ABSTRACT
Introduction The COVID-19 pandemic led to a sharp decrease in colorectal cancer screening rates as all non-urgent procedures, including average-risk screening colonoscopies, were suspended for infection control and resource conservation. In response to pandemic restrictions, many organizations have turned to alternative strategies such as fecal immunochemical test (FIT) outreach programs. Though prior randomized controlled trials have demonstrated success of mailed programmatic stool test initiatives, there are few studies examining specific strategies for delivering such programs. Methods Baseline pre-intervention FIT completion data was obtained between March 2020 and July 2020 at the Providence VA Medical Center. We then implemented a programmatic mailed FIT initiative at a single community-based outpatient clinic between February 2021 and August 2021 by 1) identifying all patients due for average risk colorectal cancer screening through a VA database, 2) sending primer letters and a brief survey to confirm average risk, 3) mailing FIT kits and 4) sending reminder letters 4 weeks after mailed FIT kits. The primary endpoint was overall FIT completion rate. Secondary endpoints included survey response rate, completed FIT after initial mailing and reminder letter, positive FIT rate, and rate of colonoscopy completion for positive FIT. Results Baseline FIT completion rate prior to the intervention was 29.8% (148/497). A total of 378 patients were identified through the database as being due for average risk colorectal cancer screening and were sent primer letters with surveys. 36.5% (138/378) of patients responded to the survey and 23.3% of those who responded (32/138) were found to be at increased risk and were removed from the FIT mailing list. 36.9% (126/347) of patients completed their FIT within 4 weeks of initial kit mailing. An additional 6.7% (15/221) returned their FIT after a reminder letter. The overall FIT completion rate after our interventions was 40.6% (141/347) which was a statistically significant improvement compared with the pre-intervention group (p=0.0012 using Fisher's exact test). 8.5% (12/141) of patients who completed their FIT had a positive result. Of these patients, 58.3% (7/12) had documented colonoscopy completion within 6 months of positive FIT and 41.6% (5/12) either declined the procedure or were unresponsive to scheduling attempts. Conclusion Programmatic mailed FIT outreach is an effective strategy to enhance colorectal cancer screening. Primer and reminder letters are a simple yet effective steps for improving mailed FIT completion rates. Further studies are needed to validate these methods to optimize averagerisk colorectal cancer screening, particularly in the era of COVID-19 where colonoscopy capability is limited at many centers. (Figure Presented)
ABSTRACT
Introduction: Hemophagocytic Lymphohistiocytosis (HLH) characterized as a cytokine storm secondary to a dysregulated immune state predominantly affects the pediatric population but, reports of adult cases are increasing. The cytokine storm mediated by natural killer cells, macrophages and cytotoxic lymphocytes can be triggered by a genetic variation, infection, malignancy, or rheumatologic disease. This case discusses an unconventional presentation of HLH. Case Description/Methods: A 61 year-old male with a past medical history of coronary artery disease, aortic stenosis, type 2 diabetes mellitus and chronic hepatitis with cirrhosis (of unknown etiology from prior workup) presented with lethargy and fevers. Physical exam was significant for jaundice and tender hepatosplenomegaly. Bloodwork showed: lymphopenia, neutropenia, direct hyperbilirubinemia, and transaminitis. Right upper quadrant ultrasound showed a diffusely echogenic nodular liver with gallbladder dilation in the absence of biliary ductal dilation. Patient was empirically treated for ascending cholangitis with broad spectrum antibiotics and was later found to have E.coli bacteremia. Given patients septic state he underwent percutaneous cholecystostomy tube placement without complication. A complete infectious, hematologic, and hepatologic workup found negative/normal: CMV, EBV, TB, HIV, COVID-19, parvovirus B19, viral hepatitis, DAT, ANA, RF, ANCA, AMA, ASMA, ceruloplasmin, alpha-1 antitrypsin, and C282Y/S/6/5/C. Fibrinogen, ferritin, D-dimer, triglycerides, CXCL-9, and CD-25 were found to be abnormal. Patient's former records were reviewed and showed: cirrhosis with lymphocytic infiltrate on liver biopsy, a normal endoscopy, and an inconclusive bone marrow biopsy only showing clusters of histiocytes. The patient met criteria for HLH and was started on dexamethasone and etoposide. The patients condition continued to worsen and he was transferred to a tertiary care center where he was diagnosed with T-cell histiocyterich diffuse large B-cell lymphoma on repeated biopsy with HLH. Discussion: In patients with high-grade fevers of unknown etiology and multi-organ failure, HLH should be on the differential despite the rarity of adult cases. This case represents an unconventional presentation of HLH in the setting of a confounding bacteremia from ascending cholangitis and underlying B-cell Lymphoma.