Evaluating a Future-Oriented Positive Youth Development Intervention to Reduce Sexual Risk Among Highly Mobile Youth: Results and Challenges.

PURPOSE: Youth experiencing or at risk of experiencing homelessness need tailored prevention programming to prevent unplanned pregnancy and sexually transmitted infections. This study evaluated the efficacy of a small-group, future-oriented positive youth development (PYD) intervention to reduce sexual risk behaviors. METHOD: Youth aged 14-19 (n = 483) experiencing or at risk of experiencing homelessness were recruited at youth-serving agencies and in alternative schools. Each cohort enrolled was randomized either to a 10-session, 5-week group future-oriented intervention to support them in adopting health-promoting behaviors such as using contraception, including condom use (n = 244) or to a no-treatment condition where they received usual services/schooling (n = 239). We assessed at baseline and 3-month and 9-month follow-up (1) vaginal intercourse without consistent contraception use, (2) vaginal and anal intercourse without consistent condom use, and (3) sexual risk behaviors, including current (last 3 months) effective contraception use by females who did not report current use at baseline. RESULTS: There was no significant difference between treatment and control conditions for most outcomes. However, among females not currently using contraception at baseline, 34% in the treatment condition compared to 12.9% in the control condition reported using contraception in the 3 months before the 9-month survey, a statistically significant difference. DISCUSSION: This sexual risk reduction intervention, grounded in PYD theory and tailored to address the needs of marginalized groups of youth, demonstrated efficacy at increasing contraceptive uptake among females. The need for PYD interventions that can be delivered in a variety of nontraditional school and service settings are discussed.

Primary peritoneal clear cell carcinoma arising in the setting of abdominal wall Endometriosis: A case report and review of the literature.

•Primary peritoneal clear cell carcinoma can arise from endometriotic implants within the abdomen and pelvis.•Immunohistochemistry can be used to confirm primary disease site. Endometriotic origin can be inferred based on clinical history and intraoperative findings suggestive of endometriosis.•While no standardized treatment exists, consideration should be given to cytoreductive surgery with adjuvant chemotherapy. Adjuvant radiation can also be considered for local control.

Uterine adenosarcoma presenting as uterine inversion: A case study.

•Non-puerperal uterine inversion can be associated with uterine sarcomas.•Adenosarcoma is a tumor composed of benign epithelium and malignant stroma.•If malignancy is suspected or confirmed treatment of uterine inversion with hysterectomy is advised.

Who Benefits from School-Based Teen Pregnancy Prevention Programs? Examining Multidimensional Moderators of Program Effectiveness Across Four Studies.

Recent research has suggested the importance of understanding for whom programs are most effective (Supplee et al., 2013) and that multidimensional profiles of risk and protective factors may moderate the effectiveness of programs (Lanza & Rhoades, 2012). For school-based prevention programs, moderators of program effectiveness may occur at both the individual and school levels. However, due to the relatively small number of schools in most individual trials, integrative data analysis across multiple studies may be necessary to fully understand the multidimensional individual and school factors that may influence program effectiveness. In this study, we applied multilevel latent class analysis to integrated data across four studies of a middle school pregnancy prevention program to examine moderators of program effectiveness on initiation of vaginal sex. Findings suggest that the program may be particularly effective for schools with USA-born students who speak another language at home. In addition, findings suggest potential positive outcomes of the program for individuals who are lower risk and engaging in normative dating or individuals with family risk. Findings suggest potential mechanisms by which teen pregnancy prevention programs may be effective.

AIM for Teen Moms: Social Support's Role in Contraception Use Among Young Mothers.

PURPOSE: Rapid repeat pregnancy is associated with negative outcomes for teen mothers and their offspring. Contraceptive use can reduce this risk. We explored the impact of AIM for Teen Moms, a future-oriented behavioral intervention, on emotional and tangible support and the influence of this support on the attitudes, intentions, and past 3-month contraceptive use behaviors. METHOD: Participants were 295 first-time moms (ages 15-19) in Los Angeles County who participated in a randomized control trial intervention to reduce rapid repeat pregnancies. Participants completed surveys at baseline and 36-months. Hypotheses were tested using multivariate and interaction analysis. RESULTS: Teen mothers in treatment group reported more emotional (ß =.13, p < .05) and tangible support (ß =.13, p < .05). Higher tangible support was positively associated with birth control attitudes (ß =.13, p < .05), which, in turn, predicted intention to use birth control (ß =.31, p < .001). Intention to use birth control also predicted higher past 3-month birth control use (ß =.18, p < .01); there was also a direct path from attitude to 3-month birth control use (ß =.35, p < .001). There was no association between emotional support and birth control attitudes, intentions, or behaviors. CONCLUSION: AIM for Teen Mom's effects on contraception use at 36 months was mediated by social support, specifically tangible support, which, in turn, affected birth control attitudes, intentions, and reported birth control use. Interventionists must consider how intervention content can specifically address the building of target support to meet the needs of teen mothers.

Non-islet cell tumor hypoglycemia in a patient with uterine carcinosarcoma.

•Non-islet cell tumor hypoglycemia (NICTH) is a rare cause of hypoglycemia in patients with uterine carcinosarcoma.•Complete surgical resection is the first-line treatment for NICTH.•In patients with tumors not amenable to complete resection, partial resection can provide improvement in severe hypoglycemia.

Surveillance of mental and behavioral health care utilization and use of telehealth, active component, U.S. Armed Forces, 1 January 2019-30 September 2020.

This analysis of population-level health care utilization data evaluates changes in monthly counts and rates of medical encounters for mental and behavioral health (MH/BH) conditions and the proportion of care delivered via telehealth among active component military members of the U.S. Armed Forces during the first 6 months (March-September 2020) of the COVID-19 pandemic. Comparisons are also made to the same time period in the previous year (2019). Telehealth usage increased during the early pandemic and was on average 25% higher during March-September 2020 as compared to the previous year. In contrast, MH/BH outpatient visit rates declined modestly between March and May 2020 before rebounding in June and remaining stable through September 2020. The number of bed days attributable to MH/BH conditions also declined during March and April 2020 and was on average 30% lower during March-September 2020 as compared to the same period in the prior year. Continued surveillance is warranted to track MH/BH health care utilization during the later months of the pandemic to ensure that sufficient resources continue to be directed towards MH/BH care to support the health and readiness of active component service members.

Asparagus officinalis Exhibits Anti-Tumorigenic and Anti-Metastatic Effects in Ovarian Cancer.

Ovarian cancer is one of the leading causes of female cancer death. Emerging evidence suggests that many dietary natural products have anti-tumorigenic activity, including that of asparagus officinalis. The current study aimed to assess the anti-tumorigenic and anti-metastatic effects of asparagus officinalis on serous ovarian cancer cell lines and a transgenic mouse model of high grade serous ovarian cancer. Asparagus officinalis decreased cellular viability, caused cell cycle G1 phase arrest and induced apoptosis in the OVCAR5 and SKOV3 cells. Induction of apoptosis and inhibition of cell proliferation was rescued by the pan-caspase inhibitor, Z-VAD-FMK, implying that its cytotoxic effects were mainly dependent on caspase pathways. Asparagus officinalis increased levels of ROS and decreased mitochondrial membrane potential with corresponding increases in PERK, Bip, Calnexin PDI and ATF4 in both cell lines. Treatment with asparagus officinalis also reduced ability of adhesion and invasion through epithelial-mesenchymal transition and reduction of VEGF expression. The combination of Asparagus officinalis with paclitaxel had synergistic anti-proliferative activity. Furthermore, Asparagus officinalis significantly inhibited tumor growth and reduced serum VEGF in a genetically engineered mouse model of ovarian cancer under obese and lean conditions, accompanied with a decrease in the expression of Ki67, VEGF and phosphorylated S6, and in an increase in phosphorylation of AMPK in the ovarian tumor tissues. Overall, our data provide a pre-clinical rationale for asparagus officinalis in the prevention and treatment of ovarian cancer as a novel natural product.

Contemporary Incidence of Medical Inoperability in Clinical Stage I Endometrial Cancer.

BACKGROUND: Minimally invasive surgical (MIS) staging is the standard treatment approach for clinical stage I endometrial cancer. Historical rates of inoperability in endometrial cancer are approximately 10%. Given surgical and medical advancements against increasing population obesity, we aimed to describe a contemporary incidence of medical inoperability in clinical stage I endometrial cancer. PATIENTS AND METHODS: Patients diagnosed with clinical stage I endometrial cancer of any histology from April 2014 to December 2018 were included in this retrospective cohort study. The primary outcome, medical inoperability, was defined as (1) patients deemed inoperable by a gynecologic oncologist at initial consultation, (2) patients deemed inoperable during preoperative clearance, or (3) an aborted hysterectomy. Fisher's exact or χ2, and Student's t-test or Wilcoxon rank sum test were used, as appropriate, for data analysis. Multivariable logistic regression was also employed. RESULTS: Overall, 767 patients were included, of which 4.6% (35/767) were determined to be inoperable. The inoperable group had a higher body mass index (52.7 vs. 33.9, p < 0.001), and increased rates of diabetes (62.8%, 22/35 vs. 27.1%, 199/732, p < 0.001), coronary artery disease (31.4%, 11/35 vs. 7.1%, 52/732, p < 0.001), and hypertension (94.3%, 33/35 vs. 70.2%, 514/732, p < 0.001). Of those with attempted surgical staging, hysterectomy was aborted intraoperatively in 0.68% (5/737). The overall complication rate was 11.6% (86/737). CONCLUSIONS: With maximal surgical effort and MIS, hysterectomy is possible in > 95% of patients with newly diagnosed endometrial cancer treated at a high-volume center. Complication rates were comparable to other trials evaluating the safety of MIS staging for endometrial cancer.

Attrition Rates and Incidence of Mental Health Disorders in an Attention-Deficit/Hyperactivity Disorder (ADHD) Cohort, Active Component, U.S. Armed Forces, 2014-2018.

Attention-deficit/hyperactivity disorder (ADHD) is a common childhood diagnosis and affects the pool of potential military applicants. Early detection and treatment of ADHD may decrease the risk of developing comorbidities; however, accession policy in place during this study period (2014-2018) disqualified applicants who used ADHD medication for more than 24 months cumulative after age 14. The objective of this study was to assess attrition from military service in newly accessed active component service members diagnosed with ADHD as compared to controls. In addition, attrition rates and incidence rates of mental health diagnoses were assessed in service members with ADHD by treatment status (i.e., treated vs untreated ADHD) where treatment was defined as being dispensed an FDA-approved ADHD medication at least twice within 181 days. Almost two-thirds (64.8%) of newly accessed ADHD cases in 2014 were identified after enlistment medical screening at Military Entrance Processing Stations (MEPS) (i.e., post-MEPS). These post-MEPS ADHD cases accounted for 99.1% of the treated ADHD cases. The vast majority of treated cases (91.0%) were dispensed ADHD medication within 6 months of accession. The treated ADHD group had higher rates of attrition and incidence of mental health disorders during the followup period. These study findings highlight the problem of nondisclosure of ADHD among military applicants. Future changes to enlistment standards should consider the optimal way to promote applicant disclosure of ADHD during MEPS screening or for medical waiver review and should discourage withholding an ADHD diagnosis during enlistment.

Psychosocial Characteristics of Transgender Youth Seeking Gender-Affirming Medical Treatment: Baseline Findings From the Trans Youth Care Study.

PURPOSE: This study aimed to characterize two developmental cohorts of transgender and nonbinary youth enrolled in the Trans Youth Care Network Study and describe their gender identity-related milestones and baseline mental health and psychosocial functioning. METHODS: Trans Youth Care participants were recruited from four pediatric academic medical centers in the U.S. before initiating medical treatment for gender dysphoria either with gonadotropin-releasing hormone agonists (GnRHa) or gender-affirming hormones (GAH). GnRHa cohort data were collected from youth and a parent; GAH cohort data were collected from youth only. RESULTS: A total of 95 youth were enrolled in the GnRHa cohort. Mean age was 11.22 years (standard deviation = 1.46), and the majority were white (52.6%) and designated male at birth (51.6%). Elevated depression symptoms were endorsed by 28.6% of GnRHa cohort youth, and 22.1% endorsed clinically significant anxiety. Approximately one fourth (23.6%) endorsed lifetime suicidal ideation, with 7.9% reporting a past suicide attempt. A total of 316 youth were enrolled in the GAH cohort. The mean age was 16.0 years (standard deviation = 1.88), and the majority were white (62%) and designated female at birth (64.9%). Elevated depression symptoms were endorsed by 51.3% of the GAH cohort, and 57.3% endorsed clinically significant anxiety. Two-thirds (66.6%) endorsed lifetime suicidal ideation, with 24.6% reporting a past suicide attempt. Life satisfaction was lower among both cohorts compared with population-based norms. CONCLUSIONS: GnRHa cohort youth appear to be functioning better from a psychosocial standpoint than GAH cohort youth, pointing to possible benefits of accessing gender-affirming treatment earlier in life.

Comparing Laparotomy with Robot-assisted Interval Debulking Surgery for Patients with Advanced Epithelial Ovarian Cancer Receiving Neoadjuvant Chemotherapy.

STUDY OBJECTIVE: Compare survival of patients with advanced epithelial ovarian cancer (EOC) undergoing interval debulking surgery (IDS) with either robot-assisted (R-IDS) or open (O-IDS) approach. Second, we assessed the impact of adjuvant and neoadjuvant chemotherapy (NACT) cycles as independent variables associated with survival in this patient population. DESIGN: Retrospective cohort study. SETTING: Single tertiary care center. PATIENTS: Total of 93 patients diagnosed with advanced EOC who underwent NACT before primary debulking surgery after consultation with a gynecologic oncologist. INTERVENTIONS: All patients underwent IDS after completion of NACT with either R-IDS or O-IDS between 2011 and 2018 at a single tertiary care center. Exclusion criteria included receiving fewer than 3 or more than 6 cycles of NACT or having concurrent diagnoses of other malignancies during the treatment period. MEASUREMENTS AND MAIN RESULTS: A total of 93 patients were identified (n = 43 R-IDS; n = 50 O-IDS). Median age (63.0 vs 66.2 years) did not differ between the 2 groups (p = .1). Of the total patients, 91% were optimally cytoreduced (57% R0 and 34% R1), and R0 rate was not influenced by surgical modality (52% O-IDS vs 63% R-IDS, p = .4). Progression-free survival (PFS) and overall survival (OS) did not differ between patients undergoing O-IDS and those undergoing R-IDS (PFS 15.4 vs 16.7 months, p = .7; OS 38.2 vs 35.6 months, p = .7). Cytoreduction to R0 improved both PFS and OS independent of surgical approach. Subgroup analysis showed that, specifically in patients undergoing R-IDS, receiving >6 total cycles of chemotherapy was independently associated with both decreased PFS (hazard ratio 3.85; 95% confidence interval, 1.52-9.73) and OS (hazard ratio 3.97; 95% confidence interval, 1.08-14.59). When analyzed separately, neither NACT nor adjuvant cycle numbers had any effect on survival. CONCLUSION: In this retrospective study of patients with advanced EOC undergoing IDS after NACT, the use of robot-assisted surgery did not affect debulking success or oncologic survival indices. Receiving >6 total cycles of chemotherapy before IDS was associated with a decrease in both PFS and OS in patients undergoing R-IDS in this cohort and warrants further investigation.

Accuracy of preoperative cross-sectional imaging in cervical cancer patients undergoing primary radical surgery.

OBJECTIVE: We aim to describe the false negative (FN) and false positive (FP) rates of preoperative cross-sectional imaging (PCI) prior to radical surgery for cervical cancer. METHODS: A retrospective cohort study of patients who underwent radical hysterectomy for early-stage cervical cancer from January 2010 until December 2017 at a single tertiary care center was performed. Patients were included if they underwent preoperative PCI and radical surgery. Patient demographics and clinicopathologic information were recorded from medical record review. Descriptive statistics were used. RESULTS: Overall, 106 patients met inclusion criteria. Eighty-four percent (89/106) of patients had no suspicion for metastatic disease on PCI, while 16% (17/106) had suspicion for metastatic disease. Of the 89 without suspicion for metastatic disease on PCI, 16% (14/89) had a false negative study with metastatic disease identified on final surgical pathology. False negative rates by modality were 16% (11/70) for PET/CT and 6% (2/33) for diagnostic CT. Of the 17 cases with suspicion for metastatic disease on imaging, 53% (9/17) were false positive studies with no metastatic disease identified histologically. False positive rates by modality were 7% (5/70) for PET/CT and 12% (4/33) for diagnostic CT. CONCLUSION: PCI is a tool to help identify patients who are optimal candidates for radical surgery. In this sample, the false negative rate was 16%, and false positive rate was 53% for PCI among women who underwent primary radical surgery. Further study is needed to explore preoperative testing that may more accurately identify optimal surgical candidates.

Characterizing the contribution of chronic pain diagnoses to the neurologic burden of disease, active component, U.S. Armed Forces, 2009-2018.

In the annual Medical Surveillance Monthly Report (MSMR) burden of disease analysis, neurologic disorders represent the fifth most common category of diagnoses among active component service members within the Military Health System. One major subcategory of this disease group is "all other neurologic conditions." Incidence analysis from 2009-2018 revealed that the vast majority of diagnoses in this undefined subcategory were related to chronic pain and that such diagnoses have been increasing in burden by a considerable amount. Chronic pain diagnoses increased from a rate of 85.5 per 10,000 person- years (p-yrs) in 2009 to 261.1 per 10,000 p-yrs in 2018. Subgroup analysis by demographic characteristics demonstrated that female, non-Hispanic black, older, and enlisted personnel were at increased risk for chronic pain diagnoses. Among the branches of service, members of the Army were at the highest risk of a chronic pain diagnosis with a rate ratio of 4.8 compared to the Navy, the branch with the lowest risk. Future annual burden analyses should consider chronic pain as its own subcategory to better characterize its impact.

Update: Incidence of acute gastrointestinal infections and diarrhea, active component, U.S. Armed Forces, 2010-2019.

Laboratory, reportable medical event, and medical encounter data were analyzed to identify cases of acute gastrointestinal (GI) infections caused by Campylobacter, nontyphoidal Salmonella, Shigella, Escherichia coli (E. coli), or norovirus, as well as cases of unspecified gastroenteritis/diarrhea among U.S. active component service members during 2010-2019. Unspecified gastroenteritis/ diarrhea diagnoses accounted for 98.8% of identified incident cases (4,135.1 cases per 100,000 person-years [p-yrs]). Campylobacter was the most frequently identified specific etiology (17.6 cases per 100,000 p-yrs), followed by nontyphoidal Salmonella (12.7 cases per 100,000 p-yrs), norovirus (10.8 cases per 100,000 p-yrs), E. coli (7.5 cases per 100,000 p-yrs), and Shigella (3.2 cases per 100,000 p-yrs). Crude annual rates of norovirus, E. coli, Campylobacter, and Salmonella infections and unspecified gastroenteritits/diarrhea increased between 2010 and 2019 while rates of Shigella infections were relatively stable. Among deployed service members during the 10-year period, only 150 cases of the 5 specific causes of gastroenteritis were identified but a total of 20,377 cases of unspecified gastroenteritis/diarrhea were diagnosed (3,062.9 per 100,000 deployed p-yrs).

A Burden and Prevalence Analysis of Chronic Pain by Distinct Case Definitions among Active Duty U.S. Military Service Members, 2018.

BACKGROUND: Chronic pain is a growing problem in the military, and the methods by which we have to perform epidemiologic surveillance are insufficient. It represents both a public health and military readiness concern, as those who suffer from it experience adverse impacts on work productivity, physiological health, and quality of life. OBJECTIVES: This study was designed to assess the prevalence of chronic pain among active component military service members utilizing 2 distinct, published case definitions. It sought to describe the demographics and military characteristics of those receiving chronic pain diagnoses. The study also aimed to provide improved granularity regarding military chronic pain patients' pain severity and its impacts on their job performance. STUDY DESIGN: Cross-sectional analysis for 2018. SETTING: This analysis utilized data available from the Defense Medical Surveillance System, a database containing longitudinal data on service members. METHODS: Patients: The surveillance population consisted of all active component service members from the U.S. Army, Navy, Air Force, and Marines of all grades serving at any point during the surveillance period of January 1, 2018 through December 31, 2018. MEASUREMENT: Diagnoses were ascertained from the administrative records of all medical encounters of individuals who received care through the Military Health System or civilian referrals. Data from patients' Periodic Health Assessment (PHA) encounters were also utilized to derive more granular data regarding their experiences of pain. RESULTS: Case Definition 1, more specific for identifying chronic pain, identified a more severe subset of chronic pain patients when compared against Case Definition 2, a more comprehensive method for identifying potential chronic pain patients. Case Definition 1 found a higher prevalence of impactful pain (CD1: 36.7% vs. CD2: 23.5%), and Case Definition 1 patients are more likely to be on limited duty and require treatment related to their pain. Several demographic groups were also found to be at increased risk of chronic pain diagnosis, including women, black non-Hispanic, Army, older age, and enlisted. LIMITATIONS: First, in utilizing administrative data, this allows for the possibility of misclassification bias. Second, some deployment data still used ICD-9 coding even in 2018, resulting in a minor underestimation by approximately 30 patients and approximately 60 encounters. Third, the prevalence estimates for the demographics were not adjusted for potential confounders. CONCLUSIONS: Chronic pain has been difficult to define via administrative and screening data, and as such its burden and prevalence estimates can vary considerably depending on which case definition is used. This is of particular importance in the U.S. military, as these estimates can significantly impact our calculations for force readiness and the protection of our national security. To our knowledge, this study is the first of its kind to examine chronic pain across the entirety of the U.S. armed forces and to utilize granular, annually collected PHA data in this way. The results of this exploratory analysis could be used as a template to better characterize the burden of chronic pain from a population-based perspective and monitor the effectiveness of pain management strategies.