Is Medicaid Expansion Associated with Improved Nonmetastatic Colon Cancer Survival? An Analysis of the National Cancer Database.

METHODS: This retrospective study of 86 413 patients (40-64 years old) undergoing surgical resection for a new diagnosis of invasive, nonmetastatic colon cancer included in the National Cancer Database (NCDB) from 2010 to 2015 compared overall survival (OS) in MES to NES. Cox proportional hazard models, fit for OS, and propensity score-matching (PSM) analysis were performed. RESULTS: In this sample, 51 297 cases (59.2%) lived in MES and 35 116 (40.8%) in NES. Medicaid expansion states had earlier pathological stage compared to NES (stage I 25.38% vs 24.17%, stage II 32.93 vs 33.4%, and stage III 41.69 vs 42.43%; P < .001). 5-year OS in MES was higher than NES (79.1% vs 77.3%; P < .001); however, on both multivariable analysis (MVA) and PSM analysis, MES did not have significantly different OS from NES (hazard ratio (HR), .99, 95% confidence interval (CI), .95-1.03; P = .570; HR, .99, 95% CI, .95-1.03; P = .68). CONCLUSION: Among NCDB patients with invasive, nonmetastatic colon cancer residing in MES at time of diagnosis was associated with earlier pathological stage. However, on both MVA and PSM analysis, OS was not significantly different in MES vs NES. Research on patient outcomes, such as receipt of guideline concordant care, can further inform the impact of insurance coverage expansion efforts on cancer outcomes.

Utilizing a combined hospital and criminal justice database to identify risk factors for repeat firearm injury or violent-crime arrest among firearm victims.

Introduction: Identifying firearm victims with the greatest risk of repeat-firearm exposure and offering interventions has the potential to disrupt recurrent violence. This study explored risk factors associated with repeat violence among survivors of intentional firearm injury in a unique clinical and criminal justice (CJ) dataset. Methods: This study analyzed a retrospective cohort (n = 4058) of persons injured by nonfatal intentional firearm violence from 2013 to 2016 in one metropolitan area. Data were collected from a single level I trauma center, city police records, and state CJ databases from 1948 to 2019. The primary outcome of interest was another firearm injury or violent-crime arrest (defined as a violent or firearm felony offense). Results: Among 4058 nonfatal intentional firearm victims, 1202 (29.6%) individuals had a repeat-firearm injury or violent-crime arrest. In a bivariate analysis, history of mental, physical, and/or emotional abuse (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.40-1.86), mental health diagnosis (OR, 1.88; 95% CI, 1.51-2.35), or illegal substance use (OR, 2.87; 95% CI, 2.48-3.32) was associated with increased risk of repeat-firearm injury or violent-crime arrest. Prior felony arrest (OR, 3.68; 95% CI, 3.19-4.24), prior incarceration (OR, 3.72; 95% CI, 3.04-4.56), prior firearm charge (OR, 4.06; 95% CI, 3.33-4.96), and suspected gang membership (OR, 8.69; 95% CI, 6.14-12.32) demonstrated the greatest association with significant repeat violence. Conclusions: Thirty percent of those who experienced an intentional firearm injury were found to have a repeat-firearm injury or violent-crime arrest multi-disciplinary interventions that address the complex needs of a CJ-involved population are needed to mitigate significant repeat violence.

TRUE-Bolivia: Trauma Responders Unifying to Empower Communities in Santa Cruz, Bolivia.

BACKGROUND: The aim of this study is to assess the efficacy of the TRUE-Bolivia (Trauma Responders Unifying to Empower Communities Bolivia) trauma first responder course at improving participant confidence in first responder abilities and increasing knowledge of trauma response skills. METHODS: Participants attended the 4-h TRUE-Bolivia course at the municipal department of urban transportation and universities and medical schools in Santa Cruz, Bolivia and completed a demographic survey and pre- and post-course knowledge assessments. All participants who attended the full course and completed both knowledge assessments were included in the study, with 453 people attending at least one portion of the course and 329 completing the full course and assessments. RESULTS: A majority of participants were men, had completed high school or attended university, and worked or trained in the fields of transportation or medicine. Participant ratings of confidence on a 5-point Likert scale improved from a median of 3 (interquartile range [IQR] 2) before the course to 5 (IQR 1) after the course (P < 0.01). The median number of correct answers on the pre-course nine-question knowledge assessment was 3 (IQR 3), improving to 7 (IQR 3) on the post-course assessment (P < 0.01). All demographic groups demonstrated improvements in scores from the pre- to post-test. Female gender, higher education level, a background in medicine, and prior training in first aid were associated with higher pre- and post-test scores. CONCLUSIONS: The TRUE-Bolivia course increased knowledge of first responder skills and improved confidence in these abilities in participants from a variety of backgrounds. Further study is needed to determine the long-term skill utilization by participants and the course's impact on local trauma morbidity and mortality.

A single surgeon's experience transitioning to robotic-assisted right colectomy with intracorporeal anastomosis.

BACKGROUND: Despite substantial evidence demonstrating benefits of minimally invasive surgery, a large percentage of right colectomies are still performed via an open technique. Most laparoscopic right colectomies are completed as a hybrid procedure with extracorporeal anastomosis. As part of a pure minimally invasive procedure, intracorporeal anastomosis (ICA) may confer additional benefits for patients. The robotic platform may shorten the learning curve for minimally invasive right colectomy with ICA. METHODS: From January 2014 to May 2016, 49 patients underwent robotic-assisted right colectomy by a board-certified colorectal surgeon (S.R). Extracorporeal anastomosis (ECA) was used in the first 20 procedures, whereas ICA was used in all subsequent procedures. Outcomes recorded in a database for retrospective review included operating time (OT), estimated blood loss (EBL), length of stay (LOS), conversion rate, complications, readmissions, and mortality rate. RESULTS: Comparison of average OT, EBL, and LOS between extracorporeal and intracorporeal groups demonstrated no significant differences. For all patients, average OT was 141.6 ± 25.8 (range 86-192) min, average EBL was 59.5 ± 83.3 (range 0-500) mL, and average LOS was 3.4 ± 1.19 (range 1.5-8) days. Four patients required conversion, all of which occurred in the extracorporeal group. There were no conversions after the 18th procedure. The 60-day mortality rate was 0%. There were no anastomotic leaks, ostomies created, or readmissions. As the surgeon gained experience, a statistically significant increase in lymph node sampling was observed in oncologic cases (p = .02). CONCLUSIONS: The robotic platform may help more surgeons safely and efficiently transition to a purely minimally invasive procedure, enabling more patients to reap the benefits of less invasive surgery. Transitioning from ECA to ICA during robotic right colectomy resulted in no significant change in OT or LOS. A lower rate of conversion to open surgery was noted with increased experience.