Health Insurance Coverage and Access to Care by Sexual Orientation During the COVID-19 Pandemic: United States, January 2021-February 2022.

Objectives. To compare health insurance coverage and access to care by sex and sexual minority status during the COVID-19 pandemic and assess whether lack of insurance hindered access to care by sexual minority status. Methods. Using Behavioral Risk Factor Surveillance System data (January 2021-February 2022), we examined differences by sex and sexual orientation among 158 722 adults aged 18 to 64 years living in 34 states. Outcomes were health insurance coverage type and 3 access to care measures. Results. Sexual minority women were significantly more likely to be uninsured than were heterosexual women, and lack of insurance widened the magnitude of disparity by sexual minority status in all measures of access. Compared with heterosexual men with health insurance, sexual minority men with health insurance were significantly more likely to report being unable to afford necessary care. Conclusions. During the pandemic, 1 in 8 sexual minority adults living in 34 study states were uninsured. Among sexual minority women, lack of insurance widened inequities in access to care. There were inequities among sexual minority men with health insurance. Public Health Implications. Sexual minority adults may be disproportionately affected by the unwinding of the COVID-19 public health emergency and may require tailored efforts to mitigate insurance coverage loss. (Am J Public Health. 2024;114(1):118-128. https://doi.org/10.2105/AJPH.2023.307446).

Antinociceptive and adverse effects of morphine:ketamine mixtures in rats.

Prescription opioids are the gold standard for treating moderate to severe pain despite their well-documented adverse effects. Of all prescription medications, opioids are abused most widely, and fatal overdoses have reached epidemic levels. One strategy for improving the margin of safety of opioids is combining them with non-opioid drugs to decrease the opioid dose needed for pain relief, thereby reducing adverse effects that occur with larger doses. The N-methyl-D-aspartate receptor antagonist ketamine has been used safely as an analgesic but only under a very limited range of conditions. The current studies characterized the antinociceptive, behavioral suppressant, and gastrointestinal effects of morphine and ketamine alone and in mixtures to determine their interaction in 24 adult male Sprague-Dawley rats (n = 8 per assay). Given alone, both morphine and ketamine produced antinociception, decreased responding for food, and reduced gastrointestinal transit (i.e. produced constipation). The effects of morphine:ketamine mixtures generally were additive, except for the antinociceptive effects of 1:1 mixtures for which the difference in slope (i.e. non-parallel shift) between the observed and predicted effects suggested synergy at smaller doses and additivity at larger doses. The potency of morphine to produce constipation was not enhanced by administration of morphine:ketamine mixtures with antinociceptive effects. The nature of the interaction between morphine and ketamine for adverse effects such as dependence, withdrawal, abuse, or respiratory depression remains unknown but also might be related to the ratio of each drug in mixtures. It will be important to identify conditions that produce the largest potential therapeutic window in humans.

Structural Racism, Historical Redlining, and Incidence of Kidney Failure in US Cities, 2012-2019.

SIGNIFICANCE STATEMENT: Residing in neighborhoods designated as grade D (hazardous) by the Home Owners' Loan Corporation (HOLC) under historical redlining-a discriminatory housing policy beginning in the 1930s-has been associated with present-day adverse health outcomes such as diabetes mortality. Historical redlining might underlie conditions in present-day neighborhoods that contribute to inequitable rates of kidney failure incidence, particularly for Black individuals, but its association with kidney disease is unknown. The authors found that among adults with incident kidney failure living in 141 metropolitan areas, residence in a historically redlined neighborhood rated grade D was associated with significantly higher kidney failure incidence rates compared with residence in a redlined grade A (best) neighborhood. These findings suggest that historical racist policies continue to affect current-day racial inequities in kidney health. BACKGROUND: Historical redlining was a 1930s federally sponsored housing policy that permitted the Home Owners' Loan Corporation (HOLC) to develop color-coded maps and grade neighborhoods' mortgage lending risk on the basis of characteristics that included racial makeup. This practice has been associated with present-day health disparities. Racial inequities in kidney disease-particularly for Black individuals-have been linked to residential segregation and other structural inequities. METHODS: Using a registry of people with incident kidney failure and digitized HOLC maps, we examined the association between residence in a historically redlined US census tract (CT) with a historical HOLC grade of D or hazardous) and present-day annual CT-level incidence of kidney failure incidence among adults in 141 US metropolitan areas, in 2012 through 2019. RESULTS: Age-adjusted and sex-adjusted kidney failure incidence rates were significantly higher in CTs with a historical HOLC grade D compared with CTs with a historical HOLC grade of A or best (mean, 740.7 per million versus 326.5 per million, respectively, a difference of 414.1 per million). Compared with national averages of all adults in our sample, rates of kidney failure incidence were higher for Black adults in our study sample, irrespective of CT HOLC grade. Age-adjusted and sex-adjusted incidence rates for Black persons in CTs with a HOLC grade D were significantly higher than for Black persons residing in HOLC grade A CTs (mean, 1227.1 per million versus 1030.5 per million, respectively [a difference of 196.6 per million]). CONCLUSIONS: Historical redlining is associated with present-day disparities in kidney failure incidence, demonstrating the legacy of historical racist policies on contemporary racial inequities in kidney health. PODCAST: This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_08_24_JASN0000000000000165.mp3.

Incorporating low haemoglobin into a risk prediction model for conversion in minimally invasive gynaecologic oncology surgeries.

BACKGROUND: A well-known complication of laparoscopic management of gynaecologic masses and cancers is the need to perform an intraoperative conversion to laparotomy. The purpose of this study was to identify novel patient risk factors for conversion from minimally invasive to open surgeries for gynaecologic oncology operations. METHODS: This was a retrospective cohort study of 1356 patients ≥18 years of age who underwent surgeries for gynaecologic masses or malignancies between February 2015 and May 2020 at a single academic medical centre. Multivariable logistic regression was used to study the effects of older age, higher body mass index (BMI), higher American Society of Anaesthesiologist (ASA) physical status, and lower preoperative haemoglobin (Hb) on odds of converting from minimally invasive to open surgery. Receiver operating characteristic (ROC) curve analysis assessed the discriminatory ability of a risk prediction model for conversion. RESULTS: A total of 704 planned minimally invasive surgeries were included with an overall conversion rate of 6.1% (43/704). Preoperative Hb was lowest for conversion cases, compared to minimally invasive and open cases (11.6 ± 1.9 vs 12.8 ± 1.5 vs 11.8 ± 1.9 g/dL, p<.001). Patients with preoperative Hb <10 g/dL had an adjusted odds ratio (OR) of 3.94 (CI: 1.65-9.41, p=.002) for conversion while patients with BMI ≥30 kg/m2 had an adjusted OR of 2.86 (CI: 1.50-5.46, p=.001) for conversion. ROC curve analysis using predictive variables of age >50 years, BMI ≥30 kg/m2, ASA physical status >2, and preoperative haemoglobin <10 g/dL resulted in an area under the ROC curve of 0.71. Patients with 2 or more risk factors were at highest risk of requiring an intraoperative conversion (12.0%). CONCLUSIONS: Lower preoperative haemoglobin is a novel risk factor for conversion from minimally invasive to open gynaecologic oncology surgeries and stratifying patients based on conversion risk may be helpful for preoperative planning.

Minimally invasive surgery for management of gynaecologic masses (masses that affect the female reproductive organs) is often preferred over more invasive surgery, because it involves smaller surgical incisions and can have overall better recovery time. However, one unwanted complication of minimally invasive surgery is the need to unexpectedly convert the surgery to an open surgery, which entails a larger incision and is a higher risk procedure. In our study, we aimed to find patient characteristics that are associated with higher risk of converting a minimally invasive surgery to an open surgery. Our study identified that lower levels of preoperative haemoglobin, the protein that carries oxygen within red blood cells, is correlated with higher risk for conversion. This new risk factor was used with other known risk factors, including having higher age, higher body mass index, and higher baseline medical complexity to create a model to help surgical teams identify high risk patients for conversion. This model may be useful for surgical planning before and during the operation to improve patient outcomes.

Patients Who Have Limited English Proficiency Have Decreased Utilization of Revision Surgeries After Hip and Knee Arthroplasty.

BACKGROUND: While racial and ethnic disparities are well documented in access to total joint arthroplasty (TJA), little is known about the association between having limited English proficiency (LEP) and postoperative care access. This study seeks to correlate LEP status with rates of revision surgery after hip and knee arthroplasty. METHODS: This was a retrospective cohort study of patients aged ≥ 18 years who underwent either total hip or total knee arthroplasty between January 2013 and December 2021 at a single academic medical center. The predictor variable was English proficiency status, where LEP was defined as having a primary language that was not English. Multivariable regressions controlling for potential demographic and clinical confounders were used to calculate adjusted odds ratios of undergoing revision surgery within 1 and 2 years after primary arthroplasty for patients who have LEP, compared to English proficient patients. RESULTS: A total of 7,985 hip and knee arthroplasty surgeries were included in the analysis. There were 577 (7.2%) patients who were classified as having LEP. Patients who have LEP were less likely to undergo revision surgeries within 1 year (1.4% versus 3.2%, P = .01) and 2 years (1.7% versus 3.9%, P = .006) of primary TJA. Patients who have LEP had adjusted odds ratios of 0.45 (confidence interval: 0.22-0.92, P = .03) and 0.44 (confidence interval: 0.23-0.85, P = .01) of receiving revision surgery within 1 and 2 years, respectively. CONCLUSION: Patients who have LEP, compared to English proficient patients, were less likely to undergo revision surgeries at the same institution up to 2 years after hip and knee arthroplasty. These findings suggest that patients who have LEP may face barriers in accessing postoperative care.

Medicare Advantage Enrollment Among Beneficiaries With End-Stage Renal Disease in the First Year of the 21st Century Cures Act.

Importance: Before 2021, most Medicare beneficiaries with end-stage renal disease (ESRD) were unable to enroll in private Medicare Advantage (MA) plans. The 21st Century Cures Act permitted these beneficiaries to enroll in MA plans effective January 2021. Objective: To examine changes in MA enrollment among Medicare beneficiaries with ESRD after enactment of the 21st Century Cures Act overall and by race or ethnicity and dual-eligible status. Design, Setting, and Participants: This cross-sectional time-trend study used data from Medicare beneficiaries with ESRD (both kidney transplant recipients and those undergoing dialysis) between January 2019 and December 2021. Data were analyzed between June and October 2022. Exposures: 21st Century Cures Act. Main Outcomes and Measures: Primary outcomes were the proportion of Medicare beneficiaries with prevalent ESRD who switched from traditional Medicare to MA between 2020 and 2021 and those with incident ESRD who newly enrolled in MA in 2021. Individuals who stayed in traditional Medicare were enrolled in 2020 and 2021 and those who switched to MA were enrolled in traditional Medicare in 2020 and MA in 2021. Results: Among 575 797 beneficiaries with ESRD in 2020 or 2021 (mean [SD] age, 64.7 [14.2] years, 42.2% female, 34.0% Black, and 7.7% Hispanic or Latino), the proportion of beneficiaries enrolled in MA increased from 24.8% (December 2020) to 37.4% (December 2021), a relative change of 50.8%. The largest relative increases in MA enrollment were among Black (72.8% relative increase), Hispanic (44.8%), and dual-eligible beneficiaries with ESRD (73.6%). Among 359 617 beneficiaries with TM and prevalent ESRD in 2020, 17.6% switched to MA in 2021. Compared with individuals who stayed in traditional Medicare, those who switched to MA had modestly more chronic conditions (6.3 vs 6.1; difference, 0.12 conditions [95% CI, 0.10-0.16]) and similar nondrug spending in 2020 (difference, $509 [95% CI, -$58 to $1075]) but were more likely to be Black (difference, 19.5 percentage points [95% CI, 19.1-19.9]) and have dual Medicare-Medicaid eligibility (difference, 20.8 percentage points [95% CI, 20.4-21.2]). Among beneficiaries who were newly eligible for Medicare ESRD benefits in 2021, 35.2% enrolled in MA. Conclusions and Relevance: Results suggest that increases in MA enrollment among Medicare beneficiaries with ESRD were substantial the first year after the 21st Century Cures Act, particularly among Black, Hispanic, and dual-eligible individuals. Policy makers and MA plans may need to assess network adequacy, disenrollment, and equity of care for beneficiaries who enrolled in MA.

Variation in Usual Source of Care in Asian American, Native Hawaiian, and Other Pacific Islander Adult Medicaid Beneficiaries.

BACKGROUND: Disparities in access to care between non-Hispanic White and Asian American, Native Hawaiian, and Pacific Islander (AANHPI) patients are often attributed to higher uninsurance rates among AANHPI patients. Less is known about variation among individuals with Medicaid health insurance coverage and among AANHPI subgroups. OBJECTIVE: The objective of this study was to examine differences in access to care between White and AANHPI adult Medicaid beneficiaries, both in the aggregate and disaggregated into 9 ethnic subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other Asian, Native Hawaiian, and Pacific Islander). RESEARCH DESIGN: Nationwide Adult Medicaid Consumer Assessment of Healthcare Providers and Systems data (2014-2015), a cross-sectional survey representative of all Medicaid beneficiaries. SUBJECTS: A total of 126,728 White and 10,089 AANHPI Medicaid beneficiaries were included. MEASURES: The study outcomes were: (1) having a usual source of care; and (2) reporting a health center or clinic as the usual site of care. Multivariable linear probability models assessed the relationship between race/ethnic subgroup and our outcomes, adjusting for sociodemographic characteristics and health status. RESULTS: Compared with White beneficiaries, Korean beneficiaries were significantly less likely to report having a usual source of care [difference=-8.9 percentage points (PP), P =0.01], and Chinese (difference=8.4 PP, P =0.001), Native Hawaiian (difference=25.8 PP, P <0.001), and Pacific Islander (difference=22.2 PP, P =0.001) beneficiaries were significantly more likely to report a health center or clinic as their usual site of care. CONCLUSIONS: Despite similar health insurance coverage, significant differences in access to care remain between White and AANHPI Medicaid beneficiaries. Disaggregated AANHPI data may reveal important variation in access to care and inform more targeted public policies.

Trends in Collection of Disaggregated Asian American, Native Hawaiian, and Pacific Islander Data: Opportunities in Federal Health Surveys.

Collection of data for Asian American, Native Hawaiian, and Pacific Islander (AANHPI) persons that is disaggregated by ethnic subgroup may identify disparities that are not apparent in aggregated data. Using content analysis, we identified national population surveys administered by the US Department of Health and Human Services (HHS) and evaluated trends in the collection of disaggregated AANHPI data between 2011 and 2021. In 2011, 4 of 15 surveys (27%) collected disaggregated data for Asian American, 2 of 15 surveys (13%) collected data on Native Hawaiian, and 2 of 15 surveys (13%) collected disaggregated data for Pacific Islander people. By 2019, 14 of 21 HHS-administered surveys (67%) collected disaggregated data for Asian American (6 subgroups), 67% collected data on Native Hawaiian, and 67% collected disaggregated data on Pacific Islander (3 subgroups) people. Collection of disaggregated AANHPI data in HHS-administered surveys increased from 2011 to 2021, but opportunities to expand collection and reporting remain. Strategies include outreach with community organizations, increased language assistance, and oversampling approaches. Increased availability and reporting of these data can inform health policies and mitigate disparities. (Am J Public Health. 2022;112(10):1429-1435. https://doi.org/10.2105/AJPH.2022.306969).

Changes in Hip Capsule Morphology after Arthroscopic Treatment for Femoroacetabular Impingement Syndrome with Periportal Capsulotomy are Correlated With Improvements in Patient-Reported Outcomes.

PURPOSE: To assess the correlation between changes in hip capsule morphology with improvements in patient-reported outcome (PRO) scores after arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) using the periportal capsulotomy technique. METHODS: Twenty-eight patients with cam morphology FAIS (without arthritis, dysplasia, or hypermobility) were prospectively enrolled before arthroscopic labral repair and femoroplasty through periportal capsulotomy (anterolateral/midanterior portals) without closure. Patients completed the Hip Disability and Osteoarthritis Outcomes Score (HOOS) and had nonarthrographic 3T magnetic resonance imaging (MRI) scans of the affected hip before and 1 year after surgery. Anterior capsule thickness, posterior capsule thickness, anterior-posterior capsule thickness ratio, and proximal-distal anterior capsule thickness ratio were measured on axial-oblique MRI sequences. Pearson correlation coefficients were calculated to determine the association between hip capsule morphology and PRO scores. RESULTS: Postoperative imaging showed that for all 28 patients (12 female), labral repairs and capsulotomies had healed within 1 year of surgery. Analysis revealed postoperative decreases in anterior hip capsule thickness (1395.4 ± 508.4 mm3 vs 1758.4 ± 487.9 mm3; P = .003) and anterior-posterior capsule thickness ratio (0.92 ± 0.33 vs 1.12 ± 0.38; P = .02). Higher preoperative anterior-posterior capsule thickness ratio correlated with lower preoperative scores for HOOS pain (R = -0.43; P = .02), activities of daily living (ADL) (R = -0.43; P = .02), and sport (R = -0.38; P = .04). Greater decrease from preoperative to postoperative anterior-posterior capsule thickness ratio correlated with greater improvement for HOOS pain (R = -0.40; P = .04), ADL (R = -0.45; P = .02), and sport (R = -0.46; P = .02). CONCLUSIONS: Periportal capsulotomy without closure demonstrates capsule healing by 1 year after arthroscopic FAIS treatment. Changes in hip capsule morphology including decreased anterior-posterior capsule thickness ratio after surgery may be correlated with improvements in patient pain, function, and ability to return to sports. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Medicaid Expansion and Incidence of Kidney Failure among Nonelderly Adults.

BACKGROUND: Low-income individuals without health insurance have limited access to health care. Medicaid expansions may reduce kidney failure incidence by improving access to chronic disease care. METHODS: Using a difference-in-differences analysis, we examined the association between Medicaid expansion status under the Affordable Care Act (ACA) and the kidney failure incidence rate among all nonelderly adults, aged 19-64 years, in the United States, from 2012 through 2018. We compared changes in kidney failure incidence in states that implemented Medicaid expansions with concurrent changes in nonexpansion states during pre-expansion, early postexpansion (years 2 and 3 postexpansion), and later postexpansion (years 4 and 5 postexpansion). RESULTS: The unadjusted kidney failure incidence rate increased in the early years of the study period in both expansion and nonexpansion states before stabilizing. After adjustment for population sociodemographic characteristics, Medicaid expansion status was associated with 2.20 fewer incident cases of kidney failure per million adults per quarter in the early postexpansion period (95% CI, -3.89 to -0.51) compared with nonexpansion status, a 3.07% relative reduction (95% CI, -5.43% to -0.72%). In the later postexpansion period, Medicaid expansion status was not associated with a statistically significant change in kidney failure incidence (-0.56 cases per million per quarter; 95% CI, -2.71 to 1.58) compared with nonexpansion status and the pre-expansion time period. CONCLUSIONS: The ACA Medicaid expansion was associated with an initial reduction in kidney failure incidence among the entire, nonelderly, adult population in the United States; but the changes did not persist in the later postexpansion period. Further study is needed to determine the long-term association between Medicaid expansion and changes in kidney failure incidence.

Asian American Access to Care in the Affordable Care Act Era: Findings from a Population-Based Survey in California.

BACKGROUND: Though Asian Americans made gains in coverage following the Affordable Care Act (ACA), substantial variations in access to care remain across different ethnic subgroups. Several states are considering adoption of policies to collect health data for Asian Americans that is disaggregated by ethnic subgroup, which may identify disparities in access to care. OBJECTIVE: We examined coverage and access to care between non-Hispanic White and Asian American adults following the ACA in California. We first compared outcomes in non-Hispanic White adults with all Asian Americans in our sample, and then evaluated whether we detect disparities when data is disaggregated into five of the most populous ethnic subgroups (Chinese, Korean, Filipino, Vietnamese, and Japanese). DESIGN: Cross-sectional California Health Interview Survey data were collected between January 2014 and December 2016. PARTICIPANTS: Our sample included 19,201 non-Hispanic White and 3077 Asian American non-elderly adults age 18 to 64 living in California. MAIN MEASURES: Our outcomes were (1) being uninsured, (2) having a usual source of care, (3) delaying necessary medical care, and (4) delaying necessary prescription medications. Using multivariable logistic regression models, we examined our outcomes, adjusting for predisposing, enabling, need, and acculturation factors. KEY RESULTS: Compared with non-Hispanic Whites, some subgroups of Asian Americans reported significantly worse access to care: disaggregated, adjusted analyses revealed that Koreans were significantly less likely to report a usual source of care (adjusted odds ratio [AOR] = 0.31, p < 0.01) relative to non-Hispanic Whites. Chinese (AOR = 0.42, p < 0.01) and Vietnamese (AOR = 0.34, p < 0.01) adults were significantly less likely to delay necessary care. CONCLUSIONS: Disaggregated analyses identified differences in access to care for Asian American subgroups following the ACA. State policies to collect disaggregated health data for Asian Americans may reveal heterogeneity in experiences of care and inform specific policies to reduce disparities in access to care.

Comparing Diagnostic Evaluations for Rectal Bleeding and Breast Lumps in Primary Care: a Retrospective Cohort Study.

BACKGROUND: Inadequate diagnostic evaluations of breast lumps and rectal bleeding in primary care are an important source of medical errors. Delays appear particularly common in evaluation of rectal bleeding. Comparing pursuit and completion of diagnostic testing for these two conditions within the same practice settings could help highlight barriers and inform interventions. OBJECTIVES: To examine processes undertaken for diagnostic evaluations of breast lumps and rectal bleeding within the same practices and to compare them with regard to (a) the likelihood that diagnostic tests are ordered according to guidelines and (b) the timeliness of order placement and completion. DESIGN: A retrospective cohort study using explicit chart abstraction methods. PARTICIPANTS: Three hundred women aged 30-80 presenting with breast lumps and 300 men and women aged 40-80 years presenting with rectal bleeding to 15 academically affiliated primary care practices, 2012-2016. MAIN MEASURES: Rates and timing of test ordering and completion and patterns of visits and communications. KEY RESULTS: At initial presentation, physicians ordered recommended imaging or procedures at higher rates for patients with breast lumps compared to those with rectal bleeding (97% vs. 86% of patients recommended to receive imaging or endoscopy; p < 0.01). Most (90%) patients with breast lumps completed recommended diagnostic testing within 1 month, versus 31% of patients with rectal bleeding (p < 0.01). By 1 year, 7% of patients with breast lumps had not completed indicated imaging, versus 27% of those with rectal bleeding. Patients with breast lumps had fewer subsequent primary care visits related or unrelated to their symptom and had fewer related communications with specialists. LIMITATIONS: The study relied on documented care, and findings may be most generalizable to academically affiliated institutions. CONCLUSIONS: Diagnostic processes for rectal bleeding were less frequently guideline-concordant and timely than those for breast lumps. The largest discrepancies occurred in initial ordering of indicated tests and the timeliness of test completion.

LGBTQI+ Data Collection in Medicaid to Advance Health Equity.

This Viewpoint explores Centers for Medicare & Medicaid Services guidance on the collection of sexual orientation and gender identity data and how these data could be used to advance health equity for LGBTQI+ people.

Discovery of Novel Small-Molecule Inducers of Heme Oxygenase-1 That Protect Human iPSC-Derived Cardiomyocytes from Oxidative Stress.

Oxidative injury to cardiomyocytes plays a critical role in cardiac pathogenesis following myocardial infarction. Transplantation of stem cell-derived cardiomyocytes has recently progressed as a novel treatment to repair damaged cardiac tissue but its efficacy has been limited by poor survival of transplanted cells owing to oxidative stress in the post-transplantation environment. Identification of small molecules that activate cardioprotective pathways to prevent oxidative damage and increase survival of stem cells post-transplantation is therefore of great interest for improving the efficacy of stem cell therapies. This report describes a chemical biology phenotypic screening approach to identify and validate small molecules that protect human-induced pluripotent stem cell cardiomyocytes (hiPSC-CMs) from oxidative stress. A luminescence-based high-throughput assay for cell viability was used to screen a diverse collection of 48,640 small molecules for protection of hiPSC-CMs from peroxide-induced cell death. Cardioprotective activity of "hit" compounds was confirmed using impedance-based detection of cardiomyocyte monolayer integrity and contractile function. Structure-activity relationship studies led to the identification of a potent class of compounds with 4-(pyridine-2-yl)thiazole scaffold. Examination of gene expression in hiPSC-CMs revealed that the hit compound, designated cardioprotectant 312 (CP-312), induces robust upregulation of heme oxygenase-1, a marker of the antioxidant response network that has been strongly correlated with protection of cardiomyocytes from oxidative stress. CP-312 therefore represents a novel chemical scaffold identified by phenotypic high-throughput screening using hiPSC-CMs that activates the antioxidant defense response and may lead to improved pharmacological cardioprotective therapies.

Diagnostic Evaluation of Patients Presenting to Primary Care with Rectal Bleeding.

BACKGROUND: Rectal bleeding is a common, frequently benign problem that can also be an early sign of colorectal cancer. Diagnostic evaluation for rectal bleeding is complex, and clinical practice may deviate from available guidelines. OBJECTIVE: To assess the degree to which primary care physicians document risk factors for colorectal cancer among patients with rectal bleeding and order colonoscopies when indicated, and the likelihood of physicians ordering and patients receiving recommended colonoscopies based on demographic characteristics, visit patterns, and clinical presentations. DESIGN: Cross-sectional study using explicit chart abstraction methods. PARTICIPANTS: Three hundred adults, 40-80 years of age, presenting with rectal bleeding to 15 academically affiliated primary care practices between 2012 and 2016. MAIN MEASURES: 1) The frequency at which colorectal cancer risk factors were documented in patients' charts, 2) the frequency at which physicians ordered colonoscopies and patients received them, and 3) the odds of ordering and patients receiving recommended colonoscopies based on patient demographic characteristics, visit patterns, and clinical presentations. KEY RESULTS: Risk factors for colorectal cancer were documented between 9% and 66% of the time. Most patients (89%) with rectal bleeding needed a colonoscopy according to a clinical guideline. Physicians placed colonoscopy orders for 74% of these patients, and 56% completed the colonoscopy within a year (36% within 60 days). The odds of physicians ordering recommended colonoscopies were significantly higher in patients aged 50-64 years of age than in those aged 40-50 years (OR = 2.23, 95% CI: 1.04, 4.80), and for patients whose most recent colonoscopy was 5 or more years ago (OR = 4.04, 95% CI: 1.50, 10.83). The odds of physicians ordering and patients receiving recommended colonoscopies were significantly lower for each primary care visit unrelated to rectal bleeding (OR = 0.85, 95% CI: 0.75, 0.96). CONCLUSIONS: Diagnostic evaluation of patients presenting to primary care with rectal bleeding may be suboptimal because of inadequate risk factor assessment and prioritization of patients' other concurrent medical problems.

Access and Quality of Care by Insurance Type for Low-Income Adults Before the Affordable Care Act.

OBJECTIVES: To compare access to care and perceived health care quality by insurance type among low-income adults in 3 southern US states, before Medicaid expansion under the Affordable Care Act. METHODS: We conducted a telephone survey in 2013 of 2765 low-income US citizens, aged 19 to 64 years, in Arkansas, Kentucky, and Texas. We compared 11 measures of access and quality of care for respondents with Medicaid, private insurance, Medicare, and no insurance with adjustment for sociodemographics and health status. RESULTS: Low-income adults with Medicaid, private insurance, and Medicare reported significantly better health care access and quality than uninsured individuals. Medicaid beneficiaries reported greater difficulty accessing specialists but less risk of high out-of-pocket spending than those with private insurance. For other outcomes, Medicaid and private coverage performed similarly. CONCLUSIONS: Low-income adults with insurance report significantly greater access and quality of care than uninsured adults, regardless of whether they have private or public insurance. Access to specialty care in Medicaid may require policy attention. PUBLIC HEALTH IMPLICATIONS: Many states are still considering whether to expand Medicaid under the Affordable Care Act and whether to pursue alternative models for coverage expansion. Our results suggest that access to quality health care will improve under the Affordable Care Act's coverage expansions, regardless of the type of coverage.

Use of and barriers to adopting standardized social risk screening tools in federally qualified health centers during the first year of the COVID-19 pandemic.

OBJECTIVE: To describe the national rate of social risk factor screening adoption among federally qualified health centers (FQHCs), examine organizational factors associated with social risk screening adoption, and identify barriers to utilizing a standardized screening tool in 2020. DATA SOURCE: 2020 Uniform Data System, a 100% sample of all US FQHCs (N = 1375). STUDY DESIGN: We used multivariable linear probability models to assess the association between social risk screening adoption and key FQHC characteristics. We used descriptive statistics to describe variations in screening tool types and barriers to utilizing standardized tools. We thematically categorized open-ended responses about tools and barriers. DATA COLLECTION: None. PRINCIPAL FINDINGS: In 2020, 68.9% of FQHCs screened patients for any social risk factors. Characteristics associated with a greater likelihood of screening adoption included having high proportions of patients best served in a language other than English (18.8 percentage point [PP] increase, 95% CI: 6.0, 31.6) and being larger in size (10.3 PP increase, 95% CI: 0.7, 20.0). Having higher proportions of uninsured patients (14.2 PP decrease, 95% CI: -25.5, -0.3) and participating in Medicaid-managed care contracts (7.3 PP decrease, 95% CI: -14.2, -0.3) were associated with lower screening likelihood. Among screening FQHCs, the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) was the most common tool (47.1%). Among non-screening FQHCs, common barriers to using a standardized tool included lack of staff training to discuss social issues (25.2%), inability to include screening in patient intake (21.7%), and lack of funding for addressing social needs (19.2%). CONCLUSIONS: Though most FQHCs screened for social risk factors in 2020, various barriers have prevented nearly 1 in 3 FQHCs from adopting a screening tool. Policies that provide FQHCs with resources to support training and workflow changes may increase screening uptake and facilitate engagement with other sectors.

Actinic Granuloma Complicated by Secondary Syphilis: A Case Report.

Introduction: Actinic granuloma (AG) is a rare skin eruption thought to result from a sun-induced inflammatory response attracting giant cells, which are large, multinucleated, and inflammatory, to form granulomas and degrade surrounding elastic material. Clinically, lesions begin on sun-exposed skin as pink papules and nodules that coalesce into demarcated annular plaques with a hypopigmented center. Histologically, actinic elastosis surrounds the outer annulus ring, with histiocytes and giant cells within the raised border, and the innermost central zone is filled with minimal to absent elastic fibers. Case Presentation: We present a middle-aged female with a pruritic eruption of diffuse erythematous macules and papules coalescing into plaques with mild scale involving the scalp, face, neck, torso, and upper and lower extremities, including the palms and soles, but sparing the ears, bilateral axillae, elbows, and knees. Skin biopsies revealed solar elastosis and abundant multinucleated foreign body giant cells with ingested elastic fibers. The patient's clinical presentation and histopathology were consistent with a diagnosis of AG. Furthermore, spirochete immunostaining of the specimens revealed multiple Treponema pallidum spirochetes throughout the epidermis and dermis. Secondary syphilis with primary chancre was added to the diagnosis. Treatment included oral and topical steroids followed by intravenous penicillin G. After 1 month, all lesions had resolved with post-inflammatory erythema. Conclusion: Our patient differs from the typical presentation in describing intense pruritus with her eruption. This interesting collision reminds clinicians to retain a high index of suspicion for multiple diagnoses in a single patient.