Evidence that the woman's ovarian cycle is driven by an internal circamonthly timing system.

The ovarian cycle has a well-established circa-monthly rhythm, but the mechanisms involved in its regularity are unknown. Is the rhythmicity driven by an endogenous clock-like timer or by other internal or external processes? Here, using two large epidemiological datasets (26,912 cycles from 2303 European women and 4786 cycles from 721 North American women), analyzed with time series and circular statistics, we find evidence that the rhythmic characteristics of the menstrual cycle are more likely to be explained by an endogenous clock-like driving mechanism than by any other internal or external process. We also show that the menstrual cycle is weakly but significantly influenced by the 29.5-day lunar cycle and that the phase alignment between the two cycles differs between the European and the North American populations. Given the need to find efficient treatments of subfertility in women, our results should be confirmed in larger populations, and chronobiological approaches to optimize the ovulatory cycle should be evaluated.

Non-native English-speaking applicants and the likelihood of physician assistant program matriculation.

PURPOSE: Effective communication is critical in patient care. Multilingual medical providers, including Physician Assistants (PAs) can contribute to improved health care among patients with limited English proficiency; however, this is contingent upon matriculating multilingual providers. In this study, the association between prospective applicants' self-reported English as second language (ESL) status and their likelihood of matriculation into a PA program was investigated. METHODS: Participants included applicants to five admission cycles of the Centralized Application Service for Physician Assistant from 2012 to 2020. Logistic regression was utilized to investigate association between applicant ESL status and odds of program matriculation in both bivariate and multivariable regression models. Models were adjusted for citizenship status, undergraduate grade point average, gender, age, race/ethnicity, number of programs applied to, and patient care hours. RESULTS: In unadjusted and adjusted models, ESL status was associated with a significantly lower odds of matriculation to a PA program across all study years. In adjusted multivariable models, associations were strongest for 2014-2015 where ESL status was associated with a 35% lower odds of matriculation (odds ratio 0.65, 95% confidence interval 0.56, 0.76) when controlling for demographics, citizenship status, patient care experience, and academic achievement. In sensitivity analyses restricting to (a) those with TOEFL scores ≥ 100, and (b) restricting to those ESL applicants without TOEFL scores, we did not observe important changes in our results. CONCLUSIONS: Results indicated that non-native English-speaking applicants have lower odds of PA program matriculation. Decrements in matriculation odds were large magnitude, minimally impacted by adjustment for confounders and persistent across the years. These findings suggest that PA program admission processes may disadvantage non-native English-speaking applicants. While there are potential explanations for the observed findings, they are cause for concern. Matriculating and training PAs who have language concordance with underserved populations are important means of improving patient outcomes.

Military Veteran Matriculation in US Physician Associate/Assistant Programs.

OBJECTIVES: This study aims to determine whether veterans have differential access to physician associate/assistant (PA) education by examining likelihood of matriculation relative to nonveteran peers. We explore associations between veteran status and likelihood of matriculation for change over time and whether effects differ among active duty versus non-active-duty applicants. METHODS: Multivariate logistic regression was used to investigate associations between self-identified military status and likelihood of PA program matriculation in five Centralized Applicant Services for Physician Assistants admissions cycles (2012-2013, 2014-2015, 2016-2017, 2018-2019, 2020-2021). Models controlled for age, sex, race/ethnicity, patient care experience hours, total undergraduate grade point average, and number of applications submitted and applied a Bonferroni correction for alpha inflation. RESULTS: Veteran applicant numbers were small across the study time frame but increased from 2012 (n = 708) to 2020 (n = 978), representing a 38% increase over the lookback period. Despite growth, the proportion of veterans in the matriculant pool has decreased from 4.2% in 2012 to 3.0% in 2020. In unadjusted models, military status was not strongly associated with odds of matriculation. In adjusted models, both veteran and active-duty status were associated with higher odds of matriculation, although this increase was not statistically significant at the 0.005 level for applicants on active-duty. CONCLUSION: Military veterans and active-duty military personnel have higher likelihood of matriculation into US PA programs relative to nonveteran peers. The proportion of veterans in the matriculant pool has decreased over time. This suggests that while PA programs seems to value previous military experience, further efforts to evaluate and address barriers to military veterans in applying for admissions is needed.

Academic Rank Disparities in Minoritized and Racialized Physician Assistant Educators.

PURPOSE: The aim of this study was to investigate the disparities in career progression and the need for inclusive mentorship in the physician assistant (PA) profession, specifically focusing on racial/ethnic minority faculty. METHODS: Pooled data from the Physician Assistant Education Association Program Survey in 2015, 2017, and 2019 were analyzed to examine the effect of PA faculty race/ethnicity on academic rank promotion. Logistic regression models were used to assess the association between faculty race/ethnicity and the likelihood of being in a middle/late-career (associate/professor) or early-career status (instructor/assistant), adjusting for confounding factors. RESULTS: The analysis revealed significant disparities in career progression, particularly for Black/African American and Hispanic faculty members, who were 44% less likely to be in late-career positions compared with White faculty. These disparities persisted even after accounting for gender, highest degree, region, and years in rank. The slower career progression experienced by minoritized faculty can have negative impacts, such as lower salaries, impostorism, reduced social capital, isolation, marginalization, burnout, and attrition. CONCLUSION: The findings highlight the urgent need for increased efforts to promote diversity and inclusion in the PA profession. Creating a more equitable academic environment requires addressing systemic biases, implementing inclusive mentorship initiatives, and promoting diversity in hiring and promotion decisions. By prioritizing equity, diversity, and inclusion, the PA profession can foster a more diverse, innovative, and satisfied workforce while reducing turnover. Continued research and evidence-based strategies are essential to effectively address these disparities and create a more inclusive and equitable environment in the PA profession.

Gender Disparities in Physician Assistant Educator Promotion and Compensation: A Mixed Methods Approach.

INTRODUCTION: The gender wage gap is well documented in many industries. A disparity in salary between female and male physician assistant (PA) educators has been demonstrated, but disparities in academic rank have not been shown. The purpose of this study was to re-examine gender disparities in compensation to PA educators and to explore whether gender-based disparities exist in promotion to higher academic rank in this field. METHODS: An explanatory sequential mixed-methods design was used to determine differences in salary and rank by gender. PA Education Association Faculty and Directors Survey data from 2014, 2017, and 2019 were analyzed. A focus group was conducted to explain the findings and understand the barriers to promotion for female faculty. RESULTS: Female PA faculty members earn $7573 less than their male colleagues when controlling for all other variables. Female faculty members have an increased likelihood (RR 1.150) for being in early career stage versus late career stage. Obtaining a doctoral degree decreased the risk for being in an early career stage (RR 0.567) with men twice as likely to have a doctoral degree as women. DISCUSSION: Rank and salary disparities exist in PA faculty by gender. Female faculty are less likely to hold doctoral degrees or to be promoted to higher academic ranks, and they earn less than men. Degree level and career track are themes unique to the PA education profession, and further research is needed to understand their impact. With more women entering PA education, pay equity and promotion need to be addressed.

Restoration of serum estradiol and reduced incidence of miscarriage in patients with low serum estradiol during pregnancy: a retrospective cohort study using a multifactorial protocol including DHEA.

Background: Low serum estradiol in early pregnancy is associated with an elevated risk of miscarriage. We sought to determine whether efforts to restore low blood estradiol via estradiol or dehydroepiandrosterone (DHEA) supplementation would reduce the risk of miscarriage as part of a multifactorial symptom-based treatment protocol. Methods: This retrospective cohort study included women with low serum estradiol levels in early pregnancy, defined as ≤50% of reference levels by gestational age. Estradiol or DHEA were administered orally, and the primary outcome measure was serum estradiol level, in reference to gestational age. The secondary outcome measures included miscarriage, birth weight, and gestational age at birth. Results: We found no significant effect of estradiol supplementation on serum estradiol levels referenced to gestational age, while DHEA supplementation strongly increased estradiol levels. For pregnancies with low estradiol, the miscarriage rate in the non-supplemented group was 45.5%, while miscarriage rate in the estradiol and DHEA supplemented groups were 21.2% (p = 0.067) and 17.5% (p = 0.038), respectively. Birth weight, size, gestational age, and preterm deliveries were not significantly different. No sexual abnormalities were reported in children (n = 29) of DHEA-supplemented patients after 5-7 years follow-up. Conclusions: In conclusion, DHEA supplementation restored serum estradiol levels, and when included in the treatment protocol, there was a statistically significant reduction in miscarriage.

Does a short luteal phase correlate with an increased risk of miscarriage? A cohort study.

BACKGROUND: Miscarriage is defined as spontaneous loss of pregnancy prior to 20 weeks gestation. With an estimated risk of 15% of clinically confirmed pregnancies ending in miscarriage, it is the most common adverse event in pregnancy. Woman's age is the primary risk factor for miscarriage, while medical conditions, including hormonal abnormalities, are also associated. Progesterone is essential for maintaining pregnancy. A short luteal phase may reflect inadequate levels of progesterone production, but it is unclear whether a short luteal phase correlates with an increase in the risk of miscarriage. METHODS: Using a cohort study design, we conducted a secondary data analysis from four cohorts of couples who used a standardized protocol to track biomarkers of the female cycles. A short luteal phase was defined as less than 10 days, with < 11, < 9, and < 8 days as alternate definitions in sensitivity analyses. We included women who experienced a pregnancy with a known outcome, identified the length of the luteal phase in up to 3 cycles prior to conception and assessed the relationship with miscarriage using a modified Poisson regression analysis, adjusting for demographic characteristics, smoking, alcohol use and previous pregnancy history. RESULTS: In our sample of 252 women; the overall miscarriage rate was 18.7%. The adjusted incident risk ratio of miscarriage in women who had at least one short luteal phase < 10 days, compared to those who had none, was 1.01 (95% CI: 0.57, 1.80) Similar null risk was found when assessing alternative lengths of short luteal phase. Women who had short luteal phases < 10 days in all 3 cycles prior to the conception cycle had an incident risk ratio of 2.14 (95% CI: 0.7, 6.55). CONCLUSIONS: Our study found that a short luteal phase in the three cycles prior to conception was not associated with higher rates of miscarriage in an international cohort of women tracking their cycles, but our sample size was limited. Further research to determine if short luteal phases or luteal phase deficiency is associated with early pregnancy losses among preconception cohorts with daily tracking of cycle parameters, in addition to progesterone and human chorionic gonadotropin levels, is warranted. Additionally, future studies should include women with recurrent short luteal phases as a more likely risk factor than isolated short luteal phases.

This study looks at whether women have a higher risk of miscarriage if the second half of their menstrual or reproductive cycle is shorter than normal. The second half of the cycle, referred to as the luteal phase, is normally 11 to 16 days long. If the luteal phase is too short this may suggest a woman does not have enough progesterone, the hormone essential for maintaining pregnancy.This study included 252 pregnant women for whom we had data on the length of at least one luteal phase prior to pregnancy and for whom we knew the outcome of the pregnancy. Almost one-fifth of the women in our study had a miscarriage. However, we found there was no difference in the risk for miscarriage if women had a short or a normal luteal phase.

PA applicant U.S. citizenship status and likelihood of program matriculation.

BACKGROUND: Barriers to matriculation into Physician Assistant (PA) programs and entry into the PA profession have disproportionate impact on historically marginalized groups. This study evaluates if U.S. citizenship status is associated with likelihood of matriculation in PA Programs. METHODS: Data from five Centralized Applicant Services for Physician Assistants (CASPA) admissions cycles (2012-2021) was evaluated cross-sectionally for the primary outcome of binary matriculation status (yes/no). Bivariate and multivariate logistic regression was utilized to investigate associations between self-identified U.S. citizenship status and likelihood of PA program matriculation. Models controlled for important potential confounders, including age, gender, race/ethnicity, non-native English speaker, patient care experience hours, total undergraduate grade point average (GPA), and number of applications submitted to various programs. RESULTS: Non-U.S. citizen status was statistically associated with persistent lower likelihood of PA program matriculation compared to U.S. citizenship. Odds of matriculation were 41% [OR 0.59 (95% CI: 0.51, 0.68; p <.001)] to 51% [OR 0.49 (95% CI: 0.41, 0.58; p <.001)] lower in unadjusted models. Odds were 32% [OR 0.68 (95% CI: 0.56, 0.83; p <.001)] to 42% OR 0.58 (95% CI: 0.48, 0.71; p <.001) lower when adjusting for important covariates. The lowest likelihood occurred in 2012-2013 with 51% lower odds of matriculation and in 2016-2017 with 42% lower odds when accounting for important covariates. DISCUSSION: PA programs are charged with improving diversity of clinically practicing PAs to improve health outcomes and better reflect patient populations. This analysis shows that non-U.S. citizenship may be a barrier to PA school acceptance. PA schools should raise awareness and create means and accessibility for admissions for this underrepresented group.

International Natural Procreative Technology Evaluation and Surveillance of Treatment for Subfertility (iNEST): enrollment and methods.

STUDY QUESTION: What is the feasibility of a prospective protocol to follow subfertile couples being treated with natural procreative technology for up to 3 years at multiple clinical sites? SUMMARY ANSWER: Overall, clinical sites had missing data for about one-third of participants, the proportion of participants responding to follow-up questionnaires during time periods when participant compensation was available (about two-thirds) was double that of time periods when participant compensation was not available (about one-third) and follow-up information was most complete for pregnancies and births (obtained from both clinics and participants). WHAT IS KNOWN ALREADY: Several retrospective single-clinic studies from Canada, Ireland and the USA, with subfertile couples receiving restorative reproductive medicine, mostly natural procreative technology, have reported adjusted cumulative live birth rates ranging from 29% to 66%, for treatment for up to 2 years, with a mean women's age of about 35 years. STUDY DESIGN SIZE DURATION: The international Natural Procreative Technology Evaluation and Surveillance of Treatment for Subfertility (iNEST) was designed as a multicenter, prospective cohort study, to enroll subfertile couples seeking treatment for live birth, assess baseline characteristics and follow them up for up to 3 years to report diagnoses, treatments and outcomes of pregnancy and live birth. In addition to obtaining data from medical record abstraction, we sent follow-up questionnaires to participants (both women and men) to obtain information about treatments and pregnancy outcomes, including whether they obtained treatment elsewhere. The study was conducted from 2006 to 2016, with a total of 10 clinics participating for at least some of the study period across four countries (Canada, Poland, UK and USA). PARTICIPANTS/MATERIALS SETTING METHODS: The 834 participants were subfertile couples with the woman's age 18 years or more, not pregnant and seeking a live birth, with at least one clinic visit. Couples with known absolute infertility were excluded (i.e. bilateral tubal blockage, azoospermia). Most women were trained to use a standardized protocol for daily vulvar observation, description and recording of cervical mucus and vaginal bleeding (the Creighton Model FertilityCare System). Couples received medical and sometimes surgical evaluation and treatments aimed to restore and optimize female and male reproductive function, to facilitate in vivo conception. MAIN RESULTS AND THE ROLE OF CHANCE: The mean age of women starting treatment was 34.0 years; among those with additional demographic data, 382/478 (80%) had 16 or more years of education, and 199/659 (30%) had a prior live birth. Across 10 clinical sites in four countries (mostly private clinical practices) with family physicians or obstetrician-gynecologists, data about clinic visits were submitted for 60% of participants, and diagnostic data for 77%. For data obtained directly from the couple, 59% of couples had at least one follow-up questionnaire, and the proportion of women and men responding to fill out the follow-up questionnaires was 69% and 67%, respectively, when participant financial compensation was available, compared to 38% and 33% when compensation was not available. Among all couples, 57% had at least one pregnancy and 44% at least one live birth during the follow-up time period, based on data obtained from clinic and/or participant questionnaires. All sites reported on female pelvic surgical procedures, and among all participants, 22% of females underwent a pelvic diagnostic and/or therapeutic procedure, predominantly laparoscopy and hysterosalpingography. Among the 643 (77%) of participants with diagnostic information, ovulation-related disorders were diagnosed in 87%, endometriosis in 31%, nutritional disorders in 47% and abnormalities of semen analysis in 24%. The mean number of diagnoses per couple was 4.7. LIMITATIONS REASONS FOR CAUTION: The level of missing data was higher than anticipated, which limits both generalizability and the ability to study different components of treatment and prognosis. Loss to follow-up may also be differential and introduce bias for outcomes. Most of the participating clinicians were not surgeons, which limits the opportunity to study the impact of surgical interventions. Participants were geographically dispersed but relatively homogeneous with regard to socioeconomic status, which may limit the generalizability of current and future findings. WIDER IMPLICATIONS OF THE FINDINGS: Multicenter studies are key to understanding the outcomes of subfertility treatments beyond IVF or IUI in broader populations, and the association of different prognostic factors with outcomes. We anticipate that the iNEST study will provide insight for clinical and treatment factors associated with outcomes of pregnancy and live birth, with appropriate attention to potential biases (including adjustment for potential confounders, multiple imputation for missing data, sensitivity analysis and inverse probability weighting for potential differential loss to follow-up, and assessments for clinical site heterogeneity). Future studies will need to either have: adequate funding to compensate clinics and participants for robust data collection, including targeted randomized trials; or a scaled-down, registry-based approach with targeted data points, similar to the multiple national and regional ART registries. STUDY FUNDING/COMPETING INTERESTS: Funding for the study came from the International Institute for Restorative Reproductive Medicine, the University of Utah, Department of Family and Preventive Medicine, Health Studies Fund, the Primary Children's Medical Foundation, the Mary Cross Tippmann Foundation, the Atlas Foundation, the St. Augustine Foundation and the Women's Reproductive Health Foundation. The authors declare no competing interests. TRIAL REGISTRATION NUMBER: The iNEST study is registered at clinicaltrials.gov, NCT01363596.

Initial Impact of the COVID-19 Pandemic on Physician Assistant Education.

PURPOSE: The COVID-19 pandemic significantly impacted United States (US) health professions educational programs. Physician assistant (PA) programs were forced to respond to rapidly changing circumstances early in the pandemic. This study describes the impact that the early phase of the COVID-19 pandemic had on PA programs in the United States. METHODS: This cross-sectional study is based on data from the COVID-19 Rapid Response Report 1, conducted by the Physician Assistant Education Association in April 2020. The survey sample included 254 US PA program directors with a response rate of 64.2%. Our outcome measures included temporary changes to PA program operations and clinical training, and current and upcoming budget and tuition changes, as well as the impact of the pandemic on faculty and staff employment. We used descriptive statistics to summarize these outcomes, stratified by 4 categories characterizing features of PA programs, including geographical location, academic housing, funding model, and academic health center status. RESULTS: The COVID-19 pandemic impact on programs varied geographically. A majority of programs reported making numerous temporary changes to their operations. Most programs moved both didactic and clinical education to an online format. Clinical training was temporarily suspended at almost all programs. CONCLUSIONS: PA programs continued training despite the pandemic. The long-term impact of the pandemic may be the instability of the PA education workforce.

Associations between state scope of practice laws and US physician assistant wages from 1997 to 2017: a longitudinal analysis.

OBJECTIVE: The purpose of this study is to determine whether, and to what degree, variations in physician assistant (PA) state scope of practice (SOP) laws across states are associated with (1) PA median wage over time and (2) if a specific SOP key element has greater impact on PA median wage than others. We hypothesise that expanded SOP laws will be associated with higher PA wage. DESIGN: Longitudinal analysis from 1997 to 2017. SETTING: Fifty states and the District of Columbia (US capital region). PARTICIPANTS: Employed PAs from 1997 to 2017. METHODS: Four national data sets were combined to allow for longitudinal analysis of state-level annual PA wage and state SOP laws. We used linear regression models to explore the associations of SOP elements with PA wage in 5-year intervals and individual growth models to assess the change in PA annual wage over the study period. RESULTS: There was a 220% increase in weighted PA annual wage over two decades. There was a positive linear correlation between annual wage and age in 2012 and 2017 (r=0.52, p<0.01; r=0.29, p=0.04, respectively). The adjusted R2 for individual SOP elements in the selected years were all small (range: 0.0-0.29), with no appreciable pattern across time for any SOP element. In 1997, several SOP laws show association with median wage but this impact disappears over time. CONCLUSIONS: PA median wage has risen over twofold in the past two decades, with the rise in PA wage mainly explained by time and provider age. In 1997 some SOP elements were associated with increased average wage; however, the impact of this increase diminished over time in all such instances. As the PA profession moves towards Optimal Team Practice, future research should examine if this move towards greater autonomy impacts wage.

Cross-sectional analysis of US scope of practice laws and employed physician assistants.

OBJECTIVE: This study examined if the variation in physician assistant (PA) state scope of practice (SOP) laws across states are associated with number of employed PAs, PA demographics and PA/population ratio per state. The hypothesis was that less restrictive SOP laws will increase the demand for PAs and the number of PAs in a state. DESIGN: Retrospective cross-sectional analysis at three time points: 1998, 2008, 2017. SETTING: Fifty states and the District of Columbia. PARTICIPANTS: Employed PAs in 1998, 2008, 2017. METHODS: SOP laws were categorised as permissive, average and restrictive. Three national datasets were combined to allow for descriptive analysis of employed PAs by year and SOP categories. We used linear predictive models to generate and compare PA/population ratio least square means by SOP categories for each year. Models were adjusted for percent female PA and PAs mean age. RESULTS: There was a median PA/population ratio of 23 per 100 000 population in 1998 and 33 in 2017. A heterogeneous expansion of SOP laws was seen with 17 states defined as super expanders while 15 were never adopters. In 2017, comparing restrictive to permissive states showed that in adjusted models permissive SOP laws were associated with 11.7 (p .03) increase in ratio of employed PAs per 100 000 population, demonstrating that states with permissive SOP laws have an increased PA density. CONCLUSIONS: There has been steady growth in the mean PA/population ratio since the turn of the century. At the same time, PA SOP laws in the USA have expanded, with just 10 states remaining in the restrictive category. Permissive SOP laws are associated with an increase in the ratio of employed PAs per state population. As states work to meet the projected physician need, SOP expansion may be an important policy consideration to increase the PA workforce.

Cervical mucus patterns and the fertile window in women without known subfertility: a pooled analysis of three cohorts.

STUDY QUESTION: What is the normal range of cervical mucus patterns and number of days with high or moderate day-specific probability of pregnancy (if intercourse occurs on a specific day) based on cervical mucus secretion, in women without known subfertility, and how are these patterns related to parity and age? SUMMARY ANSWER: The mean days of peak type (estrogenic) mucus per cycle was 6.4, the mean number of potentially fertile days was 12.1; parous versus nulliparous, and younger nulliparous (<30 years) versus older nulliparous women had more days of peak type mucus, and more potentially fertile days in each cycle. WHAT IS KNOWN ALREADY: The rise in estrogen prior to ovulation supports the secretion of increasing quantity and estrogenic quality of cervical mucus, and the subsequent rise in progesterone after ovulation causes an abrupt decrease in mucus secretion. Cervical mucus secretion on each day correlates highly with the probability of pregnancy if intercourse occurs on that day, and overall cervical mucus quality for the cycle correlates with cycle fecundability. No prior studies have described parity and age jointly in relation to cervical mucus patterns. STUDY DESIGN, SIZE, DURATION: This study is a secondary data analysis, combining data from three cohorts of women: 'Creighton Model MultiCenter Fecundability Study' (CMFS: retrospective cohort, 1990-1996), 'Time to Pregnancy in Normal Fertility' (TTP: randomized trial, 2003-2006), and 'Creighton Model Effectiveness, Intentions, and Behaviors Assessment' (CEIBA: prospective cohort, 2009-2013). We evaluated cervical mucus patterns and estimated fertile window in 2488 ovulatory cycles of 528 women, followed for up to 1 year. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants were US or Canadian women age 18-40 years, not pregnant, and without any known subfertility. Women were trained to use a standardized protocol (the Creighton Model) for daily vulvar observation, description, and recording of cervical mucus. The mucus peak day (the last day of estrogenic quality mucus) was used as the estimated day of ovulation. We conducted dichotomous stratified analyses for cervical mucus patterns by age, parity, race, recent oral contraceptive use (within 60 days), partial breast feeding, alcohol, and smoking. Focusing on the clinical characteristics most correlated to cervical mucus patterns, linear mixed models were used to assess continuous cervical mucus parameters and generalized linear models using Poisson regression with robust variance were used to assess dichotomous outcomes, stratifying by women's parity and age, while adjusting for recent oral contraceptive use and breast feeding. MAIN RESULTS AND THE ROLE OF CHANCE: The majority of women were <30 years of age (75.4%) (median 27; IQR 24-29), non-Hispanic white (88.1%), with high socioeconomic indicators, and nulliparous (70.8%). The mean (SD) days of estrogenic (peak type) mucus per cycle (a conservative indicator of the fertile window) was 6.4 (4.2) days (median 6; IQR 4-8). The mean (SD) number of any potentially fertile days (a broader clinical indicator of the fertile window) was 12.1 (5.4) days (median 11; IQR 9-14). Taking into account recent oral contraceptive use and breastfeeding, nulliparous women age ≥30 years compared to nulliparous women age <30 years had fewer mean days of peak type mucus per cycle (5.3 versus 6.4 days, P = 0.02), and fewer potentially fertile days (11.8 versus 13.9 days, P < 0.01). Compared to nulliparous women age <30 years, the likelihood of cycles with peak type mucus ≤2 days, potentially fertile days ≤9, and cervical mucus cycle score (for estrogenic quality of mucus) ≤5.0 were significantly higher among nulliparous women age ≥30 years, 1.90 (95% confidence interval (CI) 1.18, 3.06); 1.46 (95% CI 1.12, 1.91); and 1.45 (95% CI 1.03, 2.05), respectively. Between parous women, there was little difference in mucus parameters by age. Thresholds set a priori for within-woman variability of cervical mucus parameters by cycle were examined as follows: most minus fewest days of peak type mucus >3 days (exceeded by 72% of women), most minus fewest days of non-peak type mucus >4 days (exceeded by 54% of women), greatest minus least cervical mucus cycle score >4.0 (exceeded by 73% of women), and most minus fewest potentially fertile days >8 days (found in 50% of women). Race did not have any association with cervical mucus parameters. Recent oral contraceptive use was associated with reduced cervical mucus cycle score and partial breast feeding was associated with a higher number of days of mucus (both peak type and non-peak type), consistent with prior research. Among the women for whom data were available (CEIBA and TTP), alcohol and tobacco use had minimal impact on cervical mucus parameters. LIMITATIONS, REASONS FOR CAUTION: We did not have data on some factors that may impact ovulation, hormone levels, and mucus secretion, such as physical activity and body mass index. We cannot exclude the possibility that some women had unknown subfertility or undiagnosed gynecologic disorders. Only 27 women were age 35 or older. Our study participants were geographically dispersed but relatively homogeneous with regard to race, ethnicity, income, and educational level, which may limit the generalizability of the findings. WIDER IMPLICATIONS OF THE FINDINGS: Patterns of cervical mucus secretion observed by women are an indicator of fecundity and the fertile window that are consistent with the known associations of age and parity with fecundity. The number of potentially fertile days (12 days) is likely greater than commonly assumed, while the number of days of highly estrogenic mucus (and higher probability of pregnancy) correlates with prior identifications of the fertile window (6 days). There may be substantial variability in fecundability between cycles for the same woman. Future work can use cervical mucus secretion as an indicator of fecundity and should investigate the distribution of similar cycle parameters in women with various reproductive or gynecologic pathologies. STUDY FUNDING/COMPETING INTEREST(S): Funding for the three cohorts analyzed was provided by the Robert Wood Johnson Foundation (CMFS), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (TTP), and the Office of Family Planning, Office of Population Affairs, Health and Human Services (CEIBA). The authors declare that they have no conflict of interest. TRIAL REGISTRATION NUMBER: N/A.

Maximizing Black applicant matriculation in U.S. PA programs: associations between the number of submitted applications and likelihood of matriculation.

BACKGROUND: Physician Assistants (PA) are important members of the medical team, and increasing diversity in healthcare professionals has been consistently associated with improved health outcomes for underrepresented minority patients. In this study of a national cohort of PA program applicants, we investigated whether the number of programs a student applied to (Application Number, AN) was significantly associated with increased likelihood of matriculation into a PA program. METHODS: We examined all applications (n = 27,282) to the 2017-2018 admissions cycle of the Central Application Service for Physician Assistants, which is utilized by over 90% of accredited PA programs in the US. As we a priori hypothesized that associations would be non-linear, we used natural cubic splines to estimate the associations between matriculation and AN, controlling for multiple metrics of academic achievement, experience, and applicant demographics. We subsequently used segmented regression analyses (modified poisson regression with robust error variance) to investigate log-linear associations above and below inflection points identified in the spline analyses. Additionally, we explored for effect modification by race/ethnicity. RESULTS: The strongest associations were observed between application number 2-7, and a threshold effect was observed at > 16 applications, beyond which there was no significant, incremental benefit in matriculation likelihood. Associations differed by race, particularly for application number 2-7, wherein the incremental benefit from each additional application was highest for Black applicants (Likelihood Ratio [LR]: 1.243, 95% CI: 1.136 to 1.360) vs non-Latinx White (LR: 1.098, 95% CI: 1.072 to 1.125), with no additional, incremental benefit beyond 7 program applications. For all other races, significant increased likelihoods of matriculation were observed until 16 program applications. CONCLUSIONS: These findings can help guide pre-PA advisors and PA programs, providing recommended thresholds to applicants on the most cost effective ways to increase their likelihood of admissions, and the PA profession as a whole by providing actionable information that can potentially increase Race/Ethnic diversity in the PA profession and, by extension, medical teams.

State Scope of Practice Laws: An Analysis of Physician Assistant Programs and Graduates.

PURPOSE: The purpose of this study was to understand the association between physician assistant (PA) state scope of practice (SOP) laws and (1) PA program growth and (2) PA graduate demographics. METHODS: Scope of practice laws were categorized as ideal, average, and restrictive. Descriptive statistics by year and SOP categories were determined for the number of states, population density, PA programs, and PA graduate number, gender, race, and mean age. The Mann-Whitney U test was used to analyze demographic data by SOP categories. Adjusted risk ratios were generated for the number of PA programs and SOP categories. RESULTS: The number of PA programs is not associated with ideal SOP states. As of 2017, only 10 states have restrictive SOP laws. A minority of PA students now graduate from states with restrictive SOP laws. CONCLUSION: There is heterogeneity in PA SOP laws throughout the United States but only a minority of PA graduates now come from restrictive SOP states. This study provides foundational information prior to the implementation of optimal team practice.

Collaborative practice trends in US physician office visits: an analysis of the National Ambulatory Medical Care Survey (NAMCS), 2007-2016.

OBJECTIVE: Practice arrangements in physician offices were characterised by examining the share of visits that involved physician assistants (PAs) and nurse practitioners (NPs). The hypothesis was that collaborative practice (ie, care delivered by a dyad of physician-PA and/or physician-NP) was increasing. DESIGN: Temporal ecological study. SETTING: Non-federal physician offices. PARTICIPANTS: Patient visits to a physician, PA or NP, spanning years 2007-2016. METHODS: A stratified random sample of visits to office-based physicians was pooled through the National Ambulatory Medical Care Survey public use linkage file. Among 317 674 visits to physicians, PAs or NPs, solo and collaborative practices were described and compared over two timespans of 2007-2011 and 2012-2016. Weighted patient visits were aggregated in bivariate analyses to achieve nationally representative estimates. Survey statistics assessed patient demographic characteristics, reason for visit and visit specialty by provider type. RESULTS: Within years 2007-2011 and 2012-2016, there were 4.4 billion and 4.1 billion physician office visits (POVs), respectively. Comparing the two timespans, the rate of POVs with a solo PA (0.43% vs 0.21%) or NP (0.31% vs 0.17%) decreased. Rate of POVs with a collaborative physician-PA increased non-significantly. Rate of POVs with a collaborative physician-NP (0.49% vs 0.97%, p<0.01) increased. Overall, collaborative practice, in particular physician-NP, has increased in recent years (p<0.01), while visits handled by a solo PA or NP decreased (p<0.01). In models adjusted for patient age and chronic conditions, the odds of collaborative practice in years 2012-2016 compared with years 2007-2011 was 35% higher (95% CI 1.01 to 1.79). Furthermore, in 2012-2016, NPs provided more independent primary care, and PAs provided more independent care in a non-primary care medical specialty. Preventive visits declined among all providers. CONCLUSIONS: In non-federal physician offices, collaborative care with a physician-PA or physician-NP appears to be a growing part of office-based healthcare delivery.

Menstrual bleeding, cycle length, and follicular and luteal phase lengths in women without known subfertility: A pooled analysis of three cohorts.

BACKGROUND: There is variability between women for days of menstrual bleeding, cycle lengths, follicular phase lengths, and luteal phase lengths, related to age and parity. OBJECTIVE: To describe total cycle length; anovulatory cycles; follicular and luteal phase lengths; and days and intensity of menstrual and non-menstrual bleeding in women without known subfertility over the course of 1 year. METHODS: 581 women (3,324 cycles) with no known subfertility (18-40 years of age) were followed for up to 1 year. Women recorded vaginal bleeding and mucus discharge daily. We used the peak day of cervical mucus as the estimated day of ovulation and the last day of the follicular phase. We used generalised linear mixed models stratified by age and parity to describe menstrual cycle parameters. RESULTS: The majority of women were <30 years of age (74.5%), non-Hispanic White (88.6%), and nulliparous (70.4%). The mean menses length was 6.2 (1.5) days, median 6; cycle length 30.3 (6.7) days, median 29; follicular phase length 18.5 (6.5) days, median 17; and luteal phase length 11.7 (2.8) days, median 12. Nulliparous women aged ≥30 years vs nulliparous women aged <30 had shorter cycles (29.2 days, 95% confidence interval (CI) 27.8, 30.7 vs 31.5 days, 95% CI 30.8, 32.2) and shorter follicular phases (17.6 days, 95% CI 16.2, 18.9 vs 19.6 days, 95% CI 18.9, 20.2). Among all women, within-woman differences between the longest and shortest menses length >3 days, total cycle length >7 days, follicular phase >7 days, and luteal phase >3 days were found in 11.6%, 43.0%, 41.7%, and 58.8% of women, respectively. CONCLUSIONS: Our findings confirm variability between women of menstrual cycle parameters related to age and parity, and also highlight within-woman variability in the follicular and luteal phases.