A Multidimensional and Longitudinal Exploratory Study of the Stability of Pregnancy Contexts in the United States

Objective

Evaluate the longitudinal stability of six pregnancy contexts, including intention, in a diverse cohort of individuals experiencing delivery, abortion, or miscarriage.

Methods

We enrolled individuals 16-44 years of age with pregnancies <24 weeks gestation in this longitudinal study between June 2014 and June 2015 in four US urban clinics. We assessed six pregnancy contexts (intention, wantedness, planning, timing, desirability, and happiness) at enrollment and 3-month follow-up. We constructed three-level categorical measures for each context defined as favorable, ambivalent, or unfavorable. We used Wilcoxon sign tests to evaluate changes in paired observations between pregnancy context measures over time and by pregnancy outcome.

Results

Among 121 participants at median gestational age of 7 weeks and 3 days, we found intention, wantedness, planning, timing, and happiness remained unchanged from enrollment in early pregnancy to 3-month follow-up. Individuals demonstrated changes in desirability; pregnancy assessments shifted toward less desirable from enrollment to follow-up (p = 0.01) (i.e., desired to ambivalent, or ambivalent to undesired). Among participants choosing delivery (57%), assessments shifted toward more favorable planning (i.e., unplanned to ambivalent, or ambivalent to planned) (p < 0.01), and less favorable desirability (i.e., desired to ambivalent or ambivalent to undesired) (p < 0.01) at follow-up. Among participants choosing abortion (28%), assessments shifted toward more unfavorable planning (i.e., planned to ambivalent, or ambivalent to unplanned) at follow-up (p < 0.01).

Conclusion

In multidimensional, longitudinal assessment, pregnant participants' perspectives on five of six pregnancy contexts remained unchanged between enrollment and 3-month follow-up; only desirability shifted. Pregnancy planning perspectives differed by pregnancy outcome.Human Research Subjects Protection Program: 1310012926.

Estimated National Cost of Pelvic Organ Prolapse Surgery in the United States

OBJECTIVE

To estimate the national cost of pelvic organ prolapse (POP) surgery in the United States.

METHODS

In this cross-sectional, population-based study, we used the 2016-2018 Healthcare Cost and Utilization Project National Inpatient Samples and National Ambulatory Surgery Samples to identify patients undergoing POP surgery using International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes, ICD-10 procedural codes, and Current Procedural Terminology codes. Cost-to-charge ratios and weighted estimates were used to calculate nationwide costs. Descriptive analysis was used to identify the sociodemographic, clinical, and surgical characteristics of the population undergoing POP surgery.

RESULTS

Between 2016 and 2018, there were 140,762 POP surgical cases annually with an annual national cost estimated at $1.523 billion per year. The median cost per procedure increased slightly from $8,837 in 2016 to $8,958 in 2018. Overall, 82.5% of the total surgeries and 78% of the total national costs associated with POP surgery came from the ambulatory setting over this time period. Of these surgeries, 44.7% included an apical repair, and 42.3% included a concomitant hysterectomy. The average age of the population was 62 years, and 20% of the total population receiving prolapse surgery were younger than age 50 years.

CONCLUSION

The annual national cost associated with surgical correction of POP is substantial, and the majority of cases occur in an ambulatory setting. These findings will contribute to enhancing cost-effectiveness analyses and decision-making processes for both health care professionals and policymakers as the national population continues to age.

Expedited Partner Therapy: A Multicomponent Initiative to Boost Provider Counseling

BACKGROUND

Expedited partner therapy prescription remains low and highly variable throughout the United States, leading to frequent reinfections with Chlamydia trachomatis and Neisseria gonorrhoeae . We examined provider counseling on expedited partner therapy before and after an electronic smart tool-based initiative.

METHODS

In this quasi-experimental interrupted time-series study, we implemented an initiative of electronic smart tools and education for expedited partner therapy in March 2020. We reviewed the records of patients with chlamydia and/or gonorrhea at an urban, academic obstetrics and gynecology clinic in the preimplementation (March 2019-February 2020) and postimplementation (March 2020-February 2021) groups. Descriptive statistics and an interrupted time-series model were used to compare the percent of expedited partner therapy offered by clinicians to patients in each group.

RESULTS

A total of 287 patient encounters were analyzed, 155 preintervention and 132 postintervention. An increase in expedited partner therapy counseling of 13% (95% confidence interval [CI], 2%-24%) was observed before the intervention (27.1% [42 of 155]) versus after the intervention (40.2% [53 of 132]). Significant increases in provider counseling were seen for patients who were single (15%; 95% CI, 3%-26%), 25 years or older (21%; 95% CI, 6%-37%), receiving public insurance (15%; 95% CI, 3%-27%), seen by a registered nurse (18%; 95% CI, 4%-32%), or seen for an obstetrics indication (21%; 95% CI, 4%-39%). No difference was seen in patients' acceptance of expedited partner therapy ( P = 1.00).

CONCLUSIONS

A multicomponent initiative focused on electronic smart tools is effective at increasing provider counseling on expedited partner therapy. Further research to understand patient perceptions and acceptance of expedited partner therapy is critical.

Public Awareness of Uterine Power Morcellation Through US Food and Drug Administration Communications: Analysis of Google Trends Search Term Patterns

Background

Uterine power morcellation, where the uterus is shred into smaller pieces, is a widely used technique for removal of uterine specimens in patients undergoing minimally invasive abdominal hysterectomy or myomectomy. Complications related to power morcellation of uterine specimens led to US Food and Drug Administration (FDA) communications in 2014 ultimately recommending against the use of power morcellation for women undergoing minimally invasive hysterectomy. Subsequently, practitioners drastically decreased the use of morcellation.

Objective

We aimed to determine the effect of increased patient awareness on the decrease in use of the morcellator. Google Trends is a public tool that provides data on temporal patterns of search terms, and we correlated this data with the timing of the FDA communication.

Methods

Weekly relative search volume (RSV) was obtained from Google Trends using the term “morcellation.” Higher RSV corresponds to increases in weekly search volume. Search volumes were divided into 3 groups: the 2 years prior to the FDA communication, a 1-year period following, and thereafter, with the distribution of the weekly RSV over the 3 periods tested using 1-way analysis of variance. Additionally, we analyzed the total number of websites containing the term “morcellation” over this time.

Results

The mean RSV prior to the FDA communication was 12.0 (SD 15.8), with the RSV being 60.3 (SD 24.7) in the 1-year after and 19.3 (SD 5.2) thereafter (P<.001). The mean number of webpages containing the term “morcellation” in 2011 was 10,800, rising to 18,800 during 2014 and 36,200 in 2017.

Conclusions

Google search activity about morcellation of uterine specimens increased significantly after the FDA communications. This trend indicates an increased public awareness regarding morcellation and its complications. More extensive preoperative counseling and alteration of surgical technique and clinician practice may be necessary.

Characterization and testing of periodic mesoporous organosilicas as potential selective benzene adsorbents

The effects of surface imprinting on the adsorption and desorption properties of benzene- and diethylbenzene-bridged periodic mesoporous organosilicas (PMOs) acting as GC stationary-phase preconcentration sorbents for benzene and xylene were examined. Surface-imprinted and nonimprinted PMOs with diethylbenzene (DEB), benzene (BENZ), and ethane (BTSE) bridges and nonimprinted mesoporous silica (MCM-41) were prepared via well-established surfactant templating synthetic methods. The imprinted materials were synthesized using a surfactant demonstrated to produce trinitrotoluene (TNT) selective sorbents with increased adsorption capacity for cresol and 4-nitrophenol as well as TNT. Powder XRD and nitrogen sorption measurements revealed that all of the materials were mesoporous with the DEB materials having a random pore structure and lower surface area than the other materials which had ordered pore structures. Results for maximum uptake of benzene and p-xylene indicate a small but consistent positive effect on the adsorption of benzene and p-xylene due to surface imprinting. Comparing the surface area normalized uptakes (mg/m(2)) for materials having the same organic bridge with and without imprinting (DEB vs TDMI-DEB and BENZ vs TDMI-BENZ) shows that in seven of eight comparisons the imprinted analogue had a higher aromatic uptake. The imprinted samples showed higher weight normalized uptakes (mg/g) in five of eight cases. When used as a GC stationary phase, the organosilica materials yield more symmetrical chromatographic peaks and better separation than MCM-41, indicating superior trapping of BTX analytes, particularly at low concentrations. Additionally, these materials rapidly desorb the preconcentrated compounds.

Cost-effectiveness model of adjunctive lamotrigine for the treatment of epilepsy

OBJECTIVE

To predict the cost-effectiveness of lamotrigine by evaluating the costs and health outcomes in treated patients.

BACKGROUND

Lamotrigine adjunctive therapy has been found to be associated with decreased seizure frequency and severity in patients who are refractory to treatment with the older antiepileptic drugs (AEDs).

METHODS

We used a cost-effectiveness clinical decision analysis framework to assess the impact of these clinical benefits on patient health care use. The measure of effectiveness was seizure-free days gained. The measures of health care resource use included hospitalizations, outpatient and emergency department visits, surgery, and AEDs. Medical care use and cost estimates were derived from clinical trial data and published sources. Costs and effectiveness (incremental costs per seizure-free days gained) of lamotrigine adjunctive therapy versus older AEDs were compared in patients refractory to previous treatment during three time periods: the start-up year, the second year when decisions about surgery were made, and all subsequent years.

RESULTS AND CONCLUSIONS

The model predicts that use of lamotrigine would be associated with an overall reduction in use of other direct medical care resources (hospitalizations, outpatient visits, diagnostic and laboratory tests, and surgery). For a 10-year time horizon, the estimated cost-effectiveness ratio is $6.9 per seizure-free day gained. The model provides a flexible framework to analyze the effect of new antiepileptic drugs.

Diffusion and transfer of antibody proteins from a sugar-based hydrogel

Diffusion of antibody protein from hydrogel films and hydrogel encapsulated in a microcapillary was studied. Thin hydrogel films were formed by crosslinking 6-acryloyl-B-O-methylgalactoside with N,N'-methylene-bis-acrylamide and the diffusive transport of monoclonal antimouse IgG-FITC into and out of the hydrate films was measured. Diffusion coefficients in 2 and 4% crosslinked hydrogel films were measured. The measured diffusion constants determined for IgG in both the 2 and 4% hydrogel films were comparable to the free diffusion of IgG in bulk water (Dmean approximately 10(-7) cm2/s). In addition, 2% crosslinked hydrogels were prepared in a capillary tube and the transport of antimouse IgG-FITC into and out of the hydrated hydrogel was measured. Kinetic analysis indicated that the protein transport through the capillary hydrogel was faster than would be expected for a simple diffusion process. Finally, by utilizing the diffusion of antibody from the capillary hydrogel, transfer of antibody to a silica surface was demonstrated. A capillary hydrogel loaded with antimouse IgG-FITC was used to transfer the protein to a silica surface forming a 30-micron spot of antibody, which was imaged using fluorescence microscopy. These results may lead to the development of a nonlithographic method of patterning antibodies on surfaces for use in integrated microimmunosensors.

Monolayer study of mixtures of diacetylenic phosphatidylcholine and phospholipids containing metal-chelating iminodiacetic acid headgroup

The mixing behavior of polymerizable diacetylenic phosphatidylcholine (1) with two diacetylenic phospholipids containing the iminodiacetic acid (IDA) functionality in the headgroup region was studied at the air-water interface. All three phospholipids contained tricosa-10,12-diynoyl acyl chains. In phospholipid 2, the choline group (-CH2-CH2-NMe3) was replaced by an -CH2-CH2-N-(CH2-COOH)2 functionality. In phospholipid 3, the IDA unit was linked to the phosphate headgroup via a sulfonate linker, -CH2-CH2-OS(O2)-O-CH2-CH2-. Monolayers were prepared by mixing polymerizable 1,2 bis(tricosa-10,12-diynoyl)-sn-glycero-3-phosphocholine (1) with metal-chelating IDA phospholipids (2, 3) on a 10 mM CuCl2 subphase. Studies of monolayer properties of mixtures of 2 and 3 with 1 demonstrated that mixtures of 2 with 1 had better mixing behavior than mixtures of phospholipids 1 and 3.

Formation and properties of a network gel formed from mixtures of diacetylenic and short-chain phosphocholine lipids

A polymerizable gel superaggregate has been formed from low concentrations (6 mM) of phospholipid mixtures of polymerizable 1,2-bis(tricosa-10,12-diynoyl)-sn-glycero-3-phosphocholine and 1,2-bis(dinonoyl)-sn-glycero-3-phosphocholine. Transmission electron microscopy (TEM) revealed that the superaggregate structure consisted of a network of twisted, braided fibers and that the pore size of the gel ranged from 0.1 to 1.0 micron. TEM of gel plated with Ni revealed that the width of the fibers was 280 A. Optical microscopy demonstrated that the onset of the gel phase occurred at mole fraction 0.43 DNPC in the absence of salt and 0.36 in the presence of 0.25 M NaCl. Polymerization did not affect the morphology of the gel but did increase its temperature stability.

Modulation of bilayer structures derived from diacetylenic phosphocholines containing oxygen linker beta to diacetylene

Phospholipids with diacetylenes present in the acyl chains form tubules and helices in aqueous dispersions. In order to modulate the morphology of bilayer structures and to understand the role of diacetylene in lipid-bilayer assembly, two diacetylenic phosphocholines, 1,2-bis(9,16-dioxa-hexacosa-11,13-diynoyl)-sn-3-phosph ocholine and 1,2-bis(15-oxa-pentacosa-10,12-diynoyl)-sn-3-phosphocholine, in which the diacetylene is linked to the acyl chain by an oxygen spacer have been synthesized. Lipid dispersions were characterized by calorimetric, film balance and microscopic techniques. Placement of oxygen spacer influences the morphology of the bilayer assemblies formed in aqueous solution. When both ends of the diacetylene were linked to the acyl chain by oxygen atoms, liposomes (diameters ranging from 0.3-3.4 microns) were observed by optical microscopy. Linking only the terminal portion of the acyl chain to the diacetylene with an oxygen atom resulted in a lipid which formed tubular microstructures as well as vesicles. Diameter of the tubular structures ranged from 0.4-4.7 microns. Transmission electron microscopic (TEM) analysis of replicas of a freeze fractured sample of the dispersion revealed that the tubular structures were hollow cylinders consisting of an aqueous core surrounded by a wall of lipid.

Transcatheter stenting of the ductus arteriosus: evaluation as an alternative to surgical shunts

Implantation of 3.5 mm Gianturco-Roubin coronary artery stents into the ductus arteriosus was evaluated as an alternative to surgical systemic to pulmonary arterial shunts in 3 weanling piglets. Thrombosis of the ductus occurred in all 3 animals (95% confidence limits 29-100%) within 1 hour, despite pretreatment with heparin. In each case, thrombus filled the ductus arteriosus but did not extend to any extraductal portion of the stents. Rapid, heparin-resistant thrombus formation precludes use of this stent procedure as an alternative to surgical shunts.

The expense of testing in a teaching hospital: the predominant role of high-cost tests

We analyzed all 32,206 tests ordered in a random sample of 1,000 patients admitted to a teaching hospital. The analysis examined costs instead of charges, included professional costs in addition to hospital costs, and considered the effect of combining tests that are ordered as a panel (e.g., cardiac enzymes) or as part of a procedure (e.g., bronchoscopy). High-cost tests (costing more than $100) accounted for only 4 percent of the total number of tests ordered, but for nearly 50 percent of total test costs. The pattern varied by clinical service: high-cost tests accounted for 31, 47, and 51 percents of total test costs on the obstetrics, medicine, and surgery services, respectively. It would seem to be efficient to concentrate on the use of high-cost tests in attempting to foster cost-effective use of diagnostic technologies.