Vital Access: How Policymakers Can Streamline the Cancer Care Journey

Patients' odds of surviving blood cancer often hinge on their ability to access specialists who can evaluate, diagnose, and treat them with optimal treatments as quickly as possible. But too often, patients encounter roadblocks that prevent them from accessing the best care and, in some cases, benefiting from incredible advancements. Recent data reveal continued disparities in outcomes for minority populations in particular.Accessing medically necessary and high-quality blood cancer care in the United States is a process that remains overly complex and contingent on factors that are steeped in systemic, socioeconomic, and racial disparities. Numerous factors impact access, but a fragmented insurance system and similarly fragmented federal and state policies that set the rules for that insurance system are major contributors. Studies have noted the impact of narrow networks, which can restrict access to some specialty care providers such as hospitals designated as "cancer centers" or "comprehensive cancer centers" by the National Cancer Institute (NCI). Narrow networks are increasingly common in commercial insurance plans in the individual and group markets and in Medicaid-managed care organizations (MCOs). Studies have also shown that cancer patients with certain types of insurance, such as Medicaid–which covers low-income people, a disproportionate share of whom are people of color–are more likely to experience worse mortality rates. These disparities in coverage and access contribute to significant inequities by income, race, ethnicity, and other factors.In the past three-plus decades, we have seen an explosion of new therapies, including immunotherapy (such as CAR T-cell) and other personalized medicine approaches that target therapies to an individual based on a range of phenotypic and genomic factors.The policy frameworks that govern insurance have not kept pace with advances in cancer treatment, and they continue to contribute to systemic inequities that prevent access to high-quality blood cancer care. Recent efforts by federal regulators to update access-related standards still fall short of ensuring equitable access to quality blood cancer care for all. And some elements of these frameworks have remained largely unchanged for decades. Meaning consumers still struggle to navigate their options when purchasing a plan and access medically appropriate treatment when a diagnosis is received.This report offers nine recommendations in five reform pathways for state and federal policymakers to consider, as they work toward developing insurance regulations that advance a more equitable system of care–one that enables patients with blood cancer to access appropriate treatment and that maximizes the potential for long-term survival. Each of these reform pathways addresses specific deficiencies in the current insurance policy frameworks, and each is critical to pursue in order to ensure a more equitable coverage landscape for patients and familie

Diagnosis, management, and outcome of urethral obstruction secondary to the capsule associated with the artificial urethral sphincter device.

BackgroundUrethral obstruction secondary to artificial urethral sphincter (AUS) implantation is a recognized complication in dogs. However, urethral obstruction secondary to AUS-associated capsule formation has been described rarely.HypothesisDescribe clinical and diagnostic findings, management, and outcome in 6 dogs with urethral obstruction secondary to AUS-associated capsule formation.AnimalsSix client-owned dogs.MethodsRetrospective study. Medical records between January 1, 2010, and June 30, 2021, were reviewed to identify dogs with urethral obstruction associated with the AUS device.ResultsThe AUS device was implanted a median of 884 days (range, 20-2457 days) before presentation for urethral obstruction. Median age at time of urethral obstruction was 4.7 years (range, 3.1-8.7 years). Clinical signs at the time of urethral obstruction were stranguria (n = 4), pollakiuria (3), weak urine stream (2), and worsened urinary incontinence (1). In all dogs, the urethra was noted to be stenotic during urethroscopy and positive contrast cystourethrography. All dogs underwent surgery, and a fibrous capsule associated with the AUS was found to be causing urethral stenosis. Resolution of urethral obstruction occurred in all dogs after transection or removal of the capsule. Positive bacterial cultures were obtained from the capsule, AUS, or both in all dogs. Recurrence of urethral obstruction had not occurred in any dog at the time of follow-up.Conclusions and clinical importanceUrethral obstruction secondary to capsule formation is an uncommon but clinically important complication associated with use of the AUS. Continued investigation is needed to evaluate this complication more thoroughly, and its possible association with infection

Bilateral external jugular vein anomalies preventing hemodialysis catheter placement in a cat with anuria secondary to species intoxication

Case series summary A 2-year-old female spayed Abyssinian cat was evaluated for lethargy and inappetence that first occurred approximately 4 days prior. In addition, urination had not been observed by the owner for 5 days. A Lilium species plant had been brought into the house approximately 5 days before initial evaluation, and intoxication was therefore suspected. Bloodwork revealed anemia, severe azotemia and hyperkalemia. As the cat was anuric with severe azotemia, hyperkalemia and fluid overload, intermittent hemodialysis was recommended. Attempts were made to place a hemodialysis catheter into the external jugular veins bilaterally, but after initial successful venipuncture, the instrumentation would not pass into either vein. During fluoroscopic angiography, no internal jugular veins or external jugular veins caudal to the thoracic inlet were visualized and venous drainage from the head occurred via the vertebral veins. Owing to the anomalous anatomy in the cervical region, a hemodialysis catheter could not be placed into either jugular vein. Alternative sites for the placement of an extracorporeal catheter were discussed with the owner, but humane euthanasia was elected. Relevance and novel information To the authors’ knowledge, this is the first report of a cat with bilateral external jugular vein anomalies resulting in blind endings that did not communicate with the vena cava. This was discovered during attempts to place a hemodialysis catheter for the management of anuric renal failure secondary to Lilium species intoxication. While this anatomical variation is likely uncommon, it is an important differential to consider when faced with challenging external jugular vein catheterizations in feline patients

Risk factors for positive urine cultures in cats with subcutaneous ureteral bypass and ureteral stents (2010-2016).

BackgroundUreteral stent and subcutaneous ureteral bypass (SUB) placement are commonly used for managing ureteral obstructions. Urinary tract infection (UTI) is a recognized complication.ObjectivesTo determine postoperative incidence of positive urine cultures in cats undergoing ureteral stent and SUB placement and to identify risk factors associated with positive urine cultures.DesignRetrospective study.AnimalsForty-three cats that underwent 48 surgical events.ProceduresMedical records were reviewed. Cats were included if urine cultures were performed before and after surgery. Variables were compared to identify risk factors.ResultsUrine cultures were positive postoperatively pre-discharge in 5/20 (25%) cats. Median duration of follow-up post-discharge was 209 days (range, 11-2184 days), with a total of 143 urine cultures performed in cats post-discharge. Of these, 16 (11%) were positive in 12/48 (25%) cats. Nine different bacteria were identified; Enterococcus spp. (n = 8) predominated as monomicrobic or mixed infections. In 14/16 instances of positive urine cultures, affected cats had lower urinary tract signs, signs of pyelonephritis or both. Cats that received antibiotics postoperatively were significantly less likely to have a positive urine culture compared to those that did not (odds ratio, 0.2, 95% confidence interval, 0.05, 0.8, P = 0.02). Chronic kidney disease, renal implant type and postoperative urinary catheterization were not associated with positive urine cultures.Conclusions and clinical relevancePostoperatively, occurrence of positive urine cultures was similar to previous reports. Subclinical bacteriuria was less common than UTI. Postoperative urinary catheterization has been speculated to increase risk of bacteriuria, but this was not the case in this cohort

Risk factors for positive urine cultures in cats with subcutaneous ureteral bypass and ureteral stents (2010‐2016)

Background Ureteral stent and subcutaneous ureteral bypass (SUB) placement are commonly used for managing ureteral obstructions. Urinary tract infection (UTI) is a recognized complication. Objectives To determine postoperative incidence of positive urine cultures in cats undergoing ureteral stent and SUB placement and to identify risk factors associated with positive urine cultures. Design Retrospective study. Animals Forty‐three cats that underwent 48 surgical events. Procedures Medical records were reviewed. Cats were included if urine cultures were performed before and after surgery. Variables were compared to identify risk factors. Results Urine cultures were positive postoperatively pre‐discharge in 5/20 (25%) cats. Median duration of follow‐up post‐discharge was 209 days (range, 11‐2184 days), with a total of 143 urine cultures performed in cats post‐discharge. Of these, 16 (11%) were positive in 12/48 (25%) cats. Nine different bacteria were identified; Enterococcus spp. (n = 8) predominated as monomicrobic or mixed infections. In 14/16 instances of positive urine cultures, affected cats had lower urinary tract signs, signs of pyelonephritis or both. Cats that received antibiotics postoperatively were significantly less likely to have a positive urine culture compared to those that did not (odds ratio, 0.2, 95% confidence interval, 0.05, 0.8, P = 0.02). Chronic kidney disease, renal implant type and postoperative urinary catheterization were not associated with positive urine cultures. Conclusions and Clinical Relevance Postoperatively, occurrence of positive urine cultures was similar to previous reports. Subclinical bacteriuria was less common than UTI. Postoperative urinary catheterization has been speculated to increase risk of bacteriuria, but this was not the case in this cohort