Background There is little data regarding the risk of new or recurrent cancer in patients with inflammatory bowel disease (IBD) and a prior history of cancer who are exposed to ustekinumab or vedolizumab. We assessed the risk of subsequent cancer in patients exposed to these agents. Methods We performed a retrospective cohort study of patients with IBD and a history of cancer at an academic medical center between January 2013 and December 2020. We collected data on demographics, IBD and cancer disease characteristics, and drug exposures. The primary exposure was immunosuppressive therapy after diagnosis of cancer. The primary outcome was interval development of new or recurrent cancer. Results Of 390 patients with IBD and a previous history of cancer, 37 were exposed to vedolizumab, 14 ustekinumab, 41 antitumor necrosis factor (anti-TNF), and 31 immunomodulator; and 267 were not exposed to immunosuppression following cancer diagnosis. During a total median follow-up time of 52 months, 81 (20%) patients developed subsequent cancer: 6 (16%) were exposed to vedolizumab, 2 (14%) to ustekinumab, 3 (10%) to immunomodulators, 12 (29%) to anti-TNF, and 56 (21%) with no immunosuppression (P = .41). In a multivariable Cox model adjusting for age, IBD subtype, smoking, cancer recurrence risk, and cancer stage, there was no increase in subsequent cancer with vedolizumab (adjusted hazard ratio, 1.36; 95% CI, 0.27-7.01) or ustekinumab (adjusted hazard ratio, 0.96; 95% CI, 0.17-5.41). Patients with more than 1 biologic exposure also did not have an increased risk of subsequent cancer. Conclusions Exposure to ustekinumab or vedolizumab in patients with IBD and a prior history of cancer does not appear to be associated with an increased risk of subsequent new or recurrent cancer.
Evaluating the role of D-dimer and computed tomography pulmonary angiography results COVID-19 patients have a strong propensity to develop thrombosis and their respiratory symptoms often prompt clinicians to assess for the presence of a pulmonary thromboembolism (PTE) [1,2]. Prior research estimates that approximately 20% to 30% of patients with COVID-19 have a PTE demonstrated by computed tomography pulmonary angiography (CTPA) [3,4]. Some clinical decision rules such as the Pulmonary Embolism Rule-Out Criteria (PERC) and Wells' Criteria are used to assess a patient's risk of PTE. However, patients with COVID-19 can present with chest pain, tachycardia, tachypnea, and hypoxia even without a PTE; therefore, many of these clinical decisionmaking tools are unhelpful. Furthermore, elevations of d-dimer are frequent in COVID-19 given the pathophysiology of the disease. Recent studies have explored using higher thresholds for d-dimer testing among COVID-19 patients (e.g., from 2000 μg/L to 4000 μg/L) [5]. However, it is not clear that these are appropriate parameters based on their sensitivity and specificity [5,6].We performed a retrospective cohort study at our hospitals in the NYU Langone Health System across Manhattan, Brooklyn and Long Island to evaluate the sensitivity and specificity of d-dimer testing to diagnose PTE among COVID-19 patients. We specifically compared CTPA studies performed in the emergency department (ED) versus those performed in the inpatient setting since d-dimer can increase during hospitalization due to disease progression [7]. From March 1, 2020 to June 1st, 2020, a total of 367 admitted COVID-19 positive patients had a CTPA study, as described in Table 1. Of these studies 157 (43%) were performed within 6 h of their arrival in the ED, and 210 (57%) were completed later during their inpatient hospitalization. Forty-five (29%) of the emergency department (ED) patients and 52 (25%) of the inpatients were diagnosed with an identifiable PTE.We also compared the sensitivity and specificity of d-dimer levels drawn within 6 h of arrival for CTPA studies performed in the ED (139 of 157 ED patients) or within 48 h of inpatient CTPA studies (165 of 210 inpatients) to predict the presence of a PTE (Fig. 1). At a cutoff of 2000 μg/L (i.e., eight times the normal limit of 250 μg/L), a d-dimer test would have a 78% sensitivity and 67% specificity for an identifiable PTE in the ED and a 63% sensitivity and 66% specificity in the inpatient setting among patients who received a CTPA in our study. Even if we used a cutoff at just two times the normal limit (i.e., 500 μg/L), a d-dimer only had a 94% sensitivity and 30% specificity for an identifiable PTE in the ED, compared to a sensitivity of 89% and specificity of 23% in the inpatient setting. We should point out that this study is limited by its retrospective study design and reported rates of PTE may not accurately reflect the true prevalence of PTE among COVID-19 patients. Furthermore, we also noted that 31% and 40% of the ED and inpatient studies resp...
INTRODUCTION: Screening decreases colorectal cancer (CRC) incidence and mortality, but uptake in the United States remains suboptimal at 62%. Prior studies have investigated the effect of various interventions on overall CRC screening and stool-based testing, but the effect on colonoscopy—the predominant screening test in the US—has not been fully examined. We performed a systematic review and meta-analysis to assess the effect of behavioral interventions on screening colonoscopy uptake. METHODS: We searched PubMed, EMBASE, and Cochrane databases through June 2018 for controlled trials that assessed the effect of behavioral interventions on screening colonoscopy rates. Our search yielded a total of 6,952 titles. All abstracts and articles were screened by at least two independent reviewers and 54 manuscripts were selected for review. Relative risk estimates were extracted from the original article or calculated from the raw data. The primary outcome was the relative increase in screening colonoscopy completion with any behavioral intervention. Subgroup analysis by type of intervention was also performed. Random effects meta-analysis was performed using Stata. RESULTS: A total of 21 studies with 24 behavioral interventions were analyzed. The most common interventions were patient navigation (n = 8), a combination of multiple interventions (n = 7), and educational interventions (n = 4). Overall, behavioral interventions increased colonoscopy completion by 58% compared to controls (OR 1.58, 95% CI 1.33-1.88, Figure). Patient navigation (OR 1.80, 95% CI 1.22-2.67) and multiple interventions (OR 1.70, 95% CI 1.15-2.50) had the strongest effect on colonoscopy completion. Significant heterogeneity was observed both overall and by intervention type, which may be attributed to differences in study setting and control group selection. CONCLUSION: Behavioral interventions increase screening colonoscopy completion and should be considered in clinical practice. In particular, patient navigation and multiple interventions are the best-studied and most effective interventions.
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