Flexible sigmoidoscopy screening associated with long-term reduction in colorectal cancer incidence and mortality

1. Flexible sigmoidoscopy screening associated with long-term reduction in colorectal cancer incidence and mortality

Italian study suggests a screening benefit that lasts far beyond the currently recommended screening intervals

Abstract: https://www.acpjournals.org/doi/10.7326/M21-0977  

Editorial: https://www.acpjournals.org/doi/10.7326/M21-3770

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A parallel randomized controlled trial confirmed that a single flexible sigmoidoscopy screening at age 55 to 64 years represents a safe and effective strategy associated with a substantial reduction in colorectal cancer (CRC) incidence and mortality. The strong protective effect was maintained up to 15 years and 19 years, respectively. The findings are published in Annals of Internal Medicine.

Large, randomized trials of flexible sigmoidoscopy screening had shown a substantial reduction in CRC incidence (range, 18% to 26%) and mortality (range, 22% to 31%) after a median follow-up of 10 to 12 years in the intention-to-treat analysis. The recent reports of the extended incidence and mortality follow-up from three of those trials showed that the screening effect was maintained up to 15 to 17 years. Additional data about the duration of the protection conferred by a single sigmoidoscopy screening and about differences of screening effect by sex and age could offer useful insight to support evidence-based recommendations about screening intervals as well as about alternative strategies aimed to achieve a larger protective effect.

Researchers from University Hospital Città della Salute e della Scienza, Turin, Italy, randomly assigned 34,272 persons aged 55 to 64 at 6 centers in Italy to receive either a once-only flexible sigmoidoscopy screening or usual care (control group). Compared to the control group, colorectal cancer incidence was 19% lower at 15 years and CRC mortality was 22% lower 19 at years, respectively, after a single screening sigmoidoscopy. Consistent with previous estimates on the basis of the 11-year follow-up, more than 80% of averted deaths are attributable to the prevention of incident CRC via adenoma removal at screening. These findings confirm the strong preventive effect of flexible sigmoidoscopy screening.

Media contacts For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the lead author, Carlo Senore, MD, MSc, please email carlo.senore@cpo.it.

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2. Review finds many infection control policies based on outdated understanding of respiratory virus transmission

Abstract: https://www.acpjournals.org/doi/10.7326/M21-2780              

Editorial: https://www.acpjournals.org/doi/10.7326/M21-4026

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A review of COVID-19 transmission prevention studies found that many health care facility infection control policies are based on outdated models of how respiratory viruses are transmitted. Based on current best understanding of transmission, infection prevention methods should be revised. A narrative review including potential policy revisions is published in Annals of Internal Medicine.

Traditional teaching suggests that most respiratory viruses are spread through droplets. These are larger particles that are heavy enough that they will rapidly fall to the ground within one to two meters of an infected person. Public health agencies have traditionally advised healthcare workers to wear surgical masks to protect themselves from droplet organisms.  The one exception has been for patients undergoing so-called, “aerosol-generating procedures” in which case higher levels of respiratory protection, such as N95 respirators, are recommended.   

Researchers from Harvard Medical School, Harvard Pilgrim Healthcare Institute, and the University of Maryland reviewed published studies looking at SARS-CoV-2 transmission and infection control policies. They found that the traditional model of how respiratory viruses are spread may be incorrect. Most studies now suggest that respiratory viruses are primarily transmitted by aerosols.  These are smaller respiratory particles that can remain suspended in the air for long periods of time, can travel beyond 2 meters from the source patient and, most importantly, can bypass surgical masks.  People routinely generate aerosols whenever they exhale, particularly when speaking loudly, breathing heavily, or coughing.  Most so-called “aerosol generating procedures” by contrast do not meaningfully increase aerosol generation relative to talking and heavy breathing.

These insights suggest that researchers and public health specialists should reexamine recommended transmission prevention methods. The authors suggest a uniform set of respiratory precautions for all respiratory pathogens and high-risk interactions rather than differentiating between different kinds of viruses and procedures.   The authors recommend the creation of graded, risk-based approaches to prevent transmission in healthcare facilities that take into consideration the amount of disease in the community, patient factors, and care factors that better predict transmission risk. 

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author, Michael Klompas, MD, please contact Haley Bridger at hbridger@bwh.harvard.edu.

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3. App-based protocol fast and accurate for identifying delirium in the hospital setting

Abstract: https://www.acpjournals.org/doi/10.7326/M21-1687              

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A prospective cohort study found that the use of an app-based delirium identification protocol was easy, fast, and accurate for physicians, nurses, and certified nursing assistants (CNAs) to implement as part of routine daily workflow in the hospital setting. Use of the app compensated for both lack of knowledge and lack of time by providing standardized questions to complete the Confusion Assessment Method (CAM) diagnostic algorithm briefly and with high accuracy. The findings are published in Annals of Internal Medicine.

Delirium impacts up to 30 percent of older patients and up to 15 percent of hospitalized patients of any age and is associated with longer hospital stays, higher rates of mortality, poor functional recovery, cognitive decline, and incident dementia. Delirium is not often identified during routine hospital care , which has prompted many hospitals to implement delirium screening systems, few of which have been studied. Delirium screening can be considered a “brain vital sign,” similar to the heart and lung vital signs obtained frequently during acute hospitalization.

Researchers from Beth Israel Deaconess Medical Center and the Pennsylvania State University built on previous work deriving and validating the 3-Minute Diagnostic Assessment for Confusion Assessment Method (3D-CAM) and the ultra-brief 2-item screen (UB-2), which consists of the 2 most sensitive items in the 3D-CAM. In the READI (Researching Efficient Approaches to Delirium Identification) study, the researchers combined the UB-2 and 3D-CAM into a two-step adaptive delirium identification protocol facilitated by an iPad app and asked 399 physicians, nurses, and CNAs at a large teaching hospital and a small community hospital to rule out or identify delirium in 527 hospitalized patients over a 2-day period. These patients had an average age of 80 and more than one third had dementia, both of which make diagnosing delirium more challenging. The researchers found that clinicians completed more than 97% of protocols, with an average completion time of under 2 minutes. Relative to the research reference standard delirium assessment, sensitivity of the UB-2 ranged from 82% to 88%, with CNAs and nurses performing similarly to physicians. Sensitivity of the 2-step protocols was 63% to 65%, with specificity exceeding 90% and percentages for overall accuracy in the high 80s for both nurses and physicians. According to the researchers, these findings show that their app-directed protocol can be completed briefly and with high accuracy by all three hospital disciplines and could facilitate identification of delirium among high-risk older hospitalized adults.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Edward Marcantonio, MD, SM, please email emarcant@bidmc.harvard.edu.

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4. Structural factors, including the digital divide, may inhibit access to health care, especially for older adults

Abstract: https://www.acpjournals.org/doi/10.7326/M21-2972             

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A brief research report found that sociodemographic factors, including location, marital status, and level of education, significantly impacted how often older adults used telemedicine services at the beginning of the COVID-19 pandemic. The findings demonstrate how structural concerns, such as the digital divide, may impact older Americans’ access to medical care. The study is published in the Annals of Internal Medicine.

Prior to the onset of the COVID-19 pandemic, few older adults used telemedicine services as part of their regular course of care. Despite the possible benefits of telemedicine care for older adults, who are at a higher risk for serious illness and have more trouble attending in-person appointments, little is known about the characteristics of older adults who used video visits during the pandemic.

Researchers from the Icahn School of Medicine at Mount Sinai studied survey data from National Health and Aging Trends Study, an annual survey of Medicare recipients, to characterize “telemedicine use,” defined as communicating with one’s usual health care provider using video visits during the COVID-19 pandemic. The study authors found that, despite the use of video visits for older adults increasing 5-fold during the pandemic, twice as many older adults attended in-person clinician visits at the beginning the pandemic despite high risk for serious illness if infected with COVID-19. The authors also noted a trend of less telemedicine use among respondents who had less education, no spouse or partner, and lived in nonmetropolitan areas.

The authors suggest that successfully promoting telemedicine usage by older adults will require addressing the digital divide, improving the usability of telemedicine platforms, and providing community-based technical support.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author, Julia Frydman, MD, please contact Katherine Brown at katherine.brown@mssm.edu.  

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