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IMPORTANCE: Despite evidence of improved insurance coverage under the Affordable Care Act and Medicaid expansion among adults with cancer, little is known regarding the association of these policies with coverage among children with cancer. OBJECTIVE: To assess the association of early Medicaid expansion with rates of Medicaid coverage, private coverage, and no uninsurance among children with cancer. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from the Surveillance, Epidemiology, and End Results (SEER) database from January 1, 2007, to December 31, 2015, to identify children diagnosed with cancer at ages 0 to 14 years in the United States. Data were analyzed from July 27, 2017, to October 7, 2019. EXPOSURES: Changes in insurance status at diagnosis after early Medicaid expansion in California, Connecticut, Washington, and New Jersey (EXP states) were compared with changes in nonexpansion (NEXP) states (Arkansas, Georgia, Hawaii, Iowa, Kentucky, Louisiana, Michigan, New Mexico, and Utah). MAIN OUTCOMES AND MEASURES: Difference-in-differences (DID) analyses were used to compare absolute changes in insurance status (uninsured, Medicaid, private/other) at diagnosis before (2007 to 2009) and after (2011 to 2015) expansion in EXP relative to NEXP states. RESULTS: A total of 21 069 children (11 265 [53.5%] male; mean [SD] age, 6.18 [4.57] years) were included. A 5.25% increase (95% CI, 2.61%-7.89%; P < .001) in Medicaid coverage in children with cancer was observed in EXP vs NEXP states, with larger increases among children of counties with middle to high (adjusted DID estimates, 10.18%; 95% CI, 4.22%-16.14%; P = .005) and high (adjusted DID estimates, 6.13%; 95% CI, 1.10%-11.15%; P = .05) poverty levels (P = .04 for interaction). Expansion-associated reductions of children reported as uninsured (−0.73%; 95% CI, −1.49% to 0.03%; P = .06) and with private or other insurance (−4.52%; 95% CI, −7.16% to −1.88%; P < .001) were observed. For the latter, the decrease was greater for children from counties with middle to high poverty (−9.00%; 95% CI, −14.98% to −3.02%) and high poverty (−6.38%; 95% CI, −11.36% to −1.40%) (P = .04 for interaction). CONCLUSIONS AND RELEVANCE: In this study, state Medicaid expansions were associated with increased Medicaid coverage in children with cancer overall and in some subgroups primarily owing to switching from private coverage, particularly in counties with higher levels of poverty but also through reductions in the uninsured.

Supplemental Digital Content is available in the text.Routine esophagogastroduodenoscopy (EGD) is an area of continued controversy in the preoperative evaluation for bariatric surgery; more information is needed regarding its impact on surgical management and associated costs. This systematic review and meta-analysis reports rates of abnormalities detected on preoperative EGD that changed operative management or delayed bariatric surgery. Sensitivity analysis examined the impact of controversial findings of hiatal hernia, Helicobacter pylori, gastritis, peptic ulcer disease. Data were used to calculate the cost per surgical alteration made due to abnormalities detected by routine EGD, compactly termed “cost-of-routine-EGD.” Thirty-one retrospective observational studies were included. Meta-analysis found 3.9% of EGDs resulted in a change in operative management; this proportion decreased to 0.3% after sensitivity analysis, as detection of hiatal hernia comprised 85.7% of findings that changed operative management. Half of the 7.5% of cases that resulted in surgical delay involved endoscopic detection of H. pylori. Gastric pathology was detected in a significantly greater proportion of symptomatic patients (65.0%) than in asymptomatic patients (34.1%; P<0.001). Cost-of-routine-EGD to identify an abnormality that changed operative management was $601,060, after excluding controversial findings. The cost-of-routine-EGD to identify any abnormality that led to a change in type of bariatric operation was $281,230 and $766,352 when controversial findings were included versus excluded, respectively. Cost-of-routine-EGD to identify a malignancy was $2,554,506. Cost-of-routine-EGD is high relative to the low proportion of abnormalities that alter bariatric surgery. Our results highlight the need to develop alternative strategies to preoperative screening, in order to improve access and decrease cost associated with bariatric surgery.

Glyphosate is a widely used herbicide in commercial crop production for both conventional and herbicide-resistant crops. Herbicide-resistant crops, like glyphosate-resistant sugar beet, are often exposed to multiple applications of glyphosate during the growing season. The fate of this herbicide in resistant crops has not been publicly documented. We investigated the fate of glyphosate and main metabolite aminomethylphosphonic acid in glyphosate-resistant sugar beet grown in northern Colorado. Glyphosate residues were measured via directed ultra-high-performance liquid chromatography tandem mass spectrometry analysis of sugar beet shoots and roots throughout the growing season, from samples collected at various steps during sugar beet processing, and from flow-through samples of greenhouse-grown beets. Sugar beet rapidly absorbed glyphosate after foliar application, and subsequently translocated the herbicide to its roots, with between 2 and 3 μg/g fresh weight measured in both tissue types within 1 week of application. However, only trace amounts of glyphosate remained in either the shoots or the roots 2 weeks after application. Analysis of irrigation flow-through in pot assays confirmed that the herbicide readily exuded out of the roots. Processing of the beets removed glyphosate and herbicide levels were below the limit of detection in the crystalline sugar final product.

Decision support techniques and online algorithms aim to help individuals predict costs and facilitate their choice of health insurance coverage. Self-reported health status (SHS), whereby patients rate their own health, could improve cost-prediction estimates without requiring individuals to share personal health information or know about undiagnosed conditions. We compared the predictive accuracy of several models: (1) SHS only, (2) a “basic” model adding health-related variables, and (3) a “full” model adding measures of healthcare access. The Medical Expenditure Panel Survey was used to predict 2015 health expenditures from 2014 data. Relative performance was assessed by comparing adjusted-R2values and by reporting the predictive accuracy of the models for a new cohort (2015–2016 data). In the SHS-only model, those with better SHS were less likely to incur expenditures. However, after accounting for health variables, those with better SHS were more likely to incur expenses. In the full model, SHS was no longer predictive of incurring expenses. Variables indicating better access to care were associated with higher likelihood of spending and higher spending. The full model (R2= 0.290) performed slightly better than the basic model (R2= 0.240), but neither performed well at the upper tail of the cost distribution. While our SHS-based models perform well in the aggregate, predicting population-level risk well, they are not sufficiently accurate to guide individuals’ insurance shopping decisions in all cases. Policies that rely heavily on health insurance consumers making individually optimal choices cannot assume that decision tools can accurately anticipate high costs.

The 40Ar‐39Ar analyses of 28 groundmass separates from volcanic rocks from the islands of Santiago, Sal, and São Vicente, Cape Verde archipelago, are presented. The new age data record the volcanic evolution for Santiago from 4.6 to 0.7 Ma, for Sal from around 15 to 1.1 Ma, and for São Vicente from 6.6 to 0.3 Ma. The major submarine constructional phase of Santiago was erupted within a few hundred thousand years interval around 4.6 Ma. Most of the subaerial Santiago volcanic rocks were erupted in a second episode from 3.3 to 2.2 Ma and late volcanism occurred at 1.1–0.7 Ma. Volcanism on Sal evolved in five stages: (1) poorly constrained early Miocene activity, (2) 16–14 Ma, (3) 12–8 Ma, (4) around 5.4 Ma, and (5) 1.1–0.6 Ma. São Vicente was constructed during three active periods: (1) >6.6–5.9 Ma, (2) 4.7–4.5 Ma, and (3) ∼0.3 Ma. Sr isotope analyses of carbonates from Maio confirm an Early Cretaceous age for limestones deposited on the seafloor and later uplifted. The Cape Verde Rise is indicated to have fully formed in the early Miocene around 22 Ma, accompanied by the initial alkaline volcanism. Considerable volcanism on Sal, Boa Vista, and Maio took place in the Miocene and Pliocene and extended over much larger areas than the present islands, whereas volcanism of the southwestern and northwestern island groups developed mainly during the Pliocene and Pleistocene and was mostly confined to the present island areas. The periods of volcanic activity may be broadly correlated between the northwestern and southwestern groups of islands. Young volcanism (0.3–0.1 Ma) throughout the northwestern group extends along a 150 km long NW‐SE trending lineament. A relatively moderate average melting rate for the hot spot over the 22 Ma period is estimated at ∼0.026 km3/a, corresponding to a total volume of 570 × 103km3of magma emplaced in the crust and a mantle volume flux of 28 m3/s, much lower than Iceland or Hawaii. The archipelago is situated to the south and SW of the center of the mantle plume anomaly and ahead of its relative movement. The timing and location of volcanism suggest that mantle melting takes place in three channels, an eastern one that has been active for 22 Ma and in southwestern and northwestern channels since late Miocene.