bluuebunny/crossref_metadata_2025 huggingface dataset:
Period Poverty and the Menstrual Product Tax in the United States [29F]
Authors: Singh Bhuchitra , Zhang Jiahui , Segars James
Published: April 2020

INTRODUCTION:

Period poverty refers to the lack of access to menstrual products. The “luxury tax” collected on menstrual products in the majority of the United States is a major contributor to period poverty and a barrier to reproductive health for the estimated 16.9 million women living in poverty in the U.S. In this study, we sought to determine the financial, social, and political impact of the menstrual product tax on women of reproductive age in the U.S.

METHODS:

The cost and sales tax collected on a sample menstrual product (Playtex Sport Tampons, Regular & Super Multi Pack, Unscented – 50 Count) was compared when purchased through online retailers Amazon, Walmart, and Target in each state of the U.S. and the District of Columbia.

RESULTS:

As of June 2019, thirty-five states taxed menstrual products at rates between 4.70%; in Hawaii to 9.90%; in Louisiana, with a mean of 7.41%. Among them, nineteen states taxed between 6 and 7.99%, twelve at >8%, and only four states at <6%. This financial burden decreased the accessibility of menstrual products specifically for the marginalized low-income women and women with heavy menstrual bleeding. The lack of access to menstrual products led to poor menstrual hygiene, decreased participation in work and other activities and contributed to poor quality of life.

CONCLUSION:

The menstrual product tax exacerbates period poverty and negatively impacts the quality of life of women by decreasing the accessibility of menstrual products. Our research supports the repeal of this tax in consideration of its financial, social, and political implications.
Association Between Endometriosis and Lower Urinary Tract Symptoms [34F]
Authors: Gabriel Iwona , Vitonis Allison , Missmer Stacey , Terry Kathryn , DiVasta Amy , Minassian Vatche
Published: April 2020

INTRODUCTION:

Lower urinary tract symptoms (LUTS) as frequency, urgency, nocturia, and dysuria significantly affect women of all ages. We hypothesize LUTS are more commonly experienced by women with endometriosis than without.

METHODS:

We conducted a cross-sectional study of 1161 women who participated in The Women’s Health Study: from Adolescence to Adulthood. At baseline, participants completed questionnaire that included questions on the following LUTS in the past three months: loss of urine when coughing, sneezing or laughing; difficulty passing urine; blood in the urine; still feeling full after urination; and having to urinate again within minutes of urinating, dysuria (pain >5 in 1-10 scale). Women who did not complete LUTS questions or who reported frequent bladder infections were excluded. We used logistic regression modelling adjusted for race, current age, BMI, parity to estimate odds ratios (OR) and 95% confidence intervals (CI) of the associations between endometriosis and LUTS. The study was approved by IRB.

RESULTS:

Participants were predominantly white non-Hispanic (89% of cases, 72% -controls) and nulliparous (95% of cases, 91% -controls), with age range 7-55. Participants with endometriosis more frequently reported still feeling full after urination (77% vs. 23%, OR 5.14, CI 3.23-8.18), having to urinate again within minutes (61% vs. 39%, OR 2.45, CI 1.81-3.32), difficulty passing urine (76% vs. 24%, OR 3.41, CI 1.71-6.81), and dysuria (66% vs. 35%, OR 2.58, CI 1.57-4.26). LUTS were not associated with duration of endometriosis symptoms nor rASRM stage.

CONCLUSION:

Women with endometriosis report LUTS significantly more often than those without. Addressing LUTS may improve the wellbeing of women with endometriosis.
Patient Characteristics and Treatments for Women With Moderately Severe Fecal Incontinence [36F]
Authors: Rivera Gabrielle , Stewart Kelley , Jeppson Peter , Petersen Timothy , Dunivan Gena
Published: April 2020

INTRODUCTION:

Surgical treatments, such as sphincteroplasty or sacral neuromodulation, are available for fecal incontinence (FI). There has been increasing attention on the progress to surgical treatment for overactive bladder, but little is known about the progress towards this therapy for FI.

METHODS:

This was a retrospective chart review of all new patients presenting to an academic Urogynecology clinic with Wexner Incontinence Scale scores of 11-14 (equivalent to moderately severe FI). Demographics, prior treatments, and how long it took for patients to proceed to definitive treatment were collected. Our prior work described women with severe FI (Wexner score 15–20). With this study we sought to describe women with moderately severe FI and compare moderate to severe FI groups.

RESULTS:

From January 2014 to July 2017, 158 new patients with a Wexner score of 11-14 were seen in clinic. The mean age was 62.5 +/-12 years. The majority (n=117, 77%) had never had any treatment for FI. The most common treatment plan at the first visit was fiber and dietary modifications (n=59, 38%). Only 3 patients went on to surgical treatment. There were no significant differences between those with moderate versus severe FI in how many ultimate progressed to surgical therapy (3 versus 6) or the number of clinic visits until that decision was made (2 versus 3), all p>.05.

CONCLUSION:

Very few patients progress to surgical treatment despite at least moderately severe FI. Further work is needed to facilitate timely delivery of definitive care for this patient population.
Postoperative Opioid Prescribing Patterns in Women Undergoing Mid-Urethral Sling Placement [37F]
Authors: Feroz Rehan , Swailes Alexa , Schaefer Eric , Long Jaime
Published: April 2020

INTRODUCTION:

Mid-urethral slings are currently the most common surgery performed for stress urinary incontinence, however, no benchmarks exist to inform providers on appropriate opioid prescribing for this procedure.

METHODS:

Using MarketScan Commercial Claims and Encounters Database from Truven Health Analytics, we extracted all outpatient claims from 2005 through 2016 that identified women ≥ 18 years who underwent sling placement for stress incontinence using CPT codes. From this cohort, we determined whether the procedure was isolated or done concomitantly with other procedures. Patients were classified as having filled a prescription for an opioid perioperatively if a claim for a schedule II, III or tramadol prescription was filled 28 days before or after the procedure. Oral morphine milligram equivalents (MME) were calculated for each prescription.

RESULTS:

A total of 153,631 women were identified using the above-mentioned criteria. Of these, 79,069 (51.5%) underwent an isolated sling procedure while 74,562 (48.5%) underwent combined procedures. 84% of the patients in our cohort had 1 or more prescriptions in the perioperative time period. The median cumulative MME prescribed for patients preoperatively with isolated and multiple procedures were 200 and 225, respectively. Postoperatively, the median cumulative MME for isolated and multiple procedures were 150 and 225, respectively. Nearly half of patients who filled an opioid prescription preoperatively filled another postoperatively.

CONCLUSION:

Among women undergoing isolated mid-urethral sling placement, the median cumulative MME are now described. Further research optimizing prescribing practices is needed.
Application of a Severity Framework to 176 Genes on an Expanded Carrier Screening Panel [03G]
Authors: Arjunan Aishwarya , Bellerose Holly , Torres Raul , Lazarin Gabriel , Taber Katherine Johansen
Published: April 2020

INTRODUCTION:

Disease severity is considered to be an important factor for inclusion of diseases on expanded carrier screening (ECS) panels. Evaluating severity requires an objective, systematic method. Here, we applied a validated algorithm that objectively categorizes disease severity into one of four categories—profound, severe, moderate, and mild—to 176 genes on a clinically available ECS panel.

METHODS:

Eight genetic counselors (GCs) working in pairs, followed by four medical geneticists (MDs) working in pairs, applied the algorithm to subsets of the 176 genes.

RESULTS:

Upon initial GC and MD review, 107/176 genes (61%) and 133/176 genes (76%), respectively, had concordant classifications, with consensus reached for all genes after collaborative review. Final severity classifications were 68 (39%) profound, 71 (40%) severe, 36 (20%) moderate, and one (1%) mild. No classification biases were detected within the GC or MD pairs.

CONCLUSION:

This study illustrates an approach to severity classification for large sets of Mendelian genes. The observed level of initial discordance demonstrates the complexity of severity and underscores the importance of collaboration involving multiple clinicians. Severity classification, in addition to other factors suggested by ACOG, is an important factor for laboratories to consider as they aim to design clinically valid ECS panels.
Barriers to Election Day Voting Among Medical Students [06G]
Authors: Hotz Melanie , Yang David , Solomon Abigail , Hagan Joseph , Tanner La'Nasha
Published: April 2020

INTRODUCTION:

Laws enacted by elected officials can affect how physicians practice. Although civic engagement is a value emphasized throughout medical training, physicians have been found less likely to vote in national elections. Little research has been conducted looking into factors that contribute to low medical trainee or physician voter turnout. This study was designed to look at what barriers medical students encounter that may prevent them from voting in elections.

METHODS:

An anonymous online survey was emailed to Medical Students at two Medical Schools in the spring of 2019. The survey assessed demographic information and barriers students encountered related to voting in recent elections.

RESULTS:

353 medical students responded to the survey. 29% (104/352) of respondents did not vote in the 2018 Midterm election. 14% (50/352) of respondents did not vote in the 2016 Presidential election. The most prevalent voting barriers included limited time to learn about the candidates (35%, 124/353) and amendments (31%, 111/353). While 15.3% (54/353) of respondents reported that schools reminded them to vote, only 3.4% (12/353) reported that school provided time away from academic or clinical responsibilities to vote.

CONCLUSION:

Given the value that medical schools place on civic engagement, it is surprising that so few students are given time to vote. Medical schools can possibly enhance voter turnout by reminding students of upcoming elections and providing protected time to participate in elections. By reducing barriers to voting for medical trainees, medical schools can help create a generation of future physicians with a higher voter turnout.
Carrier Screening in 2019: Expanded Panels Are on the Rise [07G]
Authors: Neitzel Dana , Leahey Jocelyn , Silverberg Kaylen , Aguilar Sienna , Faulkner Nicole
Published: April 2020

INTRODUCTION:

Carrier screening utilization varies among clinicians including obstetricians (ObGyns), maternal fetal medicine specialists (MFMs) and reproductive endocrinologists (REIs). ACOG currently recommends universal screening for cystic fibrosis and spinal muscular atrophy, and ethnicity-based screening when appropriate. ACOG acknowledges that expanded carrier screening (ECS) has many benefits, however, advises that if ordered, ECS panels should only include high impact disorders (severe, prevalent and well-understood). Our laboratory offers screening for up to 301 genes. These genes are available in pre-curated panels (3, 46, or 288 genes), or they can be ordered as single tests/customized panels. Thirteen additional genes (common, variable, and/or adult onset) are available as an add-on to any panel.

METHODS:

Carrier screening was performed by next-generation sequencing with deletion and duplication analysis for up to 301 genes. Ordering patterns by clinician type was assessed.

RESULTS:

Over thirteen months, 35,390 patient samples from 2,540 clinicians were tested. The majority of orders came from REIs (37%) and ObGyns (30%). Fifty-six percent of all orders exceeded ACOG ECS guidelines (≥288 genes). Guideline-based testing accounted for 20% of orders, with ObGyns having the highest adherence to guideline-based ordering (27%).

CONCLUSION:

Despite current ACOG criteria, our data shows that more than half of carrier orders exceed ECS recommendations, even including frequent/variable disorders. Many factors, including patient preference, insurance coverage and cost impact carrier screening utilization. More specific guidelines may lead to more consistent testing across clinicians and influence patient and insurance decision factors.
Evaluation of a Novel Course in Pre-Hospital Emergency Obstetrics for US Army Special Forces Medics [11G]
Authors: Wilson Karen L. , Joseph Katherine , Carney Alexandra
Published: April 2020

INTRODUCTION:

US Army Special Forces Medics are highly trained medics that are deployed around the world. They receive training not only in trauma medicine, but in all other aspects of medicine. One field they receive minimal training in is obstetric emergency management. The Advanced Training in Obstetrics for Medics (ATOM) course, created at the US military installation Fort Bragg in 2018, was designed to augment training in management of obstetric emergencies for first responders, both civilian and military, through a novel, interactive, high-fidelity, hands-on approach.

METHODS:

Pre- and post- ATOM course assessments were administered to Special Forces Medics at Fort Bragg, NC. The assessments were identical, and evaluated basic knowledge of obstetric emergency management and confidence levels in approaching obstetric incidents. Results were compared using an independent sample t-test. In our analysis, we assess the mean of the two.

RESULTS:

Twenty-eight medics participated in the ATOM course and completed the pre-ATOM and post-ATOM course assessments. Participants overall scored higher on the knowledge-based post-ATOM assessment than on the pre-ATOM assessment, a statistically significant improvement of 30% (P<.001). As for the confidence-based pre-ATOM and post-ATOM assessment, a statistically significant improvement was also seen of 25% (P<.001).

CONCLUSION:

Worldwide maternal morbidity and mortality must be addressed at all levels of healthcare. The Advanced Training in Obstetrics for Medics (ATOM) course, an unprecedented training course designed specifically for first responders, has undoubtedly been shown to improve both first responders’ ability to manage obstetric emergencies and their confidence in approaching these emergencies.
Factors Influencing Women’s Perceptions of Shared Decision Making During Prenatal Care [13G]
Authors: Vogel Sarah , Breman Rachel B. , Fahey Jenifer , Crimmins Sarah D.
Published: April 2020

INTRODUCTION:

Shared decision-making is central to providing patient-centered care and is associated with increased patient satisfaction, decreased healthcare costs and improved health outcomes. Women from different socio-economic, racial, and ethnic backgrounds may differ in their perceptions about the medical community and engagement in care. We sought to determine how patients perceived prenatal shared decision-making in an inner-city hospital serving a predominantly black population.

METHODS:

In an IRB-approved observational cross-sectional study at two different inner-city prenatal clinics, English-speaking women between 28 and 42 weeks’ gestation completed a survey assessing shared decision-making. Maternal demographics and preferences towards prenatal education resources were collected. Our primary outcome was a participant’s independence or dependence on a provider to make decisions about their care. Secondary outcomes included patient and provider perceptions of choices. Pearson Chi Square was used for analysis.

RESULTS:

Surveys were collected from 150 gravidas. Black women were more likely to be independent decision makers in their care in comparison to whites (25 [30.1%; of black women] vs 4 (8.9%; of white women [P=.015]). No other factors demonstrated significance. Seven participants (4.6%) had not considered they had choices in their care. All of these participants were enrolled in government assistance programs (P=.007). No differences were seen in the likelihood of providers discussing options for care with participants (P>.05 for all variables).

CONCLUSION:

Maternal race and socio-economic factors may significantly influence patients’ perceptions of shared decision-making. Results from this research will help guide the development of an educational tool to provide adaptive discussions to improve the quality of patient-centered care.
Flipped Feedback: Can Medical Students Elicit Quality Feedback? [14G]
Authors: Oliver Sarah , Gambala Cecilia , Toppin Drew
Published: April 2020

INTRODUCTION:

The purpose of this study is to investigate medical students’ knowledge and perception of feedback and to provide training on how they may elicit quality feedback. The majority of research and instruction regarding feedback in medical education relies upon the perspective of the individual who provides feedback rather than the learner.

METHODS:

After obtaining IRB approval, a preliminary questionnaire was sent to medical students in their clinical years to assess their knowledge of feedback and their perception of its quality. The SNIPER method, a formal methodology to elicit quality feedback from the learners’ perspective, was taught in an interactive session. A survey assessing knowledge of and participation in feedback was sent at three timepoints: before, immediately after, and one to two weeks after the session.

RESULTS:

67 of 118 (58%) session participants indicated they received feedback at least half of the time during their clinical rotations. 100 (88%) responded that future students would benefit from the SNIPER method. 104 (94.5%) participants felt this feedback session was worthwhile. When self-evaluating their ability to elicit quality feedback, the average score of participants increased 26.4% (P<.05). 25 (64%) of 39 respondents indicated they were able to obtain feedback utilizing the SNIPER method.

CONCLUSION:

Medical students feel that information on feedback is not emphasized in the current curriculum. Student satisfaction increases with knowledge of how to elicit quality feedback and empowers them to improve their clinical skills.
Impact of a Strategic Napping Program During Call in an OBGYN Residency Program [16G]
Authors: Holtz Max , Limperg Tobias , Sutkin Gary , Dowlut-McElroy Tazim
Published: April 2020

INTRODUCTION:

Call shifts correlate with resident fatigue, impaired performance, and adverse events; furthermore, residency programs are required to practice fatigue mitigation. Our objectives were to implement and assess use of and perceptions about a napping program.

METHODS:

We implemented a protected 30 minute minimum Nighttime Alone Period (NAP) during 24-hour call shifts for residents. The NAP could be used for any activity other than work (e.g. sleeping, studying, exercise). With IRB approval and informed consent obtained, we distributed anonymous Pre- and Post- program surveys to assess perceptions of the NAP program, twelve weeks apart. Residents answered weekly surveys to assess NAP activity and barriers. We used the Stanford Sleepiness Scale to assess fatigue.

RESULTS:

36 NAPs were taken out of a total of 51 possible opportunities (71%) over 12 weeks. Mean time of NAP was 119 minutes (SD 102). 4th-year residents took longer NAPs than 1st-years (175 minutes [SD 140] versus 73 minutes [SD 76]) (P=.04). Residents reported a significant improvement in fatigue following each rest period (P=.001). Barriers to NAP included pages, phone calls or texts, and in-person interruption. In the post-survey, 85% of residents and 43% of attendings supported resident participation in a NAP program. 42% of residents felt there was an associated stigma.

CONCLUSION:

We successfully implemented a NAP program and extended rest periods during call shifts improved perceived sleepiness, but there was perception of associated stigma. Efforts to decrease the stigma will enhance personal wellness and patient safety.
Evaluation of the Effect of Obesity and Race on Incidence of Endometrial Cancer 2000-2016 [26H]
Authors: Cain Abigail
Published: April 2020

INTRODUCTION:

To examine and describe the trends and measure the association between obesity and endometrial cancer among American adults between 2000 and 2016 stratified by both race and age.

METHODS:

Data from the National Cancer Institute’s Surveillance, Epidemiology and End Results database to evaluate trends in age-adjusted uterine cancer incidence rates stratified by race. In this evaluation average annual percent change (AAPC) was used to quantify changes in incidence rates from 2000-2016 and calculated using joinpoint regression. Rates of obesity in female patients were calculated using the National Health and Nutrition Examination Survey from 2001-2016. IBM SPSS tool was used to calculate rate of obesity and conduct a multiple linear regression analysis was performed to determine the relationship between obesity and the incidence of endometrial cancer.

RESULTS:

During 2000-2016, uterine cancer rates overall increased at 0.7% per year average. There is a significant difference in the average annual percent change (AAPC) when stratified by race especially in pre-menopausal patients with overall rates increased at 3.0% per year, with rates in whites 2.2% per year, blacks 2.4% per year, and Hispanic’s 4.3% per year. The AAPC in the prevalence of obesity in the pre-menopausal patients revealed AAPC for white patients 0.5%, black 0.6%, and Hispanics of 0.9%. Linear regression analysis indicates that obesity alone doesn’t account for the increase in endometrial cancer in pre-menopausal Hispanic patients.

CONCLUSION:

During 2000-2016 there has been an increase in uterine cancer in Hispanic populations that is not solely explained by increasing rates of obesity particularly in the pre-menopausal population.
Factors Predicting Type II Histology in Endometrial Biopsies Among Postmenopausal Women at a Safety Net Hospital [27H]
Authors: Timmons Douglas , Fein Lydia A. , McCarter Kelly , Huang Marilyn , Carugno Jose A. , Schlumbrecht Matthew
Published: April 2020

INTRODUCTION:

Endometrial cancer (EC) may be categorized into two histologic subtypes, type I and type II. Type II EC are more aggressive, metastasize early, and have worse survival compared to type I. Disparities in Type II EC risk vary by race/ethnicity. Our objective was to evaluate a cohort of women undergoing endometrial biopsy (EMB) at a public safety net hospital (PSNH) to identify factors that predict type II EC.

METHODS:

A retrospective chart review was performed of postmenopausal women over age 50 who had an EMB at a PSNH between 2010 and 2016. Clinicodemographic data were abstracted. Statistical analysis included chi-square and logistic regression with significance set at P<.05.

RESULTS:

Of 461 EMB results reviewed, 80 (17.3%) had EC. Median age was 62 years, and the majority were Hispanic (64%). The most common indication for EMB was postmenopausal bleeding. 36 (45%) patients had type II histology. Among those with cancer, type II histology prevalence was 17%; in whites, 41%; in Hispanics, and 61%; in blacks (P=.03). In a univariate analysis, factors associated with type II tumors included older age (OR 1.10 [CI 1.03-1.18], P<.01), black race (OR 8.75 [CI 0.86-88.70], P=.07), number of years since menopause (OR 1.06 [CI 1.01-1.12], P=.027), and BMI >30 (OR 0.39 [0.15-0.98], P=.044).

CONCLUSION:

Our data from a SNH confirm previous findings that black women are at higher risk for type II EC and suggest menopause duration and obesity as additional risk factors. Clinician recognition of factors associated with high-grade histologies is crucial to prompt expeditious work-up for malignancy.
Genetic Counseling Referrals for Gynecologic Oncology, Are We Missing Opportunities? [29H]
Authors: Brown Florence K. , Sullivan Stephanie A. , Siff Lauren
Published: April 2020

INTRODUCTION:

NCCN and SGO recommend genetic evaluation for women with epithelial ovarian cancer (EOC) and certain endometrial cancer (EC) patients. Despite guidelines, patients are not consistently receiving referrals. Our primary aim was to evaluate if patients at a tertiary care center were being referred per recommendations. Secondary aims were to determine demographic, socioeconomic or pathologic differences associated with referrals.

METHODS:

This is a retrospective cohort study of all patients diagnosed with EOC, EC before age 50, or EC with mismatch repair deficiency on tumor testing at a tertiary referral center between 2009 and 2018. Rates of referrals were calculated. Descriptive statistics compared patients who were and were not referred to genetics. A multivariable model was fit to identify potential predictive variables.

RESULTS:

275 women were included (58 EC 217 EOC); per guidelines, 100% should have received referrals. Overall, 34.5% of the population were referred. 15.5% EC vs 39.6% EOC patients received referrals. On univariate analyses, family history, EOC diagnosis, grade and histology were the only variables that differed between those who were and weren't referred. Race, ethnicity, age, BMI, language spoken, insurance status, and stage were not associated with referral rates. EOC diagnosis and family history were the only independently associated variables on multivariable regression. Of referred patients, 73.8% attended genetic counseling appointments.

CONCLUSION:

Patients with epithelial ovarian and endometrial cancers are referred to genetics less frequently than recommended. The majority of patients who were referred attended the appointment. Family history was the only variable independently associated with referral.
High Cervical Intraepithelial Neoplasia and Its Abnormal PAP Referral: A 13-Year Analysis [30H]
Authors: Cervantes Pedro , Altamirano-Assad Roberto , Nazzal Omar
Published: April 2020

INTRODUCTION:

The objective of this work is to analyze the referral cytologies of the patients in which a CIN II and/or CIN III is histologically confirmed in the cervical pathology unit (CPU) of the San Borja Arriaran Clinical Hospital (HCSBA).

METHODS:

Retrospective analysis of the patient records derived from positive PAP, reported between January 2006 and December 2018. The admission cytology and the definitive histological diagnosis were correlated in the HCSBA CPU.

RESULTS:

During the 13 years of histological diagnoses associated with 6160 positive cytologies were reviewed. 2083 patients with histological diagnosis of CIN2+. Median age 38 years. 15.02% (n=313) made it an atypical PAP in one of its three types: second ASCUS 2.44% (n=51), ASC-H 10.99% (n=229) and AGUS 1.58% (n=33). 16.75% (n=349) came from a CIN I PAP, 64.13% (n=1336) from a CIN II or III Pap smear and the rest for an invasion-suggestive PAP.

CONCLUSION:

One in three patients referred to the HCSBA from a positive PAP has a high-grade lesion, of which 2/3 were referred from a high-grade cytology; 1/3 come from lower grade cytologies. This distribution differs from that published internationally, a phenomenon of difficult interpretation. It is necessary that specialists CPU are aware of the performance of their laboratories, in order to evaluate the procedures according to the risks of their patients.
Immunotherapy Associated Vaginal Mucositis [31H]
Authors: Patel Jharna M. , Enich Michael , Girda Eugenia
Published: April 2020

INTRODUCTION:

Immune checkpoint inhibitors (ICPi), has revolutionized our approach to treating solid tumors, including gynecologic malignancies. Compared to standard chemotherapy, the adverse events associated with immunotherapies, are often mild and localized. While a rash is most commonly reported side effect of ICPi therapy, there have been few cases of mucositis caused by ICPi therapy, and no documented case of an ICPi therapy causing vaginal mucositis.

METHODS:

This is a presentation of a 67-year-old woman with a history of stage I metastatic uterine serous carcinoma who was initially treated with a hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy. The patient had reoccurrence despite adjuvant radiation and chemotherapy and was enrolled in a phase 2 clinical trial with Cabozantinib and Nivolumab. Nine days after administration of IV Nivolumab during the second cycle, she reported onset of severe, non-radiating perineal pain. Pelvic examination revealed multiple, deep, erythematous ulcerations and necrosis around the periurethral area, consistent with grade 3 mucositis. The treatment was discontinued and she was started on prednisone therapy. Re-examination in 1 month showed decreased fibrinous material indicating that mucositis had improved.

CONCLUSION:

As immunotherapy is becoming more widely used in gynecologic malignancies, providers need to be aware of rare complications associated with these therapies. Such toxicities should be correctly identified and treated appropriately and expediently. Most patients will continue to benefit from administered immunotherapy and can be restarted once the toxicities are alleviated. To our knowledge, this is a first reported case of vaginal mucositis associated with Nivolumab therapy in a patient with gynecologic malignancy.
Gonadotropin Dose in Young IVF Population With Low Anti-müllerian Hormone Level: A SART Data Study [23A]
Authors: Sarkar Papri , Lam Clarissa J. , New Erika , Sprague Rachel , Anthony Imudia
Published: April 2020

INTRODUCTION:

One of the most common causes of infertility is diminished ovarian reserve (DOR). AMH plays a role in determining ovarian reserve and levels <1.05 ng/mL is associated with DOR. Young IVF population even with DOR have modest clinical outcome, however information on the stimulation regimen is limited. The aim of this study was to evaluate the gonadotropin dose required in young IVF patients with low AMH to achieve optimal clinical response.

METHODS:

A retrospective cohort study based on SART database between 2012–2016. The study population included 23,001 fresh autologous IVF cycles in women <35 years old with AMH level <1.05 ng/mL. Based on AMH level, women were stratified into 3 groups: low (<1.05–0.4 ng/mL), very low (<0.4–0.16 ng/mL) and ultralow (<0.16 ng/mL). Student t-test was used to compare continuous variables and chi-squared test to compare clinical outcomes.

RESULTS:

The mean age was 32.4±2.4 and BMI was 25±5.9. Women with ultralow AMH had lowest number of oocytes retrieved (5.2±0.4), followed by very low (6.1±0.1) and low AMH group (9.4± 0.07), P<.001. The total gonadotropin dose required was less in the low AMH group (4,086±13.9 IU) than very low (4,446.5±28.3 IU) and ultralow (4,319.34±66.6 IU) AMH groups (P<.001). Live birth rate was significantly higher in the low AMH (4,735/16,290; 29.1%), followed by very low (1,131/5,375; 21%) and ultralow AMH (159/1,336; 11.9%) groups.

CONCLUSION:

AMH is an independent predictor of live birth during IVF and can be used as a guide to estimate gonadotropin dose in young IVF population with DOR to optimize ovarian stimulation and response.
Improving Access for Patients Undergoing Gonadotoxic Therapy: Creation of a Formal Fertility Preservation Program [25A]
Authors: Willson Bryn , Iko Ljeoma , Cookingham Lisa
Published: April 2020

INTRODUCTION:

Prior to 2016, patients undergoing gonadotoxic therapies were not routinely directed towards educational resources regarding fertility preservation options. In 2016, a formalized fertility preservation program was initiated to increase education, referrals, and provide treatment options to this uniquely vulnerable patient population.

METHODS:

A database was created following initiation of the fertility preservation program (FPP) to track patient demographics such as diagnosis, treatment plan, referring department, consultation turn-around time, uptake of fertility preservation services, and outcomes (post treatment and post fertility preservation, if applicable). For patients undergoing sperm/oocyte/embryo cryopreservation for fertility preservation needs prior to program initiation (2006–2015), a chart review was performed to obtain the same data. We assessed the overall impact of implementation of FPP as compared to other published data from institutions providing formal fertility preservation services.

RESULTS:

Each year following implementation of FPP, noted statistically significant increase in referrals, consultations, and uptake of fertility preservation services. Similarly, the referring departments and diagnoses on referral expanded beyond oncologic providers and oncologic diagnoses, respectively. We also noted a trend of increased uptake for female patients for fertility preservation as compared to male patients, which is dissimilar from previously published data.

CONCLUSION:

A formalized program for fertility preservation improves access and uptake of services for patients undergoing gonadotoxic therapies. Our program demonstrated significant beneficial impact on multiple parameters of interest, even within the first two years following implementation. Subsequently, fertility preservation for oncology patients is now considered a covered benefit within this health maintenance organization.
Uterine Weight as a Predictor of Surgical Complications [36B]
Authors: Oh Jinhee K. , Ko Emily M. , Latif Nawar A.
Published: April 2020

INTRODUCTION:

The objective of this study is to investigate the impact of uterine weight on peri-operative hysterectomy outcomes. Risk stratification based on uterine weight may help guide surgical planning and post-operative management.

METHODS:

Hysterectomy patients were identified from the NSQIP Database (2014 – 2017). Uterine weight was evaluated as a categorical variable: Group A (less than or equal to 250 g), Group B (greater than 250 g to less than or equal to 500 g), Group C (greater than 500 g). Univariable and multivariable statistics were performed. IRB approval was waived.

RESULTS:

50,333 patients were included, 82.6% in Group A (n=41,581), 12.7% in Group B (n=6,369), and 4.7% in Group C (n=2,383). The majority of the patients were white (71.5%). Median age and BMI were 48 (IQR 42, 59) and 30.5 (IQR 25.7, 36.8). There was an association between race and the proportion of patients in Group C: white 3.3%, AA 11.6%, Asian 9.0%, Other 4.8% (P=.000). Uterine weight was moderately correlated (R2=0.038) with operative time. Group B had nearly 3 times the likelihood of blood transfusion (OR 2.82, 95% CI 2.34, 3.40). Likelihood increased to 4 times for Group C (OR 4.08, 95% CI 3.22, 5.18). Group C was associated with increased conversion from MIS to open (OR 4.93, 95% CI 1.91, 12.71). There was no association with LOS, infection, dehiscence, urinary injury, VTE, readmission/re-operation.

CONCLUSION:

Increased uterine weight is associated with transfusion and conversion to open approach. Uterine weight may assist with pre-operative risk stratification and serve as a predictor of complications.
Composite Adverse Endpoints in Obstetric Studies: A Systematic Review [10N]
Authors: Herman Dylan , Qadree Abdul , Lor Kar Yee , D'Souza Rohan D.
Published: April 2020

INTRODUCTION:

The Composite Adverse Obstetric Outcome Study (CAOOS) is currently in the process of standardizing the use of composite outcomes in obstetric trials. This study aims to determine how composite outcomes have been reported and defined, as a preliminary step towards their standardization.

METHODS:

We conducted a systematic review of English-language randomized controlled trials (RCTs) published between 1999 and 2019 that involved an obstetric condition and reported on a composite outcome. We searched MEDLINE, EMBASE, CENTRAL, www.clinicalTrials.gov and reference lists of included studies. We screened studies and extracted data in duplicate, on study characteristics, and reported on variations on composite outcomes, their components, definitions and/or measurements.

RESULTS:

Of the 4170 results screened, 156 RCTs, reporting on 183 composite outcomes, were included in the final analysis. Of the composite outcomes, 115 were related to the fetus/neonate, 46 to the mother and 22 to adverse pregnancy outcomes which included maternal and perinatal morbidity. Composites comprised between 2 and 16 components. Maternal composite outcomes included components related to mortality and morbidity (17/46), general morbidity alone (4/46), system-specific morbidity (11/46) and wound-related morbidity (14/46). Perinatal composites did not always include components related to in-utero and neonatal morbidity and mortality. Composite pregnancy outcomes included maternal and perinatal morbidity and mortality components in various combinations.

CONCLUSION:

There is considerable variation in how composite outcomes are reported and defined in obstetric RCTs. Patients and stakeholders will be invited to participate in a multi-step mixed-methods research project to determine which components should comprise composite adverse obstetric outcomes.
Nausea and Vomiting of Pregnancy and HG Risk Genes Associated With Blood Levels, Sleep, Stomach Pain, and Other Traits [23N]
Authors: Fejzo Marlena S. , Burch Kathryn , Mullin Patrick , MacGibbon Kimber W. , Pasaniuc Bogdan
Published: April 2020

INTRODUCTION:

Our genome-wide association study (GWAS) and replication study of nausea and vomiting of pregnancy (NVP) and Hyperemesis Gravidarum (HG) implicates the placenta and appetite hormone gene GDF15, its receptor GFRAL, PGR, and IGFBP7. The purpose of this study was to determine whether these genes and summary statistics overlap with other traits.

METHODS:

The GWAS catalog was searched for risk genes. The database and web interface platform, LD Hub, was used for genetic correlation analysis of summary statistics.

RESULTS:

Among 4220 GWASes, the HG risk locus GDF15 was associated with GDF15 protein levels, periodontitis, and lupus. GFRAL was associated with glomerular filtration rate, blood urea nitrogen levels, insomnia, body mass index, periodontal inflammation, blood protein levels, osteoporosis, and HIV-1 infection. IGFBP7 was associated with IGFBP7 protein levels, IgG glycosylation, diastolic blood pressure, brain volume in infants, heel bone mineral density, alcohol consumption, itch intensity from mosquitoes, and cotinine glucuronidation. PGR was associated with diastolic blood pressure, endometriosis/endometrial cancer, menstrual cycle length, lung adenocarcinoma, height, and adolescent idiopathic scoliosis. Among 855 pairs of traits, the leading findings showed variants increasing HG also increase stomach pain (P=.0004) and variants increasing NVP also increase sleeplessness/insomnia (P=1.37E-14).

CONCLUSION:

The finding that variants in GDF15 and IGFBP7 are associated with blood protein levels supports our study showing abnormal levels of GDF15 and IGFBP7 in women with HG. Overlap of the genes with other conditions provides biological insight. Associations with poor sleep and stomach pain may have implications for treatment strategies for NVP/HG.
Clinical Predictors of Histologic Chorioamnionitis at Term [06N]
Authors: Romagano Matthew P. , Pinho Gabriella , Krishnamoorthy Kaila , George Lea , Williams Shauna F. , Apuzzio Joseph
Published: April 2020

INTRODUCTION:

The objective of this study was to determine the diagnostic criteria for clinical chorioamnionitis (CC) that best predict histologic chorioamnionitis (HC).

METHODS:

This is an IRB-approved retrospective cohort study of women diagnosed with CC over a 5-year period. Inclusion criteria were: gestational age 37 to 42 weeks, diagnosis of CC as determined and documented by the provider, and available placental pathology records. CC diagnostic criteria (maternal temperature, maternal or fetal tachycardia, leukocytosis, fundal tenderness, and purulent amniotic fluid) were compared between those with and without HC.

RESULTS:

223 women met inclusion criteria; 159 (71.3%) had HC. Prostaglandin use, diabetes, epidural use, and duration from initiation of antibiotics to delivery were similar. Mean maximum body temperature and presence of other diagnostic criteria were similar between the groups. Those with HC were more likely to have a peak white blood cell count greater than or equal to 25.0x10^9cells/L (13.2 vs 3.1%, P=.03). Twenty-one (13.2%) women in the HC group and 12 (18.8%) in the normal pathology group had no documented fever despite a diagnosis of CC. Of the women without a fever, 64% had HC.

CONCLUSION:

Normal placental pathology was found in a large proportion of women with CC. Although none of the assessed clinical findings predicted HC, a significant leukocytosis was more frequent in women with HC. For women diagnosed with CC without fever, the majority had findings of HC. This study highlights the challenge of diagnosing CC. Providers should consider the diagnosis of CC in the absence of fever when other clinical criteria are present.
Pregnancy Outcomes in Patients With Inadequate Gestational Weight Gain [31N]
Authors: Sipe Bradley , Oliva Mariana , Odibo Linda , Odibo Anthony O.
Published: April 2020

INTRODUCTION:

The objective of this study is to compare the risks for small for gestational age (SGA) neonates and composite adverse neonatal outcomes (CANO) in patients with inadequate gestational weight gain (IWG) versus adequate gestational weight gain (AWG).

METHODS:

This is a secondary analysis of a prospective study of women undergoing fetal growth assessment. Participants were sorted into AWG and IWG cohorts based on IOM guidelines. Primary outcomes were SGA and CANO (neonatal ICU admission, death, seizures, IVH, respiratory distress syndrome, necrotizing enterocolitis, and pH <7.10). Secondary outcomes included: hypertensive disorders of pregnancy, preterm delivery (PTD), gestational diabetes (GDM), and large for gestational age (LGA) newborns. We performed chi square, t-test, and adjusted multivariable logistical regression. A stratified analysis was performed by pre-pregnancy BMI category.

RESULTS:

214 patients experienced IWG and 282 patients experienced AWG. The risk of SGA was increased in patients with IWG, 47 patients (22.0%) compared to 34 patients (12.2%) with AWG (aOR 1.99, CI 1.19–3.33). CANO were similar between groups (14.5% versus 11.8%, P=.384). IWG was associated with decreased risk of LGA (aOR 0.29, CI 0.12–0.71) but did not have an effect on GDM, PTD, gestational hypertension, or preeclampsia. In obese patients, IWG was protective against GDM (RR 0.44, CI 0.21–0.93) and LGA neonates (RR 0.10, CI 0.03–0.44) without increased risk of SGA neonates.

CONCLUSION:

IWG increases risk of SGA but did not increase neonatal morbidity. IWG was protective against GDM and LGA without increasing other risks in obese patients, suggesting lower weight gain in this population may be beneficial.
Analysis of a Statewide Maternal Transport System: A Four-Year Review [04N]
Authors: Kogutt Benjamin K. , Morris Bernard D. , Applebaum Jeremy , Hall Valerie , Phillips Michelle , Sheffield Jeanne S.
Published: April 2020

INTRODUCTION:

Implementing levels of maternal care (LOMC) dictates that certain maternal conditions be centralized to risk-appropriate care centers. However, the feasibility of a LOMC system is dependent on the ability to transport risk appropriate patients in a timely manner. The objective of this study is to describe maternal transports via a robust, state-sponsored maternal transport system.

METHODS:

This is a retrospective cohort study of all maternal transports from Sept ‘15 through Jun ‘19 into the Johns Hopkins Medical system. Data were extracted from maternal transport logs and electronic medical records.

RESULTS:

Of 1,392 maternal transports over the study period, 652 (47%) were for maternal indications. The majority of transports originated from Level I centers (37%). The median distance travelled per transport was 26 miles: 70% by ambulance and 21% by helicopter. 48% of transported mothers delivered during their admission at the receiving hospital. Average maternal age was 29 years, with 48% of mothers being white, 42% black. Average infant weight was 1926 grams, with a 66% NICU admission rate. 18% of transports were suspected preventable if antepartum care was transferred prior to the delivery episode with the most frequent indications for transport being hypertensive disease of pregnancy (34%), infection (8%) and placentation (6%).

CONCLUSION:

Maryland has had an established, regionalized maternal care system since the early-1990s, with clearly defined LOMC and a functioning transport network. Our findings demonstrate utilization patterns within such a program and describe key characteristics of transporting hospitals and patients. Further research is needed to determine the effectiveness of LOMC.
A Retrospective Cohort Study of Maternal and Fetal Outcomes in Pregnancies Complicated by Acute Pancreatitis [02N]
Authors: Cai Emmy , Czuzoj-Shulman Nicholas , Abenhaim Haim A
Published: April 2020

INTRODUCTION:

Acute pancreatitis is a rare condition that can be associated with significant complications. In pregnancy, pancreatitis can be linked with poor maternal and fetal outcomes. The objective of this study is to better understand the complications associated with acute pancreatitis (AP) in pregnancy.

METHODS:

A retrospective cohort study using the Healthcare Cost and Utilization Project – National Inpatient Sample from the United States was performed. All pregnant women admitted with AP were identified using International Classification of Disease-9 coding from 1999 to 2015. The maternal and neonatal outcomes among women diagnosed with AP in pregnancy were compared to women without acute pancreatitis who delivered using multivariate logistic regression adjusting for baseline maternal characteristics.

RESULTS:

There were 14,258 admissions for AP in pregnancy among 13,815,919 births in our study period for an overall incidence of 10.3 cases per 10,000 births. Women admitted with AP in pregnancy were more likely to require transfusions, OR 2.58 (95% CI 2.32–2.87), develop pre-eclampsia, 3.81 (3.33–4.36), deliver prematurely, 4.27 (3.83–4.77), develop venous thromboembolisms, 3.97 (3.30–4.78), develop acute respiratory failure, 21.99 (19.08–25.34), develop disseminated intravascular coagulation, 7.66 (5.48–10.69), and to suffer from maternal death, 9.15 (6.05–13.85) as compared to women without AP. Acute pancreatitis in pregnancy was also associated with an increased risk of intrauterine fetal demise, 2.60 (1.86–3.62).

CONCLUSION:

Acute pancreatitis in pregnancy is associated with severe maternal and newborn complications and thus should be managed in tertiary level centers capable of providing with adequate maternal care for this condition as well and appropriate fetal and premature neonatal care.