Introductory Letter Research Articles

Cytosponge-trefoil factor 3 versus usual care to identify Barrett's oesophagus in a primary care setting: a multicentre, pragmatic, randomised controlled trial

SummaryBackgroundTreatment of dysplastic Barrett's oesophagus prevents progression to adenocarcinoma; however, the optimal diagnostic strategy for Barrett's oesophagus is unclear. The Cytosponge-trefoil factor 3 (TFF3) is a non-endoscopic test for Barrett's oesophagus. The aim of this study was to investigate whether offering this test to patients on medication for gastro-oesophageal reflux would increase the detection of Barrett's oesophagus compared with standard management.MethodsThis multicentre, pragmatic, randomised controlled trial was done in 109 socio-demographically diverse general practice clinics in England. Randomisation was done both at the general practice clinic level (cluster randomisation) and at the individual patient level, and the results for each type of randomisation were analysed separately before being combined. Patients were eligible if they were aged 50 years or older, had been taking acid-suppressants for symptoms of gastro-oesophageal reflux for more than 6 months, and had not undergone an endoscopy procedure within the past 5 years. General practice clinics were selected by the local clinical research network and invited to participate in the trial. For cluster randomisation, clinics were randomly assigned (1:1) by the trial statistician using a computer-generated randomisation sequence; for individual patient-level randomisation, patients were randomly assigned (1:1) by the general practice clinics using a centrally prepared computer-generated randomisation sequence. After randomisation, participants received either standard management of gastro-oesophageal reflux (usual care group), in which participants only received an endoscopy if required by their general practitioner, or usual care plus an offer of the Cytosponge-TFF3 procedure, with a subsequent endoscopy if the procedure identified TFF3-positive cells (intervention group). The primary outcome was the diagnosis of Barrett's oesophagus at 12 months after enrolment, expressed as a rate per 1000 person-years, in all participants in the intervention group (regardless of whether they had accepted the offer of the Cytosponge-TFF3 procedure) compared with all participants in the usual care group. Analyses were intention-to-treat. The trial is registered with the ISRCTN registry, ISRCTN68382401, and is completed.FindingsBetween March 20, 2017, and March 21, 2019, 113 general practice clinics were enrolled, but four clinics dropped out shortly after randomisation. Using an automated search of the electronic prescribing records of the remaining 109 clinics, we identified 13 657 eligible patients who were sent an introductory letter with 14 days to opt out. 13 514 of these patients were randomly assigned (per practice or at the individual patient level) to the usual care group (n=6531) or the intervention group (n=6983). Following randomisation, 149 (2%) of 6983 participants in the intervention group and 143 (2%) of 6531 participants in the usual care group, on further scrutiny, did not meet all eligibility criteria or withdrew from the study. Of the remaining 6834 participants in the intervention group, 2679 (39%) expressed an interest in undergoing the Cytosponge-TFF3 procedure. Of these, 1750 (65%) met all of the eligibility criteria on telephone screening and underwent the procedure. Most of these participants (1654 [95%]; median age 69 years) swallowed the Cytosponge successfully and produced a sample. 231 (3%) of 6834 participants had a positive Cytosponge-TFF3 result and were referred for an endoscopy. Patients who declined the offer of the Cytosponge-TFF3 procedure and all participants in the usual care group only had an endoscopy if deemed necessary by their general practitioner. During an average of 12 months of follow-up, 140 (2%) of 6834 participants in the intervention group and 13 (<1%) of 6388 participants in the usual care group were diagnosed with Barrett's oesophagus (absolute difference 18·3 per 1000 person-years [95% CI 14·8–21·8]; rate ratio adjusted for cluster randomisation 10·6 [95% CI 6·0–18·8], p<0·0001). Nine (<1%) of 6834 participants were diagnosed with dysplastic Barrett's oesophagus (n=4) or stage I oesophago-gastric cancer (n=5) in the intervention group, whereas no participants were diagnosed with dysplastic Barrett's oesophagus or stage I gastro-oesophageal junction cancer in the usual care group. Among 1654 participants in the intervention group who swallowed the Cytosponge device successfully, 221 (13%) underwent endoscopy after testing positive for TFF3 and 131 (8%, corresponding to 59% of those having an endoscopy) were diagnosed with Barrett's oesophagus or cancer. One patient had a detachment of the Cytosponge from the thread requiring endoscopic removal, and the most common side-effect was a sore throat in 63 (4%) of 1654 participants.InterpretationIn patients with gastro-oesophageal reflux, the offer of Cytosponge-TFF3 testing results in improved detection of Barrett's oesophagus. Cytosponge-TFF3 testing could also lead to the diagnosis of treatable dysplasia and early cancer. This strategy will lead to additional endoscopies with some false positive results.FundingCancer Research UK, National Institute for Health Research, the UK National Health Service, Medtronic, and the Medical Research Council.

Heparin Flush Use in Transfemoral Cerebral Angiography Survey

The drug concentration of heparinized saline used for transfemoral catheter angiography flush during different types of cerebral angiogram procedures varies among providers and centers worldwide. Although heparin is recommended for use during cerebral angiograms to minimize the risk of thromboembolic events associated with the utilization of multiple endovascular devices and lengthy procedures, there is a paucity of information available regarding protocols for administration of heparin and heparinized saline. Higher concentrations of heparinized saline flush may benefit patients undergoing elective nonruptured intracranial aneurysm embolization procedures by decreasing the risk of thromboembolism. However, it could potentially place patients undergoing revascularization procedures for acute ischemic stroke at higher risk of symptomatic intracerebral hemorrhage, particularly if they received intravenous tissue plasminogen activator immediately before endovascular thrombectomy. After obtaining permission from the Association for Radiologic and Imaging Nursing (ARIN) Board of Directors, a survey was presented in English and electronically distributed by the ARIN to all current and past ARIN members with valid e-mail addresses. The survey was preceded by an introductory letter explaining the study purpose and its voluntary nature. Response to the survey was identified as consent to participate. Subjects were asked to participate if they were currently involved in the management of patients undergoing cerebral angiography with a variety of interventions including management of acute ischemic and hemorrhagic stroke. There is a paucity of evidence supporting use of a specific concentration of heparinized saline solution. It ranges from no heparin added to concentrations exceeding 5 units/mL for transfemoral flush. The most frequently used concentration is 2 units/mL (32.8–34.8% of respondents depending on endovascular intervention), and the least frequently utilized concentrations are 3 units/mL and higher than 5 units/mL (4.3–5.7% of respondents depending on endovascular intervention). Mixing and labeling bags with heparinized saline flush was noted to be the responsibility of interventional radiology registered nurse (39%, n = 46), pharmacy (26.3%, n = 31), or the angiography technologist (8.5%, n = 10). More than quarter (26.5%) of respondents noted not having readily available premixed heparinized saline flush. Twenty-four (20.3%) of survey participants claimed using only premixed bags of heparinized saline solution. Despite the Institute for Healthcare Improvement, Institute for Safe Medication Practices and Joint Commission recommendations, there are no standard protocols across stroke centers identifying optimal heparinized saline flush solution concentration, preparation, and documentation. Replication of this survey among members of the American Society of Neuroradiology is recommended to validate the findings from the present study. If confirmed, a consensus on safety of heparinized saline flush use during neuroradiology interventions is strongly advised.

Costs of Two Health Insurance Plan Programs to Mail Fecal Immunochemical Tests to Medicare and Medicaid Plan Members.

BeneFIT is a 4-year observational study of a mailed fecal immunochemical test (FIT) program in 2 Medicaid/Medicare health plans in Oregon and Washington. In Health Plan Oregon's (HPO) collaborative model, HPO mails FITs that enrollees return to their clinics for processing. In Health Plan Washington's (HPW) centralized model, FITs are mailed directly to enrollees who return them to a centralized laboratory. This paper examines model-specific Year 1 development and implementation costs and estimates costs per screened enrollee. Staff completed activity-based costing spreadsheets. Non-labor costs were from study and external data. Data matched each plan's 2016 development and implementation dates. HPO development costs were $23.0K, primarily administration (eg, clinic recruitment). HPW development costs were $37.3K, 38.8% for FIT selection and mailing/tracking protocols. Year 1 implementation costs were $51.6K for HPO and $139.7K for HPW, reflecting HPW's greater outreach. Labor was 50.4% ($26.0K) of HPO's implementation costs, primarily enrollee eligibility and processing returned FITs, and was shared by HPO ($17.0K) and 6 participating clinics ($9.0K). Labor was 10.5% of HPW's implementation costs, primarily administration and enrollee eligibility. HPO's implementation costs per enrollee were 12.3% higher ($18.36) than for HPW ($16.34). Similar proportions of completed FITs among screening-eligibles produced a 15% lower cost per completed FIT in HPW ($89.75) vs. HPO ($105.79). Implementation costs for HPO only (without clinic costs) were $15.16/mailed introductory letter, $16.09/mailed FIT, and $87.35/completed FIT, comparable to HPW. Results highlight cost implications of different approaches to implementing a mailed FIT program in 2 Medicaid/Medicare health plans.

Abstract C129: Do phone-based discussions about the importance of colorectal cancer screening delivered before a fecal immunochemical test (FIT) mailing improve return rates?

Abstract Patients who have never completed a fecal immunochemical test (FIT) may benefit from phone-based discussions about the importance of colon cancer screening before receiving the FIT in the mail. Colorectal cancer is the second-leading cause of cancer death in the United States, and screening rates are disproportionately low among Latinxs. In 2015, only 63% of eligible adults, and 50% of Latinxs, were up to date with colorectal cancer screening recommendations. Mailed FIT outreach programs have been shown to improve colorectal cancer screening rates in community health centers, with improvements ranging from 22% – 45%. Despite the widespread use of primers and reminders for mailed FIT outreach programs, data are sparse on how these communications influence FIT completion rates. Data from our previous evaluation of mailed FIT outreach showed that adults who have never completed a FIT have a much lower FIT return rate than adults who have (17.1 vs 45.1; p &amp;lt; 0.01). As part of the Participatory Research to Advance Colon Cancer Prevention (PROMPT), which involved a partnership with a Los Angeles-based community health center that provides medical services to 300,000 patients annually (82% are Latinx), we tested whether patients who had never completed a FIT could benefit from phone-based discussions about the importance of colorectal cancer screening. Eligible patients were 50-74, due for their screening, and assigned to a wedge 1 clinic (n = 8 clinics; 6,872 patients). A total of 2,825 patients had no electronic health record evidence of having completed a prior FIT. These patients were randomized to receive the text primer (n = 1,622) or live call primer (n = 1,203). All live primer calls were delivered by bilingual health education staff trained by the research team. Patients were then mailed a FIT kit with an introductory letter and wordless instructions on completing the FIT, followed by two automated phone call reminders and live reminder calls delivered by the care team. We used logistic regression to compare the effectiveness of live call vs text message primers on FIT completion rates 3 months after the FIT mailing. Randomized patients (who had never completed the FIT) had a mean age of 58 years (SD, 6.0), 51% were female, and 80% Latinx. In the text primer arm, the overall FIT completion rate was 14.7%, and 14.6% among those who were successfully delivered the text primer. In the live call arm, the overall FIT completion rate was 18.8%, and 30.0% among those who had a discussion with health education staff. Controlling for age, preliminary analyses indicate that patients who received a live call were 1.35 times more likely to complete a FIT within 3 months of the mailing than those who received a text message primer (OR=1.35 [1.10, 1.64]). Live phone call primers, delivered before the FIT is mailed, boost screening rates among those who have never completed a FIT. Note: This abstract was not presented at the conference. Citation Format: Jamie Thompson, Denis Nyongesa, Amanda Petrik, Melissa Castillo, Gloria Coronado. Do phone-based discussions about the importance of colorectal cancer screening delivered before a fecal immunochemical test (FIT) mailing improve return rates? [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C129.

Abstract B046: Incorporating Latino patient input in patient-facing materials for a mailed fecal test outreach program

Abstract Colorectal cancer screening rates are disproportionately low among Latinos. In 2015, only 63% of eligible adults, and 50% of Latinos, were up-to-date with colon cancer screening recommendations. One factor thought to contribute to the low screening rate is that patient-facing health information for Latinos is difficult to understand and patients face challenges in taking health action. As part of the Participatory Research to Advance Colon Cancer Prevention (PROMPT) study, we used boot camp translation (BCT), a community based participatory strategy, to elicit input from stakeholders and refine materials for a clinic-based mailed fecal immunochemical test (FIT) outreach program. Eligible patient participants were Latino, ages 50 to 75 years, able to speak English or Spanish, and willing to participate in an in-person meeting and follow-up phone calls. Separate sessions were held for English- and Spanish-speaking participants. The in-person session included presentations by a national expert on colon cancer prevention and screening messages, and interactive small group sessions to discuss optimal timing and modality for delivering reminders to a mailed FIT program. The phone calls consisted of iterative conversations to refine bilingual materials to encourage screening. BCT participants desired messages that increased awareness about colon cancer and prevention, stressed the importance of screening, emphasized the motivating influence of family, and used personalized statements such an “I” or “we” in letters or automated phone calls. These preferences were incorporated into outreach materials. (Samples will be provided.) 1-Patient Introductory Letter Included in the FIT Kit Mailing. Revisions recommended by BCT participants included 1) details about colon cancer and the need for prevention, 2) emphasis on a free test, 3) inclusion of a photograph of a multigenerational Latino family, 4) the addition of a colon diagram for visual appeal and education, and 5) messages about how screenings can save lives. The group also wanted emphasis on the test being “simple” and “something you can do at home.” 2-Educational Fact Sheet. We also developed a bilingual fact sheet using participant-preferred messages and simple infographics from the BCT expert presentation. The fact sheet presented statistics about colon cancer diagnoses and deaths, and answered the following questions: “What is colon cancer? When should I get tested? How do I get tested?” 3-FIT Kit Wordless Instructions. We found that patients generally preferred simple, wordless instructions, reporting they were less intimidating and helpful as they showed the small amount of fecal matter needed for the test. We developed FIT wordless instructions based on these findings and included the document with the mailing. Using BCT, we successfully incorporated feedback from English- and Spanish-speaking Latino patients to design and enhance culturally relevant materials to promote FIT testing among patients served by community clinics. Citation Format: Jamie Thompson, Melinda Davis, LeAnn Michaels, Jennifer Rivelli, Marta Castro, Brittany Younger, Melissa Castillo, Sacha Reich, Gloria Coronado. Incorporating Latino patient input in patient-facing materials for a mailed fecal test outreach program [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B046.

Introductory letter from the Editor-in-Chief

Welcome to Volume 1 Issue 3 of Journal of Nuffield Department of Surgical Sciences!

How to Write a CV

An introductory enterprise letter is meant to make a very good effect with an ability customer. Writing a letter to introduce your business to someone entails shifting the focal point on your correspondent engaging his or her interest, and launching a conversation, as opposed to a lecture.

A History dedicated to Mehmed II? Kritoboulos of Imbros and the enshrining of a Superior's memory after the conquest of Constantinople in 1453

This article examines the perception and productive acquisition of historical realities thereby questioning the imperative applicability of terms like "victory" or "defeat". This complex matter will be exemplified by an extremely controversial source: the ξυγγραΦή ίστοίων, the History of Kritoboulos of Imbros, an author who is notorious for being a biased admirer of Mehmed II. It will be argued that his work is not a mere product of Ottoman panegyric but a productive and innovative attempt to come to terms with the historical events on a broader scope. In this respect, it offers both an alternative explanatory approach and an innovative counter concept to Christian eschatology contributing to the literary discourse on the perception, interpretation and evaluation of the outcome of events. Hence, focal passages of Kritoboulos’ History such as the introductory letter of dedication and the general assault on Constantinople are analyzed.

Mary Wollstonecraft’s Reflections on the French Revolution in her Letters

Mary Wollstonecraft went to Paris in December 1792 to see revolutionary France for herself. Her experience in France had significant effects on her understanding of the French Revolution and even changed her earlier ideas about the Revolution. This paper traces Wollstonecraft’s view of the Revolution by examining her lesser known epistolary introduction for “A Series of Letters on the Present Character of the French Nation” and her other writings, including her reviews of other writers’ epistolary works and her personal correspondence. This paper first looks at Wollstonecraft’s reviews on Helen Maria Williams’s Letters Written in France (1790) and Catharine Macaulay’s Letters on Education (1790) to investigate Wollstonecraft’s ideas of the published epistolary writings and to illuminate their influence on her introductory letter. It also explores her personal letter to Joseph Johnson on 26 December 1792 to examine the ways in which she wrote her eyewitness account of revolutionary France in her personal correspondence. The introductory letter, written two months after her arrival in Paris, reveals her initial response to France and shows her confusion between her expectations of the Revolution and what she actually witnessed in France. By exploring the internal evidence in the introductory letter, this paper sketches out what “A Series of Letters on the Present Character of the French Nation” was like. It then examines how Wollstonecraft offered her philosophical reflection on the Revolution in this introductory letter. However, she discontinued her epistolary project and instead started writing the history of the Revolution of 1789. This paper finishes by tracing the reasons why she stopped writing the epistolary work and began writing in the genre of history.

Nurse academics' experience of contra-power harassment from under-graduate nursing students in Australia

BackgroundThere is growing concern around inappropriate behaviour being perpetrated by under-graduate nursing students towards nursing academics. Coined contra-power harassment, is defined as the harassment of individuals in formal positions of power and authority by those that are not. The type of harassment behaviours reported include: verbal and physical violence, character assassination through social media, stalking and sexually motivated behaviours. The most often cited reasons for the escalation in these behaviours are seen with course progression and the awarding of grades. AimThe aim of this study is to better understand the extent to which nursing academics experience contra-power harassment from under-graduate nursing students. MethodA convenience sample of nursing academics were in Australia were contacted and provided with an introductory letter, a participant information sheet and a link to an online questionnaire. A 41-item Likert scale (Strongly agree-strongly disagree) was used to elicit responses to statements on academics' experiences of and the contributing factors associated with contra-power harassment. ResultsThe main contributing factor identified from this study was seen as the consumerism of higher education; in particular paying for a degree gave a sense of entitlement with academics experiencing the highest levels of student harassment around grades. ConclusionsContra-power harassment is becoming common place in higher education especially in nursing education. The competitive nature of obtaining employment post-university has meant that some nursing student's behaviours are becoming increasingly uncivil, challenging and unprofessional.

Direct-to-member mailed colorectal cancer screening outreach for Medicaid and Medicare enrollees: Implementation and effectiveness outcomes from the BeneFIT study.

BackgroundColorectal cancer screening uptake is low, particularly among individuals enrolled in Medicaid. To the authors' knowledge, little is known regarding the effectiveness of direct‐to‐member outreach by Medicaid health insurance plans to raise colorectal cancer screening use, nor how best to deliver such outreach.MethodsBeneFIT is a hybrid implementation‐effectiveness study of 2 program models that health plans developed for a mailed fecal immunochemical test (FIT) intervention. The programs differed with regard to whether they used a centralized approach (Health Plan Washington) or collaborated with health centers (Health Plan Oregon). The primary implementation outcome of the current study was the percentage of eligible enrollees to whom the plans delivered each intervention component. The primary effectiveness outcome was the rate of FIT completion within 6 months of mailing of the introductory letter.ResultsThe health plans identified 12,000 eligible enrollees (8551 in Health Plan Washington and 3449 in Health Plan Oregon). Health Plan Washington mailed an introductory letter and FIT kit to 8551 enrollees (100%) and delivered a reminder call to 839 (10.3% of the 8132 attempted). Health Plan Oregon mailed an introductory letter, and a letter and FIT kit plus a reminder postcard to 2812 enrollees (81.5%) and 2650 enrollees (76.8%), respectively. FIT completion rates were 18.2% (1557 of 8551 enrollees) in Health Plan Washington. In Health Plan Oregon, completion rates were 17.4% (488 of 2812 enrollees) among enrollees who were mailed an introductory letter and 18.3% (484 of 2650 enrollees) among enrollees who also were mailed a FIT kit plus reminder postcard.ConclusionsThe implementation of mailed FIT outreach by health plans may be effective and could reach many individuals at risk of developing colorectal cancer.

Introductory Pages and Letter from the Editor

Introductory Pages and Letter from the Editor

Variation in pelvic radiography practice: Why can we not standardise image acquisition techniques?

IntroductionPelvic radiographs remain an essential investigation in orthopaedic practice. Although it is recognised that acquisition techniques can affect image appearances and measurement accuracy, it remains unclear what variation in practice exists and what impact this could have on decision making. MethodThis was a cross sectional survey of UK radiology departments utilising an electronic tool. An introductory letter and link was distributed. Responses were received from 69 unique hospital sites within the specified timeframe, a response rate of 37.9%. ResultsThere was no consistent technique for the positioning of patients for pelvic radiographs. The distance varied between 90 and 115 cm and 10 different centering points were described. In relation to leg position, the feet are usually internally rotated (65 of 69 [94.2%]). Only 1 teaching hospital (1 of 69 [1.4%]) uses a weight-bearing position as standard.Orthopaedic calibration devices were not in routine use, with only 21 using on pelvic x-rays (30.4%). Further, the type of device and application criteria were inconsistent. ConclusionsTo our knowledge this is the first study to directly compare radiographic positioning across hospital sites. Our data demonstrated marked variation in technique for pelvis radiographs with associated implications for clinical decision making. Research is required to determine the standard technique and quality outcome measures to provide confidence in diagnostic interpretation particularly for serial radiographs.

PENYUSUNAN DAN IMPLEMENTASI SISTEM PELAYANAN PUBLIK SURAT PENGANTAR RT/ RW ONLINE UNTUK MEWUJUDKAN SEMARANG “SMART CITY”

Every citizen expects that RT / RW cover letter service can be obtained quickly and accurately. However, the expectation of public services such as introducing RT / RW letters sometimes can not be realized. Often the handling of RT / RW cover letters takes days. The purpose of this community service activity is to improve the quality of public service in the form of introductory letter service of RT / RW for the people in need. Specific targets of community service are: (1) establishment of public service system of RT / RW introduction letter online, and (2) implementation of public service system of RT / RW introduction letter online. Based on the results of community service activities, it is concluded that the RT RW online introduction letter application system is one of the alternative solutions for effective citizen administration services, since this system can overcome the difficulties of citizens in obtaining administrative services indefinitely dimensional space and time. The residents welcomed the existence of this RT RW online introduction letter application system, especially for residents of immigrant residents (residents of residential complex). However, for the original villagers, the existence of this system has not been so needed. The majority of the original villagers will not use this online system. Based on feedback on the ease of use of the system and the attractive appearance of this system, it is realized that the system is still a lot of shortcomings, so that future improvements are still needed.

THE ANCIENT EPISTOLARY COLLECTION REDUX: ‘SOCRATES’ AND CICERO IN PETRARCH'S FAM. 1.1

Abstract: The introductory letter of Petrarch's collection of prose epistles (Epistolae Familiares) includes a number of traditional programmatic elements, including a dedication to his close friend Ludwig Van Kempen, a narrative describing the collection's genesis, and a defence of its style and contents, rooted in the example of Cicero's letters to Atticus, Quintus, and Brutus, which Petrarch had discovered some five years earlier. In other ways, Fam. 1.1 is an absolutely unprecedented introduction to an epistolary collection — ultimately staging within the letter a kind of ‘conversion narrative’ that transforms the yet-uncompleted collection into an instantiation of the spiritual journey of its author.

Effectiveness of automated and live phone reminders after mailed-FIT outreach in a pilot randomized trial.

The effectiveness of annual mailed fecal immunochemical testing (FIT) outreach is highest when return rates are optimized, which is aided by patient reminders. In a pilot patient-randomized controlled trial in two western Washington clinics of the Sea Mar Community Health Centers, we compared the effectiveness of two phone-based approaches to mailed FIT outreach reminders. In fall 2016, patients ages 50–75, due for colorectal cancer screening, and with a visit in the previous year at either of two clinics, were mailed an introductory letter and FIT. Those who did not return the FIT within 3 weeks (N = 427) were randomized to receive either: a) a series of up to 6 automated phone reminders; or b) the combination of automated and live phone reminders (up to 6 in total). The sole outcome was FIT return within 6 months after the FIT mailing. FIT completion rates were similar in the groups assigned to receive automated calls vs automated plus live calls (40% vs 39%; p = 0.89). The effectiveness of FIT reminder mode differed by language preference (p for interaction = 0.03): among Spanish-preferring patients (n = 106), FIT return rates were higher in the automated-only group than to the auto- plus live-call group (62% vs 39%, p = 0.02). Among English-preferring patients, no difference in modes was observed (n = 279, 32% vs 34%, p = 0.74). We observed no added benefit of live reminder calls in a mailed FIT plus automated call reminder program; our findings may inform efforts to efficiently optimize mailed-FIT outreach programs.ClinicalTrials.gov identifier NCT01742065

Effectiveness of a Mailed Colorectal Cancer Screening Outreach Program in Community Health Clinics

Approximately 24 million US individuals receive care at federally qualified health centers, which historically have low rates of colorectal cancer screening. The US Preventive Services Task Force recommends routine colorectal cancer screening for individuals aged 50 to 75 years. To determine the effectiveness of an electronic health record (EHR)-embedded mailed fecal immunochemical test (FIT) outreach program implemented in health centers as part of standard care. This cluster randomized pragmatic clinical trial was conducted in 26 federally qualified health center clinics, representing 8 health centers in Oregon and California, randomized to intervention (n = 13) or usual care (n = 13). All participants were overdue for colorectal cancer screening during the accrual interval (February 4, 2014 to February 3, 2015). Electronic health record-embedded tools to identify eligible adults and to facilitate implementation of a stepwise mailed intervention involving (1) an introductory letter, (2) a mailed FIT, and (3) a reminder letter; training, collaborative learning, and facilitation through a practice improvement process. Effectiveness was measured as clinic-level proportions of adults who completed a FIT, and secondarily, any colorectal cancer screening within 12 months of accrual or by August 3, 2015. Implementation was measured as clinic-level proportions of adults who were mailed an introductory letter and ordered a FIT. Twenty-six clinics with 41 193 adults (mean [SD] age, 58.5 [6.3] years; 22 994 women) were randomized to receive the direct mail colorectal screening intervention (13 clinics; 21 134 patients) or usual care (13 clinics; 20 059 patients). Compared with usual care clinics, intervention clinics had significantly higher adjusted clinic-level proportion of participants who completed a FIT (13.9% vs 10.4%; difference, 3.4 percentage points; 95% CI, 0.1%-6.8%) and any colorectal cancer screening (18.3% vs 14.5%; difference, 3.8 percentage points; 95% CI, 0.6%-7.0%). We observed large variation across health centers in effectiveness (FIT completion differences range, -7.4 percentage points to 17.6 percentage points) and implementation (proportion who were mailed a FIT range, 6.5% to 68.2%). The number needed to mail to achieve a completed FIT was 4.8 overall, and 4.0 in clinics that mailed a FIT reminder. An EHR-embedded mailed FIT outreach intervention significantly improved rates of FIT completion and rates of any colorectal cancer screening. Higher rates of colorectal cancer screening occurred in clinics that successfully implemented the mailed outreach program. ClinicalTrials.gov identifier: NCT01742065.

Organizing Chair Introductory Letter, WSRM 2017.

Organizing Chair Introductory Letter, WSRM 2017.

President Introductory Letter, WSRM 2017.

The 9th Congress of the World Society for Reconstructive Microsurgery (WSRM) was successfully held at the COEX Convention and Exhibition Center in Seoul from June 14 to 17, 2017. The theme, “Bridging the Gap and Beyond,” was met with more than 350 international faculty and 1,350 microsurgeons from 72 countries. The participants from North, Central, and South America, Europe, Asia, Australia, and Africa made it a truly global event. We are quite proud of this record-setting meeting.

Call for Editorial Board Members

The drug concentration of heparinized saline used for transfemoral catheter angiography flush during different types of cerebral angiogram procedures varies among providers and centers worldwide. Although heparin is recommended for use during cerebral angiograms to minimize the risk of thromboembolic events associated with the utilization of multiple endovascular devices and lengthy procedures, there is a paucity of information available regarding protocols for administration of heparin and heparinized saline. Higher concentrations of heparinized saline flush may benefit patients undergoing elective nonruptured intracranial aneurysm embolization procedures by decreasing the risk of thromboembolism. However, it could potentially place patients undergoing revascularization procedures for acute ischemic stroke at higher risk of symptomatic intracerebral hemorrhage, particularly if they received intravenous tissue plasminogen activator immediately before endovascular thrombectomy. After obtaining permission from the Association for Radiologic and Imaging Nursing (ARIN) Board of Directors, a survey was presented in English and electronically distributed by the ARIN to all current and past ARIN members with valid e-mail addresses. The survey was preceded by an introductory letter explaining the study purpose and its voluntary nature. Response to the survey was identified as consent to participate. Subjects were asked to participate if they were currently involved in the management of patients undergoing cerebral angiography with a variety of interventions including management of acute ischemic and hemorrhagic stroke. There is a paucity of evidence supporting use of a specific concentration of heparinized saline solution. It ranges from no heparin added to concentrations exceeding 5 units/mL for transfemoral flush. The most frequently used concentration is 2 units/mL (32.8–34.8% of respondents depending on endovascular intervention), and the least frequently utilized concentrations are 3 units/mL and higher than 5 units/mL (4.3–5.7% of respondents depending on endovascular intervention). Mixing and labeling bags with heparinized saline flush was noted to be the responsibility of interventional radiology registered nurse (39%, n = 46), pharmacy (26.3%, n = 31), or the angiography technologist (8.5%, n = 10). More than quarter (26.5%) of respondents noted not having readily available premixed heparinized saline flush. Twenty-four (20.3%) of survey participants claimed using only premixed bags of heparinized saline solution. Despite the Institute for Healthcare Improvement, Institute for Safe Medication Practices and Joint Commission recommendations, there are no standard protocols across stroke centers identifying optimal heparinized saline flush solution concentration, preparation, and documentation. Replication of this survey among members of the American Society of Neuroradiology is recommended to validate the findings from the present study. If confirmed, a consensus on safety of heparinized saline flush use during neuroradiology interventions is strongly advised.