Colorectal cancer screening uptake and adherence by modality at a large tertiary care center in the United States: a retrospective analysis

OBJECTIVE

Real-world data is crucial to inform existing opportunistic colorectal cancer (CRC) prevention programs. This study aimed to assess CRC screening adherence and utilization of various screening modalities within a Primary Care network over a three-year period (2017-2019).

METHODS

A retrospective review of individuals aged 50-75 years at average CRC risk, with at least one clinic visit in the previous 24 months. The primary outcome, CRC screening adherence (overall and by modality) was examined among the entire eligible population and newly adherent individuals each calendar year. The final sample included 107,366 patients and 218,878 records.

RESULTS

Overall CRC screening adherence increased from 71% in 2017 to 78% in 2019. For "up-to-date" individuals, colonoscopy was the predominant modality (accounting for approximately 74%, versus 4% of adherence for non-invasive options). However, modality utilization trends changed over time in these individuals: mt-sDNA increased 10.2-fold, followed by FIT (1.6-fold) and colonoscopy (1.1-fold). Among newly adherent individuals, the proportion screened by colonoscopy and FOBT decreased over time (89% to 80% and 2.4% to 1.2%, respectively), while uptake of FIT and mt-sDNA increased (7.7% to 11.5% and 0.9% to 6.8%, respectively). Notably, FIT and mt-sDNA increases were most evident in age and race-ethnicity groups with the lowest screening rates.

CONCLUSIONS

In an opportunistic CRC screening program, adherence increased but remained below the national 80% goal. While colonoscopy remained the most utilized modality, new colonoscopy uptake declined, compared with rising mt-sDNA and FIT utilization. Among minority populations, new uptake increased most with mt-sDNA and FIT.

[Risk Prediction Using Routine Data: Development and Validation of Multivariable Models Predicting 30- and 90-day Mortality after Surgical Treatment of Colorectal Cancer]

AIMS

Quality control, benchmarking, and pay for performance (P4P) require valid indicators and statistical models allowing adjustment for differences in risk profiles of the patient populations of the respective institutions. Using hospital remuneration data for measuring quality and modelling patient risks has been criticized by clinicians. Here we explore the potential of prediction models for 30- and 90-day mortality after colorectal cancer surgery based on routine data.

STUDY DESIGN

Full census of a major statutory health insurer.

SETTING

Surgical departments throughout the Federal Republic of Germany.

PATIENTS

4283 and 4124 insurants with major surgery for treatment of colorectal cancer during 2013 and 2014, respectively.

PREDICTORS

Age, sex, primary and secondary diagnoses as well as tumor locations as recorded in the hospital remuneration data according to §301 SGB V.

OUTCOMES

30- and 90-day mortality.

STATISTICAL ANALYSIS

Elixhauser comorbidities, Charlson conditions, and Charlson scores were generated from the ICD-10 diagnoses. Multivariable prediction models were developed using a penalized logistic regression approach (logistic ridge regression) in a derivation set (patients treated in 2013). Calibration and discrimination of the models were assessed in an internal validation sample (patients treated in 2014) using calibration curves, Brier scores, receiver operating characteristic curves (ROC curves) and the areas under the ROC curves (AUC).

RESULTS

30- and 90-day mortality rates in the learning-sample were 5.7 and 8.4%, respectively. The corresponding values in the validation sample were 5.9% and once more 8.4%. Models based on Elixhauser comorbidities exhibited the highest discriminatory power with AUC values of 0.804 (95% CI: 0.776 -0.832) and 0.805 (95% CI: 0.782-0.828) for 30- and 90-day mortality. The Brier scores for these models were 0.050 (95% CI: 0.044-0.056) and 0.067 (95% CI: 0.060-0.074) and similar to the models based on Charlson conditions. Regardless of the model, low predicted probabilities were well calibrated, while higher predicted values tended to be overestimates.

CONCLUSION

The reasonable results regarding discrimination and calibration notwithstanding, models based on hospital remuneration data may not be helpful for P4P. Routine data do not offer information regarding a wide range of quality indicators more useful than mortality. As an alternative, models based on clinical registries may allow a wider, more valid perspective.

IL-21 enhances chemoimmunotherapy mediated death of chronic lymphocytic leukemia cells

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Chemoimmunotherapy with fludarabine and rituximab has demonstrated promising clinical activity in CLL. We hypothesized that the IL-21 might enhance the efficacy of this regimen and play a role in immune mediated clearance of CLL cells. Expression of IL21R-a was present (>20% cells +) in 13 of 16 (81%) pts. IL-21 induced direct cytotoxicity of CLL cells (>20% apoptosis) in subset of patients (n=9, 40% ± 15.9, p<0.0001) that directly correlates with expression of surface IL-21 receptor-a (p=0.001). This direct apoptotic effect is time dependent with maximum cytotoxicity observed at 72 hours post treatment at 25ng/ml. IL-21 induced phosphorylation of STAT-1tyr- 701 and STAT-3tyr-705 was seen in cells with apoptosis >20% whereas phosphorylation of STAT-1tyr-701 was not seen in cells failing to undergo apoptosis. In contrast to this, responder and non responder cells exhibited comparable levels of STAT-1, STAT-3 and constitutive Ser727 phosphorylated STAT-3 levels. Further, IL-21 induced upregulation of Bim was observed in the cells undergoing apoptosis. Interestingly, IL-21 enhanced additively, the direct apoptosis by either antibody (rituximab or alemtuzumab) or fludarabine therapy (Pretreatment of CLL cells with IL-21 for 18–20 hours). In contrast to the enhanced fludarabine mediated direct cytotoxic death of B cells, IL-21 failed to enhance the fludarabine mediated death of T cells (n=5, % alive 56±15 vs 58±16 with IL-21) suggesting that this immunotherapeutic strategy will not augment the immunosuppressive effect of fludarabine. IL-21 also enhanced innate immune activation as demonstrated by killer inhibitory receptor matched autologous natural killer cell mediated antibody dependent cellular cytotoxicity against rituximab coated CLL cells by 33% (E: T ratio 25:1, 42% ± 4.4 versus 28% ± 3.1, p<0.0001). In conclusion, our data demonstrates that IL-21 1) enhances autologous CLL NK cell function against rituximab coated tumor cells 2) mediate direct apoptotic signaling that correlates with STAT1 signaling and BIM up-regulation, and 3) enhance sensitivity to both fludarabine and rituximab mediated direct apoptosis. These results provide strong support for future clinical investigation of IL-21 as a single agent and as part of chemoimmunotherapy regimens for CLL.

No significant financial relationships to disclose.

Alemtuzumab induces caspase-independent cell death in human chronic lymphocytic leukemia cells through a lipid raft-dependent mechanism

Alemtuzumab is a humanized IgG1 kappa antibody directed against CD52, a glycosyl-phosphatidylinositol linked cell-membrane protein of unknown function. Herein, we demonstrate that alemtuzumab promotes rapid death of chronic lymphocytic leukemia (CLL) cells in vitro, in a complement and accessory cell free system. Using minimal detergent solubilization of CLL membranes, we found that CD52 colocalizes with ganglioside GM-1, a marker of membrane rafts. Fluorescence microscopy revealed that upon crosslinking CD52 with alemtuzumab+anti-Fc IgG, large patches, and in many cases caps, enriched in CD52 and GM-1 formed upon the CLL cell plasma membrane. Depletion of membrane cholesterol or inhibition of actin polymerization significantly diminished the formation of alemtuzumab-induced caps and reduced alemtuzumab-mediated CLL cell death. We compared alemtuzumab-induced direct cytotoxicity, effector cell-mediated toxicity and complement-mediated cytotoxicity of CLL cells to normal T cells. The direct cytotoxicity and observed capping was significantly greater for CLL cells as compared to normal T cells. Cell-mediated and complement-mediated cytotoxicity did not significantly differ between the two cell types. In summary, our data support the hypothesis that alemtuzumab can initiate CLL cell death by crosslinking CD52-enriched lipid rafts. Furthermore, the differential direct cytotoxic effect suggests that CD52 directed antibodies could possibly be engineered to more specifically target CLL cells.

Biliary giardiasis in a patient with human immunodeficiency virus

A 41-year-old man with human immunodeficiency virus (HIV) (CD4 count, 446/mm3) developed a protracted course of abdominal pain, weight loss, and increasing liver function tests after undergoing a metronidazole treatment regimen for Giardia enteritis. Three months later, endoscopic retrograde cholangiography (ERCP) showed dilated common and intrahepatic bile ducts and luminal irregularities of the common bile duct. Seven months after the onset of his acute diarrhea, a repeat ERCP with aspiration demonstrated many Giardia trophozoites and cysts in the bile and continued structural abnormalities consistent with cholangiopathy. A 10-day course of high-dose intravenous metronidazole did not resolve these signs or symptoms. A gallbladder ultrasound showed a thickened wall. Laparoscopic cholecystectomy led to resolution of abdominal pain and normalization of serum alkaline phosphatase over an 8-month period. Gallbladder histopathology revealed chronic cholecystitis, but no parasites were seen on hematoxylin and eosin staining or with Giardia antigen enzyme immunoassay testing of the gallbladder. The patient refused to undergo a follow-up ERCP, but a right upper quadrant ultrasound and computed tomography of the abdomen were normal.

Computer integration and time spent on direct patient nutritional care activities in an outpatient dialysis setting

OBJECTIVE

To compare time spent in patient and administrative activities by nutrition professionals in a group of dialysis facilities, and relate differences to the degree of computer integration at the sites and between 2 time periods.

DESIGN

Survey design, self-administered activity form, completed in 1992 and 1997.

SETTING

Three of the largest outpatient dialysis centers in western Washington state.

SUBJECTS

Ten nutrition professionals completed the activity forms.

INTERVENTION

Activity form (recording time), questionnaire (results not reported here).

MAIN OUTCOME MEASURES

Amount of time spent on administrative activities in 1997 and the number of patients and number of hours per nutrition professional per month spent with patients in 1997, compared with 1992.

RESULTS

Time spent on administrative activities decreased in all facilities since 1992, with the largest decrease at the unit having the most computer integration.

CONCLUSION

Extensive computer integration seems to allow for a decrease in the amount of time spent on administrative activities by nutrition professionals.

Nutrition and feeding in infants with bronchopulmonary dysplasia after initial hospital discharge: risk factors for growth failure

OBJECTIVE

To identify nutritional risk factors for growth failure in infants with bronchopulmonary dysplasia (BPD) after initial hospital discharge, and to describe growth in and feeding concerns about these infants after discharge to the community.

DESIGN

A cohort of 40 infants with BPD was followed up for 7 monthly visits after initial hospital discharge. Data on potential risk factors were gathered prospectively.

SUBJECTS/SETTING

Forty infants with BPD were recruited from all 4 tertiary-level neonatal intensive care units in the Puget Sound area of Washington. Exclusionary criteria included congenital or chromosomal anomalies, grade IV intraventricular hemorrhage, and drug or alcohol exposure in utero.

MAIN OUTCOME MEASURES

Growth failure defined as weight less than the 5th percentile on National Center for Health Statistics growth curves at 2 or more points in time and a decrease in weight-for-age z score during the study period.

STATISTICAL ANALYSES PERFORMED

Relative risk of growth failure with exposure to each risk factor was determined. The chi 2 test was used to measure association between growth and development, and change in z scores was used to examine growth patterns.

RESULTS

Growth failure occurred in 8 of 40 infants. Twenty-nine of the infants experienced a drop in weight-for-age z score from the initial to the final study visit. Growth failure was associated with low socioeconomic status (relative risk = 4.0, 95% confidence interval = 1.3, 12.6), postdischarge days of illness (relative risk = 10.5, 95% confidence interval = 1.4, 77.4) and "suspect" development (chi 2 = 7.12, P = .014).

APPLICATIONS

Infants with BPD may benefit from comprehensive postdischarge nutrition and feeding therapy that includes ensuring adequate energy intake, parental support and education, and feeding evaluation and therapy.

Prolactin-secreting pituitary carcinoma with implants in the cheek pouch and metastases to the ovaries. A case report and literature review

BACKGROUND

Prolactin-secreting pituitary carcinomas are uncommon, locally destructive neoplasms that rarely metastasize outside the central nervous system. The authors report a case of a prolactin-secreting tumor that initially presented as the empty sella syndrome. Two recurrences along transsphenoidal surgery tracts in cheek pouches were followed by distant metastases later in the abdomen and pelvis. Only 10 previous cases of either extracranial or intracranial metastases from prolactin-secreting pituitary carcinomas have been reported. No metastases below the diaphragm have been reported previously.

METHODS

The patient's cheek pouch implants, lymph node metastases, ovarian metastases, and uterine metastases were studied with prolactin-specific immunohistochemistry.

RESULTS

Long term treatment with bromocriptine, several debulking surgeries, extensive local radiation therapy (external beam and proton beam), and cytotoxic chemotherapy had little impact. Tamoxifen, however, may have slowed tumor growth.

CONCLUSION

Tamoxifen may have efficacy in the treatment of prolactin-secreting pituitary carcinomas.

Temporal relationships and IL-2 dependency of prolactin-induced lymphocyte proliferation

Recombinant preparations of human prolactin (hPRL) and interleukin 2 (hIL-2) as well as monoclonal antibodies to these growth factors were used to study the synergistic interaction of PRL and IL-2 in Nb2 rat lymphoma lactogen-dependent cells. It was shown that IL-2 stimulated Nb2 cell proliferation in lactogen-free culture medium. Experiments with short-term exposure to growth factor demonstrated that PRL was required only during the initial 12 h of incubation while IL-2 was mitogenic regardless of the time it was added. Antibody to IL-2 partially inhibited both PRL- and IL-2-induced proliferation whereas antibody to PRL significantly decreased PRL but not IL-2-induced proliferation. These findings suggest that the complete mitogenic effect of PRL on Nb2 cells requires stimulation of IL-2 production.

Defective endogenous proviruses are expressed in feline lymphoid cells: evidence for a role in natural resistance to subgroup B feline leukemia viruses

Endogenous feline leukemia virus (FeLV)-related sequences (enFeLV) are a family of proviral elements found in domestic cats and their close relatives. These elements can recombine with exogenous, infectious FeLVs of subgroup A (FeLV-A), giving rise to host range variants of FeLV-B. We found that a subset of defective enFeLV proviruses is highly expressed in lymphoma cell lines and in a variety of primary tissues, including lymphoid tissues from healthy specific-pathogen-free cats. At least two RNA species were detected, a 4.5-kb RNA containing gag, env, and long terminal repeat sequences and a 2-kb RNA containing env and long terminal repeat sequences. Cloning of enFeLV cDNA from two FeLV-free lymphoma cell lines (3201 and MCC) revealed a long open reading frame (ORF) encoding a truncated env gene product corresponding to the N-terminal portion of gp70env. Interestingly, all of three natural FeLV-B isolates include 3' env sequences which are missing from the highly transcribed subset and hence must be derived from other enFeLV elements. The enFeLV env ORF cDNA clones were closely similar to a previously characterized enFeLV provirus, CFE-16, but were polymorphic at a site corresponding to an exogenous FeLV neutralization epitope. Site-specific antiserum raised to a C-terminal 30-amino-acid peptide of the enFeLV env ORF detected an intracellular product of 35 kDa which was also shed from cells in stable form. Expression of the 35-kDa protein correlated with enFeLV RNA levels and was negatively correlated with susceptibility to infection with FeLV-B. Cell culture supernatant containing the 35-kDa protein specifically blocked infection of permissive fibroblast cells with FeLV-B isolates. We suggest that the truncated env protein mediates resistance by receptor blockade and that this form of enFeLV expression mediates the natural resistance of cats to infection with FeLV-B in the absence of FeLV-A.

Do estrogens improve bone mineral density in osteoporotic women over age 65?

A retrospective analysis of our experience with estrogen and fluoride treatment in 91 patients with postmenopausal osteopenia followed for 6-47 months has been performed. Treatment included calcium (1000 mg/day) and either conjugated estrogens (0.625 mg/day) or sodium fluoride (50 mg/day), or both. All patients had at least two serial dual-photon spinal bone mineral density measurements performed 6 months or more apart. Estrogen treatment was associated with increased bone mineral density (5.3%/year), as was fluoride alone (7.5%/year). Estrogen and fluoride together were additive (9.6%/year). In women over age 65 the estrogen effect was just as great (6.9%/year) as in younger women. Estrogen benefit occurred predominantly in the first 18 months of treatment (7.0%/year), after which time changes in bone mineral density were similar to those in untreated controls, who showed stable bone mineral density. We conclude that aggressive estrogen and fluoride treatment tailored to the severity of the individual's postmenopausal osteopenia results in short-term improvement in spinal bone mineral density. These data further support that elderly women respond to estrogen replacement therapy with absolute and relative increments in bone density similar to those in younger women.

Effect of medical records' checklists on implementation of periodic health measures

Recent re-evaluation of preventive health care has resulted in more limited and directed guidelines; nonetheless, physician compliance has remained poor. This study assessed whether an inexpensive reminder system of preventive care checklists would improve physician implementation of periodic health measures. Residents in internal medicine were randomly placed into two groups: one received a copy of the appropriate checklist with each patient's medical record; the other did not. After one year, 200 randomly selected records were audited to determine the proportion of recommendations implemented for each patient. Residents who received checklists performed appropriate preventive health measures at a significantly higher rate than those who did not (0.56 +/- 0.26 versus 0.39 +/- 0.22, p less than 0.002). The actual use of the checklist to record the results was associated with an even higher rate of compliance compared with instances in which the checklists were provided but not used and instances in which checklists were not received (0.70 +/- 0.21 versus 0.44 +/- 0.24 and 0.39 +/- 0.22, respectively, p less than 0.002). These data suggest that a physician's use of simple checklists can provide an inexpensive and effective means of improving implementation of periodic health maintenance.

Demonstration of heterogeneity in gestational diabetes by a 400-kcal breakfast meal tolerance test

To evaluate the metabolic basis of gestational glucose intolerance (gestational diabetes), the response of normal pregnant women (N=6) and lean (N=23), and obese (N=12) gestational diabetics to the physiologic challenge of a 400-kcal mixed meal breakfast tolerance test was studied. Obese patients with gestational diabetes were more hyperglycemic than the lean gestational diabetics in both the fasting and postprandial periods. Women with gestational diabetes had a more prolonged glycemic response and a later insulin response to meal stimulation than normal control subjects. Fasting and postprandial insulin levels were higher in the obese gestational diabetes group, whereas those of lean subjects fell below the values of the control group. The percent specific binding of insulin to red blood cell receptors was lower in both gestational diabetes groups than in control subjects, with the most marked decrease in the obese group. Mean fasting plasma levels of total cholesterol and triglyceride and plasma glucagon levels during the meal tolerance test were not significantly different among the three groups. Obese gestational diabetics had significantly larger infants and placentas than lean gestational diabetics. These findings, taken together, suggest that the pathophysiology of gestational diabetes differs between obese and lean patients. Lean gestational diabetics appear to develop glucose intolerance on the basis of relative insulin deficiency in contrast to obese gestational diabetics who manifest glucose intolerance characterized by insulin resistance, hyperinsulinemia, and decreased insulin binding to red blood cell receptors.

Coli surface antigens 1 and 3 of colonization factor antigen II-positive enterotoxigenic Escherichia coli: morphology, purification, and immune responses in humans

Enterotoxigenic Escherichia coli (ETEC) of serotype O6:H16, biotype A, bearing colonization factor antigen II (CFA/II) possesses two distinct coli surface antigens, CS1 and CS3, whereas CFA/II-positive ETEC of serotype O8:H9 manifests only CS3. CS1 has been shown to be fimbrial in nature, but heretofore the morphology of CS3 has not been described. Accordingly, by immune electron microscopy we investigated the morphological characteristics of CS3 on bacterial cells and after purification. CS3 was found to consist of thin (2-nm), flexible, wiry, "fibrillar" fimbriae, visible both on bacteria (O6:H16, biotype A, and O8:H9 strains) and in the pure state. In contrast, CS1 exists as wider (6-nm), rigid fimbriae on the surface of O6:H16, biotype A, strains. By the use of antisera to CS1 and CS3 in immune electron microscopy, immunodiffusion in gel, and immunoblotting techniques, CS1 and CS3 were found to be immunologically as well as morphologically distinct. Six of nine volunteers who developed diarrhea after challenge with an O139:H28 ETEC strain bearing CS1 and CS3 had significant serological rises to purified CS1 and CS3 antigens, suggesting that both antigens are elaborated in vivo, play a role in pathogenesis, and stimulate an immune response.

Immunologic, biochemical, and ultrastructural characterization of the leukemia cell in F344 rats

Immunologic, biochemical, and morphologic characteristics of the mononuclear cell from the leukemia of F344 rats were determined. The cells were morphologically similar to large granular lymphocytes (LGL). Surface marker analysis revealed Fc gamma receptors, no Fc gamma receptor or complement receptor activity, and an inability to spontaneously rosette guinea pig erythrocytes. Leukemia cells also had a surface immunoglobulin that hemagglutinated normal rat erythrocytes. The surface immunoglobulin and Fc gamma receptors dissociated from the cell after 2 hours of in vitro incubation, but Fc gamma receptor activity was reexpressed after 6 hours of in vitro incubation. Cells were capable of adherence to glass surfaces but had a low capacity for phagocytosis of latex beads. Cytochemical analysis revealed a consistent, strongly positive reaction for esterase that was sensitive to NaF. The cytochemical profile of the leukemia cell was similar to that described for LGL.

Plasma fatty acid patterns of bone marrow transplant patients primarily supported by fat-free parenteral nutrition

Oral food tolerance is compromised by drug and radiation therapy administered to patients undergoing bone marrow transplantation for hematological malignancy or aplastic anemia. Resultant decreases in oral fat intake coincident with fat-free parenteral nutrition may predispose patients to essential fatty acid (EFA) deficiency. Determinations were made of the fatty acid composition of plasma total lipid from 20 bone marrow transplant patients on admission, at the time of bone marrow transplant, and on days 7, 14, 30, and 60 post-bone marrow transplant. Patients ate ad libitum but with little appetite and received fat-free parenteral nutrition interrupted for numerous blood product and drug infusions. Abnormal EFA status was manifest (20:3 omega 9/20:4 ratio greater than 0.2) in 12 of 20 patients during the course of treatment. Plasma EFA status was consistently correlated with oral fat intake but not with sex, age, percentage of ideal body weight, or amount of plasma infused. This suggests that dietary fat was absorbed limiting the severity of EFA deficiency. Interruptions of glucose infusion averaging only about 2 hours/day, also may have helped moderate the deficiency.

Anthropometric measurement in a protective environment

Although specifically designed for intensive chemotherapy, the LAF room is in use in other related treatment areas, including organ transplantation, burn therapy, and hematologic conditions in which the ability to ward off infections is impaired. With the increased use of protective environments in a variety of clinical conditions, the dietitian must be able to identify and develop proper sterile techniques for anthropometry to provide the health care team with ongoing nutritional assessment for this patient population.