Symptom and viral rebound uncommon after untreated COVID-19 infection

1. Symptom and viral rebound uncommon after untreated COVID-19 infection
Combination of symptom and high-level viral rebound observed in only 3% of persons with COVID-19
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2381
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An analysis of a COVID-19 trial has found that a combination of symptom and viral rebound after untreated COVID-19 infection is rare, occurring in only 3 percent of study participants. The analysis is published in Annals of Internal Medicine.

Nirmatrelvir–ritonavir is a recommended treatment for outpatients with mild to moderate COVID-19 and risk factors for severe disease. Widespread use of nirmatrelvir has been accompanied by reports of worsening symptoms and virologic rebound after treatment completion. Virologic rebound has also been reported in persons who did not receive nirmatrelvir therapy, but studies that can define the frequencies of symptom and viral rebound during the natural course of COVID-19 are lacking.

Researchers from Brigham and Women's Hospital conducted an analysis of 563 participants receiving placebo in the ACTIV-2/A5401 (Adaptive Platform Treatment Trial for Outpatients With COVID-19) platform trial. The authors found that a combination of symptom and high-level viral rebound occurred in only 3 percent of participants. Symptom rebound alone occurred in 26 percent of participants 11 days after initial symptom onset and viral rebound alone occurred in 31 percent of participants. High-level viral rebound was observed in 13 percent of participants. The researchers note that both symptom and viral rebound were short, lasting only one day in most participants. According to the authors, these results highlight the importance of accounting for underlying rates of symptom relapse in the absence of antiviral therapy when evaluating the effects of antiviral treatments.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author Jonathan Z. Li, MD, please contact Haley Bridger at hbridger@bwh.harvard.edu or Nathan Astill at NAstill@mednet.ucla.edu.
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2. Cold snare polypectomy significantly reduces bleeding risk compared to hot snare polypectomy
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2189
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A randomized controlled trial (RCT) of more than 4,000 people found that the risk for delayed bleeding after polypectomy was significantly reduced among persons who received a cold snare polypectomy. The findings are published in Annals of Internal Medicine.

More than 16 million colonoscopies are performed annually in the US and polypectomy during colonoscopy plays a pivotal role in preventing colorectal cancer. Hot snare polypectomy (HSP) has been conventionally used to remove polyps but is associated with a higher risk of delayed bleeding, post-polypectomy syndrome, or perforation. Previous research on cold snare polypectomy (CSP) demonstrated that CSP was as effective as HSP but more efficient in removing
small polyps, but its effect on reducing delayed bleeding has been shown only in high-risk patients.

Researchers from National Taiwan University Hospital conducted an RCT of 4,270 participants who were undergoing polypectomy in six centers in Taiwan. They report that only 8 out of 2,137 persons, or 0.4 percent, experienced delayed bleeding after CSP. In comparison, 31 out of 2,133 persons, or 1.5 percent, experienced delayed bleeding after HSP. They also report that only 0.2 percent of CSP group had emergency service visits compared with 0.6 percent of the HSP group. The authors note that CSP was also more efficient, with the study's results showing that the time required for polypectomy is reduced by 26.9 percent. According to the authors, the findings support the superior safety of CSP over HSP in managing colorectal polyps sized 10 mm or smaller in the general population.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Han-Mo Chiu, MD, PhD, please contact Mr. Liang at 105116@ntuh.gov.tw.
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3. Increased adenoma detection rate may significantly reduce post-colonoscopy colorectal cancer risk in a FIT-based screening program
Abstract: https://www.acpjournals.org/doi/10.7326/M22-1008
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A cohort study from the Italian Colorectal Cancer screening program including more than 49,000 colonoscopies found a significant inverse association between endoscopists’ proficiency as measured by adenoma detection rate (ADR) and post-colonoscopy colorectal cancer (PCCRC). These finding suggest that targeting only poor performing endoscopists with measures to increase ADR may significantly reduce PCCRC risk. The findings are published in Annals of Internal Medicine.

Colorectal cancer (CRC) population screening programs based on fecal testing (FITs) represent the standard of care for CRC prevention in many Western countries. The ultimate effectiveness of these screening procedures relies on the accurate detection and removal of precancerous lesions and early invasive cancer in colonoscopies of persons with positive FIT results. However, it is known that there are high miss rates and high rates of performance variability among endoscopists.

Researchers from Veneto Tumor Registry, Azienda Zero, Padova, “Sapienza” University of Rome and Humanitas University in Milan, Italy, conducted a population-based cohort study of 49,626 colonoscopies done by 113 endoscopists between 2012 and 2017 after a positive FIT result. They report that 277 cases of PCCRC were diagnosed with a mean ADR of 48.3 percent. They noted a 2.35-fold cancer risk increase in the lowest performing endoscopists group compared to the highest performing group. According to the authors, endoscopist competence is key to screening effectiveness. These results strongly suggest tailored targeting of low performing endoscopists with interventions aimed at helping them increase their ADR and consequently help their patients by reducing their PCCRC risk.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Giulio Antonelli, MD, please email giulio.antonelli@gmail.com.
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