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OBJECTIVES The amount of colorectal cancer (CRC) screening using the noninvasive fecal immunochemical test (FIT) at a federally qualified health center, Five Rivers Health Clinic (Dayton, Ohio), has been low historically. Our quality improvement (QI) project aimed to improve CRC screening adherence in eligible patients who opted for FIT. METHODS Three hundred ninety-two patients with FIT orders for CRC were screened during an 11-month period. The preintervention group (pre-I) was enrolled from December 1, 2018 to May 31, 2019, and the postintervention group (post-I) from June 1, 2019 to October 31, 2019. Three interventions were used: resident physicians trained during clinic meetings regarding FIT education for patients, posters displayed in patient rooms outlining the benefits of CRC screening, and standardized US mail reminder letters sent to FIT patients. Patient demographics and clinical variables were collected along with return rate. RESULTS The return rate for post-I was twice that of pre-I (74.4%, 95% confidence interval 64.6-82.3 vs 31.1, 95% confidence interval 26.2-36.6; P < 0.001). The pre-I/post-I groups did not differ on demographic and clinical characteristics, and, except for race, none of these variables was associated with returning the FIT screening card. CONCLUSIONS The compliance rate for FIT completion and return more than doubled among our clinic patients after using a three-component QI intervention. Except for a difference in race, the lack of association between demographic and clinical characteristics with either pre-I/post-I group or return/no return of the FIT card leads us to conclude that our QI program for increasing FIT compliance is effective. Other settings where CRC screening is a prominent component of preventive care may benefit from adopting a similar QI intervention.

Using a database of 171 studies across 62,965 organizational units with job attitude data and business performance outcomes ranging from 1994 to 2015, we tested the hypothesis that positive employe...

Background Comorbidities of tobacco and alcohol abuse and obesity are major risk factors for colon carcinogenesis. These risk factors are considered the most prevalent modifiable risk factors linked to malignancies including colorectal cancer (CRC) in both high- and low-income countries. The aim of this study was to investigate the relationship between number of comorbidities and age of CRC diagnosis in US male veteran population. Methods A retrospective single-center study using chart review and the International Classification of Diseases, Ninth Revision (ICD-9) codes to identify patients with a diagnosis of CRC and comorbidities of tobacco abuse, alcohol abuse, hypertension (HTN), diabetes mellitus (DM) and chronic kidney disease (CKD). The primary aim was to study effect of these comorbidities on age of CRC diagnosis. Univariable and then multivariable logistic regression models were fit to age at diagnosis for each patient variable. Results A total of 362 patients were included in the study. The mean age of CRC diagnosis was 66.8. Eighty percent were Caucasians, and 20% were African Americans. African Americans were diagnosed with CRC 3.8 years younger compared to Caucasians (P = 0.01). Controlling for other variables in the multivariable model, age at CRC diagnosis was significantly lower for African Americans and for patients with higher total counts for tobacco and alcohol abuse and obesity. HTN, DM and CKD were not associated with a lower age of CRC diagnosis. Conclusions Tobacco and alcohol abuse and obesity have negative cumulative effect on age of CRC diagnosis in US male veteran population. Patients with increasing number of these comorbidities are associated with significantly lower age of CRC diagnosis. It is important to identify veterans with these comorbidities and encourage CRC screening.

Administrative burdens may have substantial direct and indirect costs for employers and employees, making them important research topics. Here, we examine the time employees spend dealing with thei...

Background: Aspirin use lengthens survival in patients with colorectal cancer (CRC). We aimed to add to the evidence examining this relationship and to compare the survival benefit between aspirin started before CRC diagnosis with those started after CRC diagnosis. Methods: The study involved 173 consecutive patients who had a histopathologic diagnosis of colorectal carcinoma between 1996 and 2014. The electronic medical record was used to collect data on demographic characteristics (age, sex, and race), family history of cancer, use or non-use of aspirin before and after cancer diagnosis, cancer stage at diagnosis, and days from cancer diagnosis to death. Patients were divided into aspirin using and non-aspirin using groups. Results: Aspirin users (ASAU, n=90) were older than non-aspirin users (NASAU, n=83; 70.8±9.1 vs . 66.2±10.2 years; P=0.004). The two groups were similar in sex, race, and family history of cancer, but the non-users of aspirin were more likely to have stage III or stage IV CRC (NASAU =57.5%; ASAU =38.6%; P=0.014). Aspirin users survived more than twice the number of days than non-users (ASAU median =941 days; NASAU median =384 days; P=0.003). Patients who used aspirin only before their CRC diagnosis had a short survival period from diagnosis to death (median =149). Conclusions: Our findings support the relationship of aspirin use and duration of use with enhanced survival in patients with CRC. Physicians may want to recommend that patients at increased risk for CRC and those already diagnosed, but not yet on aspirin, start an aspirin regimen.

Introduction: Gastric manifestations of SARS-CoV-2 infection are not uncommon and may even precede respiratory symptoms. Common gastrointestinal symptoms include loss of appetite, diarrhea, nausea, vomiting and abdominal pain. Here, we describe a case of a 74 year old-old male with acute COVID-19 infection with acute gastroparesis and hypomotility in the large intestine, which to our knowledge has not been previously described. Case Description/Methods: A 74 year-old male with a past medical history of Dementia, Parkinson's Disease, Controlled Type 2 Diabetes Mellitus was admitted with worsening dyspnea found to be COVID-19 positive. Vitals on presentation: 84 beats/min heart rate, 151/95 mmHg blood arterial pressure, 98.1 F temperature, 18 breaths/min, and 89% O2 saturation. On examination, he was oriented to person, place, but not time. Breath sounds were coarse bilaterally, and the abdomen was soft, mildly distended, active bowel sounds. Initial lab work was unremarkable. He was admitted and started on dexamethasone, remdesevir, and supplemental oxygen via nasal cannula. The following day, the patient had increasing abdominal distention and nausea. An abdominal film was obtained which revealed a gas-distended stomach with concern for gastric outlet obstruction. CT showed similar gastric distention, progression of oral contrast, and dilated sigmoid colon. The patient was made NPO and nasogastric (NG) tube was placed with removal of 1L of bilious content, a bedside rectal tube was placed, and IV metoclopramide was started. Over the next several days, the patient had a gradual improvement in NG output and abdominal distention with close monitoring. Follow up abdominal plain films showed complete resolution of gastric and colonic distention, tubes were removed, and diet was advanced. Diet was advanced and oxygen was weaned off, and he was discharged in stable condition. Discussion: Our case describes an uncommon manifestation of acute gastroparesis and colonic dysmotility in the setting of acute COVID-19 as opposed to the classic diarrhea, nausea, abdominal pain. It remains unclear whether his symptoms were a direct result of the COVID-19 infection or a manifestation of his acute illness or undiagnosed condition. Nevertheless, bringing awareness to this transient manifestations of COVID-19 is clinically relevant and highlights our management strategy. Our patient improved gradually with supportive care including gastric and colonic decompression, electrolyte optimization, bowel rest, and time..

Background Several psychometrically sound measures of alcohol use have been developed to assess drinking. The Alcohol Use Disorders Identification Test (AUDIT) and its shorter counterpart the AUDIT-C, which contains the first 3 AUDIT questions, were developed by the World Health Organization and have become the preferred brief measures for screening and evaluating problem severity. This study compared the first 3 questions on the AUDIT with another psychometrically sound brief measure of alcohol use, the Quick Drinking Screen (QDS). Methods Data were obtained from a randomized controlled trial of a mail-based intervention promoting self-change with 472 alcohol abusers (n = 280, no prior alcohol treatment; n = 192, prior alcohol treatment). Participants’ retrospective self-reports of alcohol consumption were collected using the QDS and the 3 AUDIT-C questions and compared. Although both measures contain similar questions (2 quantity-frequency and 1 binge drinking), they differ in 2 important ways: (i) temporal interval over which data are collected, and (ii) formatting of response options (i.e., a continuous number vs. categorical). Results Intraclass correlations for drinking variables were moderate to moderately high. A repeated-measures MANOVA using treatment condition and gender as variables revealed significant differences in absolute values between the 2 drinking measures with the QDS showing greater consumption on almost all variables. Participants’ numerical answers on the QDS were compared to their categorical answers to the similar alcohol use questions on the AUDIT-C. The comparison revealed that participants’ answers on the AUDIT-C were associated with extreme variability compared to their QDS answers. This variability suggests the AUDIT-C would be unreliable as a quantitative measure of alcohol consumption. Conclusions The differences between the 3 alcohol use questions on the AUDIT-C and the same questions on the QDS may reflect the imprecision of the AUDIT-C's drinking response categories. Results suggest that the QDS can be used to identify risky drinking and to provide a more informative characterization of a drinker's alcohol consumption than that provided by the AUDIT-C.

Objectives Barrett's esophagus (BE) is the precursor lesion and a major risk factor for esophageal adenocarcinoma (EAC). Although patients with BE undergo routine endoscopic surveillance, current screening methodologies have proven ineffective at identifying individuals at risk of EAC. Since microRNAs (miRNAs) have potential diagnostic and prognostic value as disease biomarkers, we sought to identify an miRNA signature of BE and EAC. Methods High-throughput sequencing of miRNAs was performed on serum and tissue biopsies from 31 patients identified either as normal, gastroesophageal reflux disease (GERD), BE, BE with low-grade dysplasia (LGD), or EAC. Logistic regression modeling of miRNA profiles with Lasso regularization was used to identify discriminating miRNA. Quantitative reverse transcription polymerase chain reaction was used to validate changes in miRNA expression using 46 formalin-fixed, paraffin-embedded specimens obtained from normal, GERD, BE, BE with LGD or HGD, and EAC subjects. Results A 3-class predictive model was able to classify tissue samples into normal, GERD/BE, or LGD/EAC classes with an accuracy of 80%. Sixteen miRNAs were identified that predicted 1 of the 3 classes. Our analysis confirmed previous reports indicating that miR-29c-3p and miR-193b-5p expressions are altered in BE and EAC and identified miR-4485-5p as a novel biomarker of esophageal dysplasia. Quantitative reverse transcription polymerase chain reaction validated 11 of 16 discriminating miRNAs. Discussion Our data provide an miRNA signature of normal, precancerous, and cancerous tissue that may stratify patients at risk of progressing to EAC. We found that serum miRNAs have a limited ability to distinguish between disease states, thus limiting their potential utility in early disease detection.

The Quick Drinking Screen (QDS) and Timeline Followback (TLFB), measures of alcohol use, have yielded similar reports of drinking with English speakers. The present study, a secondary data analyses, compared three measures of alcohol use (i.e., QDS, TLFB, and AUDIT) with Russian-speaking women. This is the first study to compare all three measures. This study replicated the findings of studies with English speakers, and demonstrated that brief screening measures (QDS, AUDIT) provide reliable summary measures of alcohol use when compared to a detailed drinking measure (TLFB). The use of brief screening measures is recommended for use with Russian women.

Background: Approximately 15% to 35% of those with chronic hepatitis C (CHC) related cirrhosis will develop hepatocellular cancer (HCC). With this burden increasing across the globe, identification of risk factors for HCC has become imperative. Exposure to Agent Orange has been implicated as a possible risk factor for liver cancer in a study from the Republic of Korea. However, there has been no study in U.S. veterans with CHC and cirrhosis that has evaluated exposure to Agent Orange as a risk factor for HCC. We conducted a retrospective study of U.S. military veterans diagnosed with CHC and cirrhosis over a period of 14 years to evaluate potential risk factors for HCC including exposure to Agent Orange. Methods: We retrospectively reviewed 390 patients with confirmed CHC-related cirrhosis between 2000 and 2013 and identified patients with HCC. We compared demographic, laboratory, and other clinical characteristics of patients with and without HCC. Results: The mean age of the cohort was 51 years (SD =7.5), with the majority being male (98.5%). Seventy-nine of 390 (20.2%) patients developed HCC, diagnosed on average 8 (SD =4.8) years after diagnosis of CHC. Nearly half (49.4%) were Childs A, 40.5% were Childs B, and 10.1% were Childs C. HCC patients were more likely to be African American than non-HCC patients (40.5% vs . 25.4%, P=0.009) and to be addicted to alcohol (86.1% vs . 74.3%, P=0.027). A trend toward significance was seen in the HCC group for exposure to Agent Orange (16.5% vs . 10.0%, P=0.10) and smoking addiction (88.6% vs . 80.7%, P=0.10). Consequently, race, alcohol addiction, Agent Orange exposure, and smoking addiction were included in the multivariable logistic regression (MLR) analysis. Alcohol addiction [odds ratio (OR) =2.17; 95% confidence interval (CI), 1.07–4.43] and African American race (OR =2.07; 95% CI, 1.22–3.51) were found to be the only two definitive independent risk factors for HCC in our sample. Conclusions: African American race and alcohol addiction were independent risk factors for HCC development in this U.S. veteran population. There was no significant association between exposure to Agent Orange and HCC, although larger studies are needed in the U.S. military veteran population to evaluate further this toxic herbicide from the Vietnam War era.

A 57-year-old man underwent emergency laparoscopic loop colostomy for acute recto-sigmoid obstruction. He was hospitalised 2 months previously, at another facility for diabetic ketoacidosis (DKA) and hyperkalaemia. He had no gastrointestinal symptoms prior to the hospitalisation. Both surgical exploration and intraoperative sigmoidoscopy showed ulcerations of sigmoid colon and proximal rectum with a pinhole stricture in mid-rectum. After ruling out all aetiologies, and due to persistence of the colonic ulcerations on a follow-up colonoscopy, a diagnosis of Crohn’s colitis was made, and the patient was started on infliximab and 6-mercaptopurine (6-MP). Six months later, on rereview of all the biopsies, it was noted that a key element of presence of crystals suggestive of Kayexalate on the initial colorectal biopsies was missed. It was later found out that the patient had received rectal Kayexalate for treatment of DKA at the other facility. Hence, infliximab and 6-MP were both discontinued. All the colonoscopies, following the discontinuation of the medications, showed complete resolution of colitis but persistence of the mid-rectum stricture. This was treated with a fully covered metal stent for 12 weeks with only partial improvement of the stricture. He was hence referred for ultra-low anterior resection of rectum and take down of colostomy.

Objectives Patients with cirrhosis have a high rate of 30-day hospital readmission that affects their quality of life and contributes to increased healthcare-related costs. The aim of our study was to identify frequency, predictors, and preventable causes of hospital readmissions among patients with decompensated cirrhosis. Methods We retrospectively reviewed electronic medical records of all patients with a confirmed diagnosis of decompensated cirrhosis admitted to Dayton VA Medical Center between 2009 and 2013. Demographics, clinical factors, laboratory values, and outcomes were recorded. Univariate analysis was performed using independent samples t tests and Wilcoxon rank sums tests for continuous variables and χ(2) or Fisher exact tests for categorical variables. A multiple logistic regression analysis was performed for variables found to be significant by univariate analysis to predict the risk factors for 30-day readmission. A detailed chart review was conducted for all patients readmitted within 30 days by a single gastroenterologist to identify the reason for readmission and to decide whether any of these readmissions were preventable. Results The 30-day readmission rate for decompensated cirrhotic patients was 27.03%. The risk factors for 30-day readmission were higher body mass index (BMI), lower body temperature, higher blood urea nitrogen, higher creatinine, more cirrhosis-related complications, and more readmissions per year per univariate analysis. Multivariable analysis revealed only BMI as a significant predictor of 30-day readmission (P = 0.023). A total of 36.7% of 30-day readmissions were possibly preventable. Conclusions The independent variable that predicted 30-day readmission in patients with decompensated cirrhosis was higher BMI. Approximately one-third of 30-day readmissions were possibly preventable. These findings support the need to develop specific interventions for disease management to improve patient care and save on extraneous healthcare costs.

Low rates of contraception and at-risk drinking place many Russian women at risk of an alcohol-exposed pregnancy (AEP). The only realistic way to determine when women are at risk of AEP is by self-reports. A U.S. study found that a single binge-drinking question (SBD) effectively identified nearly all women whose drinking placed them at risk of AEP.The present study replicated the U.S.Participants were 689 non-pregnant Russian women of childbearing age who were at AEP risk. Their answers to SBD, "During the previous three months, how often did you have four or more drinks on one occasion", were compared with their reports of binge drinking on a 90-day Timeline Followback (TLFB) calendar.The SBD identified 99% of at-risk Russian women as binge drinkers, replicating U.S.Only 8% of the women were identified at-risk using a second AEP criterion of ≥8 drinks on average per week. Although Russian women did not report heavy weekly drinking and two-thirds did not meet AUDIT criteria for problem drinking, when they did drink, 40% of the time it was binge drinking.Almost all Russian women who were at risk of an AEP were identified by a single binge-drinking question. Results from this study suggest that Russian health care practitioners can use SBD to successfully screen women for AEP risk. SBD identified 99% of Russian women who were at AEP risk. Consequently, it is recommended that SBD be incorporated into routine health care screenings at OB/GYN clinic visits.

Building upon extensive research from 2 validated well-being instruments, the objective of this research was to develop and validate a comprehensive and actionable well-being instrument that informs and facilitates improvement of well-being for individuals, communities, and nations. The goals of the measure were comprehensiveness, validity and reliability, significant relationships with health and performance outcomes, and diagnostic capability for intervention. For measure development and validation, questions from the Well-being Assessment and Wellbeing Finder were simultaneously administered as a test item pool to over 13,000 individuals across 3 independent samples. Exploratory factor analysis was conducted on a random selection from the first sample and confirmed in the other samples. Further evidence of validity was established through correlations to the established well-being scores from the Well-Being Assessment and Wellbeing Finder, and individual outcomes capturing health care utilization and productivity. Results showed the Well-Being 5 score comprehensively captures the known constructs within well-being, demonstrates good reliability and validity, significantly relates to health and performance outcomes, is diagnostic and informative for intervention, and can track and compare well-being over time and across groups. With this tool, well-being deficiencies within a population can be effectively identified, prioritized, and addressed, yielding the potential for substantial improvements to the health status, performance, and quality of life for individuals and cost savings for stakeholders. (Population Health Management 2014;17:357–365)

OBJECTIVES Diabetes mellitus is a significant risk factor for total cancer incidence and mortality. Metformin, a commonly used antidiabetic drug, has been shown to be protective against different types of cancers; however, its role in esophageal cancer is unknown. The goal of this study was to determine whether the use of metformin modifies the risk of development of esophageal adenocarcinoma in patients with Barrett esophagus. METHODS Patients with diagnoses of Barrett esophagus and esophageal cancer were identified during a 20-year period. Demographic and clinical data were collected. The outcome variable was esophageal adenocarcinoma. Univariate analysis was performed using two-sample t tests for continuous variables or the Fisher exact test for categorical variables. Multiple logistic regression analysis was then performed using the significant variables. RESULTS A total of 583 patients were identified with the diagnosis of Barrett esophagus or esophageal adenocarcinoma from 1992 to 2012. Of these, 115 had esophageal adenocarcinoma and 468 had Barrett esophagus. Age, smoking, and diabetes mellitus were found to be significant risk factors for the development of esophageal cancer with the following results: age (P < 0.001), smoking (P = 0.003), diabetes mellitus (P = 0.007). Statin use was protective against the development of cancer with P = 0.001. Metformin use was neither associated with an increased nor a decreased risk of esophageal cancer. CONCLUSIONS The three independent variables that predicted progression of Barrett esophagus to esophageal adenocarcinoma in our study were older age, smoking, and diabetes mellitus. Statin use showed protective effect against development of esophageal adenocarcinoma. Metformin use did not demonstrate any statistically significant protective effect.

Objectives Esophagogastroduodenoscopy (EGD) with biopsy has become the standard procedure for diagnosing esophageal and gastric cancers (EGC) and is considered to have high sensitivity and specificity. To date, few studies have attempted to examine the rates of missed EGC after EGD and no study addresses the rate of missed EGC in a military veteran patient population. This led to us examine missed EGCs at our VA Medical Center across a 10-year period. Methods An electronic database was used to identify patients who were diagnosed between 2000 and 2010 as having EGC. Missed cancers were defined as cancers diagnosed within 1 year of EGD, possible missed cancers as those diagnosed 1 to 3 years after EGD, and latent cancers as those diagnosed between 3 and 5 years after EGD. Results A total of 94 patients fulfilled the study criteria: 69 had esophageal cancer and 25 had gastric cancer diagnosed at our institution during the study period. Of the included cases, one patient had a missed cancer (1.06%) and four patients had possible missed cancers (4.26%); no patients had latent cancer. Conclusions The true incidence of missed EGC in military veteran patients is not known. It is difficult to compare our findings to those of other studies because of the heterogeneity of studies. Our study echoes the findings of the others: EGD remains an important and effective tool in diagnosing EGC. At the same time, it also points out an important limitation, that EGC can be missed on EGD. Our findings also emphasize the importance of obtaining biopsies of any abnormality and timely clinical follow-up and by repeat EGD as needed.

Transarterial chemoembolization (TACE) is a therapeutic procedure often performed for hepatocellular carcinoma (HCC). Local complications, though generally uncommon, can arise from arterial ischemia and local cytotoxicity from the chemotherapeutic delivery. We present a case of acute pancreatitis as a rare complication of the TACE procedure along with a review of literature of this uncommon adverse effect.

Introduction Smoking cessation-related weight gain can have significant negative health and career consequences for military personnel. Alcohol reduction combined with smoking cessation may decrease weight gain and relapse. Method A randomized clinical trial of military beneficiaries compared a standard smoking cessation (i.e., brief informational) intervention ( N = 159), with a brief motivational smoking cessation intervention that emphasized reduced drinking to lessen caloric intake and minimize weight gain ( N = 158). Results Participants who received the motivational intervention were significantly more likely to quit smoking at the 3-month follow-up ( p = 0.02), but the differences were not maintained at 6 ( p = 0.18) or 12 months ( p = 0.16). Neither weight change nor alcohol reduction distinguished the 2 groups. Smoking cessation rates at 12 months (motivational group = 32.91%, informational group = 25.79%) were comparable to previous studies, but successful cessation was not mediated by reduced drinking. Conclusions Alcohol reduction combined with smoking cessation did not result in decreased weight gain or improved outcomes.

// Reilly J. Clark 1, * , Michael P. Craig 1, * , Sangeeta Agrawal 2 and Madhavi Kadakia 1 1 Department of Biochemistry and Molecular Biology, Wright State University, Dayton, OH, USA 2 Dayton VA Medical Center, Dayton, OH, USA * These authors have contributed equally to this work Correspondence to: Madhavi Kadakia, email: madhavi.kadakia@wright.edu Keywords: Barrett’s esophagus; microRNA; EAC; biomarker Received: October 27, 2016 Accepted: December 22, 2017 Published: January 11, 2018 ABSTRACT Esophageal adenocarcinoma (EAC) is a highly aggressive malignancy that develops from Barrett’s esophagus (BE), an intestinal metaplasia of the distal esophagus. microRNAs (miRNAs), short non-coding regulatory RNAs, are frequently dysregulated in BE and are thought to play key roles in the onset of BE and its progression to EAC. miRNAs thus have potential diagnostic and prognostic value and are increasingly being used as cancer biomarkers. This review summarizes the current literature related to miRNAs that are dysregulated in BE within the context of Hedgehog, Notch, MAPK, NF kappa-B, Wnt and epithelial-mesenchymal transition (EMT) signaling which are thought to drive BE onset and progression. This comprehensive analysis of miRNAs and their associated signaling in the regulation of BE provides an overview of vital discoveries in this field and highlights gaps in our understanding of BE pathophysiology that warrant further investigation.