Medicine in the marketplace: clinician and patient views on commercial influences on assisted reproductive technology.

RESEARCH QUESTION: What are the views and experiences of patient and expert stakeholders on the positive and negative impacts of commercial influences on the provision of assisted reproductive technology (ART) services, and what are their suggestions for governance reforms? DESIGN: Semi-structured interviews were conducted with 31 ART industry experts from across Australia and New Zealand and 25 patients undergoing ART from metropolitan and regional Australia, between September 2020 and September 2021. Data were analysed using thematic analysis. RESULTS: Expert and patient participants considered that commercial forces influence the provision of ART in a number of positive ways - increasing sustainability, ensuring consistency in standards and providing patients with greater choice. Participants also considered commercial forces to have a number of negative impacts, including increased costs to government and patients; the excessive use of interventions that lack sufficient evidence to be considered part of standard care; inadequately informed consent (particularly with regard to financial information); and threats to patient-provider relationships and patient-centred care. Participants varied in whether they believed that professional self-regulation is sufficient. While recognizing the benefits of commercial investment in healthcare, many considered that regulatory reforms, as well as organizational cultural initiatives, are needed as means to ensure the primacy of patient well-being. CONCLUSIONS: The views expressed in this study should be systematically and critically examined to derive insights into how best to govern ART. These insights may also inform the design and delivery of other types of healthcare that are provided in the private sector.

Storage trends, usage and disposition outcomes following egg freezing.

RESEARCH QUESTION: What happens to eggs after egg freezing? DESIGN: A retrospective cohort study was performed spanning 2012-2022. Data were obtained from seven assisted reproductive technology clinics in Victoria, Australia. Aggregated, de-identified data were collected on cycles that resulted in egg freezing and the following outcomes, including treatment involving thawed eggs and disposition outcomes of surplus eggs. RESULTS: The number of patients with eggs in storage grew rapidly from 144 in 2012 to 2015 in 2022. In 2022, 73% of patients had stored their eggs for <5 years, 25% for 5-10 years, and 2% for ≥10 years. Most thaw cycles (600/645, 93%) involved eggs that had been frozen for <5 years, of which 47% had been frozen for <6 months. Overall, the live birth rate per initiated thaw cycle was 12%. Across the study period, 2800 eggs from 286 patients were either discarded, donated or exported. Of the 128 patients who discarded their eggs, 32% had stored their eggs for <5 years, 32% for 5-10 years and 36% for >10 years. Of the 23 patients who donated their eggs to someone else, all but four had stored their eggs for <5 years. No eggs were donated to research over the study period. CONCLUSIONS: This study shows that very few patients have made the decision to use or relinquish their eggs. Strategies may be needed to address the prolonged storage of surplus eggs, and ensure that patients are supported to make decisions regarding the fate of their eggs which align with their preferences and values.

The risk of perinatal and cardiometabolic complications in pregnancies conceived by medically assisted reproduction.

PURPOSE: To examine the impact of medically assisted fertility treatments on the risk of developing perinatal and cardiometabolic complications during pregnancy and in-hospital deliveries. METHODS: We conducted a retrospective cohort study using medical health records of deliveries occurring in 2016-2022 at a women's specialty hospital in a southern state of the Unites States (US). Pregnancies achieved using medically assisted reproductive (MAR) techniques were compared with unassisted pregnancies using propensity score matching (PSM), based on demographic, preexisting health, and reproductive factors. Study outcomes included cesarean delivery, gestational diabetes mellitus (GDM), hypertensive disorders of pregnancy (HDP), delivery complications, and postpartum readmission. We used Poisson regression with robust standard errors to generate risk ratios (RRs) and 95% confidence intervals (CIs) for all study outcomes. RESULTS: Among 57,354 deliveries, 586 (1.02%) pregnancies were achieved using MAR and 56,768 (98.98%) were unassisted ("non-MAR"). Compared to the non-MAR group, MAR pregnancies had significantly higher prevalence of all study outcomes, including GDM (15.9% vs. 11.2%, p < 0.001), HDP (28.2% vs. 21.1%, p < 0.001), cesarean delivery (56.1% vs. 34.6%, p < 0.001), delivery complications (10.9% vs. 6.8%, p = 0.03), and postpartum readmission (4.3% vs. 2.7%, p = 0.02). In a PSM sample of 584 MAR and 1,727 unassisted pregnancies, MAR was associated with an increased risk of cesarean delivery (RR = 1.11, 95% CI = 1.01-1.22); whereas IVF was associated with an increased risk of cesarean delivery (RR = 1.15, 95% CI = 1.03-1.28) and delivery complications (RR = 1.44, 95% CI = 1.04-2.01). CONCLUSIONS: Women who conceived with MAR were at increased risk of cesarean deliveries, and those who conceived with IVF were additionally at risk of delivery complications.

A comparison of in-person vs. asynchronous learning with self-care patient cases.

BACKGROUND AND PURPOSE: To evaluate the effectiveness of a live laboratory setting compared to an asynchronous session in a crossover teaching design on knowledge and confidence in self-care review topics. EDUCATIONAL ACTIVITY AND SETTING: Pharmacy students (n = 88) participated in a crossover designed laboratory session where they either attended a live, active-learning laboratory session on self-care review topics, followed by a virtual, asynchronous self-care simulation or vice versa. Sessions were held one week apart. Pre- and post-assessments were administered that contained knowledge and confidence questions as well as student perceptions on the teaching modalities. FINDINGS: Of the 88 students who participated in the study, 67 (76.1%) were included in the study findings. Post-assessment knowledge and confidence significantly increased after both the live, active-learning session and the asynchronous simulation. The majority of students (85%) indicated that they preferred the in-person activity. SUMMARY: Students preferred the live, active-learning laboratory for reviewing self-care concepts. However, knowledge and confidence improved using either teaching modality, therefore, in institutions where resources are limited, the virtual, asynchronous activity may be useful especially if facilitators and/or budget are limited.

Attitudes and barriers to breastfeeding among women at high-risk for not breastfeeding: a prospective observational study.

BACKGROUND: Rates of breastfeeding are lower among minority and underserved populations in the United States. Our study objective was to assess pregnant persons attitudes and barriers to breastfeeding among a cohort at high risk for not breastfeeding. METHODS: We disseminated the Iowa Infant Feeding Attitude Scale (IIFAS) to 100 pregnant persons at least 18 years of age attending a prenatal visit in a low-resource, academic practice in south-central Louisiana (Woman's Hospital). The IIFAS, as well as questions collecting information on breastfeeding experience and sociodemographic characteristics, were administered via interview. Medical records were reviewed to investigate associations between attitudes about breastfeeding in pregnancy and patient's feeding choices during the delivery hospital stay. Fisher exact tests and Wilcoxon rank-sum tests were used to assess associations between categorical and continuous variables respectively. RESULTS: Of the 98 participants who completed the study, 8% were Hispanic, 63% were Black, 95% were Medicaid eligible, and 50% were unemployed. 59% (n = 58) went on to breastfeed/combination breast-formula feed (called "Any-Breastfeeding Group") during the delivery stay. Total IIFAS score during pregnancy was significantly higher among those who went on to breastfeed during delivery hospital stay (Any-Breastfeeding Group vs. Formula-Feeding-Only Group: 58.9 ± 5.5 vs. 53.7 ± 6.2 respectively, p < 0.001). In the group that went on to only formula feed (Formula-Feeding-Only Group), only 4% agreed breastfeeding was more convenient when surveyed during pregnancy, compared to 45% of the Any-Breastfeeding Group. 60% of Formula-Feeding-Only Group agreed formula is as healthy as breast milk. CONCLUSION: The three major themes that coincided with favorability toward breastfeeding in the study, and can be addressed during prenatal counseling, are: mother-infant bonding, convenience, and health benefits. By identifying attitudes and barriers to breastfeeding for patients during pregnancy who went on to not breastfeed, directed educational opportunities can be developed to address these specific attitudes to ultimately increase breastfeeding initiation and continuation.

[WITHDRAWN] Predicting breast cancer with AI for individual risk-adjusted MRI screening and early detection.

This paper has been withdrawn by Lukas Hirsch. Major revisions and rewriting in progress.

Clinical and Imaging Features of MRI Screen-Detected Breast Cancer.

BACKGROUND: Supplemental screening with breast MRI is recommended annually for patients who have greater than 20% lifetime risk for breast cancer. While there is robust data regarding features of mammographic screen-detected breast cancers, there is limited data regarding MRI-screen-detected cancers. PATIENTS AND METHODS: Screening breast MRIs performed between August 1, 2016 and July 30, 2022 identified 50 screen-detected breast cancers in 47 patients. Clinical and imaging features of all eligible cancers were recorded. RESULTS: During the study period, 50 MRI-screen detected cancers were identified in 47 patients. The majority of MRI-screen detected cancers (32/50, 64%) were invasive. Pathology revealed ductal carcinoma in situ (DCIS) in 36% (18/50), invasive ductal carcinoma (IDC) in 52% (26/50), invasive lobular carcinoma in 10% (5/50), and angiosarcoma in 2% (1/50). The majority of patients (43/47, 91%) were stage 0 or 1 at diagnosis and there were no breast cancer-related deaths during the follow-up periods. Cancers presented as masses in 50% (25/50), nonmass enhancement in 48% (25/50), and a focus in 2% (1/50). DCIS was more likely to present as nonmass enhancement (94.4%, 17/18), whereas invasive cancers were more likely to present as masses (75%, 24/32) (P < .001). All cancers that were stage 2 at diagnosis were detected either on a baseline exam or more than 4 years since the prior MRI exam. CONCLUSION: MRI screen-detected breast cancers were most often invasive cancers. Cancers detected by MRI screening had an excellent prognosis in our study population. Invasive cancers most commonly presented as a mass.

Population-Level Access to Breast Cancer Early Detection and Diagnosis in Nigeria.

PURPOSE: Mammography, breast ultrasound (US), and US-guided breast biopsy are essential services for breast cancer early detection and diagnosis. This study undertook a comprehensive evaluation to determine population-level access to these services for breast cancer early detection and diagnosis in Nigeria using a previously validated geographic information system (GIS) model. METHODS: A comprehensive list of public and private facilities offering mammography, breast US, and US-guided breast biopsy was compiled using publicly available facility data and a survey administered nationally to Nigerian radiologists. All facilities were geolocated. A cost-distance model using open-source population density (GeoData Institute) and road network data (OpenStreetMap) was used to estimate population-level travel time to the nearest facility for mammography, breast US, and US-guided biopsy using GIS software (ArcMAP). RESULTS: In total, 1,336 facilities in Nigeria provide breast US, of which 47.8% (639 of 1,336) are public facilities, and 218 provide mammography, of which 45.4% (99 of 218) are public facilities. Of the facilities that provide breast US, only 2.5% (33 of 1,336) also provide US-guided breast biopsy. At the national level, 83.1% have access to either US or mammography and 61.7% have access to US-guided breast biopsy within 120 minutes of a continuous one-way travel. There are differences in access to mammography (64.8% v 80.6% with access at 120 minutes) and US-guided breast biopsy (49.0% v 77.1% with access at 120 minutes) between the northern and southern Nigeria and between geopolitical zones. CONCLUSION: To our knowledge, this is the first comprehensive evaluation of breast cancer detection and diagnostic services in Nigeria, which demonstrates geospatial inequalities in access to mammography and US-guided biopsy. Targeted investment is needed to improve access to these essential cancer care services in the northern region and the North East geopolitical zone.

Women's expectations about birth, requests for pain relief in labor and the subsequent development of birth dissonance and trauma.

BACKGROUND: Birth is a significant event in women's lives. As Mansfield notes (2008) many women aim for a birth that avoids pharmacological pain relief because they are advised it is better for them and their baby. For women having their first baby, this may not be realistic as 3/4 of primiparous women in Australia will use pharmacological pain relief. This study examines the expectations that a group of women had regarding pain relief, how these expectations developed and what happened to requests for pain relief in labour. METHODS: A longitudinal prospective study design was used to recruit 15 women who were having their first baby. Women having low risk pregnancies, hoping for a 'natural birth' (vaginal, no/minimal pharmacological pain relief) were eligible. A semi-structured interview tool was used across all three interviews that asked women about their expectations, then actual labour experience, pain management requests and how these were responded to by carers. Fifteen women were interviewed - at 36 weeks gestation; as soon after delivery of their baby as possible, then six months post-delivery (N = 43 interviews). Interviews were recorded and transcribed and coded by ES using NVivo software with hierarchical thematic analysis used. RESULTS: The study found that women appear to experience a mismatch between expectations they had developed pre-birth, versus actual experience. This appears to cause a specific form of dissonance - which we have termed 'birth dissonance' leaving them feeling traumatised post birth. This is because what women expected to happen in birth was often not realised. In particular, some women requested pain relief in birth and felt that their request was not responded to as hoped, and also seemed to develop post-birth trauma. We proposed that this may have resulted from dissonance arising from their expectations about being able to birth without significant pain relief. Interventions and technology may also contribute to this sense of mismatch and post-birth trauma. CONCLUSIONS: Low risk birthing women birthing in a hospital may have to engage with higher levels of technology, intervention and pain relief than that which they expected pre-birth. This could possibly be avoided with four simple changes. Firstly, better pre-birth education for women about how painful labor is likely to be. Secondly, pre-birth education which includes a detailed explanation of the utility of pharmacological and non-pharmacological pain relief. Thirdly, more egalitarian decision-making during labour and finally delivering upon women's requests for pain relief in labor, at the time that they ask for it. Further research is required to determine the extent of birth dissonance and how women making the transition to motherhood can avoid it.

Inclusion of binary proxy variables in logistic regression improves treatment effect estimation in observational studies in the presence of binary unmeasured confounding variables.

We present a simulation study and application that shows inclusion of binary proxy variables related to binary unmeasured confounders improves the estimate of a related treatment effect in binary logistic regression. The simulation study included 60,000 randomly generated parameter scenarios of sample size 10,000 across six different simulation structures. We assessed bias by comparing the probability of finding the expected treatment effect relative to the modeled treatment effect with and without the proxy variable. Inclusion of a proxy variable in the logistic regression model significantly reduced the bias of the treatment or exposure effect when compared to logistic regression without the proxy variable. Including proxy variables in the logistic regression model improves the estimation of the treatment effect at weak, moderate, and strong association with unmeasured confounders and the outcome, treatment, or proxy variables. Comparative advantages held for weakly and strongly collapsible situations, as the number of unmeasured confounders increased, and as the number of proxy variables adjusted for increased.

Implementation of and Barriers to Optimizing Postpartum Care by Resident and Attending Physicians.

Background: The American College of Obstetricians and Gynecologists released Committee Opinion No. 736: Optimizing Postpartum Care (CO No. 736) to address severe maternal morbidity and mortality in the United States by outlining recommendations for care in the critical time following birth. This study aimed to evaluate implementation of and barriers to the recommendations of CO No. 736 among obstetricians in south Louisiana. Methods: A survey to general obstetric providers assessed opinions on the CO No. 736 recommendations, implementation of these recommendations, and barriers to implementation. Fisher exact test was used to compare distributions between resident and attending groups. Qualitative, free-text responses about barriers to implementation were organized by common themes and categorized into systemic and patient factors. Results: Of 124 survey responses, 59.7% of respondents reported that they had read CO No. 736. Of the respondents who had read the document, 86.5% believed it was important to implement these recommendations, but only 50.0% had established the recommendations in their practices. Overall, fewer than half (46.8%) of respondents reported actively implementing the recommendation to make contact with postpartum patients at 3 weeks or sooner, but 86.3% reported having comprehensive clinic visits within 12 weeks of delivery. Commonly identified systemic barriers to implementation included the 3-week contact not being common practice, overbooked schedules, and unclear provider expectations. Commonly identified patient factor barriers to implementation included childcare or transportation and no-shows at postpartum appointments. Conclusion: Both resident and attending obstetricians in South Louisiana believe that the CO No. 736 recommendations are important but reported lacking the ability to implement them into clinical practice.

High-Temporal/High-Spatial Resolution Breast Magnetic Resonance Imaging Improves Diagnostic Accuracy Compared With Standard Breast Magnetic Resonance Imaging in Patients With High Background Parenchymal Enhancement.

PURPOSE: To compare breast magnetic resonance imaging (MRI) diagnostic performance using a standard high-spatial resolution protocol versus a simultaneous high-temporal/high-spatial resolution (HTHS) protocol in women with high levels of background parenchymal enhancement (BPE). MATERIALS AND METHODS: We conducted a retrospective study of contrast-enhanced breast MRIs performed at our institution before and after the introduction of the HTHS protocol. We compared diagnostic performance of the HTHS and standard protocol by comparing cancer detection rate (CDR) and positive predictive value of biopsy (PPV3) among women with high BPE (ie, marked or moderate). RESULTS: Among women with high BPE, the HTHS protocol demonstrated increased CDR (23.6 per 1,000 patients v 7.9 per 1,000 patients; P = 0. 013) and increased PPV3 (16.0% v 6.3%; P = .021) compared with the standard protocol. This corresponded to a 9.8% (95% CI, 1.29 to 18.3) decrease in the proportion of unnecessary biopsies among high-BPE patients and an additional cancer yield of 15.7 per 1,000 patients (95% CI, 1.3 to 18.3). CONCLUSION: Among women with high BPE, HTHS MRI improved diagnostic performance, leading to an additional cancer yield of 15.7 cancers per 1,000 women and concomitantly decreasing unnecessary biopsies by 9.8%. A multisite prospective trial is warranted to confirm these findings and to pave the way for more widespread clinical implementation.

Trends in Gestational Weight Gain in Louisiana, March 2019 to March 2022.

Importance: Average gestational weight gain (GWG) increased during the COVID-19 pandemic, but it is not known whether this trend has continued. Objective: To examine patterns of GWG during the COVID-19 pandemic by delivery and conception timing through the second year of the pandemic. Design, Setting, and Participants: This cohort study is a retrospective review of birth certificate and delivery records from 2019 to 2022. Electronic health records were from the largest delivery hospital in Louisiana. Participants included all individuals giving birth from March 2019 to March 2022. Data analysis was performed from October 2022 to July 2023. Exposure: Delivery date (cross-sectionally) and conception before the pandemic (March 2019 to March 2020) and during the peak pandemic (March 2020 to March 2021) and late pandemic (March 2021 to March 2022). Main Outcomes and Measures: The primary outcome was GWG (total GWG and adherence to the 2009 Institute of Medicine recommendations) analyzed using linear and log-linear regression with control for covariates. Results: Among 23 012 total deliveries (8763 Black individuals [38.1%]; 11 774 White individuals [51.2%]; mean [SD] maternal age, 28.9 [5.6] years), 3182 individuals (42.0%) exceeded the recommended weight gain in the year proceeding the pandemic, 3400 (45.4%) exceeded recommendations during the peak pandemic, and 3273 (44.0%) exceeded recommendations in the late pandemic. Compared with those who delivered before the pandemic (reference), participants had higher total GWG if they delivered peak or late pandemic (adjusted ß [SE], 0.38 [0.12] kg vs 0.19 [0.12] kg; P = .007). When cohorts were defined by conception date, participants who conceived before the pandemic but delivered after the pandemic started had higher GWG compared with those whose entire pregnancy occurred before the pandemic (adjusted ß [SE], 0.51 [0.16] kg). GWG was lower in the pregnancies conceived after the pandemic started and the late pandemic (adjusted ß [SE], 0.29 [0.12] kg vs 0.003 [0.14] kg; P = .003) but these participants began pregnancy at a slightly higher weight. Examining mean GWG month by month suggested a small decrease for March 2020, followed by increased mean GWG for the following year. Individuals with 2 pregnancies (1289 individuals) were less likely to gain weight above the recommended guidelines compared with their prepandemic pregnancy, but this association was attenuated after adjustment. Conclusions and Relevance: In this cohort, individuals with critical time points of their pregnancy during the COVID-19 pandemic gained more weight compared with the previous year. The increased GWG leveled off as the pandemic progressed but individuals were slightly heavier beginning pregnancy.

Improving access to breast cancer screening and treatment in Nigeria: The triple mobile assessment and patient navigation model (NCT05321823): A study protocol.

BACKGROUND: In Nigeria, breast cancer incidence is rising, late presentation is common, and outcomes are poor. Patient-related factors such as lack of awareness and misperceptions in addition to health system deficiencies such as lack of a clearly defined framework for breast cancer screening and referral are some of the major drivers of this poor outlook. Guidelines for breast cancer screening in high-income countries have limited applicability in low-middle-income countries, hence the need for innovative, resource-compatible strategies to combat the negative trend. This manuscript presents our study protocol which aims to evaluate the impact of a novel breast cancer early detection program developed to address delayed presentation and lack of access to diagnostic and treatment facilities in South-West Nigeria. This entails the use of mobile technology (innovative handheld iBreast Exam [iBE] device, mobile breast ultrasound, and mobile mammography) and patient navigation as interventions at the community level. METHODS: The study (ClinicalTrials.gov identifier: NCT05321823) will adopt a randomized two group clinical trial design with one local government area (LGA) serving as an intervention arm and another serving as the control. Both LGAs will receive breast cancer awareness education but only one will receive the interventions. In the intervention arm, asymptomatic (40-70 years) and symptomatic (30-70 years) women will be invited for breast evaluation which will be performed by trained Community Health Nurses using Clinical Breast Exam (CBE), and iBE. Those with positive findings will proceed to imaging using mobile mammography and ultrasound brought to the LGA every month. Symptomatic women with negative findings on CBE and iBE will be scheduled for repeat clinical evaluation on a short-term basis (one month). The Radiologist will obtain core needle biopsies as indicated and transfer them for prompt pathological assessment. Women presenting to the Primary Healthcare Centers in the control LGA will be referred directly to Obafemi Awolowo University Teaching Hospitals Complex as per the current standard of care. Records of all breast cancer cases seen in the two LGAs during the study period will be obtained. The program metrics will include screening participation rate, cancer detection rate, stage at diagnosis, and timeline from detection to initiation of treatment. The stage at diagnosis and timeline from detection to treatment compared between the two LGAs will be used to assess the impact of the intervention. The study is proposed for 2 years; however, a descriptive analysis will be carried out at 1.5 years to evaluate the retention of the study participants. STUDY SIGNIFICANCE: It is anticipated that this study will provide vital data to support wider breast cancer screening efforts in Nigeria.

Delayed Diagnosis of Retronychia: How Ultrasound Can Nail the Diagnosis in Clinically Subtle Patients.

A 47-year-old man presented to the dermatologic surgery clinic with a 7-month history of a painful, swollen left great toe after minor trauma. Intermittently, the toe became exquisitely tender such that even weight of a blanket exacerbated pain. The patient initially presented to primary care with purulence and pain, but the culture of expressed purulence revealed normal flora. Condition of the patient did not improve despite evaluation by several medical specialists and multiple rounds of topical antifungal and steroid creams, vinegar soaks, and oral antibiotics.

Visual identifiers for people with dementia in hospitals: a qualitative study to unravel mechanisms of action for improving quality of care.

BACKGROUND: Hospitalised people with dementia (PwD) experience worse care and more patient safety incidents than non-dementia patients. Visual identifiers are commonly used to identify patients who have a diagnosis of dementia, with the aim of promoting more personalised care. However, little is known about how they work in practice, nor about the potential unintended consequences that might arise from their use. We aim to identify the mechanisms through which visual identifiers could support good care for PwD, how and why their use may have negative consequences and the conditions for their effective use. METHODS: We conducted interviews with 21 dementia leads and healthcare professionals, 19 carers and two PwD, and produced case studies of visual identification systems in four UK acute hospital trusts between 2019 and 2021. Analysis drew on the concept of classification to identify and explore mechanisms of action. RESULTS: We identified four mechanisms through which visual identifiers could help towards providing good care for PwD: enabling coordination of care at organisational level; signalling eligibility for dementia-specific interventions; informing prioritisation of resources on wards; and acting as a quick reference cue for staff. But identifier effectiveness could be undermined by: lack of standardisation and consistency; a lack of closely coupled information about individual needs; and stigma associated with a dementia diagnosis. Identifier effectiveness was dependent on their implementation being supported through staff training, resources directed and efforts to develop a supportive culture for caring for this patient group. CONCLUSION: Our research highlights the potential mechanisms of action of visual identifiers and their possible negative consequences. Optimising the use of identifiers requires consensus on the rules of classification and the symbols used, and closely coupled patient information. Organisations need to provide support, offer the right resources and training and engage meaningfully with carers and patients about the use of identifiers.

Social distancing and mental health among pregnant women during the coronavirus pandemic.

BACKGROUND: The effect of social distancing due to the COVID-19 pandemic on the mental health of pregnant women is of particular concern, given potential effects on physical health, family functioning, and child development. METHODS: Pregnant women were recruited for the "Implications of and Experiences Surrounding being Pregnant during the COVID-19 Pandemic" study at Woman's Hospital in Baton Rouge, Louisiana. Participants enrolled at any point during their pregnancy and surveys were delivered weekly until the participant indicated that she had delivered her baby; a postpartum survey followed four weeks after delivery. This analysis includes 1037 participants with baseline, 596 with follow-up, and 302 with postpartum surveys. Questions on social distancing behaviors were asked at baseline and grouped based on whether they involved social distancing from work, friends and family, or public places. Symptoms of anxiety, stress, depression, and pregnancy-related anxiety were measured. Each type of social distancing was examined as a predictor of mental health using linear model with control for confounders. RESULTS: The study population was largely white (84.1%), married (81.8%), and educated (76.2% with a bachelor's or higher degree). Women who were younger, Black, unmarried, or had less education or income reported fewer social distancing behaviors. Mean anxiety score in the highest quartile of overall social distancing was 8.3 (SD 5.6), while in the lowest quartile it was 6.0 (SD 5.0) (p < 0.01), while perceived stress postpartum and pregnancy-related stress were not associated with social distancing. Associations were substantially diminished when controlled for baseline levels of anxiety symptoms. CONCLUSIONS: Greater social distancing was associated with more anxiety symptoms, but worse mental health, particularly anxiety, may also have contributed to greater social distancing behaviors.

Automated Triage of Screening Breast MRI Examinations in High-Risk Women Using an Ensemble Deep Learning Model.

OBJECTIVES: The aim of the study is to develop and evaluate the performance of a deep learning (DL) model to triage breast magnetic resonance imaging (MRI) findings in high-risk patients without missing any cancers. MATERIALS AND METHODS: In this retrospective study, 16,535 consecutive contrast-enhanced MRIs performed in 8354 women from January 2013 to January 2019 were collected. From 3 New York imaging sites, 14,768 MRIs were used for the training and validation data set, and 80 randomly selected MRIs were used for a reader study test data set. From 3 New Jersey imaging sites, 1687 MRIs (1441 screening MRIs and 246 MRIs performed in recently diagnosed breast cancer patients) were used for an external validation data set. The DL model was trained to classify maximum intensity projection images as "extremely low suspicion" or "possibly suspicious." Deep learning model evaluation (workload reduction, sensitivity, specificity) was performed on the external validation data set, using a histopathology reference standard. A reader study was performed to compare DL model performance to fellowship-trained breast imaging radiologists. RESULTS: In the external validation data set, the DL model triaged 159/1441 of screening MRIs as "extremely low suspicion" without missing a single cancer, yielding a workload reduction of 11%, a specificity of 11.5%, and a sensitivity of 100%. The model correctly triaged 246/246 (100% sensitivity) of MRIs in recently diagnosed patients as "possibly suspicious." In the reader study, 2 readers classified MRIs with a specificity of 93.62% and 91.49%, respectively, and missed 0 and 1 cancer, respectively. On the other hand, the DL model classified MRIs with a specificity of 19.15% and missed 0 cancers, highlighting its potential use not as an independent reader but as a triage tool. CONCLUSIONS: Our automated DL model triages a subset of screening breast MRIs as "extremely low suspicion" without misclassifying any cancer cases. This tool may be used to reduce workload in standalone mode, to shunt low suspicion cases to designated radiologists or to the end of the workday, or to serve as base model for other downstream AI tools.

Co-occurrence of depression, anxiety, and perinatal posttraumatic stress in postpartum persons.

BACKGROUND: The study aim was to describe the incidence of depression, anxiety, perinatal-post-traumatic stress disorder (PTSD), and their co-occurrences in the early postpartum period in a low-resource OB/GYN clinic serving majority Medicaid-eligible persons. We hypothesized that postpartum persons screening positive for depression will have an increased risk of a positive screen for anxiety and perinatal PTSD. METHODS: A retrospective study of postpartum persons receiving care in Baton Rouge, Louisiana was conducted using responses abstracted from the electronic medical record (EMR) of the Patient Health Questionnaire-9 (PHQ9), Generalized Anxiety Disorder-7 (GAD7), and Perinatal Post Traumatic Stress Disorder Questionnaire-II (PPQII). Categorical distributions were compared using Fisher exact tests, while t-tests were used to compare continuous covariates. Multivariable logistic regression was used to predict anxiety (GAD7) and perinatal PTSD (PPQII) scores while adjusting for potential confounders, as well as to predict continuous PPQII and GAD7 based on continuous PHQ9 scores. RESULTS: There were 613 birthing persons 4-12 weeks postpartum that completed mental health screening (PHQ9, GAD7, and PPQII) between November 2020 and June 2022 as part of routine postpartum care in the clinic. The incidence of screening positive for symptoms of depression (PHQ9 > 4) was 25.4% (n = 156), while the incidence of positive screening for symptoms of anxiety (GAD7 > 4) and perinatal PTSD (PPQII [Formula: see text] 19) were 23.0% (n = 141) and 5.1% (n = 31) respectively. Postpartum patients with mild anxiety or more (i.e. GAD7 > 4) had 26 times higher odds of screening positive for symptoms of depression (PHQ9 > 4) (adjusted odds ratio [aOR] 26.3; 95% confidence interval [CI] 15.29-46.92; p < 0.001). Postpartum persons with a PPQII score indicating symptoms of perinatal PTSD (PPQII [Formula: see text] 19) had 44 times higher odds of screening positive for symptoms of depression (PHQ > 4) (aOR 44.14; 95%CI 5.07-5856.17; p < 0.001). CONCLUSIONS: Depression, anxiety, and perinatal PTSD are each independent risk factors for each other. To comply with the American College of Obstetricians and Gynecologists (ACOG) recommendations, providers should universally screen postpartum persons with validated screening tools for mood disturbances. However, if a complete full mood assessment is not feasible, this study provides evidence to support screening patients for depression, and if the patient screens positive, prompt additional screening for anxiety and perinatal PTSD.