Association of Baseline Adherence to Antihypertensive Medications With Adherence After Shelter-in-Place Guidance for COVID-19 Among US Adults

IMPORTANCE

Adherence to selected antihypertensive medications (proportion of days covered [PDC]) declined after guidance to shelter in place for COVID-19.

OBJECTIVES

To determine whether PDC for all antihypertensive medications collectively fell from the 6 months before sheltering guidance (September 15, 2019, to March 14, 2020 [baseline]) compared with the first (March 15 to June 14, 2020) and second (June 15 to September 14, 2020) 3 months of sheltering and to assess the usefulness of baseline PDC for identifying individuals at risk for declining PDC during sheltering.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included a random sample of US adults obtained from EagleForce Health, a division of EagleForce Associates Inc. Approximately one-half of the adults were aged 40 to 64 years and one-half were aged 65 to 90 years, with prescription drug coverage, hypertension, and at least 1 antihypertensive medication prescription filled at a retail pharmacy during baseline.

MAIN OUTCOMES AND MEASURES

Prescription claims were used to assess (1) PDC at baseline and changes in PDC during the first and second 3 months of sheltering and (2) the association of good (PDC ≥ 80), fair (PDC 50-79), and poor (PDC < 50) baseline adherence with adherence during sheltering.

RESULTS

A total of 27 318 adults met inclusion criteria (mean [SD] age, 65.0 [11.7] years; 50.7% women). Mean PDC declined from baseline (65.6 [95% CI, 65.2-65.9]) during the first (63.4 [95% CI, 63.0-63.8]) and second (58.9 [95% CI, 58.5-59.3]) 3 months after sheltering in all adults combined (P < .001 for both comparisons) and both age groups separately. Good, fair, and poor baseline adherence was observed in 40.0%, 27.8%, and 32.2% of adults, respectively. During the last 3 months of sheltering, PDC declined more from baseline in those with good compared with fair baseline adherence (-13.1 [95% CI, -13.6 to -12.6] vs -8.3 [95% CI, -13.6 to -12.6]; P < .001), whereas mean (SD) PDC increased in those with poor baseline adherence (mean PDC, 31.6 [95% CI, 31.3-31.9] vs 34.4 [95% CI, 33.8-35.0]; P < .001). However, poor adherence during sheltering occurred in 1034 adults (9.5%) with good baseline adherence, 2395 (31.6%) with fair baseline adherence, and 6409 (72.9%) with poor baseline adherence.

CONCLUSIONS AND RELEVANCE

These findings suggest that individuals with poor baseline adherence are candidates for adherence-promoting interventions irrespective of sheltering guidance. Interventions to prevent poor adherence during sheltering may be more useful for individuals with fair vs good baseline adherence.

Port site metastasis of ovarian carcinoma remote from laparoscopic surgery for benign disease

BACKGROUND

The use of laparoscopic surgical procedures has continued to expand due to the many advantages that this surgical approach offers. However, as we continue to realize the benefits and expand the scope of laparoscopic procedures, new complications may occur.

CASE

This is the case of a 77-year-old gravida 2 para 2 who underwent exploratory laparotomy and surgical staging with optimal cytoreduction for Stage IIIC papillary serous ovarian carcinoma in February 1998. Her past surgical history was significant for total abdominal hysterectomy and left salpingo-oophorectomy in 1955 for symptomatic leiomyomata and for a laparoscopic cholecystectomy in July 1997. After initial platinum-based chemotherapy, she presented with an enlarging nodule at the right upper quadrant laparoscopic port site. Fine needle aspiration confirmed recurrent papillary serous ovarian carcinoma. After a discussion of her options, she elected to undergo surgical resection with postoperative salvage chemotherapy.

CONCLUSION

Port site recurrences have been previously reported in patients who underwent initial surgical evaluation for ovarian carcinoma utilizing the laparoscopic approach. However, it is unusual for recurrent cancer to appear in port sites or operative incisions not related to the initial cancer surgery. This report serves to caution the gynecologic oncologist that the first evidence of recurrence may be at a laparoscopic port site from prior benign gynecologic or nongynecologic surgery.

Equal care ensures equal survival for African-American women with cervical carcinoma

BACKGROUND

[corrected] It was the purpose of this study to investigate whether race is an independent prognostic factor in the survival of patients with cervical carcinoma in a health care system with minimal racial bias, and few barriers to access to care.

METHODS

Records for patients with a diagnosis of invasive cervical carcinoma from 1988 to 1999 were obtained from the Automated Central Tumor Registry for the United States Military Health Care System. Clinical data including race, age at diagnosis, histology, grade, stage, socioeconomic status, treatment modality, and survival also were obtained. Survival analysis was performed with Kaplan-Meier survival curves.

RESULTS

One thousand five hundred fifty-three patients were obtained for review. Sixty-five percent of patients were Caucasian, and 35% were minorities. Of the minorities, 29% were African Americans (AAs). Mean age of diagnosis was similar among AAs and Caucasians, 44 and 42 years, respectively. There was no statistically significant difference between the distribution of age, stage, grade, or histology between Caucasians and AAs. Forty-six percent of patients were treated with surgery and 56% with radiation therapy, with no difference in type of treatment between the Caucasian and AA groups. Five- and 10-year survival rates for Caucasians and AAs were 75%, and 76%, and 64% 65% (P = 0.59), respectively.

CONCLUSIONS

In an equal access, unbiased, nonracial environment, race is not an independent predictor of survival for patients with cervical carcinoma. This study has shown, for the first time to the authors' knowledge, that when they receive equal treatment for cervical carcinoma, AA women's survival can approach that of their nonminority counterparts (75% at 10 years).

Asymptomatic intussusception of the appendix due to endometriosis

We present the case of a 29-year-old woman with an asymptomatic intussuscepted appendix found incidentally during surgical evaluation for a pelvic mass in a patient with endometriosis. This case represents the rare nature of this presentation and the need to fully evaluate the gastrointestinal tract in patients with endometriosis.

Evaluation of routine antepartum and postpartum blood counts

OBJECTIVE

To evaluate routine screening 28-week, admission and postpartum complete blood counts (CBCs) during a six-month period on the labor and delivery service and to correlate the laboratory data with clinical characteristics of the patients, to determine if routine CBCs are necessary in evaluating blood loss in low-risk patients and to determine whether routine admission screening for thrombocytopenia is necessary prior to epidural placement is necessary in low-risk patients.

STUDY DESIGN

Laboratory data form all patients were obtained from a centralized computer system. Clinical characteristics were obtained from the medical record.

RESULTS

Blood loss was determined by a change in hematocrit on admission and postpartum, and the mean of this data was used for analysis. First, the data reflected common clinical assumptions about delivery blood loss. The mean change in hematocrit for operative deliveries (7.93 +/- 5.10, 6.19 +/- 4.42; forceps and cesarean, respectively) was higher than that of spontaneous vaginal deliveries (4.31 +/- 3.78). Forcep deliveries had a larger decrease in hematocrit than repeat or primary cesarean sections combined, although it was not statistically significant (P = .04). More extensive vaginal lacerations were associated with larger decreases in hematocrit. There was a low percentage of patients requiring transfusion (1.3%) during the study period. All these patients had an estimated blood loss of > 1500 mL and delivery circumstances that would alert the clinician to the possibility of transfusion. Second, our data showed that the 28-week platelet count is predictive of the admission platelet count, with a regression coefficient of. 71.

CONCLUSION

Often clinical assessment of blood loss, including history and physical examination, will predict the results of routine screening CBCs, and we question the need for routine screening of blood loss in uncomplicated deliveries. Our data on the 28-week and admission platelet counts support other authors' data showing that this screen is not necessary prior to epidural placement in low-risk patients.

Granulosa cell tumor of the ovary associated with antecedent tamoxifen use

BACKGROUND

Increased attention has been focused recently on the estrogenic effects of tamoxifen. Review of the literature reveals an association between tamoxifen use and gynecologic tumors.

CASE

A 52-year-old postmenopausal woman was treated with tamoxifen for stage II estrogen receptor-positive breast carcinoma. Her aspartate transaminase and alanine transaminase levels increase markedly after 6 months of tamoxifen use. After an additional 17 months of elevated serum transaminases, the patient was found to have a stage Ic granulosa cell tumor of the ovary.

CONCLUSION

Patients with tamoxifen-induced liver dysfunction may be at increased risk for granulosa cell tumors because of alterations in tamoxifen metabolism.

Highly elevated CA125 and tubo-ovarian abscess mimicking ovarian carcinoma

Elevated serum CA125 levels may be caused by any condition which produces peritoneal irritation as well as by the presence of various malignancies. This report of a case with atypical presentation of tubo-ovarian abscess and CA125 level of 1,160 U/ml serves to re-emphasize cautious operative planning in patients desirous of reproductive capability in the face of findings highly consistent with probable malignancy. This is the highest reported serum CA125 level in a reproductive age woman with well-documented reversible benign disease.

Bilateral giant primary ovarian leiomyomas. A case report

The majority of ovarian leiomyomas are found incidentally during pathologic review of ovaries removed for other reasons. A 21-year-old woman, a virgin whose only symptom was abdominal discomfort of several months' duration, was found to have a large abdominopelvic mass, an elevated CA-125 level and ascites. Surgical exploration revealed the presence of large, bilateral ovarian neoplasms with a normal-appearing uterus. Since no normal ovarian tissue was identifiable, a bilateral oophorectomy and right salpingectomy were performed, preserving the uterus for assisted reproductive techniques. Histopathologic review confirmed benign giant primary ovarian leiomyomas with only microscopic foci of intermixed normal ovarian tissue.

Analysis of fine-needle aspirates for HPV by PCR may be useful in diagnosis of metastatic gynecologic malignancies

Human papillomavirus (HPV) DNA has been shown by molecular hybridization studies to persist in both recurrent and metastatic disease in tumors of the female genital tract. We report here the use of the polymerase chain reaction to identify HPV DNA in material from fine-needle aspirates (FNA) of recurrent or metastatic lesions to document the primary malignancy arising in the lower genital tract. Fine-needle aspirates of suspected recurrent or metastatic tumors were obtained from nine patients with carcinoma of the lower genital tract and five patients with malignancies that have not been associated with HPV. DNA was extracted from the FNA and tissue block, when available, and amplified with HPV 6, HPV 16, and HPV 18 specific primers. In eight of the nine tumors from the lower genital tract, HPV DNA was identified in both the primary and metastatic lesions. In every case the HPV genotype was identical. One cervical carcinoma and five non-HPV associated tumors were negative for papillomavirus DNA. This study demonstrates that molecular hybridization techniques can be useful in identifying the source of a metastasis and have the potential to diagnose the presence of metastatic disease by detecting HPV DNA even when the cytologic criteria are equivocal.