Judgments of sex trafficked women: The role of emotions.

This study examined how incidental emotions influence decisions to arrest or release sex trafficking survivors. Community members (N = 984) completed an autobiographical memory task invoking disgust, sympathy, or no emotion and read case facts from United States v. Bell (2014) varying whether the survivor had a prior history of sex work and whether she came from a vulnerable or nonvulnerable background. Participants in the vulnerable condition believed that the survivor was less able to resist the trafficker's proposal. Furthermore, women but not men made to feel disgust believed that she should have resisted. Regarding arresting the survivor for prostitution versus releasing her for services, invoking either incidental disgust or sympathy, but especially disgust, triggered feelings of disgust, which in turn predicted an arrest decision. Finally, our data supported a moderated mediation model in which the belief that the survivor should have been able to resist the trafficker predicted a greater probability of an arrest judgment. Furthermore, participants in the vulnerable condition believed that the survivor had less ability to resist, and they disfavored her arrest. However, this was only true when we invoked no emotion. When we invoked disgust, vulnerability ceased to have this moderation effect. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Association of State Funding for Comprehensive Reproductive Health Care With Use of Contraception Among Latina Patients and Non-Latina Patients in Oregon.

Importance: There are well-documented racial and ethnic disparities in effective contraceptive use due to multiple factors. A key contributor may be differential insurance coverage and patient costs. The Oregon Reproductive Health Equity Act (RHEA), enacted in 2017, ensures full coverage of reproductive health care without cost sharing for all Oregonians with low income. Objective: To assess whether removing financial barriers to accessing contraceptive care is associated with an improvement in use of moderately and highly effective contraceptive methods among Latina women compared with non-Latina women. Design, Setting, and Participants: This cohort study included women aged 12 to 51 years who sought contraceptive care in the Oregon Health Authority Reproductive Health Program from April 2016 to March 2020. Patients using permanent contraception, those missing data on ethnicity, and non-Oregon residents were excluded. Data analysis was performed in January 2021. Exposures: Contraceptive care in the Reproductive Health Program after RHEA implementation. Main Outcomes and Measures: The main outcome was prevalence of use of moderately effective methods (contraceptive pills, patch, ring, or injection) or highly effective methods (long-acting reversible contraceptives) at the time of the contraceptive visit. Difference-in-differences analysis was used to compare moderately and highly effective contraception use between Latina and non-Latina patients. Secondary outcomes were proportions of adoption or continuation of moderately and highly effective methods, prevalence of highly effective methods, and adoption or continuation of highly effective methods. The unit of analysis was at the clinic visit level. Results: The study sample consisted of 295 604 evaluable clinic visits, in which 28.4% of individuals identified as Latina and 71.6% of individuals identified as non-Latina. The mean (SD) age was 25.5 (8.1) years. With difference-in-differences analysis, there was a significant adjusted 1.9 percentage point (95% CI, 0.2-3.6 percentage points) increase in prevalence of moderately or highly effective contraceptive methods for Latina patients compared with non-Latina patients. There were no significant differences for other outcomes of interest. Conclusions: This cohort study found that in Oregon, legislation removing financial barriers to accessing contraceptive care was associated with significant mitigation in disparate moderately and highly effective contraceptive method prevalence for Latina patients compared with non-Latina patients. The findings suggest that state funds successfully supplanted federal funds to enable continued robust comprehensive family planning services after withdrawal from Title X.

Risk of thromboembolism in patients with COVID-19 who are using hormonal contraception.

BACKGROUND: The novel coronavirus disease (COVID-19) has led to significant mortality and morbidity, including a high incidence of related thrombotic events. There has been concern regarding hormonal contraception use during the COVID-19 pandemic, as this is an independent risk factor for thrombosis, particularly with estrogen-containing formulations. However, higher estrogen levels may be protective against severe COVID-19 disease. Evidence for risks of hormonal contraception use during the COVID-19 pandemic is sparse. We conducted a living systematic review that will be updated as new data emerge on the risk of thromboembolism with hormonal contraception use in patients with COVID-19. OBJECTIVES: To determine if use of hormonal contraception increases risk of venous and arterial thromboembolism in women with COVID-19. To determine if use of hormonal contraception increases other markers of COVID-19 severity including hospitalization in the intensive care unit, acute respiratory distress syndrome, intubation, and mortality. A secondary objective is to maintain the currency of the evidence, using a living systematic review approach. SEARCH METHODS: ⁠⁠⁠⁠⁠⁠We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, Global Health, and Scopus from inception on March 2023, and monitored the literature monthly. We updated the search strategies with new terms and added the database Global Index Medicus in lieu of LILACS. SELECTION CRITERIA: We included all published and ongoing studies of patients with COVID-19 comparing outcomes of those on hormonal contraception versus those not on hormonal contraception. This included case series and non-randomized studies of interventions (NRSI). DATA COLLECTION AND ANALYSIS: One review author extracted study data and this was checked by a second author. Two authors individually assessed risk of bias for the comparative studies using the ROBINS-I tool and a third helped reconcile differences. For the living systematic review, we will publish updates to our synthesis every six months. In the event that we identify a study with a more rigorous study design than the current included evidence prior to the planned six-month update, we will expedite the synthesis publication. MAIN RESULTS: We included three comparative NRSIs with 314,704 participants total and two case series describing 13 patients. The three NRSIs had serious to critical risk of bias in several domains and low study quality. Only one NRSI ascertained current use of contraceptives based on patient report; the other two used diagnostic codes within medical records to assess hormonal contraception use, but did not confirm current use nor indication for use. None of the NRSIs included thromboembolism as an outcome. Studies were not similar enough in terms of their outcomes, interventions, and study populations to combine with meta-analyses. We therefore narratively synthesized all included studies. Based on results from one NRSI, there may be little to no effect of combined hormonal contraception use on odds of mortality for COVID-19 positive patients (OR 1.00, 95% CI 0.41 to 2.40; 1 study, 18,892 participants; very low-certainty evidence). Two NRSIs examined hospitalization rates for hormonal contraception users versus non-users. Based on results from one NRSI, the odds of hospitalization for COVID-19 positive combined hormonal contraception users may be slightly decreased compared with non-users for patients with BMI under 35 kg/m2 (OR 0.79, 95% CI 0.64 to 0.97; 1 study, 295,689 participants; very low-certainty evidence). According to results of the other NRSI assessing use of any type of hormonal contraception, there may be little to no effect on hospitalization rates for COVID-19 positive individuals (OR 0.99, 95% CI 0.68 to 1.44; 1 study, 123 participants; very low-certainty evidence). We included two case series because no comparative studies directly assessed thromboembolism as an outcome. In a case series of six pediatric COVID-19 positive patients with pulmonary embolism, one (older than 15 years of age) was using combined hormonal contraception. In a second case series of seven COVID-19 positive patients with cerebral venous thrombosis, one was using oral contraceptives. One comparative study and one case series reported on intubation rates, but the evidence for both is very uncertain. In the comparative study of 123 COVID-19 positive patients (N = 44 using hormonal contraception and N = 79 not using hormonal contraception), no patients in either group required intubation. In the case series of seven individuals with cerebral venous thromboembolism, one oral contraceptive user and one non-user required intubation. AUTHORS' CONCLUSIONS: There are no comparative studies assessing risk of thromboembolism in COVID-19 patients who use hormonal contraception, which was the primary objective of this review. Very little evidence exists examining the risk of increased COVID-19 disease severity for combined hormonal contraception users compared to non-users of hormonal contraception, and the evidence that does exist is of very low certainty. The odds of hospitalization for COVID-19 positive users of combined hormonal contraceptives may be slightly decreased compared with those of hormonal contraceptive non-users, but the evidence is very uncertain as this is based on one study restricted to patients with BMI under 35 kg/m2. There may be little to no effect of combined hormonal contraception use on odds of intubation or mortality among COVID-19 positive patients, and little to no effect of using any type of hormonal contraception on odds of hospitalization and intubation for COVID-19 patients. We noted no large effect for risk of increased COVID-19 disease severity among hormonal contraception users. We specifically noted gaps in pertinent data collection regarding hormonal contraception use such as formulation, hormone doses, and duration or timing of contraceptive use. Differing estrogens may have different thrombogenic potential given differing potency, so it would be important to know if a formulation contained, for example, ethinyl estradiol versus estradiol valerate. Additionally, we downgraded several studies for risk of bias because information on the timing of contraceptive use relative to COVID-19 infection and method adherence were not ascertained. No studies reported indication for hormonal contraceptive use, which is important as individuals who use hormonal management for medical conditions like heavy menstrual bleeding might have different risk profiles compared to individuals using hormones for contraception. Future studies should focus on including pertinent confounders like age, obesity, history of prior venous thromboembolism, risk factors for venous thromboembolism, and recent pregnancy.

Risk of thromboembolism in patients with COVID-19 who are using hormonal contraception: a Cochrane systematic review.

BACKGROUND: The coronavirus disease COVID-19 is associated with an increased risk of thrombotic events. Individuals with COVID-19 using hormonal contraception could be at additional risk for thromboembolism, but evidence is sparse. METHODS: We conducted a systematic review on the risk of thromboembolism with hormonal contraception use in women aged 15-51 years with COVID-19. We searched multiple databases through March 2022, including all studies comparing outcomes of patients with COVID-19 using or not using hormonal contraception. We applied standard risk of bias tools to evaluate studies and GRADE methodology to assess certainty of evidence. Our primary outcomes were venous and arterial thromboembolism. Secondary outcomes included hospitalisation, acute respiratory distress syndrome, intubation, and mortality. RESULTS: Of 2119 studies screened, three comparative non-randomised studies of interventions (NRSIs) and two case series met the inclusion criteria. All studies had serious to critical risk of bias and low study quality. Overall, there may be little to no effect of combined hormonal contraception (CHC) use on odds of mortality for COVID-19-positive patients (OR 1.0, 95% CI 0.41 to 2.4). The odds of hospitalisation for COVID-19-positive CHC users may be slightly decreased compared with non-users for patients with body mass index <35 kg/m2 (OR 0.79, 95% CI 0.64 to 0.97). Use of any type of hormonal contraception may have little to no effect on hospitalisation rates for COVID-19-positive individuals (OR 0.99, 95% CI 0.68 to 1.44). CONCLUSIONS: Not enough evidence exists to draw conclusions regarding risk of thromboembolism in patients with COVID-19 using hormonal contraception. Evidence suggests there may be little to no or slightly decreased odds of hospitalisation, and little to no effect on odds of mortality for hormonal contraception users versus non-users with COVID-19.

Risk of thromboembolism in patients with COVID-19 who are using hormonal contraception.

BACKGROUND: The novel coronavirus disease (COVID-19) has led to significant mortality and morbidity, including a high incidence of related thrombotic events. There has been concern regarding hormonal contraception use during the COVID-19 pandemic, as this is an independent risk factor for thrombosis, particularly with estrogen-containing formulations. However, higher estrogen levels may be protective against severe COVID-19 disease. Evidence for risks of hormonal contraception use during the COVID-19 pandemic is sparse. We therefore conducted a living systematic review that will be updated as new data emerge on the risk of thromboembolism with hormonal contraception use in patients with COVID-19. OBJECTIVES: To determine if use of hormonal contraception increases risk of venous and arterial thromboembolism in women with COVID-19. To determine if use of hormonal contraception increases other markers of COVID-19 severity including hospitalization in the intensive care unit, acute respiratory distress syndrome, intubation, and mortality. A secondary objective is to maintain the currency of the evidence, using a living systematic review approach. SEARCH METHODS: ⁠⁠⁠⁠⁠⁠We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, Global Health, and Scopus from inception to search update in March 2022. For the living systematic review, we monitored the literature monthly. SELECTION CRITERIA: We included all published and ongoing studies of patients with COVID-19 comparing outcomes of those on hormonal contraception versus those not on hormonal contraception. This included case series and non-randomized studies of interventions (NRSI). DATA COLLECTION AND ANALYSIS: One review author extracted study data and this was checked by a second author. Two authors individually assessed risk of bias for the comparative studies using the ROBINS-I tool and a third author helped reconcile differences. For the living systematic review, we will publish updates to our synthesis every six months. In the event that we identify a study with a more rigorous study design than the current included evidence prior to the planned six-month update, we will expedite the synthesis publication. MAIN RESULTS: We included three comparative NRSIs with 314,704 participants total and two case series describing 13 patients. The three NRSIs had serious to critical risk of bias in several domains and low study quality. Only one NRSI ascertained current use of contraceptives based on patient report; the other two used diagnostic codes within medical records to assess hormonal contraception use, but did not confirm current use nor indication for use. None of the NRSIs included thromboembolism as an outcome. Studies were not similar enough in terms of their outcomes, interventions, and study populations to combine with meta-analyses. We therefore narratively synthesized all included studies. Based on results from one NRSI, there may be little to no effect of combined hormonal contraception use on odds of mortality for COVID-19 positive patients (odds ratio (OR) 1.00, 95% confidence interval (CI) 0.41 to 2.40; 1 study, 18,892 participants; very low-certainty evidence). Two NRSIs examined hospitalization rates for hormonal contraception users versus non-users. Based on results from one NRSI, the odds of hospitalization for COVID-19 positive combined hormonal contraception users may be slightly decreased compared with non-users for patients with body mass index (BMI) under 35 kg/m2 (OR 0.79, 95% CI 0.64 to 0.97; 1 study, 295,689 participants; very low-certainty evidence). According to results of the other NRSI assessing use of any type of hormonal contraception, there may be little to no effect on hospitalization rates for COVID-19 positive individuals (OR 0.99, 95% CI 0.68 to 1.44; 1 study, 123 participants; very low-certainty evidence). We included two case series because no comparative studies directly assessed thromboembolism as an outcome. In a case series of six pediatric COVID-19 positive patients with pulmonary embolism, one (older than 15 years of age) was using combined hormonal contraception. In a second case series of seven COVID-19 positive patients with cerebral venous thrombosis, one was using oral contraceptives. One comparative study and one case series reported on intubation rates, but the evidence for both is very uncertain. In the comparative study of 123 COVID-19 positive patients (N = 44 using hormonal contraception and N = 79 not using hormonal contraception), no patients in either group required intubation. In the case series of seven individuals with cerebral venous thromboembolism, one oral contraceptive user and one non-user required intubation. AUTHORS' CONCLUSIONS: There are no comparative studies assessing risk of thromboembolism in COVID-19 patients who use hormonal contraception, which was the primary objective of this review. Very little evidence exists examining the risk of increased COVID-19 disease severity for combined hormonal contraception users compared to non-users of hormonal contraception, and the evidence that does exist is of very low certainty. The odds of hospitalization for COVID-19 positive users of combined hormonal contraceptives may be slightly decreased compared with those of hormonal contraceptive non-users, but the evidence is very uncertain as this is based on one study restricted to patients with BMI under 35 kg/m2. There may be little to no effect of combined hormonal contraception use on odds of intubation or mortality among COVID-19 positive patients, and little to no effect of using any type of hormonal contraception on odds of hospitalization and intubation for COVID-19 patients. At a minimum, we noted no large effect for risk of increased COVID-19 disease severity among hormonal contraception users. We specifically noted gaps in pertinent data collection regarding hormonal contraception use such as formulation, hormone doses, and duration or timing of contraceptive use. Differing estrogens may have different thrombogenic potential given differing potency, so it would be important to know if a formulation contained, for example, ethinyl estradiol versus estradiol valerate. Additionally, we downgraded several studies for risk of bias because information on the timing of contraceptive use relative to COVID-19 infection and method adherence were not ascertained. No studies reported indication for hormonal contraceptive use, which is important as individuals who use hormonal management for medical conditions like heavy menstrual bleeding might have different risk profiles compared to individuals using hormones for contraception. Future studies should focus on including pertinent confounders like age, obesity, history of prior venous thromboembolism, risk factors for venous thromboembolism, and recent pregnancy.

Global Preconception and Contraception Care: Using a Life-Course Approach to Improve Health Outcomes in Lower-Resource Settings.

A life-course approach incorporating appropriate preconception and contraception care is key to achieving optimal maternal, neonatal, and child health outcomes. In low- and middle-income countries (LMIC), there is a large unmet need for contraception and an estimated 49% of pregnancies are unintended. In this article, we discuss preconception and contraception care in LMIC settings including key recommendations for content and service delivery. We discuss barriers and facilitators to contraceptive provision, discuss considerations for providers who may practice in LMIC settings, and highlight strategies for achieving increased contraceptive uptake including several examples of successful programs.

Abortion Care Beyond 13 Weeks' Gestation: A Global Perspective.

The majority of abortions are performed early in pregnancy, but later abortion accounts for a large proportion of abortion-related morbidity and mortality. People who need this care are often the most vulnerable-the poor, the young, those who experience violence, and those with significant health issues. In settings with access to safe care, studies demonstrate significant declines in abortion-related morbidity and mortality. This review focuses on evidence-based practices for induced abortion beyond 13 weeks' gestation and post-abortion care in both high- and low-resource settings. We also highlight key programmatic issues to consider when expanding the gestational age for abortion services.

Postpartum care content and delivery throughout the African continent: An integrative review.

OBJECTIVE: The objective of this review was to describe and evaluate the content of postpartum care and models of delivery throughout the African continent. DESIGN: Integrative review was used to allow for the combination of studies using diverse research methodologies. DATA SOURCES: A comprehensive search strategy using the phrases 'postpartum period', 'healthcare delivery', and 'Africa,' including all spelling variants and countries within the continent, was used in the following databases: PubMed, Cumulative Index of Nursing and Allied Health Literature Plus, and Embase for studies published through September 2019. REVIEW METHOD: The integrative review process included five stages: problem identification, literature search, data evaluation, data analysis and presentation. Twelve studies from eight African countries were identified in the search and met the inclusion criteria for the review. The Mixed Methods Appraisal Tool was used to evaluate the quality of the studies included in the review. The theoretical framework developed by the World Health Organization Maternal Morbidity Working Group for healthcare interventions to address maternal morbidity was used for data analysis and to synthesize the results for presentation. RESULTS: Definitions of the postpartum period varied among studies with service delivery ranging from six weeks to one year postpartum. There was no standard package of postpartum care across studies. Based on the World Health Organization theoretical framework, five primary topics were covered in postpartum care interventions: preventive care and counseling, health systems innovation, a life course approach, family planning, and health literacy and education. In contrast, five gaps in content of postpartum care services and service delivery included: integration of screening and treatment of noncommunicable diseases with maternal healthcare, intimate partner violence screening, social protection, a rights-based approach, and social vulnerability. No study addressed all aspects of the World Health Organization framework to address maternal morbidity. CONCLUSIONS: The results from this review indicate the need to address gaps in postpartum care services throughout the African continent in order to reduce maternal morbidity. Re- conceptualizing the paradigm of maternal health to take a life course approach and focusing future research on developing and building interventions to target postpartum care and healthcare delivery of postpartum care are necessary and important in efforts to reduce maternal morbidity and improve health outcomes for mother and child.

Cochrane Review Summaries-April 2021.

In this month's issue, the journal continues to bring new insights from Cochrane Systematic Reviews to the readers of Obstetrics & Gynecology. This month, we highlight the use of self-administered medication for abortion, antibiotic use during operative vaginal delivery, and timing of labor induction. The summaries are published below. The complete references with hyperlinks are listed in Box 1.

Acceptability and Barriers to Use of the ASMAN Provider-Facing Electronic Platform for Peripartum Care in Public Facilities in Madhya Pradesh and Rajasthan, India: A Qualitative Study Using the Technology Acceptance Model-3.

The evolving field of mobile health (mHealth) is revolutionizing collection, management, and quality of clinical data in health systems. Particularly in low- and middle-income countries (LMICs), mHealth approaches for clinical decision support and record-keeping offer numerous potential advantages over paper records and in-person training and supervision. We conducted a content analysis of qualitative in-depth interviews using the Technology Acceptance Model 3 (TAM-3) to explore perspectives of providers and health managers in Madhya Pradesh and Rajasthan, India who were using the ASMAN (Alliance for Saving Mothers and Newborns) platform, a package of mHealth technologies to support management during the peripartum period. Respondents uniformly found ASMAN easy to use and felt it improved quality of care, reduced referral rates, ensured timely referral when needed, and aided reporting requirements. The TAM-3 model captured many determinants of reported respondent use behavior, including shifting workflow and job performance. However, some barriers to ASMAN digital platform use were structural and reported more often in facilities where ASMAN use was less consistent; these affect long-term impact, sustainability, and scalability of ASMAN and similar mHealth interventions. The transitioning of the program to the government, ensuring availability of dedicated funds, human resource support, and training and integration with government health information systems will ensure the sustainability of ASMAN.

Special ambulatory gynecologic considerations in the era of coronavirus disease 2019 (COVID-19) and implications for future practice.

The coronavirus disease 2019 pandemic has altered medical practice in unprecedented ways. Although much of the emphasis in obstetrics and gynecology to date has been on the as yet uncertain effects of coronavirus disease 2019 in pregnancy and on changes to surgical management, the pandemic has broad implications for ambulatory gynecologic care. In this article, we review important ambulatory gynecologic topics such as safety and mental health, reproductive life planning, sexually transmitted infections, and routine screening for breast and cervical cancer. For each topic, we review how care may be modified during the pandemic, provide recommendations when possible on how to ensure continued access to comprehensive healthcare at this time, and discuss ways that future practice may change. Social distancing requirements may place patients at higher risk for intimate partner violence and mental health concerns, threaten continued access to contraception and abortion services, affect prepregnancy planning, interrupt routine screening for breast and cervical cancer, increase risk of sexually transmitted infection acquisition and decrease access to treatment, and exacerbate already underlying racial and minority disparities in care and health outcomes. We advocate for increased use of telemedicine services with increased screening for intimate partner violence and depression using validated questionnaires. Appointments for long-acting contraceptive insertions can be prioritized. Easier access to patient-controlled injectable contraception and pharmacist-provided hormonal contraception can be facilitated. Reproductive healthcare access can be ensured through reducing needs for ultrasonography and laboratory testing for certain eligible patients desiring abortion and conducting phone follow-up for medication abortions. Priority for in-person appointments should be given to patients with sexually transmitted infection symptoms, particularly if at risk for complications, while also offering expedited partner therapy. Although routine mammography screening and cervical cancer screening may be safely delayed, we discuss society guideline recommendations for higher-risk populations. There may be an increasing role for patient-collected human papillomavirus self-samples using new cervical cancer screening guidelines that can be expanded considering the pandemic situation. Although the pandemic has strained our healthcare system, it also affords ambulatory clinicians with opportunities to expand care to vulnerable populations in ways that were previously underutilized to improve health equity.

Tamoxifen for the prevention of unscheduled bleeding in new users of the levonorgestrel 52-mg intrauterine system: a randomized controlled trial.

OBJECTIVE: To determine if a course of oral tamoxifen initiated following placement of a levonorgestrel 52-mg intrauterine system (IUS) reduces bleeding/spotting days over 30 days. STUDY DESIGN: In this single-center, double-blind, placebo-controlled trial, we recruited women ages 15-45 years initiating the levonorgestrel 52-mg IUS. We randomized eligible women to tamoxifen 10 mg or placebo twice daily for 7 days starting 21 days after levonorgestrel 52-mg IUS insertion. Participants tracked bleeding/spotting days via daily electronic diaries for 30 days after starting drug treatment. We assessed participant satisfaction with their bleeding pattern and the IUS using a visual analog scale (0-100 mm). A sample size of 42 provided 80% power to detect a difference of 7 bleeding/spotting days in 30 days by two-sample t test, accounting for an expected 20% dropout rate. RESULTS: From September 2016 to January 2018, 42 women enrolled. A total of 34 women provided complete bleeding/spotting data, and 30 women provided satisfaction data. Mean bleeding/spotting days over 30 days did not differ between tamoxifen (12.0±5.8 days) and placebo users (16.8±9.0 days), p=.08. We found no significant differences in mean satisfaction with bleeding profiles (51 mm tamoxifen vs. 59 mm placebo, p=.48) or with the IUS (83 mm vs. 75 mm, p=.36) between groups. Both groups reported similar rates of adverse events, with no serious adverse events reported. CONCLUSION: A course of oral tamoxifen did not improve early breakthrough bleeding or satisfaction in new users of the levonorgestrel 52-mg IUS. IMPLICATIONS: Although tamoxifen treatment caused a trend toward modest bleeding/spotting day reduction in new levonorgestrel 52-mg IUS users, bleeding satisfaction did not improve. Future studies of tamoxifen treatment for IUS-related bleeding issues may be best targeted toward users with ongoing bleeding irregularities or lower-dose IUS products which cause more bleeding irregularities.

ASMBS pediatric metabolic and bariatric surgery guidelines, 2018.

The American Society for Metabolic and Bariatric Surgery Pediatric Committee updated their evidence-based guidelines published in 2012, performing a comprehensive literature search (2009-2017) with 1387 articles and other supporting evidence through February 2018. The significant increase in data supporting the use of metabolic and bariatric surgery (MBS) in adolescents since 2012 strengthens these guidelines from prior reports. Obesity is recognized as a disease; treatment of severe obesity requires a life-long multidisciplinary approach with combinations of lifestyle changes, nutrition, medications, and MBS. We recommend using modern definitions of severe obesity in children with the Centers for Disease Control and Prevention age- and sex-matched growth charts defining class II obesity as 120% of the 95th percentile and class III obesity as 140% of the 95th percentile. Adolescents with class II obesity and a co-morbidity (listed in the guidelines), or with class III obesity should be considered for MBS. Adolescents with cognitive disabilities, a history of mental illness or eating disorders that are treated, immature bone growth, or low Tanner stage should not be denied treatment. MBS is safe and effective in adolescents; given the higher risk of adult obesity that develops in childhood, MBS should not be withheld from adolescents when severe co-morbidities, such as depressed health-related quality of life score, type 2 diabetes, obstructive sleep apnea, and nonalcoholic steatohepatitis exist. Early intervention can reduce the risk of persistent obesity as well as end organ damage from long standing co-morbidities.

Unhealthy weight control behaviors mediate the association between weight status and weight-specific health-related quality of life in treatment-seeking youth who are obese.

PURPOSE: Examine whether unhealthy and extreme weight control behaviors (WCBs) mediate the relationship between youth weight status and disease-specific health-related quality of life (HRQOL) in treatment-seeking youth who are overweight and obese (OV/OB). METHOD: 82 youth 10-17 years of age who were OV/OB and attending an outpatient obesity-related medical appointment completed measures assessing unhealthy and extreme WCBs and disease-specific HRQOL. Parents completed a demographic questionnaire and medical staff measured youth height and weight. RESULTS: Regression analyses revealed that unhealthy WCBs mediated the associations between youth weight status and emotional and social avoidance disease-specific HRQOL, such that higher body mass index (BMI) predicted unhealthy WCBs, which were ultimately associated with poorer emotional and social HRQOL. Mediation analyses were not significant for total, physical, teasing/marginalization, and positive attributes disease-specific HRQOL. In addition, extreme WCBs did not mediate the association between youth weight status and any subscales of the disease-specific HRQOL measure. DISCUSSION: Weight status is an important predictor of disease-specific HRQOL in OV/OB youth; however, the association with emotional and social HRQOL is partially accounted for by youth engagement in unhealthy WCBs. Clinicians and researchers should assess WCBs and further research should explore and evaluate appropriate intervention strategies to address unhealthy WCBs in pediatric weight management prevention and treatment efforts.

Psychological contributors to noncompletion of an adolescent preoperative bariatric surgery program.

BACKGROUND: Noncompletion of preoperative bariatric programs is a significant problem among adolescents. Adult studies suggest that psychological factors contribute to noncompletion of preoperative bariatric programs. OBJECTIVE: The aim of this study was to determine the association between adolescent psychological functioning and completion of the preoperative phase of a bariatric program. SETTING: The study was conducted at a tertiary care children's hospital affiliated with a university medical center. METHODS: Seventy-four adolescents and their parents completed an assessment measure of psychological functioning with the Behavior Assessment System for Children, Second Edition. We compared these scores between adolescents who completed the preoperative phase of the bariatric program and proceeded to surgery (completers) to those who did not (noncompleters) using multivariate analysis of covariance and logistic regression analyses, adjusting for demographic characteristics and baseline body mass index. RESULTS: The mean age was 16.0 (1.1) years, most were female (79.8%), and the group was diverse (48.6%, Caucasian; 33.8%, black; 17.6%, other, including Hispanic, Asian, and biracial). Average body mass index was 50.5 (7.6) kg/m2. Forty-two percent of participants were noncompleters. Noncompleters were reported by parents to have more clinically significant externalizing and internalizing behaviors and fewer adaptive behaviors. Noncompleters self-reported more clinically significant internalizing symptoms, emotional problems, and poor personal adjustment. CONCLUSION: Adolescents who did not complete the preoperative phase of a bariatric surgery program had more clinically significant psychological symptoms across multiple domains compared with those who successfully proceeded to bariatric surgery. Early identification and treatment of psychological symptoms may be important in helping adolescents successfully proceed to surgery.

Assessing providers' vaccination behaviors during routine immunization in India.

Progress has been made toward improving routine immunization coverage in India, but universal coverage has not been achieved. Little is known about how providers' vaccination behaviors affect coverage rates. The purpose of this study was to identify provider behaviors that served as barriers to vaccination that could lead to missed opportunities to vaccinate. We conducted a study of health-care providers' vaccination behaviors during clinic visits for children <3 years of age. Information on provider behaviors was collected through parent report and direct observation. Compared with illness visits, parents were eight times more likely to report vaccination status was verified (p < 0.001) and three times more likely to report receiving counseling on immunization (p = 0.022) during vaccination visits. Training of all vaccination practitioners should focus on behaviors such as the necessity of verifying vaccination status regardless of visit type, stressing the importance of counseling parents on immunization and emphasizing what is a valid contraindication to vaccination.