Incorporating faecal haemoglobin measurement using the faecal immunochemical test (FIT) in the referral, triage and prioritisation pathway for patients with colorectal symptoms.

Incorporating faecal haemoglobin (FHb) measurement using the faecal immunochemical test (FIT) in the investigation pathway for patients with colorectal symptoms may improve access to colonoscopy for those at greatest risk of significant disease. AIM: To derive a colorectal symptom pathway incorporating standard clinical and FIT data to guide referral, triage, and prioritisation of cases in New Zealand. METHOD: Diagnostic accuracy of FIT to rule out colorectal cancer (CRC) was determined by meta-analysis. Thereafter, the risk of CRC after FIT was estimated for common clinical presentations by Bayesian methodology, using a specifically collated retrospective cohort of symptomatic cases. A symptom/FIT pathway was developed iteratively following multi-disciplinary engagement. RESULTS: Eighteen studies were included in meta-analysis. The sensitivity and specificity for CRC were 89.0% (95%CI 87.0-90.9%) and 80.1% (95%CI 77.7-82.4%) respectively, at a FHb threshold of >10mcg haemoglobin per gram stool, and 95.7% (95%CI 93.2-97.7%) and 60.5% (95%CI 53.8-67.0%) respectively, at the limit of detection. The final pathway was 97% sensitive for CRC, compared with 90% for the current direct access criteria, and requires 47% fewer colonoscopies. Estimated prevalence of CRC among those declined investigation was 0.23%. CONCLUSION: Incorporating FIT in the new patient symptomatic pathway as presented appears feasible, safe, and allows for resources to be targeted to those at greatest risk of disease. Further work is needed to ensure equity for Maori if this pathway were introduced nationally.

Evaluation of community-based CT abdomen for acute abdominal pain during COVID-19.

AIM: The purpose of this study was to determine the utility of community-based imaging to reduce use of inpatient surgical resources and enforce social distancing at the outset of the COVID-19 pandemic. METHOD: A prospective evaluation of community-based CT for patients presenting to Christchurch general practitioners with acute abdominal pain from April to November 2020. Eligible patients were discussed with the on-call general surgical team, and then referred for CT abdomen rather than hospital assessment. The positivity rate of CT scans, the 30-day all-cause hospital admission rate, and the proportion of patients where community scanning altered management setting and the number of incidental findings, were all assessed. RESULTS: Of 131 included patients, 67 (51%) patients had a positive CT scan. Thirty-nine (30%) patients were admitted to hospital within 30 days, 34 (87%) of whom had a positive CT scan and were admitted under a surgical specialty. Ninety-two (70%) patients did not require hospital admission for their acute abdominal pain, thirty-three (35%) of whom had a positive CT scan. There were three deaths within 30 days of the community CT, and the setting of the community CT did not contribute to the death of any of the cases. Forty patients (30%) had incidental findings on CT, 10 (25%) of which were significant and were referred for further investigation. CONCLUSION: Community based abdominal CT scanning is a feasible option in the management of acute abdominal pain. While trialed in response to the initial nationwide COVID-19 lockdown in New Zealand, there may be utility for acute community-based CT scanning in regular practice.

Should diabetes be considered a coronary heart disease risk equivalent?: results from 25 years of follow-up in the Renfrew and Paisley survey.

OBJECTIVE: The purpose of our study was to confirm or refute the view that diabetes be regarded as a coronary heart disease (CHD) risk equivalent and to test for sex differences in mortality. RESEARCH DESIGN AND METHODS: This was a prospective cohort study of 7,052 men and 8,354 women aged 45-64 years from Renfrew and Paisley, Scotland, who were first screened in 1972-1976 and followed for 25 years. All-cause mortality was calculated as death per 1,000 person-years. A Cox proportional hazards model was used to adjust survival for age, smoking habit, blood pressure, serum cholesterol, BMI, and social class. RESULTS: There were 192 deaths in 228 subjects with diabetes and 2,016 deaths in 3,076 subjects with CHD. The highest mortality was in the group with both diabetes and CHD (100.2 deaths/1,000 person-years in men, 93.6 in women) and the lowest in the group with neither (29.2 deaths/1,000 person-years in men, 19.4 in women). Men and women with diabetes only and CHD only formed an intermediate risk group. The adjusted hazard ratio (HR) for CHD mortality in men with diabetes only compared with men with CHD only was 1.17 (95% CI 0.78-1.74; P = 0.56). Corresponding HR for women was 1.97 (1.27-3.08; P = 0.003). CONCLUSIONS: Diabetes without previous CHD carries a lifetime risk of vascular death as high as that for CHD alone. Women may be at particular risk. Our data support the view that cardiovascular risk factors in diabetes should be treated as aggressively as in people with CHD.