Abnormal Colorectal Cancer Test Follow-Up: A Quality Improvement Initiative at a Federally Qualified Health Center

INTRODUCTION/OBJECTIVES

Colonoscopy completion rates after an abnormal fecal immunochemical test (FIT) are suboptimal, resulting in missed opportunities for early detection and prevention of colorectal cancer. Patient navigation and structured follow-up may improve colonoscopy completion, but implementation of these strategies is not widespread.

METHODS

We conducted a quality improvement study using a Plan-Do-Study-Act (PDSA) Model to increase colonoscopy completion after abnormal FIT in a large federally qualified health center serving a diverse and low-income population. Intervention components included patient navigation, and a checklist to promote completion of key steps required for abnormal FIT follow-up. Primary outcome was proportion of patients achieving colonoscopy completion within 6 months of abnormal FIT, assessed at baseline for 156 patients pre-intervention, and compared to 208 patients during the intervention period from April 2017 to December 2019. Drop offs at each step in the follow-up process were assessed.

RESULTS

Colonoscopy completion improved from 21% among 156 patients with abnormal FIT pre-intervention, to 38% among 208 patients with abnormal FIT during the intervention (P < .001; absolute increase: 17%, 95% CI: 6.9%-25.2%). Among the 130 non-completers during the intervention period, lack of completion was attributable to absence of colonoscopy referral for 7.7%; inability to schedule a pre-colonoscopy specialist visit for 71.5%; failure to complete a pre-colonoscopy visit for 2.3%; the absence of colonoscopy scheduling for 9.2%; failure to show for a scheduled colonoscopy for 9.2%.

CONCLUSIONS

Patient navigation and structured follow-up appear to improve colonoscopy completion after abnormal FIT. Additional strategies are needed to achieve optimal rates of completion.

Impact of school closures during the pandemic on screen time and behavior of children: Evidence from a developing country

Introduction

Serious concerns regarding the indirect physical and mental health impact of the extended school closure measure to control the spread of the pandemic have been raised, however, the extent of the problem remains unquantified in India.

Objectives

To examine the impact of school closures on recreational screen time, emotional, and behavioral functioning of school-going children during the pandemic.

Methods

The survey utilized a Google form that was sent to parents of children (6-14 years) through emails and social media platforms. Parents were asked to report on the child’s duration of recreational screen time and whether the child’s overall behavioral functioning had changed since the school closures. The child’s emotional and behavioral functioning was assessed by the Strength and Difficulties Questionnaire (SDQ). The study was cleared by the Ethics committee.

Results

A total of 160 parents were recruited for the study. Overall, a little more one-fourth (28.1%) of the children’s behavior was reported to have worsened. The mean recreational screen time was 2.65 hours (SD=1.89). A significantly higher proportion of children whose behavior worsened after school closures, relative to those whose behavior improved or remained same, had scores in the abnormal range of functioning on three of the subscales of SDQ. Stepwise multiple regression analysis indicated that recreational screen time explained 2% of the variance in the total SDQ score (F=4.18. P=.04).

Conclusions

Increase in psychological services supporting healthy behaviors and anticipatory telehealth consultations for high-risk children and families is the need of the hour to foster psychological wellbeing during the pandemic.

Disclosure

No significant relationships.

A Promotor-Led Pilot Study to Increase Colorectal Cancer Screening in Latinos: The Juntos Contra El Cáncer Program

Background. Latinos have lower colorectal cancer (CRC) screening rates compared to other racial/ethnic groups in the United States, despite an overall increase in CRC screening over the past 10 years. To address this disparity, we implemented a promotor-led intervention to increase CRC screening test adherence in community-based settings, connecting community members with a partnering federally qualified health center. Purpose. To evaluate the Juntos Contra el Cáncer/Together Against Cancer (JUNTOS) intervention, by assessing pre-post changes in (1) CRC screening test adherence and (2) CRC knowledge and perceived barriers to CRC screening. We also assessed the feasibility and acceptability of program activities. Method. JUNTOS was a group-based intervention, delivered by promotores (community health workers), to promote CRC screening test adherence among Latino adults. The intervention consisted of a culturally tailored 2½-hour interactive workshop followed by an appointment scheduling assistance from a promotor. Workshop participants were Latino adults (males and females) aged 50 to 75 years who were not up-to-date with CRC screening guidelines. We conducted interviews before and 6 to 9 months after the workshop to assess program outcomes. Results. Of the 177 participants included, 118 reported completing the CRC screening test (66.7%) by 6 to 9 months postintervention. We observed baseline to 6- to 9-month increase in CRC knowledge and lower perceived barriers to obtaining CRC screening. Furthermore, the intervention was found to be feasible and acceptable. Conclusion. Results suggest that JUNTOS can be feasibly implemented in partnership with a federally qualified health center. The current study supports group-based CRC interventions in community and clinic settings.

Abstract C106: Multilevel patient navigator-led intervention to optimize colonoscopy completion after an abnormal fecal immunochemical test

Purpose: Impact of colorectal cancer (CRC) screening with the fecal immunochemical test (FIT) depends on completion of diagnostic colonoscopy after abnormal FIT, as failure to complete diagnostic colonoscopy is associated with 2.4 fold increased risk of CRC death. Colonoscopy completion after abnormal FIT ranges from 18% to 57% among Federally Qualified Health Centers (FQHCs) in San Diego County. Our goal is to report the initial successes and challenges of a multi-level, patient navigator (PN) led intervention to optimize colonoscopy completion after abnormal FIT faced largely by Hispanic/Latino patients in our geographic area. Methods: At a single primary clinic within a large FQHC in San Diego’s predominantly Latino community, we implemented a multi- component intervention to promote colonoscopy completion for patients with abnormal FIT led by a bilingual/bicultural PN. PN responsibilities included monitoring timely review of FIT results by ordering provider, results provision to patients, insurance authorization, facilitating referrals for GI consultation and colonoscopy scheduling. Health system barriers (such as failure to order colonoscopy) were addressed by having the PN prompt the relevant team member to complete required care steps. Patient barriers (such as understanding FIT results, procedure scheduling and fears) were addressed through phone and in-person encounters by the PN. Summary: During the period of March to August 2017, 45 patients had an abnormal FIT. Out of 45 patients, three were not eligible for navigation due to prior colonoscopy completion. Of the remaining 42, 26 did not complete colonoscopy (14 lost to follow-up, 4 pending GI consult, 4 pending colonoscopy, 4 declined). The PN directly interacted with 28 patients of which 16 (57%) successfully completed colonoscopy. These preliminary results show a low overall rate of colonoscopy completion (16/45=36%) with nearly one third of patients (14/45=31%) lost to follow-up. Conclusions: In our initial experience with a PN-led, multi-level intervention for promoting colonoscopy completion after abnormal FIT, 57% of patients who interacted with the PN completed a colonoscopy procedure. Challenges such as loss to follow up remain a barrier to intervention success. Our results suggest that multi-level interventions led by a PN have potential to optimize follow through of colonoscopy completion after abnormal FIT.

Citation Format: Monica Hernandez, Jesse Nodora, Balambal Bharti, Jose L Diaz, Jessica Marquez, Felipe Garcia-Bigley, Christian Ramers, Jessica Haughton, Elva Arredondo, Samir Gupta. Multilevel patient navigator-led intervention to optimize colonoscopy completion after an abnormal fecal immunochemical test [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C106.

Development of a Group-Based Community Health Worker Intervention to Increase Colorectal Cancer Screening Among Latinos

INTRODUCTION

Latinos are at higher risk of colorectal cancer (CRC) mortality than non-Hispanic Whites due, in part, to disparities in cancer screening. There is a need to evaluate community-based CRC interventions as they may reach underinsured communities and those at highest risk for CRC. This article describes the development of a group-based CRC intervention (Juntos contra el Cancer).

METHOD

Purposive sampling was used to recruit Latino men and women aged 50 to 75 years not-up-to-date with CRC screening. The development of the intervention was guided by the socioecologic framework, a community needs assessment, literature reviews, five focus groups (n = 39) from the target community and feedback from a Community Advisory Board.

RESULTS

Findings from focus groups suggested that a group-based, promotor or community health worker (CHW) led, cancer prevention education with linkages to care would address barriers to CRC screening.

CONCLUSION

Development of community-based CRC screening interventions should be informed by early and sustained community engagement. Interventions led by CHWs with linkages to care are feasible and can reach populations not connected to health care settings.

Magnetic field-driven assembly and reconfiguration of multicomponent supraparticles

Suprastructures at the colloidal scale must be assembled with precise control over local interactions to accurately mimic biological complexes. The toughest design requirements include breaking the symmetry of assembly in a simple and reversible fashion to unlock functions and properties so far limited to living matter. We demonstrate a simple experimental technique to program magnetic field-induced interactions between metallodielectric patchy particles and isotropic, nonmagnetic "satellite" particles. By controlling the connectivity, composition, and distribution of building blocks, we show the assembly of three-dimensional, multicomponent supraparticles that can dynamically reconfigure in response to change in external field strength. The local arrangement of building blocks and their reconfigurability are governed by a balance of attraction and repulsion between oppositely polarized domains, which we illustrate theoretically and tune experimentally. Tunable, bulk assembly of colloidal matter with predefined symmetry provides a platform to design functional microstructured materials with preprogrammable physical and chemical properties.

Potential impact of family history-based screening guidelines on the detection of early-onset colorectal cancer

BACKGROUND

Initiating screening at an earlier age based on cancer family history is one of the primary recommended strategies for the prevention and detection of early-onset colorectal cancer (EOCRC), but data supporting the effectiveness of this approach are limited. The authors assessed the performance of family history-based guidelines for identifying individuals with EOCRC.

METHODS

The authors conducted a population-based, case-control study of individuals aged 40 to 49 years with (2473 individuals) and without (772 individuals) incident CRC in the Colon Cancer Family Registry from 1998 through 2007. They estimated the sensitivity and specificity of family history-based criteria jointly recommended by the American Cancer Society, the US Multi-Society Task Force on CRC, and the American College of Radiology in 2008 for early screening, and the age at which each participant could have been recommended screening initiation if these criteria had been applied.

RESULTS

Family history-based early screening criteria were met by approximately 25% of cases (614 of 2473 cases) and 10% of controls (74 of 772 controls), with a sensitivity of 25% and a specificity of 90% for identifying EOCRC cases aged 40 to 49 years. Among 614 individuals meeting early screening criteria, 98.4% could have been recommended screening initiation at an age younger than the observed age of diagnosis.

CONCLUSIONS

Of CRC cases aged 40 to 49 years, 1 in 4 met family history-based early screening criteria, and nearly all cases who met these criteria could have had CRC diagnosed earlier (or possibly even prevented) if earlier screening had been implemented as per family history-based guidelines. Additional strategies are needed to improve the detection and prevention of EOCRC for individuals not meeting family history criteria for early screening.

Outreach and Inreach Strategies for Colorectal Cancer Screening Among Latinos at a Federally Qualified Health Center: A Randomized Controlled Trial, 2015-2018

Objectives. To compare usual care, inreach consisting of one-on-one education, mailed outreach offering a fecal immunochemical test (FIT), and a combination of outreach and inreach for promoting colorectal cancer (CRC) screening.Methods. We conducted a 4-arm randomized controlled trial from 2015 to 2018 at a US federally qualified health center near the California-Mexico border primarily serving low-income Hispanics/Latinos. A total of 673 individuals aged 50 to 75 years not up to date with screening were assigned to 1 of the 4 intervention groups. The primary outcome was CRC screening through 6 months follow-up.Results. A total of 671 patients were included in intention-to-screen analyses. Their mean age was 59.9 years, 48.9% were male, and 86.3% were primarily Spanish-speaking. Screening was 27.5% for usual care (95% confidence interval [CI] = 0.21, 0.34), 52.7% for inreach (95% CI = 0.45, 0.60), 77.2% for outreach (95% CI = 0.71, 0.83), and 78.9% for combination of inreach and outreach (95% CI = 0.73, 0.85; P < .001 for all comparisons except P = .793 for outreach vs combination).Conclusions. Among individuals at high risk for noncompletion, inreach with one-on-one education nearly doubled, and outreach offering mailed FIT alone or in combination with inreach nearly tripled screening compared with usual care. Mailed FIT outreach was superior to inreach for promoting screening.

Diagnostic colonoscopy completion after abnormal fecal immunochemical testing and quality of tests used at 8 Federally Qualified Health Centers in Southern California: Opportunities for improving screening outcomes

BACKGROUND

The effectiveness of colorectal cancer screening with fecal immunochemical tests (FITs) of stool blood depends on high rates of colonoscopy follow-up for abnormal FITs and the use of high-quality tests. This study characterized colonoscopy referral and completion among patients with abnormal FITs and the types of FITs implemented in a sample of Southern California Federally Qualified Health Centers (FQHCs).

METHODS

FQHCs in San Diego, Imperial, and Los Angeles Counties were invited to define a cohort of ≥150 consecutive patients with abnormal FITs in 2015-2016 and to provide data on sex, insurance status, diagnostic colonoscopy referrals and completion within 6 months of abnormal FITs, and the types (brands) of FITs implemented. The primary outcomes were the proportions with colonoscopy referrals and completion for all patients at each FQHC and in aggregate.

RESULTS

Eight FQHCs provided data for 1229 patients with abnormal FITs; 46% were male, and 20% were uninsured. Among patients with abnormal FITs, 89% (1091 of 1229; 95% confidence interval [CI], 0.87-0.91) had a colonoscopy referral, and 44% (539 of 1229; 95% CI, 0.41-0.47) had colonoscopy completion. Across FQHCs, the range for colonoscopy referral was 73% to 96%, and the range for completion was 18% to 57%. Six of the 8 FQHCs (75%) reported FIT brands with limited data to support their effectiveness.

CONCLUSIONS

In a sample of Southern California FQHCs, diagnostic colonoscopy completion after abnormal FITs was substantially below the nationally recommended benchmark to achieve 80% completion, and the use of FIT brands with limited data to support their effectiveness was high. These findings suggest a need for policies and multilevel interventions to promote diagnostic colonoscopy among individuals with abnormal FITs and the use of higher quality FITs.

Mailed Outreach Is Superior to Usual Care Alone for Colorectal Cancer Screening in the USA: A Systematic Review and Meta-analysis

Mailed outreach promoting colorectal cancer (CRC) screening with a stool blood test kit may increase participation, but magnitude and consistency of benefit of this intervention strategy is uncertain. Our aim was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing mailed outreach offering stool tests to usual care, clinic-based screening offers on CRC screening uptake in the USA. We performed a systematic literature search of five databases for RCTs of mailed outreach from January 1980 through June 2017. Primary outcome was screening completion, summarized using random-effects meta-analysis as pooled differences in proportion completing the screening and relative risk of achieving screening compared to control. Subgroup analyses by test type offered-fecal immunochemical test (FIT) or guaiac fecal occult blood test (gFOBT), the presence of telephone reminders, and the presence of predominant underserved/minority population within study were performed. Quality of evidence was evaluated using the GRADE framework. Seven RCTs which enrolled 12,501 subjects were included (n = 5703 assigned mailed outreach and n = 6798 usual care). Mailed outreach resulted in a 28% absolute (95% CI 25-30%; I² = 47%) and a 2.8-fold relative (RR 2.65, 95% CI 2.03-3.45; I² = 92%) increase in screening completion compared to usual care, with a number needed to invite estimated to be 3.6. Similar outcomes were observed across subgroups. Overall body of evidence was at moderate quality. Mailed outreach offering a gFOBT or FIT is associated with a large and consistent increase in CRC screening completion and should be considered for more widespread implementation for improving screening rates nationwide.

Abstract C71: Discrepancies in perceptions of colorectal cancer screening and willingness to screen among Federally Qualified Health Centers staff and Latino community members

Background: With colorectal cancer (CRC) persisting as the second leading cause of cancer deaths in the US, it is imperative that screening perceptions and behaviors among underserved populations be investigated and better understood. Latinos have exhibited lower rates of maintaining consistent and timely screening measures for CRC: while nearly 61% of non-Hispanic whites are screening regularly for CRC, Latinos fall behind at just below 45%.

Federally Qualified Health Centers (FQHCs) attempt to address this disparity by providing outreach and screening services to medically underserved patients. In 2014, approximately 13% of FQHC patients nationwide self-identified as Latino; this underscores this population's need for affordable and tailored care. As the passing of the Affordable Care Act has gradually increased access to health care among Americans who had previously been uninsured, FQHCs have a unique opportunity to implement interventions that target populations and individuals who now have access to regular care.

Objective: The purpose of the present study was to identify discrepancies in perceptions of CRC screening and willingness to screen among FQHCs staff and Latino community members living in San Diego, California. In-depth interviews (n=17) were held with health care providers and staff at local FQHCs (mean age: 38.8 years; 64.7% female; 88.2% Latino) and five focus groups (n=39) were conducted with community members who reside in neighborhoods served by FQHCs (mean age: 59.4 years; 79.5% female; 97.4% Latino).

Method: Using standardized interview and focus group guides based on Social Ecological Model (SEM), FQHCs staff and community members were asked to describe their experience with CRC screening. Beliefs, attitudes, and perceptions regarding CRC screening and related referrals were also discussed. Interviews and focus groups were audio recorded and transcribed, and content analysis was used to create a codebook based on SEM. Two coders independently reviewed transcripts and applied codes, meeting to resolve inconsistent coding via consensus. Data were summarized according to two themes: 1) patient-level facilitators and barriers to CRC screening and 2) organizational barriers to CRC screening.

Results: While patients often reported feeling that they had access to medical information and had a grasp of the basic tenets of preventive health care, FQHCs staff consistently reported a lack of CRC-specific knowledge among patients in their clinics. Community members' reported willingness to screen for CRC was higher than FQHCs staffs' perception of it. FQHCs patients were viewed by staff as being afraid or embarrassed to screen, while community members generally reported feeling comfortable with CRC screening methods. FQHCs staff identified organizational barriers, such as the fragmentation of the referral process and a lack of knowledge of appropriate screening procedures. Organizational facilitators at FQHCs were also identified, including the option of mailing completed fecal immunochemical tests (FIT) to labs as well as the overall cohesion and organizational capacities of the FQHCs' Electronic Health Record systems. Additionally, FQHCs staff reported having implemented a pilot program that sought to aid patients in understanding the importance and processes of using the FIT kit as well as facilitating the completion and return of FIT tests.

Discussion: The present study's findings suggest FQHCs staff may lack confidence in their patients' abilities and knowledge in obtaining CRC screening. Several discrepancies were noted with regard to patients' willingness and ability to obtain CRC screening. Interventions that work to improve communication between FQHC staff and patients would be beneficial to the Latino populations living in this region.

Citation Format: Elizabeth N. Alpert, Sumayah Nuhaily, Carolina López De la Torre, Jessica Haughton, Samir Gupta, Jesse Nodora, Balambal Bharti, Christian Ramers, Felipe Garcia, Tatianna Clark, Claudia Carrizosa, Elva M. Arredondo, Kristen J. Wells. Discrepancies in perceptions of colorectal cancer screening and willingness to screen among Federally Qualified Health Centers staff and Latino community members [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C71.

Abstract C80: Colonoscopy follow up after abnormal colorectal cancer screening tests at a large Federally Qualified Community Health Center

Background.

Screening for colorectal cancer (CRC) can reduce cancer incidence and mortality, but participation rates are low among underserved populations. Federally Qualified Health Centers (FQHCs) in many states have an opportunity to be at the vanguard of improving screening rates among underserved populations, due to new acquisition of Medicaid insurance by patients. Many FQHCs are employing non-invasive strategies, such as the fecal immunochemical test (FIT), to increase screening rates. Non-invasive tests such as the FIT are generally inexpensive, convenient, and often acceptable for patients. However, effectiveness of non-invasive screening in prevention or early detection of CRC depends heavily on ability to ensure diagnostic colonoscopy after abnormal screening tests. Specifically, prevention and early detection benefits of identifying patients through non-invasive screening at increased risk for CRC and polyps can only be realized if rates of diagnostic colonoscopy after positive tests are high. Indeed, up to 1 in 33 patients with an abnormal FIT have CRC. As part of a community-academic partnership between Family Health Centers of San Diego (FHCSD), San Diego State University, and UC San Diego Moores Cancer Center, we aimed to characterize CRC screening processes, including rates of complete diagnostic follow up after abnormal FIT testing.

Methods. FHCSD is a large FQHC serving 134,788 patients annually through 19 community clinics. The patient population is largely Latino (55%); 97% live at or below 200% of poverty, with most patients having less than a high school education. Following the Quality of Cancer Care Continuum principles adapted by Tiro et al.1 for CRC screening, we mapped the CRC screening process at FHCSD, and characterized drop-offs at various steps in the screening process by querying the electronic health record to identify all individuals with FIT orders over a six-month period (10/01/15 - 03/31/16). Outcomes of interest included rates of FIT completion, abnormal test results, and colonoscopy orders and completion among patients with an abnormal FIT, characterized via descriptive statistics.

Results. Over a six-month period, across 19 clinics within FHCSD, 9,378 FITs were ordered. Patients returned 25% of FITs ordered (2327/9378). Among returned FITs, 7% were abnormal (156/2327). Among patients with an abnormal FIT 85% (132/156) had orders for referral colonoscopy, and 21% had documented evidence of colonoscopy completion (33/156). FIT return was statistically significantly higher for patients without (33%; 368/1119) vs. with insurance (24%; 1959/8259; p comparison = &lt;0.001). However, diagnostic colonoscopy completion after abnormal FIT was higher for patients with (24%; 31/132) vs. without insurance (8%; 2/24), though the difference was not statically significant.

Conclusions.Low rates of diagnostic colonoscopy after abnormal non-invasive CRC screening tests may adversely impact effectiveness of CRC screening programs. Research should focus on understanding reasons for fall offs in the screening process, and developing multilevel interventions to optimize follow up, particularly given the expanding array of non-invasive CRC screening tests being made available in usual practice. Conducting these studies in FQHC settings is critical, since increases in screening in these settings may largely occur as a result of implementation and promotion of non-invasive tests.

References:

1. Tiro JA, Kamineni A, Levin TR et al. The colorectal cancer screening process in community settings: a conceptual model for the population-based research optimizing screening through personalized regimens consortium. Cancer Epidemiol Biomarkers Prev. 2014;23(7):1147-1158

Citation Format: Samir Gupta, Balambal Bharti, Jesse Nodora, Kristen J. Wells, Christian Ramers, Felipe G. Garcia, Eden Sosa, Yessenia Magana, Anthony White, Jamie Moody, Jessica Haughton, Elva Arredondo. Colonoscopy follow up after abnormal colorectal cancer screening tests at a large Federally Qualified Community Health Center. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C80.

Disease Severity and Pregnancy Outcomes in Women with Rheumatoid Arthritis: Results from the Organization of Teratology Information Specialists Autoimmune Diseases in Pregnancy Project

OBJECTIVE

To determine the effect of rheumatoid arthritis (RA) disease severity on pregnancy outcomes in pregnant women with and without autoimmune diseases.

METHODS

A prospective cohort study was conducted using the Organization of Teratology Information Specialists Autoimmune Diseases in Pregnancy Project. Pregnant women with RA enrolled between 2005 and 2013 were selected if they (1) delivered a live-born singleton infant; and (2) completed 3 telephone-based measures of RA disease severity prior to 20 weeks' gestation, including the Health Assessment Questionnaire Disability Index (HAQ-DI), pain score, and patient's global scale. Associations between RA disease severity and preterm delivery, small for gestational age (SGA), or cesarean delivery were tested in unadjusted and multivariate analyses using modified Poisson regression models.

RESULTS

The sample consisted of 440 women with RA. Several unadjusted comparisons yielded significant associations. After adjustment for covariates, increasing disease severity was associated with risk for preterm delivery and SGA. For each unit increase in HAQ-DI (0-1), the adjusted relative risk (aRR) for preterm delivery increased by 58% (aRR 1.58, 95% CI 1.17-2.15). Among those with HAQ-DI > 0.5, the aRR for SGA was 1.81 (95% CI 1.01-3.33).

CONCLUSION

RA disease severity in early pregnancy, as measured in this study, was predictive of preterm delivery and SGA. These findings suggest that the risk of preterm delivery and SGA in women with RA might be lowered if RA is well controlled early in pregnancy.

A randomized controlled trial of burping for the prevention of colic and regurgitation in healthy infants

BACKGROUND

Efficacy of burping in lowering colic and regurgitation episodes in healthy term babies lacks evidence in literature.

METHODS

We conducted a randomized controlled trial to compare efficacy of burping versus no-burping in 71 mother-baby dyads in community setting. Primary outcome was reduction in event rates of colic and regurgitation episodes over 3 months.

RESULTS

Baseline characteristics were similar in two groups. Difference in incidence rates of colic between the control and burping group was 1.57 episodes/infant/100 weeks [95% confidence interval (CI): -0.63 to 3.76]. There was statistically no significant reduction in colic episodes between burping and non-burping study subjects during 3 months of follow-up (adjusted relative risk 0.64; 95% CI: 0.22-1.86, P-value 0.41). Incidence rate difference of regurgitation episodes/infant/week between burping and control group was 4.36 (95% CI: 4.04 to 4.69) and there was statistically significant increase in burping group (adjusted relative risk 2.05; 95% CI: 1.92-2.18, P-value < 0.0001).

CONCLUSIONS

Although burping is a rite of passage, our study showed that burping did not significantly lower colic events and there was significant increase in regurgitation episodes in healthy term infants up to 3 months of follow-up.

The personal human oral microbiome obscures the effects of treatment on periodontal disease

Periodontitis is a progressive disease of the periodontium with a complex, polymicrobial etiology. Recent Next-Generation Sequencing (NGS) studies of the microbial diversity associated with periodontitis have revealed strong, community-level differences in bacterial assemblages associated with healthy or diseased periodontal sites. In this study, we used NGS approaches to characterize changes in periodontal pocket bacterial diversity after standard periodontal treatment. Despite consistent changes in the abundance of certain taxa in individuals whose condition improved with treatment, post-treatment samples retained the highest similarity to pre-treatment samples from the same individual. Deeper phylogenetic analysis of periodontal pathogen-containing genera Prevotella and Fusobacterium found both unexpected diversity and differential treatment response among species. Our results highlight how understanding interpersonal variability among microbiomes is necessary for determining how polymicrobial diseases respond to treatment and disturbance.

Potential risk of hypoxaemia in patients with severe pneumonia but no hypoxaemia on initial assessment: a prospective pilot trial

BACKGROUND

The World Health Organization recommends oxygen therapy for children under 5 years of age with pneumonia and lower chest indrawing. In patients with severe pneumonia who are initially normoxaemic, there is little information on the risk of subsequently developing hypoxaemia and the benefit of routine oxygen therapy.

OBJECTIVES

To study the incidence of subsequent hypoxaemia in initially normoxaemic children with pneumonia and lower chest indrawing.

METHODS

Children (n = 58, 3-59 mths) with pneumonia, lower chest indrawing and normoxaemia (SpO(2) >90%) were randomly assigned to receive supplemental oxygen (nasal prongs, 1-2 L/min flow) (n = 29) or room air (n = 29). Vital signs and SpO(2) were monitored continuously and recorded every 6 hours. Outcome variables were incidence of hypoxaemia, length of tachypnoea and lower chest indrawing.

RESULTS

The two groups had similar demographic and clinical profiles. Thirty-one patients (53%) developed hypoxaemia later, without significant differences between the two arms (RR 0·61, 95% CI 0·36-1·04). Patients who developed hypoxaemia later were similar to those who did not, except for a lower SpO(2) on enrolment. However, they took more time to recover from tachypnoea (P<0·05), chest indrawing (P<0·05) and fever, indicating that they had more severe disease. Early oxygen therapy did not alter the course of disease.

CONCLUSIONS

About half of the normoxaemic patients with severe pneumonia developed hypoxaemia after enrolment, indicating a significant potential risk. Children hospitaled with severe pneumonia might benefit from routine oxygen therapy. Alternatively, oxygen might be provided to those who develop hypoxaemia identified by a pulse oximeter.

Ventricular tachycardia in congenital adrenal hyperplasia

Severe hyperkalaemia in patients with congenital adrenal hyperplasia in association with aggravating factors such as acidosis and hypocalcaemia can cause life-threatening ventricular arrhythmias. Treatment of the underlying cause may be the only modality required in such cases. We report a 20-day-old male presenting with ventricular tachycardia due to electrolyte abnormalities in salt-losing congenital adrenal hyperplasia. Sudden cardiac deaths reported earlier in such cases thus gain credence.