Risk of Death and Cardiovascular Events Following an Exacerbation of COPD: The EXACOS-CV US Study

Purpose

This study estimated the magnitude and duration of risk of cardiovascular events and mortality following acute exacerbations of chronic obstructive pulmonary disease (AECOPD), and whether risks varied by number and severity of exacerbation in a commercially insured population in the United States.

Methods

This was a retrospective cohort study of newly diagnosed COPD patients ≥40 years old in the Healthcare Integrated Research Database from 2012 to 2019. Patients experiencing exacerbations comprised the "exacerbation cohort". Moderate exacerbations were outpatient visits with contemporaneous antibiotic or glucocorticoid administration; severe exacerbations were emergency department visits or hospitalizations for AECOPD. Follow-up started on the exacerbation date. Distribution of time between diagnosis and first exacerbation was used to assign index dates to the "unexposed" cohort. Cox proportional hazards models estimated risks of a cardiovascular event or death following an exacerbation adjusted for medical and prescription history and stratified by follow-up time, type of cardiovascular event, exacerbation severity, and rank of exacerbation (first, second, or third).

Results

Among 435,925 patients, 170,236 experienced ≥1 exacerbation. Risk of death was increased for 2 years following an exacerbation and was highest during the first 30 days (any exacerbation hazard ratio (HR)=1.79, 95% CI=1.58-2.04; moderate HR=1.22, 95% CI=1.04-1.43; severe HR=5.09, 95% CI=4.30-6.03). Risks of cardiovascular events were increased for 1 year following an AECOPD and highest in the first 30-days (any exacerbation HR=1.34, 95% CI=1.23-1.46; moderate HR=1.23 (95% CI 1.12-1.35); severe HR=1.93 (95% CI=1.67-2.22)). Each subsequent AECOPD was associated with incrementally higher rates of both death and cardiovascular events.

Conclusion

Risk of death and cardiovascular events was greatest in the first 30 days and rose with subsequent exacerbations. Risks were elevated for 1-2 years following moderate and severe exacerbations, highlighting a sustained increased cardiopulmonary risk associated with exacerbations.

Contraceptive Methods Women Have Ever Used:United States, 2015-2019

Objective-This report describes methods of contraception ever used by U.S. women ages 15-49 who had ever had sexual intercourse with a male partner. Estimates are shown overall and by Hispanic origin and race, education, religious affiliation and importance, and urban-rural residence. Discontinuation of selected contraceptive methods is also described. Methods-This report focuses on information collected from the 11,695 women ages 15-49 interviewed in the 2015-2019 National Survey of Family Growth, a nationally representative survey conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics. Most estimates shown are based on data on contraceptive methods ever used by the 10,122 interviewed women who had ever had sexual intercourse with a male partner. Results-Based on 2015-2019 data, virtually all women of reproductive age who had ever had sexual intercourse with a male partner used at least one contraceptive method at some point in their life up to the time of interview (99.2%, or 63.2 million women ages 15-49), including 87.8% who had ever used a "most or moderately effective reversible method": the pill, an injectable, contraceptive patch, contraceptive ring, contraceptive implant, or intrauterine device. Most women had used the male condom with a partner (94.5%), the pill (79.8%), or withdrawal (65.7%). About one in four women reported ever using long-acting reversible contraception (intrauterine device or contraceptive implant) (24.9%) or emergency contraception (23.5%). The type of methods ever used varied by Hispanic origin and race, nativity among Hispanic women, education, religious affiliation and importance, and urban-rural residence. Among women who had ever discontinued use of the pill or intrauterine devices due to dissatisfaction (and not for seeking a pregnancy), side effects were the most common reason.

Comparative safety of conjugated estrogens/bazedoxifene versus estrogen/progestin combination hormone therapy among women in the United States: a multidatabase cohort study

OBJECTIVE

To assess the risk of select safety outcomes including endometrial cancer, endometrial hyperplasia, and breast cancer among women using conjugated estrogens/bazedoxifene (CE/BZA) as compared with estrogen/progestin combination hormone therapy (EP).

METHODS

We conducted a new-user cohort study in five US healthcare claims databases representing more than 92 million women. We included CE/BZA or EP new users from May 1, 2014, to August 30, 2019. EP users were propensity score (PS) matched to users of CE/BZA. Incidence of endometrial cancer, endometrial hyperplasia, breast cancer, and eight additional cancer and cardiovascular outcomes were ascertained using claims-based algorithms. Rate ratios (RR) and differences pooled across databases were estimated using random-effects models.

RESULTS

The study population included 10,596 CE/BZA and 33,818 PS-matched EP new users. Rates of endometrial cancer and endometrial hyperplasia were slightly higher among CE/BZA users (1.6 and 0.4 additional cases per 10,000 person-years), although precision was limited because of small numbers of cases (endometrial cancer: RR, 1.50 [95% confidence interval {CI}, 0.79-2.88]; endometrial hyperplasia: RR, 1.69 [95% CI, 0.51-5.61]). Breast cancer incidence was lower in CE/BZA users (9.1 fewer cases per 10,000 person-years; RR, 0.79; 95% CI, 0.58-1.05). Rates of other outcomes were slightly higher among CE/BZA users, but with confidence intervals compatible with a wider range of possible associations.

CONCLUSIONS

CE/BZA users might experience slightly higher rates of endometrial cancer and endometrial hyperplasia, and a lower rate of breast cancer, than EP users in the first years of use.

Fertility of Men and Women Aged 15-49 in the United States: National Survey of Family Growth,2015-2019

Objective-This report presents national estimates of selected fertility measures for men and women aged 15-49 in the United States in 2015-2019, based on data from the National Survey of Family Growth (NSFG). Overall estimates for 2015-2019 are compared with those for 2011-2015.

Development of an international, multidisciplinary, patient-centered Standard Outcome Set for Multiple Sclerosis: The S.O.S.MS project

BACKGROUND

Currently, outcomes of Multiple Sclerosis (MS) are not standardized and it is unclear which outcomes matter most to people living with MS. A consensus between patients and healthcare professionals on which outcomes to measure and how, would facilitate a move towards value-based MS care.

OBJECTIVE

to develop an internationally accepted, patient-relevant Standard Outcome Set for MS (S.O.S.MS).

METHODS

A mixed-method design was used, including a systematic literature review, four patient focus groups (n=30) and a RAND-modified Delphi process with seventeen MS experts of five disciplines from seven countries (the Netherlands, United States of America, Portugal, Ireland, India, New Zealand, Switzerland and Turkey).

RESULTS

A standard outcome set for MS was defined, consisting of fourteen outcomes divided in four domains: disease activity (n=3), symptoms (n=4), functional status (n=6), and quality of life (n=1). For each outcome, an outcome measure was selected and the measurement protocol was defined. In addition, seven case-mix variables were selected.

CONCLUSION

This standard outcome set provides a guideline for measuring outcomes of MS in clinical practice and research. Using this set to monitor and (inter)nationally benchmark real-world outcomes of MS can support improvement of patient value and ultimately guide the transition towards value-based MS care.

Utilization, user characteristics, and adverse outcomes of bevacizumab products in oncology in a distributed research network

400

Background: Bevacizumab (Avastin), an anti-angiogenic agent, was approved for various oncologic indications in 2004 in the US. Two biosimilars, bevacizumab-awwb (Mvasi) and bevacizumab-bvzr (Zirabev), were on the market 2017 and 2019, respectively. Real-world data on adverse events for bevacizumab biosimilars is limited. Methods: We conducted a retrospective cohort study using the Biologics and Biosimilars Collective Intelligence Consortium (BBCIC) distributed database to evaluate utilization patterns, patient characteristics, and prespecified adverse events of interest for the originator bevacizumab relative to its biosimilars in oncology among users 21 years of age and older between January 1, 2010, to December 31, 2020. Oncology indications included colon, lung, and gynecologic (cervical, uterine, and ovarian) cancers. Adverse events (AEs) of interest were arterial thromboembolism (ATE), congestive heart failure (CHF), gastrointestinal perforation, stroke and acute myocardial infarction (AMI), and venous thromboembolism (VTE). The study analyzed biosimilars collectively, which include bevacizumab-awwb and bevacizumab-bvzr. Results: Both bevacizumab originator and biosimilar users for colon cancer were mostly male (55%), had a mean age of 61 years, and a mean Charlson/Elixhauser combined comorbidity score from 7.0 to 8.0. Among patients with lung cancer users, 53% were female with an overall mean age of 64 years and comorbidity scores from 6.4 to 7.5. Patients with gynecologic cancers had mean age of 63 years, and comorbidity scores from 6.1 to 6.7. Overall, oncologic bevacizumab use increased by 19% over time. Of the 24,044 total episodes from 2010 to 2020, AEs included ATE (2,560 events, 11%), CHF (2,092 events, 9%), gastrointestinal perforation (2,858 events, 12%), stroke/AMI (399 events, 2%), and VTE (4,447 events, 19%). AE rates were comparable between the originator and biosimilars: 7% and 8% for ATE, 5% and 4% for CHF, 9% and 8% for gastrointestinal perforation, 0.6% and 1% for stroke and AMI, and 10% and 8% for VTE, respectively. From 2019 to 2020, biosimilar use increased from 6% to 49% of total bevacizumab utilization for patients with colon cancer, from 2% to 36% for patients with lung cancer, and from 2% to 38% for patients with gynecologic cancers. Conclusions: Bevacizumab utilization increased across all oncology indications evaluated during the study period. From 2019 to 2020, utilization for biosimilars relative to the originator increased. As there are limited data available on bevacizumab biosimilar use in real world settings, future research should be conducted to see if utilization for biosimilar products continues to rise as well as safety over time.

Redesigning value-based hospital structures: a qualitative study on value-based health care in the Netherlands

Background

A crucial component of value-based health care concerns the redesign of organizational structures. In theory, hospital structures should follow value creation: addressing medical conditions for specific groups of patients over full cycles of care. In practice, however, it remains unclear how hospitals can reorganize themselves into value-based structures. The purpose of this study is to explore the ways in which Dutch hospitals are currently implementing and pursuing value-based redesign.

Methods

This qualitative exploratory study used semi-structured interviews and a focus group for data collection. Transcripts were analyzed through deductive coding, for which we used Mintzberg’s theory on organizational structures, particularly his work on design parameters.

Results

In their efforts to create more value-based structures, Dutch hospitals often employ a variety of liaison devices, such as project teams and committees. By contrast, the actual formation of units around medical conditions is much rarer. Outcome data are widely used within planning and control systems, and some hospitals partake in external benchmarking. Not all hospitals use cost indicators for monitoring performance.

Conclusions

Value-based redesign is not necessarily a matter of radical changes or binary choices. Instead, as Dutch hospitals show, it can be an incremental process, with a variety of potential knobs to turn to various degrees. Health care executives, managers, and professionals thus have a wide range of options when they aim for more value-based structures. Our conceptualization of “value-based design parameters” can help guide the selection and implementation of strategies and mechanisms for further coordination around medical conditions over full cycles of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08564-4.

Current Contraceptive Status Among Women Aged 15-49: United States, 2017-2019

Nearly all women use contraception in their lifetimes (1), although at any given time, they may not be using contraception for reasons such as seeking pregnancy, being pregnant or postpartum, or not being sexually active. Using data from the 2017-2019 National Survey of Family Growth (NSFG), this report provides a snapshot of current contraceptive status, in the month of interview, among women aged 15-49 in the United States. In addition to describing use of any method by age, Hispanic origin and race, and education, patterns of use are described for the four most commonly used contraceptive methods: female sterilization; oral contraceptive pills; long-acting reversible contraceptives (LARCs), which include contraceptive implants and intrauterine devices; and the male condom.

Refining assessment of contraceptive use in the past year in relation to risk of unintended pregnancy

OBJECTIVES

Healthy People 2020 establishes objectives for reducing the proportion of pregnancies in the United States that are unintended and for improving contraceptive use. This analysis describes ways to more closely align measurement of contraceptive use with periods of risk for unintended pregnancy using the National Survey of Family Growth (NSFG).

METHODS

Using the 2011-2015 NSFG we constructed two measures of contraceptive use for women we defined as at risk of an unintended pregnancy: (1) we augmented a measure of recent contraceptive use by recoding non-users according to their method use during their last month of sex in the past 12 months; (2) we augmented use at last sex in the past 12 months by excluding women who were pregnant at last sex. Estimates were compared overall and within 5-year age groups.

RESULTS

The augmented measure of recent contraceptive use found fewer women to be using no contraception than the standard measure (7.3% vs 15.4%; p < .001); greater differences were found between the two measures for younger women. When considering contraceptive use at last sex, the augmented measure identified fewer women as using no contraception (15.8% vs 21.0%; p < .001) than the standard measure and more women to be using a most effective method (33.3% vs 31.1%; p = .04) than the standard measure.

CONCLUSIONS

Aligning periods of unintended pregnancy risk with contraceptive use assessment reduced estimates of no contraceptive use; changes in estimates by method type varied by age.

IMPLICATIONS

When assessing contraceptive use for the purpose of unintended pregnancy prevention, researchers may consider the methods described here to further align contraceptive use measurement with periods of unintended pregnancy risk.

Feasibility of Diabetes Self-Management Telehealth Education for Older Adults During Transitions in Care

The current study investigated the feasibility of telehealth-delivered diabetes self-management education and support (DSMES) for older adults with type 2 diabetes mellitus following hospital discharge. The intervention included one in-person home visit and follow-up weekly virtual DSMES for 4 additional weeks. Diabetes knowledge was measured at baseline and completion of the program. The Telehealth Usability Questionnaire was completed following the final session. Hemoglobin A1C (A1C) level was abstracted from the electronic health record at baseline and 3 months post hospital discharge. Hospital re-admissions were measured at 30 days post index hospital stay. Of the 20 patients enrolled, 12 completed the intervention. The most common reason for attrition was discharge to a skilled nursing facility (3/20). Participants who completed the intervention increased their diabetes knowledge scores. A1C values decreased by 1.1%, and there were no hospital readmissions for any patient who completed the program. Participants described the program as useful and were satisfied with the program. These results suggest that it is feasible to identify and enroll patients in a telehealth education program for diabetes during hospital admission. [Research in Gerontological Nursing, 13(3), 138-145.].

Salmonella in Foods: New Enrichment Procedure for TECRA Salmonella Visual Immunoassay Using a Single RV(R10) Only, TT Only, or Dual RV(R10) and TT Selective Enrichment Broths (AOAC Official Method 998.09): Collaborative Study

A collaborative study was conducted to compare a new enrichment procedure for the TECRA® Salmonella Visual Immunoassay (TSVIA) with the reference method given in the U.S. Food and Drug Administration's Bacteriological Analytical Manual (7th Ed.). Three food types (milk powder, pepper, and soy flour) were analyzed in Australia and 3 food types (milk chocolate, dried egg, and raw turkey) were analyzed in the United States. Thirty-eight collaborators participated in the study. The TECRA method was evaluated using both Rappaport-Vassiliadis R10 (RV(R10)) and tetrathionate (TT) broths for selective enrichment. M broth cultures arising from each of the 2 selective enrichment broths were tested in the TSVIA using 2 individual wells, one for each selective broth, and a single well to test the pooled selective enrichment broths. The results for the pooled enrichment broths were reported elsewhere. This study presents the results for the use of single enrichment broths, i.e., RV(R10) only or TT only, with the TSVIA. No significant differences (p &gt; 0.05) were observed for the pairwise comparison of the proportion of positive samples for either RV(R10) or TT used as a single enrichment broth for the TSVIA with that for the reference method.

Determination of Naringin and Neohesperidin in Orange Juice by Liquid Chromatography with UV Detection to Detect the Presence of Grapefruit Juice: Collaborative Study

Fifteen collaborating laboratories were sent 9 samples of citrus juice mixtures as blind duplicates for determination of naringin and neohesperidin by liquid chromatography. Two sample pairs were 100% orange juice and did not contain any naringin or neohesperidin. The remaining 7 sample pairs contained naringin at levels ranging from 3.9 to 46.5 ppm and neohesperidin at levels ranging from 0.14 to 35.6 ppm. Five sample pairs consisted of orange juice mixtures containing 1, 3, and 5% grapefruit juice; 5% sour orange; and 5% K-Early citrus variety. Two sample pairs were orange juice spiked with naringin, neohesperidin, sodium benzoate, and potassium sorbate. Data were received from 13 laboratories. Data from 1 collaborator were eliminated because the method protocol was not followed. Neohesperidin values from another laboratory were also not used because of problems with a coeluting component. Repeatability relative standard deviations ranged from 2.95 to 15.23% for naringin and from 3.00 to 11.74% for neohesperidin. Reproducibility relative standard deviations ranged from 11.34 to 31.94% for naringin and from 10.45 to 26.17% for neohesperidin. The method is reliable for detecting the presence of grapefruit juice in orange juice as indicated by a finding of ≥10 ppm naringin and ≤2 ppm neohesperidin. The method was adopted First Action by AOAC INTERNATIONAL.

Fertility of Men and Women Aged 15-44 in the United States: National Survey of Family Growth, 2011-2015

This report presents national estimates of selected fertility measures for men and women aged 15-44 in the United States in 2011-2015 based on data from the National Survey of Family Growth (NSFG). Estimates for 2011-2015 are compared with those for 2006-2010.

We wanted to choose us: how embryo donors choose recipients for their surplus embryos

OBJECTIVE

This study aimed to explore factors affecting donors' choice of recipients for their surplus embryos in the New Zealand context of conditional, known donations.

BACKGROUND

Internationally, embryo donation has a low uptake in spite of large numbers of cryopreserved embryos. Possible reasons include a lack of knowledge about and concern for the future welfare of the resultant offspring. In New Zealand, donors and recipients meet prior to donation and legislation supports disclosure and access to genetic knowledge.

METHOD

Twenty-two embryo donors (10 couples, two individuals) were interviewed between March 2012 and February 2013 about their experiences of donation and factors affecting their donation. Interview data were analysed thematically.

RESULTS

In the interests of the welfare of the child resulting from donation, donors were invested in choosing recipients who would make suitable parents. They attempted to choose recipients similar to themselves, as well as those that they trusted to disclose the manner of conception and facilitate agreed-upon information exchange and contact.

CONCLUSION

The interest of donors in ensuring offspring well-being may lend support to conditional forms of open donation, allowing for assessment of recipients' suitability to parent, and for negotiation around information exchange and contact.

Otologic Disease Following Palatoplasty In International Cleft Palate Cohort

OBJECTIVE

Study the prevalence of otologic disease in a pediatric post-palatoplasty population with no prior ear tube placement in resource-deprived countries and assess patient characteristics associated with these abnormal results.

DESIGN

Retrospective data review.

PARTICIPANTS

Ecuadorian and Chinese children identified during humanitarian cleft lip and palate repair trips with cleft palates undergoing palatoplasty from 2007 to 2010.

INTERVENTIONS

Tympanometry and otoacoustic emission (OAE) testing performed following palatoplasty. Patients' parents administered surveys regarding perceived hearing deficits.

MAIN OUTCOME MEASURES

Age, gender, Veau classification, follow-up time, laterality, and country of origin were evaluated for possible association with type B tympanogram, "Refer" Otoacoustic results, and presence of hearing difficulty as identified by a parent. Significant predictors were further evaluated with multivariate analysis.

RESULTS

The cohorts included 237 patients (129 Ecuadorian, 108 Chinese); mean age: 3.9 years; mean follow-up: 4.2 years. Thirty-nine percent scored type B, 38% failed OAE testing, and 8% of parents noted hearing deficits. The country of origin and a younger age were identified as predictive variables regarding type B tympanogram. Follow-up time, country of origin, and bilateral OAE "Refer" results all significantly predicted parental questionnaire results. Subsequent multivariable analysis further demonstrated effect modification between the 2 variables of age at palatoplasty and country of origin when predicting type B vs type A tympanometry.

CONCLUSION

Without otologic intervention, cleft palate children in resource-deprived settings suffer type B tympanometry and failed OAE results with similar to increased incidences to other studied cleft palate populations with otologic interventions available.

Receipt of Selected Preventive Health Services for Women and Men of Reproductive Age - United States, 2011-2013

Problem/Condition

Receipt of key preventive health services among women and men of reproductive age (i.e., 15–44 years) can help them achieve their desired number and spacing of healthy children and improve their overall health. The 2014 publication Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs (QFP) establishes standards for providing a core set of preventive services to promote these goals. These services include contraceptive care for persons seeking to prevent or delay pregnancy, pregnancy testing and counseling, basic infertility services for those seeking to achieve pregnancy, sexually transmitted disease (STD) services, and other preconception care and related preventive health services. QFP describes how to provide these services and recommends using family planning and other primary care visits to screen for and offer the full range of these services. This report presents baseline estimates of the use of these preventive services before the publication of QFP that can be used to monitor progress toward improving the quality of preventive care received by women and men of reproductive age.

Period Covered

2011–2013.

Description of the System

Three surveillance systems were used to document receipt of preventive health services among women and men of reproductive age as recommended in QFP. The National Survey of Family Growth (NSFG) collects data on factors that influence reproductive health in the United States since 1973, with a focus on fertility, sexual activity, contraceptive use, reproductive health care, family formation, child care, and related topics. NSFG uses a stratified, multistage probability sample to produce nationally representative estimates for the U.S. household population of women and men aged 15–44 years. This report uses data from the 2011–2013 NSFG.

The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing, state- and population-based surveillance system designed to monitor selected maternal behaviors and experiences that occur before, during, and shortly after pregnancy among women who deliver live-born infants in the United States. Annual PRAMS data sets are created and used to produce statewide estimates of preconception and perinatal health behaviors and experiences. This report uses PRAMS data for 2011–2012 from 11 states (Hawaii, Maine, Maryland, Michigan, Minnesota, Nebraska, New Jersey, Tennessee, Utah, Vermont, and West Virginia).

The National Health Interview Survey (NHIS) is a nationally representative survey of noninstitutionalized civilians in the United States. NHIS collects data on a broad range of health topics, including the prevalence, distribution, and effects of illness and disability and the services rendered for or because of such conditions. Households are identified through a multistage probability household sampling design, and estimates are produced using weights that account for the sampling design, nonresponse, and poststratification adjustments. This report uses data from the 2013 NHIS for women aged 18–44 years.

Results

Many preventive health services recommended in QFP were not received by all women and men of reproductive age. For contraceptive services, including contraceptive counseling and advice, 46.5% of women aged 15–44 years at risk for unintended pregnancy received services in the past year, and 4.5% of men who had vaginal intercourse in the past year received services in that year. For sexually transmitted disease (STD) services, among all women aged 15–24 years who had oral, anal, or vaginal sex with an opposite sex partner in the past year, 37.5% were tested for chlamydia in that year. Among persons aged 15–44 years who were at risk because they were not in a mutually monogamous relationship during the past year, 45.3% of women were tested for chlamydia and 32.5% of men were tested for any STD in that year. For preconception care and related preventive health services, data from selected states indicated that 33.2% of women with a recent live birth (i.e., 2–9 months postpartum) talked with a health care professional about improving their health before their most recent pregnancy; of selected preconception counseling topics, the most frequently discussed was taking vitamins with folic acid before pregnancy (81.2%), followed by achieving a healthy weight before pregnancy (62.9%) and how drinking alcohol (60.3%) or smoking (58.2%) during pregnancy can affect a baby. Nationally, among women aged 18–44 years irrespective of pregnancy status, 80.9% had their blood pressure checked by a health care professional and 31.7% received an influenza vaccine in the past year; 54.5% of those with high blood pressure were tested for diabetes, 44.9% of those with obesity had a health care professional talk with them about their diet, and 55.2% of those who were current smokers had a health professional talk with them about their smoking in the past year. Among all women aged 21–44 years, 81.6% received a Papanicolaou (Pap) test in the past 3 years.

Receipt of certain preventive services varied by age and race/ethnicity. Among women with a recent live birth, the percentage of those who talked with a health care professional about improving their health before their most recent pregnancy increased with age (range: 25.9% and 25.2% for women aged ≤19 and 20–24 years, respectively, to 35.9% and 37.8% for women aged 25–34 and ≥35 years, respectively). Among women with a recent live birth, the percentage of those who talked with a health care professional about improving their health before their most recent pregnancy was higher for non-Hispanic white (white) (35.2%) compared with non-Hispanic black (black) (30.0%) and Hispanic (26.0%) women. Conversely, across most STD screening services evaluated, testing was highest among black women and men and lowest among their white counterparts.

Receipt of many preventive services recommended in QFP increased consistently across categories of family income and continuity of health insurance coverage. Prevalence of service receipt was highest among women in the highest family income category (>400% of federal poverty level [FPL]) and among women with insurance coverage for each of the following: contraceptive services among women at risk for unintended pregnancy; medical services beyond advice to help achieve pregnancy; vaccinations (hepatitis B and human papillomavirus [HPV], ever; tetanus, past 10 years; influenza, past year); discussions with a health care professional about improving health before pregnancy and taking vitamins with folic acid; blood pressure and diabetes screening; discussions with a health care professional in the past year about diet, among those with obesity; discussions with a health care professional in the past year about smoking, among current smokers; Pap tests within the past 3 years; and mammograms within the past 2 years.

Interpretation

Before 2014, many women and men of reproductive age were not receiving several of the preventive services recommended for them in QFP. Although differences existed by age and race/ethnicity, across the range of recommended services, receipt was consistently lower among women and men with lower family income and greater instability in health insurance coverage.

Public Health Action

Information in this report on baseline receipt during 2011–2013 of preventive services for women and men of reproductive age can be used to target improvements in the use of recommended services through the development ofresearch priorities, information for decision makers, and public health practice. Health care administrators and practitioners can use the information to identify subpopulations with the greatest need for preventive services and make informed decisions on resource allocation. Public health researchers can use the information to guide research on the determinants of service use and factors that might increase use of preventive services. Policymakers can use this information to evaluate the impact of policy changes and assess resource needs for effective programs, research, and surveillance on the use of preventive health services for women and men of reproductive age.

Unmarried Men's Contraceptive Use at Recent Sexual Intercourse: United States, 2011-2015

Contraception is used to help prevent unintended pregnancies and sexually transmitted infections (STI). Higher percentages of pregnancies to unmarried persons are unintended than for those who are married (1). Patterns of contraceptive use as reported by women, including differences by marital status, are well documented using National Survey of Family Growth (NSFG) data (2–4); however, less research focuses on contraceptive use as reported by men. Using 2011–2015 NSFG data from men, with selected time trends, this data brief describes contraceptive use at last recent vaginal sexual intercourse (within 3 months) among unmarried men, focusing primarily on male methods of contraception (condom, withdrawal, and vasectomy).

Urban and Rural Variation in Fertility-related Behavior Among U.S. Women, 2011-2015

In 2010, one-fifth of the U.S. population lived in rural areas (1). There is known variation in social, demographic, and health characteristics across urban and rural residence (1–3). Recent National Center for Health Statistics (NCHS) reports show higher teen birth and infant mortality rates in rural counties than in urban counties (4,5). Less is known about urban and rural variation in fertility-related behavior, such as sexual activity and contraceptive use. Using National Survey of Family Growth (NSFG) data from 2011 through 2015 for women aged 18–44, this report describes urban-rural differences in first sexual intercourse, marital and cohabitation status, number of births, and contraceptive use based on residence at the time of interview.

Trends in Long-Acting Reversible Contraception Use in Adolescents and Young Adults: New Estimates Accounting for Sexual Experience

PURPOSE

The purposes of the analysis were to compare long-acting reversible contraception (LARC) use estimates that include all reproductive age women with estimates that are limited to women at risk for unintended pregnancy and to examine trends for adolescents (15-19 years) and young adults (20-24 years).

METHODS

Using the 2006-2010 and 2011-2013 National Surveys of Family Growth, we compared LARC estimates for all women with estimates limited to women at risk for unintended pregnancy (those who were sexually experienced, and neither pregnant, seeking pregnancy, postpartum or infecund). We used t tests to detect differences according to the population included and to evaluate trends for adolescents and young adults.

RESULTS

Among adolescents and young adults, 56% and 14%, respectively, have never had vaginal intercourse, versus 1%-4% for women aged 25-44 years. Given the high percentage of adolescents and young adults who never had vaginal intercourse, LARC estimates were higher for these age groups (p < .05), but not for women aged 25-44 years, when limited to those at risk for unintended pregnancy. Among adolescents at risk, the increase in LARC use from 2006-2008 (1.1%) to 2008-2010 (3.6%) was not significant (p = .07), and no further increase occurred from 2008-2010 to 2011-2013 (3.2%); by contrast, among young adults at risk, LARC use increased from 2006-2008 (3.2%) to 2008-2010 (6.9%) and from 2008-2010 to 2011-2013 (11.1%).

CONCLUSIONS

Because many adolescents and young adult women have never had vaginal intercourse, for these groups, including all women underestimates LARC use for pregnancy prevention. Among young adults, use of LARC for pregnancy prevention has increased but remains low among adolescents.

Notes from the Field: Verona Integron-Encoded Metallo-Beta-Lactamase-Producing Carbapenem-Resistant Enterobacteriaceae in a Neonatal and Adult Intensive Care Unit--Kentucky, 2015

During August 4-September 1, 2015, eight cases of Verona integron-encoded metallo-beta-lactamase (VIM)-producing Carbapenem-resistant Enterobacteriaceae (CRE) colonization were identified in six patients, using weekly active surveillance perirectal cultures in a Kentucky tertiary care hospital. No cases of clinical infection or complications attributable to colonization were reported. Four of the eight isolates were identified as Enterobacter cloacae; other organisms included Raoultella species (one), Escherichia coli (one), and Klebsiella pneumoniae (two). Six isolates were reported in a neonatal intensive care unit (ICU), and two isolates in an adult trauma and surgical ICU. Patient ages at isolate culture date ranged from 21 days to 68 years. Fifty percent of the patients were male. Previously, only one VIM-producing CRE-colonized patient (an adult, in 2013) had been reported by the same hospital. The six cases are the largest occurrence of VIM-producing CRE colonization reported in the United States and the only recognized cluster of VIM-producing CRE colonization in the United States reported to include a neonatal population. Despite environmental sampling over the same period, surveying patients for exposure to health care outside the United States, surveying health care providers for risk factors, and surveillance culturing of health care provider nares and axillae, a source of VIM-producing CRE has not been identified for this cluster. Prevention measures throughout the ICUs have been enhanced in response to this cluster, as detailed in CDC's 2015 CRE toolkit update.

Checklists and multidisciplinary team performance during simulated obstetric hemorrhage

BACKGROUND

Checklists can optimize team performance during medical crises. However, there has been limited examination of checklist use during obstetric crises. In this simulation study we exposed multidisciplinary teams to checklist training to evaluate checklist use and team performance during a severe postpartum hemorrhage.

METHODS

Fourteen multidisciplinary teams participated in a postpartum hemorrhage simulation occurring after vaginal delivery. Before participating, each team received checklist training. The primary study outcome was whether each team used the checklist during the simulation. Secondary outcomes were the times taken to activate our institution-specific massive transfusion protocol and commence red blood cell transfusion, and whether a designated checklist reader was used.

RESULTS

The majority of teams (12/14 (86%)) used the checklist. Red blood cell transfusion was administered by all teams. The median [IQR] times taken to activate the massive transfusion protocol and transfuse red blood cells were 5min 14s [3:23-6:43] and 14min 40s [12:56-17:28], respectively. A designated checklist reader was used by 7/12 (58%) teams that used the checklist. Among teams that used a checklist with versus without a designated reader, we observed no differences in the times to activate the massive transfusion protocol or to commence red blood cell transfusion (P>0.05).

CONCLUSIONS

Although checklist training was effective in promoting checklist use, multidisciplinary teams varied in their scope of checklist use during a postpartum hemorrhage simulation. Future studies are required to determine whether structured checklist training can result in more standardized checklist use during a postpartum hemorrhage.

Embryo donation and counselling for the welfare of donors, recipients, their families and children

STUDY QUESTION

How do counsellors facilitating known 'open' embryo donation (ED) experience their roles and responsibilities?

SUMMARY ANSWER

Counsellors regard counselling for ED as entailing significant responsibility to ensure that the longer-term implications of the practice are understood and that positive relationships are established that will promote the well-being of donors, recipients, their families and the children involved.

WHAT IS KNOWN ALREADY

While counselling is frequently recommended in third-party assisted reproduction, there has been little research into the experiences of counsellors and their perceptions of their roles and responsibilities.

STUDY DESIGN, SIZE, DURATION

Fertility counsellors were interviewed between March and October 2012 as to their experiences and perceptions of their roles and responsibilities.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Fertility counsellors were recruited from across New Zealand and interviews were conducted with all nine counsellors involved in ED counselling. Interview data were analysed thematically to identify main themes.

MAIN RESULTS AND THE ROLE OF CHANCE

Counsellors regard ED as a complex practice with enduring implications arising from the genetic link between donors and offspring, which is seen to bestow immutable social ties. They see their role as the provision of implications counselling and the facilitation of ongoing positive relationships between donors and recipients in an 'open' context. Counsellors express concern about their responsibility for promoting the welfare of all parties--including that of the child--the limitations of counselling, and the conflation of assessment and counselling roles.

LIMITATIONS, REASONS FOR CAUTION

Experiences of counselling for ED may change over time as longer-term outcomes become more apparent.

WIDER IMPLICATIONS OF THE FINDINGS

Further consideration needs to be given as to how the welfare principle may best be operationalised in counselling practice, particularly in contexts of 'open' donation.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by an AUT University Faculty of Health and Environmental Sciences research grant. The authors have no conflicts of interest to declare.

Current Contraceptive Use and Variation by Selected Characteristics Among Women Aged 15-44: United States, 2011-2013

This report describes current contraceptive use among women of childbearing age (ages 15-44) during 2011-2013. Current contraceptive use is defined as use during the month of interview, not for a specific act of sexual intercourse. This report's primary focus is describing patterns of contraceptive use among women who are currently using contraception, by social and demographic characteristics. Data from 2002 and 2006-2010 are presented for comparison. METHODS-Data for the 2011-2013 National Survey of Family Growth (NSFG) were collected through in-person interviews in respondents' homes. The 2011-2013 NSFG, a nationally representative survey conducted by the Centers for Disease Control and Prevention's National Center for Health· Statistics, was based on interviews with 10,416 women and men aged 15-44 in the U.S. household population. This report is based on the sample of 5,601 women interviewed in 2011-2013, with a response rate of 73.4%. RESULTS-Among women currently using contraception, the most commonly used methods were the pill (25.9%, or 9.7 million women), female sterilization (25.1 %, or 9.4 million women), the male condom (15.3%, or 5.8 million women), and long-acting reversible contraception (LARC)-intrauterine devices or contraceptive implants (11.6%, or 4.4 million women). Differences in method use were seen across social and demographic characteristics. Comparisons between time points reveal some differences, such as higher use of LARC in 2011-2013 compared with earlier time points.

Current contraceptive status among women aged 15-44: United States, 2011-2013

Nearly all women use contraception at some point in their lifetimes, although at any given time they may not be using contraception for reasons such as seeking pregnancy, being pregnant, or not being sexually active. Using data from the 2011-2013 National Survey of Family Growth (NSFG) on contraceptive use in the month of the interview, this report provides a snapshot of current contraceptive status among women aged 15-44 in the United States. In addition to describing use of any method by age, Hispanic origin and race, and educational attainment, patterns of use are described for the four most commonly used contraceptive methods: the oral contraceptive pill, female sterilization, the male condom, and long-acting reversible contraceptives, which include contraceptive implants and intrauterine devices.

Ear Disease following Cleft Lip and Palate Surgery without Tympanostomy Tube Placement

Objectives:

(1) Describe the current benefits and risks associated with perioperative prophylactic myringotomy during cleft lip/palate surgery. (2) Recognize potential predictive factors associated with middle ear disease following cleft lip/palate surgery. (3) Incorporate ethnic differences into treatment algorithms regarding tympanostomy tubes.

Methods:

A total of 241 children (129 Ecuadorian, 112 Chinese) underwent cleft lip/palate repair (2000-2009). Veau classification, age, history of ear infections, and cleft side were recorded. Average age was 2.4 years and 11.1 years for Ecuadorian and Chinese children, respectively. No patients underwent tympanostomy tube placement. Following surgical correction, serial otoacoustic emissions (OAE) testing, and tympanometry were performed, and a parental questionnaire was administered regarding behavioral hearing deficits and history of ear infections before and after surgery. Data were recorded and compared individually for the 2 populations and as a group to identify disease prevalence and correlative factors.

Results:

No association existed between Veau classification and deficits in tympanometry, OAE, or subjective hearing. Reported ear infections after surgery were fewer than before but were not significant (26% to 21%). Abnormal OAE testing was associated with abnormal tympanometry and subjective hearing deficits ( P < .0001 and P = .004). Ecuadorian children had higher number of ear infections pre- and postoperatively ( P = .043 and P < .001) and higher number of abnormal tympanograms ( P = .003). No significant difference existed regarding OAE testing.

Conclusions:

Severity of the cleft lip/palate is not a predictive factor of middle ear disease and hearing impairment when no tympanostomy tube is placed. Ideal pressure equalization tube protocols should incorporate ethnic differences.

First premarital cohabitation in the United States: 2006-2010 National Survey of Family Growth

OBJECTIVE

This report provides an updated description of trends and patterns in first premarital cohabitations among women aged 15-44 in the United States using the National Survey of Family Growth (NSFG). Trends in pregnancies within first premarital cohabiting unions and differences by Hispanic origin and race, and education are also presented.

METHODS

Data for 2006-2010 were collected through in-person interviews with 22,682 women and men aged 15-44 in the household population of the United States. This report is based primarily on the sample of 12,279 women interviewed in 2006-2010, and is supplemented by data from the 1995 and 2002 NSFGs.

RESULTS

Forty-eight percent of women interviewed in 2006-2010 cohabited with a partner as a first union, compared with 34% of women in 1995. Between 1995 and 2006-2010, the percentage of women who cohabited as a first union increased for all Hispanic origin and race groups, except for Asian women. In 2006-2010, 70% of women with less than a high school diploma cohabited as a first union, compared with 47% of women with a bachelor's degree or higher. First premarital cohabitations were longest for foreign-born Hispanic women (33 months) and shortest for white women (19 months). In 2006-2010, 40% of first premarital cohabitations among women transitioned to marriage by 3 years, 32% remained intact, and 27% dissolved. Nearly 20% of women experienced a pregnancy in the first year of their first premarital cohabitation.

Contraceptive methods women have ever used: United States, 1982-2010

OBJECTIVE

This report presents national estimates of the proportion of sexually experienced women aged 15-44 who have ever used various methods of contraception in the United States. Trends are shown since 1982, and results are shown by Hispanic origin and race, education, and religious affiliation. The number of methods ever used is also shown, along with reasons for stopping use of selected methods.

METHODS

Data for 2006-2010 were collected through in-person interviews with 22,682 women and men aged 15-44 in the household population of the United States. Interviews were conducted by female interviewers in the homes of sampled persons. This report is based primarily on the sample of 12,279 women interviewed in 2006-2010 from the National Survey of Family Growth (NSFG). Data from earlier NSFGs are presented to show trends in method choice since 1982.

RESULTS

Virtually all women of reproductive age in 2006-2010 who had ever had sexual intercourse have used at least one contraceptive method at some point in their lifetime (99%, or 53 million women aged 15-44), including 88% who have used a highly effective, reversible method such as birth control pills, an injectable method, a contraceptive patch, or an intrauterine device. In 2006-2010, the most common methods that women or their partners had ever used were: the male condom (93%), the pill (82%), withdrawal (60%), and the injectable, Depo-Provera (23%). Method use varied by race and Hispanic origin, nativity among Hispanics, education, and religious affiliation, with significant proportions of women in all categories having used one or more of the most effective methods. The median number of methods ever used by women was about three, but nearly 30% have used five or more methods. Side effects were the most common reason for discontinuing use of the pill, Depo-Provera, and the patch among women who had ever discontinued using these methods due to dissatisfaction.

Use of emergency contraception among women aged 15-44: United States, 2006-2010

Emergency contraception can be used by women after sexual intercourse in an effort to prevent an unintended pregnancy. Roughly one-half of all pregnancies in the United States are unintended (1,2). The FDA first approved emergency contraceptive pills in 1998, but there is evidence of limited use of hormonal contraceptives for emergency contraception since the 1960s (3,4). Now, there are at least four brands of emergency contraceptive pills; most are available over the counter for women aged 17 and over (5). Although insertion of a copper intrauterine device can be used for emergency contraception (1,4), this report focuses only on emergency contraceptive pills. This report describes trends and variation in the use of emergency contraception and reasons for use among sexually experienced women aged 15-44 using the 2006-2010 National Survey of Family Growth.

Current contraceptive use in the United States, 2006-2010, and changes in patterns of use since 1995

OBJECTIVE

Use of contraception and the effectiveness of the method used to prevent pregnancy are major factors affecting national pregnancy and birth rates and the ability of women to plan their pregnancies. This report presents national estimates of contraceptive use among women of childbearing age (15-44 years) in 2006-2010. Selected comparisons are made with 1995 data to describe changes in contraceptive use and in method choice over time.

METHODS

Data for 2006-2010 were collected through in-person interviews with 22,682 women and men aged 15-44 years in the household population of the United States. Interviews were conducted by female interviewers in the homes of sampled persons. This report is based primarily on the sample of 12,279 women interviewed in 2006-2010; some tables are supplemented with the sample of 10,847 women interviewed in 1995.

RESULTS

Sixty-two percent of women of reproductive age are currently using contraception. Of women using a contraceptive method in the month of the interview, the most common methods used are the pill (28%, or 10.6 million women) and female sterilization (27%, or 10.2 million women). Use of intrauterine devices as a current method has increased since 1995 (from 0.8% in 1995 to 5.6% in 2006-2010), whereas fewer women report that their partners are using condoms as their current, most effective contraceptive method. Of women at risk of an unintended pregnancy, 11% report not currently using a method of contraception.

Young Adults' Fertility Expectations and Events: Associations With College Enrollment and Persistence

The analyses described in this article investigated the association between adolescent fertility expectations and college enrollment (N = 7,838). They also explored the potential impact of fertility expectations and events on college persistence among 4-year (n = 2,605) and 2-year (n = 1,962) college students. The analysis, which used data from the National Longitudinal Survey of Youth 1997 cohort, showed a significant association between expectations for early parenthood and the likelihood of going to a 4-year college or 2-year college for both men and women. In addition, the authors found that pregnancies were associated with an increased risk of college dropout for women; however, if all of the estimated effect of pregnancies on the risk of dropout were causal, they would still not be a major factor contributing to educational attainment because fertile pregnancies among college women are so rare.

Fertility of men and women aged 15-44 years in the United States: National Survey of Family Growth, 2006-2010

OBJECTIVE

This report presents national estimates of the fertility of men and women aged 15-44 years in the United States in 2006-2010 based on the National Survey of Family Growth (NSFG). Data are compared with similar measures for 2002.

METHODS

Descriptive tables of numbers, percentages, and means are presented and discussed. Data were collected through in-person interviews of a nationally representative sample of the household population aged 15-44 years in the United States between July 2006 and June 2010. The 2006-2010 NSFG sample is comprised of 22,682 respondents including 10,403 men and 12,279 women. The overall response rate for the 2006-2010 NSFG was 77%, 75% for men and 78% for women.

RESULTS

Many of the fertility measures among men and women aged 15-44 based on the 2006-2010 NSFG were generally similar to those reported based on the 2002 NSFG. The mean age at first child's birth for women was 23 and the mean age at first child's birth for men was 25. One-half of first births to women were in their 20s and two-thirds of first births were fathered by men who were in their 20s. On average, women aged 15-44 have 1.3 children as of the time of the interview. By age 40, 85% of women had had a birth, and 76% of men had fathered a child. In 2006-2010, 22% of first births to women occurred within cohabiting unions, up from 12% in 2002. These measures differed by Hispanic origin and race and other demographic characteristics.

First marriages in the United States: data from the 2006-2010 National Survey of Family Growth

OBJECTIVES

This report shows trends and group differences in current marital status, with a focus on first marriages among women and men aged 15-44 years in the United States. Trends and group differences in the timing and duration of first marriages are also discussed. These data are based on the 2006-2010 National Survey of Family Growth (NSFG). National estimates of probabilities of first marriage by age and probabilities of separation and divorce for women and men's first marriages are presented by a variety of demographic characteristics. Data are compared with similar measures for 1982, 1995, and 2002.

METHODS

The analyses presented in this report are based on a nationally representative sample of 12,279 women and 10,403 men aged 15-44 years in the household population of the United States. The overall response rate for the 2006-2010 NSFG was 77%-78% for women and 75% for men.

RESULTS

The percentage of women who were currently cohabiting (living with a man in a sexual relationship) rose from 3.0% in 1982 to 11% in 2006-2010; it was higher in some groups, including Hispanic groups, and the less educated. In 2006-2010, women and men married for the first time at older ages than in previous years. The median age at first marriage was 25.8 for women and 28.3 for men. Premarital cohabitation contributed to the delay in first marriage for both women and men.

Early Family Formation among White, Black and Mexican American Women

Using data from Waves I and III of Add Health, we examine early family formation among 6,144 White, Black, and Mexican American women. Drawing on cultural and structural perspectives, we estimate models of the first and second family transitions (cohabitation, marriage, or childbearing) using discrete time multinomial logistic regression. Complex differences by race/ethnicity and generation are partially explained by differences in attitudes and values in adolescence and family SES; marriage values are especially important in first-generation Mexican women's early entry into marriage. Examination of sequential family transitions sheds light on race/ethnic differences in the meaning and consequences of early cohabitation and pre-union births.

Single- versus double-layer hysterotomy closure at primary caesarean delivery and bladder adhesions

OBJECTIVE

To determine the association between single-layer (one running suture) and double-layer (second layer or imbricating suture) hysterotomy closure at primary caesarean delivery and subsequent adhesion formation.

DESIGN

A secondary analysis from a prospective cohort study of women undergoing first repeat caesarean section.

SETTING

Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA.

POPULATION

One hundred and twenty-seven pregnant women undergoing first repeat caesarean section.

METHODS

Patient records were reviewed to identify whether primary caesarean hysterotomies were closed with a single or double layer. Data were analysed by Fisher's exact tests and multivariable logistic regression.

MAIN OUTCOME MEASURE

Prevalence rate of pelvic and abdominal adhesions.

RESULTS

Of the 127 women, primary hysterotomy closure was single layer in 56 and double layer in 71. Single-layer hysterotomy closure was associated with bladder adhesions at the time of repeat caesarean (24% versus 7%, P = 0.01). Single-layer closure was associated in this study with a seven-fold increase in the odds of developing bladder adhesions (odds ratio, 6.96; 95% confidence interval, 1.72-28.1), regardless of other surgical techniques, previous labour, infection and age over 35 years. There was no association between single-layer closure and other pelvic or abdominal adhesions.

CONCLUSIONS

Primary single-layer hysterotomy closure may be associated with more frequent bladder adhesions during repeat caesarean deliveries. The severity and clinical implications of these adhesions should be assessed in large prospective trials.

Confidence in the use of donor insemination: an evaluation of the impact of participating in a group preparation programme

This paper argues that infertility can result in a range of negative emotional reactions, including a lack of confidence. This is more marked when donor insemination (DI) is used because of the additional shame this is associated with. Parents who do not feel confident may be less likely to share information about their use of DI with others and their child. Legislation in several countries has been introduced to abolish donor anonymity, but this has does not necessarily have an impact on parental confidence. In order to evaluate whether educational preparation programmes can impact on parental confidence and their intention to share information about DI, the confidence levels of 60 participants of three seminars were examined at three different points in time: before, immediately after and several months after attending the programme. Results indicate that most participants' confidence increased markedly as a result of attending an educational seminar. Furthermore, this increased confidence also impacted positively on the intention to share information about DI with future children. Both remained high several months after having attended the programme. These results point out that group preparation programmes can enhance levels of confidence, both as treatment is begun and as family building is undertaken.

Primary health care nurses implement and evaluate a community outreach approach to health care in the South African agricultural sector

BACKGROUND

Early detection and effective case management of tuberculosis (TB) among a high-risk group of materially poor farm workers in an area of the Cape Winelands, South Africa, presents special challenges to the health community, where resource constraints lead to service reduction. In order to address this problem, local nurses established a collaborative partnership between permanent farm workers and their families, their employers, selected non-governmental organizations and the public health sector. In consultation with stakeholders, they developed an intervention primarily focusing on having peer selected trained lay health workers (LHWs) on farms, mentored and managed by nurses.

PURPOSE

To describe the complex process of implementation and evaluation of the LHW project, and provide a summary of a number of discrete studies evaluating the effectiveness, cost implications, and the perceptions and experiences of key stakeholders of the intervention.

METHODS

Quantitative and qualitative research methods conducted within the context of a pragmatic unblinded community cluster randomized control trial were used. Emphasis was placed on an iterative participatory interaction between the researchers and key stakeholders.

RESULTS

The intervention contributed to significantly better successful treatment completion rates among adult new smear-positive TB cases. The process implemented proved cost-effective and was pivotal in initiating a community-based social development programme.

CONCLUSIONS

The use of peer-selected LHWs within a wider programme of integrated care designed to merge technical biomedical approaches to disease management with more holistic social development activities, appears essential to meet the complex health needs in conjunction with public health of the rural poor.

Family transitions in Young Adulthood

Using the first (1995) and third (2001–2002) waves of the Add Health survey, we examine women’s family transitions up to age 24. Only a third of all women marry, and a fifth of those marriages dissolve before age 24. Three out of eight women have a first birth, with a substantial majority of those births outside of marriage: 66% for whites, 96% for blacks, and 72% for Mexican Americans. Cohabitation is the predominant union form; 59% of women cohabit at least once by age 24. Most cohabitations are short lived, with approximately one in five resulting in a marriage. We summarize the family and relationship experience of women up to age 24 in terms of four categories, each accounting for roughly a quarter of all women. Category 1 has the women who remain single nonparents. Category 2 has the early marriers, women whose marriage is not preceded by a first birth. Category 3 has those who become single parents. Category 4 has the women who cohabit at least once, but who do not marry or have a birth by age 24. The strictly ordered transitions of the 1950s are long gone and have been replaced by a variety of paths to adulthood.

Otophyma: a case report

Objective:

We report a rare case of otophyma.

Method:

A case report of otophyma and a review of the current literature concerning otophyma and the more common rhinophyma, are presented.

Results:

A 46-year-old male presented with slow growing fleshy growths on both auricles which were excised. A diagnosis of otophyma was made. Although rosacea is more common, otophyma and other ‘phymas’ are thought to be the end stage of the rosacea spectrum of skin disease. However, unlike rhinophyma, otophyma is rarely seen and as a result there is little in the English language literature regarding it. Consequently, the management of otophyma is largely based on previous experiences with rhinophyma.

Conclusion:

To our knowledge this is the first case report of otophyma in the otolaryngology literature and only the second described in the English language literature. This case demonstrates the difficulties faced in diagnosing this rare condition and our successful management of this case.