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Cross-Sectional Studies

Surveillance Colonoscopy Findings in Older Adults With a History of Colorectal Adenomas

Author/s: 
Lee, JK, Roy, A., Jensen, C.D., Chan, J.T., Zhao, W.K.

Importance
Postpolypectomy surveillance is a common colonoscopy indication in older adults; however, guidelines provide little direction on when to stop surveillance in this population.

Objective
To estimate surveillance colonoscopy yields in older adults.

Design, Setting, and Participants
This population-based cross-sectional study included individuals 70 to 85 years of age who received surveillance colonoscopy at a large, community-based US health care system between January 1, 2017, and December 31, 2019; had an adenoma detected 12 or more months previously; and had at least 1 year of health plan enrollment before surveillance. Individuals were excluded due to prior colorectal cancer (CRC), hereditary CRC syndrome, inflammatory bowel disease, or prior colectomy or if the surveillance colonoscopy had an inadequate bowel preparation or was incomplete. Data were analyzed from September 1, 2022, to February 22, 2024.

Exposures
Age (70-74, 75-79, or 80-85 years) at surveillance colonoscopy and prior adenoma finding (ie, advanced adenoma vs nonadvanced adenoma).

Main Outcomes and Measures
The main outcomes were yields of CRC, advanced adenoma, and advanced neoplasia overall (all ages) by age group and by both age group and prior adenoma finding. Multivariable logistic regression was used to identify factors associated with advanced neoplasia detection at surveillance.

Results
Of 9740 surveillance colonoscopies among 9601 patients, 5895 (60.5%) were in men, and 5738 (58.9%), 3225 (33.1%), and 777 (8.0%) were performed in those aged 70-74, 75-79, and 80-85 years, respectively. Overall, CRC yields were found in 28 procedures (0.3%), advanced adenoma in 1141 (11.7%), and advanced neoplasia in 1169 (12.0%); yields did not differ significantly across age groups. Overall, CRC yields were higher for colonoscopies among patients with a prior advanced adenoma vs nonadvanced adenoma (12 of 2305 [0.5%] vs 16 of 7435 [0.2%]; P = .02), and the same was observed for advanced neoplasia (380 of 2305 [16.5%] vs 789 of 7435 [10.6%]; P < .001). Factors associated with advanced neoplasia at surveillance were prior advanced adenoma (adjusted odds ratio [AOR], 1.65; 95% CI, 1.44-1.88), body mass index of 30 or greater vs less than 25 (AOR, 1.21; 95% CI, 1.03-1.44), and having ever smoked tobacco (AOR, 1.14; 95% CI, 1.01-1.30). Asian or Pacific Islander race was inversely associated with advanced neoplasia (AOR, 0.81; 95% CI, 0.67-0.99).

Conclusions and Relevance
In this cross-sectional study of surveillance colonoscopy yield in older adults, CRC detection was rare regardless of prior adenoma finding, whereas the advanced neoplasia yield was 12.0% overall. Yields were higher among those with a prior advanced adenoma than among those with prior nonadvanced adenoma and did not increase significantly with age. These findings can help inform whether to continue surveillance colonoscopy in older adults.

Keywords 
Adenoma Colonoscopy older adults

The frequency and impact of undiagnosed benign paroxysmal positional vertigo in outpatients with high falls risk

Author/s: 
Hawke, L. J., Barr, C. J., McLoughlin, J. V.

Background
The frequency and impact of undiagnosed benign paroxysmal positional vertigo (BPPV) in people identified with high falls risk has not been investigated.

Objective
To determine the frequency and impact on key psychosocial measures of undiagnosed BPPV in adult community rehabilitation outpatients identified with a high falls risk.

Design
A frequency study with cross-sectional design.

Setting
A Community Rehabilitation Program in Melbourne, Australia.

Subjects
Adult community rehabilitation outpatients with a Falls Risk for Older People in the Community Screen score of four or higher.

Methods
BPPV was assessed in 34 consecutive high falls risk rehabilitation outpatients using the Dix–Hallpike test and supine roll test. Participants were assessed for anxiety, depression, fear of falls, social isolation and loneliness using the Hospital Anxiety and Depression Scale, Falls Efficacy Scale-International and De Jong Gierveld 6-Item Loneliness Scale.

Results
A total of 18 (53%; 95% confidence interval: 36, 70) participants tested positive for BPPV. There was no significant difference between those who tested positive for BPPV and those who did not for Falls Risk for Older People in the Community Screen scores (P = 0.555), Hospital Anxiety and Depression Scale (Anxiety) scores (P = 0.627), Hospital Anxiety and Depression Scale (Depression) scores (P = 0.368) or Falls Efficacy Scale-International scores (P = 0.481). Higher scores for the De Jong Gierveld 6-Item Loneliness Scale in participants with BPPV did not reach significance (P = 0.056).

Conclusions
Undiagnosed BPPV is very common and associated with a trend towards increased loneliness in adult rehabilitation outpatients identified as having a high falls risk.

Do carotid artery calcifications seen on radiographs predict stenosis in asymptomatic adults?

Author/s: 
Cowdrey, D., Hahn, T. W., Vellardita, L.

EVIDENCE-BASED ANSWER:
NOT VERY WELL. IN ASYMPTOMATIC PATIENTS, CAROTID ARTERY CALCIFICATION SEEN ON RADIOGRAPH HAS A POSITIVE PREDICTIVE VALUE OF 70% AND A NEGATIVE PREDICTIVE VALUE OF 75% FOR CAROTID ARTERY STENOSIS (STRENGTH OF RECOMMENDATION [SOR]: B, SYSTEMATIC REVIEW OF OBSERVATIONAL STUDIES WITH HETEROGENEOUS RESULTS AND A RETROSPECTIVE COHORT STUDY). CAROTID CALCIFICATIONS ON RADIOGRAPHS MAY BE MORE PREDICTIVE OF CAROTID STENOSIS IN PEOPLE WITH ATHEROSCLEROTIC RISK FACTORS (SOR: C, CROSS-SECTIONAL STUDY). HARMS OUTWEIGH BENEFITS IN SCREENING FOR CAROTID ARTERY STENOSIS IN ASYMPTOMATIC ADULTS (SOR: B, MULTIPLE COHORT STUDIES); THEREFORE, INCIDENTAL RADIOGRAPHIC CAROTID ARTERY CALCIFICATIONS IN ASYMPTOMATIC PATIENTS SHOULD NOT PROMPT FURTHER TESTING.

Evaluation of a Chronic Pain Screening Program Implemented in Primary Care

Author/s: 
Bifulco, L., Anderson, D. R., Blankson, M. L, Channamsetty, V., Blaz, J. W., Nguyen-Louie, T., Scholle, S. H.

Importance: Although pain is among the most common symptoms reported by patients, primary care practitioners (PCPs) face substantial challenges identifying and assessing pain.

Objective: To evaluate a 2-step process for chronic pain screening and follow-up in primary care.

Design, setting, and participants: A cross-sectional study of patients with a primary care visit between July 2, 2018, and June 1, 2019, was conducted at a statewide, multisite federally qualified health center. Participants included 68 PCPs and 58 medical assistants from 13 sites who implemented the screening process in primary care, and 38 866 patients aged 18 years or older with a primary care visit during that time.

Exposures: Single-question assessment of pain frequency, followed by a 3-question PEG (pain, enjoyment of life, general activity) functional assessment for patients with chronic pain.

Main outcomes and measures: Adherence to a 2-step chronic pain screening and PEG process, proportion of patients with positive screening results, mean PEG pain severity greater than or equal to 7, and documented chronic painful condition diagnosis in patient's electronic health record between 1 year before and 90 days after screening.

Results: Of 38 866 patients with a primary care visit, 31 600 patients (81.3%) underwent screening. Mean (SD) age was 46.2 (15.4) years, and most were aged 35 to 54 years (12 987 [41.1%]), female (18 436 [58.3%]), Hispanic (14 809 [46.9%]), and English-speaking (22 519 [71.3%]), and had Medicaid insurance (18 442 [58.4%]). A total of 10 262 participants (32.5%) screened positive and, of these, 9701 (94.5%) completed the PEG questionnaire. PEG responses indicated severe pain interference with activities of daily living (PEG ≥7) in 5735 (59.1%) participants. A chronic painful condition had not been diagnosed in 4257 (43.9%) patients in the year before screening. A new chronic painful condition was diagnosed at screening or within 90 days in 2250 (52.9%) patients. Care teams found the workflow acceptable, but cited lengthy administration time, challenges with comprehension of the PEG questions, and limited comprehensiveness as implementation barriers.

Conclusions and relevance: A systematic, 2-step process for chronic pain screening and functional assessment in primary care appeared to identify patients with previously undocumented chronic pain and was feasible to implement. Patient-provided information on the frequency of pain, pain level, and pain interference can help improve the assessment and monitoring of pain in primary care.

Keywords 
chronic pain Screening Program primary care Pain Measurement

The Unrecognized Prevalence of Primary Aldosteronism

Author/s: 
Brown, JM, Siddiqui, M, Calhoun, DA, Carey, RM, Hopkins, PN, Williams, GH, Vaidya, A

Background:

Primary aldosteronism is a nonsuppressible renin-independent aldosterone production that causes hypertension and cardiovascular disease.

 

Objective:

To characterize the prevalence of nonsuppressible renin-independent aldosterone production, as well as biochemically overt primary aldosteronism, in relation to blood pressure.

 

Design:

Cross-sectional study.

 

Setting:

4 U.S. academic medical centers.

 

Participants:

Participants with normotension (n = 289), stage 1 hypertension (n = 115), stage 2 hypertension (n = 203), and resistant hypertension (n = 408).

 

Measurements:

Participants completed an oral sodium suppression test, regardless of aldosterone or renin levels, as a confirmatory diagnostic for primary aldosteronism and to quantify the magnitude of renin-independent aldosterone production. Urinary aldosterone was measured in participants in high sodium balance with suppressed renin activity. Biochemically overt primary aldosteronism was diagnosed when urinary aldosterone levels were higher than 12 µg/24 h.

 

Results:

Every blood pressure category had a continuum of renin-independent aldosterone production, where greater severity of production was associated with higher blood pressure, kaliuresis, and lower serum potassium levels. Mean adjusted levels of urinary aldosterone were 6.5 µg/24 h (95% CI, 5.2 to 7.7 µg/24 h) in normotension, 7.3 µg/24 h (CI, 5.6 to 8.9 µg/24 h) in stage 1 hypertension, 9.5 µg/24 h (CI, 8.2 to 10.8 µg/24 h) in stage 2 hypertension, and 14.6 µg/24 h (CI, 12.9 to 16.2 µg/24 h) in resistant hypertension; corresponding adjusted prevalence estimates for biochemically overt primary aldosteronism were 11.3% (CI, 5.9% to 16.8%), 15.7% (CI, 8.6% to 22.9%), 21.6% (CI, 16.1% to 27.0%), and 22.0% (CI, 17.2% to 26.8%). The aldosterone–renin ratio had poor sensitivity and negative predictive value for detecting biochemically overt primary aldosteronism.

 

Limitation:

Prevalence estimates rely on arbitrary and conventional thresholds, and the study population may not represent nationwide demographics.

 

Conclusion:

The prevalence of primary aldosteronism is high and largely unrecognized. Beyond this categorical definition of primary aldosteronism, there is a prevalent continuum of renin-independent aldosterone production that parallels the severity of hypertension. These findings redefine the primary aldosteronism syndrome and implicate it in the pathogenesis of “essential” hypertension.

 

Primary Funding Source:

National Institutes of Health.

Keywords 
primary aldosteronism hypertension cardiovascular disease

Adolescent Opioid Misuse Attributable to Adverse Childhood Experiences

Author/s: 
Swedo, E.A., Sumner, S.A., Fijter, S., Werhan, L., Norris, K., Beauregard, J.L., Montgomery, M.P., Rose, E.B., Hillis, S. D., Massetti, G.M.

Objectives

To estimate the proportion of opioid misuse attributable to adverse childhood experiences (ACEs) among adolescents.

Study design

A cross-sectional survey was administered to 10,546 7th‒12th grade students in northeastern Ohio in Spring 2018. Study measures included self-reported lifetime exposure to 10 ACEs and past 30 day use of nonmedical prescription opioid or heroin. Using generalized estimating equations, we evaluated associations between recent opioid misuse, individual ACEs, and cumulative number of ACEs. We calculated population attributable fractions (PAF) to determine the proportion of adolescents’ recent opioid misuse attributable to ACEs.

Results

Nearly one in 50 adolescents reported opioid misuse within 30 days (1.9%); ∼60% of youth experienced ≥1 ACE; 10.2% experienced ≥5 ACEs. Cumulative ACE exposure demonstrated a significant graded relationship with opioid misuse. Compared with youth with zero ACEs, youth with 1 ACE (adjusted odds ratio [AOR]: 1.9, 95% confidence interval [CI]: 0.9‒3.9), 2 ACEs (AOR: 3.8, CI: 1.9‒7.9), 3 ACEs (AOR: 3.7, CI: 2.2‒6.5), 4 ACEs (AOR: 5.8, CI: 3.1‒11.2), and ≥5 ACEs (AOR: 15.3, CI: 8.8‒26.6) had higher odds of recent opioid misuse. The population attributable fraction of recent opioid misuse associated with experiencing ≥1 ACE was 71.6% (CI: 59.8–83.5).

Conclusions

There was a significant graded relationship between number of ACEs and recent opioid misuse among adolescents. Over 70% of recent adolescent opioid misuse in our study population was attributable to ACEs. Efforts to decrease opioid misuse could include programmatic, policy, and clinical practice interventions to prevent and mitigate the negative effects of ACEs.

Keywords 
adverse childhood experience

Twenty-Four-Hour Movement Guidelines and Body Weight in Youth

Author/s: 
Zhu, X, Healy, S, Haegele, JA, Patterson, F

Objective

To examine the prevalence of youth meeting the 24-hour healthy movement guidelines (ie, ≥60 minutes of moderate-to-vigorous physical activity, ≤2 hours of screen time, age-appropriate sleep duration), and which combination of meeting these guidelines was most associated with bodyweight status, in a nationally representative US sample.

Study design

Cross-sectional data from the 2016-2017 National Survey of Children's Health were used. A multinomial regression model of body weight status was generated (underweight, overweight, obese vs healthy weight) and then stratified by sex. Analyses were adjusted for potential confounders.

Results

The sample (n = 30 478) was 50.4% female, 52.4% white, and the mean age was 13.85 ± 2.28 years; 15% percent were obese and 15.2% were overweight. Overall, 9.4% met all 3 of the 24-hour healthy movement guidelines, 43.6% met 2, 37.9% met 1, and 9.1% met none. Meeting zero guidelines (vs 3) was associated with the greatest likelihood of overweight (aOR, 1.85; 95% CI, 1.31-2.61), and obesity (aOR, 4.25; 95% CI, 2.87-6.31). Females (aOR, 4.97; 95% CI, 2.59-9.53) had higher odds of obesity than males (aOR, 3.99; 95% CI, 2.49-6.40) when zero (vs 3) guidelines were met. Meeting the moderate-to-vigorous physical activity guideline, either alone or in combination with screen time or sleep duration (vs all 3), was associated with the lowest odds for overweight and obesity in the full sample.

Conclusion

Meeting all movement guidelines was associated with the lowest risk for obesity, particularly in females. Meeting the moderate-to-vigorous physical activity guideline may be a priority to prevent overweight and obesity in youth.

Keywords 
24-hour healthy movement screen time sleep physical activity children adolescent
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