Low BMD is prevalent in Swedish pediatric patients with IBD. Possible risk factors for lower BMD are male gender, low BMI, and treatment with azathioprine, as a probable marker of disease course severity.

Background The Affordable Care Act (ACA) included provisions to extend dependent healthcare coverage up to the age of 26 years in 2010. We examined the early impact of the ACA (prior to implementation of insurance exchanges in 2014) on insurance rates in young adults with cancer, a historically underinsured group. Methods Using National Cancer Institute Surveillance, Epidemiology and End Results (SEER) data for 18 cancer registries, we examined insurance rates pre-(January 2007–September 2010) vs. post-(October 2010–December 2012) dependent insurance provisions among young adults aged 18–29 years when diagnosed with cancer during 2007–2012. Using multivariate generalized mixed effect models, we conducted difference-in-differences analysis to examine changes in overall and Medicaid insurance after the ACA among young adults eligible (18–25 years) and ineligible (26–29 years) for policy changes. Results Among 39,632 young adult cancer survivors, we found an increase in overall insurance rates in 18–25 year-olds after the dependent provisions (83.5% pre vs. 85.4% post, p<0.01), but not among 26–29 year-olds (83.4% pre vs. 82.9% post, p=0.38). After adjusting for patient socio-demographics and cancer characteristics, we found 18–25 year-olds had a 3.1% increase in being insured relative to 26–29 year-olds (p<0.01); however, there were no significant changes in Medicaid enrollment (p=0.17). Conclusions Our findings identify an increase in insurance rates for young adults 18–25 relative to those 26–29 (1.9% vs. −0.5%) that were not due to increases in Medicaid enrollment, demonstrating a positive impact of the ACA dependent care provisions on insurance rates in this population.

Introduction Young adults have historically been the least likely to have health insurance in the United States. Previous studies of childhood cancer survivors found lower rates of insurance and less access to medical care compared to siblings; however, no studies have examined continuity of insurance after cancer diagnosis in adolescents and young adults (AYAs). Methods Using the AYA Health Outcomes and Patient Experience study, a cohort of 465 15-39 year-olds from participating Surveillance, Epidemiology and End Results registries, we evaluated changes in and sponsors of health insurance coverage after diagnosis, coverage of doctor-recommended tests, and factors associated with lack of insurance post-diagnosis using chi-square tests and multivariable logistic regression. Results Over 25% (n=118) of AYA cancer survivors experienced some period without insurance up to 35 months post-diagnosis. Insurance rates were high in the initial year after diagnosis (6-14 months; 93.3%) but decreased substantially at follow-up (15-35 months; 85.2%). The most common sponsor of health insurance was employer/school-coverage (43.7%). Multivariable analysis indicated that older survivors (25-39 vs. 15-19; Odds Ratio (OR): 3.35, p<0.01) and those with less education (high school or less vs. college graduate; OR: 2.80, p<0.01) were more likely to experience a period without insurance after diagnosis. Furthermore, >20% of survivors indicated there were doctor-recommended tests/treatments not covered by insurance, but >80% received them regardless of coverage. Discussion Insurance rates decrease with time since diagnosis in AYA cancer survivors. Future studies should examine how new policies under the Affordable Care Act extend access and insurance coverage beyond initial treatment.

We report a case of a 6-month-old girl suffering from a kaposiform hemangioendothelioma of the chest wall, associated with Kasabach-Merritt phenomenon. Despite rapid intervention with cortisone and interferon alpha the tumor led to a life-threatening clinical condition with progressive growth and consumption coagulopathy under therapy. Because therapy for kaposiform hemangioendotheliomas with a single anti-angiogenic or anti-proliferative agent has not been reported to be very successful, we administered vincristine, combined with cyclophosphamide, actinomycin D, and methotrexate in a critically ill patient. After six cycles of the applied four-drug regiment, the infant was in remission, which has been maintained for 5 months since stopping therapy.

Objectives: Low bone mineral density (BMD) is recognized as a potential problem in children with inflammatory bowel disease (IBD). We aimed to describe the longitudinal development of BMD in a population of Swedish pediatric patients with IBD. Methods: A total of 144 patients with IBD (93 males; 83 with ulcerative colitis [UC], 45 with Crohn disease [CD]) were examined with dual-energy x-ray absorptiometry at baseline. At follow-up 2 years later, 126 of the initial 144 patients were reexamined. BMD values are expressed as z scores. Results: Children with UC and CD had significantly lower mean BMD z scores for the lumbar spine (LS) at baseline and after 2 years. The reduction in BMD was equally pronounced in patients with UC and CD, and neither group improved their z score during the follow-up period. Furthermore, significantly lower mean BMD z scores for the LS were found at baseline in boys (À1.1 SD, AE2.7 SD, P < 0.001), but not in girls (À0.0 SD, AE3.0 SD). This finding remained unchanged at follow-up. Subanalyses of the different age groups at baseline showed the lowest BMD values in the group of patients ages 17 to 19 years in boys (mean z score for the LS 1.59 SD, AE3.1 SD) and in girls (mean z score for the LS À3.40 SD, AE3.1 SD); however, at follow-up, these patients had improved their BMD significantly (mean change z score for the LS 1.00 SD, 95% CI 0.40-1.60; 1.90 SD, 95% CI 0.60-3.20). Conclusions: In this longitudinal study, the entire group of pediatric patients with IBD showed permanent decreases in their BMD z scores for the LS; however, our data indicate that afflicted children have the potential to improve their BMD by the time they reach early adulthood.

Most AYAs with cancer were treated by non-pediatric physicians in community settings, although physician characteristics varied significantly by patient cancer type and age at diagnosis.

BackgroundThis research explores the healthy soldier effect (HSE) – a lower mortality risk among veterans relative to the general population—in United States (US) veterans deployed in support of operations in Iraq and Afghanistan (OEF/OIF/OND). While a HSE has been affirmed in other OEF/OIF/OND populations, US veterans of OEF/OIF/OND have not been systematically studied.MethodsUsing US Department of Veterans Affairs (VA) administrative data, we identified veterans who (1) had been deployed in support of OEF/OIF/OND between 2002 and 2011 and (2) were enrolled in the VA health care system. We divided the VA population into VA health care utilizers and non-utilizers. We obtained Department of Defense (DOD) administrative data on the OEF/OIF/OND population and obtained VA and DOD mortality data excluding combat deaths from the analyses. Indirect standardization was used to compare VA and DOD cohorts to the US population using total population at risk to compute the Standardized Mortality Ratio (SMR). A directly standardized relative risk (DSRR) was calculated to enable comparisons between cohorts. To compare VA enrollee mortality on military specific characteristics, we used a DOD population standard.ResultsThe overall VA SMR of 2.8 (95% Confidence Interval [CI] 2.8-2.9), VA utilizer SMR of 3.2 (95% CI 3.1-3.3), VA non-utilizer SMR of 0.9 (95% CI 0.8-1.1), and DOD SMR of 1.5 (95% CI 1.4-1.5) provide no evidence of a HSE in any cohort relative to the US standard population. Relative to DOD, both the total VA population SMR of 2.1 (95% CI 2.0-2.2) and the SMR for VA utilizers of 2.3 (95% CI 2.3-2.4) indicate mortality twice what would be expected given DOD mortality rates. In contrast, the VA enrollees who had not used clinical services had 40% lower than expected mortality relative to DOD.ConclusionsNo support was found for the HSE among US veterans of OEF/OIF/OND. These findings may be attributable to a number of factors including post-deployment risk-taking behavior, an abbreviated follow up period, and the nature of the OEF/OIF/OND conflict.

IMPORTANCEAs opioid-related deaths continue to climb, methods to reduce barriers to prescribing buprenorphine for individuals with opioid use disorder (OUD) are needed. Recent conversations by state and federal authorities targeting low-threshold buprenorphine aim to reduce some barriers to prescribing buprenorphine; however, what remains unclear is whether removal of the requirement to obtain a waiver for prescribing buprenorphine through the Drug Addiction Treatment Act of 2000 (an X-waiver) will be enough to increase access to buprenorphine. OBJECTIVE To assess barriers and facilitators of obtaining an X-waiver and prescribing buprenorphine. DESIGN, SETTING, AND PARTICIPANTSThis mixed-method survey study was conducted between September and December 2020; 607 office-based Texas clinicians were surveyed after they attended a buprenorphine X-waiver training course. All attendees between March 2, 2019, and February 28, 2020, were eligible to receive this survey; 126 responses were received (20% response rate: 81 physicians, 37 nurse practitioners, and 8 physician assistants). Data analysis was performed October 2021. MAIN OUTCOMES AND MEASURES Surveys measured the extent to which clinicians experienced 9 previously identified barriers during the waiver process and in prescribing buprenorphine. The survey included open-ended items assessing facilitating factors to obtaining a waiver and to prescribing buprenorphine for OUD. The barriers were analyzed using χ 2 tests of homogeneity.Qualitative data were analyzed using a constant comparative method. RESULTS Among 126 clinicians who responded, 61 (48.4%) had received an X-waiver; of these waivered clinicians, 22 (36%) were prescribing buprenorphine and 39 (64%) were not. "Complexity of X-waiver process," "Perceived lack of professional support and referral network," and "Getting started" were significantly different barriers among waivered and nonwaivered clinicians. Significant differences in barriers experienced between prescribers and nonprescribers were "Getting started" and "Accessing reimbursement for treatment." The most frequently mentioned facilitators involved changes to the waiver training and the need for networks connecting experienced clinicians with those in the initial stages of readiness for prescribing buprenorphine for OUD. CONCLUSIONS AND RELEVANCEThis survey study's results contribute new understanding of facilitators to obtaining the X-waiver and to prescribing buprenorphine. Furthermore, these findings suggest that to increase access to compassionate evidence-based treatment for OUD, clinicians need ongoing support and mentorship from experienced and knowledgeable clinicians. Interventions (continued)