Comprehensive transition of care for polycystic ovary syndrome from adolescence to adulthood.

Polycystic ovary syndrome (PCOS) is a lifelong chronic condition that affects one in ten females and can be diagnosed in adolescence. As adolescents with PCOS transition to adulthood, counselling for lifestyle management and mental health concerns often transition from involving the family unit to increasingly individual-focused approaches. PCOS is associated with a large range of comorbidities affecting reproductive, metabolic, dermatological, and psychological health. The diagnosis and comorbidities of PCOS are influenced by pubertal hormones and need to be reassessed continuously to ensure that treatment remains appropriate for age and development. As young patients grow up, personal concerns often change, especially in relation to reproductive management. In this Review, we present prevalence rates, screening tools, and treatment recommendations for PCOS-related conditions, and we consider the diagnostic and clinical elements of optimal transition of care models that ensure continuity of comprehensive care for adolescents moving from the paediatric health-care system to the adult health-care system.

Abnormal uterine bleeding in anticoagulated patients by drug class: outcomes and management.

BACKGROUND: Although abnormal uterine bleeding is a known adverse effect of anticoagulant drugs, true rates have not been widely studied. Society-backed recommendations and guidelines do not yet exist for prevention and management of abnormal uterine bleeding among anticoagulated patients. OBJECTIVE: This study aimed to describe the incidence of new-onset abnormal uterine bleeding among patients receiving therapeutic anticoagulation by anticoagulant class, and to evaluate gynecologic treatment patterns. STUDY DESIGN: We conducted an institutional review board-waived retrospective chart review of female patients aged 18 to 55 years and prescribed therapeutic anticoagulants, including vitamin-K antagonists, low-molecular-weight heparins, and direct oral anticoagulants, in an urban hospital network from January 2015 through January 2020. We excluded patients with antecedent abnormal uterine bleeding and menopause. Associations between abnormal uterine bleeding, anticoagulant class, and other covariates were evaluated with Pearson chi-square and analysis-of-variance tests. The primary outcome, abnormal uterine bleeding odds by anticoagulant class, was modeled with logistic regression. Age, antiplatelet therapy, body mass index, and race were included in our multivariable model. Secondary outcomes included emergency department visits and treatment patterns. RESULTS: Of the 2479 patients who met the inclusion criteria, 645 were diagnosed with abnormal uterine bleeding after initiating therapeutic anticoagulation. After adjusting for age, race, body mass index, and concurrent use of antiplatelet therapy, those receiving all 3 classes of anticoagulants had higher odds of experiencing abnormal uterine bleeding (adjusted odds ratio, 2.63; confidence interval, 1.70-4.08; P<.001), whereas those taking only direct oral anticoagulants had the lowest odds (adjusted odds ratio, 0.70; confidence interval, 0.51-0.97; P=.032), with vitamin-K antagonists as the reference group. Race other than White was associated with higher odds of abnormal uterine bleeding, as was lower age. The most common hormone therapies used among patients with abnormal uterine bleeding were levonorgestrel intrauterine devices (7.6%; 49/645) and oral progestins (7.6%; 49/645). Sixty-eight patients (10.5%; 68/645) had an emergency department visit for abnormal uterine bleeding; 29.5% (190/645) of patients received a blood transfusion; 12.2% (79/645) began any pharmacologic therapy for bleeding; and 18.8% (121/645) underwent any gynecologic procedure. CONCLUSION: Abnormal uterine bleeding occurs frequently among patients on therapeutic anticoagulation. Incidence in this sample varied considerably by anticoagulant class and race; use of single-agent direct oral anticoagulation carried the lowest risk. Important sequelae such as bleeding-related emergency department visits, blood transfusions, and gynecologic procedures were common. Balancing bleeding and clotting risk in patients on therapeutic anticoagulation requires a nuanced approach and should involve collaborative management between hematologists and gynecologists.

The Uptake of Telemedicine in Obstetric Care During the Early Acute Phase of the Coronavirus 2019 Pandemic.

Introduction: The early acute phase of the coronavirus disease 2019 pandemic created rapid adaptation in health care delivery. Methods: Using electronic medical record data from two different institutions located in two different states, we examined how telemedicine was integrated into obstetric care. Results: With no telemedicine use prior, both institutions rapidly incorporated telemedicine into prenatal care (PNC). There were significant patient-level and institutional-level differences in telemedicine use. Telemedicine users initiated PNC earlier and had more total visits, earlier timing of ultrasounds, and earlier diabetes screening during pregnancy compared with nonusers. There were no significant differences in delivery mode or stillbirth associated with telemedicine use at either institution. Conclusions: Rapid adoption of obstetric telemedicine maintained adequate prenatal care provision during the early pandemic, but implementation varied across institutions.

Changes in prenatal testing during the COVID-19 pandemic.

Objective: The coronavirus disease 2019 (COVID-19) pandemic disrupted healthcare delivery, including prenatal care. The study objective was to assess if timing of routine prenatal testing changed during the COVID-19 pandemic. Methods: Retrospective observational cohort study using claims data from a regional insurer (Highmark) and electronic health record data from two academic health systems (Penn Medicine and Yale New Haven) to compare prenatal testing timing in the pre-pandemic (03/10/2018-12/31/2018 and 03/10/2019-12/31/2019) and early COVID-19 pandemic (03/10/2020-12/31/2020) periods. Primary outcomes were second trimester fetal anatomy ultrasounds and gestational diabetes (GDM) testing. A secondary analysis examined first trimester ultrasounds. Results: The three datasets included 31,474 pregnant patients. Mean gestational age for second trimester anatomy ultrasounds increased from the pre-pandemic to COVID-19 period (Highmark 19.4 vs. 19.6 weeks; Penn: 20.1 vs. 20.4 weeks; Yale: 18.8 vs. 19.2 weeks, all p < 0.001). There was a detectable decrease in the proportion of patients who completed the anatomy survey <20 weeks' gestation across datasets, which did not persist at <23 weeks' gestation. There were no consistent changes in timing of GDM screening. There were significant reductions in the proportion of patients with first trimester ultrasounds in the academic institutions (Penn: 57.7% vs. 40.6% and Yale: 78.7% vs. 65.5%, both p < 0.001) but not Highmark. Findings were similar with multivariable adjustment. Conclusion: While some prenatal testing happened later in pregnancy during the pandemic, pregnant patients continued to receive appropriately timed testing. Despite disruptions in care delivery, prenatal screening remained a priority for patients and providers during the COVID-19 pandemic.

Pregnancy-related stroke through a neuropsychology lens.

Objective: Stroke represents a primary cause of morbidity and mortality in pregnant and postpartum people. While pregnancy-related stroke has drawn increased attention in certain domains of health research (e.g. obstetrics, neurology), neuropsychology has yet to contribute to this literature. Given neuropsychologists' crucial role in stroke evaluation and rehabilitation efforts, our field is poised to offer insights into this important topic. Method: This review presents facts about pregnancy-related stroke most relevant for neuropsychologists, including epidemiology, risk factors, and mechanisms, alongside clinical considerations and open areas of inquiry. Structured in the format of a traditional neuropsychological evaluation, we walk readers through factors to consider in record review, the clinical interview, and providing feedback and recommendations. Conclusions: Pregnancy-related stroke can be associated with marked functional disability and decreased quality of life, and it is notable that prevalence rates are increasing. Presenting at a time when people are experiencing adjustment to a new phase of life, and most commonly affecting women of color and other vulnerable populations, pregnancy-related stroke is a unique condition warranting special attention within the broader stroke discourse. This review aims to serve as a starting point for neuropsychologists to better understand the unique attributes of pregnancy-related stroke through a neuropsychology lens. Beyond that, it aims to promote broader meaningful discussion of neuropsychology's role in women's health.

Patient navigation across the spectrum of women's health care in the United States.

Patient navigation is a patient-centered intervention that uses trained personnel to identify patient-level barriers, including financial, cultural, logistical, and educational obstacles to health care and then mitigate these barriers to facilitate complete and timely access to health services. For example, to assist a woman with Medicaid who is seeking postpartum care, a patient navigator could help her schedule an appointment before her insurance benefits change, coordinate transportation and child care, give her informational pamphlets on contraception options, and accompany her to the appointment to ensure her questions are answered. Existing studies examining the efficacy of patient navigation interventions show particularly striking benefits in the realm of cancer care, including gynecological oncology; patient navigation has been demonstrated to increase access to screening, shorten time to diagnostic resolution, and improve cancer outcomes, particularly in health disparity populations, such as women of color, rural populations, and poor women. Because of the successes in cancer care at reducing disparities in health care access and health outcomes, patient navigation has the potential to improve care and reduce disparities in obstetric and benign gynecological care. We review the concept of patient navigation, offer potential roles for patient navigation in obstetrics and gynecology, and discuss areas for further investigation.

Associations Between Postpartum Depression, Breastfeeding, and Oxytocin Levels in Latina Mothers.

BACKGROUND: Postpartum depression (PPD), often comorbid with anxiety, is the leading medical complication among new mothers. Latinas have elevated risk of PPD, which has been associated with early breastfeeding cessation. Lower plasma oxytocin (OT) levels have also been associated with PPD in non-Latinas. This pilot study explores associations between PPD, anxiety, breastfeeding, and OT in Latinas. MATERIALS AND METHODS: Thirty-four Latinas were enrolled during their third trimester of pregnancy and followed through 8 weeks postpartum. Demographic data were collected at enrollment. Depression was assessed using the Edinburgh Postnatal Depression Scale (EPDS) at each time point (third trimester of pregnancy, 4 and 8 weeks postpartum). The Spielberger State-Trait Anxiety Inventory (STAI) was administered postpartum and EPDS anxiety subscale was used to assess anxiety at each time point. Breastfeeding status was assessed at 4 and 8 weeks postpartum. At 8 weeks, OT was collected before, during, and after a 10-minute breast/bottle feeding session from 28 women who completed the procedures. Descriptive statistics are provided and comparisons by mood and breastfeeding status were conducted. Analyses of variance were used to explore associations between PPD, anxiety, breastfeeding status, and OT. RESULTS: Just under one-third of women were depressed at enrollment. Prenatal depression, PPD, and anxiety were significantly associated with early breastfeeding cessation (i.e., stopped breastfeeding before 2 months) (p < 0.05). There was a significant interaction between early breastfeeding cessation and depression status on OT at 8 weeks postpartum (p < 0.05). CONCLUSIONS: Lower levels of OT were observed in women who had PPD at 8 weeks and who had stopped breastfeeding their infant by 8 weeks postpartum. Future studies should investigate the short- and long-term effects of lower OT levels and early breastfeeding cessation on maternal and child well-being.

Clinical Interventions to Promote Breastfeeding by Latinas: A Meta-analysis.

CONTEXT: Breastfeeding duration and exclusivity among Latinas fall below recommended levels, indicating a need for targeted interventions. The effectiveness of clinical breastfeeding interventions for Latinas remains unclear. OBJECTIVE: To systematically review the documented effectiveness of clinical breastfeeding interventions on any and exclusive breastfeeding among Latinas. DATA SOURCES: English-language publications in Medline, CINAHL, and Embase were searched through May 28, 2015. STUDY SELECTION: Fourteen prospective, controlled studies describing 17 interventions met inclusion criteria. DATA EXTRACTION: Extracted study characteristics include study design, population characteristics, intervention components, timing and intensity of delivery, provider type, control procedures, and outcome measures. RESULTS: Random-effects meta-analyses estimated risk differences (RDs) between breastfeeding mothers in intervention and control arms of each study and 95% prediction intervals (PIs) within which 95% of intervals cover the true value estimated by a future study. Interventions increased any breastfeeding at 1 to 3 and 4 to 6 months (RD 0.04 [95% PI -0.15 to 0.23] and 0.08 [-0.08 to 0.25], respectively) and exclusive breastfeeding at 1 to 3 and 4 to 6 months (0.04 [-0.09 to 0.18] and 0.01 [-0.01 to 0.02]). Funnel plot asymmetry suggested publication bias for initiation and 1- to 3-month any breastfeeding. Estimates were slightly larger among interventions with prenatal and postpartum components, 3 to 6 patient contacts, and delivery by an International Board Certified Lactation Consultant or lay provider. LIMITATIONS: The published evidence for Latinas is limited, and studies have varying methodologic rigor. CONCLUSIONS: Breastfeeding interventions targeting Latinas increased any and exclusive breastfeeding compared with usual care.

Epidemiological support for genetic variability at hypothalamic-pituitary-adrenal axis and serotonergic system as risk factors for major depression.

BACKGROUND: Major depressive disorder (MDD) is a serious, and common psychiatric disorder worldwide. By the year 2020, MDD will be the second cause of disability in the world. The GranadΣp study is the first, to the best of our knowledge, epidemiological study of mental disorders carried out in Andalusia (South Spain), being one of its main objectives to identify genetic and environmental risk factors for MDD and other major psychiatric disorders. In this study, we focused on the possible association of 91 candidate single nucleotide polymorphisms (SNPs) with MDD. METHODS: A total of 711 community-based individuals participated in the GranadΣp study. All individuals were extensively assessed for clinical, psychological, sociodemographic, life style, and other environmental variables. A biological sample was also collected for subsequent genetic analyses in 91 candidate SNPs for MDD. DSM-IV diagnosis of MDD was used as the outcome variable. Logistic regression analysis assuming an additive genetic model was performed to test the association between MDD and the genetic data. The experiment-wide significance threshold adjusted with the SNP spectral decomposition method provided a maximum P-value (8×10(-3)) required to identify an association. Haplotype analyses were also performed. RESULTS: One SNP (rs623580) located in the tryptophan hydroxylase 1 gene (TPH1; chromosome 11), one intergenic variant (rs9526236) upstream of the 5-hydroxytryptamine receptor 2A gene (HTR2A; chromosome 13), and five polymorphisms (rs17689966, rs173365, rs7209436, rs110402, and rs242924) located in the corticotropin-releasing hormone receptor 1 gene (CRHR1; chromosome 17), all showed suggestive trends for association with MDD (P<0.05). Within CRHR1 gene, the TATGA haplotype combination was found to increase significantly the risk for MDD with an odds ratio =1.68 (95% CI: 1.16-2.42, P=0.006). CONCLUSION: Although limited, perhaps due to insufficient sample size power, our results seem to support the notion that the hypothalamic-pituitary-adrenal and serotonergic systems are likely to be involved in the genetic susceptibility for MDD. Future studies, including larger samples, should be addressed for further validation and replication of the present findings.

Promotoras across the border: a pilot study addressing depression in Mexican women impacted by migration.

The migration of working-aged men from Mexico to the United States fractures the family-centered support structures typical of Latin America and contributes to high levels of depression in women left behind in migratory sending communities in Mexico. Mujeres en Solidaridad Apoyandose (MESA) was developed to improve depression in women through social support in a resource poor setting. MESA is a promotora intervention that trains women in the community to lead social support groups over a five-week period. The MESA curriculum uses a combination of cognitive behavioral theory techniques, psychoeducation, and social support activities aimed at alleviating or preventing depression in women. Results from this pilot efficacy study (n = 39) show that depressed participants at baseline experienced declines in depression as measured by the Center for Epidemiologic Studies Depression Scale at follow-up. Other findings demonstrate the complexity behind addressing social support and depression for women impacted by migration in different ways.

Anxiety, depression and alexithymia in fibromyalgia: are there any differences according to age?

This article analyzes the evolution of alexithymia, anxiety, and depression associated with fibromyalgia (FM) in three age groups in comparison to how they evolve in the same age groups in healthy women. A total of 240 women participated in the study (120 diagnosed with fibromyalgia and 120 healthy women), divided into three age groups (≤35 years,>35 and <65 years, and ≥65 years old). Our analysis revealed that alexithymia, anxiety, and depression in FM patients showed increased levels compared to healthy controls. Also, young women with FM (under 35) show lower alexithymia, anxiety, and depression levels in comparison to older patients (≥65). Alexithymia in FM patients follows a similar pattern as in healthy women (although with significantly higher scores), increasing with age. Our results show that depression, anxiety, and alexithymia develop over age in a different way in FM patients than in healthy individuals, increasing over age.

Deficits in executive and memory processes in delusional disorder: a case-control study.

OBJECTIVE: Delusional disorder has been traditionally considered a psychotic syndrome that does not evolve to cognitive deterioration. However, to date, very little empirical research has been done to explore cognitive executive components and memory processes in Delusional Disorder patients. This study will investigate whether patients with delusional disorder are intact in both executive function components (such as flexibility, impulsivity and updating components) and memory processes (such as immediate, short term and long term recall, learning and recognition). METHODS: A large sample of patients with delusional disorder (n = 86) and a group of healthy controls (n = 343) were compared with regard to their performance in a broad battery of neuropsychological tests including Trail Making Test, Wisconsin Card Sorting Test, Colour-Word Stroop Test, and Complutense Verbal Learning Test (TAVEC). RESULTS: When compared to controls, cases of delusional disorder showed a significantly poorer performance in most cognitive tests. Thus, we demonstrate deficits in flexibility, impulsivity and updating components of executive functions as well as in memory processes. These findings held significant after taking into account sex, age, educational level and premorbid IQ. CONCLUSIONS: Our results do not support the traditional notion of patients with delusional disorder being cognitively intact.

Infectious agents associated with schizophrenia: a meta-analysis.

Schizophrenia is a highly disabling and limiting disorder for patients and the possibility that infections by some microorganisms may be associated to its development may allow prevention and recovery. In the current study we have done a meta-analysis of studies that have assessed the possible association between detection of different infectious agents and schizophrenia. We report results that support the idea that there is a statistically significant association between schizophrenia and infection by Human Herpesvirus 2 (OR=1.34; CI 95%: 1.09-1.70; p=0.05), Borna Disease Virus (OR=2.03; CI 95%: 1.35-3.06; p<0.01), Human Endogenous Retrovirus W (OR=19.31; CI 95%: 6.74-55.29; p<0.001), Chlamydophila pneumoniae (OR=6.34; CI 95%: 2.83-14.19; p<0.001), Chlamydophila psittaci (OR=29.05; CI 95%: 8.91-94.70; p<0.001) and Toxoplasma gondii (OR=2.70; CI 95%: 1.34-4.42; p=0.005). The implications of these findings are discussed and further research options are also explicated.

Epidemiología de los trastornos de personalidad en el anciano: prevalencia asistida, comorbilidad y uso de servicios / No disponible

Este trabajo actualiza la evidencia científica sobre aspectos epidemiológicos y de comorbilidad de los trastornos de personalidad en el anciano. Los diagnósticos de trastorno de personalidad en el anciano deben ser adaptados a la especial configuración de los factores psicológicos que ocurren en edades avanzadas. Los trastornos de personalidad en edades avanzadas continúan siendo un tema inexplorado, existiendo pocos estudios y resultados contradictorios. Decidimos realizar una breve revisión de la literatura y un estudio para determinar la comorbilidad con eje I en pacientes diagnosticados de T. de Personalidad y estudiar las posibles diferencias de comorbilidad entre población joven y anciana con un diagnóstico de eje II. 2.082 pacientes diagnosticados de T. de Personalidad mediante criterios DSM-IV fueron incluidos en este trabajo, de los cuales el 9,55 % eran mayores de 65 años. Estudiamos los grupos de edad por separado; examinamos diferencias por sexo, por clústers de personalidad, por subtipos de personalidad y por la comorbilidad con eje I por edades y clústers; también examinamos funcionalidad y consumo de recursos sanitarios. Hallamos diferencias estadísticamente significativas en los diagnósticos para los grupos de distintas edades, y fueron los trastornos más frecuentes entre los ancianos los del clúster A, mientras que en los jóvenes fueron los Trastornos no especificados; también existieron diferencias en la distribución de sexos. El nivel de funcionalidad era menor entre las personas de mayor edad. Existe gran variedad de resultados en este área, esto es posiblemente debido a problemas para el diagnóstico a estas edades. Es importante en el futuro estudiar la personalidad normal en el anciano para poder generar instrumentos válidos (AU)

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Depressive comorbidity in personality disorders.

INTRODUCTION: We aimed to investigate the nature of the associations between PD clusters and MDs, functionality and mental health services use. METHODS: This is a case register study of all cases with a diagnosis of PD detected clinically in a well-defined area in the province of Barcelona covered by 7 Community Mental Health Teams. DSM-IV diagnoses were established by fully trained psychiatrists. Data was also gathered on socio-demographic variables; functional status (GAF) and data on use of health resources, using a systematic computerized method. We performed a non-parametric univariate statistical analysis. RESULTS: We found a higher percentage of major depressive disorder (MDD) among cluster C patients (17%), followed by cluster A (10%) and cluster B (9, 8%). As for the comorbidity between PD clusters and dysthymic disorder, we found that the prevalence was higher among cluster B patients (23,7%) than cluster C (20,2%) or cluster A (7,1%). When considering both MDs together, we found the highest prevalence among cluster C patients (36,87%), followed by cluster B (33,5%) and cluster A (17,1%). Cluster A patients showed worse functioning and visited hospitals most. CONCLUSIONS: A high comorbidity between all MDs analyzed and personality disorders was found, being particularly prominent among cluster C PDs.

Variability in the COMT gene and modification of the risk of schizophrenia conferred by cannabis consumption.

INTRODUCTION: The risk of schizophrenia conferred by cannabis has recently been proposed to be modulated by the Val158Met polymorphism (rs4680) at the COMT gene. To date, these findings have not been replicated in independent samples. MATERIAL AND METHODS: We tested the potential gene-by-environment interaction between Val158Met genotype at the COMT gene and previous use of cannabis in schizophrenia in 192 healthy controls and 91 inpatients with DSM-IV schizophrenia. The functional COMT Val158Met polymorphism was analyzed using TaqMan technology. Cannabis use was measured by taking into account the frequency of intake during the previous month. Logistic regression models were used to test the interaction between genetic and environment factors. RESULTS: Cannabis use was strongly associated with the case condition (p<0.0001). The Val158Met polymorphism at the COMT gene was not associated with schizophrenia, although Val/Val homozygosity tended to be more frequent in the case group than in the control group (34% vs 27%; OR=1.39; 95% CI, 0.78-2.47). Finally, in women we found a non-significant trend toward the association when we tested for the interaction between cannabis use, the number of Val alleles and susceptibility to schizophrenia (p=0.152). CONCLUSIONS: Our results tend to support recent findings suggesting that the Val158Met polymorphism at the COMT gene modifies the risk of schizophrenia conferred by cannabis use. In our study, this possible effect was only detected in women.