Impact of the COVID-19 Pandemic on Fecal Immunochemical Testing, Colonoscopy Services, and Colorectal Neoplasia Detection in a Large United States Community-based Population.

BACKGROUND & AIMS: The COVID-19 pandemic has affected clinical services globally, including colorectal cancer (CRC) screening and diagnostic testing. We investigated the pandemic's impact on fecal immunochemical test (FIT) screening, colonoscopy utilization, and colorectal neoplasia detection across 21 medical centers in a large integrated health care organization. METHODS: We performed a retrospective cohort study in Kaiser Permanente Northern California patients ages 18 to 89 years in 2019 and 2020 and measured changes in the numbers of mailed, completed, and positive FITs; colonoscopies; and cases of colorectal neoplasia detected by colonoscopy in 2020 vs 2019. RESULTS: FIT kit mailings ceased in mid-March through April 2020 but then rebounded and there was an 8.7% increase in kits mailed compared with 2019. With the later mailing of FIT kits, there were 9.0% fewer FITs completed and 10.1% fewer positive tests in 2020 vs 2019. Colonoscopy volumes declined 79.4% in April 2020 compared with April 2019 but recovered to near pre-pandemic volumes in September through December, resulting in a 26.9% decline in total colonoscopies performed in 2020. The number of patients diagnosed by colonoscopy with CRC and advanced adenoma declined by 8.7% and 26.9%, respectively, in 2020 vs 2019. CONCLUSIONS: The pandemic led to fewer FIT screenings and colonoscopies in 2020 vs 2019; however, after the lifting of shelter-in-place orders, FIT screenings exceeded, and colonoscopy volumes nearly reached numbers from those same months in 2019. Overall, there was an 8.7% reduction in CRC cases diagnosed by colonoscopy in 2020. These data may help inform the development of strategies for CRC screening and diagnostic testing during future national emergencies.

A Comparative Analysis of Short-term Patient Outcomes After Laparoscopic Versus Robotic Rectal Surgery.

BACKGROUND: The popularity of robot-assisted colorectal surgery has risen over recent years; however, patient-related advantages over laparoscopic surgery remain uncertain. OBJECTIVE: The goal of this study was to compare short-term patient outcomes following robotic and laparoscopic partial or complete rectal resections. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at 5 large tertiary care Kaiser Permanente medical centers across Southern California. PATIENTS: There were 863 consecutive robotic and laparoscopic pelvic rectal surgeries, including low anterior resections, proctectomies with coloanal anastomosis, and abdominoperineal resections, performed between January 2010 and December 2019. MAIN OUTCOME MEASURES: Short-term patient outcomes, including postoperative length of hospital stay, emergency department returns, and 30-day readmissions, and mortality. RESULTS: A total of 458 surgical procedures were performed via robotic versus 405 via laparoscopic approaches. The robotic group had a higher proportion of male patients (57.4% vs 50.4%; p = 0.04) and a higher proportion of obese (27.1% vs 26.9%; p = 0.02) and overweight patients (36.9% vs 35.1%; p = 0.01). There was no difference in underlying comorbidities of diabetes or smoking, or in the rate of ileostomy creation. After adjusting for Charlson Comorbidity Index, no significant difference was found in emergency department returns between robotic and laparoscopic surgical patients ( p = 0.17). There were no significant outcome differences between the 2 groups with regards to length of stay during procedure, 30-day readmission, or death rates. LIMITATIONS: This study was limited by the lack of randomization in its design, selection of patients for surgical approach, and training and familiarity with robotic rectal surgery. CONCLUSIONS: This study shows length of stay during the procedure and postoperative 30-day readmission rates were generally similar between robotic and laparoscopic patients. Male patients and those with a higher BMI were more likely to have been operated via a robotic method. See Video Abstract at http://links.lww.com/DCR/B857 . UN ANLISIS COMPARATIVO DE LOS RESULTADOS A CORTO PLAZO DE LOS PACIENTES DESPUS DE LA CIRUGA RECTAL LAPAROSCPICA VERSUS LA ROBTICA: ANTECEDENTES:La popularidad de la cirugía colorrectal asistida por robot ha aumentado en los últimos años. Sin embargo, las ventajas relacionadas con el paciente siguen siendo inciertas sobre la cirugía laparoscópica.OBJETIVO:Nuestro objetivo era comparar los resultados de los pacientes a corto plazo después de resecciones rectales completas o parciales robóticas y laparoscópicas.DISEÑO:Este fue un estudio de cohorte retrospectivo.AJUSTE:El estudio se llevó a cabo en cinco grandes centros médicos de Kaiser Permanente de atención terciaria en el sur de California.PACIENTES:Se realizaron 863 cirugías robóticas y laparoscópicas rectales pélvicas consecutivas, incluidas resecciones anteriores bajas, proctectomías con anastomosis coloanal y resecciones abdominoperineales, realizadas entre enero de 2010 y diciembre de 2019.PRINCIPALES MEDIDAS DE RESULTADO:Resultados de los pacientes a corto plazo, incluida la duración de la estancia hospitalaria después del procedimiento, los retornos al departamento de emergencias y los reingresos y la mortalidad a los 30 días.RESULTADOS:Se realizaron un total de 458 procedimientos quirúrgicos a través del robot versus 405 con laparoscopia. El grupo robótico tuvo una mayor proporción de pacientes masculinos (57,4 vs 50,4%, p = 0,04) y una mayor proporción de pacientes obesos (27,1 vs 26,9%, p = 0,02) y con sobrepeso (36,9 vs 35,1%, p = 0,01). No hubo diferencia en las comorbilidades subyacentes de la diabetes y el tabaquismo, y en la tasa de creación de ileostomía. Después de ajustar por el índice de comorbilidad de Charlson, no se encontraron diferencias significativas en los retornos al servicio de urgencias entre los pacientes robóticos y laparoscópicos ( p = 0,17). No hubo diferencias significativas en los resultados entre los dos grupos con respecto a la duración de la estadía durante el procedimiento, las tasas de readmisión a los 30 días y las tasas de muerte.LIMITACIONES:Falta de aleatorización en el diseño del estudio, selección de pacientes para abordaje quirúrgico, capacitación y familiaridad con la cirugía rectal robótica.CONCLUSIONES:Este estudio muestra la duración de la estadía durante el procedimiento y las tasas de reingreso a los 30 días después del procedimiento fueron generalmente similares entre los pacientes robóticos y laparoscópicos. Los pacientes masculinos y aquellos con un índice de masa corporal más alto tenían más probabilidades de haber sido operados mediante un método robótico. Consulte Video Resumen en http://links.lww.com/DCR/B857 . (Traducción-Dr Yolanda Colorado ).

Sinonasal tract and nasopharyngeal adenoid cystic carcinoma: a clinicopathologic and immunophenotypic study of 86 cases.

Primary sinonasal tract and nasopharyngeal adenoid cystic carcinomas (STACC) are uncommon tumors that are frequently misclassified, resulting in inappropriate clinical management. Eighty-six cases of STACC included 45 females and 41 males, aged 12-91 years (mean 54.4 years). Patients presented most frequently with obstructive symptoms (n = 54), followed by epistaxis (n = 23), auditory symptoms (n = 12), nerve symptoms (n = 11), nasal discharge (n = 11), and/or visual symptoms (n = 10), present for a mean of 18.2 months. The tumors involved the nasal cavity alone (n = 25), nasopharynx alone (n = 13), maxillary sinus alone (n = 4), or a combination of the nasal cavity and paranasal sinuses (n = 44), with a mean size of 3.7 cm. Patients presented equally between low and high stage disease: stage I and II (n = 42) or stage III and IV (n = 44) disease. Histologically, the tumors were invasive (bone: n = 66; neural: n = 47; lymphovascular: n = 33), composed of a variety of growth patterns, including cribriform (n = 33), tubular (n = 16), and solid (n = 9), although frequently a combination of these patterns was seen within a single tumor. Pleomorphism was mild with an intermediate N:C ratio in cells containing hyperchromatic nuclei. Reduplicated basement membrane and glycosaminoglycan material was commonly seen. Necrosis (n = 16) and atypical mitotic figures (n = 11) were infrequently present. Pleomorphic adenoma was present in 9 cases; de-differentiation was seen in two patients. Immunohistochemical studies showed positive reactions for pan-cytokeratin, CK7, CK5/6, CAM5.2, and EMA, with myoepithelial reactivity with SMA, p63, calponin, S100 protein and SMMHC. CD117, CEA, GFAP and p16 were variably present. CK20 and HR HPV were negative. STACC needs to be considered in the differential diagnosis of most sinonasal malignancies, particularly poorly differentiated carcinoma, olfactory neuroblastoma and pleomorphic adenoma. Surgery (n = 82), often accompanied by radiation therapy (n = 36), was generally employed. A majority of patients developed a recurrence (n = 52) 2-144 months after initial presentation. Overall mean follow-up was 19.4 years (range 0.4-37.5 years): 46 patients died with disease (mean 6.4 years); 5 were alive with disease (mean 5.4 years), and 35 patients were either alive or had died of unrelated causes (mean 16.3 years). ACC of the SNT is uncommon. Recurrences are common. The following parameters, when present, suggest an increased incidence of either recurrence or dying with disease: mixed site of involvement, high stage disease (stage IV), skull base involvement, tumor recurrence, a solid histology, perineural invasion, bone invasion, and lymphovascular invasion.

Effect of direct physician involvement on tobacco abstinence rates and other variables affecting participants of a freedom from tobacco class.

CONTEXT: Kaiser Permanente measures how often tobacco users are offered strategies to quit but not the success of such strategies. OBJECTIVE: To compare tobacco abstinence rates for participants of the Kaiser Permanente Riverside (California) Medical Center's Freedom from Tobacco Class in 2008, before direct physician involvement, and in 2009, after direct physician involvement, and to compare other variables affecting these rates. DESIGN: In a retrospective study, participants were divided into two groups based on year of participation. Data were collected using electronic medical records and phone interviews. MAIN OUTCOME MEASURES: Tobacco use status between both groups at 1, 3, 6, and 12 months after the classes started and within groups by sex, number of classes attended, medication received, and class teacher. RESULTS: The 12-month abstinence rates were 27% in 2008 and 33% in 2009 (p = 0.3). The abstinence rate for men improved from 23% to 38% (2008 vs 2009; p = 0.05), whereas for women it was 30% vs 27% (p = 0.7). Abstinence rates decreased over time for the group as a whole (p < 0.001). Attendance of 6 or more classes was associated with higher abstinence rates. There was no significant impact on abstinence rates due to age, body mass index, class teacher, or medications used. CONCLUSION: Direct physician involvement improved men's but not women's abstinence rates among class participants. The relapse rate was significant over the first year after the class. Further research is needed to study the difference between sexes and the factors affecting relapse.

Prevalence of hemochromatosis-related symptoms among individuals with mutations in the HFE gene.

OBJECTIVE: To determine the prevalence of hemochromatosis-related symptoms in homozygotes for the HFE mutation C282Y compared with controls without HFE mutations identified through a large screening program of subjects attending a health appraisal center. SUBJECTS AND METHODS: Presence of symptoms commonly associated with clinical hemochromatosis was ascertained by self-report on a written questionnaire among C282Y homozygotes and HFE wild-type subjects of white or Hispanic ethnicity identified from screening 41,599 adult subjects between March 1999 and August 2001. A subset of C282Y homozygotes and wild-type subjects identified from 12,756 subjects attending the center in the final year of the study completed a standardized double-blind interview with a physician regarding the presence, duration, and severity of a larger set of symptoms. Prevalence of symptoms among C282Y homozygotes and wild-type controls ascertained by written questionnaire and interview were compared by chi2 analysis or Fisher exact test. Symptoms among subjects with other combinations of the C282Y and H63D HFE mutations were also assessed by questionnaire. RESULTS: The 124 C282Y homozygotes who filled out the written questionnaire and the 17 C282Y homozygotes who completed the physician double-blind interview reported no significantly higher rates of arthritis or joint pain, abdominal pain, arrhythmias, darkening of skin, or other symptoms traditionally associated with hemochromatosis compared with the 22,429 wild-type controls who filled out the written questionnaire and 29 wild-type controls who completed the double-blind interview. The only symptom reported more frequently by C282Y homozygotes was loss of body hair, reported by 5 C282Y/C282Y female subjects compared with 1 wild-type male subject (P=.02) in the physician interview. Symptoms among subjects with other HFE genotypes were similar to symptoms of wild-type subjects. CONCLUSIONS: Results of this study indicate that many of the symptoms associated with hemochromatosis are common among HFE wild types and that clinical penetrance of the C282Y/C282Y genotype in regard to these symptoms is low.

Relationship of body iron stores to levels of serum ferritin, serum iron, unsaturated iron binding capacity and transferrin saturation in patients with iron storage disease.

None of the methods for assessing total body iron burden in patients with hemochromatosis is satisfactory. Although it is commonly believed that a relationship exists between serum ferritin levels and total iron burden, the extent of this relationship has not previously been documented. In the present investigation we measured the total body iron burden of 88 patients with putative hemochromatosis, 54 of whom were homozygotes for the 845G-->A (C282Y) mutation. The total body iron stores were estimated from the volume of red cells removed during therapeutic phlebotomy corrected for an estimated 2 mg/day dietary iron absorbed during the phlebotomy period; the amount of storage iron was compared to the serum ferritin, serum iron, unsaturated iron binding capacity, and transferrin saturation before the beginning of phlebotomy. The serum ferritin proved to be the best predictor of body iron stores. The correlation between all of the analytes and the body iron burden was greater in patients homozygous for the C282Y mutation than in those who were not, including the compound heterozygotes for C282Y and H63D. The body iron burden tended to be greater in patients homozygous for the C282Y mutation than the other patients at any other given ferritin level. We conclude that the serum ferritin level does provide some information regarding total iron burden but even in the case of C282Y homozygotes, the correlation is not very strong.