User login
Counsel fair-skinned patients on cancer prevention, says task force
The U.S. Preventive Services Task Force has recommended that clinicians counsel fair-skinned young adults, adolescents, children, and parents of young children about minimizing exposure to ultraviolet radiation to reduce their risk of skin cancer, in a draft recommendation statement that is available online.
The grade B recommendation applies to asymptomatic individuals who have fair skin, are aged 6 months to 24 years, and have no history of skin cancer; the recommendation is being issued because members of this population are at increased risk and are the subject of most of the existing research on skin cancer counseling, according to the USPSTF. The task force found a moderate net benefit when clinicians in a primary care setting offered behavioral counseling on skin cancer prevention to members of this population.
The draft recommendation is open for public comment until 8:00 p.m. Eastern Standard Time on Nov. 6, 2017.
The draft recommendation can be viewed and comments can be submitted online at the USPSTF site.
The U.S. Preventive Services Task Force has recommended that clinicians counsel fair-skinned young adults, adolescents, children, and parents of young children about minimizing exposure to ultraviolet radiation to reduce their risk of skin cancer, in a draft recommendation statement that is available online.
The grade B recommendation applies to asymptomatic individuals who have fair skin, are aged 6 months to 24 years, and have no history of skin cancer; the recommendation is being issued because members of this population are at increased risk and are the subject of most of the existing research on skin cancer counseling, according to the USPSTF. The task force found a moderate net benefit when clinicians in a primary care setting offered behavioral counseling on skin cancer prevention to members of this population.
The draft recommendation is open for public comment until 8:00 p.m. Eastern Standard Time on Nov. 6, 2017.
The draft recommendation can be viewed and comments can be submitted online at the USPSTF site.
The U.S. Preventive Services Task Force has recommended that clinicians counsel fair-skinned young adults, adolescents, children, and parents of young children about minimizing exposure to ultraviolet radiation to reduce their risk of skin cancer, in a draft recommendation statement that is available online.
The grade B recommendation applies to asymptomatic individuals who have fair skin, are aged 6 months to 24 years, and have no history of skin cancer; the recommendation is being issued because members of this population are at increased risk and are the subject of most of the existing research on skin cancer counseling, according to the USPSTF. The task force found a moderate net benefit when clinicians in a primary care setting offered behavioral counseling on skin cancer prevention to members of this population.
The draft recommendation is open for public comment until 8:00 p.m. Eastern Standard Time on Nov. 6, 2017.
The draft recommendation can be viewed and comments can be submitted online at the USPSTF site.
FROM USPSTF
FISH and PCR aid in diagnosis of human intestinal spirochetosis
Fluorescence in situ hybridization (FISH) combined with 16S rRNA gene amplification and sequencing allowed researchers to make a definitive diagnosis of human intestinal spirochetosis (HIS) and further identify the causative pathogens.
Pablo Rojas, PhD, of Charité Universitätsmedizin Berlin, and his colleagues evaluated 149 paraffin-embedded or native intestinal biopsies from 91 consecutive patients with histologically diagnosed HIS. The reasons for endoscopy and histological investigation included chronic diarrhea, cancer/adenoma screening, inflammatory bowel disease, and endoscopic detection of polyps or colitis. In all, 12 patients were HIV-positive.
The researchers used a FISH probe to confirm Brachyspira spp. HIS for 77 of the 91 patients. A polymerase chain reaction (PCR) analysis of part of the bacterial 16S rRNA gene confirmed the presence of Brachyspira spp. in 75 patients. The sequencing allowed the researchers to drill down on the pathogen, identifying both the B. aalborgi and B. pilosicoli species lineage among the samples.
There were 14 cases in which researchers could not confirm the diagnosis of HIS with either FISH or RNA sequencing, but they noted that these cases were likely misdiagnosed by histopathology.
“FISH at the interface of histopathology and molecular biology is a valuable diagnostic tool for the diagnosis of HIS. The bright FISH signal in most cases already allowed rapid localization of Brachyspira spp. at 400 magnification. All samples that could be tested via PCR were consistent with the FISH results, whereas 14 cases were diagnosed false positive by histopathology,” the researchers wrote. “On these grounds, we propose to include FISH for the diagnosis and follow-up observation of HIS in routine practice.”
Find the full study in Anaerobe (2017 Oct. doi: 10.1016/j.anaerobe.2017.03.012).
Fluorescence in situ hybridization (FISH) combined with 16S rRNA gene amplification and sequencing allowed researchers to make a definitive diagnosis of human intestinal spirochetosis (HIS) and further identify the causative pathogens.
Pablo Rojas, PhD, of Charité Universitätsmedizin Berlin, and his colleagues evaluated 149 paraffin-embedded or native intestinal biopsies from 91 consecutive patients with histologically diagnosed HIS. The reasons for endoscopy and histological investigation included chronic diarrhea, cancer/adenoma screening, inflammatory bowel disease, and endoscopic detection of polyps or colitis. In all, 12 patients were HIV-positive.
The researchers used a FISH probe to confirm Brachyspira spp. HIS for 77 of the 91 patients. A polymerase chain reaction (PCR) analysis of part of the bacterial 16S rRNA gene confirmed the presence of Brachyspira spp. in 75 patients. The sequencing allowed the researchers to drill down on the pathogen, identifying both the B. aalborgi and B. pilosicoli species lineage among the samples.
There were 14 cases in which researchers could not confirm the diagnosis of HIS with either FISH or RNA sequencing, but they noted that these cases were likely misdiagnosed by histopathology.
“FISH at the interface of histopathology and molecular biology is a valuable diagnostic tool for the diagnosis of HIS. The bright FISH signal in most cases already allowed rapid localization of Brachyspira spp. at 400 magnification. All samples that could be tested via PCR were consistent with the FISH results, whereas 14 cases were diagnosed false positive by histopathology,” the researchers wrote. “On these grounds, we propose to include FISH for the diagnosis and follow-up observation of HIS in routine practice.”
Find the full study in Anaerobe (2017 Oct. doi: 10.1016/j.anaerobe.2017.03.012).
Fluorescence in situ hybridization (FISH) combined with 16S rRNA gene amplification and sequencing allowed researchers to make a definitive diagnosis of human intestinal spirochetosis (HIS) and further identify the causative pathogens.
Pablo Rojas, PhD, of Charité Universitätsmedizin Berlin, and his colleagues evaluated 149 paraffin-embedded or native intestinal biopsies from 91 consecutive patients with histologically diagnosed HIS. The reasons for endoscopy and histological investigation included chronic diarrhea, cancer/adenoma screening, inflammatory bowel disease, and endoscopic detection of polyps or colitis. In all, 12 patients were HIV-positive.
The researchers used a FISH probe to confirm Brachyspira spp. HIS for 77 of the 91 patients. A polymerase chain reaction (PCR) analysis of part of the bacterial 16S rRNA gene confirmed the presence of Brachyspira spp. in 75 patients. The sequencing allowed the researchers to drill down on the pathogen, identifying both the B. aalborgi and B. pilosicoli species lineage among the samples.
There were 14 cases in which researchers could not confirm the diagnosis of HIS with either FISH or RNA sequencing, but they noted that these cases were likely misdiagnosed by histopathology.
“FISH at the interface of histopathology and molecular biology is a valuable diagnostic tool for the diagnosis of HIS. The bright FISH signal in most cases already allowed rapid localization of Brachyspira spp. at 400 magnification. All samples that could be tested via PCR were consistent with the FISH results, whereas 14 cases were diagnosed false positive by histopathology,” the researchers wrote. “On these grounds, we propose to include FISH for the diagnosis and follow-up observation of HIS in routine practice.”
Find the full study in Anaerobe (2017 Oct. doi: 10.1016/j.anaerobe.2017.03.012).
FROM ANAEROBE
Thoracic syndesmophytes common in ankylosing spondylitis
Thoracic syndesmophytes are common in ankylosing spondylitis, even in the absence of lumbar syndesmophytes, according to a study published in the Journal of Rheumatology.
Sovira Tan, PhD, and his colleagues from the National Institute of Arthritis and Musculoskeletal and Skin Diseases wrote that the current standard for radiographic assessment of ankylosing spondylitis scores only the cervical and lumbar spine because of difficulties visualizing the thoracic spine.
“Consequently, the involvement of the thoracic spine with syndesmophytes has not been widely studied,” they wrote. “If syndesmophytes differentially develop in the thoracic spine, exclusion of this large region may affect the validity of spinal fusion biomarker studies.”
In this study, 18 patients with ankylosing spondylitis who did not show complete lumbar fusion on radiographs underwent thoracolumbar CT and lumbar radiography (J Rheumatol. 2017 Oct 1. doi: 10.3899/jrheum.170340). The patients had ankylosing spondylitis for a mean duration of about 19 years, and 11 were treated with tumor necrosis factor inhibitors.
Researchers found syndesmophytes were common overall in intervertebral disc spaces, ranging from 56% to 89%. The rate of syndesmophytes peaked around the thoracolumbar junction, and bridging was both more evident and more extensive in the superior thoracic levels, compared with the lumbar levels.
In all the patients, thoracic syndesmophytes on the CT scan were at least as common as lumbar, and patients with extensive syndesmophytes at multiple lumbar locations typically also had the same in the thoracic region.
However, there were also patients with no, or very few, lumbar syndesmophytes on CT who still had thoracic syndesmophytes, some of which were extensive.
“Importantly, if syndesmophytes were observed on a lumbar radiograph, one could expect there to be syndesmophytes in the thoracic spine, but not the converse,” the authors wrote. “Several patients with normal lumbar radiographs had substantial thoracic syndesmophytes.”
The authors commented that because of its two-dimensional character, radiography has a relatively low sensitivity for detecting syndesmophytes, compared with CT. This could explain why patients with any syndesmophytes in the lumbar region on radiography also had them in the thoracic CT scans.
“By the time syndesmophytes are detectable on lumbar radiographs, structural damage may already have occurred in large portions of the thoracolumbar spine.”
They acknowledged that their method was a research tool and not intended for clinical practice, but also pointed out that CT technology had improved to allow more extensive spine coverage, at an equal effective dose, without compromising scan quality.
The study was supported by the National Institutes of Health. No conflicts of interest disclosures were available.
Thoracic syndesmophytes are common in ankylosing spondylitis, even in the absence of lumbar syndesmophytes, according to a study published in the Journal of Rheumatology.
Sovira Tan, PhD, and his colleagues from the National Institute of Arthritis and Musculoskeletal and Skin Diseases wrote that the current standard for radiographic assessment of ankylosing spondylitis scores only the cervical and lumbar spine because of difficulties visualizing the thoracic spine.
“Consequently, the involvement of the thoracic spine with syndesmophytes has not been widely studied,” they wrote. “If syndesmophytes differentially develop in the thoracic spine, exclusion of this large region may affect the validity of spinal fusion biomarker studies.”
In this study, 18 patients with ankylosing spondylitis who did not show complete lumbar fusion on radiographs underwent thoracolumbar CT and lumbar radiography (J Rheumatol. 2017 Oct 1. doi: 10.3899/jrheum.170340). The patients had ankylosing spondylitis for a mean duration of about 19 years, and 11 were treated with tumor necrosis factor inhibitors.
Researchers found syndesmophytes were common overall in intervertebral disc spaces, ranging from 56% to 89%. The rate of syndesmophytes peaked around the thoracolumbar junction, and bridging was both more evident and more extensive in the superior thoracic levels, compared with the lumbar levels.
In all the patients, thoracic syndesmophytes on the CT scan were at least as common as lumbar, and patients with extensive syndesmophytes at multiple lumbar locations typically also had the same in the thoracic region.
However, there were also patients with no, or very few, lumbar syndesmophytes on CT who still had thoracic syndesmophytes, some of which were extensive.
“Importantly, if syndesmophytes were observed on a lumbar radiograph, one could expect there to be syndesmophytes in the thoracic spine, but not the converse,” the authors wrote. “Several patients with normal lumbar radiographs had substantial thoracic syndesmophytes.”
The authors commented that because of its two-dimensional character, radiography has a relatively low sensitivity for detecting syndesmophytes, compared with CT. This could explain why patients with any syndesmophytes in the lumbar region on radiography also had them in the thoracic CT scans.
“By the time syndesmophytes are detectable on lumbar radiographs, structural damage may already have occurred in large portions of the thoracolumbar spine.”
They acknowledged that their method was a research tool and not intended for clinical practice, but also pointed out that CT technology had improved to allow more extensive spine coverage, at an equal effective dose, without compromising scan quality.
The study was supported by the National Institutes of Health. No conflicts of interest disclosures were available.
Thoracic syndesmophytes are common in ankylosing spondylitis, even in the absence of lumbar syndesmophytes, according to a study published in the Journal of Rheumatology.
Sovira Tan, PhD, and his colleagues from the National Institute of Arthritis and Musculoskeletal and Skin Diseases wrote that the current standard for radiographic assessment of ankylosing spondylitis scores only the cervical and lumbar spine because of difficulties visualizing the thoracic spine.
“Consequently, the involvement of the thoracic spine with syndesmophytes has not been widely studied,” they wrote. “If syndesmophytes differentially develop in the thoracic spine, exclusion of this large region may affect the validity of spinal fusion biomarker studies.”
In this study, 18 patients with ankylosing spondylitis who did not show complete lumbar fusion on radiographs underwent thoracolumbar CT and lumbar radiography (J Rheumatol. 2017 Oct 1. doi: 10.3899/jrheum.170340). The patients had ankylosing spondylitis for a mean duration of about 19 years, and 11 were treated with tumor necrosis factor inhibitors.
Researchers found syndesmophytes were common overall in intervertebral disc spaces, ranging from 56% to 89%. The rate of syndesmophytes peaked around the thoracolumbar junction, and bridging was both more evident and more extensive in the superior thoracic levels, compared with the lumbar levels.
In all the patients, thoracic syndesmophytes on the CT scan were at least as common as lumbar, and patients with extensive syndesmophytes at multiple lumbar locations typically also had the same in the thoracic region.
However, there were also patients with no, or very few, lumbar syndesmophytes on CT who still had thoracic syndesmophytes, some of which were extensive.
“Importantly, if syndesmophytes were observed on a lumbar radiograph, one could expect there to be syndesmophytes in the thoracic spine, but not the converse,” the authors wrote. “Several patients with normal lumbar radiographs had substantial thoracic syndesmophytes.”
The authors commented that because of its two-dimensional character, radiography has a relatively low sensitivity for detecting syndesmophytes, compared with CT. This could explain why patients with any syndesmophytes in the lumbar region on radiography also had them in the thoracic CT scans.
“By the time syndesmophytes are detectable on lumbar radiographs, structural damage may already have occurred in large portions of the thoracolumbar spine.”
They acknowledged that their method was a research tool and not intended for clinical practice, but also pointed out that CT technology had improved to allow more extensive spine coverage, at an equal effective dose, without compromising scan quality.
The study was supported by the National Institutes of Health. No conflicts of interest disclosures were available.
FROM JOURNAL OF RHEUMATOLOGY
Key clinical point:
Major finding: Within individual patients, CT-detected syndesmophytes were either more common in or equally present in thoracic intervertebral disc spaces, compared with lumbar.
Data source: CT and radiography study of 18 patients with ankylosing spondylitis.
Disclosures: The study was supported by the National Institutes of Health. No conflicts of interest disclosures were available.
Trump halts ACA cost-sharing reduction subsidy payments
“The Democrats ObamaCare [sic] is imploding. Massive subsidy payments to their pet insurance companies has stopped. Dems should call me to fix!” President Trump tweeted Oct. 13.
The action prompted criticism from medical organizations and health insurers alike.
In a statement, American Medical Association President David Barbe said he was “deeply discouraged” by the cuts. “This most recent action by the administration creates still more uncertainty in the ACA marketplace just as the abbreviated open enrollment period is about to begin, further undermining the law and threatening access to meaningful health insurance coverage for millions of Americans,” Dr. Barbe said.
“We need constructive solutions that increase consumer choice, lower consumer costs, and stabilize local markets,” America’s Health Insurance Plans and the Blue Cross Blue Shield Association said in a joint statement. “Terminating this critical program will do just the opposite. This action will make it harder for patients to access the care they need. Costs will go up and choice will be restricted.”
The U.S. Senate Committee on Health, Education, Labor & Pensions was working on a bipartisan, narrowly focused bill that would have, among other things, codified cost-sharing reduction payments in legislation for at least a year, after witnesses from across the political spectrum testified during four hearings that maintenance of the payments would bring stability to the individual market. That effort was derailed when Senate Majority Leader Mitch McConnell (R-Ky.) instead pushed a broad repeal-and-replace effort, which never reached the Senate floor for consideration when it was clear the action did not have enough votes to pass.
The president’s move follows an executive order that could further destabilize the individual market through broader use of association health plans and an expansion of short-term health insurance plans, neither of which would have to meet the coverage and benefits requirements of the Affordable Care Act.
“The Democrats ObamaCare [sic] is imploding. Massive subsidy payments to their pet insurance companies has stopped. Dems should call me to fix!” President Trump tweeted Oct. 13.
The action prompted criticism from medical organizations and health insurers alike.
In a statement, American Medical Association President David Barbe said he was “deeply discouraged” by the cuts. “This most recent action by the administration creates still more uncertainty in the ACA marketplace just as the abbreviated open enrollment period is about to begin, further undermining the law and threatening access to meaningful health insurance coverage for millions of Americans,” Dr. Barbe said.
“We need constructive solutions that increase consumer choice, lower consumer costs, and stabilize local markets,” America’s Health Insurance Plans and the Blue Cross Blue Shield Association said in a joint statement. “Terminating this critical program will do just the opposite. This action will make it harder for patients to access the care they need. Costs will go up and choice will be restricted.”
The U.S. Senate Committee on Health, Education, Labor & Pensions was working on a bipartisan, narrowly focused bill that would have, among other things, codified cost-sharing reduction payments in legislation for at least a year, after witnesses from across the political spectrum testified during four hearings that maintenance of the payments would bring stability to the individual market. That effort was derailed when Senate Majority Leader Mitch McConnell (R-Ky.) instead pushed a broad repeal-and-replace effort, which never reached the Senate floor for consideration when it was clear the action did not have enough votes to pass.
The president’s move follows an executive order that could further destabilize the individual market through broader use of association health plans and an expansion of short-term health insurance plans, neither of which would have to meet the coverage and benefits requirements of the Affordable Care Act.
“The Democrats ObamaCare [sic] is imploding. Massive subsidy payments to their pet insurance companies has stopped. Dems should call me to fix!” President Trump tweeted Oct. 13.
The action prompted criticism from medical organizations and health insurers alike.
In a statement, American Medical Association President David Barbe said he was “deeply discouraged” by the cuts. “This most recent action by the administration creates still more uncertainty in the ACA marketplace just as the abbreviated open enrollment period is about to begin, further undermining the law and threatening access to meaningful health insurance coverage for millions of Americans,” Dr. Barbe said.
“We need constructive solutions that increase consumer choice, lower consumer costs, and stabilize local markets,” America’s Health Insurance Plans and the Blue Cross Blue Shield Association said in a joint statement. “Terminating this critical program will do just the opposite. This action will make it harder for patients to access the care they need. Costs will go up and choice will be restricted.”
The U.S. Senate Committee on Health, Education, Labor & Pensions was working on a bipartisan, narrowly focused bill that would have, among other things, codified cost-sharing reduction payments in legislation for at least a year, after witnesses from across the political spectrum testified during four hearings that maintenance of the payments would bring stability to the individual market. That effort was derailed when Senate Majority Leader Mitch McConnell (R-Ky.) instead pushed a broad repeal-and-replace effort, which never reached the Senate floor for consideration when it was clear the action did not have enough votes to pass.
The president’s move follows an executive order that could further destabilize the individual market through broader use of association health plans and an expansion of short-term health insurance plans, neither of which would have to meet the coverage and benefits requirements of the Affordable Care Act.
Are those hemorrhoids? Get to know the anorectal imitators
ESTES PARK, COLO. – As a colorectal surgeon, Michelle Cowan, MD, sees a steady parade of primary care referrals for surgical evaluation of hemorrhoids.
The thing is, most of the time, the referred patients don’t have hemorrhoids. They have one of the other common anorectal disorders, including anal fissure, anoperineal abscess, fistula-in-ano, or an anorectal sexually transmitted infection, according to Dr. Cowan.
The diagnostic challenge stems from the fact that most common anorectal diseases – whether benign or malignant – present with the same constellation of symptoms: pain, bleeding, itching or burning, swelling, and leakage.
The quality and intensity of the pain “down under” provides a useful clue in differentiating the disorders.
“Hemorrhoids rarely cause legit pain,” said Dr. Cowan, who practices at the University of Colorado at Denver, Aurora. “Excruciating pain, where the patient will only sit on one side, that’s typically an abscess, a fissure, or an STI.”
The exceptions in the hemorrhoid realm are external thrombosed hemorrhoids, which are exceedingly painful but also readily identifiable, and incarcerated hemorrhoids, which are quite rare.
The pain associated with an anal fissure is distinct from that of an abscess or thrombosed hemorrhoid – it’s a throbbing pain lasting minutes to hours per episode.
“These are the people who won’t sit down in your office,” Dr. Cowan said.
Anal fissure is a common condition in young and middle-aged adults, and especially in peripartum women. The pathophysiology involves microtrauma, typically either because of passing rock-hard stools, diarrhea, or the rigors of childbirth, any of which can cause a break in the anal mucosa. That break causes the internal sphincter muscle to go into spasm, temporarily choking off the blood supply to the area of the fissure. Those wounds won’t heal on their own. Close to 90% of the fissures are located in the posterior midline; if the fissure is ectopic, it’s time to consider Crohn’s disease, HIV infection, tuberculosis, cancer, and other possibilities.
The patient with an anoperineal abscess presents with extreme pain, a sensation of fullness in the anus and rectum, erythema, fullness of the perineum, drainage, and sometimes fever.
“This is legit pain, like with a fissure or thrombosed hemorrhoids,” she explained. “Patients with any of these conditions can tell you exactly when they went from feeling normal to when the pain started.”
The abscess is caused by an infected anal gland. The location is most commonly perianal or ischioanal. If that’s not the suppuration site, the abscess is intersphincteric or supralevator, in which case a confirmatory CT scan is called for before proceeding with treatment.
Regardless of the suspected cause of a patient’s anorectal symptoms, any GI bleeding needs to be taken seriously. Young adults are the only segment of the population in whom the incidence of colorectal cancer is going up. In response, the American Society for Gastrointestinal Endoscopy and other groups now recommend colonoscopy for all patients older than age 40 years with GI bleeding, even if their family histories for colorectal cancer are negative and they lack other high-risk factors. For those younger than age 40 years, flexible sigmoidoscopy is recommended, even if it’s obvious that the patient has external thrombosed hemorrhoids that are bleeding.
“I tell people that I will not do hemorrhoid surgery until they have the scope,” Dr. Cowan said.
Office-based treatment of common anorectal disorders
Nonoperative treatment of anal fissures and internal hemorrhoids is all about encouraging patient adherence.
“Patient expectations are often overlooked,” according to the surgeon. “It’s rare that these patients actually need to go to surgery, but they oftentimes don’t do what we tell them to do, which is why they end up in my office.”
With anal fissure, the goal is to relax the spastic sphincter muscle, allowing the fissure to heal. That can be accomplished medically or surgically.
Medically, treatment consists of increased water intake, incorporation of more fiber in the diet, undertaking warm sitz baths a couple times a day, and application of a pea-sized amount of topical 2% diltiazem three times daily on the outside of the anus for 6-8 weeks.
“Compliance is huge. This whole thing is about consistency. Oftentimes, the reason treatment fails is people can’t do this. They feel good after about a week, so they stop before the fissure is completely healed,” she said.
The topical diltiazem must be prepared at a compounding pharmacy. It’s usually covered by insurance. Even if it’s not, an 8-week prescription costs only about $25. The drug is effective in up to 95% of patients who follow the instructions.
Topical 0.2% nitroglycerin, an alternative treatment, is less attractive because 30% of patients experience often-disabling headaches as a side effect. Topical diltiazem has a much better side effect profile, Dr. Cowan noted. If a patient shows a partial response to 6-8 weeks of topical diltiazem, it’s worth prescribing a second round. If the fissure still hasn’t healed after that, it’s time for referral to a surgeon. The options are onabotulinumtoxinA (Botox) and lateral internal sphincterotomy.
Botox is effective in 60%-80% of patients, she explained, providing temporary benefit lasting up to 3 months with a much lower risk of incontinence than with lateral internal sphincterotomy. Open and closed sphincterotomy techniques yield a similar success rate, with healing in 93% of cases.
For internal hemorrhoids, stool softeners, 25-30 g of fiber supplements per day, warm sitz baths, avoiding straining during defecation, and not loitering on the toilet are key elements in achieving symptomatic control nonoperatively.
Patients who don’t have a bathtub in which to take sitz baths can accomplish the same thing using an easily removable, commercially available device that fits over a toilet bowl.
Disposable baby wipes for adults have become the No. 1 cause of anal itching and are to be shunned by patients with internal hemorrhoids or other anorectal disorders.
“Patients often engage in excessive wiping because of the poor consistency of their bowel movements,” Dr. Cowan explained. “If they’re pasty and not coming out in one fell swoop, it leads to residue that patients appropriately feel they need to wipe multiple times to keep clean. The majority of these dipe wipes for adults are alcohol based, and even though on your exam you may see nothing, the dipe wipes cause microexcoriations of the skin. The patient itches and doesn’t know why.”
Primary care physicians can readily learn to do mucosal banding for grade II and III prolapsing hemorrhoids in the office, she noted. However, banding should never be attempted on external thrombosed hemorrhoids, though.
Surgical excisional hemorrhoidectomy is a lasting solution for such hemorrhoids, but patients need to understand that even though it’s only a 10- to 15-minute procedure performed in an outpatient setting, it’s excruciatingly painful for a week – and that’s not the end of the story.
“I tell patients to take a week off work,” the surgeon said. “And don’t sit on a donut; it pulls on the suture line. Pillows are okay. But it takes 6-8 weeks to heal, so even though they’re only in excruciating pain for about a week, they have to poop past the suture line, so they’ve got to avoid rock-hard stools.”
With an anoperineal abscess, first-line treatment is incision of the abscess as close as possible to the anus, followed by placement of a drain to be left in place for 7-10 days. Prophylactic antibiotics are reserved for immunosuppressed patients.
Patients need to understand up front that, 30%-50% of the time, a fistula can develop after drainage of an abscess. Indeed, abscessed anoperineal fistula is one of the most common conditions Dr. Cowan sees in the emergency department and clinic. The telltale symptoms are recurrent abscess and/or persistent drainage. Those patients need referral to a colorectal surgeon.
“Fistula-in-ano is a frustrating disease for the patient and the surgeon. As surgeons, we like to fix – and there’s really no good option,” according to Dr. Cowan.
Among the surgical treatment options are debridement followed by fibrin glue injection, an anal fistula plug, an endorectal flap closure, and ligation of the intersphincteric fistula tract, or LIFT, procedure.
Dr. Cowan reported serving as a consultant to Applied Medical.
ESTES PARK, COLO. – As a colorectal surgeon, Michelle Cowan, MD, sees a steady parade of primary care referrals for surgical evaluation of hemorrhoids.
The thing is, most of the time, the referred patients don’t have hemorrhoids. They have one of the other common anorectal disorders, including anal fissure, anoperineal abscess, fistula-in-ano, or an anorectal sexually transmitted infection, according to Dr. Cowan.
The diagnostic challenge stems from the fact that most common anorectal diseases – whether benign or malignant – present with the same constellation of symptoms: pain, bleeding, itching or burning, swelling, and leakage.
The quality and intensity of the pain “down under” provides a useful clue in differentiating the disorders.
“Hemorrhoids rarely cause legit pain,” said Dr. Cowan, who practices at the University of Colorado at Denver, Aurora. “Excruciating pain, where the patient will only sit on one side, that’s typically an abscess, a fissure, or an STI.”
The exceptions in the hemorrhoid realm are external thrombosed hemorrhoids, which are exceedingly painful but also readily identifiable, and incarcerated hemorrhoids, which are quite rare.
The pain associated with an anal fissure is distinct from that of an abscess or thrombosed hemorrhoid – it’s a throbbing pain lasting minutes to hours per episode.
“These are the people who won’t sit down in your office,” Dr. Cowan said.
Anal fissure is a common condition in young and middle-aged adults, and especially in peripartum women. The pathophysiology involves microtrauma, typically either because of passing rock-hard stools, diarrhea, or the rigors of childbirth, any of which can cause a break in the anal mucosa. That break causes the internal sphincter muscle to go into spasm, temporarily choking off the blood supply to the area of the fissure. Those wounds won’t heal on their own. Close to 90% of the fissures are located in the posterior midline; if the fissure is ectopic, it’s time to consider Crohn’s disease, HIV infection, tuberculosis, cancer, and other possibilities.
The patient with an anoperineal abscess presents with extreme pain, a sensation of fullness in the anus and rectum, erythema, fullness of the perineum, drainage, and sometimes fever.
“This is legit pain, like with a fissure or thrombosed hemorrhoids,” she explained. “Patients with any of these conditions can tell you exactly when they went from feeling normal to when the pain started.”
The abscess is caused by an infected anal gland. The location is most commonly perianal or ischioanal. If that’s not the suppuration site, the abscess is intersphincteric or supralevator, in which case a confirmatory CT scan is called for before proceeding with treatment.
Regardless of the suspected cause of a patient’s anorectal symptoms, any GI bleeding needs to be taken seriously. Young adults are the only segment of the population in whom the incidence of colorectal cancer is going up. In response, the American Society for Gastrointestinal Endoscopy and other groups now recommend colonoscopy for all patients older than age 40 years with GI bleeding, even if their family histories for colorectal cancer are negative and they lack other high-risk factors. For those younger than age 40 years, flexible sigmoidoscopy is recommended, even if it’s obvious that the patient has external thrombosed hemorrhoids that are bleeding.
“I tell people that I will not do hemorrhoid surgery until they have the scope,” Dr. Cowan said.
Office-based treatment of common anorectal disorders
Nonoperative treatment of anal fissures and internal hemorrhoids is all about encouraging patient adherence.
“Patient expectations are often overlooked,” according to the surgeon. “It’s rare that these patients actually need to go to surgery, but they oftentimes don’t do what we tell them to do, which is why they end up in my office.”
With anal fissure, the goal is to relax the spastic sphincter muscle, allowing the fissure to heal. That can be accomplished medically or surgically.
Medically, treatment consists of increased water intake, incorporation of more fiber in the diet, undertaking warm sitz baths a couple times a day, and application of a pea-sized amount of topical 2% diltiazem three times daily on the outside of the anus for 6-8 weeks.
“Compliance is huge. This whole thing is about consistency. Oftentimes, the reason treatment fails is people can’t do this. They feel good after about a week, so they stop before the fissure is completely healed,” she said.
The topical diltiazem must be prepared at a compounding pharmacy. It’s usually covered by insurance. Even if it’s not, an 8-week prescription costs only about $25. The drug is effective in up to 95% of patients who follow the instructions.
Topical 0.2% nitroglycerin, an alternative treatment, is less attractive because 30% of patients experience often-disabling headaches as a side effect. Topical diltiazem has a much better side effect profile, Dr. Cowan noted. If a patient shows a partial response to 6-8 weeks of topical diltiazem, it’s worth prescribing a second round. If the fissure still hasn’t healed after that, it’s time for referral to a surgeon. The options are onabotulinumtoxinA (Botox) and lateral internal sphincterotomy.
Botox is effective in 60%-80% of patients, she explained, providing temporary benefit lasting up to 3 months with a much lower risk of incontinence than with lateral internal sphincterotomy. Open and closed sphincterotomy techniques yield a similar success rate, with healing in 93% of cases.
For internal hemorrhoids, stool softeners, 25-30 g of fiber supplements per day, warm sitz baths, avoiding straining during defecation, and not loitering on the toilet are key elements in achieving symptomatic control nonoperatively.
Patients who don’t have a bathtub in which to take sitz baths can accomplish the same thing using an easily removable, commercially available device that fits over a toilet bowl.
Disposable baby wipes for adults have become the No. 1 cause of anal itching and are to be shunned by patients with internal hemorrhoids or other anorectal disorders.
“Patients often engage in excessive wiping because of the poor consistency of their bowel movements,” Dr. Cowan explained. “If they’re pasty and not coming out in one fell swoop, it leads to residue that patients appropriately feel they need to wipe multiple times to keep clean. The majority of these dipe wipes for adults are alcohol based, and even though on your exam you may see nothing, the dipe wipes cause microexcoriations of the skin. The patient itches and doesn’t know why.”
Primary care physicians can readily learn to do mucosal banding for grade II and III prolapsing hemorrhoids in the office, she noted. However, banding should never be attempted on external thrombosed hemorrhoids, though.
Surgical excisional hemorrhoidectomy is a lasting solution for such hemorrhoids, but patients need to understand that even though it’s only a 10- to 15-minute procedure performed in an outpatient setting, it’s excruciatingly painful for a week – and that’s not the end of the story.
“I tell patients to take a week off work,” the surgeon said. “And don’t sit on a donut; it pulls on the suture line. Pillows are okay. But it takes 6-8 weeks to heal, so even though they’re only in excruciating pain for about a week, they have to poop past the suture line, so they’ve got to avoid rock-hard stools.”
With an anoperineal abscess, first-line treatment is incision of the abscess as close as possible to the anus, followed by placement of a drain to be left in place for 7-10 days. Prophylactic antibiotics are reserved for immunosuppressed patients.
Patients need to understand up front that, 30%-50% of the time, a fistula can develop after drainage of an abscess. Indeed, abscessed anoperineal fistula is one of the most common conditions Dr. Cowan sees in the emergency department and clinic. The telltale symptoms are recurrent abscess and/or persistent drainage. Those patients need referral to a colorectal surgeon.
“Fistula-in-ano is a frustrating disease for the patient and the surgeon. As surgeons, we like to fix – and there’s really no good option,” according to Dr. Cowan.
Among the surgical treatment options are debridement followed by fibrin glue injection, an anal fistula plug, an endorectal flap closure, and ligation of the intersphincteric fistula tract, or LIFT, procedure.
Dr. Cowan reported serving as a consultant to Applied Medical.
ESTES PARK, COLO. – As a colorectal surgeon, Michelle Cowan, MD, sees a steady parade of primary care referrals for surgical evaluation of hemorrhoids.
The thing is, most of the time, the referred patients don’t have hemorrhoids. They have one of the other common anorectal disorders, including anal fissure, anoperineal abscess, fistula-in-ano, or an anorectal sexually transmitted infection, according to Dr. Cowan.
The diagnostic challenge stems from the fact that most common anorectal diseases – whether benign or malignant – present with the same constellation of symptoms: pain, bleeding, itching or burning, swelling, and leakage.
The quality and intensity of the pain “down under” provides a useful clue in differentiating the disorders.
“Hemorrhoids rarely cause legit pain,” said Dr. Cowan, who practices at the University of Colorado at Denver, Aurora. “Excruciating pain, where the patient will only sit on one side, that’s typically an abscess, a fissure, or an STI.”
The exceptions in the hemorrhoid realm are external thrombosed hemorrhoids, which are exceedingly painful but also readily identifiable, and incarcerated hemorrhoids, which are quite rare.
The pain associated with an anal fissure is distinct from that of an abscess or thrombosed hemorrhoid – it’s a throbbing pain lasting minutes to hours per episode.
“These are the people who won’t sit down in your office,” Dr. Cowan said.
Anal fissure is a common condition in young and middle-aged adults, and especially in peripartum women. The pathophysiology involves microtrauma, typically either because of passing rock-hard stools, diarrhea, or the rigors of childbirth, any of which can cause a break in the anal mucosa. That break causes the internal sphincter muscle to go into spasm, temporarily choking off the blood supply to the area of the fissure. Those wounds won’t heal on their own. Close to 90% of the fissures are located in the posterior midline; if the fissure is ectopic, it’s time to consider Crohn’s disease, HIV infection, tuberculosis, cancer, and other possibilities.
The patient with an anoperineal abscess presents with extreme pain, a sensation of fullness in the anus and rectum, erythema, fullness of the perineum, drainage, and sometimes fever.
“This is legit pain, like with a fissure or thrombosed hemorrhoids,” she explained. “Patients with any of these conditions can tell you exactly when they went from feeling normal to when the pain started.”
The abscess is caused by an infected anal gland. The location is most commonly perianal or ischioanal. If that’s not the suppuration site, the abscess is intersphincteric or supralevator, in which case a confirmatory CT scan is called for before proceeding with treatment.
Regardless of the suspected cause of a patient’s anorectal symptoms, any GI bleeding needs to be taken seriously. Young adults are the only segment of the population in whom the incidence of colorectal cancer is going up. In response, the American Society for Gastrointestinal Endoscopy and other groups now recommend colonoscopy for all patients older than age 40 years with GI bleeding, even if their family histories for colorectal cancer are negative and they lack other high-risk factors. For those younger than age 40 years, flexible sigmoidoscopy is recommended, even if it’s obvious that the patient has external thrombosed hemorrhoids that are bleeding.
“I tell people that I will not do hemorrhoid surgery until they have the scope,” Dr. Cowan said.
Office-based treatment of common anorectal disorders
Nonoperative treatment of anal fissures and internal hemorrhoids is all about encouraging patient adherence.
“Patient expectations are often overlooked,” according to the surgeon. “It’s rare that these patients actually need to go to surgery, but they oftentimes don’t do what we tell them to do, which is why they end up in my office.”
With anal fissure, the goal is to relax the spastic sphincter muscle, allowing the fissure to heal. That can be accomplished medically or surgically.
Medically, treatment consists of increased water intake, incorporation of more fiber in the diet, undertaking warm sitz baths a couple times a day, and application of a pea-sized amount of topical 2% diltiazem three times daily on the outside of the anus for 6-8 weeks.
“Compliance is huge. This whole thing is about consistency. Oftentimes, the reason treatment fails is people can’t do this. They feel good after about a week, so they stop before the fissure is completely healed,” she said.
The topical diltiazem must be prepared at a compounding pharmacy. It’s usually covered by insurance. Even if it’s not, an 8-week prescription costs only about $25. The drug is effective in up to 95% of patients who follow the instructions.
Topical 0.2% nitroglycerin, an alternative treatment, is less attractive because 30% of patients experience often-disabling headaches as a side effect. Topical diltiazem has a much better side effect profile, Dr. Cowan noted. If a patient shows a partial response to 6-8 weeks of topical diltiazem, it’s worth prescribing a second round. If the fissure still hasn’t healed after that, it’s time for referral to a surgeon. The options are onabotulinumtoxinA (Botox) and lateral internal sphincterotomy.
Botox is effective in 60%-80% of patients, she explained, providing temporary benefit lasting up to 3 months with a much lower risk of incontinence than with lateral internal sphincterotomy. Open and closed sphincterotomy techniques yield a similar success rate, with healing in 93% of cases.
For internal hemorrhoids, stool softeners, 25-30 g of fiber supplements per day, warm sitz baths, avoiding straining during defecation, and not loitering on the toilet are key elements in achieving symptomatic control nonoperatively.
Patients who don’t have a bathtub in which to take sitz baths can accomplish the same thing using an easily removable, commercially available device that fits over a toilet bowl.
Disposable baby wipes for adults have become the No. 1 cause of anal itching and are to be shunned by patients with internal hemorrhoids or other anorectal disorders.
“Patients often engage in excessive wiping because of the poor consistency of their bowel movements,” Dr. Cowan explained. “If they’re pasty and not coming out in one fell swoop, it leads to residue that patients appropriately feel they need to wipe multiple times to keep clean. The majority of these dipe wipes for adults are alcohol based, and even though on your exam you may see nothing, the dipe wipes cause microexcoriations of the skin. The patient itches and doesn’t know why.”
Primary care physicians can readily learn to do mucosal banding for grade II and III prolapsing hemorrhoids in the office, she noted. However, banding should never be attempted on external thrombosed hemorrhoids, though.
Surgical excisional hemorrhoidectomy is a lasting solution for such hemorrhoids, but patients need to understand that even though it’s only a 10- to 15-minute procedure performed in an outpatient setting, it’s excruciatingly painful for a week – and that’s not the end of the story.
“I tell patients to take a week off work,” the surgeon said. “And don’t sit on a donut; it pulls on the suture line. Pillows are okay. But it takes 6-8 weeks to heal, so even though they’re only in excruciating pain for about a week, they have to poop past the suture line, so they’ve got to avoid rock-hard stools.”
With an anoperineal abscess, first-line treatment is incision of the abscess as close as possible to the anus, followed by placement of a drain to be left in place for 7-10 days. Prophylactic antibiotics are reserved for immunosuppressed patients.
Patients need to understand up front that, 30%-50% of the time, a fistula can develop after drainage of an abscess. Indeed, abscessed anoperineal fistula is one of the most common conditions Dr. Cowan sees in the emergency department and clinic. The telltale symptoms are recurrent abscess and/or persistent drainage. Those patients need referral to a colorectal surgeon.
“Fistula-in-ano is a frustrating disease for the patient and the surgeon. As surgeons, we like to fix – and there’s really no good option,” according to Dr. Cowan.
Among the surgical treatment options are debridement followed by fibrin glue injection, an anal fistula plug, an endorectal flap closure, and ligation of the intersphincteric fistula tract, or LIFT, procedure.
Dr. Cowan reported serving as a consultant to Applied Medical.
EXPERT ANALYSIS FROM THE ANNUAL INTERNAL MEDICINE PROGRAM
Negative nasal swabs reliably predicted no MRSA infection
SAN DIEGO – , said Darunee Chotiprasitsakul, MD, of Johns Hopkins Medicine in Baltimore.
But physicians often prescribed vancomycin anyway, accumulating nearly 7,400 potentially avoidable treatment days over a 19-month period, she said during an oral presentation at an annual meeting on infectious diseases.
Current guidelines recommend empiric vancomycin to cover MRSA infection when ill patients have a history of MRSA colonization or recent hospitalization or exposure to antibiotics. Patients whose nasal screening swabs are negative for MRSA have been shown to be at low risk of subsequent infection, but guidelines don’t address how to use swab results to guide decisions about empiric vancomycin, Dr. Chotiprasitsakul said.
Therefore, she and her associates studied 11,882 adults without historical MRSA infection or colonization who received nasal swabs for routine surveillance in adult ICUs at Johns Hopkins. A total of 441 patients (4%) had positive swabs, while 96% tested negative.
Among patients with negative swabs, only 25 (0.22%) developed MRSA infection requiring treatment. Thus, the negative predictive value of a nasal swab for MRSA was 99%, making the probability of infection despite a negative swab “exceedingly low,” Dr. Chotiprasitsakul said.
But clinicians seemed not to use negative swab results to curtail vancomycin therapy, she found. Rates of empiric vancomycin use were 36% among patients with positive swabs and 39% among those with negative swabs. Over 19 months, ICU patients received 7,371 avoidable days of vancomycin, a median of 3 days per patient.
Matching patients by ICU and days at risk identified no significant predictors of MRSA infection, Dr. Chotiprasitsakul said. Johns Hopkins Medicine has robust infection control practices, high compliance with hand hygiene and contact precautions, and low rates of nosocomial MRSA transmission, she noted. The predictive value of a negative MRSA nasal swab could be lower at institutions where that isn’t the case, she said.
Johns Hopkins is working to curtail unnecessary use of vancomycin, said senior author Sara Cosgrove, MD, professor of medicine in infectious diseases and director of the department of antimicrobial stewardship. The team has added the findings to its guidelines for antibiotic use, which are available in an app for Johns Hopkins providers, she said in an interview.
The stewardship also highlights the data when discussing starting and stopping vancomycin in patients at very low risk for MRSA infections, she said. “In general, providers have responded favorably to acting upon this new information,” Dr. Cosgrove noted.
Johns Hopkins continues to track median days of vancomycin use per patient and per 1,000 days in its units. “[We] will assess if there is an impact on vancomycin use over the coming year,” said Dr. Cosgrove.
The investigators had no conflicts of interest. The event marked the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
SAN DIEGO – , said Darunee Chotiprasitsakul, MD, of Johns Hopkins Medicine in Baltimore.
But physicians often prescribed vancomycin anyway, accumulating nearly 7,400 potentially avoidable treatment days over a 19-month period, she said during an oral presentation at an annual meeting on infectious diseases.
Current guidelines recommend empiric vancomycin to cover MRSA infection when ill patients have a history of MRSA colonization or recent hospitalization or exposure to antibiotics. Patients whose nasal screening swabs are negative for MRSA have been shown to be at low risk of subsequent infection, but guidelines don’t address how to use swab results to guide decisions about empiric vancomycin, Dr. Chotiprasitsakul said.
Therefore, she and her associates studied 11,882 adults without historical MRSA infection or colonization who received nasal swabs for routine surveillance in adult ICUs at Johns Hopkins. A total of 441 patients (4%) had positive swabs, while 96% tested negative.
Among patients with negative swabs, only 25 (0.22%) developed MRSA infection requiring treatment. Thus, the negative predictive value of a nasal swab for MRSA was 99%, making the probability of infection despite a negative swab “exceedingly low,” Dr. Chotiprasitsakul said.
But clinicians seemed not to use negative swab results to curtail vancomycin therapy, she found. Rates of empiric vancomycin use were 36% among patients with positive swabs and 39% among those with negative swabs. Over 19 months, ICU patients received 7,371 avoidable days of vancomycin, a median of 3 days per patient.
Matching patients by ICU and days at risk identified no significant predictors of MRSA infection, Dr. Chotiprasitsakul said. Johns Hopkins Medicine has robust infection control practices, high compliance with hand hygiene and contact precautions, and low rates of nosocomial MRSA transmission, she noted. The predictive value of a negative MRSA nasal swab could be lower at institutions where that isn’t the case, she said.
Johns Hopkins is working to curtail unnecessary use of vancomycin, said senior author Sara Cosgrove, MD, professor of medicine in infectious diseases and director of the department of antimicrobial stewardship. The team has added the findings to its guidelines for antibiotic use, which are available in an app for Johns Hopkins providers, she said in an interview.
The stewardship also highlights the data when discussing starting and stopping vancomycin in patients at very low risk for MRSA infections, she said. “In general, providers have responded favorably to acting upon this new information,” Dr. Cosgrove noted.
Johns Hopkins continues to track median days of vancomycin use per patient and per 1,000 days in its units. “[We] will assess if there is an impact on vancomycin use over the coming year,” said Dr. Cosgrove.
The investigators had no conflicts of interest. The event marked the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
SAN DIEGO – , said Darunee Chotiprasitsakul, MD, of Johns Hopkins Medicine in Baltimore.
But physicians often prescribed vancomycin anyway, accumulating nearly 7,400 potentially avoidable treatment days over a 19-month period, she said during an oral presentation at an annual meeting on infectious diseases.
Current guidelines recommend empiric vancomycin to cover MRSA infection when ill patients have a history of MRSA colonization or recent hospitalization or exposure to antibiotics. Patients whose nasal screening swabs are negative for MRSA have been shown to be at low risk of subsequent infection, but guidelines don’t address how to use swab results to guide decisions about empiric vancomycin, Dr. Chotiprasitsakul said.
Therefore, she and her associates studied 11,882 adults without historical MRSA infection or colonization who received nasal swabs for routine surveillance in adult ICUs at Johns Hopkins. A total of 441 patients (4%) had positive swabs, while 96% tested negative.
Among patients with negative swabs, only 25 (0.22%) developed MRSA infection requiring treatment. Thus, the negative predictive value of a nasal swab for MRSA was 99%, making the probability of infection despite a negative swab “exceedingly low,” Dr. Chotiprasitsakul said.
But clinicians seemed not to use negative swab results to curtail vancomycin therapy, she found. Rates of empiric vancomycin use were 36% among patients with positive swabs and 39% among those with negative swabs. Over 19 months, ICU patients received 7,371 avoidable days of vancomycin, a median of 3 days per patient.
Matching patients by ICU and days at risk identified no significant predictors of MRSA infection, Dr. Chotiprasitsakul said. Johns Hopkins Medicine has robust infection control practices, high compliance with hand hygiene and contact precautions, and low rates of nosocomial MRSA transmission, she noted. The predictive value of a negative MRSA nasal swab could be lower at institutions where that isn’t the case, she said.
Johns Hopkins is working to curtail unnecessary use of vancomycin, said senior author Sara Cosgrove, MD, professor of medicine in infectious diseases and director of the department of antimicrobial stewardship. The team has added the findings to its guidelines for antibiotic use, which are available in an app for Johns Hopkins providers, she said in an interview.
The stewardship also highlights the data when discussing starting and stopping vancomycin in patients at very low risk for MRSA infections, she said. “In general, providers have responded favorably to acting upon this new information,” Dr. Cosgrove noted.
Johns Hopkins continues to track median days of vancomycin use per patient and per 1,000 days in its units. “[We] will assess if there is an impact on vancomycin use over the coming year,” said Dr. Cosgrove.
The investigators had no conflicts of interest. The event marked the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
AT IDWEEK 2017
Key clinical point: Only 0.2% of ICU patients with negative surveillance nasal swabs developed MRSA infections during the same hospitalization.
Major finding: The predictive value of a negative swab was 99%.
Data source: A study of 11,882 adults without historical MRSA infection or colonization who received nasal swabs for routine surveillance.
Disclosures: The investigators had no conflicts of interest.
Clinical Trial Summary: Ergonomics of robotic surgery
The Ergonomics in Robotic Surgery clinical trial is being conducted to study the role of ergonomics in adjusting robotic surgery consoles to individual body types of operators. The study will look at comfort and physical support of gynecologic surgeons after performing a hysterectomy using a da Vinci robotic surgery console. One group of surgeons will adjust their own console and another group will have the console adjusted by an ergonomist. 
For a further description of the study, go to www.clinicaltrials.gov.
[email protected]
On Twitter @ThereseBorden
The Ergonomics in Robotic Surgery clinical trial is being conducted to study the role of ergonomics in adjusting robotic surgery consoles to individual body types of operators. The study will look at comfort and physical support of gynecologic surgeons after performing a hysterectomy using a da Vinci robotic surgery console. One group of surgeons will adjust their own console and another group will have the console adjusted by an ergonomist.
For a further description of the study, go to www.clinicaltrials.gov.
[email protected]
On Twitter @ThereseBorden
The Ergonomics in Robotic Surgery clinical trial is being conducted to study the role of ergonomics in adjusting robotic surgery consoles to individual body types of operators. The study will look at comfort and physical support of gynecologic surgeons after performing a hysterectomy using a da Vinci robotic surgery console. One group of surgeons will adjust their own console and another group will have the console adjusted by an ergonomist.
For a further description of the study, go to www.clinicaltrials.gov.
[email protected]
On Twitter @ThereseBorden
FROM CLINICALTRIALS.GOV
SHM pushes to protect patients from ‘surprise’ out-of-network expenses
Patients entering a hospital should not be on the hook for costs related to out-of-network insurance coverage when that hospital is in-network, according to the Society of Hospital Medicine and other major medical societies, especially if it is an emergency situation and the patient is unable to make an informed choice regarding who is administering care to them.
“We want to see it come to a resolution that does not put patients in jeopardy for paying these extra costs when they are going a hospital that is in-network, and they assume that the physicians are in-network,” Ron Greeno, MD, FCCP, MHM, president of the Society of Hospital Medicine, said in an interview.
Other groups signing onto the resolution include the American College of Emergency Physicians, the American Academy of Orthopedic Surgeons, the American College of Radiology, the American Society of Anesthesiologists, the College of American Pathologists, the American Association of Neurological Surgeons, and the Congress of Neurological Surgeons.
“States are tackling this on a state-by-state basis and creating laws that are meant to protect patients from being placed in legal jeopardy,” Dr. Greeno said. “But you still want to maintain the rights of the health plan and the physicians to negotiate in good faith. That is basically the stance we take.”
According to Dr. Greeno, the joint resolution passed at the AMA meeting was “designed to make recommendations to states who are considering such laws.” The medical societies want to provide guidance on what to include in those laws that will make the process fair. “If you have a law that says ‘out of network doctors cannot balance bill at a hospital that is in-network,’ then the health plans have no reason to negotiate in good faith,” he said. “They will just pay those doctors whatever they feel like paying them.”
Ultimately, though, the resolution was about medical societies affirming their desire to protect patients from burdensome, unexpected bills.
“We want to make sure whatever laws are passed that they actually protect the patients while maintaining the ability of physicians and health plans to negotiate in good faith to a mutual resolution,” Dr. Greeno said.
Patients entering a hospital should not be on the hook for costs related to out-of-network insurance coverage when that hospital is in-network, according to the Society of Hospital Medicine and other major medical societies, especially if it is an emergency situation and the patient is unable to make an informed choice regarding who is administering care to them.
“We want to see it come to a resolution that does not put patients in jeopardy for paying these extra costs when they are going a hospital that is in-network, and they assume that the physicians are in-network,” Ron Greeno, MD, FCCP, MHM, president of the Society of Hospital Medicine, said in an interview.
Other groups signing onto the resolution include the American College of Emergency Physicians, the American Academy of Orthopedic Surgeons, the American College of Radiology, the American Society of Anesthesiologists, the College of American Pathologists, the American Association of Neurological Surgeons, and the Congress of Neurological Surgeons.
“States are tackling this on a state-by-state basis and creating laws that are meant to protect patients from being placed in legal jeopardy,” Dr. Greeno said. “But you still want to maintain the rights of the health plan and the physicians to negotiate in good faith. That is basically the stance we take.”
According to Dr. Greeno, the joint resolution passed at the AMA meeting was “designed to make recommendations to states who are considering such laws.” The medical societies want to provide guidance on what to include in those laws that will make the process fair. “If you have a law that says ‘out of network doctors cannot balance bill at a hospital that is in-network,’ then the health plans have no reason to negotiate in good faith,” he said. “They will just pay those doctors whatever they feel like paying them.”
Ultimately, though, the resolution was about medical societies affirming their desire to protect patients from burdensome, unexpected bills.
“We want to make sure whatever laws are passed that they actually protect the patients while maintaining the ability of physicians and health plans to negotiate in good faith to a mutual resolution,” Dr. Greeno said.
Patients entering a hospital should not be on the hook for costs related to out-of-network insurance coverage when that hospital is in-network, according to the Society of Hospital Medicine and other major medical societies, especially if it is an emergency situation and the patient is unable to make an informed choice regarding who is administering care to them.
“We want to see it come to a resolution that does not put patients in jeopardy for paying these extra costs when they are going a hospital that is in-network, and they assume that the physicians are in-network,” Ron Greeno, MD, FCCP, MHM, president of the Society of Hospital Medicine, said in an interview.
Other groups signing onto the resolution include the American College of Emergency Physicians, the American Academy of Orthopedic Surgeons, the American College of Radiology, the American Society of Anesthesiologists, the College of American Pathologists, the American Association of Neurological Surgeons, and the Congress of Neurological Surgeons.
“States are tackling this on a state-by-state basis and creating laws that are meant to protect patients from being placed in legal jeopardy,” Dr. Greeno said. “But you still want to maintain the rights of the health plan and the physicians to negotiate in good faith. That is basically the stance we take.”
According to Dr. Greeno, the joint resolution passed at the AMA meeting was “designed to make recommendations to states who are considering such laws.” The medical societies want to provide guidance on what to include in those laws that will make the process fair. “If you have a law that says ‘out of network doctors cannot balance bill at a hospital that is in-network,’ then the health plans have no reason to negotiate in good faith,” he said. “They will just pay those doctors whatever they feel like paying them.”
Ultimately, though, the resolution was about medical societies affirming their desire to protect patients from burdensome, unexpected bills.
“We want to make sure whatever laws are passed that they actually protect the patients while maintaining the ability of physicians and health plans to negotiate in good faith to a mutual resolution,” Dr. Greeno said.
VA study finds high MRSA infection risk among those colonized with the bacterium
SAN DIEGO – Patients colonized with MRSA are at high risk of MRSA infection both in the predischarge and postdischarge time periods, results from an 8-year Veterans Affairs study showed.
“MRSA colonization is recognized as being a strong predictor of subsequent infection,” Richard E. Nelson, PhD, said at an annual scientific meeting on infectious diseases. “What’s less understood is, are there differences in infection rates among patients who are colonized at different times? And, is there a difference between patients who import colonization with them to a hospital versus those who acquire it during a hospital stay? In addition, infection control efforts mainly focus on the predischarge time period. What about infections that develop post discharge?”
In an effort to investigate these questions, Dr. Nelson of the VA Salt Lake City Healthcare System, and his associates, evaluated more than 1.3 million acute care inpatient admissions to 125 VA hospitals nationwide from January 2008 through December 2015 who had surveillance tests performed for MRSA carriage. 
The researchers restricted admissions to individuals with at least 365 days of VA activity prior to admission and categorized them into three groups: no colonization (defined as those who had no positive surveillance tests (n = 1,196,928); importation (defined as those who tested positive for MRSA colonization on admission (n = 95,833); and acquisition (defined as those who did not test positive for MRSA on admission but tested positive on a subsequent surveillance test during their admission (n = 15,146). Next, they captured MRSA infections in these individuals prior to discharge and at 30 and 90 days post discharge. Infections were defined as positive MRSA cultures taken from sterile sites, including blood, catheter site, or bone.
Overall, patients were in their mid-60s, and those who imported MRSA and those who acquired it were more likely to be male, less likely to be married, and more likely to not have health insurance. , which peaked in 2010 and declined through 2015,” said Dr. Nelson, who also holds a faculty position in University of Utah’s department of internal medicine, in the division of epidemiology. Specifically, the proportion of predischarge MRSA infections, compared with 30 days post discharge, were 40.4% vs. 59.6%, respectively, in the no colonization group; 63% vs. 37% in the importation group, and 80.8% vs. 19.2% in the acquisition group.
He also reported that the proportion of predischarge MRSA infections, compared with 90 days post discharge, were 20.5% vs. 79.5%, respectively, in the no colonization group; 47.3% vs. 52.7% in the importation group, and 70.5% vs. 29.5% in the acquisition group. The time from acquisition to infection was a mean of 8.7 days in the 30-day analysis and a mean of 22.4 days in the 90-day analysis.
Multivariate logistic regression revealed that the impact of colonization status on infection was highest in the acquisition group, compared with the importation group. Specifically, the odds ratio of developing a MRSA infection among the importation group was 29.22 in the predischarge period, OR 10.87 at post discharge 30 days, and OR 7.64 at post discharge 90 days (P less than .001 for all). Meanwhile, the OR among the acquisition group was 85.19 in the predischarge period, OR 13.01 at post discharge 30 days, and OR 8.26 at post discharge 90 days (P less than .001 for all).
Dr. Nelson acknowledged certain limitations of the study, including the fact that it only identified postdischarge infections that were detected in a VA facility. “This is likely an underestimate of postdischarge infections, because we’re missing the infection that occur in non-VA facilities,” he said at the event, which marked the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. “Also, patients can be colonized in many different body locations, but the VA protocol is that the surveillance test be done in the nostrils. So we may have misclassified patients who were colonized in a different body location as being uncolonized, when in fact they were colonized.”
The study was funded by a grant from the VA. Dr. Nelson reported having no financial disclosures.
SAN DIEGO – Patients colonized with MRSA are at high risk of MRSA infection both in the predischarge and postdischarge time periods, results from an 8-year Veterans Affairs study showed.
“MRSA colonization is recognized as being a strong predictor of subsequent infection,” Richard E. Nelson, PhD, said at an annual scientific meeting on infectious diseases. “What’s less understood is, are there differences in infection rates among patients who are colonized at different times? And, is there a difference between patients who import colonization with them to a hospital versus those who acquire it during a hospital stay? In addition, infection control efforts mainly focus on the predischarge time period. What about infections that develop post discharge?”
In an effort to investigate these questions, Dr. Nelson of the VA Salt Lake City Healthcare System, and his associates, evaluated more than 1.3 million acute care inpatient admissions to 125 VA hospitals nationwide from January 2008 through December 2015 who had surveillance tests performed for MRSA carriage.
The researchers restricted admissions to individuals with at least 365 days of VA activity prior to admission and categorized them into three groups: no colonization (defined as those who had no positive surveillance tests (n = 1,196,928); importation (defined as those who tested positive for MRSA colonization on admission (n = 95,833); and acquisition (defined as those who did not test positive for MRSA on admission but tested positive on a subsequent surveillance test during their admission (n = 15,146). Next, they captured MRSA infections in these individuals prior to discharge and at 30 and 90 days post discharge. Infections were defined as positive MRSA cultures taken from sterile sites, including blood, catheter site, or bone.
Overall, patients were in their mid-60s, and those who imported MRSA and those who acquired it were more likely to be male, less likely to be married, and more likely to not have health insurance. , which peaked in 2010 and declined through 2015,” said Dr. Nelson, who also holds a faculty position in University of Utah’s department of internal medicine, in the division of epidemiology. Specifically, the proportion of predischarge MRSA infections, compared with 30 days post discharge, were 40.4% vs. 59.6%, respectively, in the no colonization group; 63% vs. 37% in the importation group, and 80.8% vs. 19.2% in the acquisition group.
He also reported that the proportion of predischarge MRSA infections, compared with 90 days post discharge, were 20.5% vs. 79.5%, respectively, in the no colonization group; 47.3% vs. 52.7% in the importation group, and 70.5% vs. 29.5% in the acquisition group. The time from acquisition to infection was a mean of 8.7 days in the 30-day analysis and a mean of 22.4 days in the 90-day analysis.
Multivariate logistic regression revealed that the impact of colonization status on infection was highest in the acquisition group, compared with the importation group. Specifically, the odds ratio of developing a MRSA infection among the importation group was 29.22 in the predischarge period, OR 10.87 at post discharge 30 days, and OR 7.64 at post discharge 90 days (P less than .001 for all). Meanwhile, the OR among the acquisition group was 85.19 in the predischarge period, OR 13.01 at post discharge 30 days, and OR 8.26 at post discharge 90 days (P less than .001 for all).
Dr. Nelson acknowledged certain limitations of the study, including the fact that it only identified postdischarge infections that were detected in a VA facility. “This is likely an underestimate of postdischarge infections, because we’re missing the infection that occur in non-VA facilities,” he said at the event, which marked the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. “Also, patients can be colonized in many different body locations, but the VA protocol is that the surveillance test be done in the nostrils. So we may have misclassified patients who were colonized in a different body location as being uncolonized, when in fact they were colonized.”
The study was funded by a grant from the VA. Dr. Nelson reported having no financial disclosures.
SAN DIEGO – Patients colonized with MRSA are at high risk of MRSA infection both in the predischarge and postdischarge time periods, results from an 8-year Veterans Affairs study showed.
“MRSA colonization is recognized as being a strong predictor of subsequent infection,” Richard E. Nelson, PhD, said at an annual scientific meeting on infectious diseases. “What’s less understood is, are there differences in infection rates among patients who are colonized at different times? And, is there a difference between patients who import colonization with them to a hospital versus those who acquire it during a hospital stay? In addition, infection control efforts mainly focus on the predischarge time period. What about infections that develop post discharge?”
In an effort to investigate these questions, Dr. Nelson of the VA Salt Lake City Healthcare System, and his associates, evaluated more than 1.3 million acute care inpatient admissions to 125 VA hospitals nationwide from January 2008 through December 2015 who had surveillance tests performed for MRSA carriage.
The researchers restricted admissions to individuals with at least 365 days of VA activity prior to admission and categorized them into three groups: no colonization (defined as those who had no positive surveillance tests (n = 1,196,928); importation (defined as those who tested positive for MRSA colonization on admission (n = 95,833); and acquisition (defined as those who did not test positive for MRSA on admission but tested positive on a subsequent surveillance test during their admission (n = 15,146). Next, they captured MRSA infections in these individuals prior to discharge and at 30 and 90 days post discharge. Infections were defined as positive MRSA cultures taken from sterile sites, including blood, catheter site, or bone.
Overall, patients were in their mid-60s, and those who imported MRSA and those who acquired it were more likely to be male, less likely to be married, and more likely to not have health insurance. , which peaked in 2010 and declined through 2015,” said Dr. Nelson, who also holds a faculty position in University of Utah’s department of internal medicine, in the division of epidemiology. Specifically, the proportion of predischarge MRSA infections, compared with 30 days post discharge, were 40.4% vs. 59.6%, respectively, in the no colonization group; 63% vs. 37% in the importation group, and 80.8% vs. 19.2% in the acquisition group.
He also reported that the proportion of predischarge MRSA infections, compared with 90 days post discharge, were 20.5% vs. 79.5%, respectively, in the no colonization group; 47.3% vs. 52.7% in the importation group, and 70.5% vs. 29.5% in the acquisition group. The time from acquisition to infection was a mean of 8.7 days in the 30-day analysis and a mean of 22.4 days in the 90-day analysis.
Multivariate logistic regression revealed that the impact of colonization status on infection was highest in the acquisition group, compared with the importation group. Specifically, the odds ratio of developing a MRSA infection among the importation group was 29.22 in the predischarge period, OR 10.87 at post discharge 30 days, and OR 7.64 at post discharge 90 days (P less than .001 for all). Meanwhile, the OR among the acquisition group was 85.19 in the predischarge period, OR 13.01 at post discharge 30 days, and OR 8.26 at post discharge 90 days (P less than .001 for all).
Dr. Nelson acknowledged certain limitations of the study, including the fact that it only identified postdischarge infections that were detected in a VA facility. “This is likely an underestimate of postdischarge infections, because we’re missing the infection that occur in non-VA facilities,” he said at the event, which marked the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. “Also, patients can be colonized in many different body locations, but the VA protocol is that the surveillance test be done in the nostrils. So we may have misclassified patients who were colonized in a different body location as being uncolonized, when in fact they were colonized.”
The study was funded by a grant from the VA. Dr. Nelson reported having no financial disclosures.
REPORTING FROM ID WEEK 2017
Key clinical point: About half of postdischarge MRSA infections were in patients who acquired the organism before discharge.
Major finding: The proportion of predischarge MRSA infections, compared with 30 days post discharge, were 40.4% vs. 59.6%, respectively, in the no colonization group; 63% vs. 37% in the importation group, and 80.8% vs. 19.2% in the acquisition group.
Study details: An analysis of more than 1.3 million acute care inpatient admissions to 125 VA hospitals nationwide from January 2008 through December 2015.
Disclosures: The study was funded by a grant from the VA. Dr. Nelson reported having no financial disclosures.
Patient and physician outreach boost CRC screening rates
Can outreach improve the globally low rates of adherence to colorectal cancer screening? Yes, according to two recent studies in JAMA; the studies found that both patient-focused and physician-focused outreach approaches can result in significantly better patient participation in colorectal cancer (CRC) screening.
The first study (JAMA. 2017;318[9]:806-15) compared a colonoscopy outreach program and a fecal immunochemical test (FIT) outreach program both with each other and with usual care. The results of the pragmatic, single-site, randomized, clinical trial showed that completed screenings were higher for both outreach groups, compared with the usual-care group.
The primary outcome measure of the study was completion of the screening process, wrote Amit Singal, MD, and his coauthors. This was defined as any adherence to colonoscopy completion, the completion of annual testing for patients who had a normal FIT test, or treatment evaluation if CRC was detected during the screening process. Screenings were considered complete even if, for example, a patient in the colonoscopy arm eventually went on to have three consecutive annual FIT tests rather than a colonoscopy.
A total of 5,999 patients eligible for screening were initially randomized to one of the three study arms. Across all study arms, approximately half were lost to follow-up. These patients were excluded from the primary analysis but were included in an additional intention-to-screen analysis. A total of 2,400 patients received a colonoscopy outreach mailing; 2,400 received FIT outreach, including a letter, the home FIT testing kit, and instructions; 1,199 received usual care. Patients in both intervention arms also received up to two phone calls if they didn’t respond to the initial mailing within 2 weeks. Mailings and phone calls were conducted in English or Spanish, according to the patients’ stated language preferences (those whose spoke neither language were excluded from the study).
Of the patients in the colonoscopy outreach group, 922 (38.4%) completed the screening process, compared with 671 (28.0%) in the FIT outreach group and 128 (10.7%) in the usual-care group.
Compared with the group receiving usual care, completion of the screening process was 27.7% higher in the colonoscopy outreach group and 17.3% higher in the FIT outreach group. Screening process completion was 10.4% higher for the colonoscopy outreach group, compared with the FIT outreach group (P less than .001 for all).
Dr. Singal, who is with the department of internal medicine at UT Southwestern Medical Center, Dallas, and his colleagues also performed several post-hoc secondary analyses. In one, they used a less-stringent definition of screening process completion in which biennial FIT testing was considered satisfactory. When this definition was applied, the colonoscopy outreach group had 0.5% lower screening process completion than the FIT outreach group. The chances of a patient receiving any screening during the study period was highest in the FIT group (65%), with 51.7% of those in the colonoscopy outreach group and 39% of those in the usual-care group receiving any screening.
“FIT has lower barriers to one-time participation but requires annual screening and diagnostic evaluation of abnormal results,” wrote Dr. Singal and his colleagues.
Strengths of the study, said Dr. Singal and his colleagues, included the fact that the study took place at a “safety net” institution with a racially and socioeconomically diverse population. Also, the study design avoided volunteer bias, and offered a pragmatic head-to-head comparison of colonoscopy and FIT.
The second study took place in western France, and targeted outreach to physicians rather than patients (JAMA. 2017;318[9];816-84). When physicians were given a list of their own patients who were not up to date on CRC screening, investigators saw a small, but significant, uptick in patient participation in FIT screening.
One year after the reminders went out, FIT screening had been initiated in 24.8% of patients whose physicians had received the list, compared with 21.7% of patients of physicians who had received a more generic notice and 20.6% of patients whose physicians received no notification, according to first author Cedric Rat, MD, and his colleagues.
The study examined which notification approach was most effective in increasing FIT screening among the physicians’ patient panels: sending general practitioners (GPs) letters that included a list of their own patients who had not undergone CRC screening, or sending them generic letters describing CRC screening adherence rates specific to their region. A usual-care group of practices received no notifications in this three-group randomized cluster design.
Patients in the patient-specific reminders group had an odds ratio of 1.27 for participation in FIT screening (P less than .001) compared to the usual-care group. The odds ratio for the generic-reminders group was 1.09, a nonsignificant difference.
Between-group comparison showed statistical significance for both the 3.1% difference between the patient-specific and generic-reminders groups, and for the 4.2% difference between the patient-specific and usual-care groups (P less than .001 for both). There was no significant difference between the generic- reminders group and the usual-care group.
Dr. Rat, professor of medicine at the Faculty of Medicine, Nantes, France, and his colleagues enrolled GPs in a total of 801 practices that included patients aged 50. Participating GPs cared for 33,044 patients who met study criteria.
Physician characteristics that were associated with higher FIT participation included younger age and an initially smaller number of unscreened patients. Patients with low socioeconomic status and those with a higher chronic disease burden were less likely to participate in FIT screening.
Dr. Rat and his colleagues noted that the busiest practices actually had higher CRC screening rates. The investigators hypothesized that a recent physician pay-for-performance grant for CRC completion might be more appealing for some busy physicians.
This was the largest study of CRC screening participation to date, according to Dr. Rat and his coauthors, and showed the small but detectable efficacy of an inexpensive intervention that, given complete patient records, is relatively easy to effect. Though the effect size was smaller than the 12% difference the investigators had anticipated seeing for the patient-specific reminders group, the study still showed that targeting physicians can be an effective public health intervention to increase CRC screening rates, said Dr. Rat and his colleagues.
None of the investigators in either study reported conflicts of interest.
The AGA Colorectal Cancer Clinical Service Line provides tools to help you become more efficient, understand quality standards and improve the process of care for patients. Learn more at www.gastro.org/crc.
Both studies, though they used different outreach interventions, highlight the same problem: the need to identify and execute effective colorectal cancer (CRC) screening programs. Effective screening has great lifesaving potential; if screening rates were elevated to greater than 80% in the United States, an estimated 200,000 deaths would be prevented within the next 2 decades.
The nature of CRC screening options means that a home fecal sample collection is inexpensive, and will result in an initial higher screening rate; however, complete screening via fecal occult blood testing requires annual repeats of negative tests, and patients with positive fecal occult blood tests still need colonoscopy.
Colonoscopy, although it’s burdensome for patients and perhaps cost prohibitive for those without health insurance, offers a one-time test that, if negative, provides patients with a 10-year window of screening coverage.
Any effective programs to increase CRC screening rates will need to use a systems change approach, with creative interventions that take patient education, and even delivery of preventive health services, out of the context of the already too-full office visit.
Staff supports, such as the follow-up telephone calls used in the patient-targeted intervention, are key to effective interventions, especially for vulnerable populations. Additionally, institutions must ensure that they have adequate physical and staff resources to support the increased screening they are seeking to achieve.
Michael Pignone, MD, MPH is a professor of medicine at the University of Texas at Austin. David Miller Jr., MD is a professor of internal medicine, Wake Forest University, Winston-Salem, N.C. Dr. Pignone is a medical director for Healthwise; Dr. Miller reported no relevant conflicts of interest. These remarks were drawn from an editorial accompanying the two clinical trials.
Both studies, though they used different outreach interventions, highlight the same problem: the need to identify and execute effective colorectal cancer (CRC) screening programs. Effective screening has great lifesaving potential; if screening rates were elevated to greater than 80% in the United States, an estimated 200,000 deaths would be prevented within the next 2 decades.
The nature of CRC screening options means that a home fecal sample collection is inexpensive, and will result in an initial higher screening rate; however, complete screening via fecal occult blood testing requires annual repeats of negative tests, and patients with positive fecal occult blood tests still need colonoscopy.
Colonoscopy, although it’s burdensome for patients and perhaps cost prohibitive for those without health insurance, offers a one-time test that, if negative, provides patients with a 10-year window of screening coverage.
Any effective programs to increase CRC screening rates will need to use a systems change approach, with creative interventions that take patient education, and even delivery of preventive health services, out of the context of the already too-full office visit.
Staff supports, such as the follow-up telephone calls used in the patient-targeted intervention, are key to effective interventions, especially for vulnerable populations. Additionally, institutions must ensure that they have adequate physical and staff resources to support the increased screening they are seeking to achieve.
Michael Pignone, MD, MPH is a professor of medicine at the University of Texas at Austin. David Miller Jr., MD is a professor of internal medicine, Wake Forest University, Winston-Salem, N.C. Dr. Pignone is a medical director for Healthwise; Dr. Miller reported no relevant conflicts of interest. These remarks were drawn from an editorial accompanying the two clinical trials.
Both studies, though they used different outreach interventions, highlight the same problem: the need to identify and execute effective colorectal cancer (CRC) screening programs. Effective screening has great lifesaving potential; if screening rates were elevated to greater than 80% in the United States, an estimated 200,000 deaths would be prevented within the next 2 decades.
The nature of CRC screening options means that a home fecal sample collection is inexpensive, and will result in an initial higher screening rate; however, complete screening via fecal occult blood testing requires annual repeats of negative tests, and patients with positive fecal occult blood tests still need colonoscopy.
Colonoscopy, although it’s burdensome for patients and perhaps cost prohibitive for those without health insurance, offers a one-time test that, if negative, provides patients with a 10-year window of screening coverage.
Any effective programs to increase CRC screening rates will need to use a systems change approach, with creative interventions that take patient education, and even delivery of preventive health services, out of the context of the already too-full office visit.
Staff supports, such as the follow-up telephone calls used in the patient-targeted intervention, are key to effective interventions, especially for vulnerable populations. Additionally, institutions must ensure that they have adequate physical and staff resources to support the increased screening they are seeking to achieve.
Michael Pignone, MD, MPH is a professor of medicine at the University of Texas at Austin. David Miller Jr., MD is a professor of internal medicine, Wake Forest University, Winston-Salem, N.C. Dr. Pignone is a medical director for Healthwise; Dr. Miller reported no relevant conflicts of interest. These remarks were drawn from an editorial accompanying the two clinical trials.
Can outreach improve the globally low rates of adherence to colorectal cancer screening? Yes, according to two recent studies in JAMA; the studies found that both patient-focused and physician-focused outreach approaches can result in significantly better patient participation in colorectal cancer (CRC) screening.
The first study (JAMA. 2017;318[9]:806-15) compared a colonoscopy outreach program and a fecal immunochemical test (FIT) outreach program both with each other and with usual care. The results of the pragmatic, single-site, randomized, clinical trial showed that completed screenings were higher for both outreach groups, compared with the usual-care group.
The primary outcome measure of the study was completion of the screening process, wrote Amit Singal, MD, and his coauthors. This was defined as any adherence to colonoscopy completion, the completion of annual testing for patients who had a normal FIT test, or treatment evaluation if CRC was detected during the screening process. Screenings were considered complete even if, for example, a patient in the colonoscopy arm eventually went on to have three consecutive annual FIT tests rather than a colonoscopy.
A total of 5,999 patients eligible for screening were initially randomized to one of the three study arms. Across all study arms, approximately half were lost to follow-up. These patients were excluded from the primary analysis but were included in an additional intention-to-screen analysis. A total of 2,400 patients received a colonoscopy outreach mailing; 2,400 received FIT outreach, including a letter, the home FIT testing kit, and instructions; 1,199 received usual care. Patients in both intervention arms also received up to two phone calls if they didn’t respond to the initial mailing within 2 weeks. Mailings and phone calls were conducted in English or Spanish, according to the patients’ stated language preferences (those whose spoke neither language were excluded from the study).
Of the patients in the colonoscopy outreach group, 922 (38.4%) completed the screening process, compared with 671 (28.0%) in the FIT outreach group and 128 (10.7%) in the usual-care group.
Compared with the group receiving usual care, completion of the screening process was 27.7% higher in the colonoscopy outreach group and 17.3% higher in the FIT outreach group. Screening process completion was 10.4% higher for the colonoscopy outreach group, compared with the FIT outreach group (P less than .001 for all).
Dr. Singal, who is with the department of internal medicine at UT Southwestern Medical Center, Dallas, and his colleagues also performed several post-hoc secondary analyses. In one, they used a less-stringent definition of screening process completion in which biennial FIT testing was considered satisfactory. When this definition was applied, the colonoscopy outreach group had 0.5% lower screening process completion than the FIT outreach group. The chances of a patient receiving any screening during the study period was highest in the FIT group (65%), with 51.7% of those in the colonoscopy outreach group and 39% of those in the usual-care group receiving any screening.
“FIT has lower barriers to one-time participation but requires annual screening and diagnostic evaluation of abnormal results,” wrote Dr. Singal and his colleagues.
Strengths of the study, said Dr. Singal and his colleagues, included the fact that the study took place at a “safety net” institution with a racially and socioeconomically diverse population. Also, the study design avoided volunteer bias, and offered a pragmatic head-to-head comparison of colonoscopy and FIT.
The second study took place in western France, and targeted outreach to physicians rather than patients (JAMA. 2017;318[9];816-84). When physicians were given a list of their own patients who were not up to date on CRC screening, investigators saw a small, but significant, uptick in patient participation in FIT screening.
One year after the reminders went out, FIT screening had been initiated in 24.8% of patients whose physicians had received the list, compared with 21.7% of patients of physicians who had received a more generic notice and 20.6% of patients whose physicians received no notification, according to first author Cedric Rat, MD, and his colleagues.
The study examined which notification approach was most effective in increasing FIT screening among the physicians’ patient panels: sending general practitioners (GPs) letters that included a list of their own patients who had not undergone CRC screening, or sending them generic letters describing CRC screening adherence rates specific to their region. A usual-care group of practices received no notifications in this three-group randomized cluster design.
Patients in the patient-specific reminders group had an odds ratio of 1.27 for participation in FIT screening (P less than .001) compared to the usual-care group. The odds ratio for the generic-reminders group was 1.09, a nonsignificant difference.
Between-group comparison showed statistical significance for both the 3.1% difference between the patient-specific and generic-reminders groups, and for the 4.2% difference between the patient-specific and usual-care groups (P less than .001 for both). There was no significant difference between the generic- reminders group and the usual-care group.
Dr. Rat, professor of medicine at the Faculty of Medicine, Nantes, France, and his colleagues enrolled GPs in a total of 801 practices that included patients aged 50. Participating GPs cared for 33,044 patients who met study criteria.
Physician characteristics that were associated with higher FIT participation included younger age and an initially smaller number of unscreened patients. Patients with low socioeconomic status and those with a higher chronic disease burden were less likely to participate in FIT screening.
Dr. Rat and his colleagues noted that the busiest practices actually had higher CRC screening rates. The investigators hypothesized that a recent physician pay-for-performance grant for CRC completion might be more appealing for some busy physicians.
This was the largest study of CRC screening participation to date, according to Dr. Rat and his coauthors, and showed the small but detectable efficacy of an inexpensive intervention that, given complete patient records, is relatively easy to effect. Though the effect size was smaller than the 12% difference the investigators had anticipated seeing for the patient-specific reminders group, the study still showed that targeting physicians can be an effective public health intervention to increase CRC screening rates, said Dr. Rat and his colleagues.
None of the investigators in either study reported conflicts of interest.
The AGA Colorectal Cancer Clinical Service Line provides tools to help you become more efficient, understand quality standards and improve the process of care for patients. Learn more at www.gastro.org/crc.
Can outreach improve the globally low rates of adherence to colorectal cancer screening? Yes, according to two recent studies in JAMA; the studies found that both patient-focused and physician-focused outreach approaches can result in significantly better patient participation in colorectal cancer (CRC) screening.
The first study (JAMA. 2017;318[9]:806-15) compared a colonoscopy outreach program and a fecal immunochemical test (FIT) outreach program both with each other and with usual care. The results of the pragmatic, single-site, randomized, clinical trial showed that completed screenings were higher for both outreach groups, compared with the usual-care group.
The primary outcome measure of the study was completion of the screening process, wrote Amit Singal, MD, and his coauthors. This was defined as any adherence to colonoscopy completion, the completion of annual testing for patients who had a normal FIT test, or treatment evaluation if CRC was detected during the screening process. Screenings were considered complete even if, for example, a patient in the colonoscopy arm eventually went on to have three consecutive annual FIT tests rather than a colonoscopy.
A total of 5,999 patients eligible for screening were initially randomized to one of the three study arms. Across all study arms, approximately half were lost to follow-up. These patients were excluded from the primary analysis but were included in an additional intention-to-screen analysis. A total of 2,400 patients received a colonoscopy outreach mailing; 2,400 received FIT outreach, including a letter, the home FIT testing kit, and instructions; 1,199 received usual care. Patients in both intervention arms also received up to two phone calls if they didn’t respond to the initial mailing within 2 weeks. Mailings and phone calls were conducted in English or Spanish, according to the patients’ stated language preferences (those whose spoke neither language were excluded from the study).
Of the patients in the colonoscopy outreach group, 922 (38.4%) completed the screening process, compared with 671 (28.0%) in the FIT outreach group and 128 (10.7%) in the usual-care group.
Compared with the group receiving usual care, completion of the screening process was 27.7% higher in the colonoscopy outreach group and 17.3% higher in the FIT outreach group. Screening process completion was 10.4% higher for the colonoscopy outreach group, compared with the FIT outreach group (P less than .001 for all).
Dr. Singal, who is with the department of internal medicine at UT Southwestern Medical Center, Dallas, and his colleagues also performed several post-hoc secondary analyses. In one, they used a less-stringent definition of screening process completion in which biennial FIT testing was considered satisfactory. When this definition was applied, the colonoscopy outreach group had 0.5% lower screening process completion than the FIT outreach group. The chances of a patient receiving any screening during the study period was highest in the FIT group (65%), with 51.7% of those in the colonoscopy outreach group and 39% of those in the usual-care group receiving any screening.
“FIT has lower barriers to one-time participation but requires annual screening and diagnostic evaluation of abnormal results,” wrote Dr. Singal and his colleagues.
Strengths of the study, said Dr. Singal and his colleagues, included the fact that the study took place at a “safety net” institution with a racially and socioeconomically diverse population. Also, the study design avoided volunteer bias, and offered a pragmatic head-to-head comparison of colonoscopy and FIT.
The second study took place in western France, and targeted outreach to physicians rather than patients (JAMA. 2017;318[9];816-84). When physicians were given a list of their own patients who were not up to date on CRC screening, investigators saw a small, but significant, uptick in patient participation in FIT screening.
One year after the reminders went out, FIT screening had been initiated in 24.8% of patients whose physicians had received the list, compared with 21.7% of patients of physicians who had received a more generic notice and 20.6% of patients whose physicians received no notification, according to first author Cedric Rat, MD, and his colleagues.
The study examined which notification approach was most effective in increasing FIT screening among the physicians’ patient panels: sending general practitioners (GPs) letters that included a list of their own patients who had not undergone CRC screening, or sending them generic letters describing CRC screening adherence rates specific to their region. A usual-care group of practices received no notifications in this three-group randomized cluster design.
Patients in the patient-specific reminders group had an odds ratio of 1.27 for participation in FIT screening (P less than .001) compared to the usual-care group. The odds ratio for the generic-reminders group was 1.09, a nonsignificant difference.
Between-group comparison showed statistical significance for both the 3.1% difference between the patient-specific and generic-reminders groups, and for the 4.2% difference between the patient-specific and usual-care groups (P less than .001 for both). There was no significant difference between the generic- reminders group and the usual-care group.
Dr. Rat, professor of medicine at the Faculty of Medicine, Nantes, France, and his colleagues enrolled GPs in a total of 801 practices that included patients aged 50. Participating GPs cared for 33,044 patients who met study criteria.
Physician characteristics that were associated with higher FIT participation included younger age and an initially smaller number of unscreened patients. Patients with low socioeconomic status and those with a higher chronic disease burden were less likely to participate in FIT screening.
Dr. Rat and his colleagues noted that the busiest practices actually had higher CRC screening rates. The investigators hypothesized that a recent physician pay-for-performance grant for CRC completion might be more appealing for some busy physicians.
This was the largest study of CRC screening participation to date, according to Dr. Rat and his coauthors, and showed the small but detectable efficacy of an inexpensive intervention that, given complete patient records, is relatively easy to effect. Though the effect size was smaller than the 12% difference the investigators had anticipated seeing for the patient-specific reminders group, the study still showed that targeting physicians can be an effective public health intervention to increase CRC screening rates, said Dr. Rat and his colleagues.
None of the investigators in either study reported conflicts of interest.
The AGA Colorectal Cancer Clinical Service Line provides tools to help you become more efficient, understand quality standards and improve the process of care for patients. Learn more at www.gastro.org/crc.