Disentangling Safety Culture's Role in Reducing Cesarean Overuse: Creating a Revised Labor Culture Survey.

Objective: To measure and assess the relationship of patient safety culture to reducing cesarean overuse. Study Setting: Maternity care hospitals in Michigan. Study Design: Cross-sectional observational design, combining individual survey data with hospital characteristics using existing databases. Multivariate Poisson regression assessed the associations between survey scores and hospital nulliparous term singleton vertex cesarean rates. Factor analysis determined the scalability of survey items. Data Collection Methods: Electronic survey distributed at the hospital site level. Principal Findings: A total of 3091 clinicians from 54 out of 57 eligible hospitals completed the survey. Confirmatory factor analysis demonstrated best fit with a univariate model with two local factors. The new scale encompassing both local factors, including vaginal birth microculture and safety culture, is entitled "Unit Norms." The safety culture subdomain demonstrated an association with a reduction in hospital cesarean rate [-0.15; 95% CI: -0.27 to -0.04; incident rate ratio (IRR) 0.86], parallel to but lower in magnitude to vaginal birth microculture (-0.18; 95% CI: -0.35 to -0.02; IRR 0.84). Conclusions: Vaginal birth microculture remains the strongest predictor of cesarean delivery overuse; however, safety culture characteristics, including teamwork, psychological safety, and communication, correlate with lower cesarean delivery rates. Measuring these aspects of hospitals' culture may be important for other areas of quality improvement initiatives focused on quality and safety.

Impact of the COVID-19 Pandemic on Chlamydia, Gonorrhea, and Pelvic Inflammatory Disease Encounters in a United States Uniformed Service Female Beneficiary Population.

INTRODUCTION: We sought to evaluate the impact of the COVID-19 pandemic on trends in chlamydia, gonorrhea, and pelvic inflammatory disease (PID) encounter rates within the Military Health System. MATERIALS AND METHODS: This cross-sectional study queried electronic health records of 18- to 44-year-old female active duty service members and dependents during the pre-pandemic period (January 2018-February 2020), pandemic period 1 (March 2020-March 2021), and pandemic period 2 (April 2021-April 2022). We calculated monthly chlamydia, gonorrhea, and PID encounter rates using ICD-10 codes. We used change point analysis for trends in encounter rates and Poisson regression for differences in rates by age, active duty status, military rank, TRICARE region, and pandemic period. RESULTS: There were 36,102, 7,581, and 16,790 unique individuals with chlamydia, gonorrhea, and PID encounters, respectively, over the pre-pandemic and pandemic time frames. Chlamydia and gonorrhea encounter rates were highest in ages 18 to 19, in active duty service members, and junior enlisted compared to senior enlisted and officer sponsor rank. Chlamydia and gonorrhea encounter rates varied by TRICARE region. Chlamydia encounter rates were lower in both pandemic periods 1 and 2 compared to the pre-pandemic period, whereas gonorrhea encounter rates were lower only in pandemic period 2 compared to the pre-pandemic period. Trend analysis showed monthly chlamydia encounter rates did not significantly change from January 2018 through August 2020, and then decreased 2.4% monthly through the remainder of the study period (P < .05). Gonorrhea encounter rates did not significantly change from the beginning of the study period through February 2021 and then declined 1.9% monthly through the remainder of the study period (P < .05). Pelvic inflammatory disease encounter rates were highest in ages 18 to 19 and 20 to 24, in the TRICARE North region compared to the South region, in active duty service members compared to non-active duty, and in junior enlisted compared to senior enlisted and officer sponsor rank. Pelvic inflammatory disease encounter rates were lower in pandemic periods 1 and 2 compared to the pre-pandemic period. Pelvic inflammatory disease encounter rates declined 8.0% monthly from January 2020 through April 2020 (P < .05), followed by a 11.0% monthly increase from May 2020 through July 2020 (P < .05) and a 0.9% monthly decrease for the remainder of the study period (P < .05). CONCLUSIONS: Chlamydia, gonorrhea, and PID encounter rates in the Military Health System all declined in the pandemic period. Pelvic inflammatory disease was most influenced by the pandemic onset as demonstrated by an immediate decline in encounter rates followed by an increase several months into the pandemic. Young age, active duty, and junior enlisted status were associated with higher chlamydia, and gonorrhea, and PID encounter rates over the pre-pandemic and pandemic time frames. Lower encounter rates during the pandemic may be related to decreased access to health care services, reduced screening for sexually transmitted infections, or changes in sexual behavior. The less profound decline in gonorrhea encounter rates likely reflects the more symptomatic nature of gonorrhea compared to chlamydia. TRICARE regional differences varied for chlamydia, gonorrhea, and PID encounters.

Decision and economic evaluation of abortion availability in the United States military.

BACKGROUND: Active-duty service women rely on the civilian sector for most abortion care due to limits on federal funding for abortion. Abortion is now banned in many states with large military presences. The Department of Defense has implemented policies to assist active-duty service women in accessing abortion, but there is debate to reverse this support. OBJECTIVE: Our goal was to compare the cost-effectiveness and incidence of adverse maternal and neonatal outcomes of a hypothetical cohort of active-duty service women living in abortion-restricted states comparing restricted abortion access (abortion not available cohort) to abortion available with Department of Defense travel support (abortion available cohort). STUDY DESIGN: We developed a decision tree model to compare abortion not available and abortion available cohorts for active-duty service women living in abortion-restricted states. Our cohorts were subdivided into normal pregnancies and those with a major fetal anomaly. Cost estimates, probabilities, and disability weights of various health conditions associated with abortion and pregnancy were obtained and derived from the literature. Effectiveness was expressed in disability-adjusted life years and the willingness-to-pay threshold was set to $100,000 per disability-adjusted life year gained or averted. We completed probabilistic sensitivity analyses with 10,000 simulations to test the robustness of our results. Secondary outcomes included numbers of stillbirths, neonatal deaths, neonatal intensive care unit admissions, maternal deaths, severe maternal morbidities, and first and second trimester abortions. RESULTS: The abortion not available cohort had a higher annual cost to the military ($299.1 million, 95% confidence interval 239.2-386.6, vs $226.0 million, 95% confidence interval 181.9-288.5) and was associated with 203 more disability-adjusted life years compared to the abortion available cohort. The incremental cost-effectiveness ratio was dominant for abortion available. Abortion not available resulted in an annual additional 7 stillbirths, 1 neonatal death, 112 neonatal intensive care unit admissions, 0.016 maternal deaths, 24 severe maternal morbidities, 27 less second trimester abortions, and 602 less first trimester abortions. Probabilistic sensitivity analysis revealed that the chance of the abortion available cohort being the more cost-effective strategy was greater than 95%. CONCLUSION: Limiting active-duty service women's access to abortion care increases costs to the military, even with costs of travel support, and increases adverse maternal and neonatal outcomes. This analysis provides important information for policymakers about economic and health burdens associated with barriers to abortion care in the military.

Applying Engagement Marketing And Human-Centered Design to Cocreate a Digital Decision Support Tool for Research Participation with LGBTQIA+ Community Members.

We used engagement marketing and human-centered design principles to cocreate a digital decision support tool for research participation with LGBTQIA+ community members to help them make an informed decision about joining the All of Us Research Program. Building on results from the research phase, we conducted eight problem validation and solutioning workshops with 48 LGBTQIA+ community members. Community members validated barriers to engagement with All of Us and brainstormed 47 potential digital solutions. We developed potential solutions into 27 concepts (descriptive text and visual storyboards) and assessed acceptability, appropriateness, feasibility, and engagement in a set of 10 concept testing workshops with 57 community members. We developed one of the highest rated concepts, the "Decide Later Tool," into a prototype and tested it with 45 LGBTQIA+ community members and 14 community advisory group members to assess acceptability, appropriateness, feasibility, usability, and engagement. Prototype testing participants indicated that the tool provides information to help with decision making, provides a clear value or benefit to them, was designed for someone like them, provides the right amount of information, and is easy to use; they also offered constructive feedback to improve it. Across the design and development phases, community members indicated that the process of engaging them demonstrated integrity, competence, dependability, trust, and collaboration; fostered a sense of connection to All of Us; and will enhance future engagement with All of Us. Our next steps are to develop the prototype into a fully functioning web tool and pilot test it in community and health care settings.

Maternal and Fetal Health Risks Among Female Military Aviation Officers.

INTRODUCTION: Military aviation poses unique occupational risks, including exposures to intermittent hypoxia, high gravitational force, and toxic materials, in addition to circadian disruption, cosmic radiation, and ergonomic stressors also present in commercial flight. We sought to investigate whether a military aviation officer's career is associated with adverse maternal or fetal health outcomes.METHODS: We conducted a retrospective cohort study of female aviation and nonaviation officers in the Military Health System from October 2002 to December 2019. Exposure was identified as assignment of an aviation occupation code. Maternal and fetal health outcomes were identified by International Classification of Diseases codes from medical records. Regression analysis was used to estimate adjusted relative risks (aRR).RESULTS: Included in the study were 25,929 active-duty female officers, with 46,323 recorded pregnancies and 32,853 recorded deliveries; 2131 pregnancies were diagnosed in aviation officers. Pregnant aviation officers had a decreased risk of composite adverse pregnancy outcomes [aRR 0.82 (0.73-0.92)], including gestational diabetes [aRR 0.69 (0.57-0.85)] and gestational hypertension [aRR 0.84 (0.71-0.99)]. Pregnant aviation officers had a decreased risk of depression prior to delivery [aRR 0.43 (0.35-0.53)] and hyperemesis gravidarum [aRR 0.74 (0.57-0.96)], but an increased risk of placental complications [aRR 1.15 (1.02-1.30)] and fetal growth restriction [aRR 1.36 (1.16-1.60)].DISCUSSION: Pregnant military aviation officers have an increased risk of placental complications and fetal growth restriction in spite of a lower risk of gestational diabetes and gestational hypertension. Further research is needed to determine how flight-related occupations impact pregnancy.Stark CM, Sorensen IS, Royall M, Dorr M, Brown J, Dobson N, Salzman S, Susi A, Hisle-Gorman E, Huggins BH, Nylund CM. Maternal and fetal health risks among female military aviation officers. Aerosp Med Hum Perform. 2024; 95(9):675-682.

Impact of the COVID-19 Pandemic on the Delivery of Congenital Syphilis Care in the Military Health System.

INTRODUCTION: Congenital syphilis (CS) case rates have increased significantly in the United States over the past 20 years, accelerating during the COVID-19 pandemic. Increasing rates may relate to access to care but have not been evaluated in a fully-insured population, such as the Military Health System. MATERIALS AND METHODS: We performed a repeated monthly cross-sectional study of CS cases and total encounters (care rates) using the queried Military Health System database. We defined CS by International Classifications of Diseases 10th Revision Clinical Modification diagnosis codes in beneficiaries ≤ 2 years old. We evaluated pre-COVID-19 (March 2018 to February 2020), pandemic year 1 (March 2020 to February 2021), and pandemic year 2 (March 2021 to February 2022) periods. We performed change-point and trend analyses and Poisson regression to evaluate differences by sponsor rank, TRICARE region, and pandemic period. The Uniformed Services University Institutional Review Board approved the study. RESULTS: A total of 69 unique CS cases were identified with a median monthly care rate of 0.90/100,000 eligible beneficiaries. The CS care rate showed a 5.8% average monthly percent increase throughout the study period (P < .001) and a 20.8% average monthly percent increase in year 2 (P < .05). Compared to the pre-pandemic era, CS care rates increased in pandemic years 1 and 2 (adjusted rate ratio [aRR] 2.76 [95% CI: 1.95-3.92], 5.52 [95% CI: 4.05-7.53], respectively). Congenital syphilis care rates were lower in children of senior enlisted sponsors versus junior enlisted, aRR 0.24 (95% CI: 0.17-0.33), and higher in the West and North regions versus South, aRR 2.45 (95% CI: 1.71-3.53) and aRR 2.88 (95% CI: 2.01-4.12), respectively. CONCLUSIONS: Congenital syphilis care rates were substantially lower in this insured group than national rates but increased significantly during the COVID-19 pandemic. Higher care rates were seen in children of military members of lower rank. Regional trends differed from national data. These findings suggest that, even in a fully-insured population, income and regional differences impact CS, and the COVID-19 pandemic may have exacerbated differences in care delivery.

One Size Does Not Fit All: A Multifaceted Approach to Educate Families about Newborn Screening.

All families deserve access to readily available, accurate, and relevant information to help them navigate the newborn screening system. Current practices, limited resources, and a siloed newborn screening system create numerous challenges for both providers and families to implement educational opportunities to engage families in ways that meet their needs with relevant and meaningful approaches. Engaging families in newborn screening, especially those from historically underserved communities, is necessary to increase knowledge and confidence which leads to overall improved outcomes for families. This article describes three strategies that the Navigate Newborn Screening Program developed, tested, and implemented in the United States, including online learning modules, a prenatal education pilot program, and social media awareness campaign, as well as the extent to which they were successful in reaching and educating families about newborn screening. Using quality improvement methods and evidence-driven approaches, each of these three strategies demonstrate promising practices for advancing awareness, knowledge, and self-efficacy for families navigating the newborn screening system-particularly families in medically underserved and underrepresented communities. A model for bidirectional engagement of families is outlined to support scaling and implementing promising educational efforts for both providers and families in the newborn screening system.

Gaining Recovery in Addiction for Community Elders (GRACE) Project: The Impact of Age-Specific Care on Clinical Outcomes and Health Care Resource Utilization in Older Adults With Substance Use Disorder in an Interprofessional Addiction Clinic.

BACKGROUND: The prevalence of substance use disorders (SUDs) in older adults has been increasing, necessitating tailored and effective addiction care for this aging demographic. AIMS: The purpose of this study was to assess the impact of age-specific, interprofessional addiction care on clinical outcomes and health care resource utilization in older adults with SUD. METHODS: This quasi-experimental study directly compares patients enrolled in the Gaining Recovery in Addiction for Community Elders (GRACE) Project, an interprofessional age-specific addictions treatment program, with age-matched older adults who received conventional "treatment as usual" (TAU). Through retrospective comparative analysis, substance use outcomes, mental and physical health improvements, and inappropriate use of emergency services were examined among 78 older adults with SUD. RESULTS: Clinical outcomes and health care resource utilization were superior for older adults who received age-specific addictions care through the GRACE Project, as compared to mixed-age conventional "TAU." GRACE patients had improved treatment adherence, fewer relapses, and longer treatment engagement. While both groups exhibited significant reductions in depression and anxiety scores, GRACE patients showed greater improvements. This group demonstrated superior control of both hypertension and diabetes. Importantly, they had fewer inappropriate emergency department visits and avoidable hospitalizations than conventional "TAU." CONCLUSIONS: Addiction treatment delivered by an interprofessional team to meet the unique strengths and needs of older adults has the potential to improve treatment adherence and more favorable long-term outcomes in substance use, mental health, and chronic medical conditions. Nurses are poised to lead interprofessional teams to meet the growing demand for specialized addiction treatment and integrated care for older adults.

Patterns of Use and Barriers to STI Point-of-care Tests for Military Obstetrician Gynecologists.

INTRODUCTION: Sexually transmitted infections (STIs) are commonly reported in military populations. Point-of-care tests (POCTs) are commercially available, but their use is variable in the civilian sector. Their use among military providers has not been evaluated. We sought to identify the pattern of use and barriers to using STI POCTs for military obstetrician/gynecologists (OBGYNs). MATERIALS AND METHODS: We adapted a survey of civilian OBGYNs on patterns of use and barriers to STI POCTs for military OBGYNs. We sent an online questionnaire to 479 military OBGYNs via Army, Air Force, and Navy specialty leaders in May 2023. The questionnaire included 14 demographic questions and up to 52 questions regarding availability, use, and barriers to STI POCTs. The USU Institutional Review Board deemed the study exempt from Institutional Review Board review. RESULTS: Of the 479 solicited, 117 participated in the survey (24.4%). Of respondents, 64.1% were women and 79.5% non-Hispanic white. Sexually transmitted infections were detected once to twice weekly by 13.0% of respondents and once or twice monthly by 52.8%. The most available STI-related POCTs were wet mount prep (68.7%), rapid HIV (43.3%), and urine dipstick (38.6%). Gram stain was available for 30.3%, the Affirm VPIII (Becton, Dickinson and Company, Franklin Lakes, NJ) for 24.5%, and stat RPR for 16.3%. Economic barriers to using POCTs included cost of the test from manufacturer/distributor (57.9%) and military funding/stocking decisions (10.3%). The greatest barriers to use were the purchasing of an instrument (60.8%) and the interruption to workflow in clinic (57.8%). CONCLUSIONS: Military OBGYNs rely on several STI-related POCTs. Economic factors and interruption to workflow were cited as the most significant barriers to using POCTs for military OBGYNs. Test cost and impact on workflow should be considered in future development and procurement of POCTs for the Military Health System.

Phase 1 randomized trials to assess safety, pharmacokinetics, and vaginal bleeding associated with use of extended duration dapivirine and levonorgestrel vaginal rings.

BACKGROUND: Vaginal rings formulated to deliver two drugs simultaneously have potential as user-controlled, long-acting methods for dual prevention of HIV and pregnancy. METHODS: Two phase 1 randomized trials (MTN-030/IPM 041 and MTN-044/IPM 053/CCN019) respectively enrolled 24 and 25 healthy, HIV-negative participants to evaluate safety, pharmacokinetics, and vaginal bleeding associated with use of a vaginal ring containing 200mg dapivirine (DPV) and 320mg levonorgestrel (LNG) designed for 90-day use. MTN-030/IPM 041 compared the DPV/LNG ring to a DPV-only ring (200mg) over 14 days of use. MTN-044/IPM 053/CCN019 compared continuous or cyclic use of the DPV/LNG ring over 90 days of use. Safety was assessed by recording adverse events (AEs). DPV and LNG concentrations were quantified in plasma, cervicovaginal fluid, and cervical tissue. Vaginal bleeding was self-reported. RESULTS: There were no differences in the proportion of participants with grade ≥2 genitourinary AEs or grade ≥3 AEs with DPV/LNG ring vs. DPV ring use (p = .22), or with DPV/LNG ring continuous vs. cyclic use (p = .67). Higher plasma DPV concentrations were observed in users of DPV/LNG compared to DPV-only rings (Cmax p = 0.049; AUC p = 0.091). Plasma DPV and LNG concentrations were comparable with continuous and cyclic use (Cmax p = 0.74; AUC p = 0.25). With cyclic use, median nadir plasma DPV concentration was approximately 300 pg/mL two days after removal and median t1/2 for cervicovaginal fluid DPV concentration was 5.76 hours (n = 3). Overall bleeding experiences did not differ between continuous and cyclic users (p = 0.12). CONCLUSIONS: The extended duration DPV/ LNG rings were well tolerated and the observed DPV concentrations in plasma and cervicovaginal fluid when used continuously exceeded concentrations observed in previous DPV ring efficacy studies. LNG concentrations in plasma were comparable with other efficacious LNG-based contraceptives. Genital DPV concentrations had a short half-life and were thus not well sustained following ring removal.

Contraception and abortion attitudes among military medical students: An exploratory study.

OBJECTIVES: To investigate military medical students' attitudes toward contraception and abortion after clerkships. STUDY DESIGN: We adapted a survey of civilian medical student attitudes for military students. We asked how clerkships changed perspectives and comfort discussing these topics. RESULTS: Eighty-five (85%) of 100 respondents felt more comfortable discussing contraception and abortion after clerkships. More students changed perspectives on contraception than abortion (29% vs 17%, p = 0.043). Students noted limited exposure to abortion. CONCLUSIONS: Clerkships increased comfort discussing contraception and abortion but were unlikely to change their attitudes. IMPLICATIONS: More exposure to abortion care is needed.

Emergency contraception for individuals weighing 80 kg or greater: A randomized trial of 30 mg ulipristal acetate and 1.5 mg or 3.0 mg levonorgestrel.

OBJECTIVES: To compare the efficacy of emergency contraception (EC) regimens used within 72 hours of unprotected intercourse in individuals weighing ≥80 kg. STUDY DESIGN: We enrolled reproductive-aged healthy women in a multicenter, single-blind, randomized study of levonorgestrel 1.5 mg (LNG1X) and 3.0 mg (LNG2X) and ulipristal acetate 30 mg (UPA) (enrollment goal 1200). Key eligibility requirements included regular cycles, weight >/= 80kg, unprotected intercourse within 72 hours, no recent use of hormonal contraception, a negative urine pregnancy test (UPT), and willingness to abstain from intercourse until next menses. To assess our primary outcome of incidence of pregnancy, participants completed home UPTs; if no menses by 2-weeks post-treatment, or a positive UPT, they returned for an in-person visit with quantitative serum human chorionic gonadotropin and ultrasound. RESULTS: We enrolled and randomized 532; 44 were not dosed or not evaluable for primary end point, leaving an analyzable sample of 488 (173 LNG1X, 158 LNG2X, 157 UPA) with similar demographics between groups (mean age 29.6 years [5.74], body mass index 37.09 kg/m2 [6.95]). Five pregnancies occurred (LNG1X n = 1, LNG2X n = 1, UPA n = 3); none occurred during the highest at-risk window (day of ovulation and the 3 days prior). We closed the study before achieving our enrollment goal because the low pregnancy rate in all groups established futility based on an interim blinded analysis. CONCLUSIONS: Although slow enrollment limited our study power, we found no differences in pregnancy rates between EC regimens among women weighing 80 kg or more. Our results are not able to refute or support differences between the treatment arms. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clincialtrials.gov Clinical trials#: NCT03537768. IMPLICATIONS: Women weighing 80 kg or more experienced no differences in pregnancy rates between oral EC regimens but due to several significant study limitations including sample size and the lack of a study population at high risk of pregnancy, our results are not able to determine if differences in treatment effectiveness exist.

Use of serum evaluation of contraceptive and ovarian hormones to assess reduced risk of pregnancy among women presenting for emergency contraception in a multicenter clinical trial.

OBJECTIVES: To evaluate ovulation risk among women enrolling in an emergency contraception (EC) study by measuring contraceptive steroids and ovarian hormones. STUDY DESIGN: We used standard chemiluminescent assays to evaluate endogenous hormones (estradiol, progesterone, follicle stimulating hormone, luteinizing hormone) and liquid chromatography-tandem triple quadrupole mass spectrometry to simultaneously analyze concentrations of ethinylestradiol, dienogest, norelgestromin (NGMN), norethindrone (NET), gestodene, levonorgestrel (LNG), etonogestrel (ENG), segesterone acetate, medroxyprogesterone acetate (MPA), and drospirenone in serum samples obtained at the time of enrollment in a recent study comparing oral ulipristal acetate and LNG EC in women with weight ≥80 kg reporting no recent use of hormonal contraception. RESULTS: We enrolled 532 and obtained a valid baseline blood sample from 520 women. Of these, 117 (22.5%) had detectable concentrations of progestin (MPA [n = 58, 11.2%], LNG [50, 9.6%], ENG [11, 2.1%], NET [5, 0.96%], NGMN [3, 0.06%], or drospirenone [1, 0.02%]). LNG was co-detected in all three participants with samples containing NGMN. Multiple progestins were detected in eight other women: ENG/MPA (1), ENG/LNG (2), and MPA/LNG (5). Samples from 55 (10.6%) had concentrations of one or more progestin considered above the minimum level for contraceptive (MPA ≥ 0.1 ng/mL, n = 19; NGMN/LNG ≥ 0.2 ng/mL, n = 31; ENG ≥ 0.09 ng/mL, n = 8; NET ≥ 0.35 ng/mL, n = 4). We detected concentrations of serum progesterone ≥ 3 ng/mL, indicative of luteal phase (postovulation) status, in an additional 194 (37.3%) samples. CONCLUSIONS: More than one-third of enrolled in our clinical trial of oral EC had evidence of prior ovulation at the time of enrollment. Additionally, about 23% had evidence of recent use of hormonal contraception. These results would have decreased the expected risk of pregnancy in the study. IMPLICATIONS: Many participants in a recent clinical trial of oral emergency contraception did not appear to be at risk for pregnancy or would not have benefited from intervention due to cycle timing. Investigators should consider the effects of these findings on expected pregnancy rates when determining sample size in future EC clinical trials, particularly when using noninferiority designs or historical controls.

Menstrual cup use and intrauterine device expulsion in a copper intrauterine device randomized trial.

OBJECTIVE: To evaluate menstrual cup use and intrauterine device (IUD) expulsion. STUDY DESIGN: We performed a secondary analysis of a 3-year contraceptive efficacy trial comparing two copper 380 mm2 IUDs. Investigators randomized participants approximately 1:4 to the TCu380A or NTCu380-Mini IUD. Approximately 12 months after enrollment began, we advised participants against menstrual cup use due to observed IUD expulsions in cup users. We evaluated IUD expulsion (including spontaneous partial and complete expulsion and accidental self-removal) at 12 and 36 months. We used multivariable logistic regression to evaluate IUD expulsion by age, baseline menstrual volume, body mass index, IUD type, menstrual cup use, parity, and uterine length. RESULTS: This analysis included 1046 participants (203 TCu380A and 843 NTCu380-Mini), with 879 (84.0%) nulliparas. Through 12 and 36 months, expulsion occurred in 74 (7.1%, 95% CI 5.5-8.6%) and 133 (12.7%, 95% CI 10.7-14.7%) participants, respectively. Overall, 250 (23.9%) reported menstrual cup use. More menstrual cup users than non-users experienced expulsion through 12 months (32/203 [15.8%] vs. 42/843 [5.0%]) and 36 months (58/250 [23.2%] vs. 75/796 [9.4%]). Through 36 months, NTCu380-Mini menstrual cup users had higher expulsion odds, while TCu380A cup users did not. Menstrual cup users more frequently experienced accidental self-removal than non-users in participants using the TCu380A (3/53 [5.7%] vs. 0/150 [0.0%]) and the NTCu380-Mini (20/197 [10.2%] vs. 7/646 [1.1%]). In multivariable regression, we found increased odds of expulsion through 36 months in participants using menstrual cups with the NTCu380-Mini (aOR 3.13, 95% CI 1.16-8.46) and <25 years (aOR 1.59, 95% CI 1.07-2.34). CONCLUSIONS: We found higher odds of IUD expulsion with menstrual cup and concurrent NTCu380-Mini IUD use over 36 months of use, but not with concurrent TCu380A IUD use. Menstrual cup users experienced higher likelihood of accidental self-removal regardless of IUD type. IMPLICATIONS: Menstrual cup and NTCu380-Mini use may increase IUD expulsion risk and may increase accidental self-removal risk with TCu380A and NTCu380-Mini use. Clinicians should advise patients of these risks and consider warning patients using an IUD shaped like the NTCu380-Mini (Nova-T frames) of expulsion risk with menstrual cup use.

Female-Specific Health Care of Military Female-Designated Service Members and Veterans: A Systematic Overview of Reviews.

INTRODUCTION: Since the War in Afghanistan began in 2001, service members have faced significant health effects related to service during war, with female-designated service members facing unique challenges. Numerous high-quality review articles have been published on the health and care of female-designated service members and veterans. Given the increasing volume of literature, we completed an overview of reviews on the health and health care of female-designated military populations. Our objective was to conduct an overview of reviews on the obstetrics and gynecologic health and health care of female-designated military populations since 2000 to understand female-specific health consequences of military service during war and make clinical recommendations. MATERIALS AND METHODS: On May 10, 2022, a medical librarian performed a comprehensive search across five databases (Ovid Medline, Embase, CINAHL, PsycINFO, Ovid All EBM Reviews, and Web of Science) for all relevant reviews published from 2000 to May 10, 2022. Results were limited to English language. After the removal of duplicates, 2,438 records were reviewed, and 69 studies were included in the final review. The search strategy and methods were registered with PROSPERO and are reported according to the Preferred Reporting Items for Overviews of Reviews (PRIOR) guidelines. Two independent reviewers conducted title and abstract screening and subsequent full text review using Covidence Systematic Review Software. Reviews addressing female-specific and obstetrics and gynecologic health of female-designated service members or veterans, utilizing a clear and systematic methodology, were eligible for inclusion. Quality assessment was conducted by teams of two reviewers. RESULTS: A total of 69 studies were included in the final review. Themes included mental health and impact of sexual assault on service members or veterans, veteran health care, issues of menstruation, pregnancy, and urogenital concerns. Areas with few reviews included occupational risks of military service and impact on obstetric outcomes, eating disorders, and menopause. There were insufficient or no reviews on the impact of military service on fertility, access to abortion care, reproductive health outcomes of lesbian, bisexual and transgender service members, surgical treatment of gynecologic conditions, and screening and treatment for breast, gynecologic, and non-pelvic organ cancers. CONCLUSIONS: Female-designated military populations serving during periods of war face unique health challenges that should be considered in screening practices and the delivery of trauma informed care. Further research and reviews are needed for female-specific oncology, fertility, abortion access, and sexual and non-binary and expansive gender identities to better capture female-designated service member and veteran health during wartime and beyond.

Sister chromatid cohesion is mediated by individual cohesin complexes.

Eukaryotic genomes are organized by loop extrusion and sister chromatid cohesion, both mediated by the multimeric cohesin protein complex. Understanding how cohesin holds sister DNAs together, and how loss of cohesion causes age-related infertility in females, requires knowledge as to cohesin's stoichiometry in vivo. Using quantitative super-resolution imaging, we identified two discrete populations of chromatin-bound cohesin in postreplicative human cells. Whereas most complexes appear dimeric, cohesin that localized to sites of sister chromatid cohesion and associated with sororin was exclusively monomeric. The monomeric stoichiometry of sororin:cohesin complexes demonstrates that sister chromatid cohesion is conferred by individual cohesin rings, a key prediction of the proposal that cohesion arises from the co-entrapment of sister DNAs.

Reducing risk for chronic disease: evaluation of a collective community approach to sustainable evidence-based health programming.

BACKGROUND: Community initiatives can shape health behaviors, such as physical activity and dietary habits, across a population and help reduce the risk of developing chronic disease. To achieve this goal and impact health outcomes, Pasadena Vibrant Community aimed to engage communities in an ongoing dialogue about the importance of healthy behaviors, implement and advance community-based strategies to promote health, and improve diet and physical activity behaviors. The initiative was centered around a collaboration between a backbone organization, steering committee, and 7 collaborating organizations funded to implement multicomponent, evidence-based programs.. The common agenda was detailed in a community action plan, which included 19 interventions targeting healthy eating and active living among adults and youth in Pasadena, Texas. METHODS: A mixed methods evaluation of the initiative was conducted over 4 years. Data sources included document reviews of quarterly progress reports (n = 86) and supplemental data reports (n = 16) provided by collaborating organizations, annual Steering Committee surveys (n = 4), and interviews conducted with staff from a subset of Collaborating Organizations (n = 4). RESULTS: The initiative reached over 50,000 community members per year through 19 evidence-based interventions and impacted health outcomes, including knowledge and adoption of healthy eating practices and increased physical activity. Thirty-one systems-level changes were implemented during the initiative, including 16 environmental changes. Steering Committee meetings and shared goals enabled connections, communication, and cooperation, which allowed Collaborating Organizations to address challenges and combine resources to deliver their programs. CONCLUSIONS: Community initiatives can effectively permeate the community by reaching individuals, improving physical activity and dietary habits, and ensuring sustainability. Based on the experience reported here, the success of a community initiative can be facilitated if collaborating organizations come together to implement evidence-based interventions and tailor them to the community, and if they are empowered by significant leadership and supportive collaboration and aligned by a common agenda.

Novel progestogenic androgens for male contraception: design, synthesis, and activity of C7 α-substituted testosterone†.

Male contraceptive development has included use of testosterone (T) with or without a progestin or the use of a single molecule such as progestogenic androgens (PA) for suppression of testicular T production. Expanding upon the vast amount of data accumulated from nortestosterone (NT), NT analogs, and their prodrugs, a new series of PA, the C7 methyl, and ethyl α-substituted T analogs 7α-Methyltestosterone (7α-MT) and 7α-Ethyltestosterone (7α-ET), respectively, were hypothesized and designed to have superior androgenic and progestogenic activities when compared with parent T. Results from androgen receptor and progesterone receptor competitive binding and transcriptional activation assays showed favorable activities for these T analogs. Additionally, 7α-MT and 7α-ET were shown to be active substrates for aromatase in vitro, mitigating a potential negative impact on bone mineral density with long-term use. In conjunction with this observation, the diminished metabolism of these T analogs by 5α-reductase may reduce potential concerns for prostatic growth. In the Hershberger in vivo rat bioassay, 7α-MT and 7α-ET showed superior androgenic and anabolic activities as compared with T. These C7 α-substituted T analogs also showed clear progestogenic activity in the McPhail bioassay which evaluated endometrial glandular arborization in a rabbit model. The discovery of aromatizable molecules with reduced metabolism by 5α-reductase that have androgenic, anabolic, and progestogenic properties indicates that the core and/or prodrugs of 7α-MT and 7α-ET are promising molecules for further development as male contraceptive PAs.

Impact of Obstetrics and Gynecology Clerkship Order on NBME Exam Scores After a Curriculum Change.

OBJECTIVE: Our Institution instituted curriculum reform in 2013. We sought to examine the impact of rotation order on the end of clerkship National Board of Medical Examiners (NBME) Obstetrics and Gynecology (Ob/Gyn) Subject Exam scores after curriculum restructuring. DESIGN: This is a retrospective analysis of Ob/Gyn NBME scores over 2 years after curriculum reform. At our university, a 15-week block is divided into 5-week intervals of General Surgery, Ob/Gyn, and surgical subspecialties, in any order. During the 16 weeks, students take the NBME Subject Examinations for Ob/Gyn and Surgery. We defined rotation groups by proximity to the shelf exam. Group 1 completed Ob/Gyn first, furthest away from the exam, Group 2 completed Ob/Gyn second, and Group 3 completed Ob/Gyn last, closest to the test. We compared average shelf exam scores between Groups. SETTING: Uniformed Services University of Health Sciences during the clerkship year. PARTICIPANTS: Medical students at the Uniformed Services University. RESULTS: We obtained data from 331 students (118 students in Group 1, 106 in Group 2, and 107 in Group 3). Scores ranged from 55 to 99 (mean 72.5, SD 7.3). Mean (SD) NBME score was 71.9 (6.9) in Group 1, 73.2 (7.2) in Group 2, and 72.6 (7.7) in Group 3 (p = 0.415). CONCLUSION: Rotation order does not affect NBME Ob/Gyn Subject exam scores in a fifteen-week integrated clerkship block.

Participant experiences with a multipurpose vaginal ring for HIV and pregnancy prevention during a phase 1 clinical trial: learning from users to improve acceptability.

Introduction: With high concurrent global rates of HIV incidence and unintended pregnancy, there is a need to provide options beyond condoms to enable users to simultaneously prevent HIV acquisition and pregnancy. Multiple vaginal rings are in development as "MPTs" (multipurpose prevention technologies) as they are shown to provide several co-occurring benefits such as discretion, convenience, reversibility and user control. Methods: In this Phase 1 trial of a 3-month MPT ring in the U.S., 25 participants (low-risk for HIV and pregnancy) were randomized to use the study ring for 90 days continuously or in 28-day cycles with 2-day removal periods in between. All participants completed in-depth interviews at the end of their study participation. Results: Overall, the ring was well tolerated. Participants resoundingly endorsed the concept of an extended-use, dual-purpose vaginal ring, but reported too many functional challenges and side effects to endorse this particular ring. Participants assigned to the continuous regimen reported more positive experiences with ring use than those in the cyclic group. A minority of participants who experienced minimal side effects and did not experience challenges with vaginal retention of the ring found it appealing. However, the majority of participants experienced challenges (ring slippage, expulsions, side effects, vaginal bleeding changes) with product use that outweighed the potential benefits and led them to report that - in the future - they would not be interested in using this specific version of the ring in its current form. A subset expressed interest in using the current MPT ring under certain conditions (e.g., if fewer expulsions, less bleeding, higher risk for HIV/pregnancy). Discussion: User feedback regarding participant experiences and challenges with the study ring was continuously shared with the product developer, underscoring the value of early-stage end-user feedback in product development.