Utility of Routine Postoperative Examination for Detecting Vaginal Cuff Dehiscence After Total Laparoscopic Hysterectomy.

STUDY OBJECTIVE: To determine the utility of routine postoperative vaginal cuff examination for detection of vaginal cuff dehiscence (VCD) after total laparoscopic hysterectomy (TLH). DESIGN: Retrospective cohort study. SETTING: Quaternary care academic hospital in the United States. PATIENTS: All patients who underwent TLH with a minimally invasive gynecologic surgeon at our institution from 2016 to 2022. INTERVENTIONS: Laparoscopic hysterectomy with routine vaginal cuff check 6 to 8 weeks postoperatively and laparoscopic hysterectomy without routine vaginal cuff check. MEASUREMENTS AND MAIN RESULTS: We identified 703 patients who underwent TLH, 216 (30.7%) with routine cuff checks and 487 (69.3%) without. Within the no cuff check group, 287 (58.9%) had entirely virtual follow-up. There was no difference in VCD between the routine cuff check (1.28%, n = 2) and no cuff check groups (0.93%, n = 7, p = .73). Median time to VCD was 70.0 days (27.5-114.0). No VCDs were identified in asymptomatic patients on routine examination, and both patients in the cuff check group with VCD had appropriately healing cuffs on routine examination. In the cuff check group, 7 patients (3.2%) had findings of incomplete healing requiring intervention (silver nitrate, extended pelvic rest), all of whom were asymptomatic at the time of examination. Eight patients (3.7%) in the routine cuff check group and 21 (4.3%) in the no examination group required a nonroutine cuff check owing to symptoms. There was no difference in points of contact for postoperative symptoms between the groups (median 0 [0-1.0] for both groups, p = .778). CONCLUSION: Routine postoperative vaginal cuff examination does not seem to affect or negate the risk of future VCD. Virtual follow-up for asymptomatic patients may be appropriate after TLH.

Addressing Maternal Health Disparities: Building a Novel Two-Generation Approach to Comprehensive Postpartum Care.

The United States is facing a maternal health crisis with increasing rates of severe maternal morbidity and mortality. To improve maternal health and promote health equity, the authors developed a novel 2-generation model of postpartum and pediatric care. This article describes the Two-Generation Clinic (Two-Gen) and model of care. The model combines a dyadic strategy for simultaneous maternal and pediatric care with the collaborative care model in which seamless primary and behavioral health care are delivered to address the physical health, behavioral health, and social service needs of families. The transdisciplinary team includes primary care physicians, nurse practitioners, psychiatrists, obstetrician-gynecologists, social workers, care navigators, and lactation specialists. Dyad clinic visits are coscheduled (at the same time) and colocated (in the same examination room) with the same primary care provider. In the Two-Gen, the majority (89%) of the mothers self-identify as racial and ethnic minorities. More than 40% have a mental health diagnosis. Almost all mothers (97.8%) completed mental health screenings, >50.0% have received counseling from a social worker, 17.2% had a visit with a psychiatrist, and 50.0% received lactation counseling. Over 80% of the children were up to date with their well-child visits and immunizations. The Two-Gen is a promising model of care that has the potential to inform the design of postpartum care models and promote health equity in communities with the highest maternal health disparities.

Screening fathers for postpartum depression in a maternal-child health clinic: a program evaluation in a midwest urban academic medical center.

BACKGROUND: Postpartum depression (PPD) impacts fathers as well as mothers, and is estimated to affect between 8 and 13% of fathers. Paternal PPD is a risk factor for worsened quality of life, poor physical and mental health, and developmental and relational harms in the father-mother-child triad. There are no current recommendations for PPD screening among fathers. Paternal PPD screening was piloted in an intergenerational postpartum primary care clinic. METHODS: The pilot was carried out in an intergenerational postpartum primary care clinic located at a Midwest urban academic safety net health system from October 2021 to July 2022. Fathers actively involved in relationships with mothers or infants receiving primary care in the clinic were approached with mothers' permission. A novel survey instrument was used to collect demographic/social data, as well as mental health history and current stress levels; an Edinburgh Postnatal Depression Scale (EPDS) was also administered. Screenings were completed by social workers; data were collected in REDCap and descriptive statistics were calculated in SAS. RESULTS: 29 fathers were contacted and 24 completed screening (83%). Mean age was 31 years (range 19-48). Most (87%) identified as belonging to a racial or ethnic minority group. Fathers self-reported low rates of stress and preexisting mental health conditions, but 30% screened positive for PPD on EPDS (score of ≥ 8, or suicidal ideation). Gaps in health care were found, as one-quarter (26%) of fathers were uninsured and half (54%) did not have a primary care provider. After screening, two requested mental health services, and three established new primary care with a physician. CONCLUSIONS: Participation was high in a PPD screening pilot for fathers in a primary care setting. This small sample of fathers demonstrated significant peripartum mental health challenges unlikely to have been identified otherwise. For some participants, engaging in PPD screening was an effective tool to prompt their subsequent engagement with general health care. This pilot is a step toward incorporating the health of fathers into models for supporting the health of families. Expanding screening for paternal PPD into routine primary care is necessary to reach more affected fathers.

The effectiveness of a religiously framed HPV vaccination message among Christian parents of unvaccinated adolescents in the United States.

BACKGROUND: The uptake of the human papillomavirus (HPV) vaccines has been controversial among religious parents due to beliefs that their children are expected to practice sexual purity and so do not need protection from a sex-related infection. Also, if at all they get infected in the future, God can protect them from sickness without a vaccine. Yet, most HPV vaccination messages are secular, lacking spiritual themes. This study compared the effectiveness of the Centers for Disease Control and Prevention (CDC) Vaccine Information Statement (VIS) on HPV with our intervention message- a scripture-embedded HPV vaccination message (using a randomized controlled trial design) on vaccination intention. METHODS: The study was conducted online. Participants were 342 Christian parents (from any denomination) of unvaccinated adolescents aged 11-17 years. The intervention message used the Cognitive Metaphor Theory to map the constructs of the Biblical story of Noah and the Ark to HPV vaccination. We framed Noah as the parents, the flood as HPV, and the ark as the vaccination. Multiple linear regression was used to analyze the changes in vaccination intention before and after the intervention. RESULTS: Our findings showed that parents who received the scripture-embedded message reported a higher intention to vaccinate their children than those who received the CDC VIS (ß= 0.31, 95% confidence interval [95%CI] = 0.11-0.52; p=0.003). CONCLUSION: Our findings support the need for equitable messaging regarding HPV vaccination. Faith-based messaging interventions that seek to increase HPV vaccination should be framed to address religious anti-vaccination beliefs.

The Effect of Neighborhood Disorganization on Care Engagement Among Children With Chronic Conditions Living in a Large Urban City.

Neighborhood context plays an important role in producing and reproducing current patterns of health disparity. In particular, neighborhood disorganization affects how people engage in health care. We examined the effect of living in highly disorganized neighborhoods on care engagement, using data from the Coordinated Healthcare for Complex Kids (CHECK) program, which is a care delivery model for children with chronic conditions on Medicaid in Chicago. We retrieved demographic data from the US Census Bureau and crime data from the Chicago Police Department to estimate neighborhood-level social disorganization for the CHECK enrollees. A total of 6458 children enrolled in the CHECK between 2014 and 2017 were included in the analysis. Families living in the most disorganized neighborhoods, compared with areas with lower levels of disorganization, were less likely to engage in CHECK. Black families were less likely than Hispanic families to be engaged in the CHECK program. We discuss potential mechanisms through which disorganization affects care engagement. Understanding neighborhood context, including social disorganization, is key to developing more effective comprehensive care models.

Disentangling the Role of Religiosity in Human Papillomavirus Vaccination Amidst COVID-19 Pandemic.

Religion is a complex and sociocultural driver of human papillomavirus (HPV) vaccination decisions, but its exact role has been mixed/unclear. We used a cross-sectional study of 342 Christian parents to examine the associations between the three domains of religiosity (organizational, non-organizational, and intrinsic) and the intention to (i) seek HPV information and (ii) receive the HPV vaccine. Organizational religiosity was the only domain that was positively associated with information-seeking intention regardless of the type of covariates included. Mixed findings in the association between religiosity and HPV vaccination decisions may depend on the religiosity domain being assessed.

The interdependent roles of the psychosocial predictors of human papillomavirus vaccination among Christian parents of unvaccinated adolescents.

Despite the availability of the human papillomavirus (HPV) vaccine, uptake has been sub-optimal among certain religious groups. Psychosocial factors (threat appraisal, coping appraisal, and attitudes) have been identified as independent determinants of HPV vaccination. However, their interdependent effects have not been tested. We examined the interdependency of these psychosocial factors in predicting HPV vaccination intention among Christian parents of unvaccinated adolescents (using a theory-driven conceptual model). A cross-sectional study of 342 participants showed that perceived self-efficacy (ß = 0.2, 0.11-0.29, p = <0.0001) and perceived response efficacy of HPV vaccine (ß = 0.65, 0.53-0.77. p < .0001) were positively associated with vaccination intention. Our mediation analysis (using the Preachers and Hayes' approach) shows that attitudes toward HPV vaccination mediated 59% of the relationship between perceived self-efficacy to vaccinate child and HPV vaccination intention; and 61% of the relationship between perceived response efficacy of HPV vaccine and HPV vaccination intention. Attitudes may be the psychosocial factor that drives the effects of coping appraisal. Therefore, designing an attitude-based intervention to address religious barrier beliefs among Christian parents may nullify the impact of low self-efficacy and response efficacy on HPV vaccination.

Identifying False Human Papillomavirus (HPV) Vaccine Information and Corresponding Risk Perceptions From Twitter: Advanced Predictive Models.

BACKGROUND: The vaccination uptake rates of the human papillomavirus (HPV) vaccine remain low despite the fact that the effectiveness of HPV vaccines has been established for more than a decade. Vaccine hesitancy is in part due to false information about HPV vaccines on social media. Combating false HPV vaccine information is a reasonable step to addressing vaccine hesitancy. OBJECTIVE: Given the substantial harm of false HPV vaccine information, there is an urgent need to identify false social media messages before it goes viral. The goal of the study is to develop a systematic and generalizable approach to identifying false HPV vaccine information on social media. METHODS: This study used machine learning and natural language processing to develop a series of classification models and causality mining methods to identify and examine true and false HPV vaccine-related information on Twitter. RESULTS: We found that the convolutional neural network model outperformed all other models in identifying tweets containing false HPV vaccine-related information (F score=91.95). We also developed completely unsupervised causality mining models to identify HPV vaccine candidate effects for capturing risk perceptions of HPV vaccines. Furthermore, we found that false information contained mostly loss-framed messages focusing on the potential risk of vaccines covering a variety of topics using more diverse vocabulary, while true information contained both gain- and loss-framed messages focusing on the effectiveness of vaccines covering fewer topics using relatively limited vocabulary. CONCLUSIONS: Our research demonstrated the feasibility and effectiveness of using predictive models to identify false HPV vaccine information and its risk perceptions on social media.

Monoclonal Antibodies Casirivimab and Imdevimab in Pregnancy for Coronavirus Disease 2019 (COVID-19).

BACKGROUND: For unvaccinated individuals with mild-to-moderate coronavirus disease 2019 (COVID-19), monoclonal antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) decrease the risk of severe disease and hospitalization. We describe the use of the monoclonal antibodies casirivimab and imdevimab for COVID-19 in pregnancy. CASE: Two unvaccinated pregnant individuals presented with moderate COVID-19, one in the second trimester and one in third trimester; both met criteria for outpatient management. To decrease the risk for severe disease, they were treated with casirivimab and imdevimab. Neither experienced an adverse drug reaction, and neither progressed to severe disease. CONCLUSION: Monoclonal antibodies such as casirivimab and imdevimab, approved under an emergency use authorization, should be considered in unvaccinated pregnant individuals with mild-to-moderate COVID-19 to decrease the risk of severe disease.

Addressing Women's Health Care Needs During Pediatric Care.

Objective: To determine if the use of a simple self-administered Postpartum Questionnaire for Mothers (PQM) at the well-baby visit (WBV) increased the proportion of women who received health care and contraception by 6 months postpartum (PP). Methods: This was a single-site, system-level, intervention. Women were recruited from the pediatric clinic when presenting with their infants for a 2-month WBV. During phase 1 of the study, a control group was enrolled, followed by an 8-week washout period; then enrollment of the intervention group (phase 2). During phase 2, the PQM was administered and reviewed by the pediatrician during the infant's visit; the tool prompted the pediatrician to make a referral for the mother's primary or contraceptive care as needed. Data were collected at baseline and at 6 months PP, and additional data were extracted from the electronic medical record. Results: We found that PP women exposed to the PQM during their infant's WBV were more likely to have had a health care visit for themselves between 2 and 6 months PP, compared with the control group (relative risk [RR] 1.66, [confidence interval (CI) 0.91-3.03]). In addition, at 6 months PP, women in the intervention group were more likely to identify a primary care provider (RR 1.84, [CI 0.98-3.46]), and more likely to report use of long-acting reversible contraception (LARC) (RR 1.24, [CI 0.99-1.58]), compared with women in the control group. Conclusion: A simple self-administered PQM resulted in an increase in women's receipt of health care and use of LARC by 6 months PP. Clinical Trial Registration: Use of a reproductive life planning tool at the pediatric well-baby visit with postpartum women, NCT03448289.

A two-generation approach to postpartum care: Building on the well-baby visit.

BACKGROUND: Although postpartum (PP) care is essential for the health and well-being of women and their infants, many women in the United States do not receive PP care. In order to ensure that women's PP needs are met, it is essential to develop delivery models that address their barriers to care. The objective of the current study was to obtain women's feedback and perspectives about delivering women's health care at the well-baby visit (WBV) using a modified mixed-methods approach including open-ended interviews and surveys. METHODS: Twenty brief open-ended interviews were conducted with PP women at a large urban medical center in Chicago. The interviews were recorded, transcribed, and coded following a mixed deductive and inductive approach and analyzed using Dedoose. Following the interview analysis, surveys with 50 immediate PP women and 50 who were 2-4 months PP were conducted. Statistical analyses included frequencies and chi-square tests to determine differences between participants interviewed at the two time periods. RESULTS: Key themes that emerged from the open-ended interviews include the tension between the desire for continuity of care (prenatal to PP) and the desire for convenient care. The surveys found that 86%-94% of women would be interested in receiving PP care at the same clinic site and time as their new baby. CONCLUSIONS: One approach to addressing women's PP health and need for convenient care is the provision of components of women's health care at the WBV. Therefore, we present an innovative two-generation model for PP care focusing on needs of both the woman and infant.

Trends in School Attendance for Low-Income Children with Chronic Health Conditions: Results from a Randomized Controlled Trial.

BACKGROUND: In this study, we aimed to determine how school attendance changed over time for children on Medicaid with chronic health conditions enrolled in a comprehensive care coordination program called Coordinated HEalthcare for Complex Kids (CHECK). METHODS: Medicaid beneficiaries from one managed care organization were randomized into 2 arms: CHECK program services or usual care. The final sample was 1322. RESULTS: The mean age was 10.9 (SD = 3.7) years old and children were mostly non-Hispanic Black (62.6%) or Hispanic (34.9%). The median school attendance at baseline was 94.9% (IQR 88.9, 97.9); over one-fourth of children (28.4%) were chronically absent. School attendance was not associated with race/ethnicity, risk level, and health condition. In a model including a significant time/grade interaction, school attendance increased over time for children in pre-kindergarten (OR = 1.52, 95% CI: 1.38, 1.68; p < .001) and kindergarten to 5th grade (OR = 1.21, 95% CI: 1.17, 1.26; p < .001), and decreased for children in 6th to 8th grade (OR = 0.80, 95% CI: 0.77, 0.83; p < .001). No differences were seen in school attendance or chronic absenteeism associated with enrollment in the CHECK program. CONCLUSIONS: School attendance improved for most of the low-income children with chronic health conditions in our cohort, except for children in middle school.

COVID-19 Precipitating Euglycaemic Diabetic Ketoacidosis with SGLT2 Inhibitor Use.

OBJECTIVE: To describe a patient who developed euglycaemic diabetic ketoacidosis (DKA) in the setting of SGLT2 inhibitor use precipitated by COVID-19. PATIENT AND METHODS: A 52-year-old male with type II diabetes on empagliflozin and no history of DKA presented with symptoms of COVID-19 as well as laboratory findings consistent with euglycaemic DKA. His hospital course was complicated by recurrent episodes of euglycaemic DKA as well as hyperglycaemic DKA. CONCLUSION: SGLT2 inhibitors should be held as early as possible in COVID-19 cases due to the risk of euglycaemic DKA. These patients should also have more intense glucose monitoring. LEARNING POINTS: COVID-19 can precipitate euglycaemic DKA in diabetic patients taking SGLT2 inhibitors.Clinicians should be cognizant that the effects of SGLT2 inhibitors can persist for more than 72 hours after the last dose.Diabetic patients with COVID-19 require closer strict glucose monitoring to reduce the risk of DKA.

Work-Sampling Study of an Innovative Care Coordination Program Aimed at Children With Chronic Health Conditions.

PURPOSE OF STUDY: To estimate time allocation and labor cost for care coordinators (CCs), community health workers (CHWs), and mental health workers (MHWs) to conduct care coordination tasks in a pediatric care coordination program. PRIMARY PRACTICE SETTING: A public tertiary academic medical center in Chicago, IL. METHODOLOGY AND SAMPLE: A work-sampling study was conducted using a text message-based survey on 5 CCs, 20 CHWs, and 4 MHWs who volunteered to participate. Workers were randomly sampled within working hours to collect information on who was the subject of interaction and what service was being delivered over a 6-month period. Time allocation of workers to different subjects and services was summarized using descriptive statistics. RESULTS: Care coordinators allocated 41% of their time to managing CHW teams. Community health workers allocated 37% of time providing services directly to children and 26% to the parent/caregiver. Mental health workers allocated 16% of time providing services to children and 29% to the parent/caregiver. The care coordination program serviced 5,965 patients, with a total annual labor cost of $1,455,353. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Community health workers spent the majority of time working with patients and their families to conduct assessments. Mental health workers primarily addressed children's needs through their caregivers. Care coordinators primarily supported CHWs in coordinating care. Results may be used to inform development of such programs by determining services most often utilized, and labor cost may be used to inform program implementation and reimbursement.

Expectations of Surveillance for Non-BRCA Gene Mutation Carriers at Increased Risk for Breast Cancer.

BACKGROUND: The University of Alabama at Birmingham Preventative Care Program for Women's Cancer provides genetic testing, risk evaluation, and screening for breast cancer. Women diagnosed with high-risk mutations may opt to undergo active surveillance or prophylactic surgery. This decision requires understanding of the surveillance process and its potential outcomes. In this study, we report specifically on women with non-BRCA1 or BRCA2 mutations. METHODS: A retrospective, cross-sectional study was conducted of women enrolled in our program identified as high risk because of non-BRCA mutations. Events regarding genetic mutations, method of detection of suspicious lesions, number of biopsies, results of those biopsies, prophylactic surgery, and cancer diagnosis were collected. RESULTS: We identified 78 patients with asymptomatic non-BRCA deleterious mutations. Sixteen mutations were identified, with the most common being ATM, CHEK2, and PALB2. In total, 11.5% underwent prophylactic surgery and 88.5% underwent active surveillance. In the surveillance group, 63.8% had no examination or imaging to warrant biopsy, 24.6% had biopsy with benign result, and 11.6% had biopsy with malignant result. For the nine women who developed breast cancer during surveillance, six were diagnosed with ductal carcinoma in situ, two with stage I, and one with stage IIA cancer. CONCLUSIONS: Women with non-BRCA mutations enroll in prevention clinics with hopes of early detection of breast cancer. Because of increased screening, this population undergoes biopsy more frequently; however, during surveillance most do not require a biopsy. For those that do, the result is typically benign. This information can further allow women to make informed decisions about surveillance and establish realistic expectations regarding the likelihood of tissue sampling.