Prior Term Birth Decreases the Risk of Preterm Birth in a Subsequent Twin Gestation.

OBJECTIVE: The aim of the study is to examine the association between the risk of preterm delivery among women with twin pregnancies and their obstetric history. STUDY DESIGN: We designed a retrospective cohort study of live twin births in 2008 in the United States that delivered after 240/7 weeks. Women were categorized into nulliparas, multiparas with prior term delivery, and multiparas with prior preterm delivery. The incidence of preterm birth was compared using Chi-square test and multivariable logistic regression models. RESULTS: A total of 32,895 nulliparous and 64,701 multiparous women with twin pregnancies were included in the study. Of the multiparous women, 2,505 (4%) had a history of a prior preterm delivery. Multiparous women with prior term birth were more likely to deliver at term (: 43%): in the index twin pregnancy than nulliparous women (40%) and multiparous women with a prior preterm birth (21%; p < 0.001). Compared with nulliparous women, prior term birth was protective against preterm delivery (adjusted odds ratio [aOR] = 0.67 [95% confidence interval: 0.60-0.74] for delivery <28 weeks and aOR = 0.79 [0.71-0.77] for delivery <34 weeks). CONCLUSION: Among multiparous women with twins, a prior term delivery appeared to be protective against preterm delivery compared with nulliparous women with twins. KEY POINTS: · Prior term birth is protective against preterm birth in subsequent twin pregnancy.. · A prior term birth confers an OR of 0.66 for delivery prior to 28 weeks in twin pregnancies.. · A prior preterm birth renders a twin pregnancy nearly twice as likely to deliver before 28 weeks..

The interaction between maternal race/ethnicity and chronic hypertension on preterm birth.

BACKGROUND: In both the biomedical and public health literature, the risk for preterm birth has been linked to maternal racial/ethnic background, in particular African-American heritage. Despite this well-documented health disparity, the relationship of comorbid conditions, such as chronic hypertension, to maternal race/ethnicity and preterm birth has received relatively limited attention in the literature. OBJECTIVE: The objective of the study was to evaluate the interaction between chronic hypertension and maternal racial/ethnic background on preterm birth. STUDY DESIGN: This is a retrospective cohort study of singleton pregnancies among women who delivered between 2002 and 2015 at the University of California, San Francisco. The associations of chronic hypertension with both spontaneous and medically indicated preterm birth were examined by univariate and multivariate logistical regression, adjusting for confounders including for maternal age, history of preterm birth, maternal body mass index, insurance type (public vs private), smoking, substance abuse, history of pregestational diabetes mellitus, and use of assisted reproductive technologies. The interaction effect of chronic hypertension and racial/ethnicity was also evaluated. All values are reported as odds ratios, with 95% confidence intervals and significance set at P = .05. RESULTS: In this cohort of 23,425 singleton pregnancies, 8.8% had preterm deliveries (3% were medically indicated preterm birth, whereas 5.5% were spontaneous preterm births), and 3.8% of women carried the diagnosis of chronic hypertension. Chronic hypertension was significantly associated with preterm birth in general (adjusted odds ratio, 2.74, P < .001) and medically indicated preterm birth specifically (adjusted odds ratio, 5.25, P < .001). When evaluating the effect of chronic hypertension within racial/ethnic groups, there was an increased odds of a preterm birth among hypertensive, African-American women (adjusted odds ratio, 3.91, P < .001) and hypertensive, Asian-American/Pacific Islander women (adjusted odds ratio, 3.51, P < .001) when compared with their nonhypertensive counterparts within the same racial/ethnic group. These significant effects were also noted with regard to medically indicated preterm birth for hypertensive African-American women (adjusted odds ratio, 6.85, P < .001) and Asian-American/Pacific Islander women (adjusted odds ratio, 9.87, P < .001). There was no significant association of chronic hypertension with spontaneous preterm birth (adjusted odds ratio, 0.87, P = .4). CONCLUSION: The effect of chronic hypertension on overall preterm birth and medically indicated preterm birth differs by racial/ethnic group. The larger effect of chronic hypertension among African-American and Asian/Pacific Islander women on medically indicated and total preterm birth rates raises the possibility of an independent variable that is not captured in the data analysis, although data regarding the indication for medically indicated preterm delivery was limited in this data set. Further investigation into both social-structural and biological predispositions to preterm birth should accompany research focusing on the effect of chronic hypertension on birth outcomes.

Bridging the gap: determinants of undiagnosed or untreated urinary incontinence in women.

BACKGROUND: More than a third of middle-aged or older women suffer from urinary incontinence, but less than half undergo evaluation or treatment for this burdensome condition. With national organizations now including an assessment of incontinence as a quality performance measure, providers and health care organizations have a growing incentive to identify and engage these women who are undiagnosed and untreated. OBJECTIVE: We sought to identify clinical and sociodemographic determinants of patient-provider discussion and treatment of incontinence among ethnically diverse, community-dwelling women. STUDY DESIGN: We conducted an observational cohort study from 2003 through 2012 of 969 women aged 40 years and older enrolled in a Northern California integrated health care delivery system who reported at least weekly incontinence. Clinical severity, type, treatment, and discussion of incontinence were assessed by structured questionnaires. Multivariable regression evaluated predictors of discussion and treatment. RESULTS: Mean age of the 969 participants was 59.9 (±9.7) years, and 55% were racial/ethnic minorities (171 black, 233 Latina, 133 Asian or Native American). Fifty-five percent reported discussing their incontinence with a health care provider, 36% within 1 year of symptom onset, and with only 3% indicating that their provider initiated the discussion. More than half (52%) reported being at least moderately bothered by their incontinence. Of these women, 324 (65%) discussed their incontinence with a clinician, with 200 (40%) doing so within 1 year of symptom onset. In a multivariable analysis, women were less likely to have discussed their incontinence if they had a household income < $30,000/y vs ≥ $120,000/y (adjusted odds ratio [AOR], 0.49, 95% confidence interval [CI], 0.28-0.86) or were diabetic (AOR, 0.71, 95% CI, 0.51-0.99). They were more likely to have discussed incontinence if they had clinically severe incontinence (AOR, 3.09, 95% CI, 1.89-5.07), depression (AOR, 1.71, 95% CI, 1.20-2.44), pelvic organ prolapse (AOR, 1.98, 95% CI, 1.13-3.46), or arthritis (AOR, 1.44, 95% CI, 1.06-1.95). Among the subset of women reporting at least moderate subjective bother from incontinence, black race (AOR, 0.45, 95% CI, 0.25-0.81, vs white race) and income < $30,000/y (AOR, 0.37, 95% CI, 0.17-0.81, vs ≥ $120,000/y) were associated with a reduced likelihood of discussing incontinence. Those with clinically severe incontinence (AOR, 2.93, 95% CI, 1.53-5.61, vs low to moderate incontinence by the Sandvik scale) were more likely to discuss it with a clinician. CONCLUSION: Even in an integrated health care system, lower income was associated with decreased rates of patient-provider discussion of incontinence among women with at least weekly incontinence. Despite being at increased risk of incontinence, diabetic women were also less likely to have discussed incontinence or received care. Findings provide support for systematic screening of women to overcome barriers to evaluation and treatment.

Two practice models in one labor and delivery unit: association with cesarean delivery rates.

OBJECTIVE: The objective of the study was to examine the association between labor and delivery practice model and cesarean delivery rates at a community hospital. STUDY DESGIN: This was a retrospective cohort study of 9381 singleton live births at 1 community hospital, at which women were provided labor and delivery care under 1 of 2 distinct practice models: a traditional private practice model and a midwife-physician laborist practice model. Cesarean rates were compared by practice model, adjusting for potential sociodemographic and clinical confounders. Statistical comparisons were performed using the χ(2) test and multivariable logistical regression. RESULTS: Compared with women managed under the midwife/laborist model, women in the private model were significantly more likely to have a cesarean delivery (31.6% vs 17.3%; P < .001; adjusted odds ratio [aOR], 2.11; 95% confidence interval [CI], 1.73-2.58). Women with nulliparous, term, singleton, vertex gestations also were more likely to have a cesarean delivery if they were cared for in the private model (29.8% vs 15.9%; P < .001; aOR, 1.86; 95% CI, 1.33-2.58) as were women who had a prior cesarean delivery (71.3% vs 41.4%; P < .001; aOR, 3.19; 95% CI, 1.74-5.88). CONCLUSION: In this community hospital setting, a midwife-physician laborist practice model was associated with lower cesarean rates than a private practice model.

Effect of stage of initial labor dystocia on vaginal birth after cesarean success.

OBJECTIVE: The objective of the study was to examine whether the stage of labor dystocia causing a primary cesarean delivery (CD) affects a trial of labor after cesarean (TOLAC) success. STUDY DESIGN: This was a retrospective cohort study of women who had primary CD of singleton pregnancies for first- or second-stage labor dystocia and attempted TOLAC at a single hospital between 2002 and 2014. We compared TOLAC success rates between women whose primary CD was for first- vs second-stage labor dystocia and investigated whether the effect of prior dystocia stage on TOLAC success was modified by previous vaginal delivery (VD). RESULTS: A total of 238 women were included; nearly half (49%) achieved vaginal birth after cesarean (VBAC). Women with a history of second-stage labor dystocia were more likely to have VBAC compared with those with first-stage dystocia, although this trend was not statistically significant among the general population (55% vs 45%, adjusted odds ratio, 1.4, 95% confidence interval, 0.8-2.5]). However, among women without a prior VD, those with a history of second-stage dystocia did have statistically higher odds of achieving VBAC than those with prior first-stage dystocia (54% vs 38%, adjusted odds ratio, 1.8 [95% confidence interval, 1.0-3.3], P for interaction = .043). CONCLUSION: Nearly half of women with a history of primary CD for labor dystocia will achieve VBAC. Women with a history of second-stage labor dystocia have a slightly higher VBAC rate, seen to a statistically significant degree in those without a history of prior VD. TOLAC should be offered to all eligible women and should not be discouraged in women with a prior second-stage arrest.

Mode of delivery and postpartum depression: the role of patient preferences.

OBJECTIVE: The purpose of this study was to explore the relationship between strength of preference for vaginal delivery, delivery mode undergone, and postpartum depression. STUDY DESIGN: We conducted a secondary analysis of data from a longitudinal study of delivery-mode preferences. During an interview between 24-36 weeks of gestation, participants were asked whether they preferred vaginal or cesarean delivery; the strength of this preference was measured by the standard gamble metric. Depression was assessed antepartum and at 8-10 weeks and 6-8 months after delivery by using the Patient Health Questionnaire (PHQ-9). The primary outcome was PHQ-9 score at 8-10 weeks after delivery. We used multivariable regression analysis to assess the effect of strength of preference for vaginal delivery and delivery mode undergone on postpartum depression. RESULTS: Of 160 participants, 33.1% were nulliparous, and 30.6% had a previous cesarean delivery. Most of the participants (92.4%) preferred vaginal delivery, but the strength of preference varied substantially. The mean strength-of-preference score (0-1 scale; higher scores denote stronger vaginal delivery preference) was 0.658 (SD, ±0.352). A significant interaction emerged between the effects of delivery mode and vaginal delivery preference score on postpartum PHQ-9 score (P = .047). Specifically, a stronger preference for vaginal delivery was associated with higher PHQ-9 scores among women who underwent cesarean delivery (P = .027) but not among women who underwent vaginal delivery (P = .761). The interaction between delivery mode and vaginal delivery preference score was no longer significant at 6-8 months after delivery. CONCLUSION: Women who have a strong antepartum preference for vaginal delivery and deliver by cesarean may be at increased risk for depression in the early postpartum period.

Mode of delivery preferences in a diverse population of pregnant women.

OBJECTIVE: The objective of the study was to assess women's preferences for vaginal vs cesarean delivery in 4 contexts: prior cesarean delivery, twins, breech presentation, and absent indication for cesarean. STUDY DESIGN: This was a cross-sectional study of pregnant women at 24-40 weeks' gestation. After assessing stated preferences for vaginal or cesarean delivery, we used the standard gamble metric to measure the strength of these preferences and the time tradeoff metric to determine how women value the potential processes and outcomes associated with these 2 delivery approaches. RESULTS: Among the 240 participants, 90.8% had a stated preference for vaginal delivery. Across the 4 contexts, these women indicated that, on average, they would accept a 59-75% chance of an attempted vaginal birth ending in a cesarean delivery before choosing a planned cesarean delivery, indicating strong preferences for spontaneous, uncomplicated vaginal delivery. Variations in preferences for labor processes emerged. Although uncomplicated labor ending in vaginal birth was assigned mean utilities of 0.993 or higher (on a 0-1 scale, with higher scores indicating more preferred outcomes), the need for oxytocin, antibiotics, or operative vaginal delivery resulted in lower mean scores, comparable with those assigned to uncomplicated cesarean delivery. Substantially lower scores (ranging from 0.432 to 0.598) were obtained for scenarios ending in severe maternal or neonatal morbidity. CONCLUSION: Although most women expressed strong preferences for vaginal delivery, their preferences regarding interventions frequently used to achieve that goal varied. These data underscore the importance of educating patients about the process of labor and delivery to facilitate incorporation of informed patient preferences in shared decision making regarding delivery approach.

Prevalence and use of complementary health approaches among women with chronic pelvic pain in a prospective cohort study.

OBJECTIVE: The aim of this study was to examine the prevalence of and factors associated with use of complementary health approaches among women with chronic pelvic pain (CPP). DESIGN: We analyzed data from the Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives, a prospective cohort study of women seeking care for noncancerous pelvic problems with intact uteri at enrollment. Among a subset of 699 participants who reported having CPP, we analyzed the prevalence of complementary health approaches used and associated patient sociodemographic and clinical characteristics, health-related quality of life, attitudes and beliefs, and conventional health care practices. RESULTS: At baseline, slightly over one-half (51%) of women with CPP used at least one complementary health approach in the past year, including acupuncture (8%), special foods or diets (22%), herbs (27%), and vitamins and minerals (29%). During follow-up surveys conducted annually for 4 years, a substantial proportion of women (44.8%) used complementary health approaches at more than half of the assessments. Users of complementary health approaches were more likely to undergo a hysterectomy or oophorectomy or to use gonadotropin-releasing hormone agonists or opioids during the study compared with nonusers. Women with CPP who used complementary health approaches also had more optimal health-related quality of life measured by the Pelvic Problem Impact Questionnaire (31.6 vs 25.6, P < 0.001). CONCLUSION(S): Many women with CPP consistently use complementary health approaches. The substantial interest in and high prevalence of complementary health approaches used alongside conventional medical approaches highlight the need for better understanding of multimodal approaches to address the complex condition of CPP.

Strength of preference for vaginal birth as a predictor of delivery mode among women who attempt a vaginal delivery.

OBJECTIVE: We sought to assess the relationship between strength of preference for vaginal birth and likelihood of vaginal delivery among women attempting this delivery mode. STUDY DESIGN: We conducted a longitudinal study of mode of delivery preferences among women who were <36 weeks' pregnant. Participants completed a sociodemographic and clinical questionnaire and were asked if they preferred vaginal or cesarean delivery. Participants who preferred vaginal delivery completed a standard gamble exercise to assess the strength of this preference on a 0-to-1 scale (higher scores indicate stronger preference for vaginal delivery); those preferring cesarean delivery were assigned a value of 0. Data on clinical characteristics and delivery mode were obtained via telephone interview or chart review. Logistic regression was used to identify predictors of delivery mode among women who attempted a vaginal delivery. RESULTS: Of 210 participants, 156 attempted a vaginal delivery. Their mean and median vaginal delivery preference scores were 0.70 (SD 0.31) and 0.75 (interquartile range, 0.50-0.99), respectively. In multivariate analyses, women with a prior cesarean delivery (adjusted odds ratio [aOR], 0.08; 95% confidence interval [CI], 0.02-0.39) or who delivered an infant ≥4000 g (aOR, 0.04; 95% CI, 0.01-0.28) had significantly lower odds of having a vaginal delivery. After controlling for potential confounders, participants with a stronger preference for vaginal delivery were at significantly higher odds of having a vaginal delivery (aOR, 1.54; 95% CI, 1.01-2.34 for every 0.2 increase on the 0-to-1 scale). CONCLUSION: Among women who attempt a vaginal delivery, the strength of preference for vaginal birth is predictive of the delivery mode ultimately undergone.

Effect of enhanced information, values clarification, and removal of financial barriers on use of prenatal genetic testing: a randomized clinical trial.

IMPORTANCE: Prenatal genetic testing guidelines recommend providing patients with detailed information to allow informed, preference-based screening and diagnostic testing decisions. The effect of implementing these guidelines is not well understood. OBJECTIVE: To analyze the effect of a decision-support guide and elimination of financial barriers to testing on use of prenatal genetic testing and decision making among pregnant women of varying literacy and numeracy levels. DESIGN, SETTING, AND PARTICIPANTS: Randomized trial conducted from 2010-2013 at prenatal clinics at 3 county hospitals, 1 community clinic, 1 academic center, and 3 medical centers of an integrated health care delivery system in the San Francisco Bay area. Participants were English- or Spanish-speaking women who had not yet undergone screening or diagnostic testing and remained pregnant at 11 weeks' gestation (n = 710). INTERVENTIONS: A computerized, interactive decision-support guide and access to prenatal testing with no out-of-pocket expense (n = 357) or usual care as per current guidelines (n = 353). MAIN OUTCOMES AND MEASURES: The primary outcome was invasive diagnostic test use, obtained via medical record review. Secondary outcomes included testing strategy undergone, and knowledge about testing, risk comprehension, and decisional conflict and regret at 24 to 36 weeks' gestation. RESULTS: Women randomized to the intervention group, compared with those randomized to the control group, were less likely to have invasive diagnostic testing (5.9% vs 12.3%; odds ratio [OR], 0.45 [95% CI, 0.25-0.80]) and more likely to forgo testing altogether (25.6% vs 20.4%; OR, 3.30 [95% CI, 1.43-7.64], reference group screening followed by invasive testing). Women randomized to the intervention group also had higher knowledge scores (9.4 vs 8.6 on a 15-point scale; mean group difference, 0.82 [95% CI, 0.34-1.31]) and were more likely to correctly estimate the amniocentesis-related miscarriage risk (73.8% vs 59.0%; OR, 1.95 [95% CI, 1.39-2.75]) and their estimated age-adjusted chance of carrying a fetus with trisomy 21 (58.7% vs 46.1%; OR, 1.66 [95% CI, 1.22-2.28]). Significant differences did not emerge in decisional conflict or regret. CONCLUSIONS AND RELEVANCE: Full implementation of prenatal testing guidelines using a computerized, interactive decision-support guide in the absence of financial barriers to testing resulted in less test use and more informed choices. If validated in additional populations, this approach may result in more informed and preference-based prenatal testing decision making and fewer women undergoing testing. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00505596.

Preferences for outcomes associated with decisions to undergo or forgo genetic testing for Lynch syndrome.

BACKGROUND: Current guidelines recommend offering genetic testing for Lynch syndrome to individuals whose tumors suggest this condition and to relatives of affected individuals. Little is known, however, regarding how patients view the prospect of such testing. In addition, data on preferences (utilities) for the potential outcomes of testing decisions for use in cost-effectiveness analyses are lacking. METHODS: Time tradeoff utilities were elicited for 10 potential outcomes of Lynch syndrome testing decisions and 3 associated cancers from 70 participants, representing a range of knowledge about and experiences with Lynch syndrome. RESULTS: Highest mean utilities were assigned to scenarios in which only the assessor's sibling had Lynch-associated colorectal cancer (ranging from 0.669 ± 0.231 to 0.760 ± 0.220). Utilities assigned to scenarios in which the assessor had Lynch-associated colorectal cancer ranged from 0.605 ± 0.252 to 0.682 ± 0.246, whereas the lowest mean utilities were assigned to 2 of the general cancer states (0.601 ± 0.238 and 0.593 ± 0.272 for colorectal and ovarian cancer respectively). Only 43% of the sample assigned higher values to undergoing Lynch testing and receiving negative results versus forgoing Lynch testing, whereas 50% assigned higher values to undergoing rather than forgoing surgery to prevent a subsequent cancer. CONCLUSIONS: Genetic testing for Lynch syndrome, regardless of results, can have profound effects on quality of life; the utilities we collected can be used to incorporate these effects into cost-effectiveness analyses. Importantly, preferences for the potential outcomes of testing vary substantially, calling into question the extent to which patients would avail themselves of such testing if it were offered to them.

Shielding device for endoscopic procedures during lower gastrointestinal endoscopy.

Objectives: The coronavirus pandemic significantly impacted endoscopic practice. During lower gastrointestinal endoscopy, infectious substances disseminate; therefore, we developed an infection control device (STEP-L) for lower gastrointestinal endoscopy and examined its usefulness. Methods: STEP-L wraps around the patient's buttocks and covers the endoscope. Using lower endoscopy training models, three endoscopists performed 18 colonoscopies with STEP-L (group S) and without (group C). Endoscopic insertion time and pigmented areas of ​​gloves and diapers after the examination were compared between both groups. Results: Insertion of the endoscope up to the cecum was possible in all 18 examinations. The insertion time to the cecum was 52.4 ± 19.0 s in group S and 53.9 ± 13.3 s in group C. The pigmented areas of the ​​gloves measured 39,108.0 ± 16,155.3 pixels in group C, but were significantly reduced to 2610.5 ± 4333.8 pixels in group S (p < 0.05). The pigmented areas of the diapers measured 2280.9 ± 3285.2 pixels in group C, but were significantly reduced to 138.0 ± 82.9 pixels in group S (p < 0.05). Conclusions: Using STEP-L does not change the insertion time, and is technically feasible. STEP-L significantly reduces the adhesion of virtual pollutants to the surroundings, suggesting that this device is useful for infection control during lower gastrointestinal endoscopy.

Comparisons of pelvic floor muscle performance, anxiety, quality of life and life stress in women with dry overactive bladder compared with asymptomatic women.

UNLABELLED: Study Type - Therapy (case control) Level of Evidence 3b What's known on the subject? and What does the study add? Abnormal pelvic floor muscle function has been associated with chronic pelvic pain syndromes. This study adds evidence about pelvic muscle performance in women with dry overactive bladders. OBJECTIVES: To determine if pelvic floor muscle surface electromyography (sEMG) measurements differed between women with dry overactive bladder (OAB) symptoms and asymptomatic controls. To determine whether pelvic floor muscle performance was associated with anxiety scores, quality of life and life stress measures PATIENTS AND METHODS: We enrolled 28 women with urinary urgency and frequency without urinary incontinence, and 28 age-matched controls. sEMG was used to assess pelvic muscle performance. Participants also completed the Beck Anxiety Inventory, Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire and Recent Life Changes Questionnaire. RESULTS: Anxiety scores were significantly higher in women with dry OAB than in controls. No significant differences were found in sEMG measures of pelvic muscle contraction or relaxation between the two groups. There was no significant correlation between sEMG pretest resting baseline measurements and the Beck Anxiety Inventory, the Pelvic Floor Distress Inventory, the Pelvic Floor Impact Questionnaire or life stress scores among symptomatic women. As expected, women with dry OAB had significantly higher scores on the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire. CONCLUSIONS: This study supports a relationship between dry OAB symptoms and anxiety that warrants further exploration. Resting sEMG baselines were not elevated and did not support the hypothesis that women with dry OAB are unable to relax their pelvic floor muscles.

The effect of weight loss on changes in health-related quality of life among overweight and obese women with urinary incontinence.

OBJECTIVE: To estimate the effect of change in weight and change in urinary incontinence (UI) frequency on changes in preference-based measures of health-related quality of life (HRQL) among overweight and obese women with UI participating in a weight loss trial. METHODS: We conducted a longitudinal cohort analysis of 338 overweight and obese women with UI enrolled in a randomized clinical trial comparing a behavioral weight loss intervention to an educational control condition. At baseline, 6, and 18 months, health utilities were estimated using the Health Utilities Index Mark 3 (HUI3), a transformation of the SF-36 to the preference-based SF-6D, and the estimated Quality of Well-Being (eQWB) score (a summary calculated from the SF-36 physical functioning, mental health, bodily pain, general health perceptions, and role limitations-physical subscale scores). Potential predictors of changes in these outcomes were examined using generalized estimating equations. RESULTS: In adjusted multivariable models, weight loss was associated with improvement in HUI3, SF-6D, and eQWB at 6 and 18 months (P < 0.05). Increases in physical activity also were independently associated with improvement in HUI3 (P = 0.01) and SF-6D (P = 0.006) scores at 18 months. In contrast, reduction in UI frequency did not predict improvements in HRQL at 6 or 18 months. CONCLUSION: Weight loss and increased physical activity, but not reduction in UI frequency, were strongly associated with improvements in health utilities measured by the HUI3, SF-6D, and eQWB. These findings provide important information that can be used to inform cost-utility analyses of weight loss interventions.

Success of uterus-preserving treatments for abnormal uterine bleeding, chronic pelvic pain, and symptomatic fibroids: age and bridges to menopause.

OBJECTIVE: The purpose of this study was to determine whether age at first uterus-preserving treatment (UPT) predicts symptom resolution among women with common pelvic problems. STUDY DESIGN: We conducted an analysis of 557 participants in the Study of Pelvic Problems, Hysterectomy and Intervention Alternatives cohort who reported having undergone a UPT. We performed multivariable regression modeling age at first UPT, hysterectomy, menopause, and other covariates to predict symptom resolution. RESULTS: Mean ± SD age at enrollment was 42.7 ± 4.7 years; mean follow-up time was 4.4 ± 2.7 years. Sixteen percent of the women underwent hysterectomy; 37% of the women entered menopause. Hysterectomy was a strong predictor of symptom resolution (P < .001). Compared with women who were younger (first UPT at age <40 years), older women reported greater symptom resolution, even after the data were controlled for hysterectomy use and menopausal status (P = .028). CONCLUSION: Women who are ≥40 years old when they undergo their first uterus-preserving treatment experience greater symptom resolution than younger women. Framing UPTs as hysterectomy alternatives may be accurate only for a subset of women who are >40 years old.

Comparison and correlates of three preference-based health-related quality-of-life measures among overweight and obese women with urinary incontinence.

PURPOSE: To compare three preference-based health-related quality-of-life (HRQL) measures and examine independent correlates of HRQL among overweight and obese women with urinary incontinence (UI) enrolled in a weight loss intervention trial. METHODS: Participants completed baseline questionnaires, which included the Health Utilities Index 3 (HUI3) and Medical Outcomes Study Short Form-36 (SF-36). The SF-36 was used to derive SF-6D and estimated Quality of Well-Being (eQWB) scores. Height, weight, medical history, incontinence measures, and level of physical activity also were assessed. The intraclass correlation coefficient (ICC) was computed, and differences in mean scores across HRQL measures were examined. Potential correlates of HUI3, SF-6D, and eQWB scores were evaluated using multivariable generalized linear models. RESULTS: Mean ± SD scores for the HUI3, SF-6D, and eQWB were 0.81 ± 0.18, 0.75 ± 0.10, and 0.71 ± 0.06, respectively. Significant differences were observed across measures (P < 0.0001), and the overall ICC was 0.36. In multivariable analyses, BMI was negatively associated with HUI3 (P = 0.003) and eQWB (P < 0.001), and UI episode frequency was negatively associated with eQWB (P = 0.015) and SF-6D (P < 0.001). CONCLUSIONS: Significant differences in mean utilities across the HUI3, SF-6D, and eQWB indicate that these measures do not assess identical dimensions of HRQL. Both BMI and UI episode frequency were related to HRQL in this cohort; however, the magnitude of the relationship depended on the preference-based measure used. These findings highlight the need to consider the method used to generate HRQL values for calculating quality-adjusted life-years in cost-utility analyses, since choice of method may have a substantial impact on the outcome of the analysis.

Attitudes toward prenatal testing and pregnancy termination among a diverse population of parents of children with intellectual disabilities.

OBJECTIVE: To determine how parents of children with intellectual disabilities view prenatal testing and pregnancy termination for their child's condition. METHOD: We interviewed 201 English-speaking or Spanish-speaking caregivers of children aged 2 to 10 years. Primary outcomes were being disinclined to undergo prenatal testing or pregnancy termination for the child's condition in a future pregnancy. RESULTS: While only 33% of the sample indicated they would not have prenatal testing, 75% were disinclined to terminate their pregnancy if their fetus was affected. In multivariable logistic regression analysis, Asians were significantly less likely than White participants to say they would forego prenatal testing (adjusted odds ratio (aOR) = 0.08, 95% confidence interval (CI) = 0.01-0.86, p = 0.037), while Latinos had lower odds of being disinclined to terminate (aOR = 0.27, 95% CI = 0.07-0.99, p = 0.048). Participants who felt that abortion for their child's condition should not be available were more likely to say they would forego prenatal testing (aOR = 5.10, 95% CI = 2.09-12.43, p < 0.001) and, not surprisingly, they were also at higher odds of being disinclined to terminate pregnancy for this condition (aOR = 13.63, 95% = CI 4.19-44.34, p < 0.001). Greater life satisfaction also was associated with being disinclined to terminate pregnancy (aOR = 3.40, 95% CI = 1.34-8.61, p = 0.010). CONCLUSION: Although many parents of children with intellectual disabilities believe they would desire information regarding their fetus in a future pregnancy, most feel they would not opt to terminate their pregnancy. As new tests for intellectual disabilities become available, determining what would be most useful to prospective parents should become a high priority.

Gender differences in probable posttraumatic stress disorder among police responders to the 2001 World Trade Center terrorist attack.

BACKGROUND: Police responders to the 2001 World Trade Center (WTC) disaster were previously reported to have an increased prevalence of probable posttraumatic stress disorder (PTSD). METHODS: Four thousand seventeen police responders (3,435 men and 582 women) were interviewed 2-3 years after 9/11/01 as part of the World Trade Center Health Registry. Demographic, occupational, and event-specific risk factors were evaluated for probable PTSD, determined by DSM-IV criteria using the Posttraumatic Stress Checklist (PCL). RESULTS: Overall prevalence of probable PTSD was 8.3% (women: 13.9%; men: 7.4%, P < 0.001). Risk factors for both genders included 9/11-related injury and older age. For men, specific risk factors were: presence in WTC Towers on 9/11 and Hispanic ethnicity; and for women, witnessing horror and education less than a college degree. CONCLUSIONS: Significantly higher prevalence of probable PTSD was found for female police responders. Although consistent with civilian populations, this finding contrasts with other studies of PTSD and WTC rescue and recovery workers, and police prior to 9/11.

Factors associated with undergoing bilateral salpingo-oophorectomy at the time of hysterectomy for benign conditions.

OBJECTIVE: To identify possible factors associated with undergoing bilateral salpingo-oophorectomy (BSO) at the time of hysterectomy among women with benign conditions. METHODS: This was a cross-sectional analysis using the 2005 Nationwide Inpatient Sample. Women aged 18 years or older who underwent hysterectomy with BSO or hysterectomy only for a benign condition were included. We examined a broad range of factors associated with undergoing BSO in multivariable analyses. RESULTS: Fifty-two percent of 461,321 hysterectomies included BSO, with a mean age of 49 years compared with 43 years in the hysterectomy-only group (P<.001). The odds of BSO were two times higher in the Midwest and South and 1.67 times higher in the West as compared with the Northeast (P<.001). Women who were uninsured or had Medicaid were more likely to undergo BSO compared with those with private insurance (odds ratio 1.86, 95% confidence interval 1.14-3.04 for "no charge/charity," odds ratio 1.21, 95% confidence interval 1.08-1.35 for Medicaid) Although BSO was more common among white women than African-American, Latina, and Asian women (P<.001), lower income was associated with BSO among African-American and white women only, not among Asian and Latina women (P=.007 for test for interaction). BSO was eight times as likely with a laparoscopic hysterectomy and 12 times as likely with an abdominal hysterectomy compared with a vaginal approach (P<.001). Women who had endometriosis, pelvic infection, or an ovarian cyst were more likely to undergo BSO (P<.001) compared with women who did not have these diagnoses. CONCLUSION: There is significant nationwide variation in the practice of BSO. Age, route of hysterectomy, and diagnosis at surgery affect BSO rates. Nonclinical factors such as race or ethnicity, insurance status, income, and geographic location are also associated with BSO practice. LEVEL OF EVIDENCE: II.

Computerized prenatal genetic testing decision-assisting tool: a randomized controlled trial.

OBJECTIVE: Guidelines for fetal aneuploidy testing recommend that screening and diagnostic testing be made available to pregnant women of all ages and that providers explain the differences between these tests to help their patients make informed testing decisions. We sought to estimate the effect of a computerized, interactive prenatal testing decision tool on prenatal testing decision making. METHODS: Four hundred ninety-six English- or Spanish-speaking women at 20 or fewer weeks of gestation were randomly assigned to view the interactive prenatal testing decision tool or the California Department of Health Services' educational booklet. Primary outcomes were knowledge, risk awareness, intervention satisfaction, decisional conflict, and among women aged at least 35 years, use of invasive diagnostic testing. RESULTS: Women assigned to the interactive prenatal testing decision tool had higher knowledge scores (79.5% compared with 64.9%, P<.001), were more likely to correctly estimate their risk of procedure-related miscarriage (64.9% compared with 48.1%, P=.002) and carrying a Down syndrome-affected fetus (63.5% compared with 15.1%, P<.001), were more satisfied with the intervention (P<.001), and had less decision uncertainty (P<.001) than controls after viewing the intervention. Most of these differences persisted over time. Among women aged at least 35 years, the interactive prenatal testing decision tool viewers who were originally less inclined to undergo invasive testing were ultimately more likely than similarly inclined controls to have amniocentesis or chorionic villus sampling (44.8% compared with 29.2%), whereas those who were originally more inclined to undergo an invasive procedure ultimately were less likely than similarly inclined controls to have a diagnostic procedure (84.6% compared with 94.9%; P=.015 for interaction). CONCLUSION: Using an interactive prenatal testing decision tool results in more informed prenatal genetic testing decisions than viewing standard educational booklets. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, www.clinicaltrials.gov, NCT00686062 LEVEL OF EVIDENCE: I.