Development and Validation of Algorithms to Identify COVID-19 Patients Using a US Electronic Health Records Database: A Retrospective Cohort Study.

Introduction: In order to identify and evaluate candidate algorithms to detect COVID-19 cases in an electronic health record (EHR) database, this study examined and compared the utilization of acute respiratory disease codes from February to August 2020 versus the corresponding time period in the 3 years preceding. Methods: De-identified EHR data were used to identify codes of interest for candidate algorithms to identify COVID-19 patients. The number and proportion of patients who received a SARS-CoV-2 reverse transcriptase polymerase chain reaction (RT-PCR) within ±10 days of the occurrence of the diagnosis code and patients who tested positive among those with a test result were calculated, resulting in 11 candidate algorithms. Sensitivity, specificity, and likelihood ratios assessed the candidate algorithms by clinical setting and time period. We adjusted for potential verification bias by weighting by the reciprocal of the estimated probability of verification. Results: From January to March 2020, the most commonly used diagnosis codes related to COVID-19 diagnosis were R06 (dyspnea) and R05 (cough). On or after April 1, 2020, the code with highest sensitivity for COVID-19, U07.1, had near perfect adjusted sensitivity (1.00 [95% CI 1.00, 1.00]) but low adjusted specificity (0.32 [95% CI 0.31, 0.33]) in hospitalized patients. Discussion: Algorithms based on the U07.1 code had high sensitivity among hospitalized patients, but low specificity, especially after April 2020. None of the combinations of ICD-10-CM codes assessed performed with a satisfactory combination of high sensitivity and high specificity when using the SARS-CoV-2 RT-PCR as the reference standard.

Trends in characteristics and outcomes among US adults hospitalised with COVID-19 throughout 2020: an observational cohort study.

OBJECTIVES: To examine the temporal patterns of patient characteristics, treatments used and outcomes associated with COVID-19 in patients who were hospitalised for the disease between January and 15 November 2020. DESIGN: Observational cohort study. SETTING: COVID-19 subset of the Optum deidentified electronic health records, including more than 1.8 million patients from across the USA. PARTICIPANTS: There were 51 510 hospitalised patients who met the COVID-19 definition, with 37 617 in the laboratory positive cohort and 13 893 in the clinical cohort. PRIMARY AND SECONDARY OUTCOME MEASURES: Incident acute clinical outcomes, including in-hospital all-cause mortality. RESULTS: Respectively, 48% and 49% of the laboratory positive and clinical cohorts were women. The 50- 65 age group was the median age group for both cohorts. The use of antivirals and dexamethasone increased over time, fivefold and twofold, respectively, while the use of hydroxychloroquine declined by 98%. Among adult patients in the laboratory positive cohort, absolute age/sex standardised incidence proportion for in-hospital death changed by -0.036 per month (95% CI -0.042 to -0.031) from March to June 2020, but remained fairly flat from June to November, 2020 (0.001 (95% CI -0.001 to 0.003), 17.5% (660 deaths /3986 persons) in March and 10.2% (580/5137) in October); in the clinical cohort, the corresponding changes were -0.024 (95% CI -0.032 to -0.015) and 0.011 (95% CI 0.007 0.014), respectively (14.8% (175/1252) in March, 15.3% (189/1203) in October). Declines in the cumulative incidence of most acute clinical outcomes were observed in the laboratory positive cohort, but not for the clinical cohort. CONCLUSION: The incidence of adverse clinical outcomes remains high among COVID-19 patients with clinical diagnosis only. Patients with COVID-19 entering the hospital are at elevated risk of adverse outcomes.

Pediatric BMI changes during COVID-19 pandemic: An electronic health record-based retrospective cohort study.

BACKGROUND: Beginning March 2020, the COVID-19 pandemic has disrupted different aspects of life. The impact on children's rate of weight gain has not been analysed. METHODS: In this retrospective cohort study, we used United States (US) Electronic Health Record (EHR) data from Optum® to calculate the age- and sex- adjusted change in BMI (∆BMIadj) in individual 6-to-17-year-old children between two well child checks (WCCs). The mean of individual ∆BMIadj during 2017-2020 was calculated by month. For September-December WCCs, the mean of individual ∆BMIadj (overall and by subgroup) was reported for 2020 and 2017-2019, and the impact of 2020 vs 2017-2019 was tested by multivariable linear regression. FINDINGS: The mean [95% Confidence Interval - CI] ∆BMIadj in September-December of 2020 was 0·62 [0·59,0·64] kg/m2, compared to 0·31 [0·29, 0·32] kg/m2 in previous years. The increase was most prominent in children with pre-existing obesity (1·16 [1·07,1·24] kg/m2 in 2020 versus 0·56 [0·52,0·61] kg/m2 in previous years), Hispanic children (0·93 [0·84,1·02] kg/m2 in 2020 versus 0·41 [0·36,0·46] kg/m2 in previous years), and children who lack commercial insurance (0·88 [0·81,0·95] kg/m2 in 2020 compared to 0·43 [0·39,0·47] kg/m2 in previous years). ∆BMIadj accelerated most in ages 8-12 and least in ages 15-17. INTERPRETATION: Children's rate of unhealthy weight gain increased notably during the COVID-19 pandemic across demographic groups, and most prominently in children already vulnerable to unhealthy weight gain. This data can inform policy decisions critical to child development and health as the pandemic continues to unfold. FUNDING: Amgen, Inc.

Dermatologic Toxicities: A Chart Review of Clinical Management Among Patients With Metastatic Colorectal Cancer Treated With Panitumumab.

BACKGROUND: At least 90% of patients with metastatic colorectal cancer (mCRC) who are treated with an anti-EGFR will develop a dermatologic toxicity. Preemptive management strategies have been shown to reduce the severity of rash. OBJECTIVES: This article aims to describe treatment modalities used for the management of dermatologic toxicity among patients with mCRC who were treated with panitumumab and to assess the proportion of patients who were recommended preemptive versus reactive management strategies. METHODS: This retrospective chart review evaluated different treatment modalities and routes of administration. The modalities were categorized as prescription or over-the-counter. The timing in relation to the first dose of panitumumab was used to define preemptive versus reactive treatments. FINDINGS: In a sample of 330 patients, only 10% of patients were recommended to begin treatment for rash preemptively. The two most common treatment modalities for preemptively and reactively treated patients were prescription oral antibiotics and prescription topical antibiotics.

Epidurals and the Modern Labor Curve: How Epidural Timing Impacts Fetal Station during Active Labor.

OBJECTIVE: The objective of this study was to estimate epidural timing's impact on fetal station during active labor. STUDY DESIGN: This secondary analysis of a single-institution prospective cohort study included all term singleton pregnancies, stratified by parity. Those with early epidurals (placed at <6 cm) were compared with those with late epidurals (placed at ≥6 cm). The primary outcome was median fetal station from 6 to 10 cm. Secondary outcomes included rate of prolonged first or second stage of labor (>95%). Multivariable logistic regression adjusted for labor type. RESULTS: Among 7,647 women, 3,434 were nulliparous (2,983 with early epidurals and 451 with late epidurals) and 4,213 multiparous (3,141 with early epidurals and 1,072 with late epidurals). Interquartile ranges (IQRs) suggested fetal station at 6 cm was likely lower among those with early epidurals (nulliparous: median head station -1 [IQR: -1 to 0] for early epidural vs. -1 [IQR: -2 to 0] for late epidural, p < 0.01; multiparous: -1 (IQR: -2 to 0] for early epidural vs. -1 [IQR: -3 to -1] for late epidural, p < 0.01). Early epidurals were not associated with increased risk of prolonged first stage, but among nulliparous were associated with decreased risk of prolonged second stage (adjusted odds ratio: 0.66 [95% confidence interval: 0.44-0.99]). CONCLUSION: Early epidurals were associated with lower fetal station in active labor but not prolonged first stage.

Neurologic Injury in Acidemic Term Infants.

Objective To determine whether arterial umbilical cord gas (aUCG) pH, in anatomically normal-term infants, could select infants at risk for brain injury identified on magnetic resonance imaging (MRI). Study Design We performed a nested case-control within a prospective cohort of 8,580 women. Cases, with an aUCG pH < 7.10, were temporally, age, and sex matched to controls with an aUCG pH ≥ 7.20. Bi- and multivariable analyses compared the presence and severity of brain injury. Secondary analyses estimated whether elevated arterial base excess or lactate were associated with brain injury. Results Fifty-five cases were matched to 165 controls. There was no statistical difference in brain injury between the groups (adjusted odds ratio [aOR]: 1.8, 95% confidence interval [CI]: 0.7-4.4]). Base excess ≥ -8 mEq/L was not significantly associated with brain injury (p = 0.12). There was no increase in risk of injury based on elevation of arterial lactate ≥ 4 mmol /L (p = 1.00). Cases were significantly more likely to have an abnormal score in several domains of the Dubowitz neurologic examination. Conclusion The aUCG acid-base parameters alone are not sufficient clinical markers to identify term infants that might benefit from MRI of the brain to identify injury.

Associations Between iCOGS Single Nucleotide Polymorphisms and Upgrading in Both Surgical and Active Surveillance Cohorts of Men with Prostate Cancer.

BACKGROUND: Associations have been documented recently between some of the 23 single nucleotide polymorphisms newly discovered with the Collaborative Oncological Gene-environment Study iCOGS array that indicate prostate cancer (PCa) risk and aspects of disease aggressiveness. The utility of these iCOGS SNPs remains to be determined in active surveillance (AS). OBJECTIVE: To determine associations between iCOGS SNPs and upgrading among men who underwent surgical treatment and AS for low-risk PCa. DESIGN, SETTING, AND PARTICIPANTS: The genotypes of the 23 iCOGS SNPs were determined for all white subjects with biopsy Gleason score (GS) 6 including 950 men who underwent definitive treatment with surgery and 209 men who elected AS. The clinical and pathologic characteristics were documented for all subjects. OUTCOME MEASURES AND STATISTICAL ANALYSIS: Men who underwent surgery were grouped according to their pathologic GS (upgraded was defined as GS ≥7; nonupgraded remained GS 6). Men who were enrolled in AS were also grouped according to their GS on subsequent surveillance biopsies. Statistical analyses were performed comparing the genotypes between the upgraded and nonupgraded groups. RESULTS AND LIMITATIONS: Overall, 31% and 34% of men were upgraded in the surgery and AS cohorts, respectively. Three iCOGS SNPs were significantly associated with the risk of upgrading in the surgical cohort. After correction for multiple testing, only rs11568818 on chromosome 11q22 remained significantly associated with upgrading. Assessment of this allele in the AS cohort reveals that it was present at noteworthy higher frequencies in men with high-grade disease on surveillance biopsies compared with nonupgraded men (p=0.003). This study was primarily limited by the homogeneous patient population. CONCLUSIONS: This is the first report of a SNP on chromosome 11q22 associated with higher grade disease in a surgical cohort that is also validated for eventual upgrading in a prospective AS cohort. PATIENT SUMMARY: We examined the relationship between a group of genetic markers and prostate cancer (PCa) aggressiveness in a group of patients who underwent surgery for PCa and a group of patients who were enrolled in active surveillance. We found that these genetic markers helped predict which patients had more aggressive disease in both groups.

Electronic fetal monitoring patterns associated with respiratory morbidity in term neonates.

OBJECTIVE: The purpose of this study was to identify electronic fetal monitoring patterns that are associated with neonatal respiratory morbidity. STUDY DESIGN: In an on-going prospective cohort study of >8000 consecutive term, vertex, nonanomalous singleton pregnancies during labor, we performed this analysis within the first 5000 women as a representative sample. Electronic fetal monitoring patterns in the 30 minutes preceding delivery were extracted by trained obstetrics research nurses, who were blinded to clinical data, using the National Institute of Child Health and Human Development system; the data were compared between those with respiratory morbidity and healthy infants (no morbidities). The primary outcome was neonatal respiratory morbidity, which was defined as either oxygen requirement at ≥6 hours of life or any mechanical ventilation in the first 24 hours. Multivariable logistic regression was used to adjust for confounders. RESULTS: Of 4736 neonates, 175 (3.4%) experienced respiratory morbidity. Most electronic fetal monitoring patterns were category II (96.6%; n = 4575). Baseline tachycardia (adjusted odds ratio [aOR], 2.9; 95% confidence interval [CI], 1.9-4.4), marked variability (aOR, 2.7; 95% CI, 1.5-5.0), and prolonged decelerations (aOR,2.7; 95% CI, 1.5-5.0) were significantly associated with an increased likelihood of term neonatal respiratory morbidity. Accelerations and persistent moderate variability were both significantly associated with a decreased likelihood of respiratory morbidity. CONCLUSION: Specific features of category II electronic fetal monitoring patterns make respiratory morbidity more likely in nonanomalous term infants. Tachycardia, marked variability, or prolonged decelerations before delivery can assist providers in anticipating the potential need for neonatal respiratory support.

Progress of induced labor in trial of labor after cesarean delivery.

OBJECTIVE: The purpose of this study was to compare the first stage of labor progress in women who undergo an induction of labor after cesarean delivery with women who have spontaneous labor after cesarean delivery. STUDY DESIGN: We conducted a retrospective cohort study of consecutive women who had been admitted for delivery with a vertex-presenting fetus who achieved vaginal delivery after cesarean delivery. We compared women who underwent an induction of labor after cesarean delivery with women with spontaneous labor after cesarean delivery. Labor curves were constructed with a repeated-measures analysis; interval-censored regression was used to estimate the median time spent to dilate 1 cm, stratified by induction status, and adjusted by obesity, macrosomia, epidural, and previous vaginal delivery. RESULTS: Of 473 laboring women with a previous cesarean delivery, 234 women (49%) were induced. After adjustment for obesity, macrosomia, epidural, and previous vaginal delivery, women who underwent an induction had significantly longer labors than those women who experienced spontaneous labor. The median time to dilate from 4-10 cm took 5.6 hours (95% confidence interval, 1.8-18.0 hours) in the induction group and 3.2 hours (95% confidence interval, 1.0-10.3 hours) in the spontaneous labor group (P < .01). The time to progress 1 cm in dilation from 3-7 cm was different; however, after 7 cm, the time to progress 1 cm was not statistically different. CONCLUSION: Women who undergo an induction of labor after cesarean delivery have a longer latent labor phase, but a similar active phase than those women who experience spontaneous labor. When making the diagnosis of labor dystocia for women who undergo an induction of labor after cesarean delivery, clinicians should use the same normative standards for labor treatment of women without a previous cesarean delivery as has been shown in previous work.

Associations of prostate cancer risk variants with disease aggressiveness: results of the NCI-SPORE Genetics Working Group analysis of 18,343 cases.

Genetic studies have identified single nucleotide polymorphisms (SNPs) associated with the risk of prostate cancer (PC). It remains unclear whether such genetic variants are associated with disease aggressiveness. The NCI-SPORE Genetics Working Group retrospectively collected clinicopathologic information and genotype data for 36 SNPs which at the time had been validated to be associated with PC risk from 25,674 cases with PC. Cases were grouped according to race, Gleason score (Gleason ≤ 6, 7, ≥ 8) and aggressiveness (non-aggressive, intermediate, and aggressive disease). Statistical analyses were used to compare the frequency of the SNPs between different disease cohorts. After adjusting for multiple testing, only PC-risk SNP rs2735839 (G) was significantly and inversely associated with aggressive (OR = 0.77; 95 % CI 0.69-0.87) and high-grade disease (OR = 0.77; 95 % CI 0.68-0.86) in European men. Similar associations with aggressive (OR = 0.72; 95 % CI 0.58-0.89) and high-grade disease (OR = 0.69; 95 % CI 0.54-0.87) were documented in African-American subjects. The G allele of rs2735839 was associated with disease aggressiveness even at low PSA levels (<4.0 ng/mL) in both European and African-American men. Our results provide further support that a PC-risk SNP rs2735839 near the KLK3 gene on chromosome 19q13 may be associated with aggressive and high-grade PC. Future prospectively designed, case-case GWAS are needed to identify additional SNPs associated with PC aggressiveness.

Persistent organic pollutants and early menopause in U.S. women.

OBJECTIVE: Endocrine-disrupting chemicals (EDCs) adversely affect human health. Our objective was to determine the association of EDC exposure with earlier age of menopause. METHODS: Cross-sectional survey using National Health and Nutrition Examination Survey (NHANES) data from 1999 to 2008 (n = 31,575 females). Eligible participants included: menopausal women >30 years of age; not currently pregnant, breastfeeding, using hormonal contraception; no history of bilateral oophorectomy or hysterectomy. Exposures, defined by serum lipid and urine creatinine-adjusted measures of EDCs, data were analyzed: > 90th percentile of the EDC distribution among all women, log-transformed EDC level, and decile of EDC level. Multi linear regression models considered complex survey design characteristics and adjusted for age, race/ethnicity, smoking, body mass index. EDCs were stratified into long (>1 year), short, and unknown half-lives; principle analyses were performed on those with long half-lives as well as phthalates, known reproductive toxicants. Secondary analysis determined whether the odds of being menopausal increased with EDC exposure among women aged 45-55 years. FINDINGS: This analysis examined 111 EDCs and focused on known reproductive toxicants or chemicals with half-lives >1 year. Women with high levels of ß-hexachlorocyclohexane, mirex, p,p'-DDE, 1,2,3,4,6,7,8-heptachlorodibenzofuran, mono-(2-ethyl-5-hydroxyhexyl) and mono-(2-ethyl-5-oxohexyl) phthalate, polychlorinated biphenyl congeners -70, -99, -105, -118, -138, -153, -156, -170, and -183 had mean ages of menopause 1.9 to 3.8 years earlier than women with lower levels of these chemicals. EDC-exposed women were up to 6 times more likely to be menopausal than non-exposed women. CONCLUSIONS: This study of a representative sample of US women documents an association between EDCs and earlier age at menopause. We identified 15 EDCs that warrant closer evaluation because of their persistence and potential detrimental effects on ovarian function. Earlier menopause can alter the quantity and quality of a woman's life and has profound implications for fertility, human reproduction, and our global society.

Effect of Growth Restriction on Fetal Heart Rate Patterns in the Second Stage of Labor.

OBJECTIVE: We aimed to estimate the effect of intrauterine growth restriction (IUGR) on electronic fetal monitoring (EFM) patterns in the second stage of labor. STUDY DESIGN: We performed a 5-year retrospective cohort study of consecutive singleton, non-anomalous, term gestations. We compared IUGR infants, those with a birth weight less than the 10th percentile, with non-IUGR infants, those greater than or equal to the 10th percentile. Our primary outcome was the EFM patterns in the 30 minutes before delivery. A secondary analysis was performed excluding infants with composite morbidity. Logistic regression was used to adjust for body mass index, race, nulliparity, induction, and protracted labor. RESULTS: Out of the 5,388 infants, 652 (12.1%) were IUGR. IUGR fetuses had less accelerations (29.0 vs. 35.9%, p < 0.01), even among apparently normal infants (29.0 vs. 36.4%, p < 0.01). IUGR fetuses had a higher risk of decelerations, and in all, IUGR accounted for 6% of late decelerations (attributable risk 0.06, 95% confidence interval 0.02-0.10). There was no significant association between IUGR and bradycardia or minimal variability. CONCLUSION: Growth restriction at term confers an increased risk of late decelerations, even in the absence of neonatal morbidity. EFM patterns may require different interpretations based on a priori risk and clinical factors.

Risk factors for serious morbidity in term nonanomalous neonates.

OBJECTIVE: The purpose of this study was to identify ante- and intrapartum risk factors for serious morbidity in term nonanomalous neonates. STUDY DESIGN: We analyzed the first 5000 subjects within an ongoing prospective cohort study of consecutive term births from 2010-2012. The primary outcome was a composite of serious neonatal morbidity defined as ≥1 cases of hypoxic ischemic encephalopathy, meconium aspiration with pulmonary hypertension, requirement of hypothermia therapy, respiratory distress syndrome, seizures, sepsis or suspected sepsis, or death. We calculated odds ratios for the composite morbidity that is associated with ante- and intrapartum factors. Multivariable logistic regression was used to estimate adjusted odds ratios. RESULTS: Of 5000 term nonanomalous births, 393 had the composite morbidity. Significant risk factors for morbidity were nulliparity, presence of meconium, first stage of labor >95th percentile, second stage of labor >95th percentile, pregestational diabetes mellitus, chronic hypertension, obesity, maternal intrapartum fever, and cesarean delivery. In contrast, induction of labor and gestational age ≥41 weeks were not associated with significant morbidity. CONCLUSION: We identified several significant risk factors for serious morbidity in term nonanomalous neonates. Clinicians may use these risk factors to help anticipate the potential need for additional neonatal support at delivery.

Factors associated with higher oxytocin requirements in labor.

OBJECTIVE: To identify clinical characteristics associated with high maximum oxytocin doses in women who achieve complete cervical dilation. METHODS: A retrospective nested case-control study was performed within a cohort of all term women at a single center between 2004 and 2008 who reached the second stage of labor. Cases were defined as women who had a maximum oxytocin dose during labor >20 mu/min, while women in the control group had a maximum oxytocin dose during labor of ≤20 mu/min. Exclusion criteria included no oxytocin administration during labor, multiple gestations, major fetal anomalies, nonvertex presentation, and prior cesarean delivery. Multiple maternal, fetal, and labor factors were evaluated with univariable analysis and multivariable logistic regression. RESULTS: Maximum oxytocin doses >20 mu/min were administered to 108 women (3.6%), while 2864 women received doses ≤20 mu/min. Factors associated with higher maximum oxytocin dose after adjusting for relevant confounders included maternal diabetes, birthweight >4000 g, intrapartum fever, administration of magnesium, and induction of labor. CONCLUSIONS: Few women who achieve complete cervical dilation require high doses of oxytocin. We identified maternal, fetal and labor factors that characterize this group of parturients.

Time from uterine incision to delivery and hypoxic neonatal outcomes.

OBJECTIVE: The objective of this study was to estimate the association between time from uterine incision to delivery and hypoxic neonatal outcomes in nonanomalous term infants. METHODS: All women undergoing in-labor term cesarean deliveries (CDs) in the first 2 years of an ongoing prospective cohort study were included. The primary exposure was time in seconds from uterine incision to delivery. The primary outcome was a composite of hypoxia-associated neonatal outcomes, defined as at least one of: seizures, hypoxic ischemic encephalopathy, need for hypothermia treatment, and death within 7 days. RESULTS: Of 812 patients who underwent in-labor CD, the composite hypoxia outcome occurred in 18 (2.2%) neonates. There was no significant difference in the rate of hypoxic morbidity with increasing increments of 60 seconds from uterine incision to delivery (p = 0.35). There was a significantly increased risk of hypoxic morbidity in those delivered in the highest quintile (>240 seconds) compared with those in the lowest quintile (≤ 60 seconds) in cesareans performed for an indication other than nonreassuring fetal status (relative risk, 5.58; 95% confidence interval, 1.30-23.91). CONCLUSION: Overall, duration from uterine incision to delivery for in-labor cesareans of nonanomalous term infants was not associated with an increase in risk of hypoxia-associated morbidities.

Are there differences in the first stage of labor between Black and White women?

OBJECTIVE: The objective of this study was to determine whether the duration and progress of the first stage of labor are different in black compared with white women. STUDY DESIGN: Retrospective cohort study of labor progress among consecutive black (n = 3,924) and white (n = 921) women with singleton term pregnancies (≥ 37 weeks) who completed the first stage of labor. Duration of labor and progression from 1 cm to the next was estimated using interval-censored regression. Labor duration and progress among black and white women in the entire cohort, and stratified by parity, were compared in multivariable interval-censored regression models. Repeated-measures analysis with 9th-degree polynomial modeling was used to construct average labor curves. RESULTS: There were no significant differences in duration of the first stage of labor in black compared with white women (median, 4-10 cm: 5.1 vs. 4.9 hours [p = 0.43] for nulliparous and 3.5 vs. 3.9 hours [p = 0.84] for multiparous women). Similarly, there were no significant differences in progression in increments of 1 cm. Average labor curves were also not significantly different. CONCLUSION: Duration and progress of the first stage of labor are identical in black and white women. This suggests similar standards may be applied in the first stage of labor.

State-mandated insurance coverage is associated with the approach to hydrosalpinges before IVF.

The aim of this study was to determine whether practice in states with infertility insurance mandates is associated with physician-reported practice patterns regarding hydrosalpinx management in assisted reproduction clinics. A cross-sectional, internet-based survey of 442 members of Society for Reproductive Endocrinology and Infertility or Society of Reproductive Surgeons was performed. Physicians practising in states without infertility insurance mandates were more likely to report performing diagnostic surgery after an inconclusive hysterosalpingogram than physicians practising in states with mandates (RR 1.2, 95% CI 1.1-1.3, P < 0.01). Additionally, respondents in states without mandates were more likely to report that, due to lack of infertility insurance coverage, they did not perform salpingectomy (SPX) or proximal tubal occlusion (PTO) before assisted reproduction treatment (RR 1.4, 95% CI 1.1-1.8, P = 0.01). Finally, respondents in states without mandates were less likely to report that the presence of assisted reproduction treatment coverage determined the urgency with which they pursued SPX or PTO before treatment (RR 0.7, 95% CI 0.5-1.0, NS). These results persisted after controlling for physician years in practice, age and clinic volume. In conclusion, self-reported physician practice interventions for hydrosalpinges before assisted reproduction treatment may be associated with state-mandated infertility insurance. Fallopian tube dysfunction is a known cause of infertility and severe dysfunction is manifested by dilation and occlusion, known as hydrosalpinx. Outcomes with assisted reproductive techniques (ART) are lower when hydrosalpinges are present and while there are several theories for this, reproductive specialist recommend "neutralizing" the tube either by occlusion or removal in order to enhance pregnancy rates. In the United States, coverage for infertility services is not uniform with only 15 states having some legislation requiring infertility benefits. Some states where ART is covered liberally, physicians might have different practice patterns related to the neutralization of hydrosalpinges compared to those who are in non -mandated states. We utilized a survey of over 400 providers in the United States to examine their practice patterns as it relates to hydrosalpinges based on which state they practice in and whether or not that state has mandated coverage of not.

Genetically adjusted prostate-specific antigen values may prevent delayed biopsies in African-American men.

OBJECTIVE: To evaluate whether genetic correction using the genetic variants prostate-specific antigen (PSA)-single nucleotide polymorphisms (SNPs) could reduce potentially unnecessary and/or delayed biopsies in African-American men. SUBJECTS AND METHODS: We compared the genotypes of four PSA-SNPs between 964 Caucasian and 363 African-American men without known prostate cancer (PCa). We adjusted the PSA values based on an individual's PSA-SNP carrier status, and calculated the percentage of men that would meet commonly used PSA thresholds for biopsy (≥ 2.5 or ≥ 4.0 ng/mL) before and after genetic correction. Potentially unnecessary and delayed biopsies were defined as those men who were below and above the biopsy threshold after genetic correction, respectively. RESULTS: Overall, 349 (96.1%) and 354 (97.5%) African-American men had measured PSA levels <2.5 and <4.0 ng/mL. Genetic correction in African-American men did not avoid any potentially unnecessary biopsies, but resulted in a significant (P < 0.001) reduction in potentially delayed biopsies by 2.5% and 3.9%, based on the biopsy threshold level. CONCLUSIONS: There are significant differences in the influence of the PSA-SNPs between African-American and Caucasian men without known PCa, as genetic correction resulted in an increased proportion of African-American men crossing the threshold for biopsy. These results raise the question of whether genetic differences in PSA might contribute to delayed PCa diagnosis in African-American men.

Fetal descent in labor.

OBJECTIVE: Studies using contemporary populations and modern statistical methods have redefined our understanding of cervical dilation in labor. However, modern norms for fetal descent in labor have not been developed. We sought to estimate norms for fetal descent and estimate the expected fetal station for given cervical dilations. METHODS: A retrospective cohort study of consecutive-term, vertex singletons who delivered vaginally. Detailed history, labor, and delivery information, including cervical examinations, were collected. A repeated-measures analysis was used to construct average descent curves. Interval-censored regression was used to estimate duration of labor between levels of station and to estimate the median station at a given dilation. Each analysis was stratified by parity and labor type (spontaneous compared with induced or augmented). RESULTS: Of 4,618 consecutive-term spontaneous vaginal deliveries, 1,526 (33%) were nulliparous. Sixty-one percent were augmented or induced. Multiparous women had faster fetal descent at all stations except from +2 to +3 station. The median time to descend from one station point to another ranged from 0.1 to 1.6 hours, but the 95th percentiles encompassed over 12 hours at the same high-station among nulliparous women who achieved vaginal delivery. Fetal descent was more rapid in women who labored spontaneously without augmentation. Multiparous women tended to have a higher station than nulliparous women until late in the first stage. CONCLUSION: Multiparous women and women who are not augmented or induced have faster fetal descent. There is wide variation in the expected station by increments of dilation. However, 95% of women have a fetal station of 0 or lower at complete cervical dilation.

Labor progression in teenage women.

OBJECTIVE: Compare labor progression in first and second stages in women < 18 years with those ≥18 years. STUDY DESIGN: Retrospective cohort study of consecutive women at term that reached the second stage of labor between 2004 and 2008. The first stage in women < 18 years was compared with women ≥18 years. Average labor curves were constructed and median time spent to progress 1 cm in dilation and total time from 4 to 10 cm was estimated. Time spent pushing and total duration of second stage were compared between groups. Analyses were then stratified by parity. RESULTS: There was no significant difference in progress of the first stage of labor between women < 18 years and those ≥18 years. In the second stage, nulliparous teenage women were less likely to have a duration > 60 or 120 minutes. CONCLUSION: Laboring women < 18 years should be managed with the same expectations of labor as women ≥18 years.