Federal Practitioner

SEATTLE – A family of blockbuster drugs for managing blood glucose – and now for promoting weight loss – has been linked to exacerbation of macular disease that frequently accompanies diabetes, new data show.

Two studies presented at the annual meeting of the American Society of Retina Specialists (ASRS) have found that use of injectable agonists of glucagonlike peptide-1 (GLP1) appears to hasten the progression of diabetic retinopathy and diabetic macular edema (DME).

Clinicians should be aware of these effects of GLP-1 inhibitors to ensure appropriate monitoring of patients for the possibility that retinopathy may accelerate, according to Ehsan Rahimy, MD, an adjunct clinical professor at Stanford (Calif.) University, and colleagues.

Dr. Rahimy presented results of a retrospective study of retinopathy progression in patients taking either GLP-1 agonists or sodium-glucose transporter-2 (SGLT-2) inhibitors, also known as gliflozins. “When we looked at the conversion to proliferative disease, you can see it was statistically higher in the GLP-1 group at all time points,” he said.

GLP-1 agonists can promote considerable weight loss in patients with and without diabetes. Moreover, the finding that gliflozins improve cardiovascular and renal function in patients with type 2 diabetes has accelerated the use of these agents for blood glucose control.

Using a repository of data from more than 13,500 people taking either of the two kinds of medication, the researchers looked for conversion of diabetic eye disease to proliferative diabetic retinopathy (PDR) or DME. Secondary outcomes were the need for intravitreal injections, panretinal photocoagulation (PRP), or pars plana vitrectomy (PPV).

Propensity score matching for age, sex, race, ethnicity, and baseline hemoglobin A1c resulted in the inclusion of 5,446 participants in each treatment group. After matching, the mean age of participants in either group was 64 years, and the mean A1c was 8.5%. Slightly more than half the participants were insulin-dependent.

Patients taking GLP-1 inhibitors had higher rates of conversion to PDR than those taking gliflozins at 3 years (6% vs. 4%; P < .01), the researchers found. Nearly 25% of those taking a GLP-1 agonist had progressed to DME after 3 years, compared with 18% of those taking a gliflozin.

People in the group taking GLP-1 inhibitors also had a greater need for interventions than those on a gliflozin; 8% vs. roughly 6%, respectively, required intravitreal injections, Dr. Rahimy reported. Similar trends were noted for need for PRP and PPV, he added, although the absolute numbers of patients were small.
 

Albiglutide the key culprit?

In other research reported at the meeting, a meta-analysis of data collected in 93 randomized clinical trials of the seven currently available GLP-1 agonists found only albiglutide was associated with diabetic retinopathy to a statistically significant degree. Compared with placebo, albiglutide more than doubled the risk for early-stage diabetic retinopathy (relative risk 2.18; 95% confidence interval, 1.01-4.67; P = .05).

Other GLP-1 agonists evaluated in the meta-analysis included semaglutide, tirzepatide, dulaglutide, exenatide, liraglutide, and lixisenatide. These findings were reported in a poster presented at the meeting by Ishani Kapoor, MD candidate, Drexel University, Philadelphia.

“The strength of these effects depends on the specific GLP-1 receptor agonist used, patient-specific clinical characteristics, and demographics,” Ms. Kapoor and coauthors reported. “Further studies are needed to clarify the patient populations that would benefit from GLP-1 receptor agonists and those at risk for [the] development of additional ocular damage.”
 

What causes progression?

Whether worsening of retinopathy stems from rapid weight loss and acute reductions in concentrations of blood glucose or is a direct effect of GLP-1 agonists on the eye is unclear.

“That rapid reduction is thought to play some role,” Dr. Rahimy said. “But if you actually look out there in the basic science literature, it’s suggested that there are direct effects of these medications on the retina too. That being said, it’s suggested that they may be protective to the retina. And I think that’s where we’ve gotten a lot of mixed signals in our community between what we’ve seen on the basic science side vs. what we’re seeing on the real-world side.”

The study was independently funded. Dr. Rahimy reports consultancies or speakerships with AbbVie, Allergan, Apellis, Carl Zeiss, Genentech, and Google, and research support from Regeneron. Ms. Kapoor reports no relevant financial relationships.

A version of this article appeared on Medscape.com.

SEATTLE – A family of blockbuster drugs for managing blood glucose – and now for promoting weight loss – has been linked to exacerbation of macular disease that frequently accompanies diabetes, new data show.

Two studies presented at the annual meeting of the American Society of Retina Specialists (ASRS) have found that use of injectable agonists of glucagonlike peptide-1 (GLP1) appears to hasten the progression of diabetic retinopathy and diabetic macular edema (DME).

Clinicians should be aware of these effects of GLP-1 inhibitors to ensure appropriate monitoring of patients for the possibility that retinopathy may accelerate, according to Ehsan Rahimy, MD, an adjunct clinical professor at Stanford (Calif.) University, and colleagues.

Dr. Rahimy presented results of a retrospective study of retinopathy progression in patients taking either GLP-1 agonists or sodium-glucose transporter-2 (SGLT-2) inhibitors, also known as gliflozins. “When we looked at the conversion to proliferative disease, you can see it was statistically higher in the GLP-1 group at all time points,” he said.

GLP-1 agonists can promote considerable weight loss in patients with and without diabetes. Moreover, the finding that gliflozins improve cardiovascular and renal function in patients with type 2 diabetes has accelerated the use of these agents for blood glucose control.

Using a repository of data from more than 13,500 people taking either of the two kinds of medication, the researchers looked for conversion of diabetic eye disease to proliferative diabetic retinopathy (PDR) or DME. Secondary outcomes were the need for intravitreal injections, panretinal photocoagulation (PRP), or pars plana vitrectomy (PPV).

Propensity score matching for age, sex, race, ethnicity, and baseline hemoglobin A1c resulted in the inclusion of 5,446 participants in each treatment group. After matching, the mean age of participants in either group was 64 years, and the mean A1c was 8.5%. Slightly more than half the participants were insulin-dependent.

Patients taking GLP-1 inhibitors had higher rates of conversion to PDR than those taking gliflozins at 3 years (6% vs. 4%; P < .01), the researchers found. Nearly 25% of those taking a GLP-1 agonist had progressed to DME after 3 years, compared with 18% of those taking a gliflozin.

People in the group taking GLP-1 inhibitors also had a greater need for interventions than those on a gliflozin; 8% vs. roughly 6%, respectively, required intravitreal injections, Dr. Rahimy reported. Similar trends were noted for need for PRP and PPV, he added, although the absolute numbers of patients were small.
 

Albiglutide the key culprit?

In other research reported at the meeting, a meta-analysis of data collected in 93 randomized clinical trials of the seven currently available GLP-1 agonists found only albiglutide was associated with diabetic retinopathy to a statistically significant degree. Compared with placebo, albiglutide more than doubled the risk for early-stage diabetic retinopathy (relative risk 2.18; 95% confidence interval, 1.01-4.67; P = .05).

Other GLP-1 agonists evaluated in the meta-analysis included semaglutide, tirzepatide, dulaglutide, exenatide, liraglutide, and lixisenatide. These findings were reported in a poster presented at the meeting by Ishani Kapoor, MD candidate, Drexel University, Philadelphia.

“The strength of these effects depends on the specific GLP-1 receptor agonist used, patient-specific clinical characteristics, and demographics,” Ms. Kapoor and coauthors reported. “Further studies are needed to clarify the patient populations that would benefit from GLP-1 receptor agonists and those at risk for [the] development of additional ocular damage.”
 

What causes progression?

Whether worsening of retinopathy stems from rapid weight loss and acute reductions in concentrations of blood glucose or is a direct effect of GLP-1 agonists on the eye is unclear.

“That rapid reduction is thought to play some role,” Dr. Rahimy said. “But if you actually look out there in the basic science literature, it’s suggested that there are direct effects of these medications on the retina too. That being said, it’s suggested that they may be protective to the retina. And I think that’s where we’ve gotten a lot of mixed signals in our community between what we’ve seen on the basic science side vs. what we’re seeing on the real-world side.”

The study was independently funded. Dr. Rahimy reports consultancies or speakerships with AbbVie, Allergan, Apellis, Carl Zeiss, Genentech, and Google, and research support from Regeneron. Ms. Kapoor reports no relevant financial relationships.

A version of this article appeared on Medscape.com.

SEATTLE – A family of blockbuster drugs for managing blood glucose – and now for promoting weight loss – has been linked to exacerbation of macular disease that frequently accompanies diabetes, new data show.

Two studies presented at the annual meeting of the American Society of Retina Specialists (ASRS) have found that use of injectable agonists of glucagonlike peptide-1 (GLP1) appears to hasten the progression of diabetic retinopathy and diabetic macular edema (DME).

Clinicians should be aware of these effects of GLP-1 inhibitors to ensure appropriate monitoring of patients for the possibility that retinopathy may accelerate, according to Ehsan Rahimy, MD, an adjunct clinical professor at Stanford (Calif.) University, and colleagues.

Dr. Rahimy presented results of a retrospective study of retinopathy progression in patients taking either GLP-1 agonists or sodium-glucose transporter-2 (SGLT-2) inhibitors, also known as gliflozins. “When we looked at the conversion to proliferative disease, you can see it was statistically higher in the GLP-1 group at all time points,” he said.

GLP-1 agonists can promote considerable weight loss in patients with and without diabetes. Moreover, the finding that gliflozins improve cardiovascular and renal function in patients with type 2 diabetes has accelerated the use of these agents for blood glucose control.

Using a repository of data from more than 13,500 people taking either of the two kinds of medication, the researchers looked for conversion of diabetic eye disease to proliferative diabetic retinopathy (PDR) or DME. Secondary outcomes were the need for intravitreal injections, panretinal photocoagulation (PRP), or pars plana vitrectomy (PPV).

Propensity score matching for age, sex, race, ethnicity, and baseline hemoglobin A1c resulted in the inclusion of 5,446 participants in each treatment group. After matching, the mean age of participants in either group was 64 years, and the mean A1c was 8.5%. Slightly more than half the participants were insulin-dependent.

Patients taking GLP-1 inhibitors had higher rates of conversion to PDR than those taking gliflozins at 3 years (6% vs. 4%; P < .01), the researchers found. Nearly 25% of those taking a GLP-1 agonist had progressed to DME after 3 years, compared with 18% of those taking a gliflozin.

People in the group taking GLP-1 inhibitors also had a greater need for interventions than those on a gliflozin; 8% vs. roughly 6%, respectively, required intravitreal injections, Dr. Rahimy reported. Similar trends were noted for need for PRP and PPV, he added, although the absolute numbers of patients were small.
 

Albiglutide the key culprit?

In other research reported at the meeting, a meta-analysis of data collected in 93 randomized clinical trials of the seven currently available GLP-1 agonists found only albiglutide was associated with diabetic retinopathy to a statistically significant degree. Compared with placebo, albiglutide more than doubled the risk for early-stage diabetic retinopathy (relative risk 2.18; 95% confidence interval, 1.01-4.67; P = .05).

Other GLP-1 agonists evaluated in the meta-analysis included semaglutide, tirzepatide, dulaglutide, exenatide, liraglutide, and lixisenatide. These findings were reported in a poster presented at the meeting by Ishani Kapoor, MD candidate, Drexel University, Philadelphia.

“The strength of these effects depends on the specific GLP-1 receptor agonist used, patient-specific clinical characteristics, and demographics,” Ms. Kapoor and coauthors reported. “Further studies are needed to clarify the patient populations that would benefit from GLP-1 receptor agonists and those at risk for [the] development of additional ocular damage.”
 

What causes progression?

Whether worsening of retinopathy stems from rapid weight loss and acute reductions in concentrations of blood glucose or is a direct effect of GLP-1 agonists on the eye is unclear.

“That rapid reduction is thought to play some role,” Dr. Rahimy said. “But if you actually look out there in the basic science literature, it’s suggested that there are direct effects of these medications on the retina too. That being said, it’s suggested that they may be protective to the retina. And I think that’s where we’ve gotten a lot of mixed signals in our community between what we’ve seen on the basic science side vs. what we’re seeing on the real-world side.”

The study was independently funded. Dr. Rahimy reports consultancies or speakerships with AbbVie, Allergan, Apellis, Carl Zeiss, Genentech, and Google, and research support from Regeneron. Ms. Kapoor reports no relevant financial relationships.

A version of this article appeared on Medscape.com.

Some clinicians say it’s “confusing” and “ridiculous” to change the name and diagnostic criteria of an established liver disease, while others bemoan the seemingly political reasons why it happened. Yet recently, 236 panelists from 56 countries decided that the terms nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) rely on “exclusionary confounder terms and the use of potentially stigmatizing language.”

In a report published in Hepatology, the panelists, members of the NAFLD Nomenclature Consensus Group, determined that steatotic liver disease (SLD) would be used as an “overarching term to encompass the various etiologies of steatosis.”

Metabolic dysfunction–associated steatotic liver disease (MASLD) was chosen to replace NAFLD, and the definition was changed to include at least one of five cardiometabolic risk factors.

Metabolic dysfunction–associated steatohepatitis (MASH) replaces NASH. 

Those with no metabolic parameters and no known cause will be diagnosed with cryptogenic SLD.

A new category, MetALD, now describes those with MASLD who drink more alcohol per week – 140-350 g for men and 210-420 g for women.

The changes did not sit well with this news organization’s readers from diverse specialties, including family practice, critical care, and gastroenterology.

In its report, the consensus group wrote that 74% of respondents to its rounds of surveys felt the current nomenclature “was sufficiently flawed to consider a name change.”

The terms “nonalcoholic” and “fatty” were felt to be stigmatizing by 61% and 66% of respondents, respectively, according to the group, a multi-stakeholder effort under the auspices of the American Association for Study of Liver Disease and the European Association for Study of the Liver, in collaboration with the Asociación Latinoamericana para el Estudio del Hígado.

Consensus was defined a priori as a supermajority (67%) vote. 

“The new nomenclature and diagnostic criteria are widely supported, nonstigmatizing, and can improve awareness and patient identification,” the group concluded.

“No way” sums up many of the almost 60 reader comments received on this news organization’s story covering the change. Readers must share medical credentials to publicly comment on stories.
 

‘Confusing’ and ‘ridiculous’

A number of readers questioned how the changes will help practice.

“Once again, the specialists and other experts are changing the nomenclature to make the subject even more confusing for us primary care practitioners,” an HIV/AIDS physician wrote. “They obviously have no idea what [primary care practitioners] have to put up with day in and day out. All such revisions do is increase the cynicism and anger so many [primary care practitioners] have.”

Similarly, an internist said, “These new terms are going to confuse both doctors and patients. When you give a patient a diagnosis like this, they will not understand it, and will not be able to act as they should to correct it.”

“ ‘Fatty liver’ is a jargon-free diagnosis, easy to understand and easy for patients to know what they need to do,” the internist continued. “You think patients are gonna be educated when you tell them they have a ‘metabolic disease’? 100% they will not know what you’re talking about.”

Yet another wondered, “If SLD is the ‘umbrella’ term, why (are) MetALD and ALD not MetASLD and ASLD, respectively? Furthermore, efforts to ‘destigmatize’ terminology will inadvertently condemn cryptogenic SLD (CSLD) as the new ‘closet alcoholic.’ “

“Perhaps a subclassification, CSLD-HDIRDD (CSLD–Honest, Doc, I Really Don’t Drink),” the reader added.

“Everything about this is ridiculous,” a family physician wrote. “How long will it be until the experts change obesity to ‘gravitationally challenged’ as a diagnosis!”

“I was thinking of ‘circumferentially challenged,’” a reader in Canada chimed in. “But that would be ‘body shaming’ would it not?”

This reader continued, asking, “What about returning to the old practice of using Latin names patients don’t understand so there is no ‘shame’ attached to them? Or what about this revolutionary idea: To just say it as it is – fat?”
 

Acceding to ‘wokeness’

A sizable number of readers felt the name changes were motivated by a “woke” awareness.

“The effect of this new ‘woke’ clarity is ridiculous and simply not worth it! Can we justify the cost of this? Patients will have to learn all over again how to discuss their condition,” said one reader.

The reader continued, saying, “The Internet and social media freely use the term ‘fat’ – and despite not wanting to offend – there seems to be universal agreement that FAT, in certain conditions or places, is unhealthy and undesirable.

“Why is the medical community so afraid to tell it like it is? I might hurt your feelings, but I could save your life,” concluded the reader.
 

Defending change

One commentator, a hepatologist in France, defended the changes and responded to some of complaints.

“Maybe people who comment here should read the article, reflect, and understand the reasons why the old nomenclature and definition were scientifically inaccurate and needed to be changed,” the commentator wrote.

“It was an exclusionary, negative definition not recognizing the root of the disease (adipose tissue dysfunction with insulin resistance – instead defining it by what it is not ...) and not allowing the recognition of a large segment of the population [that] accumulates metabolic risk factors and moderate alcohol consumption. These patients were left out of all studies. Those were the main reasons for change and not the stigma part – with the word ‘fatty’ only being an issue in English-speaking countries, not elsewhere,” the commentator continued.

“Calls for change have been voiced for 20 years and a first comprehensive attempt (called MAFLD) was introduced 3 years ago (J Hepatol. 2020;73:202-9). Please, a little bit of respect and restraint in the comments recognizing the research efforts and publications for those that contributed to the field over the past 25 years ...” the hepatologist wrote.

The reader added, “Clinicians and researchers were dissatisfied for a long time, but it took years to gather overwhelming evidence demonstrating what causes the disease and then to kickstart a process under the auspices of several multinational scientific societies and come up with something consensually agreed upon by a large number of clinician researchers.

“Now you can tell your patient that he has metabolic liver disease instead of telling him that the problem at the root of his disease is that he is not drinking alcohol (nonalcoholic steatohepatitis). So, again, it is not so much about changing a name but about redefining diagnostic criteria and a nosological framework,” the reader wrote.

Other readers responded to the defender:

“This nomenclature issue has been churned for 20+ years? Well, the mountain has labored heavily, and given birth to a mouse,” one said.

“Still, how is this going to help in the clinical management? The whole gamut of conditions are evaluated and treated as a whole, not in isolation,” a general practitioner in India said. “If someone has a risk factor or not, continuous follow-up is required as a whole, whether it’s nonalcoholic or alcoholic, or whatever term is coined up.”

Finally, a family physician said, “It just rolls off the tongue, doesn’t it? But I have to admit, it’s the one place where ‘persons’ from 56 countries can get together and agree on something. Not even politicians can do that! Me, I’m sticking with NAFLD.”

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

Some clinicians say it’s “confusing” and “ridiculous” to change the name and diagnostic criteria of an established liver disease, while others bemoan the seemingly political reasons why it happened. Yet recently, 236 panelists from 56 countries decided that the terms nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) rely on “exclusionary confounder terms and the use of potentially stigmatizing language.”

In a report published in Hepatology, the panelists, members of the NAFLD Nomenclature Consensus Group, determined that steatotic liver disease (SLD) would be used as an “overarching term to encompass the various etiologies of steatosis.”

Metabolic dysfunction–associated steatotic liver disease (MASLD) was chosen to replace NAFLD, and the definition was changed to include at least one of five cardiometabolic risk factors.

Metabolic dysfunction–associated steatohepatitis (MASH) replaces NASH. 

Those with no metabolic parameters and no known cause will be diagnosed with cryptogenic SLD.

A new category, MetALD, now describes those with MASLD who drink more alcohol per week – 140-350 g for men and 210-420 g for women.

The changes did not sit well with this news organization’s readers from diverse specialties, including family practice, critical care, and gastroenterology.

In its report, the consensus group wrote that 74% of respondents to its rounds of surveys felt the current nomenclature “was sufficiently flawed to consider a name change.”

The terms “nonalcoholic” and “fatty” were felt to be stigmatizing by 61% and 66% of respondents, respectively, according to the group, a multi-stakeholder effort under the auspices of the American Association for Study of Liver Disease and the European Association for Study of the Liver, in collaboration with the Asociación Latinoamericana para el Estudio del Hígado.

Consensus was defined a priori as a supermajority (67%) vote. 

“The new nomenclature and diagnostic criteria are widely supported, nonstigmatizing, and can improve awareness and patient identification,” the group concluded.

“No way” sums up many of the almost 60 reader comments received on this news organization’s story covering the change. Readers must share medical credentials to publicly comment on stories.
 

‘Confusing’ and ‘ridiculous’

A number of readers questioned how the changes will help practice.

“Once again, the specialists and other experts are changing the nomenclature to make the subject even more confusing for us primary care practitioners,” an HIV/AIDS physician wrote. “They obviously have no idea what [primary care practitioners] have to put up with day in and day out. All such revisions do is increase the cynicism and anger so many [primary care practitioners] have.”

Similarly, an internist said, “These new terms are going to confuse both doctors and patients. When you give a patient a diagnosis like this, they will not understand it, and will not be able to act as they should to correct it.”

“ ‘Fatty liver’ is a jargon-free diagnosis, easy to understand and easy for patients to know what they need to do,” the internist continued. “You think patients are gonna be educated when you tell them they have a ‘metabolic disease’? 100% they will not know what you’re talking about.”

Yet another wondered, “If SLD is the ‘umbrella’ term, why (are) MetALD and ALD not MetASLD and ASLD, respectively? Furthermore, efforts to ‘destigmatize’ terminology will inadvertently condemn cryptogenic SLD (CSLD) as the new ‘closet alcoholic.’ “

“Perhaps a subclassification, CSLD-HDIRDD (CSLD–Honest, Doc, I Really Don’t Drink),” the reader added.

“Everything about this is ridiculous,” a family physician wrote. “How long will it be until the experts change obesity to ‘gravitationally challenged’ as a diagnosis!”

“I was thinking of ‘circumferentially challenged,’” a reader in Canada chimed in. “But that would be ‘body shaming’ would it not?”

This reader continued, asking, “What about returning to the old practice of using Latin names patients don’t understand so there is no ‘shame’ attached to them? Or what about this revolutionary idea: To just say it as it is – fat?”
 

Acceding to ‘wokeness’

A sizable number of readers felt the name changes were motivated by a “woke” awareness.

“The effect of this new ‘woke’ clarity is ridiculous and simply not worth it! Can we justify the cost of this? Patients will have to learn all over again how to discuss their condition,” said one reader.

The reader continued, saying, “The Internet and social media freely use the term ‘fat’ – and despite not wanting to offend – there seems to be universal agreement that FAT, in certain conditions or places, is unhealthy and undesirable.

“Why is the medical community so afraid to tell it like it is? I might hurt your feelings, but I could save your life,” concluded the reader.
 

Defending change

One commentator, a hepatologist in France, defended the changes and responded to some of complaints.

“Maybe people who comment here should read the article, reflect, and understand the reasons why the old nomenclature and definition were scientifically inaccurate and needed to be changed,” the commentator wrote.

“It was an exclusionary, negative definition not recognizing the root of the disease (adipose tissue dysfunction with insulin resistance – instead defining it by what it is not ...) and not allowing the recognition of a large segment of the population [that] accumulates metabolic risk factors and moderate alcohol consumption. These patients were left out of all studies. Those were the main reasons for change and not the stigma part – with the word ‘fatty’ only being an issue in English-speaking countries, not elsewhere,” the commentator continued.

“Calls for change have been voiced for 20 years and a first comprehensive attempt (called MAFLD) was introduced 3 years ago (J Hepatol. 2020;73:202-9). Please, a little bit of respect and restraint in the comments recognizing the research efforts and publications for those that contributed to the field over the past 25 years ...” the hepatologist wrote.

The reader added, “Clinicians and researchers were dissatisfied for a long time, but it took years to gather overwhelming evidence demonstrating what causes the disease and then to kickstart a process under the auspices of several multinational scientific societies and come up with something consensually agreed upon by a large number of clinician researchers.

“Now you can tell your patient that he has metabolic liver disease instead of telling him that the problem at the root of his disease is that he is not drinking alcohol (nonalcoholic steatohepatitis). So, again, it is not so much about changing a name but about redefining diagnostic criteria and a nosological framework,” the reader wrote.

Other readers responded to the defender:

“This nomenclature issue has been churned for 20+ years? Well, the mountain has labored heavily, and given birth to a mouse,” one said.

“Still, how is this going to help in the clinical management? The whole gamut of conditions are evaluated and treated as a whole, not in isolation,” a general practitioner in India said. “If someone has a risk factor or not, continuous follow-up is required as a whole, whether it’s nonalcoholic or alcoholic, or whatever term is coined up.”

Finally, a family physician said, “It just rolls off the tongue, doesn’t it? But I have to admit, it’s the one place where ‘persons’ from 56 countries can get together and agree on something. Not even politicians can do that! Me, I’m sticking with NAFLD.”

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

Some clinicians say it’s “confusing” and “ridiculous” to change the name and diagnostic criteria of an established liver disease, while others bemoan the seemingly political reasons why it happened. Yet recently, 236 panelists from 56 countries decided that the terms nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) rely on “exclusionary confounder terms and the use of potentially stigmatizing language.”

In a report published in Hepatology, the panelists, members of the NAFLD Nomenclature Consensus Group, determined that steatotic liver disease (SLD) would be used as an “overarching term to encompass the various etiologies of steatosis.”

Metabolic dysfunction–associated steatotic liver disease (MASLD) was chosen to replace NAFLD, and the definition was changed to include at least one of five cardiometabolic risk factors.

Metabolic dysfunction–associated steatohepatitis (MASH) replaces NASH. 

Those with no metabolic parameters and no known cause will be diagnosed with cryptogenic SLD.

A new category, MetALD, now describes those with MASLD who drink more alcohol per week – 140-350 g for men and 210-420 g for women.

The changes did not sit well with this news organization’s readers from diverse specialties, including family practice, critical care, and gastroenterology.

In its report, the consensus group wrote that 74% of respondents to its rounds of surveys felt the current nomenclature “was sufficiently flawed to consider a name change.”

The terms “nonalcoholic” and “fatty” were felt to be stigmatizing by 61% and 66% of respondents, respectively, according to the group, a multi-stakeholder effort under the auspices of the American Association for Study of Liver Disease and the European Association for Study of the Liver, in collaboration with the Asociación Latinoamericana para el Estudio del Hígado.

Consensus was defined a priori as a supermajority (67%) vote. 

“The new nomenclature and diagnostic criteria are widely supported, nonstigmatizing, and can improve awareness and patient identification,” the group concluded.

“No way” sums up many of the almost 60 reader comments received on this news organization’s story covering the change. Readers must share medical credentials to publicly comment on stories.
 

‘Confusing’ and ‘ridiculous’

A number of readers questioned how the changes will help practice.

“Once again, the specialists and other experts are changing the nomenclature to make the subject even more confusing for us primary care practitioners,” an HIV/AIDS physician wrote. “They obviously have no idea what [primary care practitioners] have to put up with day in and day out. All such revisions do is increase the cynicism and anger so many [primary care practitioners] have.”

Similarly, an internist said, “These new terms are going to confuse both doctors and patients. When you give a patient a diagnosis like this, they will not understand it, and will not be able to act as they should to correct it.”

“ ‘Fatty liver’ is a jargon-free diagnosis, easy to understand and easy for patients to know what they need to do,” the internist continued. “You think patients are gonna be educated when you tell them they have a ‘metabolic disease’? 100% they will not know what you’re talking about.”

Yet another wondered, “If SLD is the ‘umbrella’ term, why (are) MetALD and ALD not MetASLD and ASLD, respectively? Furthermore, efforts to ‘destigmatize’ terminology will inadvertently condemn cryptogenic SLD (CSLD) as the new ‘closet alcoholic.’ “

“Perhaps a subclassification, CSLD-HDIRDD (CSLD–Honest, Doc, I Really Don’t Drink),” the reader added.

“Everything about this is ridiculous,” a family physician wrote. “How long will it be until the experts change obesity to ‘gravitationally challenged’ as a diagnosis!”

“I was thinking of ‘circumferentially challenged,’” a reader in Canada chimed in. “But that would be ‘body shaming’ would it not?”

This reader continued, asking, “What about returning to the old practice of using Latin names patients don’t understand so there is no ‘shame’ attached to them? Or what about this revolutionary idea: To just say it as it is – fat?”
 

Acceding to ‘wokeness’

A sizable number of readers felt the name changes were motivated by a “woke” awareness.

“The effect of this new ‘woke’ clarity is ridiculous and simply not worth it! Can we justify the cost of this? Patients will have to learn all over again how to discuss their condition,” said one reader.

The reader continued, saying, “The Internet and social media freely use the term ‘fat’ – and despite not wanting to offend – there seems to be universal agreement that FAT, in certain conditions or places, is unhealthy and undesirable.

“Why is the medical community so afraid to tell it like it is? I might hurt your feelings, but I could save your life,” concluded the reader.
 

Defending change

One commentator, a hepatologist in France, defended the changes and responded to some of complaints.

“Maybe people who comment here should read the article, reflect, and understand the reasons why the old nomenclature and definition were scientifically inaccurate and needed to be changed,” the commentator wrote.

“It was an exclusionary, negative definition not recognizing the root of the disease (adipose tissue dysfunction with insulin resistance – instead defining it by what it is not ...) and not allowing the recognition of a large segment of the population [that] accumulates metabolic risk factors and moderate alcohol consumption. These patients were left out of all studies. Those were the main reasons for change and not the stigma part – with the word ‘fatty’ only being an issue in English-speaking countries, not elsewhere,” the commentator continued.

“Calls for change have been voiced for 20 years and a first comprehensive attempt (called MAFLD) was introduced 3 years ago (J Hepatol. 2020;73:202-9). Please, a little bit of respect and restraint in the comments recognizing the research efforts and publications for those that contributed to the field over the past 25 years ...” the hepatologist wrote.

The reader added, “Clinicians and researchers were dissatisfied for a long time, but it took years to gather overwhelming evidence demonstrating what causes the disease and then to kickstart a process under the auspices of several multinational scientific societies and come up with something consensually agreed upon by a large number of clinician researchers.

“Now you can tell your patient that he has metabolic liver disease instead of telling him that the problem at the root of his disease is that he is not drinking alcohol (nonalcoholic steatohepatitis). So, again, it is not so much about changing a name but about redefining diagnostic criteria and a nosological framework,” the reader wrote.

Other readers responded to the defender:

“This nomenclature issue has been churned for 20+ years? Well, the mountain has labored heavily, and given birth to a mouse,” one said.

“Still, how is this going to help in the clinical management? The whole gamut of conditions are evaluated and treated as a whole, not in isolation,” a general practitioner in India said. “If someone has a risk factor or not, continuous follow-up is required as a whole, whether it’s nonalcoholic or alcoholic, or whatever term is coined up.”

Finally, a family physician said, “It just rolls off the tongue, doesn’t it? But I have to admit, it’s the one place where ‘persons’ from 56 countries can get together and agree on something. Not even politicians can do that! Me, I’m sticking with NAFLD.”

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

TOPLINE:

Five scleroderma immune responses have associations with cancer risk and could be used to stratify patients, researchers argue.

METHODOLOGY:

• Included patients from the Johns Hopkins Scleroderma Center Research Registry and the University of Pittsburgh Scleroderma Center, Pittsburgh.
• A total of 676 patients with scleroderma and a history of cancer were compared with 687 control patients with scleroderma but without a history of cancer.
• Serum tested via line blot and enzyme-linked immunosorbent assay for an array of scleroderma autoantibodies.
• Examined association between autoantibodies and overall cancer risk.

TAKEAWAYS:

• Anti-POLR3 and monospecific anti-Ro52 were associated with significantly increased overall cancer risk.
• Anti-centromere and anti-U1RNP were associated with a decreased cancer risk.
• These associations remained when looking specifically at cancer-associated scleroderma.
• Patients positive for anti-Ro52 in combination with either anti-U1RNP or anti-Th/To had a decreased risk of cancer, compared with those who had anti-Ro52 alone.

IN PRACTICE:

This study is too preliminary to have practice application.

SOURCE:

Ji Soo Kim, PhD, of John Hopkins University, Baltimore, was the first author of the study, published in Arthritis & Rheumatology on July 24, 2023. Fellow Johns Hopkins researchers Livia Casciola-Rosen, PhD, and Ami A. Shah, MD, were joint senior authors.

DISCLOSURES:

The study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the Donald B. and Dorothy L. Stabler Foundation, the Jerome L. Greene Foundation, the Chresanthe Staurulakis Memorial Discovery Fund, the Martha McCrory Professorship, and the Johns Hopkins inHealth initiative. The authors disclosed the following patents or patent applications: Autoimmune Antigens and Cancer, Materials and Methods for Assessing Cancer Risk and Treating Cancer.

A version of this article appeared on Medscape.com.

TOPLINE:

Five scleroderma immune responses have associations with cancer risk and could be used to stratify patients, researchers argue.

METHODOLOGY:

• Included patients from the Johns Hopkins Scleroderma Center Research Registry and the University of Pittsburgh Scleroderma Center, Pittsburgh.
• A total of 676 patients with scleroderma and a history of cancer were compared with 687 control patients with scleroderma but without a history of cancer.
• Serum tested via line blot and enzyme-linked immunosorbent assay for an array of scleroderma autoantibodies.
• Examined association between autoantibodies and overall cancer risk.

TAKEAWAYS:

• Anti-POLR3 and monospecific anti-Ro52 were associated with significantly increased overall cancer risk.
• Anti-centromere and anti-U1RNP were associated with a decreased cancer risk.
• These associations remained when looking specifically at cancer-associated scleroderma.
• Patients positive for anti-Ro52 in combination with either anti-U1RNP or anti-Th/To had a decreased risk of cancer, compared with those who had anti-Ro52 alone.

IN PRACTICE:

This study is too preliminary to have practice application.

SOURCE:

Ji Soo Kim, PhD, of John Hopkins University, Baltimore, was the first author of the study, published in Arthritis & Rheumatology on July 24, 2023. Fellow Johns Hopkins researchers Livia Casciola-Rosen, PhD, and Ami A. Shah, MD, were joint senior authors.

DISCLOSURES:

The study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the Donald B. and Dorothy L. Stabler Foundation, the Jerome L. Greene Foundation, the Chresanthe Staurulakis Memorial Discovery Fund, the Martha McCrory Professorship, and the Johns Hopkins inHealth initiative. The authors disclosed the following patents or patent applications: Autoimmune Antigens and Cancer, Materials and Methods for Assessing Cancer Risk and Treating Cancer.

A version of this article appeared on Medscape.com.

TOPLINE:

Five scleroderma immune responses have associations with cancer risk and could be used to stratify patients, researchers argue.

METHODOLOGY:

• Included patients from the Johns Hopkins Scleroderma Center Research Registry and the University of Pittsburgh Scleroderma Center, Pittsburgh.
• A total of 676 patients with scleroderma and a history of cancer were compared with 687 control patients with scleroderma but without a history of cancer.
• Serum tested via line blot and enzyme-linked immunosorbent assay for an array of scleroderma autoantibodies.
• Examined association between autoantibodies and overall cancer risk.

TAKEAWAYS:

• Anti-POLR3 and monospecific anti-Ro52 were associated with significantly increased overall cancer risk.
• Anti-centromere and anti-U1RNP were associated with a decreased cancer risk.
• These associations remained when looking specifically at cancer-associated scleroderma.
• Patients positive for anti-Ro52 in combination with either anti-U1RNP or anti-Th/To had a decreased risk of cancer, compared with those who had anti-Ro52 alone.

IN PRACTICE:

This study is too preliminary to have practice application.

SOURCE:

Ji Soo Kim, PhD, of John Hopkins University, Baltimore, was the first author of the study, published in Arthritis & Rheumatology on July 24, 2023. Fellow Johns Hopkins researchers Livia Casciola-Rosen, PhD, and Ami A. Shah, MD, were joint senior authors.

DISCLOSURES:

The study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the Donald B. and Dorothy L. Stabler Foundation, the Jerome L. Greene Foundation, the Chresanthe Staurulakis Memorial Discovery Fund, the Martha McCrory Professorship, and the Johns Hopkins inHealth initiative. The authors disclosed the following patents or patent applications: Autoimmune Antigens and Cancer, Materials and Methods for Assessing Cancer Risk and Treating Cancer.

A version of this article appeared on Medscape.com.

Most people hear “firm handshake” and automatically think “business world.” A cursory search reveals articles with titles like “Seven Super-Revealing Things Your Handshake Said About You” (Forbes) and “How a Handshake Can Tell You Everything You Need to Know About a Person” (Inc).

Those in the know, however, understand what a handshake really reveals: Current health and vitality. The amount of force that can be generated by the hand is a valid proxy for total-body strength. And total-body strength is one key to healthy aging.

Body temperature, weight, heart rate, and blood pressure inform any patient appointment. Should physicians include grip strength in that group?

Grip-strength testing is easy, fast, and noninvasive. It can be monitored over time. All it requires is a handgrip dynamometer, a tool that may cost less than a stethoscope, and a chair.

“Many studies have looked at strength as a predictor of positive health and weakness as a predictor of negative health outcomes,” said Mark Peterson, PhD, an associate professor at the University of Michigan, Ann Arbor, who’s worked on dozens of those studies.

Among the health risks associated with low grip strength: type 2 diabetes, heart disease, cancer, dementia and Alzheimer’s disease, depression, functional disability, osteoporosis, and premature death from any cause.

The prognostic merits of grip strength have been documented across continents and cultures. Although most of those studies have focused on older adults, they aren’t the only age group researchers have looked at.

“We have several papers on the value of grip strength for predicting diabetes and cardiovascular disease in children and adolescents,” Dr. Peterson said.
 

Survival of the strongest

The first thing to understand about grip-strength testing is that it’s only partially about grip. It’s mostly about strength. That’s what attracted Dr. Peterson to this line of research.

“I’m a former strength coach, so I wanted to make a case for why strength was important across populations, not just athletes,” he said. “I strongly believe in strength preservation and healthy living as a predictor for longevity.”

Consider a classic study of Swedish army recruits. Because of Sweden’s post–World War II conscription policy, virtually every young male in the country underwent a physical examination to see if they were fit for military service – an exam that included a grip-strength test.

That gave the researchers a database with more than a million participants. They followed up on them decades later through publicly available records.

What they found: The men with the weakest grip strength in their late teens were 20% more likely to have died by their mid-50s, compared with those with moderate to high grip strength. Even suicide rates were 20%-30% higher for the weakest recruits.

There’s a brutal Darwinian logic to the idea that a stronger person with a more powerful grip would enjoy a longer, healthier life. To our ancient ancestors, stronger hands meant they were probably better at everything that aided survival: hunting, fighting, building shelter, as well as bearing, transporting, and rearing children.

Fast forward to the 21st century where we must force ourselves to engage in physical activity. The old rules still apply: Strength aids survival.
 

Grip strength and the aging process

Some of the earliest grip-strength studies used it as a proxy for nutritional status in elderly men and women. Nourishment, in turn, predicted their ability to survive an illness or surgery.

Which makes sense; if an older person isn’t eating enough to maintain their health and vitality, their strength would decline. Declining strength would make them more susceptible to infections, hospitalizations, and postsurgical complications, leading to longer hospital stays, loss of independence, and ultimately a higher risk of death from any cause.

Along those lines, Dr. Peterson’s research team at the University of Michigan found that low grip strength is correlated with faster aging at the cellular level.

The study looked at DNA methylation, which Peterson describes as “a reflection of someone’s exposure to life events.”

For example, someone who smokes will have altered methylation patterns, compared with someone who doesn’t. Same with someone who’s had more exposure to environmental pollution.

Accelerated DNA methylation “means you’re essentially at higher risk for what are traditionally considered age-related chronic conditions,” Dr. Peterson said. Those conditions include Alzheimer’s, type 2 diabetes, chronic inflammation, and a higher risk for premature mortality.

Those things are also linked to low grip strength, which is linked to higher DNA methylation and faster biological aging.

But there’s still a missing piece of the puzzle: Why, exactly, would the strength of one’s grip be associated with so many health outcomes?
 

Grip strength and muscle function

“Declining muscle function is the first step of the disabling process,” said Ryan McGrath, PhD, an assistant professor at North Dakota State University, Fargo. “That’s what you can measure with a handgrip test. It helps you identify individuals at risk for the next step of the process, which is declines in physical performance.”

Dr. McGrath got involved in grip-strength research as a postdoctoral fellow at the University of Michigan, where he worked with Peterson. Like his mentor, he’s published multiple studies using data obtained with a handgrip dynamometer.

“It can be a nice tool for assessing muscle function and muscle strength,” he explained. Because the test is so easy to administer – you sit in a chair with your arm at your side and your elbow bent 90 degrees, and squeeze the device as hard as you can – researchers can work with large groups of study participants and come away with statistically powerful data.

“There are a lot of health outcomes it’s associated with,” Dr. McGrath added, “which is one of its greatest strengths and at the same time one of its key limitations.”

He compared the dynamometer with a tire gauge. Just as a tire gauge can alert you to a loss of air pressure without revealing the source of the leak, a dynamometer can’t tell you why your grip strength is deflated.

“It’s hard to specify the prognostic value,” he said. “You don’t know the next steps to take. As a standalone measurement, that’s a concern.”

That’s why his current research goes beyond simple tests of maximum grip strength to more sophisticated measurements of the rate of force development (how fast you can express strength), repeatability (how much your strength declines from your first to your second or third squeeze), and asymmetry (how big a gap there is between your right- and left-hand strength).

Any of those measures could detect a potential neural or neuromuscular issue.

In a 2020 study, for example, Dr. McGrath and his team at NDSU showed that older adults with both weakness and asymmetry in grip-strength tests were nearly four times more likely to experience functional limitations. Those limitations could affect their ability to do anything from routine chores to keeping themselves clean and fed.
 

Waging war on weakness

Using dynamometer readings, the generally accepted cutoffs for low grip strength are 26 kg for an adult male and 16 kg for a female.

But that’s way too simple, Dr. Peterson said.

For one thing, age matters. Grip strength typically peaks for men in their late 20s and declines rapidly in middle age and beyond. For women, it plateaus in their 20s and gently declines until their 50s. So, at minimum, the age-based standards included with a dynamometer should be consulted.

Another caveat: Dr. Peterson said grip strength tests aren’t very meaningful for people who actively train for strength, though he suggests dedicated athletes make up a relatively small percentage of the population – even as low as 10%.

The size of the person taking the test is also important.

“You absolutely must account for body mass in the context of understanding how grip strength, or any strength measure, is reflective of health and function,” Dr. Peterson said.

To calculate strength-weight ratio, which Dr. Peterson calls “normalized grip strength,” divide grip strength in kilograms by body weight in kilograms. For men, a ratio greater than 0.70 puts them in the higher percentiles. For women it’s 0.50.

And if the results suggest that the person in question is objectively weak? “For me, that’s easy,” Dr. Peterson said. “They need to exercise.”

Common sense suggests doing a lot of forearm exercises for grip strength. Not so, said Dr. Peterson. The strength of hand and forearm muscles reflects what they can do along with all other muscles moving together.

A 2019 study found that, for older adults, a variety of exercise programs can lead to modest but meaningful increases in participants’ grip strength – and they don’t necessarily have to include actual gripping exercises. The programs ranged from tai chi to water aerobics to walking, stretching, and all kinds of resistance training.

Dr. Peterson’s advice to everyone is pretty straightforward: Get stronger. It doesn’t really matter how you do it, or how much strength you ultimately gain. Even a little more strength means a little less weakness, and a little more life.

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

Most people hear “firm handshake” and automatically think “business world.” A cursory search reveals articles with titles like “Seven Super-Revealing Things Your Handshake Said About You” (Forbes) and “How a Handshake Can Tell You Everything You Need to Know About a Person” (Inc).

Those in the know, however, understand what a handshake really reveals: Current health and vitality. The amount of force that can be generated by the hand is a valid proxy for total-body strength. And total-body strength is one key to healthy aging.

Body temperature, weight, heart rate, and blood pressure inform any patient appointment. Should physicians include grip strength in that group?

Grip-strength testing is easy, fast, and noninvasive. It can be monitored over time. All it requires is a handgrip dynamometer, a tool that may cost less than a stethoscope, and a chair.

“Many studies have looked at strength as a predictor of positive health and weakness as a predictor of negative health outcomes,” said Mark Peterson, PhD, an associate professor at the University of Michigan, Ann Arbor, who’s worked on dozens of those studies.

Among the health risks associated with low grip strength: type 2 diabetes, heart disease, cancer, dementia and Alzheimer’s disease, depression, functional disability, osteoporosis, and premature death from any cause.

The prognostic merits of grip strength have been documented across continents and cultures. Although most of those studies have focused on older adults, they aren’t the only age group researchers have looked at.

“We have several papers on the value of grip strength for predicting diabetes and cardiovascular disease in children and adolescents,” Dr. Peterson said.
 

Survival of the strongest

The first thing to understand about grip-strength testing is that it’s only partially about grip. It’s mostly about strength. That’s what attracted Dr. Peterson to this line of research.

“I’m a former strength coach, so I wanted to make a case for why strength was important across populations, not just athletes,” he said. “I strongly believe in strength preservation and healthy living as a predictor for longevity.”

Consider a classic study of Swedish army recruits. Because of Sweden’s post–World War II conscription policy, virtually every young male in the country underwent a physical examination to see if they were fit for military service – an exam that included a grip-strength test.

That gave the researchers a database with more than a million participants. They followed up on them decades later through publicly available records.

What they found: The men with the weakest grip strength in their late teens were 20% more likely to have died by their mid-50s, compared with those with moderate to high grip strength. Even suicide rates were 20%-30% higher for the weakest recruits.

There’s a brutal Darwinian logic to the idea that a stronger person with a more powerful grip would enjoy a longer, healthier life. To our ancient ancestors, stronger hands meant they were probably better at everything that aided survival: hunting, fighting, building shelter, as well as bearing, transporting, and rearing children.

Fast forward to the 21st century where we must force ourselves to engage in physical activity. The old rules still apply: Strength aids survival.
 

Grip strength and the aging process

Some of the earliest grip-strength studies used it as a proxy for nutritional status in elderly men and women. Nourishment, in turn, predicted their ability to survive an illness or surgery.

Which makes sense; if an older person isn’t eating enough to maintain their health and vitality, their strength would decline. Declining strength would make them more susceptible to infections, hospitalizations, and postsurgical complications, leading to longer hospital stays, loss of independence, and ultimately a higher risk of death from any cause.

Along those lines, Dr. Peterson’s research team at the University of Michigan found that low grip strength is correlated with faster aging at the cellular level.

The study looked at DNA methylation, which Peterson describes as “a reflection of someone’s exposure to life events.”

For example, someone who smokes will have altered methylation patterns, compared with someone who doesn’t. Same with someone who’s had more exposure to environmental pollution.

Accelerated DNA methylation “means you’re essentially at higher risk for what are traditionally considered age-related chronic conditions,” Dr. Peterson said. Those conditions include Alzheimer’s, type 2 diabetes, chronic inflammation, and a higher risk for premature mortality.

Those things are also linked to low grip strength, which is linked to higher DNA methylation and faster biological aging.

But there’s still a missing piece of the puzzle: Why, exactly, would the strength of one’s grip be associated with so many health outcomes?
 

Grip strength and muscle function

“Declining muscle function is the first step of the disabling process,” said Ryan McGrath, PhD, an assistant professor at North Dakota State University, Fargo. “That’s what you can measure with a handgrip test. It helps you identify individuals at risk for the next step of the process, which is declines in physical performance.”

Dr. McGrath got involved in grip-strength research as a postdoctoral fellow at the University of Michigan, where he worked with Peterson. Like his mentor, he’s published multiple studies using data obtained with a handgrip dynamometer.

“It can be a nice tool for assessing muscle function and muscle strength,” he explained. Because the test is so easy to administer – you sit in a chair with your arm at your side and your elbow bent 90 degrees, and squeeze the device as hard as you can – researchers can work with large groups of study participants and come away with statistically powerful data.

“There are a lot of health outcomes it’s associated with,” Dr. McGrath added, “which is one of its greatest strengths and at the same time one of its key limitations.”

He compared the dynamometer with a tire gauge. Just as a tire gauge can alert you to a loss of air pressure without revealing the source of the leak, a dynamometer can’t tell you why your grip strength is deflated.

“It’s hard to specify the prognostic value,” he said. “You don’t know the next steps to take. As a standalone measurement, that’s a concern.”

That’s why his current research goes beyond simple tests of maximum grip strength to more sophisticated measurements of the rate of force development (how fast you can express strength), repeatability (how much your strength declines from your first to your second or third squeeze), and asymmetry (how big a gap there is between your right- and left-hand strength).

Any of those measures could detect a potential neural or neuromuscular issue.

In a 2020 study, for example, Dr. McGrath and his team at NDSU showed that older adults with both weakness and asymmetry in grip-strength tests were nearly four times more likely to experience functional limitations. Those limitations could affect their ability to do anything from routine chores to keeping themselves clean and fed.
 

Waging war on weakness

Using dynamometer readings, the generally accepted cutoffs for low grip strength are 26 kg for an adult male and 16 kg for a female.

But that’s way too simple, Dr. Peterson said.

For one thing, age matters. Grip strength typically peaks for men in their late 20s and declines rapidly in middle age and beyond. For women, it plateaus in their 20s and gently declines until their 50s. So, at minimum, the age-based standards included with a dynamometer should be consulted.

Another caveat: Dr. Peterson said grip strength tests aren’t very meaningful for people who actively train for strength, though he suggests dedicated athletes make up a relatively small percentage of the population – even as low as 10%.

The size of the person taking the test is also important.

“You absolutely must account for body mass in the context of understanding how grip strength, or any strength measure, is reflective of health and function,” Dr. Peterson said.

To calculate strength-weight ratio, which Dr. Peterson calls “normalized grip strength,” divide grip strength in kilograms by body weight in kilograms. For men, a ratio greater than 0.70 puts them in the higher percentiles. For women it’s 0.50.

And if the results suggest that the person in question is objectively weak? “For me, that’s easy,” Dr. Peterson said. “They need to exercise.”

Common sense suggests doing a lot of forearm exercises for grip strength. Not so, said Dr. Peterson. The strength of hand and forearm muscles reflects what they can do along with all other muscles moving together.

A 2019 study found that, for older adults, a variety of exercise programs can lead to modest but meaningful increases in participants’ grip strength – and they don’t necessarily have to include actual gripping exercises. The programs ranged from tai chi to water aerobics to walking, stretching, and all kinds of resistance training.

Dr. Peterson’s advice to everyone is pretty straightforward: Get stronger. It doesn’t really matter how you do it, or how much strength you ultimately gain. Even a little more strength means a little less weakness, and a little more life.

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

Most people hear “firm handshake” and automatically think “business world.” A cursory search reveals articles with titles like “Seven Super-Revealing Things Your Handshake Said About You” (Forbes) and “How a Handshake Can Tell You Everything You Need to Know About a Person” (Inc).

Those in the know, however, understand what a handshake really reveals: Current health and vitality. The amount of force that can be generated by the hand is a valid proxy for total-body strength. And total-body strength is one key to healthy aging.

Body temperature, weight, heart rate, and blood pressure inform any patient appointment. Should physicians include grip strength in that group?

Grip-strength testing is easy, fast, and noninvasive. It can be monitored over time. All it requires is a handgrip dynamometer, a tool that may cost less than a stethoscope, and a chair.

“Many studies have looked at strength as a predictor of positive health and weakness as a predictor of negative health outcomes,” said Mark Peterson, PhD, an associate professor at the University of Michigan, Ann Arbor, who’s worked on dozens of those studies.

Among the health risks associated with low grip strength: type 2 diabetes, heart disease, cancer, dementia and Alzheimer’s disease, depression, functional disability, osteoporosis, and premature death from any cause.

The prognostic merits of grip strength have been documented across continents and cultures. Although most of those studies have focused on older adults, they aren’t the only age group researchers have looked at.

“We have several papers on the value of grip strength for predicting diabetes and cardiovascular disease in children and adolescents,” Dr. Peterson said.
 

Survival of the strongest

The first thing to understand about grip-strength testing is that it’s only partially about grip. It’s mostly about strength. That’s what attracted Dr. Peterson to this line of research.

“I’m a former strength coach, so I wanted to make a case for why strength was important across populations, not just athletes,” he said. “I strongly believe in strength preservation and healthy living as a predictor for longevity.”

Consider a classic study of Swedish army recruits. Because of Sweden’s post–World War II conscription policy, virtually every young male in the country underwent a physical examination to see if they were fit for military service – an exam that included a grip-strength test.

That gave the researchers a database with more than a million participants. They followed up on them decades later through publicly available records.

What they found: The men with the weakest grip strength in their late teens were 20% more likely to have died by their mid-50s, compared with those with moderate to high grip strength. Even suicide rates were 20%-30% higher for the weakest recruits.

There’s a brutal Darwinian logic to the idea that a stronger person with a more powerful grip would enjoy a longer, healthier life. To our ancient ancestors, stronger hands meant they were probably better at everything that aided survival: hunting, fighting, building shelter, as well as bearing, transporting, and rearing children.

Fast forward to the 21st century where we must force ourselves to engage in physical activity. The old rules still apply: Strength aids survival.
 

Grip strength and the aging process

Some of the earliest grip-strength studies used it as a proxy for nutritional status in elderly men and women. Nourishment, in turn, predicted their ability to survive an illness or surgery.

Which makes sense; if an older person isn’t eating enough to maintain their health and vitality, their strength would decline. Declining strength would make them more susceptible to infections, hospitalizations, and postsurgical complications, leading to longer hospital stays, loss of independence, and ultimately a higher risk of death from any cause.

Along those lines, Dr. Peterson’s research team at the University of Michigan found that low grip strength is correlated with faster aging at the cellular level.

The study looked at DNA methylation, which Peterson describes as “a reflection of someone’s exposure to life events.”

For example, someone who smokes will have altered methylation patterns, compared with someone who doesn’t. Same with someone who’s had more exposure to environmental pollution.

Accelerated DNA methylation “means you’re essentially at higher risk for what are traditionally considered age-related chronic conditions,” Dr. Peterson said. Those conditions include Alzheimer’s, type 2 diabetes, chronic inflammation, and a higher risk for premature mortality.

Those things are also linked to low grip strength, which is linked to higher DNA methylation and faster biological aging.

But there’s still a missing piece of the puzzle: Why, exactly, would the strength of one’s grip be associated with so many health outcomes?
 

Grip strength and muscle function

“Declining muscle function is the first step of the disabling process,” said Ryan McGrath, PhD, an assistant professor at North Dakota State University, Fargo. “That’s what you can measure with a handgrip test. It helps you identify individuals at risk for the next step of the process, which is declines in physical performance.”

Dr. McGrath got involved in grip-strength research as a postdoctoral fellow at the University of Michigan, where he worked with Peterson. Like his mentor, he’s published multiple studies using data obtained with a handgrip dynamometer.

“It can be a nice tool for assessing muscle function and muscle strength,” he explained. Because the test is so easy to administer – you sit in a chair with your arm at your side and your elbow bent 90 degrees, and squeeze the device as hard as you can – researchers can work with large groups of study participants and come away with statistically powerful data.

“There are a lot of health outcomes it’s associated with,” Dr. McGrath added, “which is one of its greatest strengths and at the same time one of its key limitations.”

He compared the dynamometer with a tire gauge. Just as a tire gauge can alert you to a loss of air pressure without revealing the source of the leak, a dynamometer can’t tell you why your grip strength is deflated.

“It’s hard to specify the prognostic value,” he said. “You don’t know the next steps to take. As a standalone measurement, that’s a concern.”

That’s why his current research goes beyond simple tests of maximum grip strength to more sophisticated measurements of the rate of force development (how fast you can express strength), repeatability (how much your strength declines from your first to your second or third squeeze), and asymmetry (how big a gap there is between your right- and left-hand strength).

Any of those measures could detect a potential neural or neuromuscular issue.

In a 2020 study, for example, Dr. McGrath and his team at NDSU showed that older adults with both weakness and asymmetry in grip-strength tests were nearly four times more likely to experience functional limitations. Those limitations could affect their ability to do anything from routine chores to keeping themselves clean and fed.
 

Waging war on weakness

Using dynamometer readings, the generally accepted cutoffs for low grip strength are 26 kg for an adult male and 16 kg for a female.

But that’s way too simple, Dr. Peterson said.

For one thing, age matters. Grip strength typically peaks for men in their late 20s and declines rapidly in middle age and beyond. For women, it plateaus in their 20s and gently declines until their 50s. So, at minimum, the age-based standards included with a dynamometer should be consulted.

Another caveat: Dr. Peterson said grip strength tests aren’t very meaningful for people who actively train for strength, though he suggests dedicated athletes make up a relatively small percentage of the population – even as low as 10%.

The size of the person taking the test is also important.

“You absolutely must account for body mass in the context of understanding how grip strength, or any strength measure, is reflective of health and function,” Dr. Peterson said.

To calculate strength-weight ratio, which Dr. Peterson calls “normalized grip strength,” divide grip strength in kilograms by body weight in kilograms. For men, a ratio greater than 0.70 puts them in the higher percentiles. For women it’s 0.50.

And if the results suggest that the person in question is objectively weak? “For me, that’s easy,” Dr. Peterson said. “They need to exercise.”

Common sense suggests doing a lot of forearm exercises for grip strength. Not so, said Dr. Peterson. The strength of hand and forearm muscles reflects what they can do along with all other muscles moving together.

A 2019 study found that, for older adults, a variety of exercise programs can lead to modest but meaningful increases in participants’ grip strength – and they don’t necessarily have to include actual gripping exercises. The programs ranged from tai chi to water aerobics to walking, stretching, and all kinds of resistance training.

Dr. Peterson’s advice to everyone is pretty straightforward: Get stronger. It doesn’t really matter how you do it, or how much strength you ultimately gain. Even a little more strength means a little less weakness, and a little more life.

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

A new lawsuit from a woman with type 2 diabetes alleges that the makers of the drugs Ozempic and Mounjaro did not provide adequate warnings for the severity of stomach problems caused by the popular medicines.

The two drugs, which are Food and Drug Administration approved to treat type 2 diabetes, have become well known for their weight loss properties. Ozempic is made by Danish drug maker Novo Nordisk, and Mounjaro is made by Indiana-based Eli Lilly and Co.

In the lawsuit, Jaclyn Bjorklund, 44, of Louisiana, asserts that she was “severely injured” after using Ozempic and Mounjaro and that the pharmaceutical companies failed to disclose the drugs’ risk of causing vomiting and diarrhea due to inflammation of the stomach lining, as well as the risk of gastroparesis.

The prescribing labels for Mounjaro and Ozempic state that each “delays gastric emptying” and warn of the risk of severe gastrointestinal adverse reactions. The prescribing labels for both drugs state that the most common side effects include vomiting, diarrhea, and stomach pain. The Ozempic label does not mention gastroparesis, and the Mounjaro label states that the drug has not been studied in people with the condition and is therefore not recommended for people who have it. 

Ms. Bjorklund has not been diagnosed with gastroparesis, but her symptoms are “indicative of” the condition, her lawyer, Paul Pennock, told NBC News.

Ms. Bjorklund used Ozempic for more than 1 year, and in July 2023 switched to Mounjaro, the lawsuit states. The document, posted on her law firm’s website, details that using the drugs resulted in “severe vomiting, stomach pain, gastrointestinal burning, being hospitalized for stomach issues on several occasions including visits to the emergency room, [and] teeth falling out due to excessive vomiting, requiring additional medications to alleviate her excessive vomiting, and throwing up whole food hours after eating.”

Novo Nordisk spokesperson Natalia Salomao told NBC News that patient safety is “of utmost importance to Novo Nordisk,” and she also noted that gastroparesis is a known risk for people with diabetes. The Food and Drug Administration declined to comment on the case, and Eli Lilly did not immediately respond to a request for comment, NBC News reported.
 

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

A new lawsuit from a woman with type 2 diabetes alleges that the makers of the drugs Ozempic and Mounjaro did not provide adequate warnings for the severity of stomach problems caused by the popular medicines.

The two drugs, which are Food and Drug Administration approved to treat type 2 diabetes, have become well known for their weight loss properties. Ozempic is made by Danish drug maker Novo Nordisk, and Mounjaro is made by Indiana-based Eli Lilly and Co.

In the lawsuit, Jaclyn Bjorklund, 44, of Louisiana, asserts that she was “severely injured” after using Ozempic and Mounjaro and that the pharmaceutical companies failed to disclose the drugs’ risk of causing vomiting and diarrhea due to inflammation of the stomach lining, as well as the risk of gastroparesis.

The prescribing labels for Mounjaro and Ozempic state that each “delays gastric emptying” and warn of the risk of severe gastrointestinal adverse reactions. The prescribing labels for both drugs state that the most common side effects include vomiting, diarrhea, and stomach pain. The Ozempic label does not mention gastroparesis, and the Mounjaro label states that the drug has not been studied in people with the condition and is therefore not recommended for people who have it. 

Ms. Bjorklund has not been diagnosed with gastroparesis, but her symptoms are “indicative of” the condition, her lawyer, Paul Pennock, told NBC News.

Ms. Bjorklund used Ozempic for more than 1 year, and in July 2023 switched to Mounjaro, the lawsuit states. The document, posted on her law firm’s website, details that using the drugs resulted in “severe vomiting, stomach pain, gastrointestinal burning, being hospitalized for stomach issues on several occasions including visits to the emergency room, [and] teeth falling out due to excessive vomiting, requiring additional medications to alleviate her excessive vomiting, and throwing up whole food hours after eating.”

Novo Nordisk spokesperson Natalia Salomao told NBC News that patient safety is “of utmost importance to Novo Nordisk,” and she also noted that gastroparesis is a known risk for people with diabetes. The Food and Drug Administration declined to comment on the case, and Eli Lilly did not immediately respond to a request for comment, NBC News reported.
 

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

A new lawsuit from a woman with type 2 diabetes alleges that the makers of the drugs Ozempic and Mounjaro did not provide adequate warnings for the severity of stomach problems caused by the popular medicines.

The two drugs, which are Food and Drug Administration approved to treat type 2 diabetes, have become well known for their weight loss properties. Ozempic is made by Danish drug maker Novo Nordisk, and Mounjaro is made by Indiana-based Eli Lilly and Co.

In the lawsuit, Jaclyn Bjorklund, 44, of Louisiana, asserts that she was “severely injured” after using Ozempic and Mounjaro and that the pharmaceutical companies failed to disclose the drugs’ risk of causing vomiting and diarrhea due to inflammation of the stomach lining, as well as the risk of gastroparesis.

The prescribing labels for Mounjaro and Ozempic state that each “delays gastric emptying” and warn of the risk of severe gastrointestinal adverse reactions. The prescribing labels for both drugs state that the most common side effects include vomiting, diarrhea, and stomach pain. The Ozempic label does not mention gastroparesis, and the Mounjaro label states that the drug has not been studied in people with the condition and is therefore not recommended for people who have it. 

Ms. Bjorklund has not been diagnosed with gastroparesis, but her symptoms are “indicative of” the condition, her lawyer, Paul Pennock, told NBC News.

Ms. Bjorklund used Ozempic for more than 1 year, and in July 2023 switched to Mounjaro, the lawsuit states. The document, posted on her law firm’s website, details that using the drugs resulted in “severe vomiting, stomach pain, gastrointestinal burning, being hospitalized for stomach issues on several occasions including visits to the emergency room, [and] teeth falling out due to excessive vomiting, requiring additional medications to alleviate her excessive vomiting, and throwing up whole food hours after eating.”

Novo Nordisk spokesperson Natalia Salomao told NBC News that patient safety is “of utmost importance to Novo Nordisk,” and she also noted that gastroparesis is a known risk for people with diabetes. The Food and Drug Administration declined to comment on the case, and Eli Lilly did not immediately respond to a request for comment, NBC News reported.
 

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

Artificial intelligence (AI)–supported breast cancer screening appears safe and at least as accurate as standard double reading of mammograms by two breast radiologists, according to early results from a large, randomized, population-based cohort study.

The AI-supported screening also reduced radiologist workload by nearly 44%, researchers estimated.

The trial also found a 20% increase in cancer detection using AI support compared with routine double mammography reading, underscoring AI’s potential to improve screening accuracy and efficiency.

The findings, published online in Lancet Oncology, come from a planned interim safety analysis of the Swedish Mammography Screening with Artificial Intelligence (MASAI) trial.

To date, AI has shown promise in mammography screening, with retrospective evidence demonstrating similar accuracy, compared with standard double readings as well as reduced workload for radiologists. Still, randomized trials assessing the efficacy of AI-supported breast screening are needed.

The aim of the current interim randomized analysis was to assess early screening performance, which included cancer detection, recall, and false positive rates as well as cancer type detected and workload.

The MASAI trial randomized 80,033 women, with a median age of 54, to AI-supported screening (n = 40,003) or double reading without AI (n = 40,030).

The AI system provided malignancy risk scores from 1 to 10, with low-risk scores ranging from 1 to 7, intermediate risk from 8 to 9, and high risk at 10. These risk scores were used to triage screening exams to a single radiologist reading (score of 1-9) or double reading (score of 10), given that cancer prevalence “increases sharply” for those with a risk score of 10, the researchers explained. The AI system also provided computer-aided detection marks for exams with risk scores of 8-10 to radiologists.

Among nearly 40,000 women screened with AI support, 244 cancers were detected, including 184 invasive cancers (75%) and 60 in situ cancers (25%), and resulted in 861 recalls. Among 40,024 participants receiving standard screening, radiologists detected 203 cancers, including 165 invasive cancers (81%) and 38 in situ cancers (19%), and resulted in 817 recalls.

Overall, the detection rate using AI support versus standard screening was 6.1 per 1000 screened participants versus 5.1 per 1,000. The recall rates were 2.2% versus 2.0%, respectively.

The false positive rates were the same in both groups (1.5%) while the positive predictive value (PPV) of recall – how likely a recall of a participant ultimately led to a cancer diagnosis – was higher in the AI group: 28.3% versus 24.8%.

The cancer detection rate in the high-risk group – patients with a risk score of 10 – was 72.3 per 1000 participants screened, or one cancer per 14 screening exams. And, overall, 189 of 490 screening exams flagged as extra-high risk by AI (the highest 1% risk) were recalled. Of the 189 recalled participants, 136 had cancer, representing a PPV of recall of 72%.

Overall, “we found that the benefit of AI-supported screening in terms of screen-reading workload reduction was considerable,” the authors said.

Assuming a radiologist can read 50 mammograms an hour, the researchers estimated that a radiologist would take 4.6 fewer months to read more than 46,000 screening exams in the intervention group compared with more than 83,000 in the control group.

Although these early safety results are “promising,” the findings “are not enough on their own to confirm that AI is ready to be implemented in mammography screening,” lead author Kristina Lång, PhD, of Lund (Sweden) University, said in a press release.

“We still need to understand the implications on patients’ outcomes, especially whether combining radiologists’ expertise with AI can help detect interval cancers that are often missed by traditional screening, as well as the cost-effectiveness of the technology,” she said, adding that “the greatest potential of AI right now is that it could allow radiologists to be less burdened by the excessive amount of reading.”

In an accompanying editorial, Nereo Segnan, MD, and Antonio Ponti, MD, both of CPO Piemonte in Torino, Italy, said that the AI risk score for breast cancer in the trial “seems very accurate at being able to separate high-risk from low-risk women.”

However, the potential for overdiagnosis or overdetection of indolent lesions in the intervention group should “prompt caution in the interpretation of results that otherwise seem straightforward in favoring the use of AI,” the editorialists noted.

The authors agreed that increased detection of in situ cancers with AI-supported screening compared with standard screening – 25% versus 19% – “could be concerning in terms of overdiagnosis,” as the risk of overtreatment is more likely with these low-grade cancers.

In the final analysis, Dr. Lång and colleagues plan to characterize the biological features of detected lesions to provide further insight on AI-supported screening, including the risk for overdiagnosis.

In a statement to the U.K.-based Science Media Centre, Stephen Duffy, professor of cancer screening, Wolfson Institute of Population Health, Queen Mary University of London, commented that the “results illustrate the potential for artificial intelligence to reduce the burden on radiologists’ time,” which is “an issue of considerable importance in many breast screening programs.”

The MASAI study was funded by the Swedish Cancer Society, Confederation of Regional Cancer Centres, and government funding for clinical research. Dr. Lång has been an advisory board member for Siemens Healthineers and has received lecture honorarium from AstraZeneca. Dr. Segnan and Dr. Hall reported no relevant financial relationships.

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

Artificial intelligence (AI)–supported breast cancer screening appears safe and at least as accurate as standard double reading of mammograms by two breast radiologists, according to early results from a large, randomized, population-based cohort study.

The AI-supported screening also reduced radiologist workload by nearly 44%, researchers estimated.

The trial also found a 20% increase in cancer detection using AI support compared with routine double mammography reading, underscoring AI’s potential to improve screening accuracy and efficiency.

The findings, published online in Lancet Oncology, come from a planned interim safety analysis of the Swedish Mammography Screening with Artificial Intelligence (MASAI) trial.

To date, AI has shown promise in mammography screening, with retrospective evidence demonstrating similar accuracy, compared with standard double readings as well as reduced workload for radiologists. Still, randomized trials assessing the efficacy of AI-supported breast screening are needed.

The aim of the current interim randomized analysis was to assess early screening performance, which included cancer detection, recall, and false positive rates as well as cancer type detected and workload.

The MASAI trial randomized 80,033 women, with a median age of 54, to AI-supported screening (n = 40,003) or double reading without AI (n = 40,030).

The AI system provided malignancy risk scores from 1 to 10, with low-risk scores ranging from 1 to 7, intermediate risk from 8 to 9, and high risk at 10. These risk scores were used to triage screening exams to a single radiologist reading (score of 1-9) or double reading (score of 10), given that cancer prevalence “increases sharply” for those with a risk score of 10, the researchers explained. The AI system also provided computer-aided detection marks for exams with risk scores of 8-10 to radiologists.

Among nearly 40,000 women screened with AI support, 244 cancers were detected, including 184 invasive cancers (75%) and 60 in situ cancers (25%), and resulted in 861 recalls. Among 40,024 participants receiving standard screening, radiologists detected 203 cancers, including 165 invasive cancers (81%) and 38 in situ cancers (19%), and resulted in 817 recalls.

Overall, the detection rate using AI support versus standard screening was 6.1 per 1000 screened participants versus 5.1 per 1,000. The recall rates were 2.2% versus 2.0%, respectively.

The false positive rates were the same in both groups (1.5%) while the positive predictive value (PPV) of recall – how likely a recall of a participant ultimately led to a cancer diagnosis – was higher in the AI group: 28.3% versus 24.8%.

The cancer detection rate in the high-risk group – patients with a risk score of 10 – was 72.3 per 1000 participants screened, or one cancer per 14 screening exams. And, overall, 189 of 490 screening exams flagged as extra-high risk by AI (the highest 1% risk) were recalled. Of the 189 recalled participants, 136 had cancer, representing a PPV of recall of 72%.

Overall, “we found that the benefit of AI-supported screening in terms of screen-reading workload reduction was considerable,” the authors said.

Assuming a radiologist can read 50 mammograms an hour, the researchers estimated that a radiologist would take 4.6 fewer months to read more than 46,000 screening exams in the intervention group compared with more than 83,000 in the control group.

Although these early safety results are “promising,” the findings “are not enough on their own to confirm that AI is ready to be implemented in mammography screening,” lead author Kristina Lång, PhD, of Lund (Sweden) University, said in a press release.

“We still need to understand the implications on patients’ outcomes, especially whether combining radiologists’ expertise with AI can help detect interval cancers that are often missed by traditional screening, as well as the cost-effectiveness of the technology,” she said, adding that “the greatest potential of AI right now is that it could allow radiologists to be less burdened by the excessive amount of reading.”

In an accompanying editorial, Nereo Segnan, MD, and Antonio Ponti, MD, both of CPO Piemonte in Torino, Italy, said that the AI risk score for breast cancer in the trial “seems very accurate at being able to separate high-risk from low-risk women.”

However, the potential for overdiagnosis or overdetection of indolent lesions in the intervention group should “prompt caution in the interpretation of results that otherwise seem straightforward in favoring the use of AI,” the editorialists noted.

The authors agreed that increased detection of in situ cancers with AI-supported screening compared with standard screening – 25% versus 19% – “could be concerning in terms of overdiagnosis,” as the risk of overtreatment is more likely with these low-grade cancers.

In the final analysis, Dr. Lång and colleagues plan to characterize the biological features of detected lesions to provide further insight on AI-supported screening, including the risk for overdiagnosis.

In a statement to the U.K.-based Science Media Centre, Stephen Duffy, professor of cancer screening, Wolfson Institute of Population Health, Queen Mary University of London, commented that the “results illustrate the potential for artificial intelligence to reduce the burden on radiologists’ time,” which is “an issue of considerable importance in many breast screening programs.”

The MASAI study was funded by the Swedish Cancer Society, Confederation of Regional Cancer Centres, and government funding for clinical research. Dr. Lång has been an advisory board member for Siemens Healthineers and has received lecture honorarium from AstraZeneca. Dr. Segnan and Dr. Hall reported no relevant financial relationships.

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

Artificial intelligence (AI)–supported breast cancer screening appears safe and at least as accurate as standard double reading of mammograms by two breast radiologists, according to early results from a large, randomized, population-based cohort study.

The AI-supported screening also reduced radiologist workload by nearly 44%, researchers estimated.

The trial also found a 20% increase in cancer detection using AI support compared with routine double mammography reading, underscoring AI’s potential to improve screening accuracy and efficiency.

The findings, published online in Lancet Oncology, come from a planned interim safety analysis of the Swedish Mammography Screening with Artificial Intelligence (MASAI) trial.

To date, AI has shown promise in mammography screening, with retrospective evidence demonstrating similar accuracy, compared with standard double readings as well as reduced workload for radiologists. Still, randomized trials assessing the efficacy of AI-supported breast screening are needed.

The aim of the current interim randomized analysis was to assess early screening performance, which included cancer detection, recall, and false positive rates as well as cancer type detected and workload.

The MASAI trial randomized 80,033 women, with a median age of 54, to AI-supported screening (n = 40,003) or double reading without AI (n = 40,030).

The AI system provided malignancy risk scores from 1 to 10, with low-risk scores ranging from 1 to 7, intermediate risk from 8 to 9, and high risk at 10. These risk scores were used to triage screening exams to a single radiologist reading (score of 1-9) or double reading (score of 10), given that cancer prevalence “increases sharply” for those with a risk score of 10, the researchers explained. The AI system also provided computer-aided detection marks for exams with risk scores of 8-10 to radiologists.

Among nearly 40,000 women screened with AI support, 244 cancers were detected, including 184 invasive cancers (75%) and 60 in situ cancers (25%), and resulted in 861 recalls. Among 40,024 participants receiving standard screening, radiologists detected 203 cancers, including 165 invasive cancers (81%) and 38 in situ cancers (19%), and resulted in 817 recalls.

Overall, the detection rate using AI support versus standard screening was 6.1 per 1000 screened participants versus 5.1 per 1,000. The recall rates were 2.2% versus 2.0%, respectively.

The false positive rates were the same in both groups (1.5%) while the positive predictive value (PPV) of recall – how likely a recall of a participant ultimately led to a cancer diagnosis – was higher in the AI group: 28.3% versus 24.8%.

The cancer detection rate in the high-risk group – patients with a risk score of 10 – was 72.3 per 1000 participants screened, or one cancer per 14 screening exams. And, overall, 189 of 490 screening exams flagged as extra-high risk by AI (the highest 1% risk) were recalled. Of the 189 recalled participants, 136 had cancer, representing a PPV of recall of 72%.

Overall, “we found that the benefit of AI-supported screening in terms of screen-reading workload reduction was considerable,” the authors said.

Assuming a radiologist can read 50 mammograms an hour, the researchers estimated that a radiologist would take 4.6 fewer months to read more than 46,000 screening exams in the intervention group compared with more than 83,000 in the control group.

Although these early safety results are “promising,” the findings “are not enough on their own to confirm that AI is ready to be implemented in mammography screening,” lead author Kristina Lång, PhD, of Lund (Sweden) University, said in a press release.

“We still need to understand the implications on patients’ outcomes, especially whether combining radiologists’ expertise with AI can help detect interval cancers that are often missed by traditional screening, as well as the cost-effectiveness of the technology,” she said, adding that “the greatest potential of AI right now is that it could allow radiologists to be less burdened by the excessive amount of reading.”

In an accompanying editorial, Nereo Segnan, MD, and Antonio Ponti, MD, both of CPO Piemonte in Torino, Italy, said that the AI risk score for breast cancer in the trial “seems very accurate at being able to separate high-risk from low-risk women.”

However, the potential for overdiagnosis or overdetection of indolent lesions in the intervention group should “prompt caution in the interpretation of results that otherwise seem straightforward in favoring the use of AI,” the editorialists noted.

The authors agreed that increased detection of in situ cancers with AI-supported screening compared with standard screening – 25% versus 19% – “could be concerning in terms of overdiagnosis,” as the risk of overtreatment is more likely with these low-grade cancers.

In the final analysis, Dr. Lång and colleagues plan to characterize the biological features of detected lesions to provide further insight on AI-supported screening, including the risk for overdiagnosis.

In a statement to the U.K.-based Science Media Centre, Stephen Duffy, professor of cancer screening, Wolfson Institute of Population Health, Queen Mary University of London, commented that the “results illustrate the potential for artificial intelligence to reduce the burden on radiologists’ time,” which is “an issue of considerable importance in many breast screening programs.”

The MASAI study was funded by the Swedish Cancer Society, Confederation of Regional Cancer Centres, and government funding for clinical research. Dr. Lång has been an advisory board member for Siemens Healthineers and has received lecture honorarium from AstraZeneca. Dr. Segnan and Dr. Hall reported no relevant financial relationships.

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

Medical students are taking more control over how and when they learn. It’s a practice propelled by the pandemic, but it started long before COVID shifted many traditional classrooms to virtual education.

New technologies, including online lectures and guided-lesson websites, along with alternative teaching methods, such as the flipped classroom model, in which med students complete before-class assignments and participate in group projects, are helping to train future physicians for their medical careers.

So though students may not be attending in-person lectures like they did in the past, proponents of online learning say the education students receive and the subsequent care they deliver remains the same.

The Association of American Medical Colleges’ most recent annual survey of 2nd-year medical students found that 25% “almost never” attended their in-person lectures in 2022. The figure has steadily improved since 2020 but mirrors what AAMC recorded in 2017.

“The pandemic may have exacerbated the trend, but it’s a long-standing issue,” said Katherine McOwen, senior director of educational and student affairs at AAMC. She said in an interview that she’s witnessed the pattern for 24 years in her work with medical schools.

“I know it sounds alarming that students aren’t attending lectures. But that doesn’t mean they’re not learning,” said Ahmed Ahmed, MD, MPP, MSc, a recent graduate of Harvard Medical School and now a resident at Brigham and Women’s Hospital, Boston.

Today’s generation of medical students grew up in the age of technology. They are comfortable in front of the screen, so it makes sense for them to learn certain aspects of medical sciences and public health in the same way, Dr. Ahmed told this news organization.

Dr. Ahmed said that at Harvard he participated in one or two case-based classes per week that followed a flipped classroom model, which allows students to study topics on their own before discussing in a lecture format as a group. “We had to come up with a diagnostic plan and walk through the case slide by slide,” he said. “It got us to think like a clinician.”

The flipped classroom allows students to study at their own pace using their preferred learning style, leading to more collaboration in the classroom and between students, according to a 2022 article on the “new standard in medical education” published in Trends in Anaesthesia & Critical Care.

Students use online education tools to complete pre-class assignments such as watching short videos, listening to podcasts, or reading journal articles. In-class time can then be used to cement and create connections through discussions, interactive exercises, group learning, and case studies, the article stated.

Benefits of the flipped classroom include student satisfaction, learner motivation, and faculty interest in learning new teaching methods, according to the article: “Students are performing at least as well as those who attended traditional lectures, while some studies in select health care settings show increased retention in flipped classroom settings.”

Another study on the flipped classroom, published in 2018 in BMC Medical Education found that the teaching method was superior to traditional classrooms for health professions education. Researchers focused specifically on flipped classrooms that provided prerecorded videos to students.

Molly Cooke, MD, director of education for global health sciences at the University of California, San Francisco, School of Medicine, said that the school no longer requires attendance at lectures. “Personally, my position is that medical students are very busy people and make, by and large, rational decisions about how to spend their time. As learning and retention from 50-minute lectures has been shown for decades to be poor, I think it’s perfectly reasonable to watch lectures on their own time.”

Dr. Ahmed agrees. “By our standards, the old model is archaic. It’s passive, and instead we should be encouraging lifelong, self-directed learning.”

To that end, Dr. Ahmed and his fellow students also relied heavily during medical school on secondary educational sources such as Boards and Beyond and Sketchy. “There’s an entire community of medical school students across the country using them,” Dr. Ahmed explained. “You can learn what you need in a tenth of the time of lectures.”

Today lectures only provide a portion of the information delivered to students, Dr. McGowen said. “They also learn in small groups, in problem-solving sessions, and in clinical experiences, all of which make up the meat of their education.”

The purpose of medical school is to prepare students for residency, she added. “Medical school education is very different from other types of education. Students are examined in a variety of ways before they move on to residency and ultimately, practice.”

For example, every student must pass the three-part United States Medical Licensing Examination. Students complete the first two parts in medical school and the third part during residency. “The tests represent a combination of everything students have learned, from lectures, clinical time, and in self-directed learning,” Dr. McGowen said.

Post pandemic, the tools and styles of learning in medical education have changed, and they are likely to continue to evolve along with students and technology, according to the 2022 article on the flipped classroom. “The future of medical education will continue to move in ways that embrace digital technology, as this is what digital native learners are increasingly expecting for their health care education,” states the article.

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

Medical students are taking more control over how and when they learn. It’s a practice propelled by the pandemic, but it started long before COVID shifted many traditional classrooms to virtual education.

New technologies, including online lectures and guided-lesson websites, along with alternative teaching methods, such as the flipped classroom model, in which med students complete before-class assignments and participate in group projects, are helping to train future physicians for their medical careers.

So though students may not be attending in-person lectures like they did in the past, proponents of online learning say the education students receive and the subsequent care they deliver remains the same.

The Association of American Medical Colleges’ most recent annual survey of 2nd-year medical students found that 25% “almost never” attended their in-person lectures in 2022. The figure has steadily improved since 2020 but mirrors what AAMC recorded in 2017.

“The pandemic may have exacerbated the trend, but it’s a long-standing issue,” said Katherine McOwen, senior director of educational and student affairs at AAMC. She said in an interview that she’s witnessed the pattern for 24 years in her work with medical schools.

“I know it sounds alarming that students aren’t attending lectures. But that doesn’t mean they’re not learning,” said Ahmed Ahmed, MD, MPP, MSc, a recent graduate of Harvard Medical School and now a resident at Brigham and Women’s Hospital, Boston.

Today’s generation of medical students grew up in the age of technology. They are comfortable in front of the screen, so it makes sense for them to learn certain aspects of medical sciences and public health in the same way, Dr. Ahmed told this news organization.

Dr. Ahmed said that at Harvard he participated in one or two case-based classes per week that followed a flipped classroom model, which allows students to study topics on their own before discussing in a lecture format as a group. “We had to come up with a diagnostic plan and walk through the case slide by slide,” he said. “It got us to think like a clinician.”

The flipped classroom allows students to study at their own pace using their preferred learning style, leading to more collaboration in the classroom and between students, according to a 2022 article on the “new standard in medical education” published in Trends in Anaesthesia & Critical Care.

Students use online education tools to complete pre-class assignments such as watching short videos, listening to podcasts, or reading journal articles. In-class time can then be used to cement and create connections through discussions, interactive exercises, group learning, and case studies, the article stated.

Benefits of the flipped classroom include student satisfaction, learner motivation, and faculty interest in learning new teaching methods, according to the article: “Students are performing at least as well as those who attended traditional lectures, while some studies in select health care settings show increased retention in flipped classroom settings.”

Another study on the flipped classroom, published in 2018 in BMC Medical Education found that the teaching method was superior to traditional classrooms for health professions education. Researchers focused specifically on flipped classrooms that provided prerecorded videos to students.

Molly Cooke, MD, director of education for global health sciences at the University of California, San Francisco, School of Medicine, said that the school no longer requires attendance at lectures. “Personally, my position is that medical students are very busy people and make, by and large, rational decisions about how to spend their time. As learning and retention from 50-minute lectures has been shown for decades to be poor, I think it’s perfectly reasonable to watch lectures on their own time.”

Dr. Ahmed agrees. “By our standards, the old model is archaic. It’s passive, and instead we should be encouraging lifelong, self-directed learning.”

To that end, Dr. Ahmed and his fellow students also relied heavily during medical school on secondary educational sources such as Boards and Beyond and Sketchy. “There’s an entire community of medical school students across the country using them,” Dr. Ahmed explained. “You can learn what you need in a tenth of the time of lectures.”

Today lectures only provide a portion of the information delivered to students, Dr. McGowen said. “They also learn in small groups, in problem-solving sessions, and in clinical experiences, all of which make up the meat of their education.”

The purpose of medical school is to prepare students for residency, she added. “Medical school education is very different from other types of education. Students are examined in a variety of ways before they move on to residency and ultimately, practice.”

For example, every student must pass the three-part United States Medical Licensing Examination. Students complete the first two parts in medical school and the third part during residency. “The tests represent a combination of everything students have learned, from lectures, clinical time, and in self-directed learning,” Dr. McGowen said.

Post pandemic, the tools and styles of learning in medical education have changed, and they are likely to continue to evolve along with students and technology, according to the 2022 article on the flipped classroom. “The future of medical education will continue to move in ways that embrace digital technology, as this is what digital native learners are increasingly expecting for their health care education,” states the article.

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

Medical students are taking more control over how and when they learn. It’s a practice propelled by the pandemic, but it started long before COVID shifted many traditional classrooms to virtual education.

New technologies, including online lectures and guided-lesson websites, along with alternative teaching methods, such as the flipped classroom model, in which med students complete before-class assignments and participate in group projects, are helping to train future physicians for their medical careers.

So though students may not be attending in-person lectures like they did in the past, proponents of online learning say the education students receive and the subsequent care they deliver remains the same.

The Association of American Medical Colleges’ most recent annual survey of 2nd-year medical students found that 25% “almost never” attended their in-person lectures in 2022. The figure has steadily improved since 2020 but mirrors what AAMC recorded in 2017.

“The pandemic may have exacerbated the trend, but it’s a long-standing issue,” said Katherine McOwen, senior director of educational and student affairs at AAMC. She said in an interview that she’s witnessed the pattern for 24 years in her work with medical schools.

“I know it sounds alarming that students aren’t attending lectures. But that doesn’t mean they’re not learning,” said Ahmed Ahmed, MD, MPP, MSc, a recent graduate of Harvard Medical School and now a resident at Brigham and Women’s Hospital, Boston.

Today’s generation of medical students grew up in the age of technology. They are comfortable in front of the screen, so it makes sense for them to learn certain aspects of medical sciences and public health in the same way, Dr. Ahmed told this news organization.

Dr. Ahmed said that at Harvard he participated in one or two case-based classes per week that followed a flipped classroom model, which allows students to study topics on their own before discussing in a lecture format as a group. “We had to come up with a diagnostic plan and walk through the case slide by slide,” he said. “It got us to think like a clinician.”

The flipped classroom allows students to study at their own pace using their preferred learning style, leading to more collaboration in the classroom and between students, according to a 2022 article on the “new standard in medical education” published in Trends in Anaesthesia & Critical Care.

Students use online education tools to complete pre-class assignments such as watching short videos, listening to podcasts, or reading journal articles. In-class time can then be used to cement and create connections through discussions, interactive exercises, group learning, and case studies, the article stated.

Benefits of the flipped classroom include student satisfaction, learner motivation, and faculty interest in learning new teaching methods, according to the article: “Students are performing at least as well as those who attended traditional lectures, while some studies in select health care settings show increased retention in flipped classroom settings.”

Another study on the flipped classroom, published in 2018 in BMC Medical Education found that the teaching method was superior to traditional classrooms for health professions education. Researchers focused specifically on flipped classrooms that provided prerecorded videos to students.

Molly Cooke, MD, director of education for global health sciences at the University of California, San Francisco, School of Medicine, said that the school no longer requires attendance at lectures. “Personally, my position is that medical students are very busy people and make, by and large, rational decisions about how to spend their time. As learning and retention from 50-minute lectures has been shown for decades to be poor, I think it’s perfectly reasonable to watch lectures on their own time.”

Dr. Ahmed agrees. “By our standards, the old model is archaic. It’s passive, and instead we should be encouraging lifelong, self-directed learning.”

To that end, Dr. Ahmed and his fellow students also relied heavily during medical school on secondary educational sources such as Boards and Beyond and Sketchy. “There’s an entire community of medical school students across the country using them,” Dr. Ahmed explained. “You can learn what you need in a tenth of the time of lectures.”

Today lectures only provide a portion of the information delivered to students, Dr. McGowen said. “They also learn in small groups, in problem-solving sessions, and in clinical experiences, all of which make up the meat of their education.”

The purpose of medical school is to prepare students for residency, she added. “Medical school education is very different from other types of education. Students are examined in a variety of ways before they move on to residency and ultimately, practice.”

For example, every student must pass the three-part United States Medical Licensing Examination. Students complete the first two parts in medical school and the third part during residency. “The tests represent a combination of everything students have learned, from lectures, clinical time, and in self-directed learning,” Dr. McGowen said.

Post pandemic, the tools and styles of learning in medical education have changed, and they are likely to continue to evolve along with students and technology, according to the 2022 article on the flipped classroom. “The future of medical education will continue to move in ways that embrace digital technology, as this is what digital native learners are increasingly expecting for their health care education,” states the article.

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

TOPLINE:

A dramatic increase in cancer diagnoses following Medicaid expansion in Ohio suggests that expanding the program improves access to cancer care.

METHODOLOGY:

• To assess the impact of Medicaid expansion on cancer diagnosis, investigators compared the volume of patients with newly diagnosed cancer in Ohio, which expanded its Medicaid coverage in 2014, with that of Georgia, which did not.
• State cancer registries were queried from 2010 to 2017 to identify adults younger than 64 years with incident female breast cancer, cervical cancer, or colorectal cancer (CRC).

TAKEAWAY:

• In Ohio, researchers found a substantial increase in diagnoses for all three cancers among Medicaid patients after expansion. The increase ranged from 42% for breast cancer to 77% for CRC.
• In Georgia, fewer Medicaid patients were diagnosed with breast cancer in the postexpansion period. There were also smaller increases in the number of patients diagnosed with cervical cancer (6%) and CRC (13%), compared with the postexpansion increases seen in Ohio.
• The risk of being diagnosed with late-stage breast cancer fell 7% among Medicaid patients in Ohio after expansion.
• The risk of being diagnosed with late-stage CRC fell 6% among Medicaid patients in George and Ohio. The Georgia results are potentially attributable to increases in state and local screening programs, especially in rural areas.

IN PRACTICE:

“These starkly different patterns in changes in the number of diagnosed [breast cancer], [cervical cancer], and CRC cases among patients on Medicaid in Ohio versus Georgia in the postexpansion period suggest that expanding insurance coverage might have effectively improved access to care,” the authors wrote.

SOURCE:

The study, led by Kirsten Eom, PhD, of the MetroHealth Population Health Research Institute, Cleveland, was published online in Cancer.

LIMITATIONS:

• Medicaid status was determined at diagnosis; past studies have associated being enrolled in Medicaid at the time of cancer diagnosis, rather than before, with late‐stage disease.
• The team could not assess the effectiveness of state and local cancer screening programs in preventing late-stage cancer.

DISCLOSURES:

• The study was funded by the Ohio Department of Health and the Georgia Department of Public Health.
• One researcher reported a grant from Celgene.

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

TOPLINE:

A dramatic increase in cancer diagnoses following Medicaid expansion in Ohio suggests that expanding the program improves access to cancer care.

METHODOLOGY:

• To assess the impact of Medicaid expansion on cancer diagnosis, investigators compared the volume of patients with newly diagnosed cancer in Ohio, which expanded its Medicaid coverage in 2014, with that of Georgia, which did not.
• State cancer registries were queried from 2010 to 2017 to identify adults younger than 64 years with incident female breast cancer, cervical cancer, or colorectal cancer (CRC).

TAKEAWAY:

• In Ohio, researchers found a substantial increase in diagnoses for all three cancers among Medicaid patients after expansion. The increase ranged from 42% for breast cancer to 77% for CRC.
• In Georgia, fewer Medicaid patients were diagnosed with breast cancer in the postexpansion period. There were also smaller increases in the number of patients diagnosed with cervical cancer (6%) and CRC (13%), compared with the postexpansion increases seen in Ohio.
• The risk of being diagnosed with late-stage breast cancer fell 7% among Medicaid patients in Ohio after expansion.
• The risk of being diagnosed with late-stage CRC fell 6% among Medicaid patients in George and Ohio. The Georgia results are potentially attributable to increases in state and local screening programs, especially in rural areas.

IN PRACTICE:

“These starkly different patterns in changes in the number of diagnosed [breast cancer], [cervical cancer], and CRC cases among patients on Medicaid in Ohio versus Georgia in the postexpansion period suggest that expanding insurance coverage might have effectively improved access to care,” the authors wrote.

SOURCE:

The study, led by Kirsten Eom, PhD, of the MetroHealth Population Health Research Institute, Cleveland, was published online in Cancer.

LIMITATIONS:

• Medicaid status was determined at diagnosis; past studies have associated being enrolled in Medicaid at the time of cancer diagnosis, rather than before, with late‐stage disease.
• The team could not assess the effectiveness of state and local cancer screening programs in preventing late-stage cancer.

DISCLOSURES:

• The study was funded by the Ohio Department of Health and the Georgia Department of Public Health.
• One researcher reported a grant from Celgene.

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

TOPLINE:

A dramatic increase in cancer diagnoses following Medicaid expansion in Ohio suggests that expanding the program improves access to cancer care.

METHODOLOGY:

• To assess the impact of Medicaid expansion on cancer diagnosis, investigators compared the volume of patients with newly diagnosed cancer in Ohio, which expanded its Medicaid coverage in 2014, with that of Georgia, which did not.
• State cancer registries were queried from 2010 to 2017 to identify adults younger than 64 years with incident female breast cancer, cervical cancer, or colorectal cancer (CRC).

TAKEAWAY:

• In Ohio, researchers found a substantial increase in diagnoses for all three cancers among Medicaid patients after expansion. The increase ranged from 42% for breast cancer to 77% for CRC.
• In Georgia, fewer Medicaid patients were diagnosed with breast cancer in the postexpansion period. There were also smaller increases in the number of patients diagnosed with cervical cancer (6%) and CRC (13%), compared with the postexpansion increases seen in Ohio.
• The risk of being diagnosed with late-stage breast cancer fell 7% among Medicaid patients in Ohio after expansion.
• The risk of being diagnosed with late-stage CRC fell 6% among Medicaid patients in George and Ohio. The Georgia results are potentially attributable to increases in state and local screening programs, especially in rural areas.

IN PRACTICE:

“These starkly different patterns in changes in the number of diagnosed [breast cancer], [cervical cancer], and CRC cases among patients on Medicaid in Ohio versus Georgia in the postexpansion period suggest that expanding insurance coverage might have effectively improved access to care,” the authors wrote.

SOURCE:

The study, led by Kirsten Eom, PhD, of the MetroHealth Population Health Research Institute, Cleveland, was published online in Cancer.

LIMITATIONS:

• Medicaid status was determined at diagnosis; past studies have associated being enrolled in Medicaid at the time of cancer diagnosis, rather than before, with late‐stage disease.
• The team could not assess the effectiveness of state and local cancer screening programs in preventing late-stage cancer.

DISCLOSURES:

• The study was funded by the Ohio Department of Health and the Georgia Department of Public Health.
• One researcher reported a grant from Celgene.

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

This transcript has been edited for clarity.

When you stub your toe or get a paper cut on your finger, you feel the pain in that part of your body. It feels like the pain is coming from that place. But, of course, that’s not really what is happening. Pain doesn’t really happen in your toe or your finger. It happens in your brain.

It’s a game of telephone, really. The afferent nerve fiber detects the noxious stimulus, passing that signal to the second-order neuron in the dorsal root ganglia of the spinal cord, which runs it up to the thalamus to be passed to the third-order neuron which brings it to the cortex for localization and conscious perception. It’s not even a very good game of telephone. It takes about 100 ms for a pain signal to get from the hand to the brain – longer from the feet, given the greater distance. You see your foot hit the corner of the coffee table and have just enough time to think: “Oh no!” before the pain hits.

Wikimedia Commons

Dr. F. Perry Wilson

The New England Journal of Medicine

Dr. F. Perry Wilson

The New England Journal of Medicine

Dr. Wilson is an associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator, New Haven, Conn. He disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

When you stub your toe or get a paper cut on your finger, you feel the pain in that part of your body. It feels like the pain is coming from that place. But, of course, that’s not really what is happening. Pain doesn’t really happen in your toe or your finger. It happens in your brain.

It’s a game of telephone, really. The afferent nerve fiber detects the noxious stimulus, passing that signal to the second-order neuron in the dorsal root ganglia of the spinal cord, which runs it up to the thalamus to be passed to the third-order neuron which brings it to the cortex for localization and conscious perception. It’s not even a very good game of telephone. It takes about 100 ms for a pain signal to get from the hand to the brain – longer from the feet, given the greater distance. You see your foot hit the corner of the coffee table and have just enough time to think: “Oh no!” before the pain hits.

Wikimedia Commons

Dr. F. Perry Wilson

The New England Journal of Medicine

Dr. F. Perry Wilson

The New England Journal of Medicine

Dr. Wilson is an associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator, New Haven, Conn. He disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

When you stub your toe or get a paper cut on your finger, you feel the pain in that part of your body. It feels like the pain is coming from that place. But, of course, that’s not really what is happening. Pain doesn’t really happen in your toe or your finger. It happens in your brain.

It’s a game of telephone, really. The afferent nerve fiber detects the noxious stimulus, passing that signal to the second-order neuron in the dorsal root ganglia of the spinal cord, which runs it up to the thalamus to be passed to the third-order neuron which brings it to the cortex for localization and conscious perception. It’s not even a very good game of telephone. It takes about 100 ms for a pain signal to get from the hand to the brain – longer from the feet, given the greater distance. You see your foot hit the corner of the coffee table and have just enough time to think: “Oh no!” before the pain hits.

Wikimedia Commons

Dr. F. Perry Wilson

The New England Journal of Medicine

Dr. F. Perry Wilson

The New England Journal of Medicine

Dr. Wilson is an associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator, New Haven, Conn. He disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.