JAMA:消化疾病周(DDW)的亮点——大流行相关的结直肠癌筛查下降、质子泵抑制剂与痴呆症之间缺乏关联等

2022-06-27 MedSci原创 MedSci原创

消化疾病周于 5 月下旬结束后不久,JAMA 与会议理事会主席 Loren Laine 医学博士坐下来讨论会议上提出的研究重点——由 4 个专业协会合作:美国肝病研究协会、 美

消化疾病周于 5 月下旬结束后不久,JAMA 与会议理事会主席 Loren Laine 医学博士坐下来讨论会议上提出的研究重点——由 4 个专业协会合作:美国肝病研究协会、 美国胃肠病学协会、美国胃肠内镜学会和消化道外科学会。 莱恩是耶鲁大学医学院消化系统疾病科主任。

以下是该对话的编辑版本。

JAMA:关于大流行对预防性医疗保健的影响的文章很多,例如儿童疫苗接种率的下降。 Kaiser Permanente Northern California 对结直肠癌筛查利用率的分析甚至发现家庭粪便免疫化学检测筛查有所下降。筛查的减少与癌症检测的减少有关吗?这对未来意味着什么?

Laine 博士:FIT 测试(粪便免疫化学测试)当然减少了,结肠镜检查的次数也减少了更多。结肠镜检查可以自己进行筛查。但同样重要的是,如果您的 FIT 测试呈阳性,那么进行结肠镜检查至关重要。在此期间,筛查和监测结肠镜检查减少了约 40%。晚期腺瘤的检出率显着下降,结直肠癌的诊断率降低了约 10%。

尽管在大流行开始时 FIT 测试的数量仅在短时间内减少,因为患者可以将它们邮寄回来,但正在进行的结肠镜检查数量下降了更长的时间。直到 2020 年底,他们才恢复到大约正常的数字。在 2020 年的这段时间里,临床上重要的结果出现了真正的下降,例如晚期腺瘤和结直肠癌。这些人可能会在以后被诊断出来。他们可能不会很快接受治疗。几年后,人们可能做得不好,这既是因为延误诊断,也因为延误治疗。

JAMA:美国有数百万人服用质子泵抑制剂 (PPI) 来减少胃中的酸量。一些研究表明,这些药物与痴呆症风险增加有关。但一项针对美国和澳大利亚近 19000 名 65 岁以上患者的研究发现,情况并非如此。请提供有关该研究的更多详细信息,并讨论它是否明确回答了有关 PPI 和痴呆风险的问题。

Laine 博士:这可以追溯到 2016 年 JAMA Neurology 上的一篇文章,我认为这是第一个提出 PPI 与痴呆风险增加有关的观点的观察性研究。并且已经有很多观察性研究,你可以找到双方的证据。大多数其他研究都是回顾性的,并使用了所谓的保险索赔数据库。他们基本上只查看 ICD-9 [国际疾病分类,第九版] 代码之类的诊断代码,并且对痴呆症诊断的可靠性没有那么大的把握。在这类研究中,存在许多重要的潜在混杂因素。

我认为这项研究的伟大之处在于它是前瞻性的,近 5 年跟踪了近 19000 名参与者。与其他观察性研究不同,研究人员前瞻性地收集了有关药物使用和其他医疗问题的信息。此外,他们在第一年进行了一系列认知测试,然后每两年进行一次。如果这些测试有积极的触发因素,他们就会进行更高级的测试,并由痴呆症专家小组进行裁决。同样,这些分析是前瞻性定义的。当他们查看所有这些信息时,他们能够针对潜在的混杂因素调整结果,例如药物使用、年龄和其他因素。

他们跟踪研究参与者近 5 年,在此期间有 566 例新发痴呆症。确实没有迹象表明 PPI 的使用与痴呆症有关。他们观察了没有痴呆症和其他疾病的认知下降,但没有证据表明存在关联。当人们查看这些类型的研究以试图确定是否存在因果关系时,您会看到一种剂量反应。例如,如果人们服用 PPI 的时间更长,他们是否会比服用时间更短的人更容易患痴呆症?这项研究没有发现与更长使用时间的关联。

JAMA:如果服用 PPI,人们能否继续前进而不用担心可能会增加患痴呆症的风险?

Laine 博士:有研究表明,超过一半的使用 PPI 的人担心副作用。目前,证据的优势是他们可能不必担心痴呆症。

但我认为了解人们为什么服用 PPI 对我们来说很重要。我们在研究中发现,一些真正应该服用 PPI 的人担心痴呆症等问题并停止服用。然后他们会出现胃肠道出血等问题。另一方面,有很多人服用 PPI 没有好的迹象,或者不需要长期服用。我认为还应该定义人口,这样我们就可以为他们描述 PPI。

如果有人每周有一次或两次间歇性胃灼热或更少,那么根据需要服用抗酸剂或 H2 [组胺 2]-受体拮抗剂甚至 PPI 是合理的。大多数患有 PPI 反应性 GERD(胃食管反流病)且没有任何并发​​症的人也可以停止服药。也许一年一次或两次,他们必须参加间歇性课程。还有一些研究着眼于按需使用,人们只是在出现症状时服用几天然后停止使用。当然,很多每天服用 PPI 的人可能不需要服用它们,所以即使没有痴呆等风险,仍然没有理由过度用药。

JAMA:研究人员提出了一些关于早发性结直肠癌 5 年生存率的种族和民族差异的惊人发现。是什么导致了这些差异,是否在被诊断患有结直肠癌的老年人中观察到了这些差异?会议上是否提出了其他关于差异的调查结果?

Laine 博士:有大量关于获得医疗保健和医疗保健结果方面的差异的报告。这是我最感兴趣的一个。我们看到所谓的早发性结直肠癌的发病率在 50 岁之前有所增加。这很重要,因为正如许多人所知,美国预防服务工作组的指南建议刚刚发布,并将年龄降低到从 50 岁到 45 岁开始结直肠癌筛查。

这项研究的有趣之处在于他们研究了 SEER(国家癌症研究所的监测、流行病学和最终结果)计划。他们在 20 年间发现了近 34000 名新诊断的早发性结直肠癌患者。亚裔美国患者的 5 年生存率为 66%,西班牙裔患者为 63%,白人患者为 70%。但黑人人口的 5 年生存率最低,仅略高于 57%。

他们还研究了 20 年上半年与下半年相比的生存率变化。白人人口从最高水平开始,在这 20 年期间增幅最大。真正令人震惊的是,在这 20 年期间的后半段,黑人人口仍然低于这 20 年期间前半段的亚裔、西班牙裔和白人人口的 5 年生存率。

我认为所有年龄段的人都注意到有关获得护理、筛查、接受治疗和及时接受治疗的问题。研究人员还表示,可能还存在与生物学有关的问题,例如吸烟、饮食和遗传。

JAMA:会议上还介绍了哪些关于健康差异的其他研究?

Laine 博士:我的小组研究了上消化道 (GI) 出血患者接受上消化道内窥镜检查的可能性,几乎所有此类患者都建议进行上消化道内窥镜检查。在一项全国性研究中,我们发现在因上消化道出血而到急诊室就诊的患者中,黑人和美洲原住民接受上消化道内窥镜检查的可能性低于白人患者。

JAMA:这些人实际上是来接受评估的,对吧?这并不是说他们无法获得医疗保健或不知道如何获得医疗保健。

莱恩博士:是的。这不仅仅是访问问题。一旦他们访问了它,它实际上就是接受了医疗保健。可能会出现许多与医生和患者有关的障碍。这些都是我们需要处理的事情。

JAMA:在会议上您还有其他想要强调的研究吗?

Laine 博士:有一个有趣的随机对照试验,是一种内窥镜减肥治疗。对于体重管理,我们通过饮食、药物治疗,当然还有减肥手术。但介于药物和减肥手术之间的是减肥内窥镜疗法的增长领域。越来越多地使用的疗法之一是内窥镜袖状胃成形术。可能最常进行的减肥手术是袖状胃切除术。这是一种类似的内窥镜方法。它们都是胃限制程序——它们基本上使胃变成了一个小得多的水库。

这项研究纳入了 208 名体重指数 [BMI,计算方式为体重(公斤)除以身高(米)的平方] 在 30 到 40 之间的患者,并随机分配他们接受内窥镜手术或不接受内窥镜手术。两组都接受了中等强度的生活方式改变疗法。结果是体重过度减轻的百分比,接受内窥镜袖状胃成形术的患者比仅接受生活方式改变的患者高 45%。

袖状胃切除术患者的体重减轻接近 60%;他们的基线 BMI 较高,因此预计他们会减掉更多的体重。这项研究中的患者被跟踪了 2 年,即使在 2 年结束时,他们也能够保持 90% 以上的体重减轻。所以这是持续的体重减轻,他们还表明患者在糖尿病高血压等其他方面有所改善。因此,就像减肥手术一样,它也可能有助于其他健康状况。

原始出处:

Rubin R.Highlights From Digestive Disease Week-Pandemic-Related Decline in Colorectal Cancer Screening, Lack of Association Between Proton Pump Inhibitors and Dementia, and More.JAMA. 2022 Jun 10. doi: 10.1001/jama.2022.8946

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    2023-01-22 jklm09
  3. [GetPortalCommentsPageByObjectIdResponse(id=1667418, encodeId=f52c166e418e9, content=<a href='/topic/show?id=03ab923565b' target=_blank style='color:#2F92EE;'>#质子泵#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=92356, encryptionId=03ab923565b, topicName=质子泵)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=761326143554, createdName=shenxlcyp, createdTime=Sun Mar 12 14:33:26 CST 2023, time=2023-03-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1853004, encodeId=c1dd185300482, content=<a href='/topic/show?id=f0a254918f0' target=_blank style='color:#2F92EE;'>#抑制剂#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54918, encryptionId=f0a254918f0, topicName=抑制剂)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=44a360, createdName=jklm09, createdTime=Sun Jan 22 13:33:26 CST 2023, time=2023-01-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1973328, encodeId=0a7119e3328ff, content=<a href='/topic/show?id=8eb865e470b' target=_blank style='color:#2F92EE;'>#消化疾病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65747, encryptionId=8eb865e470b, topicName=消化疾病)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b78f2500065, createdName=12498761m56暂无昵称, createdTime=Wed May 10 01:33:26 CST 2023, time=2023-05-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1836310, encodeId=cb481836310ba, content=<a href='/topic/show?id=4613e1212fc' target=_blank style='color:#2F92EE;'>#痴呆症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71212, encryptionId=4613e1212fc, topicName=痴呆症)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=726030, createdName=Boyinsh, createdTime=Sat Jan 14 12:33:26 CST 2023, time=2023-01-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1429635, encodeId=19001429635af, content=<a href='/topic/show?id=97c25e83dd' target=_blank style='color:#2F92EE;'>#DDW#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=5783, encryptionId=97c25e83dd, topicName=DDW)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=de284221867, createdName=aids214, createdTime=Tue Jun 28 23:33:26 CST 2022, time=2022-06-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1453725, encodeId=5ba71453e257c, content=<a href='/topic/show?id=098ee8679ad' target=_blank style='color:#2F92EE;'>#结直肠#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=78679, encryptionId=098ee8679ad, topicName=结直肠)], attachment=null, authenticateStatus=null, createdAvatar=/v1.0.0/img/user_icon.png, createdBy=9ace5575596, createdName=crystal0564, createdTime=Tue Jun 28 23:33:26 CST 2022, time=2022-06-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1243586, encodeId=daeb1243586d4, content=JAMA上文章都是顶级的,谢谢梅斯及时上新, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=肿瘤克星, createdTime=Mon Jun 27 11:33:26 CST 2022, time=2022-06-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1247126, encodeId=c8e1124e12694, content=老年性痴呆,未来还是希望借助神经电生理吧,也许更为有效!, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=neuro.Dr, createdTime=Mon Jun 27 11:33:26 CST 2022, time=2022-06-27, status=1, ipAttribution=)]
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    2023-01-14 Boyinsh
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    2022-06-28 aids214
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    2022-06-27 肿瘤克星

    JAMA上文章都是顶级的,谢谢梅斯及时上新

    0

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    2022-06-27 neuro.Dr

    老年性痴呆,未来还是希望借助神经电生理吧,也许更为有效!

    0

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