Effects of Academic Detailing, Panel Management and Mailed Multi-Target Stool-DNA Testing on Colorectal Cancer Screening.

INTRODUCTION: Academic detailing, patient-panel management, and mailed, stool-based testing have each been utilized to increase colorectal cancer (CRC) screening in rural clinics. The effectiveness of combining these interventions to increase CRC screening during COVID-19 restrictions was unclear. METHODS: We explored the effects of a multi-component intervention including academic detailing, active patient panel management, and mailed MT-sDNA testing on colorectal cancer screening in our rural family medicine clinic. Baseline interventions included EMR-based provider alerts and mailed patient reminders. Our intervention (March-May 2020) and follow-up periods (June-August 2020) coincided with the initial COVID-19 surge, giving us the opportunity to observe the effects of our intervention during COVID-19 restrictions. RESULTS: A total of 407 patients were eligible and overdue for colorectal cancer screening. Our clinic's CRC screening rate increased significantly after intervention (69.7%) as compared with before (64.3%) (P = <0.01; 95%CI = 5.39-5.4). Our clinic's CRC screening rates increased significantly during the initial 3 months of the COVID-19 surge (67.8%) compared with the same period the prior year. (62.3%) (P = .003; 95%CI = 3.4-7.6). Our CRC screening rates increased after intervention (69.7%) compared with our regional health system (67%) (P = <0.01; 95%CI = 2.6-2.77). Our weekly stool-based CRC screening increased (94% increase) compared with other health systems nationally (61 to 83% decrease). DISCUSSION: A multi-component intervention, including academic detailing, panel management, and mailed MT-sDNA testing, can lead to significant increases in CRC screening in a rural family medicine clinic, empowering providers to maintain an effective CRC screening outreach during COVID-19 related restrictions.

Etiology and utility of hospital-onset bacteremia as a safety metric for targeted harm reduction.

BACKGROUND: Hospital acquired infections (HAIs) are a major driver of morbidity and cost in health systems. Central line-associated bloodstream infections (CLABSIs) require intensive surveillance and review. All-cause hospital-onset bacteremia (HOB) may be a simpler reporting metric, correlates with CLABSI, and is viewed positively by HAI experts. Despite the ease in the collection, the proportion of HOBs that are actionable and preventable is unknown. Moreover, quality improvement strategies targeting it may be more challenging. In this study, we describe the bedside provider-perceived sources of HOB in order to provide insight into this new metric as a target for HAI prevention. METHODS: All cases of HOBs in 2019 from an academic tertiary care hospital were retrospectively reviewed. Information was collected to assess provider-perceived etiology and associated clinical factors (microbiology, severity, mortality, and management). HOB was categorized as preventable or not preventable based on the perceived source from the care team and management decisions. Preventable causes included device-associated bacteremias, pneumonias, surgical complications, and contaminated blood cultures. RESULTS: Of the 392 instances of HOB, 56.0% (n = 220) had episodes that were determined not preventable by providers. Excluding blood culture contaminates, the most common cause of preventable HOB was secondary to CLABSIs (9.9%, n = 39). Of the HOBs that were not preventable, the most common sources were gastrointestinal and abdominal (n = 62), neutropenic translocation (n = 37), and endocarditis (n = 23). Patients with HOB were generally medically complex with an average Charlson comorbidity index of 4.97. This translated into a higher average length of stay (29.23 vs 7.56, P < .001) and higher inpatient mortality (odds ratio 8.3, confidence interval [6.32-10.77]) when compared to admissions without HOB. CONCLUSIONS: The majority of HOBs were not preventable and the HOB metric may be a marker of a sicker patient population making it a less actionable target for quality improvement. Standardization across the patient mix is important if the metric becomes linked to reimbursement. If the HOB metric were to be used in lieu of CLABSI, large tertiary care health systems that house sicker patients may be unfairly financially penalized for caring for more medically complex patients.

Cryptococcal Meningitis in Young, Immunocompetent Patients: A Single-Center Retrospective Case Series and Review of the Literature.

Background: Cryptococcal meningitis is an uncommon but serious infection with high mortality and morbidity. Classically described in immunocompromised patients, including those with solid organ transplants or HIV/AIDS, cryptococcosis has also been reported in young and otherwise healthy patients, albeit rarely. Methods: We retrospectively searched for all cases of cryptococcal meningitis in young (≤50 years) and previously healthy patients with no known immunocompromising conditions from January 2015 to January 2022 at Indiana University Health (IU Health). Additionally, a PubMed literature review was performed with the keywords "cryptococcal meningitis" and "immunocompetent" from January 1988 to January 2022. Clinical courses, including outcomes and treatment regimens, were evaluated. Results: We identified 4 local cases of cryptococcal meningitis in otherwise healthy patients age ≤50 years. Three cases were due to Cryptococcus neoformans, with 1 experiencing a postinfectious inflammatory response syndrome (PIIRS). The PubMed search identified 51 additional cases, with 32 (63%) being caused by Cryptococcus neoformans and 8 (17%) by Cryptococcus gattii. Of the 51 cases, only 2 resulted in death directly due to cryptococcosis. Fifteen (29%) had PIIRS, with steroid treatment documented in 11 of 15. Antifungal induction regimens and duration were varied but predominately consisted of amphotericin and flucytosine, with a mean induction duration of 5.0 weeks. Conclusions: Cryptococcal meningitis in young, previously healthy patients is likely under-recognized. PIIRS (akin to immune reconstitution inflammatory syndrome observed in HIV/AIDS) with prolonged recovery should be of concern. Determining risk factors for cryptococcosis in these patients remains elusive.

Physical Activity Monitoring Preferences in Adults With Bipolar Disorder.

This report investigated physical activity (PA) monitoring preferences and problems among adults with bipolar disorder (BD). Methods: PARC2 study was conducted at the Western Psychiatric Institute and Clinic at the University of Pittsburgh. This secondary data analysis assessed three PA monitors; Body Media SW Pro Armband, Actigraph AM-7164, and Pedometer Omron HJ-720IT. PA monitors were worn simultaneously for 1 week. Participants reported preferences and problems (irritating, cumbersome, movement of the activity monitor, technical difficulties, and impaired functioning) encountered with each activity monitor. Results: Approximately 70% of the participants (n = 66) were middle-aged Caucasian women with a diagnosis of BD I and overweight. Sixty-six adults with BD wore all 3 monitors simultaneously. Twelve (18%) participants had no PA monitoring preference, 28 (42%) preferred the armband, 17 (26%) preferred the pedometer and 9 (14%) preferred the Actigraph. Activity monitoring preferences did not statistically differ by age, gender, race, BMI, diagnosis, or depressive and mania symptoms (p > 0.25). Two-thirds of the participants (64%) had at least one problem with at least one activity monitor. As far as problem categories, more than a quarter of participants reported irritation with the Armband (26%, n = 17) and movement of the pedometer (32%, n = 21). No statistically significant association was observed between activity monitoring preferences and problems (p = 0.72). Discussion: Adults with BD were willing to wear activity monitors even though problems were reported. Preference of physical activity monitors, in descending order, was the armband, pedometer, and Actigraph. One fifth of the adults with BD reported no preferences in activity monitors. The activity monitors selected for investigation included the "gold standard" in activity monitoring (Actigraph) worn at the waist as well as a research grade pedometer that is considerably more affordable, provides activity feedback in real-time, and may be a more feasible option for large scale studies.

Effects of Teaching Evidence-Based Medicine on Physician Assistant Students' Critical Appraisal, Self-Efficacy, and Clinical Application: A Randomized Controlled Trial.

PURPOSE: To use a randomized controlled design to explore the effects of evidence-based medicine (EBM) education on physician assistant (PA) students' EBM knowledge, self-efficacy, and evidence-seeking behavior in a simulated clinical situation and to present a model of EBM competence. METHODS: Sixty-one didactic-year PA students from one Midwestern University (2 sequential cohorts) were randomized to receive the standard PA curriculum plus EBM training (intervention) or the standard PA curriculum only (control). Evidence-based medicine knowledge was measured with a validated Fresno test. Self-efficacy was measured with a validated Likert scale. Clinical application of EBM skills was measured with an objective structured clinical examination (OSCE). RESULTS: Evidence-based medicine education led to significant improvements on the Fresno and self-efficacy tests, both within and between groups. On the OSCE, the intervention group performed no better than the control group. Higher Fresno pretest scores were significantly related to decreasing improvements in the posttest scores: R = -0.634. CONCLUSION: Teaching EBM to PA students improved their EBM knowledge and self-efficacy but not their clinical application. Future research should focus on enhancing EBM evaluation and application in the clinical setting.

Effects of Implementing a Comprehensive Opioid Reduction Protocol on Overall Opioid Prescribing Among Patients with Chronic, Non-Cancer Pain in a Rural Family Medicine Clinic: A Controlled Cross-over Trial.

BACKGROUND: The opioid crisis presents many challenges for family practice providers in rural communities who treat patients with chronic non-cancer pain (CNCP). Unfortunately, evidence for effective opioid reduction strategies is sparse. We evaluated the effects of implementing a comprehensive opioid reduction protocol on overall opioid prescribing among patients with chronic non-cancer pain in our rural family medicine clinics. METHODS: We compared mean daily milligrams morphine equivalent (MME) prescribed to patients with CNCP in our rural family medicine clinic (n = 93) with another matched clinic (n =93) after implementation of our comprehensive protocol. We also compared mean daily MME prescribed to our patients with CNCP before and after implementation of the protocol. In a subsequent cross over phase, we examined the effects of the protocol when applied to the original control group patients. RESULTS: Mean daily MME in the intervention clinic (29.77) was significantly lower than the control clinic (93.2) after the intervention (t = 6.03; P < .00). Mean daily MME in the intervention group was significantly lower after implementation of the protocol (29.77) than before the protocol (MME 80.34) (t = 5.889; P < .00). After crossover, the mean daily MME was significantly lower (14.34) in the original control group than prior to the cross over intervention (85.68); (t = 8.19; P = .00). DISCUSSION: Our comprehensive opioid reduction protocol led to significant reductions in opioid prescribing in our rural family medicine clinics. Future studies should include important qualitative outcome measures such as patient function.

Utility of paraneoplastic antigens as biomarkers for surveillance and prediction of recurrence in ovarian cancer.

BACKGROUND: Ovarian cancer is frequently diagnosed at an advanced stage and 70% of patients experience recurrence months to years from initial diagnosis. The expression of paraneoplastic antigens can result in the occurrence of onconeural autoantibodies in ovarian cancer that may be associated with neurological disorders that are clinically manifested in patients before diagnosis of ovarian cancer. These paraneoplastic antigens can serve as excellent biomarkers not only for early detection but also for monitoring ovarian cancer recurrence. OBJECTIVE: To assess the immunoreactivity of our previous 3 biomarkers along with 3 paraneoplastic antigens, HARS, Ro52 and CDR2 for the evaluation of their sensitivity in predicting recurrence before the clinical relapse of the ovarian cancer. METHODS: Western blot immunoassays were performed to assess the immunoreactivity of 6 antigens with 21 recurrent ovarian cancer patients. RESULTS: The results indicated that antibodies to HARS, Ro52, CDR2 and 5H6 antigens predicted ovarian cancer recurrence 5.03 months before the clinical or symptomatic relapse in 21 ovarian cancer patients with a sensitivity of 90.5% when CA125 levels were below the standard cutoff (35 U/ml). CONCLUSION: Our study suggests that appearance of onconeural antibodies prior to the rise in CA125 during post treatment surveillance can be a useful diagnostic to predict ovarian cancer recurrence.