Identifying barriers individuals face in accessing fertility care after a gynecologic cancer diagnosis.

Objective: To (1) identify the major barriers premenopausal individuals face in accessing fertility care at the time of gynecologic cancer diagnosis and (2) to assess patient experiences pertaining to fertility. Methods: We distributed an online survey about cancer diagnosis and fertility goals to patients ages 18-40 who had been treated for ovarian, endometrial, or cervical cancer at a single, large academic hospital. Descriptive statistics were used to analyze survey results. Patients who completed the survey were given the option to participate in a follow-up virtual interview. We conducted semi-structured interviews to discuss their fertility goals and barriers to these. Grounded theory was used to qualitatively analyze the interviews. Results: Fifty-five patients completed the survey, and 20 patients participated in the interview. The median age at diagnosis was 32 years old. Seventy-three percent of patients recalled that at the time of their diagnosis they were considering future childbearing, and 32% underwent fertility preservation. Patients reported the emotional response to their diagnosis as a barrier to receiving fertility care, with patients reporting lack of control (80%), shock (55%), and confusion (45%). Patients also identified inadequate counseling (60.0%), lack of time (60.0%), economic constraints (55.0%) and prioritization of cancer treatment (55.0%) as barriers. Nearly all patients had a positive interview experience and expressed desire to help patients in similar situations. Conclusion: Many premenopausal patients diagnosed with gynecologic malignancies are considering future childbearing at the time of diagnosis. Both logistical and emotional barriers prevent them from undergoing fertility preservation before initiating oncologic treatment.

Calculating surgical readmission rates in gynecologic oncology: The impact of patient factors.

OBJECTIVE: To determine the 30-day surgical readmission rate after major gynecologic oncology surgeries at a high-volume academic institution and correlated risk factors. METHODS: Retrospective cohort study was conducted of surgical admissions from January 2016 - December 2019 at a single institution. Data were extracted from patient charts, including reason for readmission and length of stay. A readmission rate was calculated. Nested case control design was used to identify correlations between readmission and patient specific risk-factors. Multivariable logistic regression models were used to determine risk factors with readmission. RESULTS: A total of 2152 patients were included. The readmission rate was 3.5%, most commonly due to GI disturbance and surgical site infection. Average readmission length was 5 days. Prior to adjusting for covariates, insurance status, primary diagnosis, index admission length, and disposition at discharge differed between patients who were and were not readmitted. After adjusting for co-variates, younger patients, index admission >2 days, and higher Charlson co-morbidity index were associated with readmission. CONCLUSIONS: Our surgical readmission rate was lower than previously reported rates in gynecologic oncology patients. Patient factors associated with readmission included younger age, longer index hospital admission, and higher medical co-morbidity index scores. Provider factors and institutional practice patterns could contribute to the decreased readmission rate. These findings underscore the importance of standardizing how we calculate readmission rate and interpret these data. Varying readmission rates and institutional practice patterns deserve closer scrutiny to inform best practice and future policies.

Paraneoplastic nodular regenerative hyperplasia of the liver associated with placental site trophoblastic tumor.

•NRH-L is a rare disease that may lead to non-cirrhotic portal hypertension.•NRH-L may present as a paraneoplastic disorder, complicating oncologic treatment.•This is the first case of NRH-L as a potential paraneoplastic disorder due to PSTT.

Unplanned 30-day hospital readmission as a quality measure in gynecologic oncology.

OBJECTIVES: Thirty-day readmission is used as a quality measure for patient care and Medicare-based hospital reimbursement. The primary study objective was to describe the 30-day readmission rate to an academic gynecologic oncology service. Secondary objectives were to identify risk factors and costs related to readmission. METHODS: This was a retrospective, concurrent cohort study of all surgical admissions to an academic, high volume gynecologic oncology service during a two-year period (2013-2014). Data were collected on patient demographics, medical comorbidities, psychosocial risk factors, and results from a hospital discharge screening survey. Mixed logistic regression was used to identify factors associated with 30-day readmission and costs of readmission were assessed. RESULTS: During the two-year study period, 1605 women underwent an index surgical admission. Among this population, a total of 177 readmissions (11.0%) in 135 unique patients occurred. In a surgical subpopulation with >1 night stay, a readmission rate of 20.9% was observed. The mean interval to readmission was 11.8days (SD 10.7) and mean length of readmission stay was 5.1days (SD 5.0). Factors associated with readmission included radical surgery for ovarian cancer (OR 2.87) or cervical cancer (OR 4.33), creation of an ostomy (OR 11.44), a Charlson score of ≥5 (OR 2.15), a language barrier (OR 3.36), a median household income in the lowest quartile (OR 6.49), and a positive discharge screen (OR 2.85). The mean cost per readmission was $25,416 (SD $26,736), with the highest costs associated with gastrointestinal complications at $32,432 (SD $32,148). The total readmission-related costs during the study period were $4,523,959. CONCLUSIONS: Readmissions to a high volume gynecologic oncology service were costly and related to radical surgery for ovarian and cervical cancer as well as to medical, socioeconomic and psychosocial patient variables. These data may inform interventional studies aimed at decreasing unplanned readmissions in gynecologic oncology surgical populations.

Predictors of Human Papillomavirus Vaccination in a Large Clinical Population of Males Aged 11 to 26 years in Maryland, 2012-2013.

BACKGROUND: Despite the recommendation for routine human papillomavirus (HPV) vaccination in males, coverage estimates remain low. We sought to identify predictors of receiving each HPV vaccine dose among a large clinical population of males. METHODS: We conducted a cross-sectional analysis of electronic medical records for 14,688 males ages 11 to 26 years attending 26 outpatient clinics (January 2012-April 2013) in Maryland to identify predictors of each HPV vaccine dose using multivariate logistic regression models with generalized estimating equations. All analyses were stratified in accordance with vaccine age recommendations: 11 to 12 years, 13 to 21 years, and 22 to 26 years. Analyses of predictors of receipt of subsequent HPV doses were also stratified by the number of clinic visits (≤3 and >3). RESULTS: Approximately 15% of males initiated the HPV vaccine. Less than half of males eligible received the second and third doses, 49% and 47%, respectively. Non-Hispanic black males (vs. non-Hispanic white) ages 11 to 12 and 13 to 21 years and males with public insurance (vs. private) ages 13 to 21 years had significantly greater odds of vaccine initiation, but significantly decreased odds of receiving subsequent doses, respectively. Attendance to >3 clinic visits attenuated the inverse association between public insurance and receipt of subsequent doses. CONCLUSION: Overall, rates of HPV vaccine initiation and of subsequent doses were low. While non-Hispanic black and publicly insured males were more likely to initiate the HPV vaccine, they were less likely to receive subsequent doses. IMPACT: Tailoring different intervention strategies for increasing HPV vaccine initiation versus increasing rates of subsequent doses among males may be warranted.

Racial and ethnic differences in HPV knowledge, attitudes, and vaccination rates among low-income African-American, Haitian, Latina, and Caucasian young adult women.

OBJECTIVE: To examine facilitators and barriers to HPV vaccine uptake in African-American, Haitian, Latina, and White women aged 18-22 and to determine vaccination completion rates among participants over 5 years. DESIGN: Using semi-structured interviews and medical record review, we assessed HPV knowledge and attitudes towards HPV vaccination among young women. We then determined their subsequent HPV vaccination initiation and completion rates. We used constructs from the Health Belief Model and methods based in grounded theory and content analysis to identify attitudes towards HPV vaccination cues to initiate vaccination, perception of HPV, and how communication about issues of sexuality may impact vaccine uptake. PARTICIPANTS: We enrolled 132 African-American, Haitian, Latina, and White women aged 18-22 years who visited an urban academic medical center and 2 affiliated community health centers between the years 2007 and 2012. MAIN OUTCOME MEASURES: Intent to vaccinate and actual vaccination rates. RESULTS: Of 132 participants, 116 (90%) stated that they were somewhat or very likely to accept HPV vaccination if offered by their physician, but only 51% initiated the vaccination over the next 5 years. Seventy-eight percent of those who initiated vaccination completed the 3 doses of the HPV vaccine series. Forty-five percent (45%, n = 50) of the adolescents who started the series completed 3 doses over a 5-year period: 42% of African-American (n = 16), 33% of Haitian (n = 13), 63% of Latina (n = 10), and 65% of White young women (n = 11) completed the 3-dose series. Despite low knowledge, they reported high levels of trust in physicians and were willing to vaccinate if recommended by their physicians. CONCLUSION: Desire for HPV vaccination is high among older adolescents, physician recommendation, and use of every clinic visit opportunity may improve vaccine uptake in young women. More White young women completed the HPV vaccine series compared with other race and ethnic young women.

Socioemotional effects of fathers' incarceration on low-income, urban, school-aged children.

OBJECTIVE: The goal was to evaluate whether children of incarcerated fathers are more likely to report or exhibit behavioral symptoms than their equally disadvantaged peers without an incarcerated father. METHODS: During an ongoing longitudinal study of intrauterine cocaine exposure involving 102 children (50% male and 89% black) from urban, low-income homes, questions regarding incarceration of the child's father were asked of the child's primary caregiver at each visit during school age. Children were administered the Children's Depression Inventory between the ages of 6 and 11 years, and their primary caregivers completed the Child Behavior Checklist. In addition, the children's teachers completed the Teacher Report Form. Children's Depression Inventory, Child Behavior Checklist, and Teacher Report Form data obtained at the oldest available age after the first report of paternal incarceration were analyzed. RESULTS: In bivariate analyses, children whose fathers were in jail had higher Children's Depression Inventory total scores compared with children without incarcerated fathers, indicating more depressive symptoms. This finding was robust in multivariate analyses after adjustment for children's age, gender, prenatal cocaine and alcohol exposure, and school-age violence exposure. Teachers reported higher Teacher Report Form externalizing scores for children whose fathers were in jail, after adjustment for age, gender, prenatal cocaine and marijuana exposure, and school-age violence exposure. CONCLUSIONS: Children of incarcerated fathers reported more depressive symptoms and their teachers noted more externalizing behaviors, after controlling for other biopsychosocial risks. Interventions targeted to ameliorate the distress of children with incarcerated fathers should be considered.

Level of prenatal cocaine exposure and 48-month IQ: importance of preschool enrichment.

OBJECTIVE: This analysis was designed to determine whether prenatal cocaine exposure is related to children's standardized cognitive test scores at age 4 years after control for relevant covariates. METHODS: Masked examiners using the WPPSI-R assessed ninety-one 4-year-old children with prenatal cocaine exposure and 79 children of comparable demographic background who were not exposed. Level of cocaine exposure was documented by postpartum interviews of mothers and assays of the infants' meconium. RESULTS: Prenatal cocaine exposure, analyzed as exposed/unexposed or as an ordinal dose variable, was not associated in bivariate or multivariate models with decrements in full-scale IQ, performance IQ, verbal IQ, or in any of the subtests. In bivariate analyses, we found significant differences between exposure groups defined as "unexposed", "lighter", and "heavier" in mean scores of the WPPSI-R subtests Object Assembly (P=0.04) and Picture Completion (P=0.03). For these scores, children with heavier exposure attained higher scaled scores. Birth mother's education and child's experience with preschool enrichment were both associated with higher verbal IQ scores. CONCLUSION: These findings suggest that prenatal cocaine exposure does not exert negative effects on the cognitive competence of preschool-aged children. Children with a history of prenatal cocaine exposure benefit from preschool programs that have been shown to enhance outcomes for other low-income children.