Morphine versus methadone for neonatal opioid withdrawal syndrome: a randomized controlled pilot study.

BACKGROUND: Neonatal Opioid Withdrawal Syndrome (NOWS) is a significant public health issue and while millions of neonates are affected each year, an optimal pharmacologic weaning protocol has yet to be demonstrated. In this study, we compare hospital length of stay (LOS) and length of treatment (LOT) for treatment of neonatal opioid withdrawal (NOWS) with morphine versus methadone. METHODS: This was a single-site, open-label, randomized controlled pilot study conducted from October 2016-September 2018. Infants were eligible if their primary in-utero drug exposure was heroin, oral opioids, or methadone and they were born at greater than or equal to 34 weeks gestation. Infants were excluded for serious medical comorbidities and primary in-utero exposure to buprenorphine. RESULTS: Sixty-one infants were enrolled; 30 were randomized to methadone treatment, and 31 to morphine treatment. Overall 46% of infants required treatment for NOWS. LOS and LOT for infants treated with morphine was 17.9 days and 14.7 days respectively, compared to 16.1 days and 12.8 days for babies treated with methadone (p = 0.5, p = 0.54). Infants treated with morphine received lower total morphine equivalents than those treated with methadone (9.7 vs. 33, p < 0.01). Three treated infants in the methadone group required transfer to the Neonatal Intensive Care Unit, versus no infants in the morphine group. CONCLUSIONS: Infants treated with morphine versus methadone had no significant differences in LOS or LOT in this pilot study. Infants treated with methadone received up to 3 times the opioid based on morphine equivalents as infants treated with morphine and had more transfers to the NICU for over sedation. CLINICAL TRIAL REGISTRATION: Morphine Versus Methadone for Opiate Exposed Infants With Neonatal Abstinence Syndrome NCT02851303 , initiated 01/08/2016.

Perceived Effect of Research on Clinical Care for Women With Opioid Use Disorder.

OBJECTIVE: To describe the perceived effects of clinical research and program evaluation on perceptions of clinical care among women with opioid use disorder (OUD) and their health care providers. DESIGN: Qualitative descriptive. SETTING: Four specialty clinics in academic medical centers that provide care for pregnant women with OUD. PARTICIPANTS: Women with OUD during pregnancy or the postpartum period ("women participants"; n = 20) and health care providers ("provider participants"; n = 37). All staff in the clinics were invited to participate in focus groups. METHODS: We conduced focus groups and interviews with the women and provider participants to understand the perceived effects of clinical research and program evaluation on their perceptions of clinical care among women with OUD. We audio recorded, transcribed, and analyzed sessions using qualitative content analysis. RESULTS: Overall, nine themes emerged from the data. Two themes emerged in common among data from the providers and women data: Demands on Women's Time and Challenging Research Topics. Seven additional themes emerged only from the provider data: Potential to Improve Clinical Practice, FundingOpportunities to Provide Services, Burden to Clinical Flow, Overwhelming Number of Studies, Pressure to Engage in Research, Clinic Level Controls to Reduce Research Burden and Potential for Coercion, and Meaningful Input on the Research Process. CONCLUSION: Providers and women shared similar opinions about the opportunities and challenges of research focused on women with OUD. Providers suggested ways to improve the integration of research activities into clinical settings.

The important health impact of where a child lives: neighborhood characteristics and the burden of lead poisoning.

Toxins and other health threats can cause health problems, whether they are present in the child's own home, other neighborhood homes where the child spends time, or common areas such as playgrounds. We assess the impact of where a child lives on the burden of lead poisoning. Statewide lead screening data was obtained from the Rhode Island Department of Health. Block group level indicators of old housing and poverty were obtained from the US Census. Of the 204,746 study children, 35,416 (17.3%) had a blood lead level≥10 µg/dL. The proportion of study children who were lead poisoned in each block group ranged from 0.0 to 48.6%. The proportion of study children with an elevated blood lead level increased from 8% among children living in block groups in the lowest quintile of poverty to 31% for those in the highest quintile for poverty. Old housing also had an important impact on the risk of lead poisoning. The proportion of children with an elevated blood lead level increased from 7% among children living in block groups in the lowest quintile for pre-1950 housing to 27% for those in the highest quintile for pre-1950 housing. The adjusted odds ratio was 1.64 for the highest quintile of poverty and 1.77 for the highest quintile of pre-1950 housing. The findings of this large, statewide study demonstrate the powerful impact of where children live on the risk of lead poisoning. The findings have important implications for understanding the problem of lead poisoning and for planning primary prevention programs.

A Mixed-Methods Analysis of Physician Abortion Practice After Residency.

BACKGROUND AND OBJECTIVES: In the United States, 89% of counties have no clinics providing abortion care. Though training residents increases intention to provide abortion care, rates of postresidency abortion provision are low. This study, conducted at one family medicine residency program in the Southwest United States, examines graduates' postresidency practice of abortion care in the context of their intent to provide during residency training. METHODS: We collected cross-sectional data from a survey of graduates of University of New Mexico Family Medicine Residency from 2005 to 2017. We performed a mixed-methods analysis using descriptive statistics and conceptual content analysis, including a new methodology of performing content analysis of four subgroups based on intention to provide abortion care at different time points. RESULTS: The response rate was 46%, with 54 responses to 115 surveys. Only 35% residents who intended to provide abortion care had done so after graduation from residency. Barrier analysis revealed that the three most frequent barriers were structural, with 52% of respondents saying that their workplace would not allow abortion care. The two most frequent themes affecting intention were "competence" and feeling that abortion care was "medically necessary." However, the two most common themes affecting actual practice were "workplace support" and local "patient access." CONCLUSIONS: This study provides information about the themes associated with changing intentions and practice of abortion care, which may help elucidate new strategies for training residents to anticipate and address challenges to postresidency provision. The study also provides some insight into residents with no intention to provide abortion care in residency who develop an intention to provide abortion care after graduation, which is a group of people for whom there is little information.

The association of lifetime education with the prevalence of myocardial infarction: an analysis of the 2006 Behavioral Risk Factor Surveillance System.

Socioeconomic status is likely an independent risk factor for coronary heart disease but little research has been done in the United States to study this association in a nationally representative sample. We sought to determine the association between lifetime education and the prevalence of myocardial infarction (MI) among adults over the age of 39 in the US. A cross sectional study was conducted using the 2006 Behavioral Risk Factor Surveillance System (BRFSS). A multivariable logistic regression was performed. The analysis was conducted in 2008. Among respondents aged 40 years and older to the 2006 BRFSS survey those with less than a high school education had 3.09 (95% CI: 2.79-3.43) times the odds of having had an MI compared to college graduates. After adjusting for confounders, respondents with less than a high school education had 1.61 (95% CI: 1.41-1.83) times the odds of having had an MI compared to college graduates. Both those with a high school education and those who completed some college or technical school had 1.22 times the odds of having had an MI compared to college graduates after adjusting for confounders. This study suggests that education is a risk factor for MI. More national prospective studies are needed in the US to better understand the link between socioeconomic status and coronary heart disease.

Cognitive Outcomes of Young Children After Prenatal Exposure to Medications for Opioid Use Disorder: A Systematic Review and Meta-analysis.

Importance: The number of children with prenatal opioid exposure to medication for addiction treatment (MAT) with methadone and buprenorphine for maternal opioid use disorder is increasing, but the associations of this exposure with cognitive outcomes are not well understood. Objective: To examine the strength and consistency of findings in the medical literature regarding the association of prenatal exposure to MAT with early childhood cognitive development, particularly when accounting for variables outside MAT exposure. Data Sources: A search strategy obtained publications from PubMed, CINAHL, PsycINFO, Web of Science, and Embase from January 1972 to June 2019. Reference lists from identified articles were searched. Study Selection: Inclusion criteria were cohort studies, studies including children aged 1 to 60 months with at least 2 months of prenatal MAT exposure, studies using standardized direct-observation testing scales, and studies reporting means and SDs. Case reports, case series, historical controls, and reviews were excluded. Data Extraction and Synthesis: Two authors independently selected studies for inclusion, extracted data, and assessed study quality. Data extracted included demographic characteristics, covariates, sources of bias, and effect estimates. Meta-analysis was performed using random-effects models. This study was conducted according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Data extraction and synthesis were conducted between January 2018 and August 2019. Main Outcomes and Measures: Cognitive test scores and demographic variability between exposed and unexposed groups. Results: A total of 16 unique cohorts, described in 27 articles and including 1086 children (485 [44.7%] with MAT exposure), were included in a quantitative synthesis. On meta-analysis, MAT exposure was associated with lower cognitive development scores (pooled standardized mean difference, -0.57; 95% CI, -0.93 to -0.21; I2 = 81%). Multiple subanalyses on demographic characteristics (ie, maternal education, race/ethnicity, socioeconomic status, prenatal tobacco exposure, infant sex) were conducted. In the subanalysis of studies with comparable prenatal exposure to tobacco smoke, the association of MAT exposure with cognitive scores was no longer statistically significant and became homogeneous (standardized mean difference, -0.11; 95% CI, -0.42 to 0.20; I2 = 0%). Conclusions and Relevance: In this study, predefined subanalyses demonstrated how poor recruitment, particularly imbalances in maternal tobacco use, could contribute to a negative overall association of cognitive development test scores with prenatal MAT exposure. Promoting tobacco cessation for pregnant women with opioid use disorder should be prioritized in this high-risk population.

'Weighing in' on screening mammography.

BACKGROUND: Obesity is associated with increased post-menopausal breast cancer risk. Overweight and obese women also tend to have a poorer prognosis when diagnosed with breast cancer compared with their matched normal weight peers. In previous studies obesity was associated with decreased utilization of screening mammography. We present a study examining the association between Body Mass Index (BMI) and compliance with recommended mammographic screening using data from the 2004 Behavioral Risk Factor Surveillance Survey (BRFSS). PATIENTS AND METHODS: We included 130,185 female participants, aged 40 and older, who were randomly selected to participate in the world largest telephone survey. After weighted analysis, this is representative of 56,226,220 non-institutionalized US women. The primary outcome was the proportion of women who underwent screening mammography within the last 2 years preceding the survey stratified by BMI. The mammography screening behavior of normal weight women (BMI 18.5-24.99) was compared with underweight (<18.5), overweight (25-29.99), and women with obesity class I (30-34.99), class II (35-39.99), and class III (>or=40) using logistic regression analysis and weighted to provide estimates of women in the United States (US). RESULTS: Our sample included 1.91% underweight, 37.91% normal weight, 30.15% overweight and 14.36%, 5.44%, and 3.49% women with obesity classes' I-III respectively. Approximately 7% of women age 40 and older had insufficient information to calculate their BMI. Adjusting for age, race, smoking status, general health perception, level of education, and income level, underweight women had lower odds of complying with regular screening mammography (OR 0.57; 95% CI, 0.48-0.68). Women with obesity class III (OR 0.97; 95% CI, 0.84-1.13) showed a trend towards underutilization of screening mammograms which was not clinically significant. In contrary, in overweight women a significantly higher association with appropriate mammography utilization was identified OR 1.08 (95% CI, 1.01-1.15). Although not statistically significant, women with class I and II obesity showed a trend towards a higher utilization 1.08 (95% CI, 0.99-1.18) and 1.10 (95% CI, 0.98-1.25) respectively, when compared to women at desired weight. CONCLUSION: We present a weighted analysis of the BRFSS, evaluating the association of BMI and appropriate screening mammography among women 40 years and older. These results are generalizable to the US population of women in this age range. Underweight women had significantly lower odds of utilizing screening mammography appropriately when compared with women at desired weight. Results from previous studies reporting underutilization of screening mammography in high risk, obese, and overweighed women were not confirmed in this largest population based analysis performed to date.

Investigating reversals of association for utilization of recent mammography among Hispanic and Non-Hispanic Black women.

OBJECTIVE: Several papers have found that Hispanic and Non-Hispanic Black women have higher adjusted odds ratios for recent mammography when compared with Non-Hispanic White women, even though their crude percentages were lower than, or about equal to, Non-Hispanic White women's. This paper investigates the existence of "reversals" of association for recent mammography and describes an analysis strategy for identifying variables that might produce them. METHODS: We used every-other-year data for women aged 40-80 from the 1996-2006 Behavioral Risk Factor Surveillance System and the 1999, 2000, 2003, and 2005 National Health Interview Survey. A consistent set of covariates was used across all datasets. RESULTS: Reversals were found in almost all survey years for Hispanic women. Non-Hispanic Black women often had unadjusted rates comparable to Non-Hispanic Whites, but their adjusted odds ratios were significantly higher in most surveys. A limited number of variables contributed strongly to reversals, and differed somewhat for Hispanic and Black women. CONCLUSIONS: Reversed associations found in adjusted analyses present a challenge for interpretation, but could also denote success of programs to increase screening rates. Users of population-level surveys should be alert for reversals and attempt to find explanations.

Socioeconomic indicators and hysterectomy status in the United States, 2004.

OBJECTIVE: To examine the association between socioeconomic indicators and hysterectomy. STUDY DESIGN: We performed a cross-sectional analysis of the 2004 Behavioral Risk Factor Surveillance Survey database. The effect of multiple socioeconomic exposures (education level, annual income and employment status) on hysterectomy status was evaluated. Logistic regression was used to estimate ORs between the multiple exposures and the outcome of hysterectomy status. RESULTS: Our analytic sample included 180,982 women. Prior hysterectomy was reported by 26.4%. After adjusting for confounders, women who had not graduated from high school had 1.75 times higher odds (95% CI 1.68-1.83) of having a hysterectomy as compared to women who were college graduates, and women with an annual household income of < $15,000 had 1.06 times higher odds (95% CI 1.02 to 1.10) of having a hysterectomy as compared to women who reported an income of > $50,000/year. Women who were unemployed did not have higher odds of having a hysterectomy than women who were employed. CONCLUSION: Socioeconomic indicators of education level and income are associated with hysterectomy status; however, employment status is not.

Breastfeeding Intention Compared With Breastfeeding Postpartum Among Women Receiving Medication-Assisted Treatment.

BACKGROUND:: Women taking methadone or buprenorphine are encouraged to breastfeed if stable without polysubstance use. RESEARCH AIM:: We aimed to determine the difference between stated intention to breastfeed prenatally in women taking methadone or buprenorphine compared with breastfeeding at discharge and 2 months postpartum. Secondary outcomes were determining whether breastfeeding was more common in women taking buprenorphine, in women without hepatitis C infection, and in women without a history of heroin use, and whether breastfeeding reduced the need for pharmacological treatment of neonatal opioid withdrawal syndrome. METHODS:: This was a retrospective cohort study of 228 women enrolled in a perinatal substance abuse treatment program. Electronic medical records were reviewed to abstract data on mother-infant dyads. Chi-square tests were used to analyze our outcomes. RESULTS:: Women taking buprenorphine had a higher prevalence of breastfeeding compared with women taking methadone (83% [ n = 100] vs. 71% [ n = 76]; χ2 = 4.35, p = .03), despite no difference in their prenatal intention to breastfeed (87% vs. 81%; χ2 = 1.28, p = .25). Only 31% ( n = 38) of women taking buprenorphine and 19.6% ( n = 21) of women taking methadone exclusively breastfed at discharge (χ2 = 5.43, p = .06). Exclusively breastfed infants required less pharmacological treatment for neonatal opioid withdrawal syndrome compared with formula-fed infants (15.8% [ n = 21] vs. 47.4% [ n = 38]; χ2 = 19.72, p < .05). CONCLUSION:: Despite most women reporting a high prenatal intention to breastfeed, exclusive breastfeeding at hospital discharge postpartum was low. Breastfeeding was associated with a decreased likelihood of pharmacological treatment for neonatal opioid withdrawal syndrome.

Characteristics of women who seek emergency contraception and family planning services.

OBJECTIVE: The purpose of this study was to compare the demographic characteristics and sexual risk behaviors of women who seek emergency contraception (EC) and general family planning (FP) services. STUDY DESIGN: This cross-sectional study included 227 women aged 17-43 years who were being evaluated for either EC or FP in an outpatient setting from 2003-2004. Descriptive statistics and odds ratios were included. RESULTS: The EC group, compared with the FP group, had higher proportions of women with education beyond high school (62% vs 52%; P = .02), and not married (79% vs 42%; P < .01). The groups also differed by age, race, and income. The EC group was more likely to have been unprotected at their last intercourse (odds ratio, 5.56; 95% CI, 2.22, 14.29) and less likely to have a previous sexually transmitted infection (odds ratio, 0.41; 95% CI, 0.17, 0.96). CONCLUSION: The development of EC education programs for women is important for increasing awareness for diverse groups of women and their healthcare providers.

Accessing care: use of a specialized women's emergency care facility for nonemergent problems.

OBJECTIVE: Given the problem of emergency room overcrowding, this study was designed to examine factors associated with women seeking treatment for medically nonemergent conditions in a primarily obstetric and gynecologic emergency facility. METHODS: This is a prospective study of 287 women coming for non-emergent reasons to the Women & Infants Hospital Emergency Room/Triage Unit (WIH ER/Triage Unit). Participants completed questionnaires to assess reasons for choosing to seek care in the emergency room, symptoms, and past medical care. Data abstracted and analyzed from the participants' medical records included demographic information, recorded urgency level, pregnancy status, and medical reasons for the visit. RESULTS: Of the 287 women completing the questionnaire, 36% came because they believed they had a true emergency, 42% because of physician referral, and 21% because of access barriers. Eighty-four percent of participants reported having a primary physician, and 56% registered for care on weekdays between 9 AM and 5 PM. Seventy percent reported a reason for the visit that was related to either obstetrics or gynecology. Common symptoms among women coming to this emergency department (ED) included abdominal or pelvic pain (32%) and vaginal bleeding (22%). Seventeen percent came for diagnostic testing, such as ultrasound or laboratory testing. CONCLUSIONS: Although women with nonemergent medical conditions who came to a specialized emergency facility for care had a usual source of medical care, that source of care was not always accessible or available to them.

Age group differences among pregnant adolescents: sexual behavior, health habits and contraceptive use.

STUDY OBJECTIVE: To determine differences in sexual behavior, health habits and contraceptive use among three age groups of pregnant adolescents. DESIGN: Prospective study of pregnant adolescents participating in face-to-face interviews including questions about demographic background, sexual behavior, health history and contraceptive use. SETTING: Urban prenatal clinic. PARTICIPANTS: 300 pregnant adolescents attending their first prenatal appointment. MAIN OUTCOME MEASURES: Sexual behavior, health history and contraceptive use. RESULTS: Our cohort of pregnant adolescents included 61 (20%) 12-15-year-olds, 113 (38%) 16-17-year-olds and 126 (42%) 18-19-year-olds. A greater proportion of 12-15-year-olds were currently in school (90%) compared with 16-17-year-olds (48%) and 18-19-year-olds (38%) (P = 0.01). Of the18-19-year-olds, 41% had a previous pregnancy compared with 3% of 12-15-year-olds (P = 0.01). The youngest age group also had the lowest proportion of any drug use (25%). Contraceptive use (ever) was lower for 12-15-year-olds (46%) compared with 16-17-year-olds (59%), and 18-19-year-olds (66%) (P < 0.01). Reasons for not using contraception at the time of conception also differed by age with 9% of the youngest group reporting they wanted to get pregnant compared with 27% of the 18-19-year-old group (P = 0.01). CONCLUSIONS: Sexual behavior, health habits and contraceptive use in pregnant adolescents differed by age group. Understanding that there are distinct risk behaviors associated with teen pregnancy among these three separate age groups will enhance the thoughtful development and evaluation of programs and policies targeted at preventing first pregnancies and repeat pregnancies in adolescents.

Where people die: a multilevel approach to understanding influences on site of death in America.

Despite documented preferences for home death, the majority of deaths from terminal illness occur in hospital. To better understand variation in place of death, we conducted a systematic literature review and a multilevel analysis in which we linked death certificates with county and state data. The results of both components revealed that opportunities for home death are disproportionately found in certain groups of Americans; more specifically, those who are White, have greater access to resources and social support, and die of cancer. From the multilevel analysis, the higher the proportion minority and the lower the level of educational attainment, the higher the probability of hospital death while investment in institutional long-term care, measured by regional density of nursing home beds and state Medicaid payment rate, was associated with higher probability of nursing home death. These results reinforce the importance of both social and structural characteristics in shaping the end-of-life experience.

Oral thalidomide as palliative chemotherapy in women with advanced ovarian cancer.

OBJECTIVE: We prospectively evaluated thalidomide, an oral agent with antiangiogenic and immunomodulatory properties, in patients with recurrent ovarian cancer, comparing the drug to standard intravenous chemotherapy and treatment holiday in terms of both progression-free interval and quality of life. METHODS: Eligible patients had recurrent ovarian or primary peritoneal cancer and had received a minimum of two prior therapeutic regimens. Patients were offered one of three arms: (Arm A) any standard intravenous single-agent chemotherapy; (Arm B) oral thalidomide 200 mg daily; (Arm C) treatment holiday. Computed tomography (CT) scans were performed every two cycles until disease progression by Response Evaluation Criteria in Solid Tumors (RECIST) criteria. CA-125 was measured monthly as was quality of life using the Functional Assessment of Cancer Therapy (FACT-O) questionnaire. RESULTS: Forty patients participated: 18 on Arm A; 18 on Arm B; and 4 on Arm C. The groups were comparable in terms of number of prior regimens and cycles of chemotherapy. The progression- free intervals were similar in Arm A and Arm B (3.7 versus 3.8 months). The PR/SD rate was 6.7%/60% for Arm A, and 7.7%/53.8% in Arm B. Of those treated with thalidomide, 53% had a drop in CA-125 greater than 50%, compared to 13% receiving intravenous chemotherapy. FACT-O scores at baseline and throughout treatment were equivalent. CONCLUSION: The oral chemotherapeutic agent thalidomide appears to be comparable in response and quality of life, compared to single agent intravenous chemotherapy, in our population of heavily pretreated patients with ovarian cancer.

Management of cervical intraepithelial neoplasia 2 in adolescent and young women.

STUDY OBJECTIVE: To evaluate regression rates among adolescents (aged < or =21) with cervical intraepithelial neoplasia (CIN) 2 managed expectantly and to determine factors associated with disease regression. DESIGN: Cohort study using a colposcopic database of 2,996 women seen between August 1999 and November 2005. SETTING: Colposcopy clinic in urban, tertiary care medical center. PARTICIPANTS: Adolescents with CIN 2. Routine management consisted of two options: immediate treatment or repeat colposcopic evaluation in 6 months. MAIN OUTCOME MEASURES: For those managed conservatively, regression was defined either as a subsequent normal colposcopy and/or biopsy and at least 2 smears read as negative for epithelial abnormality or at least 3 consecutive negative smears if repeat colposcopy was not performed. Demographic information, including age, was assessed to determine possible associations with disease regression. RESULTS: Of the 93 adolescents, 53 (57%) elected to undergo immediate treatment with a diagnostic excisional procedure, and 40 (43%) chose management with colposcopic follow-up. Of those treated, high-grade disease (CIN 2+) was found in 40 (75%). Of the 36 young women followed conservatively (4 were lost to follow-up), regression after a median follow-up time of 378 days was documented in 14 (39%). Of the 22 adolescents not fulfilling our criteria for regression, only 3 had evidence of CIN 2 or worse during follow-up. The remaining 19 had either CIN 1 or mildly abnormal cytologic results. Kaplan-Meier survival estimates indicated younger age (< or =16 years) tended to be associated with decreased time to regression. CONCLUSION: Based on significant regression of CIN 2 among adolescent women, primary management in this population should consist of cytologic and colposcopic follow-up.

Fear of inability to conceive in pregnant adolescents.

OBJECTIVE: To estimate the demographic and health history differences between pregnant adolescents who had fears that they would not be able to conceive and those without these fears. METHODS: Three hundred pregnant adolescents presenting for their first prenatal visit participated in a cohort study that addressed attitudes about pregnancy. All participants were aged younger than 20 years and gave informed consent. The outcome of interest was a positive response to the question "Did you have any fears that you wouldn't be able to get pregnant?" Independent measures included health history and demographic variables. RESULTS: Among participants, 42% stated they had fears about not being able to conceive. The total sample included 20% 12-15 year olds, 39% 16-17 year olds and 41% 18-19 year-olds. There was no statistically significant difference in fear of not being able to conceive by maternal age, reported sexually transmitted disease rates, or age at first intercourse. More adolescents who expressed fear of infertility had a previous spontaneous abortion, previous pelvic examination, and were sexually active for a longer period of time compared with those without this fear. CONCLUSION: A large proportion of pregnant adolescents in this study expressed fear that they would not be able to conceive. Understanding the basis of the fear is critical to appreciating its association with current and future adolescent pregnancy and contraceptive use. LEVEL OF EVIDENCE: III.

Abortion training in United States obstetrics and gynecology residency programs.

OBJECTIVE: To identify characteristics of programs which provide training in abortion, to calculate the number of procedures done during training, and to compare the availability of abortion training in 2004 with that of prior national surveys. METHODS: An investigator-designed questionnaire about abortion training in obstetrics and gynecology residency programs was mailed to all U.S. residency directors. Collected data included program information, abortion training, and numbers of residents trained. Data were analyzed to estimate differences in abortion training by region, program size, and type of training offered. RESULTS: Of the 252 questionnaires mailed, 185 (73%) were returned. Of the 185, 94 (51%) program directors reported routine instruction in elective abortion, 72 (39%) optional training, and 19 (10%) no training. Large programs and programs located in the Northeast and West Coast were significantly more likely to offer routine training in terminations (P < .01). In the programs offering routine training, more than 50% of residents received instruction in termination practices. Of those practices, the most common were first-trimester surgical abortion (85% of programs), followed by medical abortion (59%), second-trimester induction (51% of programs), and dilation and extraction (36%). As compared with those in programs with optional training, residents in programs with routine training were significantly more likely to receive instruction in all modalities of abortion provision and performed proportionally more first- and second-trimester terminations (P < .01). CONCLUSION: Routine training in elective abortion resulted in greater exposure to abortion practices and greater experience in more complicated abortion techniques during residency.

Effect of patient age on increasing morbidity and mortality following urogynecologic surgery.

OBJECTIVE: The purpose of this study was to estimate the effect of age on the risk of in-hospital mortality and morbidity following urogynecologic surgery and to compare risks associated with obliterative versus reconstructive procedures for prolapse in elderly women. STUDY DESIGN: We conducted a retrospective cohort study utilizing data from 1998 to 2002 from the Nationwide Inpatient Sample. Multivariable logistic regression was performed to obtain odds ratios estimating the effect of age on risk of death and complications, adjusting for comorbidities and demographic factors. RESULTS: There were 264,340 women in our study population. Increasing age was associated with higher mortality risks per 1000 women (< 60 years, 0.1; 60-69 years, 0.5; 70-79 years, 0.9; > or = 80 years, 2.8; P < .01) and higher complication risks per 1000 women (< 60 years, 140; 60-69 years, 130; 70-79 years, 160; > or = 80 years, 200; P < .01). Using multivariable logistic regression, increasing age was associated with an increased risk of death (60-69 years, odds ratio [OR] 3.4 [95% CI 1.7-6.9]; 70-79 years, OR 4.9 [95% CI 2.2-10.9]; > or = 80 years, OR 13.6 [95% CI 5.9-31.4]), compared with women < 60 years. The risk of peri-operative complications was also higher in elderly women 80 years of age and older (OR 1.4 [95% CI 1.3-1.5]) compared with younger women. Elderly women 80 years and over who underwent obliterative procedures had a lower risk of complication compared with those who underwent reconstructive procedures for prolapse (17.0% vs 24.7%, P < .01). CONCLUSION: Although the absolute risk of death is low, elderly women have a higher risk of mortality and morbidity following urogynecologic surgery.

Fetal heart rate patterns and sudden infant death syndrome.

OBJECTIVE: To determine differences in electronic fetal monitoring patterns between infants who died of sudden infant death syndrome and controls. DESIGN: Case-control study (N = 127). SETTING: A tertiary-level women's hospital in Providence, Rhode Island. PARTICIPANTS: Infants born between 1990 and 1998 who subsequently died of sudden infant death syndrome and controls. Demographic and clinical data included medical maternal charts and fetal monitoring records. RESULTS: Compared with controls (n = 98), the mothers whose infants subsequently died of sudden infant death syndrome (n = 29) had lower birthweight babies (sudden infant death syndrome 2,840 vs. controls 3,385 g; p < .01), were younger (22 vs. 28 years; p < .01), were more likely to receive Medicaid health insurance (odds ratio 4.6; confidence interval 1.9-11.2), were more likely to be unmarried (odds ratio 5.2; confidence interval 2.1-12.8), had less intention to breastfeed (26% vs. 57%), and were more likely to smoke (odds ratio 4.6; confidence interval 9-11.2). MAIN OUTCOME MEASURES: There were no statistical differences in fetal heart rate variability or sleep/wake cycles detected between groups. CONCLUSION: Statistical differences were found in demographic characteristics between sudden infant death syndrome mother-infant couples and their controls. However, no differences were detected in the intrapartum electronic fetal monitoring records, specifically in variability and sleep/wake cycles.