Perceived Value of a Women's Health Journal Club in Rural Hawai'i.

OBJECTIVES: Rural Hawai'i faces a shortage of physicians specializing in women's health. Improving clinician collaboration and access to the scientific literature are potential strategies for improving physician retention in this community. In 2021, a monthly women's health journal club was established for local clinicians and trainees on Hawai'i Island. Although journal clubs are common in large academic institutions, there are limited data regarding the value of journal clubs in rural and community practices. This study aimed to evaluate the value of a women's health journal club on Hawai'i Island. METHODS: We used an anonymous Web-based survey to evaluate the value of the journal club. RESULTS: Of the 18 eligible clinicians participating in the women's health journal club, 13 completed a Web-based survey (response rate 72%). The common reasons for attending journal club included wanting to learn about research methods/statistics (100%), seeking opportunities to discuss current best practices (86%), and desiring to practice critical review skills (71%). The majority of respondents (77%) believed that journal club was a valuable activity, and 92% of respondents would recommend this activity to a colleague. This journal club allowed participants to improve their understanding of research methods (85%) and stay up-to-date with medical advancements (85%). CONCLUSIONS: This community-based journal club is a valuable activity for clinicians practicing on Hawai'i Island. Other rural communities may similarly benefit from engaging in structured scholarly discussion.

Just World Beliefs among Medical Students and the General Public in Hawai'i.

Just World Beliefs (JWBs) are a psychological tendency to conclude the world is an inherently fair place in which people experience the outcomes they deserve. Strong JWBs positively correlate with a personal commitment to long-term ambitions and blaming people for their negative health outcomes. This study aimed to measure JWBs in medical students and the general population of Hawai'i. It was hypothesized that (1) medical students would have stronger JWBs than the general public, and (2) JWBs would be strongest for medical students in the latter part of their training. Current residents of Hawai'i and medical students at the University of Hawai'i at Manoa were recruited to complete a web-based survey measuring JWBs using the Global Belief in a Just World Scale. A t-test was used to compare JWB strength between the groups. A regression analysis identified factors predicting strength of JWBs. Contrary to both hypotheses, medical students in Hawai'i possessed weaker JWBs than Hawai'i residents (P<.01), and JWBs did not differ based on training duration (P=.97). Age (P<.01) was the only demographic variable to significantly predict JWBs. The difference in JWBs among medical and non-medical cohorts was no longer significant after controlling for age. Among medical students, younger age was associated with weaker JWBs. Future studies should explore the prevalence and effects of JWBs among diverse populations and the medical professionals that care for them.

Contraception After Abortion.

After a spontaneous or induced abortion, people may desire to delay or prevent a future pregnancy and many desire to use contraceptive methods to do so. Contraception counseling and provision at the time of abortion care are important components to improve contraceptive access and convenience for people undergoing abortion care. The majority of hormonal and barrier contraceptive methods may be safely initiated at the time of medication or procedural abortion or shortly thereafter, although delayed initiation may be necessary in certain circumstances. A patient-centered approach to contraceptive counseling can identify patients' priorities and mitigate provider coercion or pressure.

A qualitative study of perspectives on research participation among individuals who recently experienced an abortion in Hawai'i.

OBJECTIVES: The United States Code of Federal Regulations mandates extra protections for research involving pregnant participants seeking abortions. This study aims to understand the perspectives of abortion patients regarding recruitment, decision-making, and participation in research. STUDY DESIGN: We recruited adults in Hawai'i who reported at least one induced abortion in the previous 6 months. Recruitment strategies included online advertisements and flyers posted in reproductive health clinics. We conducted in-person, semistructured interviews exploring research preferences. The authors collaboratively reviewed the resulting transcripts and created a code dictionary. We reviewed, organized, condensed, and diagrammed the resulting data to identify dominant themes. RESULTS: Between February and November 2019, we interviewed 25 participants aged 18-41 years who had medication (n = 14) or procedural (n = 11) abortions. Interviews ranged from 32 to 77 minutes (mean = 48 minutes). Four themes emerged: (1) people having abortions are capable of making informed decisions about research participation, (2) abortion-related stigma influences research decision-making, (3) people having abortions prefer to learn about study opportunities early and through participant-driven recruitment methods, and (4) the ideal role of the abortion provider in research is unclear. CONCLUSIONS: Abortion patients in this study want to be informed of research opportunities and feel capable of deciding about participation in research studies. Current federally mandated protections and common research practices could be revisited and revised to better reflect these preferences. IMPLICATIONS: Revision of federal regulations and optimization of recruitment methods may allow researchers to improve the research experience for patients having an abortion.

Perceived Impact of a Core Rotation on Hawai'i Island on Future Career Intentions among Obstetrics and Gynecology Residents.

Hawai'i Island faces a growing shortage of obstetric and gynecology providers. Increased exposure of obstetrics and gynecology residents to rural rotations during their core training may increase their interest in rural practice after graduation. In an effort to address the health care needs of women on Hawai'i Island, the University of Hawai'i Obstetrics and Gynecology Residency Program established a 4-week required gynecology rotation in the town of Hilo. Between July 2019 and June 2020, third- and fourth-year obstetrics and gynecology residents provided outpatient gynecologic care and participated in gynecologic surgeries at Hilo-based medical facilities. A total of 9 residents participated in this Hilo-based rotation. This retrospective study extracted data from post-rotation evaluations. Eight out of 9 participating residents (89%) felt that the rotation slightly or far exceeded their expectations. After the rotation, 7 residents (78%) reported an interest in practicing in a rural community, while only 3 residents (33%) reported having this interest prior to the rotation. Underserved rural areas seeking to recruit and retain obstetrics and gynecology physicians may benefit from partnering with residency training programs.

Just-word beliefs and community-level abortion stigma: An exploratory survey.

OBJECTIVES: This study aimed to evaluate whether belief in a just world is associated with community-level abortion stigma. STUDY DESIGN: From December 2020 to June 2021, we conducted a national U.S. survey of 911 adults using Amazon Mechanical Turk. Survey respondents completed both the Community-Level Abortion Stigma Scale and Global Belief in a Just World Scale. We used linear regression to evaluate the association between just-world beliefs, demographic characteristics, and community-level abortion stigma. RESULTS: The mean Global Belief in a Just World Scale score was 25.8. The mean Community-Level Abortion Stigma Scale score was 2.6. The strength of just-world beliefs (ß = 0.7), male gender (ß = 4.1), a history of a previous pregnancy (ß = 3.1), post college education (ß = 2.8), and strength of religious beliefs (ß = 0.3) were associated with higher community-level abortion stigma. Asian race was associated with lower community-level abortion stigma (ß = -7.2). CONCLUSIONS: After controlling for demographic characteristics, strong just-world beliefs were associated with higher community-level abortion stigma. IMPLICATIONS: Understanding just-world beliefs may provide a potential target for stigma-reduction strategies.

Fetal tissue donation for research at the time of abortion: A qualitative study of individuals who experienced an abortion in Hawaii in 2018-19.

OBJECTIVES: This qualitative study explores how individuals recently experiencing abortions feel about donating fetal tissue for research. In addition, we sought to identify motivating or discouraging factors that influence decision making for these individuals. STUDY DESIGN: We recruited individuals living in Hawaii who reported undergoing an abortion in the previous 6 months for one-on-one semi-structured interviews as part of a broader study investigating views on peri-abortion research practices and protections. We devoted approximately 15 minutes of each 1-hour interview to discussing the donation of aborted fetal tissue for research. We double coded transcribed interviews and identified themes related to fetal tissue donation. RESULTS: We interviewed 25 respondents and identified 4 themes. (1) Individuals viewed fetal tissue donation as an opportunity to help others. (2) Respondents preferred for aborted fetal tissue to be used rather than discarded. (3) Respondents viewed the fetal tissue to be an extension of themselves, so informed consent is critical. (4) Information found online promotes mistrust of fetal tissue handling. CONCLUSIONS: Individuals who have had an abortion are open to fetal tissue donation for research purposes. Pre-abortion counseling could be improved by clarifying the process of fetal tissue handling and, when available, discussing options for fetal tissue donation. IMPLICATIONS: Informed pregnant individuals who have had an abortion appear to be supportive of fetal tissue research and their views can differ from the concerns of ethicists, politicians, and scientists. The perspective of the individuals donating fetal tissue should be included in future discussions of fetal tissue research.

Guam: The US territory where America's day begins but abortion access is still in the dark.

Despite a constitutional right to legal abortion, residents of the unincorporated United States territory of Guam have no local access to abortion. Telehealth has the potential to address this need. However, current abortion restrictions in the Guamanian legal code in combination with the Risk Evaluation and Mitigation Strategy requirements obstruct telehealth provision of medication abortion.

Provision of medication abortion in Hawai'i during COVID-19: Practical experience with multiple care delivery models.

OBJECTIVE: To demonstrate the effectiveness of medication abortion with the implementation of telemedicine and a no-test protocol in response to the COVID-19 pandemic. STUDY DESIGN: This is a retrospective cohort study of patients who had a medication abortion up to 77 days gestation at the University of Hawai'i between April and November 2020. Patients had the option of traditional in clinic care or telemedicine with either in clinic pickup or mailing of medications. During this time, a no-test protocol for medication abortion without prior labs or ultrasound was in place for eligible patients. The primary outcome was the rate of successful medication abortion without surgical intervention. Secondary outcomes included abortion-related complications. RESULTS: A total of 334 patients were dispensed mifepristone and misoprostol, 149 (44.6%) with telemedicine with in-person pickup of medications, 75 (22.5%) via telemedicine with medications mailed, and 110 (32.9%) via traditional in person visits. The overall rate of complete medication abortion without surgical intervention was 95.8%, with success rates of 96.8, 97.1, and 93.6% for the clinic pickup, mail, and clinic visit groups, respectively. Success for those without an ultrasound performed prior to the procedure was 96.6%, compared to 95.5% for those with ultrasound. We obtained follow-up data for 87.8% of participants. CONCLUSIONS: Medication abortion was safe and effective while offering multiple modes of care delivery including telemedicine visits without an ultrasound performed prior to dispensing medications. IMPLICATIONS: Incorporating telemedicine and a no-test protocol for medication abortion is safe and has the potential to expand access to abortion care. All care models had low rates of adverse events, which contradicts the idea that the Risk Evaluation and Mitigation Strategyincreases the safety of medication abortion.

Documentation of Sexual and Menstrual Histories for Adolescent Patients in the Inpatient Setting.

STUDY OBJECTIVE: In this study, we aimed to determine the frequency of menstrual history and sexual history documentation in the inpatient setting. DESIGN, SETTING, AND PARTICIPANTS: A retrospective chart review was conducted for 307 female patients ages 11-18 years admitted from the emergency department at a single institution within a 7-month period. These charts were reviewed for documentation of menstrual and sexual history. INTERVENTIONS AND MAIN OUTCOME MEASURES: Rates of menstrual and sexual history documentation were compared according to patient age, chief complaint, admitting specialty, and medical complexity. RESULTS: Sexual history documentation was noted in 158 (45.9%) of the 344 reviewed charts. Sexual history documentation rates were higher for patients with mental health symptoms (62.9%; 61 of 98 charts; P = .02) and lower for patients admitted to surgical services (30.6%; 19 of 62 charts; P = .04). At least 1 aspect of menses was documented in 113 (32.8%) of the 344 reviewed charts. Last menstrual period was the most commonly documented aspect of menstrual history, appearing in 100 (29.1%) of the 344 reviewed charts. Menarche (4.4%; 15/344), menses frequency (7.0%; 24/344), menses duration (2.6%; 9/344), flow quantity (4.9%; 17/344), and dysmenorrhea (4.4%; 15/344) were rarely documented, regardless of chief complaint or admitting service. Menstrual history documentation rates were significantly higher for patients requiring a gynecology consultation (73.3%; 11 of 15 charts; P < .01). CONCLUSION: Menstrual and sexual history documentation rates for adolescent patients requiring inpatient admission were low, with fewer than half of patients having a documented menstrual or sexual history.

Use of levonorgestrel as emergency contraception in overweight women.

OBJECTIVE: Levonorgestrel (LNG) emergency contraception (EC) may have decreased efficacy for women with body mass indices (BMI)≥26kg/m2. This study aims to evaluate the prevalence of LNG EC use and EC counseling among overweight women. METHODS: The 2013-2015 dataset from the National Survey of Family Growth was analyzed to determine the proportion of women with BMI≥26kg/m2 who report recent use of LNG EC and EC counseling. RESULTS: Overall, 2.4% of respondents reported recent use of LNG EC. Among women using oral LNG for EC, 29.8% of survey participants reported BMI≥26kg/m2. Additionally, 40.2% of women with BMI≥26kg/m2 using oral LNG EC reported having a doctor or medical provider talk to them about emergency contraception within the last 12 months, compared to 18.3% of LNG EC users with BMI<26kg/m2 (p<0.001). CONCLUSIONS: Despite recent counseling from clinicians and concerns for decreased efficacy, a significant number of overweight women continue to use LNG for EC. Clinicians should counsel women with BMI≥26kg/m2 on the potential limitations of oral LNG for EC and offer more effective EC methods, including the copper intrauterine device and oral ulipristal acetate.

National survey of attitudes towards pregnancy termination procedures among anaesthesiology residents in the US.

Anaesthesiologists are vital to abortion access in the US. An online survey of 215 anaesthesiology residents assessed attitudes towards abortion. Among the surveyed residents, first-trimester abortion was more acceptable than second-trimester abortion (P<0.001). Few respondents objected to abortion in cases of fetal anomalies or maternal health indications. Further, 77.3% of surveyed residents reported past participation in abortion procedures, including 77.8% of residents with objections to abortion in some circumstances. Anaesthesiology residents who are female, childless and non-religious were more likely to find first-trimester abortion acceptable.

A p53 drug response signature identifies prognostic genes in high-risk neuroblastoma.

Chemotherapy induces apoptosis and tumor regression primarily through activation of p53-mediated transcription. Neuroblastoma is a p53 wild type malignancy at diagnosis and repression of p53 signaling plays an important role in its pathogenesis. Recently developed small molecule inhibitors of the MDM2-p53 interaction are able to overcome this repression and potently activate p53 dependent apoptosis in malignancies with intact p53 downstream signaling. We used the small molecule MDM2 inhibitor, Nutlin-3a, to determine the p53 drug response signature in neuroblastoma cells. In addition to p53 mediated apoptotic signatures, GSEA and pathway analysis identified a set of p53-repressed genes that were reciprocally over-expressed in neuroblastoma patients with the worst overall outcome in multiple clinical cohorts. Multifactorial regression analysis identified a subset of four genes (CHAF1A, RRM2, MCM3, and MCM6) whose expression together strongly predicted overall and event-free survival (p<0.0001). The expression of these four genes was then validated by quantitative PCR in a large independent clinical cohort. Our findings further support the concept that oncogene-driven transcriptional networks opposing p53 activation are essential for the aggressive behavior and poor response to therapy of high-risk neuroblastoma.

G-CSF receptor positive neuroblastoma subpopulations are enriched in chemotherapy-resistant or relapsed tumors and are highly tumorigenic.

Neuroblastoma is a neural crest-derived embryonal malignancy, which accounts for 13% of all pediatric cancer mortality, primarily due to tumor recurrence. Therapy-resistant cancer stem cells are implicated in tumor relapse, but definitive phenotypic evidence of the existence of these cells has been lacking. In this study, we define a highly tumorigenic subpopulation in neuroblastoma with stem cell characteristics, based on the expression of CSF3R, which encodes the receptor for granulocyte colony-stimulating factor (G-CSF). G-CSF receptor positive (aka G-CSFr(+) or CD114(+)) cells isolated from a primary tumor and the NGP cell line by flow cytometry were highly tumorigenic and capable of both self-renewal and differentiation to progeny cells. CD114(+) cells closely resembled embryonic and induced pluripotent stem cells with respect to their profiles of cell cycle, miRNA, and gene expression. In addition, they reflect a primitive undifferentiated neuroectodermal/neural crest phenotype revealing a developmental hierarchy within neuroblastoma tumors. We detected this dedifferentiated neural crest subpopulation in all established neuroblastoma cell lines, xenograft tumors, and primary tumor specimens analyzed. Ligand activation of CD114 by the addition of exogenous G-CSF to CD114(+) cells confirmed intact STAT3 upregulation, characteristic of G-CSF receptor signaling. Together, our data describe a novel distinct subpopulation within neuroblastoma with enhanced tumorigenicity and a stem cell-like phenotype, further elucidating the complex heterogeneity of solid tumors such as neuroblastoma. We propose that this subpopulation may represent an additional target for novel therapeutic approaches to this aggressive pediatric malignancy.