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Department: CLINICAL ROUNDS

Clinical Rounds

doi: 10.1097/01.NURSE.0000827156.74744.d5
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In Brief

HEART HEALTH

USPSTF cannot support asymptomatic AF screenings

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In a new paper published in JAMA, the US Preventive Services Task Force (USPSTF) says that it does not have enough evidence to recommend either for or against screening for atrial fibrillation (AF) in asymptomatic adults.

The USPSTF conducted a systematic review on the benefits and harms of screening for AF in older adults, accuracy of screening tests, effectiveness at detecting previously undiagnosed AF compared with usual care, and benefits and harms of anticoagulant therapy for the treatment of screen-detected AF in older adults. Adults included in the analysis were 50 years of age or older without a diagnosis or symptoms of AF and a history of transient ischemic attack or stroke.

Ultimately, the USPSTF concluded that current evidence is insufficient to recommend either for or against AF screening in asymptomatic adults. They are also uncertain whether some screening approaches could detect stroke risk associated with subclinical AF of shorter duration (less than 24 hours) or lower burden (amount or percentage of time spent in AF).

The duration that might warrant anticoagulant therapy also remains uncertain. The USPSTF acknowledges that ECG or other portable or wearable rhythm-monitoring devices are not associated with significant harm, though abnormal test results may induce anxiety.

Misinterpretation of ECG reports could lead to misdiagnosis and unnecessary treatment with anticoagulants or pharmacologic, surgical, endovascular, or combined treatments to control heart rhythm or rate.

Furthermore, detection of other abnormalities, either true- or false-positives, could lead to other testing and treatments that carry other potentials for harm.

The USPSTF suggests randomized trials of asymptomatic individuals that compare screening with usual care and assess health outcomes and harms to understand the balance between benefits and risks of AF screening. Other studies should assess how to best optimize the accuracy of AF screening tests and strategies. And finally, further research is needed to understand the risk of stroke associated with subclinical AF and AF detected by consumer devices, and how that risk varies with AF burden or duration, along with the potential benefit of anticoagulation therapy for those persons.

Reference: Davidson KW, Barry MJ, Mangione CM, et al. Screening for atrial fibrillation. JAMA. 2022;327(4):360-367. doi:10.1001/jama.2021.23732.

COVID-19

Patients report lasting ICU effects

Patients admitted to the ICU because of COVID-19 are still experiencing physical, mental, and cognitive symptoms 1 year after survival, according to a recent study published in JAMA.

Researchers at the Radboud University Medical Center Nijmegen in the Netherlands conducted an exploratory prospective multicenter cohort study in ICUs of 11 Dutch hospitals. They followed-up with 452 patients with COVID-19 age 16 years and older, 1 year after hospital discharge. Only 301 (66.8%) were included in the final study and only 246 (81.5%) of the included group completed the follow-up questionnaire.

Physical symptoms such as frailty, fatigue, and other physical problems were reported by about 75% of respondents; mental symptoms such as anxiety, depression, and posttraumatic stress disorder were reported by about 26%; and cognitive symptoms were reported in about 16%.

The most frequently reported new physical problems included weakened condition, joint stiffness, joint pain, muscle weakness, and myalgia (38.9%, 26.3%, 25.5%, 24.8%, and 21.3%, respectively).

This study has been limited due to the self-reported nature of the outcome measures. These reports cannot be used as diagnostic tools and may differ from formal neuropsychological testing.

They also operated on limited information. ICU sedation use, prone positioning, and occurrence of delirium were unavailable. Furthermore, information concerning post-ICU rehabilitation program participation was unavailable.

The authors said that physical symptoms reported in their study are more likely to be overrepresented in relation to the mental and cognitive symptoms because the patients' self-report outcome measures were primarily used to assess physical symptoms.

Finally, the occurrence of similar symptoms in ICU patients with no COVID-19 diagnoses could not be included.

The authors do note, however, that other studies have identified similar physical, mental, and cognitive outcomes in non-COVID-19 ICU patients. Another study included in an ongoing MONITOR-IC study used similar questionnaires and cut-off values. Results of that study were similar in prevalence rates among ICU survivors regardless of COVID-19 status.

Interestingly, mental symptoms in the related study were lower in patients admitted to the ICU for reasons other than COVID-19 than for those admitted because of COVID-19.

Reference: Heesakkers H, van der Hoeven JG, Corsten S, et al. Clinical outcomes among patients with 1-year survival following intensive care unit treatment for covid-19. JAMA. 2022;327(6):559-565. doi:10.1001/jama.2022.0040.

PEDIATRIC HEALTH

Enteral feeding tube strangulation warning

The US FDA has issued a warning regarding the risk of strangulation from the use of enteral feeding delivery sets in pediatric patients.

Two reports were issued to the FDA in 2021 in which toddlers died after strangulation by the tubing. Both children were under 2 years old. One instance lasted for over 10 minutes when the toddler was not supervised by a caregiver.

The FDA believes that death or serious injury from strangulation with enteral feeding tubes is rare. Nonetheless, it is recommended that healthcare providers be aware of the risk of strangulation by these devices and continue to follow protocols that allow them to monitor medical line safety.

Healthcare providers can also discuss concerns about the risk of strangulation by enteral feeding delivery sets with parents and caregivers.

The FDA is currently working to inform parents, caregivers, and healthcare providers of the risk to children. They are also working with manufacturers to evaluate risk in pediatric patients including follow-ups to evaluate the factors that could have contributed to the two 2021 cases.

The apparent rarity of these events could be due to insufficient reporting. All injuries from these sets should be reported to the FDA. Links to that reporting system are available in the reference.

Reference: Center for Devices and Radiological Health. Risk of strangulation with enteral feeding delivery sets. U.S. Food and Drug Administration. www.fda.gov/medical-devices/safety-communications/potential-risk-strangulation-children-who-use-enteral-feeding-delivery-sets?utm_medium=email&utm_source=govdelivery.

COVID-19 AND STROKE

New stroke risk stratification score

Researchers have developed a new clinical score to stratify patients at risk for stroke when hospitalized with COVID-19.

The new tool was published in Stroke and presented at the 2022 International Stroke Conference held in New Orleans in February.

Researchers used data from the American Heart Association's COVID-19 CVD Registry. They included the records of 21,420 patients, age 18 years and older, hospitalized in 122 locations between March 2020 and March 2021. The mean age was 61 years and 54% of the patients were men.

The researchers included information regarding demographics, preexisting comorbidities, home medications, and vital signs and lab values collected upon admission. The outcome was a cerebrovascular event including any ischemic or hemorrhagic stroke, TIA, or cerebral vein thrombosis.

Out of the total population analyzed, 312 (1.5%) had a cerebrovascular event. The researchers made an internally validated risk stratification score (CANDLE) with a C-statistic of 0.66 (95% CI, 0.60-0.72). Compared with a machine-learning algorithm, the performance was similar (a C-statistic of 0.69 (95% CI, 0.65-0.72). For ischemic stroke or TIA, CANDLE's C-statistic was 0.67 (95% CI, 0.59-0.76).

Reference: Merkler AE, Zhang C, Diaz I, et al. Risk stratification models for stroke in patients hospitalized with covid-19 infection: an American heart association covid-19 CVD registry study. Stroke. 2022;53(suppl 1). doi:10.1161/str.53.suppl_1.tmp13.

IN MAY, CELEBRATE

COLORECTAL CANCER

Increasing screening with cultural programming

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A culturally tailored patient navigation program (CTPNP) has been shown to be effective in increasing colorectal screening among Hispanic patients, finds a new study published in Cancer.

Researchers at the Roger Williams Medical Center, in Rhode Island, designed CTPNP with a Spanish-speaking instructor to measure colonoscopy completion (CC), colonoscopy cancelation (CN), and colonoscopy no-show (NS) rates recorded and compared with historical rates in Rhode Island.

The study originally included 733 patients; 698 patients were enrolled (53% female, 47% male) and received an introductory letter, initial phone call for education, and follow-up calls in Spanish to ensure barriers were overcome.

Overall, 85% of the enrolled patients (592) completed a colonoscopy screening. No difference was found between males and females. Only 9% (62) did not complete a screening and 6% (44) did not show up for scheduled screening.

The most common cause for a CN or NS were costs and inability to contact the patient after referral.

Forty-three percent underwent polypectomy. Just over 1% required colectomy. Almost all patients (90%) reported that they would not have completed a screening without the CTPNP.

The researchers noted that patient education about the importance of the procedure, its low complication rate, and bowel preparation are crucial factors in patient engagement. They also stressed the roles of healthcare providers in ensuring patients learn about the benefits of screening and addressing patient concerns.

The main limitation reported in the study was related to funding. The research was initially supported by a foundation grant for the 2-year project, but the group secured funding from the additional colonoscopy and colectomy procedures to continue offering services. Replication of this program will require identifying sustainable funding.

Several factors, including cultural sensitivity, language appropriateness, patient education, screening for and addressing potential barriers, and direct booking contributed to this improvement.

Reference: Winkler CS, Hardaway JC, Ceyhan ME, Espat NJ, Saied Calvino A. Decreasing colorectal cancer screening disparities: A culturally tailored patient navigation program for Hispanic patients. Cancer. [e-pub Feb. 7, 2022]

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