Progression-free survival is a weakly predictive surrogate end-point for overall survival in follicular lymphoma: A systematic review and meta-analysis.

Although progression-free survival (PFS) is a commonly used surrogate end-point for clinical trials of follicular lymphoma (FL), no analyses have evaluated the strength of surrogacy for PFS with overall survival (OS). A systematic review was performed and 20 studies (total participants, 10 724) met final inclusion criteria. PFS was weakly associated with OS (correlation coefficient; 0.383, p < 0.001). The coefficient of determination was 0.15 (95% CI: 0.002-0.35) suggesting 15% of OS variance could be explained by changes in PFS. This challenges the role for PFS as a surrogate end-point for clinical trials and drug approvals.

Ovarian Cancer Risk-Reduction and Screening in BRCA1/2 Mutation Carriers.

Objective: To determine the utilization of risk-reducing strategies and screening protocols for ovarian cancer in female BRCA1/2 carriers. Methods: This study was a sub-analysis of female participants from a larger multicenter, cross-sectional survey of BRCA1/2 mutation carriers unaffected by cancer. The questionnaire was administered electronically via email at four institutions located in the northeast United States. Data were analyzed with Fisher's exact test. Results: The survey was completed by 104 female BRCA mutation carriers. BRCA subtypes included 54.3% BRCA2, 41.0% BRCA1, and 2.9% both. The age at which patients underwent genetic testing varied 21.2% were 18-24 years, 25.0% were 25-34 years, 29.8% were 35-44 years, and 24.0% were 45 years or older. Nearly, all respondents (97.1%) reported that a provider had discussed risk-reducing surgeries. Of the 79 females who underwent genetic testing before 45 years of age, 53.2% reported that a health care provider recommended taking combined oral contraceptive pills (COCs) to reduce their risk of ovarian cancer, and, of these women, 88.1% chose to use them. COCs were offered at higher rates among women who were younger at the age of genetic testing (18-24: 86%, 25-34: 62%, 35-44: 23%; p < 0.0001). Approximately half (55.8%) of the respondents reported having been offered increased screening for possible early detection of ovarian cancer, of which 81.0% chose to undergo screening. The majority utilized a combination of transvaginal ultrasound and serum CA125 measurements. There were no differences observed in screening utilization based on BRCA mutation type. Conclusion: In our cohort of female BRCA mutation carriers, risk-reducing surgery was offered to almost all women, whereas only half were offered risk-reducing medication and/or increased screening. Further investigation is needed to identify barriers to the utilization of risk-reducing strategies among this high-risk population.

Unexpected Medical Conditions Discovered During Live Donor Kidney Evaluation: Single Center Study.

OBJECTIVES: Living donor kidney transplantation (LDKT) is the preferred method of treatment for patients with end-stage kidney disease. Potential living kidney donors (PLKD) are evaluated through a thorough medical, psychological and surgical work-up to ensure successful transplantation with minimal risks to all parties involved. The transplant center at Rhode Island Hospital has noticed an increasing number of PLKDs excluded from donation due to conditions newly diagnosed during the screening process. Our objective is to understand the local trends underlying the high PLKD exclusion rates in the context of newly diagnosed conditions, age, race, and sex of the excluded donors. STUDY DESIGN AND METHODS: Our study is a retrospective electronic medical record review of the 429 PLKDs screened at Rhode Island Hospital Kidney Transplant Center between December 2012 and April 2023. Age, race, gender, relationship to recipient, and reasons for exclusion were collected from the medical record for each PLKD. CONCLUSION: 115 of the 429 total PLKDs screened were excluded for newly diagnosed conditions, the most common of which were renal issues (49%), diabetes mellitus (33%), and hypertension (13%), with many comorbid diagnoses. While these donors were able to receive proper treatment after their diagnosis, the earliest intervention possible yields the best prognosis. The high prevalence of treatable yet undiagnosed conditions raise many public health concerns, such as primary care gaps or discontinuous healthcare, and increases awareness about the importance of follow-up care for the excluded PLKDs.

Maternal education and its association with maternal and neonatal adverse outcomes in live births conceived using medically assisted reproduction (MAR).

BACKGROUND: To examine the association between maternal education and adverse maternal and neonatal outcomes in women who conceived using medically assisted reproduction, which included fertility medications, intrauterine insemination, or in vitro fertilization. METHODS: We conducted a retrospective cohort study utilizing the US Vital Statistics data set on national birth certificates from 2016 to 2020. Women with live, non-anomalous singletons who conceived using MAR and had education status of the birthing female partner recorded were included. Patients were stratified into two groups: bachelor's degree or higher, or less than a bachelor's degree. The primary outcome was a composite of maternal adverse outcomes: intensive care unit (ICU) admission, uterine rupture, unplanned hysterectomy, or blood transfusion. The secondary outcome was a composite of neonatal adverse outcomes: neonatal ICU admission, ventilator support, or seizure. Multivariable modified Poisson regression models with robust error variance adjusted for maternal age, race, marital status, prenatal care, smoking during pregnancy, neonatal sex, and birth year estimated the relative risk (RR) of outcomes with a 95% confidence interval (CI). RESULTS: 190,444 patients met the inclusion criteria: 142,943 had a bachelor's degree or higher and 47,501 were without a bachelor's degree. Composite maternal adverse outcomes were similar among patients with a bachelor's degree (10.1 per 1,000 live births) and those without a bachelor's degree (9.4 per 1,000 live births); ARR 1.05, 95% CI (0.94-1.17). However, composite adverse neonatal outcomes were significantly lower in women with a bachelor's degree or higher (94.1 per 1,000 live births) compared to women without a bachelor's degree (105.9 per 1,000 live births); ARR 0.91, 95% CI (0.88-0.94). CONCLUSIONS: Our study demonstrated that lower maternal education level was not associated with maternal adverse outcomes in patients who conceived using MAR but was associated with increased rates of neonatal adverse outcomes. As access to infertility care increases, patients who conceive with MAR may be counseled that education level is not associated with maternal morbidity. Further research into the association between maternal education level and neonatal morbidity is indicated.

Dietary Magnesium Intake and Kidney Stone: The National Health and Nutrition Examination Survey 2011-2018.

BACKGROUND: The association between dietary magnesium intake (DMI) and kidney stone (KS) disease is not clear. AIM: To determine the association between DMI and prevalent KS disease defined as self-report of any previous episode of KS. METHODS: We examined The National Health and Nutrition Examination Survey (NHANES) 2011-2018 and used logistic regression analyses adjusting for demographics, BMI, histories of hypertension, diabetes, thiazide use, cigarette smoking, alcohol drinking, relevant dietary and supplemental intakes to determine the independent association between DMI and prevalent KS disease. RESULTS: A total of 19,271 participants were eligible for the final analysis, including 1878 prevalent KS formers. Mean DMI among stone formers was 295.4 mg/day, as compared to 309.6 mg/day among non-stone formers (p=0.02). Higher DMI was strongly associated with lower odds of prevalent KS disease in univariate analysis regardless of when DMI was analyzed as a continuous variable (OR=0.94, 95% CI: 0.89-0.99, p=0.02) or when the extreme quartiles of DMI were compared (OR=0.74, 95% CI: 0.60-0.92, p=0.007). In the multivariable-adjusted regression analysis, those in the highest quartile of DMI compared to the lowest quartile (≥379 mg vs. <205 mg) had significantly reduced odds of prevalent KS (OR=0.70, 95% CI: 0.52-0.93, p=0.01). When DMI was analyzed as a continuous variable, there was a trend toward reduced odds of prevalent KS disease with higher DMI (OR=0.92 per 100 mg, 95% CI: 0.84-1.01, p=0.07). CONCLUSIONS: Our study suggests that higher DMI is associated with a reduced risk of KS disease. Future prospective studies are needed to clarify the causal relationship between DMI and KS disease.

A randomized trial comparing the 52-mg levonorgestrel system with combination oral contraceptives for treatment of heavy menstrual bleeding.

BACKGROUND: The levonorgestrel intrauterine system and combined oral contraceptives are the 2 most commonly used nonsurgical treatments for heavy menstrual bleeding in the United States. However, there are limited data on their relative effectiveness and on their impact on bleeding-specific quality of life. OBJECTIVE: This study aimed to compare the effectiveness of the 52-mg levonorgestrel intrauterine system with that of combined oral contraceptives for improving quality of life among individuals who self-report heavy menstrual bleeding. We hypothesized that the levonorgestrel intrauterine system would be more effective than combined oral contraceptives at 6 and 12 months after treatment. STUDY DESIGN: We conducted a pragmatic randomized trial of individuals who self-reported heavy menstrual bleeding. Individuals were eligible if they did not have contraindications to either the levonorgestrel intrauterine system or combined oral contraceptives and were determined to have a nonstructural cause of heavy menstrual bleeding. Eligible and consenting participants were randomly assigned in a 1:1 ratio to receive a 52-mg levonorgestrel intrauterine system or a monophasic 30- or 35-µg ethinyl estradiol-containing combined oral contraceptive. The main outcome was mean change in bleeding-related quality of life, measured by the 20-question Menstrual Bleeding Questionnaire (score range, 0-75) at 6 and 12 months. Differences in group means and confidence intervals for the Menstrual Bleeding Questionnaire score were computed by multivariable linear mixed-effects regression; 24 participants per group were needed to detect a 10-point difference in change in mean Menstrual Bleeding Questionnaire score between individuals treated with the levonorgestrel intrauterine system and those treated with combined oral contraceptives at each follow-up time point. RESULTS: A total of 62 individuals were randomly assigned to treatment (n=29 allocated to levonorgestrel intrauterine system and n=33 allocated to combined oral contraceptives) and included in the intention-to-treat analyses; 19 of 29 received the levonorgestrel intrauterine system and 31 of 33 received combined oral contraceptives. Eleven percent identified as Black or African American and 44% identified as Hispanic or Latina. Participant characteristics were similar among study groups. Bleeding-related quality of life increased in both study arms, as reflected by a significant decrease in Menstrual Bleeding Questionnaire scores beginning at 6-week follow-up. In the main intention-to-treat analyses (n=62), there were no differences in mean change in Menstrual Bleeding Questionnaire scores at 6 months (difference=-2.5; 95% confidence interval, -10.0 to +5.0) or 12 months (difference=-1.1; 95% confidence interval, -8.7 to +6.5). Findings were similar in the subsets of participants with any follow-up visits (n=52) and who completed all follow-up visits (n=42). In the per-protocol analyses (n=47), a significantly greater decrease in Menstrual Bleeding Questionnaire score was observed in the levonorgestrel intrauterine system arm at 6 months after treatment (difference=-7.0; 95% confidence interval, -13.8 to -0.2) but not at 12 months (difference=-4.8; 95% confidence interval, -11.8 to 2.3) compared with the combined oral contraceptive arm. CONCLUSION: No differences in change of bleeding-related quality of life were observed between the levonorgestrel intrauterine system and combined oral contraceptives at 6 or 12 months. Patients should be counseled that the levonorgestrel intrauterine system and combined oral contraceptives are both effective options for improving bleeding-related quality of life.

Survey of young women with breast cancer to identify rates of fertility preservation (FP) discussion and barriers to FP care.

PURPOSE: To identify the proportion of reproductive age women with breast cancer that engaged in a fertility preservation discussion and reproductive endocrinology and infertility (REI) consultation. METHODS: This cross-sectional survey recruited women 18-42 years who were diagnosed with breast cancer from 2006 to 2016 by phone or email and asked them to complete an online survey. Demographic characteristics, barriers to FP, utilization of FP consultation, and FP procedures (oocyte and embryo cryopreservation) were analyzed. RESULTS: A majority of women (64%) did not have FP discussed by any provider. Older women and those who were parents at the time of diagnosis were less likely to engage in a FP discussion. However, there were no significant differences in partner status or cancer stage between women with or without FP discussions. Of the women who desired future children prior to the cancer diagnosis, 93% received chemotherapy; however, only 34% of these women had a consultation with an REI. The most common reasons for declining FP consultation were already having their desired number of children (41%), financial barriers (14%), and concern about delaying cancer treatment and cancer recurrence (12%). Forty percent of women who desired future children and met with an REI pursued FP procedures. CONCLUSION: Younger women were more likely to receive FP counseling. FP consultations and procedures were low even in women who desired future fertility, with the predominant barriers being cost, fears concerning a delay in cancer treatment, and future cancer recurrence.

The association between trial of labor after cesarean in obese patients and adverse maternal outcomes.

PURPOSE: We hypothesized that among obese patients with a history of cesarean birth, a TOLAC is associated with decreased composite maternal adverse outcomes (CMAO) compared to planned repeat low transverse cesarean section (RLTCS). METHODS: In this population-based cross-sectional study using the National Birth Certificate database from 2016 to 2020, we compared obese patients who attempted TOLAC at term (≥ 37 weeks estimated gestational age) to planned RLTCS. The primary outcome was a CMAO, defined as delivery complications, including intensive care unit (ICU) admission, uterine rupture, unplanned hysterectomy, or maternal blood transfusion. RESULTS: Overall, 794,278 patients met inclusion criteria for the study; 126,809 underwent a TOLAC, and 667,469 had a planned RLTCS. The overall CMAO was significantly higher for patients undergoing TOLAC (9.0 per 1000 live births) compared to RLTCS (5.3 per 1000 live births; aRR 1.64, 95% CI 1.53-1.75). CONCLUSION: This data demonstrate that in obese patients with prior cesarean birth, a trial of labor is associated with increased maternal morbidity when compared to a planned repeat cesarean birth.

Barriers to hormone therapy following prophylactic bilateral salpingo-oophorectomy in BRCA1/2 mutation carriers.

OBJECTIVE: This study aimed to identify barriers to hormone therapy (HT) use among women with BRCA1/2 mutations after prophylactic bilateral salpingo-oophorectomy (BSO). METHODS: A cross-sectional, electronic survey was conducted of BRCA1/2 mutation carriers at Women and Infants Hospital, Yale Medical Center, Hartford Healthcare, and Maine Medical Center. This study was a subanalysis of a subset of female BRCA1/2 mutation carriers who had undergone a prophylactic BSO. Data were analyzed using the Fisher's exact test or t test. RESULTS: We performed a subanalysis of 60 BRCA mutation carriers who underwent a prophylactic BSO. Only 24 women (40%) reported ever using HT. HT use was higher in women who underwent their prophylactic BSO at age younger than 45 years (51% vs. 25%, P = 0.06). Among all women who had a prophylactic BSO, the majority (73%) reported that a provider talked to them about using HT. Two thirds reported having seen contradictory information in the media about long-term consequences of HT. Seventy percent listed their provider as the primary influence in their decision to start HT. The most common reasons for not starting HT included it not being recommended by their physician (46%) and that it was not necessary (37%). CONCLUSIONS: BRCA mutation carriers frequently undergo prophylactic BSO at young ages, and less than half report using HT. This study highlights barriers to HT use, such as patient fears and physician discouragement, and identifies potential areas to improve educational efforts.

Adoption of Complete Bilateral Salpingectomy for Permanent Contraception at Time of Cesarean Delivery in Rhode Island.

OBJECTIVE: Complete bilateral salpingectomy (CBS) can decrease the risk of developing ovarian cancer, although adoption of CBS at cesarean delivery (CD) for permanent contraception has been low. The primary objective was to measure the annual rates of CBS at CD before and after an educational initiative. The secondary objective was to assess rates of providers who offer CBS at CD and their comfort level with the procedure. METHODS: We performed an observational study of OBGYN physicians who perform CD at a single institution. We compared the annual rates of CBS among CD with permanent contraception procedures from the year before and the year after an in-person OBGYN Grand Rounds presentation on December 5, 2019 reviewing the latest research on opportunistic CBS at the time of CD. To evaluate the secondary objectives, anonymous surveys were administered to physicians in-person the month before the presentation. The statistical analysis included chi-square, Fisher's exact test, T-test, ANOVA, and the Cochran-Armitage trend test. RESULTS: After our educational intervention, annual rates of CBS at CD increased from 5.1% [12/05/2018-12/04/2019] to 31.8% [12/5/2019-12/4/2020] (p<0.001), and up to 52% in the last study quarter (p<0.001). Surgical outcomes were similar between tubal ligation and CBS, except for a 5-minute increased total operative time for CBS (p=0.005). Fifty physicians completed the survey prior to the presentation (93% response rate). All physicians offered CBS at time of hysterectomy and interval sterilization, while only 36% offered CBS at time of CD. More physicians felt comfortable performing a CBS with bipolar electrocautery (90%) than suture ligation (56%). CONCLUSION: Our presentation-based educational initiative was associated with a significant increase in performance of CBS at the time of CD.

Endometrial Cancer Surgery With or Without Concomitant Stress Urinary Incontinence Surgery.

OBJECTIVE: To compare quality of life (QOL) among patients with endometrial intraepithelial neoplasia or early-stage endometrial cancer and stress urinary incontinence (SUI) who chose to have concomitant surgery with cancer surgery alone. METHODS: A multicenter, prospective cohort study was conducted across eight U.S. sites. Potentially eligible patients were screened for SUI symptoms. Those who screened positive were offered referral to urogynecology and incontinence treatment, including concomitant surgery. Participants were categorized into two groups: 1) concomitant cancer and SUI surgery or 2) cancer surgery alone. The primary outcome was cancer-related QOL as measured by the FACT-En (Functional Assessment of Cancer Therapy-Endometrial) (range 0-100; higher score indicates better QOL). The FACT-En and questionnaires assessing urinary symptom-specific severity and effects were assessed before surgery and 6 weeks, 6 months, and 12 months after surgery. Adjusted median regression accounting for clustering was used to examine the relationship between SUI treatment group and FACT-En scores. RESULTS: Of 1,322 (53.1%) patients, 702 screened positive for SUI with 532 analyzed; 110 (21%) chose concomitant cancer and SUI surgery, and 422 (79%) chose cancer surgery alone. FACT-En scores increased for both the concomitant SUI surgery and cancer surgery-only groups from the preoperative to the postoperative period. After adjustment for timepoint and preoperative covariates, the median change in FACT-En score (postoperative-preoperative) was 1.2 points higher (95% CI -1.3 to 3.6) for the concomitant SUI surgery group compared with the cancer surgery-only group across the postoperative period. Median time until surgery (22 days vs 16 days; P <.001), estimated blood loss (150 mL vs 72.5 mL; P <.001), and operative time (185.5 minutes vs 152 minutes; P <.001) were all greater for the concomitant cancer and SUI surgery group compared with the cancer-only group, respectively. CONCLUSION: Concomitant surgery did not result in improved QOL compared with cancer surgery alone for endometrial intraepithelial neoplasia and patients with early-stage endometrial cancer with SUI. However, FACT-En scores were improved in both groups.

Effect of Patient Sex on Neurocognitive Decline after Cardiac Surgery.

BACKGROUND: Neurocognitive decline (NCD) is a common complication of cardiac surgery. Understanding risk factors helps surgeons counsel patients pre- and perioperatively about risk, prevention, and treatment. STUDY DESIGN: Patients undergoing cardiac surgery using cardiopulmonary bypass underwent pre- and postoperative neurocognitive testing. Neurocognitive data are presented as a change from baseline to either postoperative day 4 or to 1 month. The score is standardized with respect to age. RESULTS: Eighty-four patients underwent surgery and completed postoperative neurocognitive testing. There was no significant difference in baseline neurocognitive function. NCD was more common in female patients (71%) than male patients (26.4%) on postoperative day 4. By 1 month, the incidence of NCD is similar between female (15.0%) and male patients (14.3%). Of note, female patients differed from male patients in preoperative hematocrit, preoperative creatinine, and type of surgery. CONCLUSIONS: In the acute postoperative period, female patients are both more likely to experience NCD and experience a more severe change from baseline cognitive function. This difference between male and female patients resolves by the 1 month follow-up point. Female patients had a lower preoperative hematocrit and were more likely to receive intraoperative and perioperative blood transfusion. Lower preoperative hematocrit appears to mediate the difference in NCD between male and female patients.

Financial toxicity in BRCA1 and BRCA2 carriers.

OBJECTIVE: Financial toxicity (FT), the cumulative financial burden experienced due to medical care, is a well-established adverse effect of healthcare. Patients with BRCA mutations have significantly increased cancer risks compared to non-affected individuals, requiring more frequent screenings and, at times, prophylactic surgery, increasing their risk for FT. Our primary aim in this study was to describe rates of FT among BRCA carriers. METHODS: We performed a novel, cross-sectional study of FT in BRCA1/2 carriers. Participants were recruited via phone and/or email to complete consents and surveys on REDCap. The FACIT-COST tool, a validated tool for measuring FT, was used to assess FT; scores were divided into tertiles, with high FT defined as COST score < 24. RESULTS: 265 BRCA positive female participants met enrollment criteria; 76 (28.7%) consented to participate and completed the survey. Participants were primarily non-Hispanic White (97.4%), privately insured (82.9%), and employed full time (67.1%). A significant proportion (22.7%) of participants reported delaying or avoiding care secondary to finances. No statistically significant association was seen between financial toxicity groups and analyzed demographics. Participants with high FT were more likely to engage in all surveyed cost-saving measures, with 41.7% of participants reporting delays/avoidance of care due to cost (p = 0.02). CONCLUSIONS: This study of FT in BRCA carriers shows that financial toxicity exists as an issue in this high-risk patient population. This work serves as the first description of FT in BRCA mutation carriers and highlights the importance of incorporating routine counseling on cost when discussing recommendations for screening and clinical care with this patient population.

Comparing Effectiveness of Remote-learning Formats for Resident Physician Didactics.

BACKGROUND: It is important to investigate remote- learning options for medical education. We evaluated retention of research-related knowledge after exposure to pre-recorded audio-based didactics (AUDIO) versus video conference-based didactics (ZOOM). METHODS: Obstetrics and Gynecology residents over the 2020-2021 academic year were randomized to didactics delivered in AUDIO versus ZOOM formats. At baseline, immediately post-exposure, and 3-month post-exposure, objective knowledge was assessed through 15 multiple choice questions. Confidence and satisfaction were assessed on a 5-point Likert scale. Median differences and 95% confidence intervals (CI) were applied to identify a 10% non-inferiority margin. RESULTS: Thirty of thirty-one (30/31, 96.8%) eligible residents participated. At 3-month post-exposure, AUDIO was non-inferior to ZOOM (6.3% mean difference in knowledge scores, 95% CI -3.5-16.2). There were no differences in satisfaction or confidence, though a greater proportion of AUDIO participants indicated they would use a similar resource independently (p=0.008). CONCLUSION: AUDIO didactics may be non-inferior to ZOOM.

"I'm Not Going Home With a Catheter": Patient-Perceived Outcomes Associated With Perioperative Intermittent Catheterization.

IMPORTANCE: Indwelling catheters are a known source of dissatisfaction for postoperative patients. There is a paucity of data describing patient-perceived outcomes associated with the alternative of intermittent self-catheterization (ISC). OBJECTIVES: The aim of this study was to describe patient satisfaction and outcomes associated with ISC after outpatient female pelvic reconstructive surgery. STUDY DESIGN: This was a secondary analysis of a prospective cohort study at an academic tertiary referral center from September 2018 to June 2021. Participants completed preoperative ISC instruction that included an instructional video, 1:1 demonstration with a health care provider, and provision of ISC supplies. Participants were instructed to perform ISC postoperatively until they had 2 consecutive outpatient PVRs less than one-half the voided volume. Participant satisfaction was assessed 2 weeks postprocedure, with adverse events evaluated at 6 weeks. RESULTS: One hundred sixty participants completed preoperative ISC instruction and were included in this analysis. Mean age was 52.1 (SD +/- 11.4) years, mean body mass index was 28.9 (SD +/- 5.8), and mean time from ISC instruction to surgery was 16.4 (SD +/- 15.7) days. Most participants reported no difficulty with ISC (124/160 [78%]) and had high levels of satisfaction (148/151 [98%]). Difficulty performing ISC was not associated with time since ISC instruction ( P = 0.32), difficulty noted at ISC instruction by the health care provider ( P = 0.24), or the duration of ISC instruction ( P = 0.16). On multiple logistic regression, age, body mass index, and prolapse beyond the hymen did not predict difficulty learning or performing ISC. At 6 weeks postprocedure, 22 of 155 participants (14%) endorsed symptoms of a urinary tract infection, and 15 of 160 (9%) had a culture-proven urinary tract infection. CONCLUSIONS: Women undergoing outpatient pelvic reconstructive surgery report ease and satisfaction with ISC.

The association between gestational age and maternal adverse outcomes in patients undergoing trial of labor after cesarean.

BACKGROUND: Although successful trial of labor after cesarean (TOLAC) resulting in vaginal birth after cesarean (VBAC) can lead to improved maternal and neonatal outcomes, an unsuccessful TOLAC is associated with increased risk of uterine rupture, higher blood loss, and increased risk of infection. Data remain limited in terms of whether differences in gestational age of patients who attempt TOLAC affect maternal morbidity. Out objective was to examine the association between gestational age and maternal adverse outcomes in women undergoing trial of labor after cesarean. METHODS: This population-based cross-sectional study used birth data from the U.S. National Vital Statistics from 2014 to 2018. Women with liveborn singleton gestation who underwent TOLAC at 23 - 41 weeks' gestation were included in the analytic population. The primary outcome was a composite of maternal adverse outcomes: admission to the intensive care unit, blood transfusion, uterine rupture, or unplanned hysterectomy. Secondary outcomes were individual measures within the primary composite outcome. Outcomes were compared between patients who underwent TOLAC at term (37-41 weeks gestational age) and those who underwent TOLAC at preterm (23-36 weeks gestational age). Multivariable analyses adjusted for demographic and obstetric differences between the two groups. RESULTS: 455,284 patients met inclusion criteria for the study; 39,589 (8.7%) were at a preterm gestational age (GA) and 415,695 (91.3%) were at a term GA. The overall composite maternal adverse outcome was significantly higher for patients undergoing TOLAC at preterm GA (12.0 per 1,000 live births) compared to term GA (8.0 per 1,000 live births; aRR1.42; 95% CI 1.29-1.56). Among individual conditions within the primary composite outcome, preterm gestational age was associated with increased risk of admission to the intensive care unit, blood transfusion, and unplanned hysterectomy. CONCLUSIONS: In patients who underwent TOLAC, preterm gestational age was associated with increased risk of adverse maternal outcomes.

Underrepresentation in Pelvic Floor Disorder Patient-Reported Outcomes: Whose Outcomes Are We Measuring?

IMPORTANCE: Patient-reported outcome (PRO) instruments measure the patient's perspective. It is unclear whether commonly used PRO measures were tested in populations that had racial and ethnic distributions comparable with those reported in U.S. census data. OBJECTIVE: The aim of this study was to compare the proportion of non-White race and Hispanic ethnicity participants with their expected proportion based on U.S. census data for PRO instruments with U.S.-based validation studies. STUDY DESIGN: This was a retrospective review of PRO measures considered by the Pelvic Floors Disorders Consortium Working Group on Patient-Reported Outcomes in their 2020 consensus publication. Study and participant information were abstracted from PRO validation studies. Racial and ethnic representation in U.S.-based studies were compared with U.S. census data. The primary outcome was the representation quotient of reported races and ethnicities, calculated as the reported percentage of the study population identifying with a race and/or ethnicity divided by the proportion of the U.S. population identifying with that race and/or ethnicity when the study was published. RESULTS: Forty-five studies with 21,080 total participants were included. Race was reported in 17 of 45 studies (37.8%), and ethnicity was reported in 7 of 45 (15.6%). Most studies did not specify how race and ethnicity information was collected. For U.S.-based studies, the representation quotient of White participants from 1995 to 2019 was 1.15. Indigenous American/Native American/American Indian/Alaska Natives had the lowest representation quotient (0.22). Reporting of ethnicity increased over time (P = 0.001), although there was no significant change in the reporting of race or the representation of various races and ethnicities (P > 0.05). CONCLUSION: Non-White and Hispanic patients may be underrepresented in U.S.-based validation studies for PRO instruments in pelvic floor disorders.

Factors associated with disparate outcomes among Black women undergoing in vitro fertilization.

Objective: To determine if Black women have worse in vitro fertilization (IVF) outcomes than women of other races/ethnicities, and to establish which factors are associated with the IVF outcomes of Black women. Design: Retrospective cohort study. Setting: Not applicable. Patients: All patients undergoing IVF. Interventions: Not applicable. Main Outcome Measures: Spontaneous abortion rate, clinical pregnancy rate, and live birth rate. Results: A total of 71,389 patient cycles were analyzed. Of the 40,545 patients who were included, 6.4% of patients were Black, 62% were White, 7.3% were Hispanic/Latino, and 15% were Asian. After IVF, Black women had significantly more miscarriages than White but not Hispanic or Asian patients (8.0% Black vs. 6.9% White, 7.4% Hispanic, and 7.5% Asian). Clinical pregnancy rates were significantly lower for Black women compared with all other races (45% Black vs. 52% White, 52% Hispanic, and 53% Asian). The odds ratio (OR) of live birth from all cycles were 30% less than that for White women (OR, 1.00 Black vs. 1.43 White) and 22% less than that for Hispanic women (OR, 1.00 Black vs. 1.29 Hispanic). This statistically significant difference in the live birth rate persisted even after adjusting for patient characteristics (OR, 1.00 Black vs. 1.32 White, 1.23 Hispanic, and 1.18 Asian). Conclusions: Black women have worse IVF outcomes than women of all other racial backgrounds undergoing IVF. The factors associated with the disparate outcomes of Black women undergoing IVF outcomes include older age starting IVF, higher body mass index, tubal factor infertility, and diabetes.

Breast-Specific Sensuality in Breast Cancer Survivors: Sexually Active or Not.

BACKGROUND: We sought to better understand breast-specific sensuality (BSS) in sexually inactive breast cancer survivors. METHODS: We conducted an anonymous cross-sectional survey of breast cancer survivors during surveillance appointments from 2014 to 2016. Sexual inactivity was defined as no sexual activity within 4 weeks prior. Categorical data were analyzed using Fisher's exact test. Multiple logistic regression adjusted for age and menopausal status, and Firth's bias correction accommodated sparse data. RESULTS: Of 585 respondents, 546 (93.3%) were between the ages of 40 and 79 years, of whom 285 (48.7%) were sexually inactive. Favorable post-treatment appearance satisfaction was reported by 413 (71.0%) respondents. Sexually inactive respondents were more likely to score discomfort with their partner seeing their chest after surgery compared with sexually active respondents (41 [20.4%] vs. 34 [11.4%]; p = 0.002). Both sexually inactive and active respondents reported that their chest was important in intimacy after surgery but at significantly different rates (117 [44.3%] vs. 217 [72.6%]; p < 0.001). Post-surgical appearance satisfaction for sexually inactive respondents was positively associated with level of comfort with partner seeing their chest after surgery (p < 0.001) and with rating of a pleasurable caress of the treated breast (p < 0.001). CONCLUSIONS: Over 40% of sexually inactive respondents reported their chest was important in intimacy after surgery, suggesting that BSS may be a route to intimacy for sexually inactive breast cancer survivors. Post-surgical breast appearance satisfaction significantly correlated with comfort being seen by one's partner and appreciation of a pleasurable breast caress. Optimizing breast cancer surgical aesthetic outcomes may improve survivorship.