Commencing colorectal cancer screening at age 45 years in U.S. racial groups.

Screening for colorectal cancer (CRC) is cost-effective for reducing its mortality among the average-risk population. In the US, CRC incidence and mortality differ among racial/ethnic groups, with non-Hispanic Blacks (NHB) and American Indian/Alaska Natives showing highest incidence and mortality and earlier presentation. Since 2005, some professional societies have recommended CRC screening for NHB to commence at 45 years or earlier; this was not implemented due to lack of recommendation from key groups that influence insurance payment coverage. In 2017 the highly influential U.S. Multi-Society Task Force for Colorectal Cancer recommended screening to commence at 45 years for NHB; this recommendation was supplanted by data showing an increase in early-onset CRCs in non-Hispanic Whites approaching the under-50-year rates observed for NHB. Subsequently the American Cancer Society and the USPSTF recommended that the entire average-risk population move to commence CRC screening at 45 years. Implementing screening in 45-49-year-olds has its challenges as younger groups compared with older groups participate less in preventive care. The US had made extensive progress pre-COVID-19 in closing the disparity gap for CRC screening in NHB above age 50 years; implementing screening at younger ages will take ingenuity, foresight, and creative strategy to reach a broader-aged population while preventing widening the screening disparity gap. Approaches such as navigation for non-invasive and minimally invasive CRC screening tests, removal of financial barriers such as co-pays, and complete follow up to abnormal non-invasive screening tests will need to become the norm for broad implementation and success across all racial/ethnic groups.

Surveillance of RNase P, PMMoV, and CrAssphage in wastewater as indicators of human fecal concentration across urban sewer neighborhoods, Kentucky.

Wastewater surveillance has been widely used as a supplemental method to track the community infection levels of severe acute respiratory syndrome coronavirus 2. A gap exists in standardized reporting for fecal indicator concentrations, which can be used to calibrate the primary outcome concentrations from wastewater monitoring for use in epidemiological models. To address this, measurements of fecal indicator concentration among wastewater samples collected from sewers and treatment centers in four counties of Kentucky (N = 650) were examined. Results from the untransformed wastewater data over 4 months of sampling indicated that the fecal indicator concentration of human ribonuclease P (RNase P) ranged from 5.1 × 101 to 1.15 × 106 copies/ml, pepper mild mottle virus (PMMoV) ranged from 7.23 × 103 to 3.53 × 107 copies/ml, and cross-assembly phage (CrAssphage) ranged from 9.69 × 103 to 1.85 × 108 copies/ml. The results showed both regional and temporal variability. If fecal indicators are used as normalization factors, knowing the daily sewer system flow of the sample location may matter more than rainfall. RNase P, while it may be suitable as an internal amplification and sample adequacy control, has less utility than PMMoV and CrAssphage as a fecal indicator in wastewater samples when working at different sizes of catchment area. The choice of fecal indicator will impact the results of surveillance studies using this indicator to represent fecal load. Our results contribute broadly to an applicable standard normalization factor and assist in interpreting wastewater data in epidemiological modeling and monitoring.

Clostridium Difficillae Infection in Post-Covid Patients

Intro: The ongoing pandemic caused by the SARS-CoV-2 virus has brought many new insights into medicine. During the first months of the pandemic, when there were no comprehensive guidelines for precise antimicrobial therapy, empirical overuse of broad-spectrum antibiotics was observed. Which resulted in the development of clostidium infection in certain cases. In our report, we address 83 cases of clostridial colitis in post-covid patients from 3/2020 to 3/2021 and their specific therapy. Method(s): Retrospective analysis of risk factors for clostridial infection and therapy of clostridial colitis. Finding(s): In the period 3/2020-3/2021, 9617 patients were diagnosed with SARS-CoV-2 virus infection in our hospital, of which 1247 were hospitalized. In 83 cases, clostridial colitis occurred during or after the covid infection had resolved. Mortality in this group was 17%, which corresponds to 14 patients. Previous empirical administered antiobiotics in COVID-19 infection contributed to the development of clostridial colitis in case of 22 patients (27%) by clarithromycin, in 14 pacients (17%) by penicillins and by 3rd generation cephalosporins in 9 patients (11%). The average duration of therapy with broad-spectrum antibiotics was 15.63 days (+-8.99). Other risk factors we observed are: PPI use (25%), active malignant disease (10%), previous glucocorticoid therapy (22%). Vancomycin was used in clostridial infection therapy in 47% (39), metronidazole in 31% (25) and fidaxonicin in 7% (6). In the group, we observed recurrence of clostridium difficile infection in 14% of patients and FMT was performed in 6 patients. Conclusion(s): This study shows a higher percentage of clostridial infection in cases of long-term therapy with broad-spectrum antibiotics. It also points to the effect of specific antimicrobial therapy for infection caused by the bacterium Clostridium difficile and the possibility of using fecal bacteriotherapy.Copyright © 2023

Emerging applications of phage therapy and fecal virome transplantation for treatment of Clostridioides difficile infection: challenges and perspectives.

Clostridioides difficile, which causes life-threatening diarrheal disease, is considered an urgent threat to healthcare setting worldwide. The current standards of care solely rely on conventional antibiotic treatment, however, there is a risk of promoting recurrent C. difficile infection (rCDI) because of the emergence of antibiotic-resistant strains. Globally, the alarming spread of antibiotic-resistant strains of C. difficile has resulted in a quest for alternative therapeutics. The use of fecal microbiota transplantation (FMT), which involves direct infusion of fecal suspension from a healthy donor into a diseased recipient, has been approved as a highly efficient therapeutic option for patients with rCDI. Bacteriophages or phages are a group of viruses that can infect and destroy bacterial hosts, and are recognized as the dominant viral component of the human gut microbiome. Accumulating data has demonstrated that phages play a vital role in microbial balance of the human gut microbiome. Recently, phage therapy and fecal virome transplantation (FVT) have been introduced as promising alternatives for the treatment of C. difficile -related infections, in particular drug-resistant CDI. Herein, we review the latest updates on C. difficile- specific phages, and phage-mediated treatments, and highlight the current and future prospects of phage therapy in the management of CDI.

The Distribution of Fecal Contamination in an Urbanized Tropical Lake and Incidence of Acute Diarrheal Disease

Aquatic ecosystems of tropical countries are vulnerable to fecal contamination that could cause spikes in the incidences of acute diarrheal disease (ADD) and challenge public health management systems. Vembanad lake, situated along the southwest coast of India, was monitored for one year (2018-2019). Escherichia coli, an indicator of fecal contamination, was prevalent in the lake throughout the year. Multiple antibiotic resistance among more than 50% of the E. coli isolates adds urgency to the need to control this contamination. The high abundance of E. coli and incidence of ADD were recorded during the early phase of the southwest monsoon (June-July), prior to the once-in-a-century floods that affected the region in the later phase (August). The extent of inundation in the low-lying areas peaked in August, but E. coli in the water peaked in July, suggesting that contamination occurred even prior to extreme flooding. During the COVID-19-related lockdown in March-May 2021, fecal contamination in the lake and incidence of ADD reached minimum values. These results indicate the need for improving sewage treatment facilities and city planning in flood-prone areas to avoid the mixing of septic sewage with natural waters during extreme climate events or even during the normal monsoon.

Quantities and qualities of fecal sludge: Experiences from field implementation with a Volaser in 7 countries during a pandemic

Reasonable estimates for quantities and qualities (Q&Q) of fecal sludge that accumulate in onsite sanitation containments are fundamental for the design of appropriate management and treatment solutions, from community to city-scale. There are increasing attempts to improve Q&Q estimates, but current approaches are still at a conceptual level, and are not yet standardized with confirmed statistical relationships. To reach this level, we will need consistent approaches for planning, measuring, and global collaborations. Hence, the objectives of this study were: (1) to assess and compare Q&Q of fecal sludge from seven cities and communities, and explore statistical relationships that could be used to increase accuracy of Q&Q estimations;(2) to test and launch the Volaser device for measuring in situ volumes of fecal sludge;and (3) to capture lessons learned from field implementation with collaborators in seven countries during a global pandemic when no international travel was possible. The study took place in Ghana, India, Lebanon, Kenya, Sierra Leone, Uganda, and Zambia during the COVID-19 pandemic. Q&Qs were measured in 204 containments with a Volaser, laboratory analysis, and questionnaire. Results indicate that there are differences in Total Solids (TS) and Chemical Oxygen Demand (COD) in fecal sludge based on containment type, toilet type, source, and whether there is a water connection on the premises. Based on the results of this study, together with previously published open-source data, an empirical relationship for Volatile Solids (VS) and TS of 0.49 (R2 = 0.88) was established using 1,206 data points. For COD/TS, no significant relationship was observed. Developing such empirical relationships will be useful for planning and modeling approaches. An external evaluation was conducted to evaluate overall project management, Volaser technology transfer, and effects of collaborating during the COVID-19 pandemic. Success factors for collaborating with new and existing partners without face-to-face meetings included laboratory capacity and experience with analytical methods, study objectives that were relevant for the partner and locality, and a strong quality assurance plan to ensure comparability of results. The lessons learned can be taken forward as ways to reduce carbon footprint, and contribute to resilient, inclusive development research projects. Copyright © 2023 Andriessen, Appiah-Effah, Browne, al Jahjah, Kabika, Kinobe, Korir, Nishimwe, Niwagaba, Pradeep, Prasad, Tembo, William, Ambuehl and Strande.

Idiopathic anomalous congenital band causing small intestinal obstruction in a 5-month-old dog

A 5-month-old, intact male, yellow Labrador retriever was presented with a 24-hour history of anorexia and vomiting. Abdominal imaging revealed the presence of a mechanical obstruction in the jejunum and peritoneal effusion. Cytologic evaluation and culture of the effusion prior to surgery identified a suppurative exudate with bacteria consistent with septic peritonitis and suspected to be related to the intestinal lesion. An exploratory laparotomy was performed, and a segment of jejunum was circumferentially severely constricted by an off-white, fibrous band of tissue. Resection and anastomosis of the strangulated segment of jejunum and excision of the constricting band provided resolution of the clinical signs. The dog made a complete recovery. Histologic evaluation revealed the band to be composed of fibrovascular and smooth muscle tissue, consistent with an idiopathic anomalous congenital band. No other gastrointestinal lesions were observed, either grossly at surgery or histologically in the resected segment of intestine. To our knowledge, a similar structure has not been reported in the veterinary literature.Copyright © 2022 Canadian Veterinary Medical Association. All rights reserved.

The Role of Microbiota in Gut Inflammation and Sepsis

In healthy individuals, the microbiome and human gut are in homeostasis. Upon dysbiosis, disease and injury, homeostasis is disrupted, which can lead to inflammation and sepsis. In this review, we will focus on how the microbiome interacts with the gut epithelium, underlying vasculature and immune system to maintain homeostasis and how disruption leads to inflammatory bowel disease (IBD), type II diabetes (T2D), novel coronavirus disease-19 (COVID-19) and sepsis. We will discuss antibiotics and the potential for fecal microbiota transplantation (FMT) in sepsis treatment. Finally, we will examine the role of diet and review current experimental models for studying host-microbiome interactions. © 2022 Elsevier Inc. All rights reserved.

Fecal Microbiota Transplantation in Inflammatory Bowel Disease.

Inflammatory bowel diseases represent a complex array of diseases of incompletely known etiology that led to gastrointestinal tract chronic inflammation. In inflammatory bowel disease, a promising method of treatment is represented by fecal microbiota transplantation (FMT), FMT has shown its increasing effectiveness and safety in recent years for recurrent CDI; moreover, it showed real clinical benefits in treating SARS-CoV-2 and CDI co-infection. Crohn's disease and ulcerative colitis are characterized by immune dysregulation, resulting in digestive tract damage caused by immune responses. Most current therapeutic strategies are associated with high costs and many adverse effects by directly targeting the immune response, so modifying the microbial environment by FMT offers an alternative approach that could indirectly influence the host's immune system in a safe way. Studies outline the endoscopic and clinical improvements in UC and CD in FMT patients versus control groups. This review outlines the multiple benefits of FMT in the case of IBD by improving patients unbalanced gut, therefore improving endoscopic and clinical symptomatology. We aim to emphasize the clinical importance and benefits of FMT in order to prevent flares or complications of IBD and to highlight that further validation is needed for establishing a clinical protocol for FMT in IBD.

Gut microbiota in COVID-19: new insights from inside.

The epidemic of coronavirus disease-19 (COVID-19) has grown to be a global health threat. Gastrointestinal symptoms are thought to be common clinical manifestations apart from a series of originally found respiratory symptoms. The human gut harbors trillions of microorganisms that are indispensable for complex physiological processes and homeostasis. Growing evidence demonstrate that gut microbiota alteration is associated with COVID-19 progress and severity, and post-COVID-19 syndrome, characterized by decrease of anti-inflammatory bacteria like Bifidobacterium and Faecalibacterium and enrichment of inflammation-associated microbiota including Streptococcus and Actinomyces. Therapeutic strategies such as diet, probiotics/prebiotics, herb, and fecal microbiota transplantation have shown positive effects on relieving clinical symptoms. In this article, we provide and summarize the recent evidence about the gut microbiota and their metabolites alterations during and after COVID-19 infection and focus on potential therapeutic strategies targeting gut microbiota. Understanding the connections between intestinal microbiota and COVID-19 would provide new insights into COVID-19 management in the future.

Gut Microbiota Modulation for Therapeutic Management of Various Diseases: A New Perspective Using Stem Cell Therapy.

Dysbiosis has been linked to various diseases ranging from cardiovascular, neurologic, gastrointestinal, respiratory, and metabolic illnesses to cancer. Restoring of gut microbiota balance represents an outstanding clinical target for the management of various multidrug-resistant diseases. Preservation of gut microbial diversity and composition could also improve stem cell therapy which has now diverse clinical applications in the field of regenerative medicine. Gut microbiota modulation and stem cell therapy may be considered a highly promising field that could add up towards improvement of different diseases, increasing the outcome and efficacy of each other, through mutual interplay or interaction between both therapies. Importantly, more investigations are required to reveal the cross-talk between microbiota modulation and stem cell therapy to pave the way for the development of new therapies with enhanced therapeutic outcome. This review provides an overview of dysbiosis in various diseases and their management. It also discusses microbiota modulation via antibiotic, probiotics, prebiotics and fecal microbiota transplant, to introduce the concept of dysbiosis correction for the management of various diseases. Furthermore, we demonstrate the beneficial interactions between microbiota modulation and stem cell therapy as a way for the development of new therapies in addition to limitations and future challenges regarding the applications of these therapies.

Molecular identification and characterization of SARS-Co V-2 from the clinical stool and sewage samples to study waste water-based epidemiology and monitoring circulating virus

The Coronaviridae family's severe acute respiratory syndrome corona virus 2 (SARS-Co V-2) outbreak has infected a large number of the population during the COVID- 19 pandemic. The most prominent mode of virus transmission is considered through respiratory droplets of the infected person. Virus-mediated respiratory infection depends upon the binding between spike protein and the Angiotensinconverting enzyme 2 (ACE2) receptor expressed in lung alveolar type 2 cells. But some studies reported that gastrointestinal infection is also one of the prominent symptoms of COVID-19 because of the high expression of the ACE2 receptor in absorptive enterocytes of the small intestine. In a country like India, with high population density and due to unhygienic sanitation, it is crucial to understand the potential fecal-oral transmission route of SARS-CoV-2 during infection because of presence of ACE2 in small intestine. Therefore in our study, we aim to trace the potential fecal-oral transmission route of SARS-Co V-2 by examining human stool (collected from hospital settings) and nearby sewage water systems, followed by molecular characterization and viral load kinetics evaluation of SARSCOV- 2. qRT-PCR and NGS sequencing methods were used. The presence of SARS-COV-2 was reported in around 70% of samples (both clinical and environmental), this will help us to establish the epidemiological link between clinical and environmental samples after genomic analysis to alter the circulation of silent SARS Co V2 in the community.

Identification of feline corona- virus in breeding catteries by molecular biological methods and shedding persistency

Infectious peritonitis virus (FIPV) causes a fatal disease in cats. This virus occurs both in cats bred in households with optimal welfare and outdoor cats. Feline patients with the effusive form of disease usually survive a few days to weeks from the appearance of the first clinical signs. Cats with the non- effusive form survive for weeks to months. FIPV is caused by a mutation from feline enteric coronavirus (FECV). In our study, we diagnosed feline coronavirus from the feces of 82% of the tested cats. The persistence of the feline coronavirus in the organism is influenced by environmental factors, the genome of the host and the causative agent. Negative environmental conditions that increase the likelihood of FIPV disease are long-term stress, mainly more labile individuals and a high concentration of domesticated cats in one place. In the host, there are important factors such as immune system performance, age, breed and genetic background. In our study, we primarily verified the real time RT-PCR method for identifying the virus from the feces of 71 cats and subsequently gaine the valuable data on the dynamics of feline coronavirus excretion, primarily for epizootological purposes and for the purposes of genetic analyzes of susceptibility to infection.

Methodology, efficacy and safety of fecal microbiota transplantation in treating inflammatory bowel disease

Fecal microbiota transplantation (FMT), as an emerging therapy, can be used to treat microbiota related diseases. Progresses in donor screening, washed microbiota preparation, microbiota delivery routes, clinical administrative strategies, and long-term safety are moving FMT forward. Increasing clinical studies, especially those randomized controlled trials about ulcerative colitis and pilot real-word studies about serious inflammatory bowel disease (IBD), have been conducted. This review presents the latest findings about the efficacy, safety and methodology of FMT in treating IBD.Copyright © 2020 The Authors

Evaluation of intra- and inter-lab variability in quantifying SARS-CoV-2 in a state-wide wastewater monitoring network

In December 2019, SARS-CoV-2, the virus that causes coronavirus disease 2019, was first reported and subsequently triggered a global pandemic. Wastewater monitoring, a strategy for quantifying viral gene concentrations from wastewater influents within a community, has served as an early warning and management tool for the spread of SARS-CoV-2 in a community. Ohio built a collaborative statewide wastewater monitoring network that is supported by eight labs (university, government, and commercial laboratories) with unique sample processing workflows. Consequently, we sought to characterize the variability in wastewater monitoring results for network labs. Across seven trials between October 2020 and November 2021, eight participating labs successfully quantified two SARS-CoV-2 RNA targets and human fecal indicator virus targets in wastewater sample aliquots with reproducible results, although recovery efficiencies of spiked surrogates ranged from 3 to 75%. When SARS-CoV-2 gene fragment concentrations were adjusted for recovery efficiency and flow, the proportion of variance between laboratories was minimized, serving as the best model to account for between-lab variance. Another adjustment factor (alone and in different combinations with the above factors) considered to account for sample and measurement variability includes fecal marker normalization. Genetic quantification variability can be attributed to many factors, including the methods, individual samples, and water quality parameters. In addition, statistically significant correlations were observed between SARS-CoV-2 RNA and COVID-19 case numbers, supporting the notion that wastewater surveillance continues to serve as an effective monitoring tool. This study serves as a real-time example of multi-laboratory collaboration for public health preparedness for infectious diseases. © 2023 The Royal Society of Chemistry

Effectiveness of rapid immunochromatographic tests to the detection of feline Coronavirus

Feline coronavirus (FCoV) belongs among pathogens with common occurrence in the cats population in the whole world. FCoV is ubiquitous in environments with a higher concentration of cats, e.g. in shelters, multicat households and kennels. FCoV primarily attacks the digestive feline tract, replicates in its cells and is excreted in the feces to surroundings of permanently or transiently infected cats. The aim of the study was the detection of FCoV in the feces of newly admitted cats to the shelter by the qPCR method and by means of commercial rapid immunochromatographic (antigen) tests from three different producers. For each of the antigen tests, sensitivity and specifity were determined by comparison with the qPCR analysis result. Out of 70 examined fecal samples, viral RNA was by the qPCR analysis identified in 44 samples (62.9%). Neither the age nor the gender of cats played a significant role in the viral excretion. Found sensitivity of the antigen tests was at a low (< 35%;tests A and C) to a satisfactory level (> 50%, test B). The number of viral particles in the samples determined by the qPCR method did not correlate significantly with the result of the antigen tests. The results of this study suggest that the use of rapid antigen tests for routine screening of FCoV shedding in feline shelters is limited due to the high rate of false-negative results.

Seroepidemiological and clinicopathological investigation of Canine Coronavirus infection in dogs, in t..rkiye

Domestic and wild dogs of all ages and breeds are susceptible to Canine Coronavirus(CCoV) infections and be seen in T..rkiyeand amongst world. CCoV has recently been declared a zoonotic disease agent and the eighth pathogenic human coronavirus. This study was conducted on 143 naturally infected dogs with gastroenteritis which were not vaccinated against CCoV in T..rkiye in 2015-2020. The data of dogs were analyzed seroepidemiologically, clinicopathologically and statistically. CCOV antibodies in serum and CCOV antigens in stool were detected by ELISA and lateral immunochromatography. The rising CCoV IgG antibody titers were detected at all dogs and were as follows;<10 ng/L in 3 (2%), 10-20 ng/L in 18 (13%), 20-30 ng/L in 16 (11%), 30-40 ng/L in 14 (%10), 40-64 ng/L in 11 (8%) and >64 ng/L in 81 (81%) dogs. CCOV and Canine Parvovirus (CPV) antigen were detected together in the stool of the 41 (28.7%) dogs. As a result, it was concluded that the CCOV agent is in circulation among dogs living in T..rkiye. CCOV and CPV can cause co-infections and increased mortality. Although infection can be seen in dogs of all ages, it can be seen more frequently in dogs younger than 1 year of age, and especially in dogs younger than 6 months, and can cause enteritis, low hemoglobin, erythropenia, lymphopenia, leukopenia, thrombocytopenia, and hypoproteinemia.

Ulcerative Colitis: Rapid Evidence Review

Ulcerative colitis is a relapsing and remitting inflammatory bowel disease of the large intestine. Risk factors include recent Salmonella or Campylobacter infection and a family history of ulcerative colitis. Diagnosis is suspected based on symptoms of urgency, tenesmus, and hematochezia and is confirmed with endoscopic findings of continuous inflammation from the rectum to more proximal colon, depending on the extent of disease. Fecal calprotectin may be used to assess disease activity and relapse. Medications available to treat the inflammation include 5-aminosalicylic acid, corticosteroids, tumor necrosis factor-alpha antibodies, anti-integrin antibodies, anti-interleukin-12 and -23 antibodies, and Janus kinase inhibitors. Choice of medication and method of delivery depend on the location and severity of mucosal inflammation. Other treatments such as fecal microbiota transplantation are considered experimental, and complementary therapies such as probiotics and curcumin have mixed data. Surgical treatment may be needed for fulminant or refractory disease. Increased risk of colorectal cancer and use of immunosuppressive therapies affect the preventive care needs for these patients. (Am Fam Physician. 2022;105(4):406-411. Copyright © 2022 American Academy of Family Physicians.)Copyright © 2022 American Academy of Family Physicians. All rights reserved.

Underused Physical Therapy Services in Primary Care Settings: An Overview

The combined effects of longer life, noncommunicable diseases, and injuries increase the need for rehabilitation services. Although physical therapists' unique skill set on movement-related dysfunction allows for broad contributions to health care, physical therapy (PT) remains underutilized. This article situates the problem within the broader primary care context, focusing on PT's ability to mitigate disability and dysfunction in complex syndromes including pelvic floor incontinence, vertigo, cancer, chronic neuromusculoskeletal pain, and long coronavirus disease (ie, lingering effects after acute coronavirus disease infection passes). The path from PT research to clinical implementation remains dependent on factors beyond research evidence. This overview underscores the need to address this evidence to practice gap.

Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement.

Colorectal cancer (CRC) screening reduces morbidity and mortality, but screening rates in the USA remain suboptimal. The Colorectal Cancer Control Program (CRCCP) was established in 2009 to increase screening among groups disproportionately affected. The CRCCP utilizes implementation science to support health system change as a strategy to reduce disparities in CRC screening by directing resources to primary care clinics to implement evidence-based interventions (EBIs) proven to increase CRC screening. As COVID-19 continues to impede in-person healthcare visits and compel the unpredictable redirection of clinic priorities, understanding clinics' adoption and implementation of EBIs into routine care is crucial. Mailed fecal testing is an evidence-based screening approach that offers an alternative to in-person screening tests and represents a promising approach to reduce CRC screening disparities. However, little is known about how mailed fecal testing is implemented in real-world settings. In this retrospective, cross-sectional analysis, we assessed practices around mailed fecal testing implementation in 185 clinics across 62 US health systems. We sought to (1) determine whether clinics that do and do not implement mailed fecal testing differ with respect to characteristics (e.g., type, location, and proportion of uninsured patients) and (2) identify implementation practices among clinics that offer mailed fecal testing. Our findings revealed that over half (58%) of clinics implemented mailed fecal testing. These clinics were more likely to have a CRC screening policy than clinics that did not implement mailed fecal testing (p = 0.007) and to serve a larger patient population (p = 0.004), but less likely to have a large proportion of uninsured patients (p = 0.01). Clinics that implemented mailed fecal testing offered it in combination with EBIs, including patient reminders (92%), provider reminders (94%), and other activities to reduce structural barriers (95%). However, fewer clinics reported having the leadership support (58%) or funding stability (29%) to sustain mailed fecal testing. Mailed fecal testing was widely implemented alongside other EBIs in primary care clinics participating in the CRCCP, but multiple opportunities for enhancing its implementation exist. These include increasing the proportion of community health centers/federally qualified health centers offering mailed screening; increasing the proportion that provide pre-paid return mail supplies with the screening kit; increasing the proportion of clinics monitoring both screening kit distribution and return; ensuring patients with abnormal tests can obtain colonoscopy; and increasing sustainability planning and support.