Time Differences From Abnormal Cervical Cancer Screening to Colposcopy Between Insurance Statuses

OBJECTIVE

Screening and diagnostic follow-up to prevent cervical cancer are influenced by socioeconomic and systemic factors. This study sought to characterize intervals from abnormal cervical cancer screening to colposcopy between practices differing by insurance status at a large, urban academic center.

MATERIALS AND METHODS

This retrospective cohort study included patients aged 21-65 who presented for colposcopy between January 1, 2021, and January 1, 2022, at the resident and faculty gynecology practices of a single large urban academic medical center. Patient characteristics were compared using t tests or Wilcoxon rank sum tests for continuous measures and χ2 or Fisher exact tests for categorical measures. Intervals from abnormal cervical cancer screening to colposcopy were compared using the Wilcoxon rank sum test and linear regression analysis with multivariable models adjusted for age, cervical cytology result, human papillomavirus result, and HIV status.

RESULTS

Resident practice patients were publicly insured and more likely to be Black or Hispanic (p < .0001); rates of high-risk human papillomavirus and smoking were similar. Resident practice patients had longer intervals from abnormal cervical cancer screening to colposcopy compared with faculty practice patients (median 79.5 vs 34 d, p < .0001). On adjusted analysis, resident practice patients faced a 95% longer interval (p < .0001).

CONCLUSIONS

Publicly insured patients of a resident-based practice faced significantly longer intervals from abnormal cervical cancer screening to colposcopy than faculty practice patients at a single urban academic center. Effort to address these differences may be an area of focus in improving health disparities.

Adoption of Complete Bilateral Salpingectomy for Permanent Contraception at Time of Cesarean Delivery in Rhode Island

OBJECTIVE

Complete bilateral salpingectomy (CBS) can decrease the risk of developing ovarian cancer, although adoption of CBS at cesarean delivery (CD) for permanent contraception has been low. The primary objective was to measure the annual rates of CBS at CD before and after an educational initiative. The secondary objective was to assess rates of providers who offer CBS at CD and their comfort level with the procedure.

METHODS

We performed an observational study of OBGYN physicians who perform CD at a single institution. We compared the annual rates of CBS among CD with permanent contraception procedures from the year before and the year after an in-person OBGYN Grand Rounds presentation on December 5, 2019 reviewing the latest research on opportunistic CBS at the time of CD. To evaluate the secondary objectives, anonymous surveys were administered to physicians in-person the month before the presentation. The statistical analysis included chi-square, Fisher's exact test, T-test, ANOVA, and the Cochran-Armitage trend test.

RESULTS

After our educational intervention, annual rates of CBS at CD increased from 5.1% [12/05/2018-12/04/2019] to 31.8% [12/5/2019-12/4/2020] (p<0.001), and up to 52% in the last study quarter (p<0.001). Surgical outcomes were similar between tubal ligation and CBS, except for a 5-minute increased total operative time for CBS (p=0.005). Fifty physicians completed the survey prior to the presentation (93% response rate). All physicians offered CBS at time of hysterectomy and interval sterilization, while only 36% offered CBS at time of CD. More physicians felt comfortable performing a CBS with bipolar electrocautery (90%) than suture ligation (56%).

CONCLUSION

Our presentation-based educational initiative was associated with a significant increase in performance of CBS at the time of CD.

Missing a chance to prevent: disparities in completion of genetic evaluation in high-risk patients with endometrial cancer

OBJECTIVE

The primary goal of this study is to examine disparities in high-risk endometrial cancer (EC) patients in relation to rates of genetic referrals (GR), testing (GT), and counseling (GC).

METHODS

This is a retrospective analysis of patients with newly diagnosed EC between January 1, 2014 and September 1, 2020 at a single institution. Patients were defined as high-risk EC patients when they were 1) diagnosed at 50 years or younger, 2) had a positive family history for cancer or 3) had evidence of loss of mismatch repair protein expression on tumor immunohistochemistry. Rates of GR, GT and GC were analyzed based on race, ethnicity, primary language and insurance status.

RESULTS

During the study period, 674 patients were diagnosed with EC and 249 (36.9%) were considered high-risk EC patients. Among high-risk patients, 128 (51.2%) were referred to GT and GC. Of those referred, 103 (80.5%) underwent GT and 85 (66.4%) completed GC. Out of all high-risk patients, 20 (18.4%) were positive for LS on GT and 29 (28.2%) had VUS results. In multivariate analysis, the odds of GT and GC referral were lower among patients who identified as Hispanic (OR=0.40; 95% CI=0.19-0.87; p=0.020). Patients who identified as black were less likely to receive GC when compared to patients of other races (p=0.030).

CONCLUSION

It is our hope that through this data we will increase awareness around existing disparities in genetic evaluation for patients with EC and ultimately create strategies to improve equitable access to care for all patients.

Validation of the CARPREG II risk stratification model and the WHOm scale in pregnant women with heart disease

 

The physiological changes of pregnancy imply a state of haemodynamic stress, which increases the risk of maternal-fetal complications in women with cardiac pathology. Risk stratification models allow clinical decisions to be guided and optimal diagnostic, follow-up and management strategies to be established according to each estimated category in order to reduce adverse outcomes.

Objective

To validate the CARPREG II and WHOm risk prediction models in a population of pregnant women with heart disease.

Materials and methods

Validation and comparison study of a risk prediction model in a prospective cohort of pregnant women with heart disease assessed between 2016 and 2019 by a cardiobstetric team in an average income country. The CARPREG II score was established and patients were classified according to the WHOm risk scale. We assessed cardiovascular and perinatal outcomes and determined the calibration and level of discrimination of these tools.

Results

In a cohort of 328 pregnant women (27±7 years), 33% (n=110) had congenital heart disease, followed by arrhythmias in 30% (n=98), valvular pathologies in 14% (n=46) and cardiomyopathies in 9% (n=29). In 56% of the pregnancies, the route of delivery was caesarean section, 84% of these by obstetric indication. A cardiac event occurred in 15%, with left heart failure (5.3%) and arrhythmias (2.3%) being the most frequent. The frequency of maternal death of cardiac origin during the study was 1.6%. Neonatal outcomes occurred in 37% of gestations (preterm delivery (16%) and low weight for gestational age (8.4%)) and obstetric events in 12.5%: pregnancy-induced hypertension (9%) and postpartum haemorrhage (2.3%).

NYHA functional class III-IV or cyanosis (OR 12 95% CI 3.1 - 46.4) and left ventricular dysfunction (LVEF &lt;55%) (OR 3 95% CI 1 - 10.9) were the most statistically significant risk predictors. Discrimination of both models was adequate (AUC-ROC of 0.74 95% CI 0.64 - 0.84) for the CARPREG II risk index and 0.77 for the WHOm scale (95% CI 0.69 - 0.86) (Figure 2). Calibration is also good in the study population (Hosmer- Lemeshow goodness-of-fit 0.6 and 0.1, respectively). By including in the CARPREG II model the variables ejection fraction and pulmonary artery systolic pressure in their numerical and not dichotomised form, a discrete improvement in the predictive ability of the scale is evident (AUC-ROC 0.81 95% CI 0.71–0.91).

Conclusions

The CARPREG II and WHOm risk stratification models have good ability to discriminate the risk of adverse cardiac outcomes in pregnant women with heart disease and fit our population. To improve the predictive power of CARPREG II, the variables pulmonary hypertension and left ventricular dysfunction could be used numerically and not dichotomised as in the original model.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): San Vicente Foundation University Hospital, Cardio-obstetric Center

Molecular dissection of TNFR-TNFα bidirectional signaling reveals both cooperative and antagonistic interactions with p75 neurotrophic factor receptor in axon patterning

During neural development, complex organisms rely on progressive and regressive events whereby axons, synapses, and neurons are overproduced followed by selective elimination of a portion of these components. Tumor necrosis factor α (TNFα) together with its cognate receptor (Tumor necrosis factor receptor 1; TNFR1) have been shown to play both regressive (i.e. forward signaling from the receptor) and progressive (i.e. reverse signaling from the ligand) roles in sympathetic neuron development. In contrast, a paralog of TNFR1, p75 neurotrophic factor receptor (p75NTR) promotes mainly regressive developmental events in sympathetic neurons. Here we examine the interplay between these paralogous receptors in the regulation of axon branch elimination and arborization. We confirm previous reports that these TNFR1 family members are individually capable of promoting ligand-dependent suppression of axon growth and branching. Remarkably, p75NTR and TNFR1 physically interact and p75NTR requires TNFR1 for ligand-dependent axon suppression of axon branching but not vice versa. We also find that p75NTR forward signaling and TNFα reverse signaling are functionally antagonistic. Finally, we find that TNFα reverse signaling is necessary for nerve growth factor (NGF) dependent axon growth. Taken together these findings demonstrate several levels of synergistic and antagonistic interactions using very few signaling pathways and that the balance of these synergizing and opposing signals act to ensure proper axon growth and patterning.

Degradation of Performance Due to Sleep Deprivation: A Field Test

During a 72 h field test, two groups of elite, “ranger type” soldiers were evaluted five times (during the first 8 h, after 30 h of continuous field duty, after a rest period, after 30 more h of continuous field duty, and after a second rest). One group (7 soldiers) received two rests of 3 h each. The second group (6 soldiers) received two rests of 6 h each. Five military tasks (map reading, decoding messages, vehicle/aircraft recognition, assembly and disassembly of the M-16 rifle, and preparation of an AN/PRC radio for operation) were used. These tasks were considered by the commander to be representative of duties that the soldiers would do and were considered to be completely familiar to the soldiers. In addition, a peg into pegboard task and a subjective evaluation of fatigue questionnaire were given.

There was no significant effect of time or difference between the two groups. The soldiers completed these tasks of short duration (less than 3 min) without decreasing performance—even after extended periods of sleep loss. These performance results occurred even though subjectively the soldiers reported they were tired.

Multiplexed genotyping using a novel digitally inscribed bead-based system

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Background: Genotyping of clinical samples has been limited to low levels of multiplexing, ranging from one to a few dozen single nucleotide polymorphisms (SNPs) per sample. By increasing multiplexing levels, a clinical lab can increase information content per sample, decreasing costs and sample material requirements. Methods: We have adapted the GoldenGate® Assay for simultaneously genotyping 96 to 1,536 SNPs to the BeadXpress™ System, a new high-throughput platform that utilizes digitally inscribed VeraCode™ beads in a compact fluidic instrument. Genotyping on this platform ranges from 96 to 384 multiplexing, using the same GoldenGate Assay that has proven highly robust for millions of genotypes. In preliminary tests, we have observed greater than 99% call rates, and greater than 99.5% rates for reproducibility and heritability. In a test of 96 SNP genotypes chosen for a study of colorectal cancer, a point mutation in the MSH2 gene, previously implicated in predisposition to several cancers, was correctly genotyped when compared to qPCR analysis of the same samples. Conclusion: Together with genotyping data from reference samples, the GoldenGate Assay on the BeadXpress System has yielded highly reproducible and accurate genotypes, suggesting that this approach will prove useful for rapid refinement of SNPs for development of clinical genotyping tests.

No significant financial relationships to disclose.

IR Spectroscopy of M+(Acetone) Complexes (M = Mg, Al, Ca): Cation−Carbonyl Binding Interactions

M(+)(acetone) ion-molecule complexes (M = Mg, Al, Ca) are produced in a pulsed molecular beam by laser vaporization and studied with infrared photodissociation spectroscopy in the carbonyl stretch region. All of the spectra exhibit carbonyl stretches that are shifted significantly to lower frequencies than the free-molecule value, consistent with metal cation binding on the oxygen of the carbonyl. Density functional theory is employed to elucidate the shifts and patterns in these spectra. Doublet features are measured for the carbonyl region of Mg(+) and Ca(+) complexes, and these are assigned to Fermi resonances between the symmetric carbonyl stretch and the overtone of the symmetric carbon stretch. The carbonyl stretch red shift is greater for Al(+) than it is for the Mg(+) and Ca(+) complexes. This is attributed to the smaller size of the closed-shell Al(+), which enhances its ability to polarize the carbonyl electrons. Density functional theory correctly predicts the direction of the carbonyl stretch shift and the relative trend for the three metals.

Counseling services at the University of California, Davis: helping medical students cope

Our on-site counseling for medical students at UCD School of Medicine has provided easily accessible services by psychologists who understand the rules, values, and traditions of the medical training experience. We also have had the benefit of a close working relationship with the faculty, staff, and administration of the School of Medicine. Counseling can facilitate exploration of personal issues that have been exposed during medical training, and it offers medical students an opportunity to learn new coping skills and enhance their understanding of themselves and their training environment, which in turn contributes to their professional growth. On-site psychological services also provide faculty and staff with a referral resource when they encounter students who present with specific psychological challenges and concerns. We encourage students who are experiencing the stress of their arduous training experience to seek counseling when their usual coping strategies are exhausted. We encourage other medical schools to provide effective, accessible counseling services to their students. These services will assist in the development of a training atmosphere in which students can learn that medical education involves their whole person.

Cognitive, psychosocial, and reported sexual behavior differences between pregnant and nonpregnant adolescents

A wide variety of variables have been related to the occurrence of adolescent pregnancy. However, many previous studies have produced conflicting results and are univariate in nature. The purpose of this study was to assess differences in pregnant and nonpregnant adolescents on variables from three domains: cognitive, psychosocial, and reported sexual behavior. Sixty-nine pregnant adolescents and 58 comparison adolescents filled out nine questionnaires presented on microcomputers. Significant differences were found on 10 of 24 univariate tests. The strongest differences concerned areas of scholastic functioning and reported sexual behavior; pregnant teenagers were more likely than nonpregnant peers to be doing poorly in school and less likely to use contraceptives. In addition, pregnant teenagers were more likely to have a relative or friend who was an adolescent mother and to expect child rearing to be easier than did the nonpregnant adolescents. A discriminant analysis was computed which correctly classified 83% of the sample, based on variables from each of the three domains. This study has served to replicate, refute, and expand on previous findings concerning the antecedents of teenage pregnancy. More importantly, this study has empirically demonstrated the multivariate and interrelated nature of variables associated with teenage pregnancy.

Contrast enhancement of light emitting diode displays

This paper describes a technique for calculating the resultant contrast of displays incorporating various filters or filter combinations. In particular, contrast of such displays employing red or green light emitting diodes (LED's) as the active elements is tabulated. The results indicate that adequate contrast enhancement of red LED's in high light level environments is usually achieved using neutral density or bandpass filters with antireflective coatings. Green LED'S must be designed to have a high degree of specular reflectance so that a circular polarizer may be employed in order to achieve similar results. A discussion of required filter bandwidth to accommodate shifts in peak spectral output of LED'S due to manufacturer's tolerances and temperature effects is also included.