Are Physicians’ Recommendations For Colorectal Cancer Screening Guideline-Consistent?

BACKGROUND  

Many older adults in the U.S. do not receive appropriate colorectal cancer (CRC) screening. Although primary care physicians’ recommendations to their patients are central to the screening process, little information is available about their recommendations in relation to guidelines for the menu of CRC screening modalities, including fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), colonoscopy, and double contrast barium enema (DCBE). The objective of this study was to explore potentially modifiable physician and practice factors associated with guideline-consistent recommendations for the menu of CRC screening modalities.     

Is Colonoscopic Screening Necessary for Patients with Gastric Adenoma or Cancer?

Background

Since colorectal adenoma or cancer is commonly associated with gastric adenoma or cancer, early colorectal adenoma detection can affect the survival of gastric adenoma or cancer patients.

Aims

The purpose here was to investigate the colorectal adenoma or cancer prevalence and evaluate the necessity for screening colonoscopy in gastric adenoma or cancer patients.

Patients and methods

From September 2005 through August 2010, 857 patients younger than 70 years who had gastric adenoma or cancer were enrolled. Healthy age- and sex-matched controls were selected from the general screening population. The prevalence and risk of colorectal adenoma or cancer were compared between the participants and the controls.

Results

Data from 416 patients in the gastric neoplasm group (123 with gastric adenoma and 293 with gastric cancer) and 416 healthy control group participants were included in the statistical analysis. The presence of gastric adenoma or cancer was an independent risk factor for colorectal neoplasm (OR = 1.348, 95 % CI = 1.001–1.815). Patients with diffuse type gastric cancer had a lower prevalence of colorectal adenoma or cancer than those with gastric adenoma or intestinal type cancer. In gastric cancer patients younger than 50 years, intestinal type histology was significantly associated with colorectal adenoma or cancer (OR = 3.838, 95 % CI = 1.077–13.677).

Conclusions

The colorectal adenoma or cancer risk was significantly increased in patients with gastric adenoma or cancer. Therefore, screening colonoscopy should be considered for gastric adenoma or cancer patients including young patients, in the case of intestinal type gastric cancer.     

How Much Time Do Low-Income Patients and Primary Care Physicians Actually Spend Discussing Pain? A Direct Observation Study

BACKGROUND

We know little about how much time low-income patients and physicians spend discussing pain during primary care visits.

OBJECTIVE

To measure the frequency and duration of pain-related discussions at a primary care clinic serving mostly low-income black patients; to investigate variables associated with these discussions.

DESIGN

We measured the frequency and duration of pain-related discussions using video-recorded primary care visits; we used multiple regression to evaluate associations between discussions and patient self-report variables.

PARTICIPANTS

A total of 133 patients presenting to a primary care clinic for any reason; 17 family medicine residents.

MAIN MEASURES

Independent variables were pain severity, health status, physical function, chief complaint, and whether the patient and physician had met previously. Dependent variables were presence of pain-related discussions and percent of total visit time spent discussing pain.

KEY RESULTS

Sixty-nine percent of visits included pain-related discussions with a mean duration of 5.9?min (34% of total visit time). Increasing pain severity [OR 1.69, 95% CI (1.18, 2.41)] and pain-related chief complaints [OR 4.10, 95% CI (1.39, 12.12)] were positively associated with the probability of discussing pain. When patients discussed pain, they spent 4.5% more [95% CI (0.60, 8.37)] total visit time discussing pain for every one-point increase in pain severity. Better physical function was negatively associated with the probability of discussing pain [OR 0.65, 95% CI (0.48, 0.86)], but positively associated with the percent of total visit time spent discussing pain [3% increase; 95% CI (0.32, 5.75)] for every one-point increase in physical function). Patients and physicians who had met previously spent 11% less [95% CI (-21.65, -0.55)] total visit time discussing pain. Pain severity was positively associated with time spent discussing pain only when patients and physicians had not met previously.

CONCLUSIONS

Pain-related discussions comprise a substantial proportion of time during primary care visits. Future research should evaluate the relationship between time spent discussing pain and the quality of primary care pain management.     

Transforming Growth Factor-β (TGF-β) Protein Levels Are Not Elevated in the Blood or Bile of Patients with Primary Sclerosing Cholangitis: A Pilot Study

Primary sclerosing cholangitis (PSC) is a chronic cholestatic disorder of unknown etiology characterized by progressive fibrosis and stricturing of the biliary tract. Transforming growth factor-beta (TGF-beta) is a family of cytokines produced by biliary tract epithelial cells that promote fibrinogenesis. Our objective was to determine whether TGF-beta levels are increased in the blood and/or bile of PSC patients compared to patients with other causes of obstructed biliary tracts (controls). Serum and bile TGF-beta levels were documented by enzyme-linked immunoassay in 10 adult PSC and 10 control patients obtained at the time of endoscopic retrograde cholangiography. Serum and bile TGF-beta levels were similar in the two groups (PSC versus control sera, 33.4 +/- 4.3 versus 27.5 +/- 7.7 ng/ml, and bile, 367 +/- 275 versus 457 +/- 247 ng/mg, respectively). Serum and bile TGF-beta levels are not increased in patients with PSC. Hence, the results of this pilot study do not support the hypotheses that PSC is caused by dysregulated TGF-beta expression.     

Should Patients with Obesity and Hypertension be Treated Differently from Those Who Are Not Obese?

Obesity and hypertension frequently coexist. Measuring blood pressure (BP) accurately in obese patients is challenging and may require strategies that are less accurate, such as forearm cuffing or use of wrist cuffs. Pathophysiologic mechanisms of hypertension may differ between obese and non-obese individuals, which may result in differing effects of common BP-lowering medications. However, to date, there is insufficient trial data to recommend a different approach to medication selection based on body mass index. Additionally, the goal BP is generally not different between obese and non-obese patients. Weight loss should be emphasized for obese patients with hypertension, and interventions in addition to diet and exercise may include weight loss medications and bariatric surgery. Recognition and treatment of obstructive sleep apnea is also important.     

A National Survey of Medical Students’ Beliefs and Knowledge in Screening for Prostate Cancer

Background Today’s medical students are being educated at a time when there are no evidence-based guidelines for prostate cancer screening. Objective To examine medical students’ knowledge and beliefs concerning prostate cancer screening and specific determinants for their beliefs. Design, Setting, and Participants One thousand six hundred and forty four students were sampled at 20 medical schools using a web-based, cross-sectional survey. Main Outcome Measures Basic knowledge and beliefs about prostate cancer testing, epidemiology, and therapy were ascertained. Results Four of 8 knowledge items were answered incorrectly by 50% or more of students. Seven of 8 students believe that early diagnosis from screening can improve survival from prostate cancer. Second- and third-year students were more likely than fourth-year students to believe that the digital rectal exam (DRE) and the prostate-specific antigen test were accurate, adjusted odds ratio (AOR) 1.8; 95% confidence interval (CI), 1.2 to 2.7 and 1.7; 1.3 to 2.2 for second and third years, respectively, for the DRE. Black and Hispanic students were no more likely than white students to agree that early screening diagnosis improves survival, but blacks were more likely to agree with screening black or Hispanic men (AOR 7.8; 95% CI, 5.3 to 11.4 and 3.2; 2.2 to 4.7, respectively). More knowledgeable students were less likely to believe in the benefit of early detection and the accuracy of the prostate-specific antigen (AOR 0.3; 95%CI, 0.2 to 0.5). Conclusions Medical students generally are very optimistic about the benefits of screening for prostate cancer. Increased knowledge about prostate cancer is associated with a more conservative view of screening. Other predictors are independent of this knowledge. A portion of these results was presented in part at the 2004 ASPO (American Society of Preventive Oncology) in Bethesda Maryland on March 14th, 2004. The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.     

A Transient Increase in the Serum ANCAs in Patients with SARS-CoV-2 Infection: A Signal of Subclinical Vasculitis or an Epiphenomenon with No Clinical Manifestations? A Pilot Study

A relationship is emerging between SARS-CoV-2 infections and ANCA-associated vasculitis (AAV) because: (i) the pulmonary involvement of COVID-19 may mimic that observed in patients with AAV; (ii) the two diseases may occur together; (iii) COVID-19 may trigger AAV. However, few cases of AAV have been identified so far in COVID-19 patients. To define the frequency of ANCA autoimmunity in patients with SARS-CoV-2 infection, we analyzed the serum ANCAs and the serum PR3 and MPO antigens by immunoassays in 124 adult patients with a diagnosis of SARS-CoV-2 infection (16 were asymptomatic and 108 were hospitalized) and 48 control subjects. The serum ANCAs were significantly higher in the hospitalized patients compared with either the controls or the asymptomatic patients and increased with the progression of the COVID-19 severity. After one week of hospitalization, the values were significantly lower. In contrast, no differences emerged among the controls, asymptomatic and hospitalized patients for the PR3 and MPO serum levels. None of the patients had clinical signs of AAV with the exception of a severe pulmonary involvement. Further studies are necessary to define whether the increase in the serum ANCAs might mask subclinical vasculitis in a percentage of patients with SARS-CoV-2 infection or it is an epiphenomenon of SARS-CoV-2 infection with no clinical manifestations.     

Are Co-Morbidities Associated with Guideline Adherence? The MI-Plus Study of Medicare Patients

BACKGROUND/OBJECTIVES  

The impact of co-morbid illnesses on adherence to guideline recommendations in chronic illness is of growing concern. We tested a framework [Piette and Kerr, Diabetes Care. 29(3):725–31, 2006] of provider adherence to guidelines in the presence of co-morbid conditions, which suggests that the effect of co-morbid conditions depends on treatment recommendations for the co-morbid conditions and how symptomatic they are.     

Are Survival Rates Different for Young and Older Patients With Rectal Cancer?

PURPOSE Although it is generally believed that young patients with rectal cancer have worse survival rates, no comprehensive analysis has been reported. This study uses a national-level, population-based cancer registry to compare rectal cancer outcomes between young vs. older populations.METHODS All patients with rectal carcinoma in the Surveillance, Epidemiology, and End Results cancer database from 1991 to 1999 were evaluated. Young (range, 20–40 years; n = 466) and older groups (range, 60–80 years; n = 11,312) were compared for patient and tumor characteristics, treatment patterns, and five-year overall and stage-specific survival. Cox multivariate regression analysis was performed to identify predictors of survival.RESULTS Mean ages for the groups were 34.1 and 70 years. The young group was comprised of more black and Hispanic patients compared with the older group (P < 0.001). Young patients were more likely to present with late-stage disease (young vs. older: Stage III, 27 vs. 20 percent respectively, P < 0.001; Stage IV, 17.4 vs. 13.6 percent respectively, P < 0.02). The younger group also had worse grade tumors (poorly differentiated 24.3 vs. 14 percent respectively, P < 0.001). Although the majority of both groups received surgery (85 percent for each), significantly more young patients received radiation (P < 0.001). Importantly, overall and stage-specific, five-year survival rates were similar for both groups (P = not significant).CONCLUSIONS Although previous studies have found young rectal cancer patients to have poorer survival compared with older patients, this population-based study shows that young rectal cancer patients seem to have equivalent overall and stage-specific survival.Supported in part by The American Society of Colon and Rectal Surgeons Limited Project Grant.Presented at the meeting of the Association for Academic Surgery, Sacramento, California, November 13 to 15, 2003.     

JIKEI HEART Study—A Morbi-Mortality and Remodeling Study with Valsartan in Japanese Patients with Hypertension and Cardiovascular Disease

BACKGROUND: Several recent clinical trials have demonstrated that angiotensin II receptor blockers (ARBs) have cardiovascular as well as renal protective effects. Asian patients including Japanese were under-represented in these trials, however, and no large-scale clinical trials of ARBs have yet been performed in Japan. It is therefore important to verify that the results of these studies are also valid for Japanese patients. The JIKEI HEART Study has been designed to investigate whether concomitant treatment with valsartan, an angiotensin II receptor blocker, in addition to conventional treatment, will improve the prognosis of Japanese patients with cardiovascular diseases (hypertension, ischemic heart disease, congestive heart failure). METHOD AND EVALUATION OF RESULTS: Around 3,000 patients with hypertension, ischemic heart disease and/or congestive heart failure will be randomized to receive either additional treatment with valsartan (80 mg/day) or conventional therapy. The follow-up period will be three years. The primary endpoint will be the onset of any cardiovascular event. Secondary endpoints will include death from any cause, changes in left ventricular size and function, renal function, changes in neuro-hormonal levels and quality-of-life assessments. Sub-studies will explore the effect in patients with diabetes mellitus, hyperlipidemia and the effects of combination of drugs. CONCLUSION: Improved prognosis would confirm the role of angiotensin II receptor blockers in the treatment of the cardiovascular disease in Japanese patients.     

Efficacy of the Combination of Tetracycline, Amoxicillin, and Lansoprazole in the Eradication of Helicobacter pylori in Treatment-Naïve Patients and in Patients Who Are Not Responsive to Clarithromycin-Based Regimens: A Pilot Study

Background/Aims

The aim of this study was to evaluate the eradication rate of a triple therapy regimen that included a proton pump inhibitor, amoxicillin, and tetracycline instead of clarithromycin in treatment-Naïve patients and in patients who did not respond to standard triple therapy.

Methods

This study included 110 patients infected with Helicobacter pylori. Patients in groups A and B were treatment-Naïve, and those in group C were not responsive to previous standard triple therapy. Patients in group A (n=40) received lansoprazole 30 mg b.i.d., amoxicillin 1,000 mg b.i.d., and clarithromycin 500 mg b.i.d. for 14 days. Patients in groups B (n=40) and C (n=30) received lansoprazole 30 mg b.i.d., amoxicillin 1,000 mg b.i.d., and tetracycline 500 mg q.i.d. for 14 days.

Results

In group A, eradication was achieved in 18 (45%) of the 40 patients included in the intention-to-treat (ITT) analysis and in 18 (47.4%) of the 38 patients included in the per-protocol (PP) analysis. In group B, eradication was achieved in 15 (37.5%) of the 40 patients included in the ITT analysis and in 15 (39.3%) of the 38 patients included in the PP analysis. In group C, eradication was achieved in 14 (46.6%) of the 30 patients included in the ITT analysis and in 14 (43.8%) of the 29 patients included in the PP analysis. There was no statistically significant difference among the 3 groups with regard to eradication rates (p>0.05).

Conclusions

Despite the low rate of resistance to tetracycline, the combination of lansoprazole, amoxicillin, and tetracycline instead of clarithromycin is not a good option for the eradication of H. pylori.     

To Clot or Not To Clot: Are there Predictors of Clinically Significant Thrombus Formation in Patients with Gastroparesis and Prolonged IV Access?

Some patients with gastroparesis (GP) require sustained central intravenous access for hydration, medication and/or nutrition, leaving them at risk for venous thrombosis. We studied a group of 53 patients with gastroparesis for identifiable risk factors of clinically significant thrombosis. Patients requiring prolonged central IV access fell into two groups: those who had clinical incidence of IV catheter-related thrombosis confirmed radiologically (CLOT, n = 14), and those who did not form IV catheter thrombosis (NOCLOT, n = 39). We analyzed and compared clinical symptoms, serum/plasma coagulation studies, and autoimmune antibodies in the CLOT and NOCLOT groups. Patients in the CLOT group had statistically more Scl 70 antibodies than did the NOCLOT group, and another autoantibody, Ku 66, was found in higher titers in the NOCLOT group than the CLOT group. Other autoimmune and coagulation factors were not statistically different between the two groups, although a sub-group of CLOT patients had lower plasma Protein S levels. We conclude that the presence of Scl 70 autoantibodies is associated with increased clotting risk in this group of GP patients, and that the Ku 66 antibody may be associated with decreased risk of thrombosis in patients with GP. These findings, coupled with lower Protein S levels in some CLOT patients, suggests that autoimmune factors may be associated with GP patients who thrombose IV access versus patients who do not. Portions of this paper have been previously presented in abstract form [11–14].     

Magnetic Resonance Elastography for Assessing Fibrosis in Patients with Crohn’s Disease: A Pilot Study

Digestive Diseases and Sciences - Patients with Crohn’s disease can develop intestinal strictures, containing various degrees of inflammation and fibrosis. Differentiation of the main...     

Reducing PSA-Based Prostate Cancer Screening in Men Aged?75?Years and Older with the Use of Highly Specific Computerized Clinical Decision Support

INTRODUCTION

In 2012, the Veterans Health Administration (VHA) implemented guidelines seeking to reduce PSA-based screening for prostate cancer in men aged 75 years and older.

OBJECTIVES

To reduce the use of inappropriate PSA-based prostate cancer screening among men aged 75 and over.

SETTING

The Veterans Affairs Greater Los Angeles Healthcare System (VA GLA)

PROGRAM DESCRIPTION

We developed a highly specific computerized clinical decision support (CCDS) alert to remind providers, at the moment of PSA screening order entry, of the current guidelines and institutional policy. We implemented the tool in a prospective interrupted time series study design over 15 months, and compared the trends in monthly PSA screening rate at baseline to the CCDS on and off periods of the intervention.

RESULTS

A total of 30,150 men were at risk, or eligible, for screening, and 2,001 men were screened. The mean monthly screening rate during the 15-month baseline period was 8.3 %, and during the 15-month intervention period, was 4.6 %. The screening rate declined by 38 % during the baseline period and by 40 % and 30 %, respectively, during the two periods when the CCDS tool was turned on. The screening rate ratios for the baseline and two periods when the CCDS tool was on were 0.97, 0.78, and 0.90, respectively, with a significant difference between baseline and the first CCDS-on period (p < 0.0001), and a trend toward a difference between baseline and the second CCDS-on period (p = 0.056).

CONCLUSION

Implementation of a highly specific CCDS tool alone significantly reduced inappropriate PSA screening in men aged 75 years and older in a reproducible fashion. With this simple intervention, evidence-based guidelines were brought to bear at the point of care, precisely for the patients and providers for whom they were most helpful, resulting in more appropriate use of medical resources.KEY WORDS: electronic health records, physician decision support, cancer screening, applied informatics, implementation research, quality improvement