2 Minute Medicine Rewind May 1, 2023

Comparative Effectiveness of 2 Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening Among Women in the Rural US: A Randomized Clinical Trial

1. For female patients living in rural areas, an interactive DVD intervention and telephone-based patient navigation (PN) intervention increased rates being up-to-date with guideline-based breast, cervical, and colorectal cancer screening.

Evidence Rating Level: 1 (Excellent)

Individuals living in rural areas tend to have lower rates of screening as per guidelines, for breast, cervical, and colorectal cancer. Previous interventions have employed technological advancements and patient navigation tools to reach rural patients and promote screening for a single cancer. However, there are no known interventions that have been studied to promote screening for multiple types of cancer at once. Therefore, this current randomized controlled trial evaluated the effectiveness of various interventions at increasing women patients’ adherence to screening of breast, cervical, and colorectal cancer. The study compared a digital video disc (DVD) intervention, a DVD and telephoned patient navigation (PN) intervention, and usual care. The study population consisted of 963 female patients who were not up-to-date with at least 1 form of cancer screening. Participants were between 50 and 74 years, and came from rural Ohio and Indiana counties. For the DVD intervention, patients were mailed a DVD that allowed them to answer prompts and receive information based on their responses, educating patients on the advantages and barriers to screening. The DVD also provided information based on the patient’s age, family history, and thoughts about their own risk of cancer. The DVD/PN intervention added social workers who telephoned patients, an average of 3 times, to reiterate the DVD information, and provide counselling to explore how the patient’s barriers to screening could be overcome. Outcomes were evaluated 12 months, identifying which patients had completed screening for the 3 types of cancer, in accordance with guidelines. The results showed rates of 10%, 15%, and 30% for up-to-date screening of all cancers, for usual care, DVD, and DVD/PN interventions respectively. As well, the DVD participants had twice higher odds of being up-to-date with all screening compared to usual care (odds ratio 1.84, 95% CI 1.02-3.43, p = 0.048). The DVD/PN group had 3 times greater odds of being up-to-date with all screenings compared to the DVD group (OR 3.09, 95% CI 2.05-4.68, p < 0.001). Furthermore, the DVD/PN intervention had 4 times greater odds of patients being up-to-date for any one cancer compared to usual care (OR 4.01, 95% CI 2.60-6.28, p < 0.001), though this was not significant for the DVD intervention alone. Overall, this study showed that an interactive DVD intervention and a telephone patient navigation intervention were effective in improving cancer screening rates for female patients in rural areas.

Propensity score-matched analysis of physician-controlled wire-guided cannulation as an effective technique against difficult cannulation in endoscopic retrograde cholangiopancreatography: A retrospective study

1. Physician-controlled wire-guided cannulation (PCWGC) in ERCP demonstrated higher success rates and no increased post-ERCP pancreatitis (PEP) rates when used as a second-line cannulation technique, compared to the conventional double-guidewire technique (DGT).

Evidence Rating Level: 2 (Good)

In endoscopic retrograde cholangiopancreatography (ERCP), cannulation of the common bile duct is a common area of challenge for endoscopists. However, overstimulation of the guidewire by an endoscopic assistant can be associated with post-ERCP pancreatitis (PEP). Therefore, a new technique known as physician-controlled wire-guided cannulation (PCWGC) has been developed, to allow endoscopists to control the guidewire without an assistant. This current single-centre retrospective study based in South Korea evaluated ERCP outcomes from using the PCWGC technique. The study population consisted of patients with a naïve ampulla undergoing ERCP. Prior to January 2019, the centre’s conventional strategy for cannulation involved attempting cannulation catheter access first, then switching to the double-guidewire technique (DGT) if the former was unsuccessful, before switching to precut infundibulotomy if DGT was also unsuccessful. After January 2019, the centre’s new strategy replaced DGT with PCWGC as the second-line technique. In total, the study included 536 patients, 281 under the conventional strategy and 255 in the new strategy groups. After propensity matching, there were 219 patients included in each group. The results found similar cannulation success rates (96.8% vs 99.1%) in the conventional and new strategy groups respectively, with no difference in time (p = 0.0779). As well, there was a higher success rate with PCWGC compared to DGT (13.4% vs 4.2%), and shorter cannulation time (131.0 seconds vs 639.7 seconds), with no difference in PEP. In a subgroup of difficult cannulation patients, there was also a higher success rate for PCWGC compared to DGT (78.1% vs 39.1%, p = 0.007) with similar rates of PEP (8.7% vs 13.0%). Overall, this study demonstrated that PCWGC is more effective than conventional second-line techniques for common bile duct cannulation in ERCP, with no difference in complications.

Evaluation of Birth by Cesarean Delivery and Development of Early-Onset Colorectal Cancer

1. In a case-control study based in Sweden, females born by C-section had greater odds of developing early-onset colorectal cancer (CRC), compared to females born by vaginal delivery.

2. No association was found between males born by C-section and early-onset CRC.

Evidence Rating Level: 3 (Average)

In the USA and Europe, there have been reports of increasing incidence of colorectal cancer (CRC) in patients less than 50 years old. Risk factors such as obesity, diabetes, and metabolic syndrome, have been identified for early-onset CRC. As well, the gut microbiome has been linked to the development of CRC. Altogether, experts have wondered if there may be an early-life etiology for metabolic dysfunction that leads to CRC. Furthermore, reports from the USA have showed that the incidence of early-onset CRC increased with each successive birth cohorts. One hypothesis is that this may be linked to increasing rates of C-section deliveries, which have been associated with obesity and diabetes, likely due to gut dysbiosis early in life. Therefore, this case-control study based in Sweden examined individuals with early-onset CRC, stratifying by their mode of birth, either vaginal delivery or C-section. The study population included patients from 1991 to 2007 between ages 18 and 49, who were diagnosed with histopathologic findings of CRC. In total, there were 705 individuals included with early-onset CRC, matched by age, sex, birth year, and country to 3509 controls. The study found that those born by C-section did not have higher odds of early-onset CRC (adjusted odds ratio 1.28, 95% CI 0.91-1.79). However, when stratifying by gender, there was an association between females delivered C-section and early-onset CRC (aOR 1.62, 95% CI 1.01-2.60), but not males (aOR 1.05, 95% CI 0.64-1.72). Overall, this study found that females born by C-section had increased odds of developing early-onset CRC, compared to females born by vaginal delivery.

The role of PEEP for cannulation of the subclavian vein: A prospective observational study

1. Stepwise changes in positive end expiratory pressure (PEEP) were not associated with clinically significant changes in subclavian vein (SCV) and parietal pleura distance (DVP), or SCV cross-sectional area (CSA), factors that impact the optimization of SCV cannulation.

Evidence Rating Level: 2 (Good)

When considering cannulation of the subclavian vein (SCV), the utility of positive end expiratory pressure (PEEP) is unclear. For instance, PEEP could increase the risk of pneumothorax from this procedure, secondary to decreasing the parietal pleura and SCV distance (DVP). However, PEEP could also increase the SCV cross-sectional area (CSA), improving the success rate. Therefore, this single-centre prospective study evaluated the effects of varying PEEP levels on DVP and CSA. This study enrolled 27 adults who had underwent invasive mechanical ventilation, with a clinical indication for stepwise trials of PEEP. The DVP and CSA were measured bilaterally using ultrasound examination of the SCV at 0, 5, 10, and 15 cm H2O of PEEP. A clinically relevant change was considered to be >2 mm for DVP and >2mm² for CSA. The results showed a statistically and clinically significant increase in the CSA on the right side at a PEEP of 10 compared to 0 (difference 2.5). There was also a statistically significant increase in DVP at PEEP of 15 compared to 0, with the in-plane ultrasound view on the left side (difference 0.7, p = 0.048). Otherwise, there were no statistically or clinically significant differences in DVP or CSA at varying PEEP levels in this study. Overall, this demonstrated that stepwise changes in PEEP do not generally affect factors impacting the optimization of SCV cannulation, such as DVP and CSA.

Multi-faceted intervention to improve management of antibiotics for children presenting to primary care with acute cough and respiratory tract infection (CHICO): efficient cluster randomised controlled trial

1. Amongst children aged 0-9 years presenting to a general practice clinic with respiratory infections, an intervention encompassing risk stratification and caregiver education did not decrease antibiotic dispensing rates, or increase hospital admission rates.

Evidence Rating Level: 1 (Excellent)

Widespread and unnecessary prescribing of antibiotics carries the potential for development of antibiotic resistance. However, an estimated 50% of antibiotics prescribed in primary care are unnecessary, particularly for respiratory infections in children. Prior studies have identified contributing factors, including physicians prescribing antibiotics “just in case” or parents needing more information on managing and monitoring respiratory infections at home. As such, this current study, known as the CHICO trial, randomized primary care practices in England to evaluate an intervention aimed at reducing antibiotic prescriptions without increasing hospital admissions, in children aged 0-9 years with respiratory infection symptoms. This intervention employed the STARWAVe prognostic algorithm to determine a child’s risk of hospital admission in 30 days, into very low, normal, and high risk categories. Since the intervention was embedded into the physician’s electronic medical record, the physician would be prompted to elicit concerns from the child’s caregivers during the appointment. They would also be able to provide a handout outlining strategies to manage and monitor their child’s symptoms for deterioration, which would also be personalized to the caregivers’ concerns. In total, there were 150 general practices enrolled in the control group and 144 enrolled in the intervention group. Amongst the intervention, 17% of practices had zero usage over the 12-month study period. The results showed no differences in antibiotic dispensing between intervention and control groups (rate ratio 1.011, 95% CI 0.992-1.029, p = 0.25). As well, the hospital admission rate for respiratory infections was non-inferior in the intervention compared to the control (rate ratio 0.952, 95% CI 0.905-1.003). Overall, this study demonstrated that an intervention incorporating risk stratification and caregiver education did not reduce antibiotic dispensing or increase hospital admission rates, for children with respiratory infections presenting to a general practice clinic.

Image: PD

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