Christian A. Mayorga

Outreach invitations for FIT and colonoscopy improve colorectal cancer screening rates: A randomized controlled trial in a safety-net health system.

The effectiveness of colorectal cancer (CRC) screening is limited by underuse, particularly among underserved populations. Among a racially diverse and socioeconomically disadvantaged cohort of patients, the authors compared the effectiveness of fecal immunochemical test (FIT) outreach and colonoscopy outreach to increase screening participation rates, compared with usual visit‐based care.

Effect of Colonoscopy Outreach vs Fecal Immunochemical Test Outreach on Colorectal Cancer Screening Completion: A Randomized Clinical Trial

Importance Mailed fecal immunochemical test (FIT) outreach is more effective than colonoscopy outreach for increasing 1-time colorectal cancer (CRC) screening, but long-term effectiveness may need repeat testing and timely follow-up for abnormal results. Objective Compare the effectiveness of FIT outreach and colonoscopy outreach to increase completion of the CRC screening process (screening initiation and follow-up) within 3 years. Design, Setting, and Participants Pragmatic randomized clinical trial from March 2013 to July 2016 among 5999 participants aged 50 to 64 years who were receiving primary care in Parkland Health and Hospital System and were not up to date with CRC screenings. Interventions Random assignment to mailed FIT outreach (n = 2400), mailed colonoscopy outreach (n = 2400), or usual care with clinic-based screening (n = 1199). Outreach included processes to promote repeat annual testing for individuals in the FIT outreach group with normal results and completion of diagnostic and screening colonoscopy for those with an abnormal FIT result or assigned to colonoscopy outreach. Main Outcomes and Measures Primary outcome was screening process completion, defined as adherence to colonoscopy completion, annual testing for a normal FIT result, diagnostic colonoscopy for an abnormal FIT result, or treatment evaluation if CRC was detected. Secondary outcomes included detection of any adenoma or advanced neoplasia (including CRC) and screening-related harms (including bleeding or perforation). Results All 5999 participants (median age, 56 years; women, 61.9%) were included in the intention-to-screen analyses. Screening process completion was 38.4% in the colonoscopy outreach group, 28.0% in the FIT outreach group, and 10.7% in the usual care group. Compared with the usual care group, between-group differences for completion were higher for both outreach groups (27.7% [95% CI, 25.1% to 30.4%] for the colonoscopy outreach group; 17.3% [95% CI, 14.8% to 19.8%] for FIT outreach group), and highest in the colonoscopy outreach group (10.4% [95% CI, 7.8% to 13.1%] for the colonoscopy outreach group vs FIT outreach group; P < .001 for all comparisons). Compared with usual care, the between-group differences in adenoma and advanced neoplasia detection rates were higher for both outreach groups (colonoscopy outreach group: 10.3% [95% CI, 9.5% to 12.1%] for adenoma and 3.1% [95% CI, 2.0% to 4.1%] for advanced neoplasia, P < .001 for both comparisons; FIT outreach group: 1.3% [95% CI, −0.1% to 2.8%] for adenoma and 0.7% [95% CI, −0.2% to 1.6%] for advanced neoplasia, P < .08 and P < .13, respectively), and highest in the colonoscopy outreach group (colonoscopy outreach group vs FIT outreach group: 9.0% [95% CI, 7.3% to 10.7%] for adenoma and 2.4% [95% CI, 1.3% to 3.3%] for advanced neoplasia, P < .001 for both comparisons). There were no screening-related harms in any groups. Conclusions and Relevance Among persons aged 50 to 64 years receiving primary care at a safety-net institution, mailed outreach invitations offering FIT or colonoscopy compared with usual care increased the proportion completing CRC screening process within 3 years. The rate of screening process completion was higher with colonoscopy than FIT outreach. Trial Registration clinicaltrials.gov Identifier: NCT01710215

Effectiveness of direct-acting antiviral therapy for hepatitis C in difficult-to-treat patients in a safety-net health system: A retrospective cohort study

BackgroundDirect-acting antivirals (DAAs) have revolutionized chronic hepatitis C (HCV) treatment, but real-world effectiveness among vulnerable populations, including uninsured patients, is lacking. This study was conducted to characterize the effectiveness of DAAs in a socioeconomically disadvantaged and underinsured patient cohort.MethodsThis retrospective observational study included all patients undergoing HCV treatment with DAA-based therapy between April 2014 and June 2016 at a large urban safety-net health system (Parkland Health and Hospital System, Dallas, TX, USA). The primary outcome was sustained virologic response (SVR), with secondary outcomes including treatment discontinuation, treatment relapse, and loss to follow-up.ResultsDAA-based therapy was initiated in 512 patients. The cohort was socioeconomically disadvantaged (56% uninsured and 13% Medicaid), with high historic rates of alcohol (41%) and substance (50%) use, and mental health disorders (38%). SVR was achieved in 90% of patients (n = 459); 26 patients (5%) were lost to follow-up. SVR was significantly lower in patients with decompensated cirrhosis (82% SVR; OR 0.37, 95% CI 0.16–0.85) but did not differ by insurance status (P = 0.98) or alcohol/substance use (P = 0.34). Reasons for treatment failure included loss to follow-up (n = 26, 5%), viral relapse (n = 16, 3%), non-treatment-related death (n = 7, 1%), and treatment discontinuation (n = 4, 1%). Of patients with viral relapse, 6 reported non-compliance and have not been retreated, 5 have been retreated and achieved SVR, 4 have undergone resistance testing but not yet initiated retreatment, and 1 was lost to follow-up.ConclusionsEffective outcomes with DAA-based therapy can be achieved in difficult-to-treat underinsured populations followed in resource-constrained safety-net health systems.

Gastric Ischemia as a Rare Cause of Hematemesis

A 59-year-old woman with a past medical history significant for anxiety and acid reflux presented to the hospital with acute-onset hematemesis after eating 2-day-old Chinese food. The patient did not drink alcohol or use illicit drugs. She had no recorded episodes of hypotension or syncope and no history of vasculopathy or vasculitis. On admission, she was afebrile with normal vital signs. The patient’s abdomen was tender to palpation. She had an elevated white blood cell count (20 g/dL) and normal hemoglobin. Abdominal computed tomography revealed diffuse gastric wall thickening, edema with perigastric inflammation, and upper abdominal free fluid, but no evidence of pneumoperitoneum or significant gastric distention. It also showed patent gastric and mesenteric vasculature without radiographic evidence of vasculitis. Blood cultures grew beta hemolytic Streptococcus, and the patient’s stool polymerase chain reactionwas positive forClostridium difficile. Anti-nuclear antibodywas negative, and no other vasculitis workup was performed. Upper endoscopy to evaluate hematemesis showed the entire stomach to be dark, purplish-black with necrotic, bleeding tissue; no healthy appearing tissue was present (Figure 1). Biopsies of the stomach confirmed acute mucosal necrosis consistent with ischemia. The patient was treated with bowel rest and broad-spectrum antibiotics, and she recovered without the need for surgical intervention.

Can Chronic Disease Management Programs Improve Outcomes in Patients With Cirrhosis

doors for novel areas of research. Preclinical data and case series suggest possible benefits for a variety of intestinal and extraintestinal conditions including irritable bowel syndrome, ulcerative colitis, metabolic syndrome, multiple sclerosis syndrome, and idiopathic thrombocytopenic purpura. Although well-designed, larger, randomized studies are needed to more conclusively characterize the benefits of fecal transplantation, the therapeutic potential for microbiome manipulation is nevertheless intriguing. Given the high-level evidence of the van Nood study, it seems that both patients and physicians will begin to embrace the benefits of FMT and leave the barriers behind. With regard to CDI, better data have now arrived, and dynamic improvements of logistics along with standardization of FMT procedures are already in the works. Considering the visceral, emotional assumptions of the esthetics involved, there are data suggesting that patients may be a step ahead of their clinicians, where likely the prospect of disease morbidity relief strongly influences patient preferences. Based on these data, patients who develop recurrent CDI after treatment with both metronidazole and vancomycin should be offered FMT and referral to a center that is experienced at FMT if needed.