscopic healing despite an algorithmic approach. For example, in STARDUST, only 11% of individuals achieved endoscopic remission.149…There are specific patient populations, such as those who have recently undergone intestinal resection,155 in which endoscopic evaluation may be particularly valuable in clinical decision making...
The benefit of a monitoring strategy incorporating biochemical monitoring over clinical monitoring alone was demonstrated in the CALM trial,152 and has been addressed in previous AGA guidelines on the role of biomarkers in patients with CD.12“
My take: These “living” guidelines are likely to be quite influential in selecting Crohn’s disease therapy. In pediatrics, ImproveCareNow provides a similar role of guiding treatment.
In this retrospective study with 985 ileocolonoscopies (2021-2024):
Methods: “Quality indicators were compared across groups using Kruskal–Wallis analyses. Multivariate modeling was performed to identify variables predicting terminal ileal intubation and TIIR ≥ 85%.”
Key findings:
Overall ileal intubation rate (TIIR) and cecal intubation rate (CIR) were 86.3% and 91.6%, respectively
Annual procedure volume ( APV ≥ 40) was identified as predictive for TIIR ≥ 85% (p < 0.01)
Faculty years’ experience (≥10 vs. <10 years) predicted shorter procedure duration (adjusted hazard ratio [confidence interval]: 1.40)
Adequate bowel prep was associated with higher TIIR (901% vs 76.7%), CIR (93.8% vs 86.0%) and shorter duration procedures (34 min vs 41 min)
a Presented as median (IQR) in minutes. b Includes only 967 combined esophagogastroduodenoscopy/ileocolonoscopy procedures without multiservice involvement. Bolded text and numbers reflect results demonstrating statistical significance
My take (borrowed in part from the authors): The authors state that “our findings suggest that a threshold of 40 annual procedures [ileocolonoscopies] is necessary to maintain high pediatric endoscopic quality.” While I agree that adequate procedural volume is helpful, there is a great deal of individual variation/ability. Particularly if the endoscopist has a lower procedural volume, metrics like ileal intubation rate can be useful to assure good quality.
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