Sediment Spatial Distribution and Quality Assessment of Metals in Chinook Salmon and Resident Killer Whale Marine Habitat in British Columbia, Canada.

At-risk resident killer whale (Orcinus orca) populations of the northeastern Pacific, Canada, and their main prey, Chinook Salmon (Oncorhynchus tshawytscha), are exposed to a variety of contaminants including chemical elements from both natural and anthropogenic sources, which may be constraining their recovery. Concentrations of 36 chemical elements in subtidal surface sediments (1-435 m depth) collected from 98 sites along the British Columbia coast were used to characterize coast-wide patterns, and a subset of metals (mercury (Hg), cadmium (Cd), arsenic (As), nickel (Ni), copper (Cu), and lead (Pb)) were selected to assess Chinook Salmon and resident killer whale marine habitat quality. Principal component analysis (PCA) showed a dominance of Hg, antimony (Sb), Pb, Cu, and zinc (Zn) for Prince Rupert Harbour, Victoria Harbour, and Burrard Inlet, suggesting local sources. Based on the PCA, geochemical properties such as total organic carbon (TOC), acid volatile sulfide (AVS), and pH explained the spatial distribution of all elements in sediment (p < 0.001). Mercury, Cd, As, Ni, Cu, and Pb hotspots were identified along the coast of Vancouver Island, the central and north coast, in the Strait of Georgia, and Haida Gwaii. Bischof Island of Haida Gwaii and Ardmillan Bay on the central coast were most contaminated and enriched by Cd, determined by geoaccumulation index (Igeo) and enrichment factor (EF), respectively. Marine habitat quality was assessed by comparing metal concentrations to Canadian Sediment Quality Guidelines (SQGs). Chinook Salmon populations may be indirectly affected by metal toxicity (As > Cd and Cu > Ni > Hg > Pb) to lower trophic level prey species. Toxicity related impacts to benthic organisms as a result of exposure to elevated Cd and As concentrations in Northern Resident Killer Whale critical habitat and to Hg, Cd, As, Ni, Cu, and Pb concentrations in Southern Resident Killer Whale critical habitat may indirectly pose a threat to resident killer whale populations, highlighting a need for management actions to reduce risks associated with these metals.

Food Insecurity Is Associated With Urge Urinary Incontinence: An Analysis of the 2005-2010 National Health and Nutrition Examination Survey.

PURPOSE: Urge urinary incontinence is the involuntary leakage of urine associated with a sudden compelling urge to void. A previous study found an association between urge urinary incontinence and household income, indicating that social determinants of health may influence urge urinary incontinence. Food insecurity is a relevant social determinant of health, as a diet with bladder irritants may worsen urge urinary incontinence symptoms. This study aimed to investigate the association between urge urinary incontinence and food insecurity. MATERIALS AND METHODS: We collected data from the 2005-2010 cycles of the National Health and Nutrition Examination Survey, a nationally representative health survey administered by the Centers for Disease Control and Prevention. The association between urge urinary incontinence and food insecurity was analyzed using survey-weighed logistic regression with adjustments for demographic, socioeconomic status, behavioral, and medical comorbidities covariates. RESULTS: We included 14,847 participants with mean age 50.4±17.9 years; 22.4% of participants reported at least 1 episode of urge urinary incontinence. We found that participants who reported food insecurity had 55% greater odds of experiencing urge urinary incontinence compared to those who have not (OR=1.55, 95% CI=1.33-1.82, P < .001). When comparing diets, food-insecure participants reported significantly less intake of bladder irritants (caffeine and alcohol) compared to food-secure participants. When the sample was stratified by food insecurity status (yes vs no), consumption of caffeine did not differ by urge urinary incontinence status and consumption of alcohol was lower among participants with vs without urge urinary incontinence. CONCLUSIONS: Adults reporting food insecurity in the past year are significantly more likely to experience urge urinary incontinence than those who did not. Consumption of bladder irritants including caffeine and alcohol was significantly less in food-insecure compared to food-secure participants. When the sample was stratified by food insecurity status (yes vs no), consumption of caffeine did not differ by urge urinary incontinence status and consumption of alcohol was lower among participants with vs without urge urinary incontinence. These data indicate that diet alone does not drive the association between urge urinary incontinence and food insecurity. Instead, food insecurity may be a proxy for social inequity, perhaps the greatest driver of disease.

Use of External Comparators for Health Technology Assessment Submissions Based on Single-Arm Trials.

BACKGROUND: Single-arm trial (SAT) data is increasingly reviewed for drug approvals by regulators and Health Technology Assessment (HTA) bodies. Supplementary data in the form of external comparators (ECs) can be used to provide clinical context to support these drug evaluations. In this study we characterized HTAs for SAT-based submissions, the use of supplementary EC data and outcomes from HTA review. METHODS: HTA Accelerator database was used to describe SAT-based HTA submissions with decisions (2011-2019). RESULTS: A total of 433 SAT-based HTA submissions were identified between 2011 and 2019 with a 13-fold increase during this period. Around 65%(283/433) were in oncology or hem-oncology. Around 52%(226/433) of submissions contained some type of EC data, including prior clinical trials (24%, 104) and real-world data (RWD) (20%, 87), but 40%(175) contained no EC data. The overall acceptance rate for SAT-based submissions was 48% and with RWD EC data acceptance was 59%. In the latest 5-year period (2015-2019), use of RWD ECs increased 22% as a proportion of submissions per year, whereas, prior trial ECs decreased (-14%) and use of no EC remained stable (-2%). Between 2015 to 2017 and 2018 to 2019, acceptance rate for RWD ECs increased by 20% (41% in 2015-2017 to 61% in 2018-2019) whereas prior trial EC use decreased by 10% and no EC submissions decreased 16%. Of 226 submissions using ECs, only 29%(66) used an adjusted indirect treatment comparison method. CONCLUSIONS: SAT-based submissions to HTA bodies are rapidly evolving in terms of composition and acceptance. Types of EC and methodological approach used are important determinants of positive outcomes.

Impact of instituting hard-waiver on a student health insurance program at a public university.

OBJECTIVE: The purpose of this study is to assess the impact of implementing hard-waiver on the student health insurance landscape at a major public university. Methods: Data from two years before (2013-2015) and after (2015-2017) the hard-waiver program was implemented were analyzed descriptively using the university data sources. Results: The university-sponsored insurance group pre-waiver was made up of 4,850 students, while this group included 9,002 students after the hard-waiver program was implemented. Approximately 62% of the waived insurance group were White, compared to 47% in the university-sponsored insurance group. The White population who waived the insurance plan was 20% greater than the minority population. The proportion of the White population having a university-sponsored insurance plan was 0.6 times that of the minority population. Conclusions: University-sponsored insurance enrollment increased markedly following the implementation of hard-waiver and impacted various student demographic groups differently.

A Framework for Methodological Choice and Evidence Assessment for Studies Using External Comparators from Real-World Data.

Several approaches have been proposed recently to accelerate the pathway from drug discovery to patient access. These include novel designs such as using controls external to the clinical trial where standard randomised controls are not feasible. In parallel, there has been rapid growth in the application of routinely collected healthcare 'real-world' data for post-market safety and effectiveness studies. Thus, using real-world data to establish an external comparator arm in clinical trials is a natural next step. Regulatory authorities have begun to endorse the use of external comparators in certain circumstances, with some positive outcomes for new drug approvals. Given the potential to introduce bias associated with observational studies, there is a need for recommendations on how external comparators should be best used. In this article, we propose an evaluation framework for real-world data external comparator studies that enables full assessment of available evidence and related bias. We define the principle of exchangeability and discuss the applicability of criteria described by Pocock for consideration of the exchangeability of the external and trial populations. We explore how trial designs using real-world data external comparators fit within the evidence hierarchy and propose a four-step process for good conduct of external comparator studies. This process is intended to maximise the quality of evidence based on careful study design and the combination of covariate balancing, bias analysis and combining outcomes.

The effect of image quality, repeated study, and assessment method on anatomy learning.

The use of two-dimensional (2D) images is consistently used to prepare anatomy students for handling real specimen. This study examined whether the quality of 2D images is a critical component in anatomy learning. The visual clarity and consistency of 2D anatomical images was systematically manipulated to produce low-quality and high-quality images of the human hand and human eye. On day 0, participants learned about each anatomical specimen from paper booklets using either low-quality or high-quality images, and then completed a comprehension test using either 2D images or three-dimensional (3D) cadaveric specimens. On day 1, participants relearned each booklet, and on day 2 participants completed a final comprehension test using either 2D images or 3D cadaveric specimens. The effect of image quality on learning varied according to anatomical content, with high-quality images having a greater effect on improving learning of hand anatomy than eye anatomy (high-quality vs. low-quality for hand anatomy P = 0.018; high-quality vs. low-quality for eye anatomy P = 0.247). Also, the benefit of high-quality images on hand anatomy learning was restricted to performance on short-answer (SA) questions immediately after learning (high-quality vs. low-quality on SA questions P = 0.018), but did not apply to performance on multiple-choice (MC) questions (high-quality vs. low-quality on MC questions P = 0.109) or after participants had an additional learning opportunity (24 hours later) with anatomy content (high vs. low on SA questions P = 0.643). This study underscores the limited impact of image quality on anatomy learning, and questions whether investment in enhancing image quality of learning aids significantly promotes knowledge development. Anat Sci Educ 10: 249-261. © 2016 American Association of Anatomists.

Assessment of the Double-Staple Technique for Esophagoenteric Anastomosis in Gastric Cancer.

INTRODUCTION: Reports on outcomes after double-staple technique (DST) for total and proximal gastrectomy are limited, originating mostly from Asian centers. Our objective was to examine anastomotic leak and stricture with DST for esophagoenteric anastomosis in gastric cancer patients. METHODS: A single institution review was performed for patients who underwent total/proximal gastrectomy with DST between 2006 and 2015. DST was performed using transoral anvil delivery (OrVil) with end-to-end anastomosis. Clinical characteristics and outcomes, including anastomotic leak and stricture, were recorded. RESULTS: Overall, DST was performed in 60 patients [total gastrectomy (81.7%, n = 49/60), proximal gastrectomy (10.0%, n = 6/60), and completion gastrectomy (8.3%, n = 5/60)]. Neoadjuvant chemotherapy was administered to 21 patients (35.0%), and 6 patients (10.0%) received external beam radiation therapy prior to completion gastrectomy. Operative approach was open (51.7%, n = 31/60), laparoscopic (43.3%, n = 26/60), or robotic (5.0%, n = 3/60). Anastomotic leak occurred in 6.7% (n = 4/60), while stricture independent of leak was identified in 19.0% (n = 11/58) of patients. Complications occurred in 38.3% (n = 23/60) of patients, of which 52% were classified as Clavien-Dindo grades III-V complications. CONCLUSION: In the largest Western series of DST for esophagoenteric anastomoses in gastric cancer surgery, our experience demonstrates that DST is safe and effective with low rates of leak and stricture.

Estimates of conditional survival in gastric cancer reveal a reduction of racial disparities with long-term follow-up.

INTRODUCTION: In prior analyses, conditional survival (CS) estimates for gastric cancer have weighed clinical and pathologic factors to predict prognosis at time intervals after surgery. Since racial disparities in gastric cancer outcomes were not considered, our objective was to determine whether race influences CS estimates. METHODS: Data from the Surveillance, Epidemiology, and End Results cancer registry were used to identify gastric adenocarcinoma patients who underwent curative surgical intervention between 1988 and 2005. Five-year relative conditional survival (RCS) was computed for patients who survived at least 1 to 5 years after surgery. RCS was calculated by assessing observed and expected survival in an age- and race-matched standard population. Results were compared across time and racial groups (white, black, and Asian) using z test statistics. RESULTS: Of 14,067 patients, 63.8 % were white, 15.5 % black, and 20.7 % Asian. Racial disparities among groups were observed with improved survival of Asians at time point zero and improved RCS at 1 year. At 5 years following curative surgery, each racial group had increased RCS and the greatest magnitude of relative increase was observed in white and black patients (121 and 118 %, respectively). Comparison of RCS at the 5-year time point revealed a reduction of racial disparities in survival among the three groups. CONCLUSIONS: Our investigation shows that racial disparities in gastric cancer outcomes are pronounced at the time of curative surgery but diminish after years of survival, thus suggesting race has less influence over outcomes the longer patients survive. The reasons for reduction of racial disparities remain unclear and warrant future study.

Racial and ethnic disparities in gastric cancer outcomes: more important than surgical technique?

Racial and ethnic disparities in cancer care are major public health concerns and their identification is necessary to develop interventions to eliminate these disparities. We and others have previously observed marked disparities in gastric cancer outcomes between Eastern and Western patients. These disparities have long been attributed to surgical technique and extent of lymphadenectomy. However, more recent evidence suggests that other factors such as tumor biology, environmental factors such as Helicobacter pylori infection and stage migration may also significantly contribute to these observed disparities. We review the literature surrounding disparities in gastric cancer and provide data pertaining to potential contributing factors.

Dental pain in the ED: costs that hurt patients and EDs.

BACKGROUND AND OBJECTIVES: The objective of this retrospective study was to determine if the collection rates for dental related visits to the emergency department (ED) are less than collection rates for ED visits for other problems. METHODS: Data were analyzed from one Kentucky hospital's electronic health record system from April 2010 to April 2012. Collection rates for patients who received care in the ED for uncomplicated dental problems were compared to collection rates for all patients who received care in the ED for any reason. RESULTS: Each month during the study period, an average of 77 patients presented to the ED for dental problems. Compensation rates for physician fees were 9.8% for dental related care and 39% for all patients who received care for any reason. Compensation rates for hospital fees were 16% for dental related care and 20.1% for all patients who received care for any reason. Uninsured patients accounted for 68.8% of physician fees and 62.4% of hospital fees for dental related care. CONCLUSIONS: Using the ED as a dental safety net is costly to the patient because the underlying problem is typically not resolved and costly to the hospital because of very low collection rates. In addition, other patients who present to the ED for non-dental, high acuity problems may have delayed care or no care because of the number of patients using the ED for dental pain.

Socioeconomic factors impact colon cancer outcomes in diverse patient populations.

PURPOSE: Cancer disparities among racial and ethnic groups are major public health concerns. Our objective was to examine the impact of socioeconomic status (SES) on survival of colon cancer patients within major racial and ethnic groups. METHODS: Patients with colon adenocarcinoma from Los Angeles County (LAC) were assessed. SES was utilized as an indicator of healthcare access and categorized by tertiles (high, middle, and low). Patient characteristics were compared and survival analyses were performed. RESULTS: In our heterogeneous LAC cohort, we confirmed survival disparities. Asians had the best survival followed by Hispanics, whites, and blacks. For each stage of disease, Asians and Hispanics had better outcomes than whites and blacks. Then, we evaluated the impact of SES on survival within each racial and ethnic group. We observed significantly longer survival for high SES patients compared to middle and low SES patients for all racial/ethnic groups. CONCLUSIONS: While disparities across racial/ethnic groups are well-documented, our study is the first to identify socioeconomic disparities in survival for patients within the same group. These novel findings demonstrate the complex role of SES on race and ethnicity and identify the need to improve healthcare access even within select populations.

A review of risk measures in pharmacoepidemiology with tips for statisticians in the pharmaceutical industry.

Pharmacoepidemiology is the study of the therapeutic effects, risk, and use of drugs in large populations, which applies epidemiological methods and reasoning. As reflected in the recent strengthening of the pharmacovigilance legislation in Europe, greater attention has been placed to epidemiological research in response to an increasing call by the public for further post-marketing studies on the safety and efficacy of drugs. Various measures of risk are used in pharmacoepidemiology to quantify the probability of experiencing an adverse outcome and capture the relative increases in risk between treated and untreated populations: cumulative incidence, incidence rate, absolute risk reduction, relative risk, odds ratio, incidence rate ratio, and time to event outcomes. We review in this paper the commonly used measures of risk in pharmacoepidemiology and provide some practical tips for the industry statistician.

DNA-based influenza vaccines: evaluating their potential to provide universal protection.

The recent outbreaks of the H5N1 and H1N1 pandemic influenza have highlighted the importance of developing fast, effective therapeutic strategies to prevent and/or limit the spread of future influenza outbreaks. Although current vaccines against influenza are generally effective, several limitations, including those associated with the amount of available vaccine, the time to vaccine production and vaccine efficacy, may encumber a mass vaccination strategy and effective targeting against future outbreaks. This feature review discusses the prospects of SynCon-derived DNA vaccines against influenza; such vaccines are expected to be effective at targeting many currently circulating influenza virus strains, as well as potentially targeting strains that may be associated with future outbreaks. Because of advantages associated with safety, time to production and ease of production, as well as the generation of more effective immune responses, influenza DNA vaccines provide a promising potential solution to a global medical concern.

Race, ethnicity, and socioeconomic status influence the survival of patients with hepatocellular carcinoma in the United States.

BACKGROUND: Racial, ethnic, and socioeconomic disparities in the survival of patients with hepatocellular carcinoma (HCC) continue to exist. The authors of this report hypothesized that these differences result from inequities in access to care and in response to therapy. METHODS: Patients with HCC (n = 20,920) were identified from the Surveillance, Epidemiology, and End Results (SEER) database, and patients who underwent liver transplantation for HCC (n = 4735) were identified from the United Network for Organ Sharing (UNOS) database. Clinical and pathologic factors were compared after patients were stratified by race and ethnicity. RESULTS: The survival of patients with HCC improved over time for all racial, ethnic, and income groups (P < .001). Black and low income individuals had the poorest long-term survival (P < .001). On multivariate analysis, black race was predictive of the poorest survival (hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.09-1.22; P < .001), whereas Asian race was associated with the best survival (HR, 0.87; 95% CI, 0.83-0.91; P < .001). After liver transplantation, black patients had the worst graft survival and overall survival (median survival [MS], 30.5 months and 39.7 months, respectively; P < .001), whereas Hispanics had the best survival (MS, 83.4 months and 86.6 months, respectively; P < .001). In a multivariate analysis of transplantation patients, race and ethnicity were associated significantly with outcome. CONCLUSIONS: Significant racial and ethnic disparities in the outcome of patients with HCC persist despite the receipt of comparable treatment. The authors concluded that further investigations are warranted to identify the reasons for the stark disparity in outcomes between black patients and Hispanic patients after liver transplantation for HCC.

Safety assessment of intradiscal gene therapy II: effect of dosing and vector choice.

STUDY DESIGN: Clinical, biochemical, and histologic analysis was performed after in vivo delivery of cDNA encoding various anabolic cytokines and marker genes to the lumbar epidural space of New Zealand white rabbits, using both adenoviral and adeno-associated viral vectors. OBJECTIVE: To mimic errant or misplaced doses of gene therapy to better ascertain the potential risks associated with alternative vectors and transgene products with regard to their application to problems of the intervertebral disc. SUMMARY OF BACKGROUND DATA: Work done with several anabolic cytokines including bone morphogenic proteins and transforming growth factors, has demonstrated the potential of gene therapy. Recently, data has been published demonstrating that improperly dosed or delivered adenoviral-mediated gene therapy within the subarachnoid space can result in significant morbidity in rabbits. There are currently no studies examining the effect of these errors within the epidural space or using an adeno-associated viral (AAV) vector. METHODS: Using either adenoviral or AAV vectors, complementary DNA (cDNA) encoding anabolic cytokines bone morphogenic protein-2 (BMP-2) and transforming growth factor-beta 1 and marker proteins LacZ and green fluorescent protein were injected into the epidural space of 37 New Zealand white rabbits at the L5/6 level. Rabbits were then observed clinically for up to 6 weeks, after which the rabbits were sacrificed in order to perform a comprehensive biochemical and histologic analysis. RESULTS: Following adenoviral-mediated delivery of anabolic cytokine cDNA, up to eighty percent of rabbits demonstrated significant clinical, biochemical, and histologic morbidity. Conversely, AAV-mediated delivery of any cDNA and adenoviral-mediated delivery of marker protein cDNA resulted in no clinical, histologic, or biochemical morbidity. CONCLUSION: Properly dosed and directed gene therapy seems to be both safe and potentially efficacious. This study suggests that side effects of gene therapy may be due to a combination of dosing, transgene product, and vector choice, and that newer AAV vectors may reduce these side-effects and decrease the risk of this technology.

Improved survival with adjuvant external-beam radiation therapy in lymph node-negative pancreatic cancer: a United States population-based assessment.

BACKGROUND: Although chemoradiation often is administered as an adjuvant to pancreatic cancer surgery, recent reports have disputed the benefit of radiation therapy. The objective of this study was to determine the effect of adjuvant radiation therapy in patients with locally confined, lymph node-negative (N0) pancreatic cancer. METHODS: The Surveillance, Epidemiology, and End Results registry was used to identify patients who had undergone cancer-directed surgery for N0 pancreatic adenocarcinoma between 1988 and 2003. Kaplan-Meier survival curves were constructed to compare overall survival between patients who did and did not receive adjuvant external-beam radiation therapy (EBRT). Multivariate Cox regression analysis was used to determine the prognostic significance of EBRT when additional clinicopathologic factors were assessed. The analysis also examined the potential treatment selection bias of patients with survival <3 months. RESULTS: A cohort of 1930 surgical patients with N0 disease was identified. The median survival was 17 months. Irradiated patients had significantly better survival compared with nonirradiated patients (20 months vs 15 months, respectively; P < .001). On multivariate analysis, adjuvant EBRT (hazard ratio [HR], 0.72; 95% confidence interval [95% CI], 0.63-0.82; P < .001), age, grade, tumor classification, and tumor location were independent predictors of survival. When patients with survival <3 months were excluded from the analysis, no difference in survival between the EBRT group and the nonradiation group was noted on univariate comparison (P value not significant). However, on multivariate analysis, EBRT remained an independent predictor of improved overall survival (HR, 0.87; 95% CI, 0.75-1.00; P = .044). CONCLUSIONS: Adjuvant EBRT was associated with improved survival in patients with operable, N0 pancreatic cancer. Its use should be considered in patients who have early-stage N0 disease.

Safety assessment of intradiscal gene transfer: a pilot study.

BACKGROUND: Several recent in vitro and in vivo studies have reported the beneficial properties of gene delivery of therapeutic factors to the intervertebral disc, as a potential treatment strategy for degenerative disc disease; however, to date, no studies have assessed the safety and toxicity of the practical application of this treatment modality. PURPOSE: To assess the safety of inappropriately dosed or misdirected gene delivery to the spinal column in an in vivo model. STUDY DESIGN: The potential toxicity of gene therapy to the spinal column was assessed in this pilot study by monitoring clinical and histological changes in the spinal cord after intradural injections of an adenoviral vector containing the complementary deoxyribonucleic acid (cDNA) for potentially therapeutic factors in the treatment of degenerative disc disease. METHODS: Fourteen New Zealand White rabbits were divided into experimental groups to receive an intradural injection (<10 microL) of saline alone or saline in combination with recombinant transforming growth factor beta1 (TGF-beta1) or an adenoviral vector containing the cDNA for either TGF-beta1 (at previously established therapeutic or elevated concentrations) or bone morphogenic protein-2 (BMP-2). Animals were monitored clinically and spinal cords were harvested for histological analysis. RESULTS: No neurological deficits developed in any of the animals receiving injections of saline alone or saline in combination with the therapeutic dose of Ad-TGF-beta1, Ad-BMP-2, or with recombinant TGF-beta1. However, animals receiving a higher concentration of Ad-TGF-beta1 developed bilateral lower extremity paralysis with significant histological changes. CONCLUSIONS: Inappropriately dosed or directed gene delivery to the spinal column may result in significant complications. However, with appropriate dosing, a therapeutic window may exist where the potential benefits of gene therapy in the treatment of degenerative disc disease outweigh its risks.

Volume and yield of screening colonoscopy at a tertiary medical center after change in medicare reimbursement.

OBJECTIVE: Starting July 1, 2001, Medicare began to reimburse for screening colonoscopy in asymptomatic adults older than 50 yr with no risk factors for colorectal cancer. We sought to determine the short-term impact of the change in Medicare reimbursement on the demand for and yield of screening colonoscopy at our tertiary institution. METHODS: Asymptomatic patients older than 50 referred for first screening colonoscopy after the change in Medicare reimbursement from July 1, 2001 to December 31, 2001 were compared with a similar cohort screened before Medicare coverage for a family history of cancer or polyps during the same months the previous year (July 1, 2000 to December 31, 2000). Patient demographics, number, size, location, and histology of polyps/cancers for these screening colonoscopies were collected. RESULTS: A total of 1282 colonoscopies were performed in our institution from July 1, 2001 to December 31, 2001, 257 (20%) for screening. During the same months in the previous year, 121 of 938 colonoscopies (12.9%) were for screening (p < 0.01). This was a 55% increase in the percentage of colonoscopies performed for screening, and a 112% increase in the number of screening colonoscopies. Patients screened after the change in Medicare reimbursement were on average 5 yr older compared with patients of the previous year (62 +/- 10 [mean +/- SD] vs 56 +/- 9 yr; p < 0.01). A total of 61 screening colonoscopies (24%) performed after the change in Medicare reimbursement had adenomatous lesions, compared with 25 (21%) screened for family history (p = ns). The number of adenomas 10 mm or larger or cancers did not differ significantly between the two groups (17 in 2001 vs 12 in 2000; p = ns). Age of 65 or older was associated with detection of adenomatous lesions (OR = 1.7; 95% CI = 1.01-2.9013). CONCLUSIONS: Since the change in Medicare reimbursement, there has been a significant increase in the number and proportion of colonoscopies performed for screening at our institution. Patients screened since this change are older, and the detection rate of neoplastic lesions is similar to those previously screened for a family history of colorectal cancer or polyps.