Utilization of access to colorectal cancer screening modalities in low-income populations after medicaid expansion.

BACKGROUND: Colorectal cancer (CRC) remains a relevant public health problem. Current research suggests that racial, economic and geographic disparities impact access. Despite the expansion of Medicaid eligibility as a key component of the Affordable Care Act (ACA), there is a dearth of information on the utilization of newly gained access to CRC screening by low-income individuals. This study investigates the impact of the ACA's Medicaid expansion on utilization of the various CRC screening modalities by low-income participants. Our working hypothesis is that Medicaid expansion will increase access and utilization of CRC screening by low-income participants. AIM: To investigate the impact of the Affordable Care Act and in particular the effect of Medicaid expansion on access and utilization of CRC screening modalities by Medicaid state expansion status across the United States. METHODS: This was a quasi-experimental study design using data from the Behavioral Risk Factor Surveillance System, a large health system survey for participants across the United States and with over 2.8 million responses. The period of the study was from 2011 to 2016 which was dichotomized as pre-ACA Medicaid expansion (2011-2013) and post-ACA Medicaid expansion (2014-2016). The change in utilization of access to CRC screening strategies between the expansion periods were analyzed as the dependent variables. Secondary analyses included stratification of the access by ethnicity/race, income, and education status. RESULTS: A greater increase in utilization of access to CRC screening was observed in Medicaid expansion states than in non-expansion states [+2.9%; 95% confidence interval (95%CI): 2.12, 3.69]. Low-income participants showed a +4.02% (95%CI: 2.96, 5.07) change between the expansion periods compared with higher income groups +3.19% (1.70, 4.67). Non-Hispanic Whites and Hispanics [+3.01% (95%CI: 2.16, 3.85) vs +5.51% (95%CI: 2.81, 8.20)] showed a statistically significant increase in utilization of access but not in Non-Hispanic Blacks, or Multiracial. There was an increase in utilization across all educational levels. This was significant among those who reported having a high school graduate degree or more +4.26 % (95%CI: 3.16, 5.35) compared to some high school or less +1.59% (95%CI: -1.37, 4.55). CONCLUSION: Medicaid expansion under the Affordable Care Act led to an overall increase in self-reported use of CRC screening tests by adults aged 50-64 years in the United States. This finding was consistent across all low-income populations, but not all races or levels of education.

The Efficacy and Safety of Hemospray for the Management of Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.

GOALS/BACKGROUND: Hemospray is a new hemostatic powder recently approved for endoscopic hemostasis in gastrointestinal (GI) bleeding. Data are limited in terms of its clinical outcomes, and its role in the treatment algorithm of GI bleeds. We conducted a systematic review and meta-analysis to study the clinical performance of Hemospray in the management of GI bleeding. STUDY: We searched multiple databases from inception through March 2019 to identify studies that reported on the clinical outcomes of Hemospray in GI bleeding. The primary outcome was pooled rates of clinical success after the application of Hemospray in GI bleeding. The secondary outcomes were pooled rebleeding rates and adverse events after use of Hemospray. RESULTS: A total of 19 studies, 814 patients, of which 212 patients were treated with Hemospray as monotherapy, and 602 patients were treated with Hemospray with conventional hemostatic techniques. Overall pooled clinical success after the application of Hemospray was 92% [95% confidence interval (95% CI), 87%-96%; I2=70.4%]. Overall pooled early rebleeding rates after application of Hemospray was 20% (95% CI, 16%-26%; I2=54%). Overall pooled delayed rebleeding rates after the application of Hemospray was 23% (95% CI, 16%-31%; I2=34.9%). There was no statistical difference in clinical success (RR, 1.02; 95% CI, 0.96-1.08; P=0.34) and early rebleeding (RR, 0.89; 95% CI, 0.75-1.07; P=0.214) in studies that compared the use of Hemospray as monotherapy versus combination therapy with conventional therapy. CONCLUSIONS: Hemospray is highly effective in achieving immediate hemostasis in gastrointestinal bleeding. However, due to significantly high rebleeding rates, Hemospray is not suited for definitive long-term therapy.

Clinically Silent Intracardiac Metastasis with Extremely Poor Prognosis in a Patient with Hepatocellular Carcinoma.

Intracavitary cardiac extension remains an unusual site of extrahepatic metastasis in patients with hepatocellular carcinoma. While patients can present with signs and symptoms suggestive of right-sided heart failure, it may be totally asymptomatic, which is very rare with only a few cases reported so far. Also, cardiac metastasis is of great prognostic importance as patients with intracardiac metastasis can have an extremely poor prognosis. Here, we present the case of a 52-year-old male patient with advanced hepatocellular carcinoma, with an incidentally found tumor thrombus extending from the inferior vena cava to the right atrium, protruding through the tricuspid valve into the right ventricle, on routine echocardiography. The patient did not have any signs or symptoms of heart involvement and unfortunately died on the 18th day of the hospital stay.

A decade of improved access to screening is associated with fewer colorectal cancer deaths in African Americans: a single-center retrospective study.

BACKGROUND: Controversy exists as to whether disparities in colorectal cancer (CRC) outcomes in African Americans (AAs) are best resolved by screening at age 45 or by proper use of existing guidelines. In 2004, an aggressive colonoscopy-based CRC screening program was implemented throughout New York City. Our goal was to determine the effect of that program on CRC outcomes in our mostly AA population. METHODS: CRC cases entered into Harlem Hospital's tumor registry from January 1992 to December 2011 were divided into two cohorts: 1992-2003, the pre-intensive screening era (PSE), and 2004-2011, the intensive screening era (ISE). Each cohort was reviewed for demographics, indication for colonoscopy, tumor location, tumor stage, and mortality. Multivariate analysis was applied to the pooled cohorts to determine factors associated with survival. RESULTS: Inclusion criteria were met by 379 patients: 207 PSE and 172 ISE. Racial distribution, gender, age at presentation, and tumor location were not different during the two eras. Over 75% of patients were AA. During the ISE, 84% were insured compared to 34% in the PSE (P<0.0001). Fewer patients died during the ISE (21%) than during the PSE (67%) (P<0.0001). The ISE patients were diagnosed with earlier stages of CRC compared to the PSE. Increased survival was associated with being insured (hazard ratio [HR] 1.91, 95% confidence interval [CI] 1.30-2.81), distal tumors (HR 1.43, 95%CI 1.05-1.95), and being female (HR 1.36, 95%CI 1.01-1.850). CONCLUSIONS: A multifaceted program reduced CRC outcome disparities in a poor AA community. Aggressive implementation of current colonoscopy screening guidelines still has unrealized potential to reduce CRC mortality disparities in AAs.