bluuebunny/crossref_metadata_2025_split huggingface dataset:
Patient Perception of Mammographic Breast Density Notification Laws [37K]
Authors: Metcalfe-Klaw Robin , Woodman Sarah , Fenimore Emily , Copit Debra , Jaspan David , Goldberg Jay 
Published: May 2017

INTRODUCTION:
50% of women undergoing screening mammography will be diagnosed with increased breast density. These women may have slightly increased risk for and decreased detection of breast cancer (RR 1.2 – 2.1). Many states have passed laws requiring patient notification of increased breast density and offering additional breast imaging. Few states, however, require insurance coverage of additional imaging.

METHODS:
After IRB approval, a survey study of asymptomatic women undergoing screening mammography was performed. Data collected included patient demographics and patient knowledge of and perception towards breast density notification laws. Patients were additionally queried regarding if they would undergo additional breast imaging if notified of increased breast density on mammography. Statistical analysis was performed using Chi-squared, Fisher's exact test, and Student's t-test.

RESULTS:
18% of women were aware of breast density notification laws. 40% of women reported they would be worried if notified of increased breast density. 84% of women would choose to undergo additional breast imaging if the cost was completely covered by insurance compared to only 44% paying out of pocket.98% of women believed insurance coverage for additional imaging should be required. 88% believed breast density notification laws were economically discriminatory.

CONCLUSION:
If notified of increased breast density on their mammogram, women are twice as likely to undergo additional breast imaging when fully covered by insurance. However, approximately only half of these women would be willing to pay for additional breast imaging out of pocket. Breast density notification laws are economically discriminatory as they require offering additional breast imaging without mandating insurance coverage.
Increased Breast Density on Screening Mammography: Laws Leading to Confusion Amongst Providers [38K]
Authors: Mirghani Sara , Goldberg Jay , Jaspan David , Copit Debra , Scaven Christopher 
Published: May 2017

INTRODUCTION:
The breast density notification act is a law that mandates that providers notify patients with increased breast density on screening mammography and offer these patients additional breast imaging. The American College of Obstetricians and Gynecologists has concluded that no studies have demonstrated improved prognosis when additional imaging is obtained, however they state that physicians should comply with their state laws. The aim of this project is to assess providers' knowledge of and management of increased breast density.

METHODS:
An anonymous nine question survey was administered to obstetrician gynecologist residents and attending physicians and primary care physicians. It was sent to providers via email through a Survey Monkey link. Data was collected over a two-month period with a total of 64 responses.

RESULTS:
Only 32% of providers understand the clinical significance of increased breast density on mammography. Only 21% of providers discuss the option of additional imaging with patients who have increased breast density. Sixty-one percent of providers are unaware of the Breast Density Notification Act. Approximately, 47% of providers stated that they would now change their management of increased breast density on mammogram, after having read the Breast Density Notification Act.

CONCLUSION:
There is a lack of provider knowledge regarding the finding of increased breast density on screening mammography. Most providers do not comply with state breast density laws. Simple interventions, such as clinician education and reformatting screening mammography result letters to both patients and providers can improve compliance with breast density notification laws and limit legal liability.
The Effect of Hypertensive Disorders in Pregnancy on Preterm Birth Rates Among African-American Women [4L]
Authors: Premkumar Ashish , Baer Rebecca J. , Jelliffe-Pawlowski Laura L. , Norton Mary E. 
Published: May 2017

INTRODUCTION:
To investigate the role gestational and chronic hypertension (HTN) play in rates of preterm birth (PTB) among African-American women.

METHODS:
The study population was drawn from singleton, non-anomalous live births delivered between 20 and 44 weeks' among African-American Women from 2007-2011 in the birth cohort file maintained by the California Office of Statewide Health Planning and Development. Poisson logistic regression was used to calculate the risk of PTB by gestational age and type of PTB among women with a diagnosis of chronic or gestational HTN. Relative risks (RR) and 95% confidence intervals (CI) were calculated for PTB, adjusting for maternal age; payment for delivery; level of education; body mass index; pre-gestational diabetes mellitus; smoking; location of mother's birth; urban or rural residence; previous PTB; and inter-pregnancy interval less than 6 months.

RESULTS:
61,561 African-American women were included; 2,276 had chronic HTN and 5,861 had gestational HTN. Women with chronic HTN progressing to preeclampsia were at 43-fold higher risk of a medically-indicated PTB less than 32 weeks compared with women without chronic HTN. When comparing women with the diagnosis of chronic HTN progressing to preeclampsia versus those with gestational HTN progressing to preeclampsia, those with chronic HTN had higher risks of spontaneous and medically-indicated PTB, especially less than 32 weeks (aRR 2.5 and 3.4, respectively).

CONCLUSION:
Among African-American women, chronic HTN progressing to preeclampsia increased the risk for spontaneous and medically-indicated PTB, especially less than 32 weeks. Further inquiry into the pathophysiology of hypertensive disorders and evaluation of inequality should accompany research on PTB.
Maternal Outcomes and Management of the Third Stage of Labor Following Midtrimester Delivery [6L]
Authors: Sweat Haylea , Zuber Matthew , Cotton-Caballero Amaya , Wakefield Brian , Pettit Kate , Chisholm Christian 
Published: May 2017

INTRODUCTION:
Preterm delivery is associated with a prolonged third stage of labor. Our objective was to evaluate the risk of maternal morbidity associated with duration of the third stage after midtrimester delivery.

METHODS:
We performed a retrospective cohort study examining vaginal deliveries between 14-24 weeks gestation. Univariate logistic regression was used for statistical analysis. A receiving operating characteristics (ROC) curve was generated to estimate sensitivity and specificity of the composite outcome (PPH, maternal infection, D&C) at 60 minutes. The proportion of undelivered placentas and risk of PPH or infection were plotted over length of third stage of labor.

RESULTS:
Of 131 participants, 38.2% had a third stage duration greater than or equal to 60 minutes. The risk of PPH was significantly higher among women with a third stage of labor greater than 60 minutes (OR=4.85, 95% CI: 2.11-11.11). This group was also more likely to undergo a post-delivery D&C (OR=18.6, 95% CI: 5.15-67.04). There was no difference in infection risk (OR=0.76, 95% CI: 0.17-3.30). The AUROC was 0.70 (sensitivity 67.0%, specificity 71.0%) for the composite outcome at 60 minutes. The proportion of undelivered placentas demonstrated exponential decay over time, while the risk of PPH and/or infection increased after 90 minutes.

CONCLUSION:
Maternal risk of PPH and need for post-delivery D&C at the time of midtrimester delivery increases with a third stage of labor greater than 60 minutes. Our data suggest that if the placenta is undelivered after 90 minutes, manual extraction or D&C is indicated to mitigate the increasing risk of maternal morbidity.
Genetic Approaches Reveal a Non-Hormonal Etiology for Hyperemesis Gravidarum [7L]
Authors: Fejzo Marlena S. , MacGibbon Kimber W. , Schoenberg Frederic P. , Sazonova Olga , Vacic Vladimir , Mullin Patrick 
Published: May 2017

INTRODUCTION:
While very common, the cause of nausea and vomiting in pregnancy (NVP) remains elusive. Evidence suggests a genetic predisposition to the most severe form of NVP, hyperemesis gravidarum (HG). An understanding of the molecular mechanism behind HG will lead to targeted therapies to predict, diagnose, treat, and even prevent HG.

METHODS:
Using a novel approach to study NVP, we performed both a genome-wide association study (GWAS) on 1,306 cases with HG treated with intravenous fluids and 15,766 cases without NVP, and a whole-exome sequencing (WES) study of five families with HG to identify common and rare predisposing genes.

RESULTS:
WES identified RYR2, an intracellular calcium release channel that signals vomiting. GWAS identified a gene in the same pathway as RYR2 as well as genes that appear to play major roles in pregnancy and nausea. Neither method identified mutations or associations between HG and pregnancy hormones.

CONCLUSION:
This study suggests a possible paradigm shift away from a hormonal etiology for NVP. The genes linked to HG play roles in pregnancy and in nausea and vomiting. Treatments that affect some of these new targets are already under investigation. New avenues for prediction, diagnosis, and treatment should follow.
Frequency of Peripartum Gestational Hypertension and Associated Adverse Outcomes [8L]
Authors: Codsi Elisabeth , Garovic Vesna D. , Borowski Krist S. , White Wendy W. 
Published: May 2017

INTRODUCTION:
Criteria for gestational hypertension (GH) include only 2 systolic blood pressures (BP) equal or greater than 140 or diastolic BP equal or greater than 90 at least 4 hours apart after 20 weeks gestation. We sought to determine the frequency of previously-normotensive patients meeting criteria for GH when presenting for delivery, and its association with adverse maternal/fetal outcomes.

METHODS:
We performed a retrospective cohort study of consecutive term deliveries without a diagnosis of hypertensive disorder of pregnancy (HDP) prior to admission. Characteristics of BP elevations, evaluations for and diagnosis of HDP; and associations with adverse composite maternal (seizure, pulmonary edema, unplanned ICU admission, emergent treatment of HTN, stroke, death) or fetal adverse events (5 minute Apgar more than 7, death or unplanned NICU admission) were determined.

RESULTS:
Of 185 patients, 140 (76%) had at least 1 BP elevation and 55 (30%) met formal criteria for HDP. Most elevated BPs occurred from admission to 1 hour postpartum (73%). Of those meeting GH criteria, only 18 (10%) underwent evaluation and 16 (9%) were formally diagnosed with HDP. A higher rate of fetal composite outcomes (7% vs 1%) was found in patients meeting criteria for HDP.

CONCLUSION:
BP elevations during admission for delivery were common, and though 30% met the strict definition for GH, only 9% were formally diagnosed reflecting low clinical suspicion. BP elevations through 1 hour postpartum appear to be most often a normal physiologic response to stress rather than a manifestation of HDP, yet GH is associated with risk for poor fetal outcomes.
Parity and Foley Catheter Using Tension or No Tension: A Randomized Controlled Trial [12L]
Authors: Fruhman Gary , Gavard Jeffrey , Amon Erol , Flick Kathleen , Gross Gilad 
Published: May 2017

INTRODUCTION:
A secondary analysis of a randomized controlled trial was performed to determine the effects of parity on the use of a Foley transcervical balloon catheter for cervical ripening and the effects of tension on each group.

METHODS:
73 nulliparous and 67 multiparous women underwent cervical ripening with a Bishop score ≤ 6. Tension was created by securing the catheter to the thigh and replacing tension in 30 minute increments. Major outcomes included time from insertion to delivery, time from insertion to catheter expulsion, and mode of delivery. A p value of < 0.05 denoted statistical significance.

RESULTS:
Nulliparous patients had a higher rate of Cesarean delivery (CD) (39.7% vs 22.4%, p = 0.027). They had a longer median time to delivery (17.5 vs 14.6 hours, p=0.054). Applied tension did not shorten times from catheter insertion to delivery or to expulsion. A significantly shorter median time from catheter insertion to expulsion was found in the tension group in multiparous women (2.88 vs 4.61 hours, p= 0.003). Multiparous women in the no tension group had a higher rate of CD than women in the tension group (31.6 % vs 10.3%, p= 0.039).

CONCLUSION:
Within multiparous patients, applied tension decreased the time to expulsion of the catheter, whereas no tension may increase the likelihood of CD. Further studies to evaluate these findings are needed. As expected, nulliparity increased the risk of CD and there was a trend towards longer delivery times compared to multiparous patients.
The Impact of Labor and Delivery Unit Management on Long Childbirth Length of Stay [27L]
Authors: Plough Avery C. , Galvin Grace E. , Li Zhonghe , Declercq Eugene R. , Caughey Aaron B. , Shah Neel T. 
Published: May 2017

INTRODUCTION:
The link between operational management of clinical services and quality of patient care has not been well characterized in obstetrics. We aimed to assess the impact of labor and delivery unit management practices on hospital length of stay (LOS) for low-risk patients during childbirth.

METHODS:
Using a validated instrument, we assessed the management practices of 51 diverse labor and delivery units across the United States. We constructed a patient-level relative risk regression model using all 226,463 low-risk patients discharged from these hospitals during 2013 and 2014. The model controlled for patient and hospital characteristics and accounted for clustering within hospitals. We defined our low-risk sample based on the AHRQ IQI#33 denominator specifications and excluded patients with ICD-9 codes indicating antepartum care. We defined long LOS as greater than 3 days for vaginal deliveries and greater than 5 days for cesarean deliveries.

RESULTS:
Delivering at a hospital with one standard deviation better patient flow management was associated with a 15% lower risk of long LOS (P=.004), and delivering at a hospital with one standard deviation better nursing management was associated with a 20% lower risk of long LOS (P < .001). In contrast, delivering at a hospital with one standard deviation better unit culture management was associated with a 30% higher risk of long LOS (P < .001).

CONCLUSION:
The management practices of labor and delivery units appear to independently influence the likelihood that a patient will experience prolonged hospitalization. Further research is needed to understand how optimal management can improve quality of care.
Maternal and Neonatal Outcomes of African-American Women in a Suburban Community Setting [34L]
Authors: May Carissa , Jovanovski Andrew , Ogunyemi Dotun 
Published: May 2017

INTRODUCTION:
To evaluate the maternal and neonatal outcomes of African-American women delivering in a suburban community setting.

METHODS:
This is a retrospective study of 16,980 term, singleton deliveries from a single hospital system from 2013-2014. Obstetrical data was extracted from the electronic record, and obstetrical factors for African-American women (1625, 9.6%) were compared to non-African-American women, the majority of whom were Caucasian. For factors that were significant on univariate analysis, independent associations were ascertained using logistic regression.

RESULTS:
Compared to a primarily Caucasian suburban population, African-American women were more likely to be unmarried (OR 4.49), use opioids (OR 2.81), have a history of drug use (OR 5.26), and have class II obesity (OR 2.21). They were less likely to be current smokers (OR 0.11) and to use psychiatric medications during pregnancy (OR 0.28). Babies born to African-American mothers were more likely to have meconium staining (OR 1.52), umbilical arterial pH less than 7.0 (OR 4.32), and length of stay greater than 5 days (OR 1.24). All other factors showed no statistically significant association.

CONCLUSION:
Despite key demographic and historical differences, African-Americans delivering in a suburban community setting had similar maternal and neonatal outcomes to the comparison population. The greatest adverse association was with umbilical arterial pH less than 7.0, although the absolute number of cases was small (n = 8).
Maternal Depression Scale: Does Access to Prenatal Care Influence Postpartum Depression Score? [35L]
Authors: Lua Lannah , Magliarditi Alexandra , Kelley Melissa , Jackson David 
Published: May 2017

INTRODUCTION:
In 2016, the United States Preventative Task Force recommends screening for depression in adults, including postpartum women. Our purpose was to assess the prevalence of “screen-positive” postpartum women delivering within our system, and to determine if access to prenatal care (PNC) has a measurable influence on depression scale results.

METHODS:
The ten-question Edinburgh Postnatal Depression Scale was routinely administered to postpartum women in our hospital. A score of 10 or greater triggered physician notification and social services consultation. Multivariate analysis was performed to investigate correlations between positive postpartum depression scale in patients with no PNC (zero office visits), limited PNC (1 to 3 office visits) and adequate PNC (greater than 3 office visits).

RESULTS:
A total of 970 women from January 2015 to May 2015 were included. The sample distribution consisted of 81% with adequate PNC (n=786), 12.7% no PNC (n=123), and 6.3% limited PNC (n=61). Scores of 10 or greater occurred in 21.1% (n=26/123) with no PNC compared to 10.9% (n=86/786) with adequate PNC (P=.003). A greater percentage of patients with adequate PNC had private insurance compared to those without PNC (23.5% vs 8.1%, P=.0001). Furthermore, significantly more patients with no PNC were self-pay compared to those with adequate PNC (37.4% vs 4.3%, P=.0001).

CONCLUSION:
Few studies have confirmed inadequate PNC as a measurable variable for positive postpartum depression screen. Financial issues appear to be a confounding variable. Obstetrician surveillance for management of depression in this population is warranted. Further prospective, interventional studies can potentially use this cohort as a base.
Maternal Factors and Neonatal Morbidity Associated With Opioid Use in Pregnancy [36L]
Authors: Losso MerryJean , Friedman Perry , Whitten Amy 
Published: May 2017

INTRODUCTION:
To identify the maternal factors and neonatal outcomes associated with opioid use in pregnancy.

METHODS:
This is a retrospective study of 16,980 term, singleton deliveries in a single hospital system from 2013-2014. Cases of opioid use during pregnancy (n = 1,648) were compared to unaffected pregnancies (n = 15,332) via logistic regression.

RESULTS:
In terms of maternal factors, opioid use was associated with black race (OR 2.78), gestational age greater than or equal to 41 weeks (OR 1.25), smoking (OR 1.66), history of drug use (OR 1.59), and history of any psychiatric disorder (OR 1.38). Multiparity was protective against opioid use (OR 0.48). For intrapartum factors, opioid use was associated with induction of labor (OR 2.42), use of antihypertensive medications (OR 1.79), severe perineal lacerations (OR 1.59), chorioamnionitis (OR 2.29), postpartum hemorrhage (OR 3.02), and operative or wound complications (OR 4.85). For neonatal outcomes, opioid use was associated with abstinence syndrome (OR 5.17), major birth defects (OR 2.65), and umbilical arterial pH less than 7.0 (OR 2.65).

CONCLUSION:
There are distinct demographic, social, medical, and obstetrical correlates of opioid use in pregnancy. Major maternal adverse associations include operative and wound complications and postpartum hemorrhage, while major neonatal adverse associations include abstinence syndrome and decreased umbilical arterial pH.
Association Between Skin Tags and Acanthosis nigricans With GDM and Hypertensive Disorders of Pregnancy [39L]
Authors: Park YeonJung , Patwardhan Sanjay , Chang Eugene 
Published: May 2017

INTRODUCTION:
Acanthosis nigricans (AN) and skin tags (ST) are associated with metabolic syndrome and insulin resistance in nonpregnant women. Studies have shown similar risk factors for metabolic syndrome and preeclampsia. The purpose of this study was to determine whether the presence of AN/ST are associated with increased risk of GDM and preeclampsia.

METHODS:
This was a prospective cohort study at MUSC. Patients ages 18-45 were examined at their prenatal visit for AN/ST and offered enrollment prior to their glucose tolerance test. Patients with pregestational diabetes, known fetal anomalies, and late transfers were excluded. A validated scale was used to assess AN. ST was defined as the presence of skin tags in the neck or axillae. Rates of GDM and hypertensive disorders of pregnancy were compared using chi square analysis with significance set at p < 0.05.

RESULTS:
191 patients were enrolled but 24 dropped out. 81 of these patients had skin changes. 28.4% had AN and ST, 34.6% had just ST, and 37% had AN alone. No difference was found in GDM incidence between those with and without AN/ST (4.9% vs. 7%, p= 0.75). The presence of skin findings was significantly associated with an increased risk for hypertensive disorders of pregnancy (p < 0.001).

CONCLUSION:
The presence of AN/ST is not associated with an increased risk for GDM but associated with an increased risk for hypertensive disorders of pregnancy. Larger studies are warranted to explore this association. If valid, we may be able to identify women in whom low dose aspirin may be helpful.
Bioidentical, Synthetic, and Animal Based Hormone Replacement Therapies and Risk of Breast Cancer [1M]
Authors: Abenhaim Haim Arie , Czuzoj-Shulman Nicholas , Spence Andrea R. , Azoulay Laurent , Suissa Samy , Tulandi Togas 
Published: May 2017

INTRODUCTION:
Hormone Replacement Therapy (HRT) has been associated with an increased risk of breast cancer. Our study objective was to evaluate whether the increased risk is dependent on the formulation used.

METHODS:
We carried out a population-based case-control study using data from the United Kingdom Clinical Practice Research Datalink on women aged >50. Newly diagnosed breast cancer cases were age-matched with women of comparable follow-up time with no history of breast cancer at a 1:10 ratio. Exposures were classified as ever/never for the HRT formulations: Bioidentical Estrogens (BE), Conjugated Equine Estrogens (CEE), Micronized Progesterone (MP), and Synthetic Progestogens (SP). Logistic regression estimated adjusted effects of HRT formulation on breast cancer.

RESULTS:
Between 1995-2014, 43,183 cases of breast cancer were identified and matched to 431,830 controls. Compared with women who had never used HRT, HRT use was associated with an overall increased risk of breast cancer OR 1.12 (1.09-1.15), p < 0.0001. Compared to never users, estrogens were not associated with breast cancer: BE (OR 1.04 (1.00-1.09), p=0.07), CEE (OR 1.01 (0.96-1.05), p=0.78), both (OR 1.32 (0.30-5.77), p=0.25). As compared to never users, progestogens appeared differentially associated with breast cancer: MP (OR 0.99 (0.55-1.79), p=0.98), SP (OR 1.28 (1.22-1.35), p < 0.0001), both (OR 1.32 (0.30-5.77), p=0.72).

CONCLUSION:
While HRT use is associated with an overall increased risk of breast cancer, this association appears to be uniquely in women having been given synthetic progestogens. Synthetic progestogens should not be given as part of HRT and counseling regarding the risk of breast cancer should consider the effect of formulation used.