Burden and trajectory of social needs after breast cancer diagnosis at a safety-net hospital.

PURPOSE: Unmet social needs pose barriers to cancer care, contributing to adverse outcomes and health inequities. A better understanding of how social needs change after cancer diagnosis can inform more effective, equity-focused interventions. METHODS: In this study, we examined self-reported social needs at 0, 3, and 6 months after a breast cancer diagnosis in a racially diverse, multilingual sample (n = 222) enrolled in patient navigation intervention at an urban safety-net hospital. At each timepoint, respondents completed surveys about social needs related to employment, disability benefits, housing and utilities, and personal and family stability. RESULTS: Over three-quarters (78%, n = 175) reported ≥ 1 social need, and 46% (n = 102) reported ≥ 3 social needs. The most frequently reported need was housing and utilities (64%, n = 142), followed by employment (40%, n = 90). Individuals from minoritized groups more frequently reported an increased number of social needs over time, compared with their White counterparts (p = 0.02). CONCLUSION: Our findings suggest that despite navigation, many cancer patients from historically underrepresented populations continue to experience social concerns over the first 6 months of treatment. Further research, conducted with historically underrepresented populations in research, is needed to better understand the social needs of breast cancer patients to inform effective and equitable interventions.

Primary Care After Pregnancy Survey: Patient Preferences, Health Concerns, and Anticipated Barriers.

Despite recommendations for ongoing care after pregnancy, many individuals do not see a primary care clinician within the first postpartum year, missing a critical window to engage reproductive-age individuals in primary care. We administered an anonymous, cross-sectional, trilingual survey at a large urban safety-net hospital to assess postpartum individuals' preferences, health concerns, and anticipated barriers to primary care during the year after pregnancy. While 90% of respondents preferred a visit within one year, most individuals - including those with complicated pregnancies - did not recall a primary care recommendation from their pregnancy care team. Respondents reported a variety of primary care-amenable health concerns, and many social and logistical barriers to care. Preference for virtual care increased if self-monitoring tools were hypothetically available, indicating virtual visits may improve primary care access.

Primary Care-Based Cardiovascular Disease Risk Management After Adverse Pregnancy Outcomes: a Narrative Review.

Several common adverse pregnancy outcomes can reveal subclinical or latent cardiovascular disease (CVD) risk, transiently exposed through the physiologic stress of pregnancy. The year after pregnancy may be a singular opportunity to identify and initiate treatment for CVD risk, even before the onset of traditional CVD risk factors. However, clinical guidance regarding CVD risk management after adverse pregnancy outcomes is lacking. We therefore conducted a systematic review of US clinical practice guidelines and professional society recommendations to inform primary care-based CVD risk management after adverse pregnancy outcomes. We identified 13 relevant publications. While most recommendations were based on limited or weak evidence, we identified several areas of consensus. First, individuals with an adverse pregnancy outcome associated with future CVD are likely to benefit from CVD risk assessment-accompanied by education, counseling, and support for lifestyle modification-beginning within the first postpartum year. Second, among clinicians, clear and consistent documentation about adverse pregnancy outcomes and recommended follow-up is important to coordinate care after pregnancy. In addition, patients need to be informed about their pregnancy complications and associated CVD risks, so that they can make informed health care and lifestyle decisions. Finally, in general, CVD prevention in the year after an adverse pregnancy outcome focuses on lifestyle modification, reserving pharmacotherapy for the highest-risk patients and those with traditional CVD risk factors. While postpartum lifestyle interventions show promise for reducing CVD risk after adverse pregnancy outcomes, continued research to determine the optimal content, timing, and long-term effects of such interventions is needed.

Use of Intrauterine Devices and Risk of Human Immunodeficiency Virus Acquisition Among Insured Women in the United States.

Concerns have been raised about progestin-containing contraceptives and the risk of human immunodeficiency virus (HIV) acquisition. Based on health insurance data from women in the United States with intrauterine device (IUD) insertions during 2011-2018, there was no increased risk of incident HIV diagnosis for levonorgestrel-releasing IUDs versus copper IUDs.

Trends and Disparities in Sexual and Reproductive Health Behaviors and Service Use Among Young Adult Women (Aged 18-25 Years) in the United States, 2002-2015.

OBJECTIVES: To describe trends in sexual and reproductive health behaviors and service utilization among young women in the United States. METHODS: We analyzed data from 8835 female respondents aged 18 to 25 years from 4 cycles of the National Survey of Family Growth, a nationally representative cross-sectional survey, from 2002 to 2015. We used bivariate and multivariable logistic regression to compare rates of self-reported sexual activity, sexually transmitted infection-related care, and contraception use over time and by race/ethnicity. RESULTS: Sexually transmitted infection-related care and human papilloma virus vaccination increased from 2002 to 2013-2015, whereas sexual activity and contraception use remained stable. Compared with White women, racial/ethnic minority women were less likely to report effective contraception use, and Black women were less likely to report human papilloma virus vaccination; these differences did not change over time. CONCLUSIONS: Sexual and reproductive health service utilization increased from 2002 to 2015 among young women, whereas sexual activity remained stable. Overall, rates of recommended care were low, and racial and ethnic disparities persisted. Public Health Implications. Young women could benefit from clinical interventions and health policies to increase recommended care and reduce disparities.

Strategies for Recruiting a Diverse Postpartum Survey Sample.

BACKGROUND: Data from diverse populations are needed to inform interventions for maternal health equity. However, research recruitment of postpartum individuals is challenging, especially in minoritized and structurally marginalized populations. MATERIALS AND METHODS: We developed a recruitment strategy for a cross-sectional survey among postpartum individuals at an urban safety-net hospital in New England, inclusive of those with a language preference other than English (LPOE) and those not attending scheduled postpartum visits. Recruitment was primarily conducted before, during, and after clinic visits in obstetrics or pediatrics. Surveys could be completed in-person, over the phone, or online. All study materials were trilingual (English, Spanish, Haitian Creole). After reaching our recruitment goal of 120 individuals, we analyzed our recruitment efforts to identify key recruitment strategies. RESULTS: From April to June 2022, 245 individuals were invited to participate, and 120 (49%) completed the survey, of whom 119 contributed recruitment data to the present analysis. Most participants (83.1%) self-identified as Black or Hispanic, and 30.2% had an LPOE. Compared with the overall sample, participants with an LPOE were more likely to have been recruited in-person (73% versus 78%), while those not attending postpartum visits required more outreach attempts (mean 2.3 versus 2.6). We identified 4 key strategies contributing to recruitment success: multilingual materials, frequent assessment and adjustment of our recruitment approach, pediatrics-based recruitment, and multiple timings and modes of outreach. CONCLUSIONS: Using a multi-stage, multilingual, and multi-method recruitment strategy including pediatrics-based outreach, we recruited a diverse postpartum sample with > 80% individuals of color and > 30% with an LPOE. Our experience can inform more inclusive postpartum research.

The effect of postpartum lifestyle interventions on blood pressure: a systematic literature review.

Postpartum lifestyle modification is recommended to hypertension risk. We conducted a systematic literature review to assess the evidence for postpartum lifestyle interventions to reduce blood pressure. We searched for relevant publications from 2010 through November 2022. Two authors independently conducted article screening and data extraction; a third resolved discrepancies. Ultimately, nine studies met inclusion criteria. Most were randomized controlled trials and had sample sizes <100. In all but one of the eight studies reporting race data, nearly all participants identified as White. None of the studies reported a significant intervention effect on blood pressure. However, most interventions were associated with improvements in other outcomes, such as physical activity. Overall, the evidence for postpartum lifestyle interventions to reduce blood pressure is limited to a handful of studies characterized by small sample sizes and a lack of racial diversity. Additional research with larger samples, more diverse populations, and intermediate outcomes is warranted.

Peripheral blood monocyte count is a dynamic prognostic biomarker in multiple myeloma.

With the growing knowledge of multiple myeloma (MM) pathobiology and the introduction of novel therapies, risk stratification continues to evolve. Myeloid-derived suppressor cells and tumor-associated macrophages, derived from peripheral blood monocytes, support malignant plasma cell proliferation in the bone marrow. Because peripheral blood absolute monocyte count (AMC) is thought to reflect the bone marrow microenvironment, we sought to evaluate the prognostic significance of AMC in MM. We retrospectively analyzed 10 822 patients newly diagnosed with MM between 2000 and 2019 at Veteran's Administration hospitals. We obtained AMC closest to diagnosis and every 3 months thereafter up to 2.5 years. Patients were stratified into 4 groups: low, normal, elevated, and severely elevated AMC (<0.2, 0.2-<0.8, 0.8-<1.25, and ≥1.25 × 103/mm3, respectively). Abnormal AMC at diagnosis was observed in 25.3% of the patients and was associated with an inferior overall survival (OS). In patients with low, severely elevated, elevated, and normal AMC, respectively, median OS at diagnosis was 2.3, 2.7, 3.1, and 3.6 years (P < .001) and at 2.5 years was 2.0, 2.6, 3.4, and 3.9 years (P < .001). Patients with normal AMC at diagnosis who developed an abnormal AMC >1 year after diagnosis also had an inferior OS relative to patients who maintained a normal AMC. Abnormal AMC was also associated with inferior OS independent of validated prognostic markers, including the international staging system and lactate dehydrogenase. Our findings provide novel clues for future prospective studies on the functional role of monocytes in MM, which could be a readily available metric for risk stratification.

Prepregnancy Cardiovascular Disease Risk Factors and Adverse Pregnancy Outcomes in a Safety-Net Hospital.

Background: Many adverse pregnancy outcomes (APOs) are associated with elevated cardiovascular disease (CVD) risk. However, APO data in the context of pre-existing CVD risk factors, and from diverse populations, are limited. We assessed the occurrence of APOs among individuals with and without prepregnancy CVD risk factors, overall and by race/ethnicity. Methods: We conducted a retrospective study using electronic medical record data from a large urban safety-net hospital. Individuals with prenatal care and delivery between 2016 and 2018 at the hospital were included, and data from prenatal intake through the delivery hospitalization were captured. The exposure, prepregnancy CVD risk factors (hypertension, diabetes, tobacco use, and obesity), and the outcome, APOs (hypertensive disorders of pregnancy, gestational diabetes, preterm delivery, low birth weight, and stillbirth), were identified from electronic medical records. Results: We identified 3760 unique delivering individuals, of whom 55.1% self-identified as Black non-Hispanic and 17% as Hispanic. Prepregnancy CVD risk factor prevalence was 45.6%, most commonly obesity (26.6%). APO prevalence was 35.6%, most commonly a hypertensive disorder of pregnancy (20.1%). Overall, 45.7% of APOs occurred in the absence of recognized prepregnancy CVD risk factors, representing 16.3% of the total sample. Among individuals without prepregnancy CVD risk factors, APO prevalence was 30.0% and did not vary by race/ethnicity. Conclusions: In this racially and ethnically diverse hospital-based sample, APOs were present in one in three parous individuals without prepregnancy CVD risk factors-a group with potentially elevated CVD risk who might otherwise be missed by traditional CVD risk factor screening.

Use of contraception before and after a diabetes diagnosis: An observational matched cohort study.

AIMS: To determine how a diabetes diagnosis affects contraception use. METHODS: This retrospective cohort study used private insurance data from non-pregnant women aged 15-49 years, 2000-2014. We identified women with a new diabetes diagnosis and a control group without diabetes, matched on important potential confounders. We compared rates of prescription or procedural contraception use in the two groups before and after an index date (diabetes diagnosis and outpatient visit, respectively), yielding difference-in-differences estimates of the effect of a diabetes diagnosis on contraception use. RESULTS: We identified 75,355 women with a new diabetes diagnosis and 7.5 million women without a diabetes diagnosis. Overall rates of contraception use did not increase in the year after diagnosis (absolute difference-in-difference: 0.4% [99.9% CI, -2.1% to 2.9%]; p < 0.001). In method-specific analyses, there was a decline in estrogen-containing and injectable contraceptives in the year after diagnosis (absolute difference-in-difference: -2.2% [-4.0% to -0.4%] and -0.8% [-1.5% to -0.1%], respectively; p < 0.001); no corresponding increase was noted for intrauterine contraception or subdermal implants. CONCLUSIONS: Women with diabetes are less likely to use contraception after their diabetes diagnosis. Efforts are needed to ensure that women with diabetes receive the counseling and clinical services needed to carefully plan their pregnancies.

Postpartum health risks among women with hypertensive disorders of pregnancy, California 2008-2012.

OBJECTIVES: The aim of this study was to understand the associations between hypertensive disorders of pregnancy (HDP) and postpartum complications throughout the newly defined 12-week postpartum transition. STUDY DESIGN: We conducted a retrospective cohort study of the associations of HDP (any/subtype) with postpartum complications among 2.5 million California births, 2008-2012. We identified complications from discharge diagnoses from maternal hospital encounters (emergency department visits and readmissions) in the 12 weeks after giving birth. We compared rates of complications, overall and by diagnostic category, between groups defined by HDP. In survival analyses, we calculated the adjusted hazard ratios of postpartum complications associated with HDP. We adjusted for maternal age, race/ethnicity, prepregnancy obesity, chronic diabetes, gestational diabetes, insurance, delivery mode, gestational age and birth outcome (term and size). RESULTS: Among women with and without HDP, 12.8 and 7.7%, respectively, had a hospital encounter within 12 weeks of giving birth [adjusted hazard ratio 1.5, 95% confidence interval (95% CI): 1.5-1.5]. HDP was associated with increased risk across all major categories of complications: hypertension-related, adjusted hazard ratio 11.8 (95% CI: 11.2-12.3); childbirth-related, 1.4 (1.3-1.4); and other, 1.4 (1.4-1.4). Risk of any complication differed by hypertensive subtype: chronic hypertension with super-imposed preeclampsia, adjusted hazard ratio 1.8 (95% CI: 1.7-1.8); chronic hypertension, 1.6 (1.6-1.7); preeclampsia/eclampsia, 1.3 (1.3-1.4); and gestational hypertension, 1.2 (1.2-1.3). Over a quarter (28.9%) of maternal hospital encounters occurred more than 6 weeks after giving birth; this did not differ substantially by HDP status. CONCLUSION: Women with HDP are at an increased risk for virtually all postpartum complications, including those not related to hypertension, and may benefit from enhanced and comprehensive postpartum care.

Contraceptive Initiation Among Women in the United States: Timing, Methods Used, and Pregnancy Outcomes.

BACKGROUND: Timely contraceptive initiation is increasingly common, yet population trends by method and among subgroups with increased risk of unintended pregnancy are not well described. The impact of timing and type of contraceptive initiation on risk of unwanted pregnancy is unknown. METHODS: We used nationally representative cross-sectional data from 4 cycles of the National Survey of Family Growth, 2002-2015. We calculated outcomes from self-reported dates of sexual debut, contraceptive initiation, and unwanted pregnancy. We compared trends in timely contraceptive initiation (within 1 month of sexual debut) by method and by race and/or ethnicity and income. Using multivariable regression, we identified predictors of delayed contraceptive initiation. We compared the risk of unwanted pregnancy for delayed versus timely contraceptive initiation. RESULTS: We analyzed responses from 26 359 women with sexual debuts in 1970-2014. One in 5 overall and 1 in 4 African American, Hispanic, or low-income respondents reported delayed contraceptive initiation, which was associated with unwanted pregnancy within 3 months of sexual debut (adjusted risk ratio 3.7 versus timely contraceptive initiation; 99.9% confidence interval: 2.3-5.9; P < .001). Timely contraceptive initiation with less effective versus effective methods was not associated with unwanted pregnancy within 3 months. CONCLUSIONS: Delayed contraceptive initiation is more common among African American, Hispanic, and low-income women and is strongly associated with short-term risk of unwanted pregnancy. Pediatricians play a key role in making timely contraception available to adolescents at or before sexual debut. More research is needed to understand the importance of early contraceptive methods on pregnancy risk.

Altitude, life expectancy and mortality from ischaemic heart disease, stroke, COPD and cancers: national population-based analysis of US counties.

BACKGROUND: There is a substantial variation in life expectancy across US counties, primarily owing to differentials in chronic diseases. The authors' aim was to examine the association of life expectancy and mortality from selected diseases with altitude. METHODS: The authors used data from the National Elevation Dataset, National Center for Heath Statistics and US Census. The authors analysed the crude association of mean county altitude with life expectancy and mortality from ischaemic heart disease (IHD), stroke, chronic obstructive pulmonary disease (COPD) and cancers, and adjusted the associations for socio-demographic factors, migration, average annual solar radiation and cumulative exposure to smoking in multivariable regressions. RESULTS: Counties above 1500 m had longer life expectancies than those within 100 m of sea level by 1.2-3.6 years for men and 0.5-2.5 years for women. The association between altitude and life expectancy became non-significant for women and non-significant or negative for men in multivariate analysis. After adjustment, altitude had a beneficial association with IHD mortality and harmful association with COPD, with a dose-response relationship. IHD mortality above 1000 m was 4-14 per 10,000 people lower than within 100 m of sea level; COPD mortality was higher by 3-4 per 10,000. The adjusted associations for stroke and cancers were not statistically significant. CONCLUSIONS: Living at higher altitude may have a protective effect on IHD and a harmful effect on COPD. At least in part due to these two opposing effects, living at higher altitude appears to have no net effect on life expectancy.