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African Americans and Appalachians experience greater incidence and mortality rates of colorectal cancer due to factors, such as reduced prevalence of screening. An educational session (the Screen to Save Initiative) was conducted to increase intent to screen for colorectal cancer among African Americans and Appalachians in Ohio. Using a community-based approach, from April to September 2017, 85 eligible participants were recruited in Franklin County and Appalachia Ohio. Participants completed a knowledge assessment on colorectal cancer before and after participating in either an educational PowerPoint session or a guided tour through an Inflatable Colon. Logistic regression models were used to determine what factors were associated with changes in colorectal cancer knowledge and intent to screen for colorectal cancer. The majority (71.79%) of participants gained knowledge about colorectal cancer after the intervention. Multivariate results showed that race (OR = 0.30; 95% CI: 0.11–0.80 for African Americans versus White participants) and intervention type (OR = 5.97; 95% CI: 1.94–18.43 for PowerPoint versus Inflatable Colon) were associated with a change in knowledge. The association between education and intent to screen was marginally statistically significant (OR = 0.42; 95% CI: 0.16–1.13 for college graduate versus not a college graduate). A change in colorectal cancer knowledge was not associated with intent to screen. Future educational interventions should be modified to increase intent to screen and screening for colorectal cancer. Further research with these modified interventions should aim to reduce disparities in CRC among underserved populations while listening to the voices of the communities.

ContextThe coronavirus disease 2019 (COVID-19) pandemic has created a need for remote blood glucose (BG) monitoring in the intensive care unit (ICU).ObjectiveTo evaluate feasibility and patient safety of a hybrid monitoring strategy of point-of-care (POC) BG plus continuous glucose monitor (CGM) in the ICU.DesignRetrospective analysis.SettingICU of an academic medical center.PatientsPatients with COVID-19 on IV insulin.InterventionAfter meeting initial validation criteria, CGM was used for IV insulin titration and POC BG was performed every 6 hours or as needed.Main Outcome MeasuresOutcomes included frequency of POC BG, workflow, safety, and accuracy measures.ResultsThe study included 19 patients, 18 with CGM data, mean age 58 years, 89% on mechanical ventilation, 37% on vasopressors, and 42% on dialysis. The median time to CGM validation was 137 minutes (interquartile range [IQR] 114-206). During IV insulin, the median number of POC values was 7 (IQR 6-16) on day 1, and declined slightly thereafter (71% reduction compared with standard of 24/day). The median number of CGM values used nonadjunctively to titrate IV insulin was 11.5 (IQR 0, 15) on day 1 and increased thereafter. Time in range 70 to 180 mg/dL was 64 ± 23% on day 1 and 72 ± 16% on days 2 through 7, whereas time ConclusionsThis study provides data to support that CGM using a hybrid protocol is feasible, accurate, safe, and has potential to reduce nursing and staff workload.

Individuals who are on long-term opioid therapy (LTOT) for chronic noncancer pain are frequently admitted to the hospital with acute pain, exacerbations of chronic pain, or comorbidities. Consequently, hospitalists find themselves faced with complex treatment decisions in the context of uncertainty about the effectiveness of LTOT as well as concerns about risks of overdose, opioid use disorders, and adverse events. Our multidisciplinary team sought to synthesize guideline recommendations and primary literature relevant to assessing medical inpatients on LTOT, with the objective of assisting practitioners in balancing effective pain treatment and opioid risk reduction. We identified no primary studies or guidelines specific to assessing medical inpatients on LTOT. Recommendations from outpatient guidelines on LTOT and guidelines on pain management in acute-care settings include the following: evaluate both pain and functional status, differentiate acute from chronic pain, investigate the preadmission course of opioid therapy, obtain a psychosocial history, screen for mental health conditions, screen for substance use disorders, check state prescription drug monitoring databases, order urine drug immunoassays, detect use of sedative-hypnotics, and identify medical conditions associated with increased risk of overdose and adverse events. Although approaches to assessing medical inpatients on LTOT can be extrapolated from related guidelines, observational studies, and small studies in surgical populations, more work is needed to address these critical topics for inpatients on LTOT.

The widely used Official Disability Guidelines (ODG), a utilization review guideline for occupational conditions, has not been independently evaluated recently.We applied the appraisal of guidelines for research and evaluation (AGREE II) and modified a measurement tool to assess systematic reviews (AMSTAR) instruments to assess guideline development methods and the quality of supporting systematic reviews. Multidisciplinary experts rated the validity of clinical content for 47 topics.The overall AGREE II score was 58% due to a combination of favorable attributes (breadth, clear recommendations, frequent updating, and application tools) and unfavorable attributes (scant input from workers and uncertainty about editorial independence). The modified AMSTAR rating was fair/good due to limited information on methods. Panelists rated clinical content as valid for 41 topics.ODG appears to be acceptable to clinicians, but ODG requires greater rigor to keep pace with methodological advances in the field of guideline development.

Background Neuroendocrine carcinomas (NECs) of the cervix comprise only 2% of all cervical cancers. Prospective data is limited and treatment guidelines rely on retrospective reviews and literature from lung NEC. The objective of this study was to report our experience in the management of this rare disease. Methods This was an IRB-approved retrospective review. Study criteria included patients with cervical NEC diagnosed between 1990 and 2012. Demographic, treatment and survival data was collected. Progression free survival (PFS) and overall survival (OS) were assessed. Results Twenty-six patients met inclusion criteria. Advanced-stage disease (II–IV) was diagnosed in 58% (n=15) of patients. Of the eleven patients with stage I disease, five were treated with platinum-based neoadjuvant chemotherapy (NACT), six with initial radical surgery, and seven received adjuvant therapy including chemotherapy and/or radiation. Nine patients (82%) are currently without evidence of disease (NED). Patients with stage I disease had significantly improved PFS and OS compared to stages II–IV with a median OS that was not reached and 12.1months, respectively (p=0.0013). The majority of stage I patients with lymph node metastasis and large tumors achieved durable remission with triple-modality therapy including NACT and surgery followed by adjuvant therapy. Conclusions Cervical NEC is an aggressive disease associated with a high mortality rate. Patients with advanced-stage disease have a poor prognosis regardless of therapy. However, multimodality with consideration of triple-modality therapy in early-stage disease has the potential for complete response and long-term survival, supporting the goal of curative intent in these patients.

While it is known that positive surgical margins increase the risk of cervical cancer recurrence, little is known about the effect of close surgical margins (CSM). Therefore, we set out to determine the impact of margin status on recurrence and survival in patients with early-stage cervical cancer.A retrospective review was conducted of patients undergoing radical hysterectomy from 2000 to 2010 with Stage IA2-IIA cervical cancer. CSM were defined as ≤5mm; association with other clinicopathologic factors as well as recurrence and survival was evaluated.Of the 119 patients, 75 (63%) with CSM had a recurrence rate of 24% compared to 9% without CSM. Though not independently associated with recurrence, CSM were significantly associated with positive lymph nodes (44% vs. 18%), positive parametria (33.3% vs. 2.3%), larger tumors (3.5 vs. 2.5cm), greater depth of stromal invasion (DOI) (84% vs. 33%), and lymphovascular space invasion (LVSI) (61.3% vs. 34.1%). We failed to find an association between adjuvant therapy and recurrence in those with CSM. Exploratory analysis revealed that a surgical margin of ≤2mm was significantly associated with an increased risk of overall recurrence (36% vs. 9%, p=0.009) as well as loco-regional recurrence (22% vs. 4%, p=0.0034).Surgical margins of ≤5mm on radical hysterectomy specimens are often associated with other high or intermediate risk factors for recurrence. While not a proven independent risk factor, the distance to surgical margin may warrant further investigation as an intermediate risk factor along with tumor size, DOI and LVSI.

e15585 Background: Neuroendocrine carcinomas (NEC) of the cervix comprise only 2% of all cervical cancers. As a result, prospective data is limited and treatment guidelines rely on literature from lung NEC. The objective of this study was to examine and report on our experience in the management of this rare, aggressive disease. Methods: This was an IRB-approved, single-institution, retrospective review. Study criteria included patients with cervical NEC diagnosed between 1990-2011. Demographic, treatment and survival data was collected. Progression-free survival (PFS) and overall survival (OS) was defined as the time from date of initial treatment until progression or death respectively, or date of last contact. Results: A total of 24 patients met inclusion criteria. The median age at diagnosis was 43. Median PFS was 13.6 months and median OS was 16.4 months. The majority of patients had advanced-stage disease (61% stage II-IV, 39% stage I). Of the 9 patients with stage I disease, 4 were treated with platinum + etoposide-based neoadjuvant chemotherapy and 5 were treated with initial radical surgery. Seven of the 9 patients had post-operative adjuvant therapy consisting of chemotherapy, chemo-radiation or radiation only. Seven of the 9 patients (78%) were alive at last follow-up. Of the two patients who were deceased, one had metastatic disease found at surgery and the other declined adjuvant therapy and died of recurrence. Patients with stage II-IV disease (n=15) had a median PFS and OS of 11.5 and 12.1 months, respectively. Only 2 had no evidence of disease at last encounter. The remainder died without achieving remission. Patients with metastatic disease had significantly worse survival when compared to those with loco-regional disease with a median OS of 8 vs. 28 months (p = .03), respectively. Conclusions: We report one of the largest single-institution experiences of neuroendocrine cervical cancer. Advanced-stage patients had a poor prognosis regardless of therapy. However, multi-modality therapy in early-stage disease resulted in an excellent prognosis (78% survival) for these rare, highly aggressive tumors. These findings support the goal of curative intent for early-stage disease using multi-modality therapy.

Intrathoracic goiter remains an interesting diagnostic and surgical problem. A case of a patient with intrathoracic goiter causing a superior vena cava syndrome which resulted in "downhill" esophageal varices and bleeding is presented. This is the 36th case of reported "downhill" esophageal varices and the ninth to cause massive upper gastrointestinal hemorrhage. Intrathoracic goiter is a rare benign cause of "downhill" esophageal varices and bleeding, which can be completely cured by thyroidectomy. It is advisable to consider the addition of a vertical sternotomy in such instances for easier and safer control of the vast collateral venous drainage encountered during removal of the mediastinal component of the tumor.