Efficacy of medication abortion with concurrent initiation of progestin contraceptives: a retrospective cohort study.

OBJECTIVES: To evaluate medication abortion (MAB) outcomes for participants receiving intramuscular depot medroxyprogesterone acetate (DMPA) injections or subdermal etonogestrel implants concurrently with mifepristone compared to those who did not in a real-world setting. STUDY DESIGN: This retrospective cohort study included MAB patients from one Planned Parenthood health center in St. Paul, MN, between 2017-2019. We abstracted electronic health records and compared sociodemographic variables, clinical information, and treatment failure rates (primary outcome) between study groups with logistic regression (generating odds ratios [OR] and 95% confidence intervals [CI]). RESULTS: Among 7296 MAB participants, 224 (3.1%) received DMPA injections and 309 (4.2%) received etonogestrel implants concurrently with mifepristone; 141 (62.9%) and 200 (64.7%) completed follow-up respectively. From a random sample of 1000, 990 comparison participants met inclusion criteria; 704 (71.1%) completed follow-up. Fourteen (9.9%) DMPA participants (aOR 4.26, 95% CI 1.87-9.68, p<0.001) and 6 (3.0%) etonogestrel implant participants (aOR 1.38, 95% CI 0.48-3.55, p=0.522) required additional treatment to empty the uterus and/or had an ongoing pregnancy, each contrasted with 15 (2.1%) comparison patients (models adjusted for gestational duration, patient age, parity, and race). CONCLUSION: Although our study is limited by high rates of loss to follow-up, our analysis suggests that concurrent administration of DMPA with mifepristone may decrease MAB efficacy, while etonogestrel implant placement does not appear to alter MAB outcomes. These findings are overall consistent with prior literature and inform post-MAB contraception counseling. IMPLICATIONS: This retrospective cohort study reinforces prior randomized controlled trial findings that concurrent depot medroxyprogesterone acetate injection with mifepristone administration may decrease medication abortion efficacy. Conversely, concurrent etonogestrel contraceptive implant placement with mifepristone administration does not appear to decrease medication abortion efficacy. These findings inform post-abortion contraception counseling.

Development of a Semiautomated Search Tool to Identify Grading From Pathology Reports for Tumors of the CNS and Prostate Cancers.

PURPOSE: This study demonstrates the functionality of semiautomated algorithms to classify cancer-specific grading from electronic pathology reports generated from military treatment facilities. Two Perl-based algorithms are validated to classify WHO grade for tumors of the CNS and Gleason grades for prostate cancer. METHODS: Case-finding cohorts were developed using diagnostic codes and matched by unique identifiers to obtain pathology records generated in the Military Health System for active duty service members from 2013 to 2018. Perl-based algorithms were applied to classify document-based pathology reports to identify malignant CNS tumors and prostate cancer, followed by a hand-review process to determine accuracy of the algorithm classifications. Inter-rater reliability, sensitivity, specificity, positive predictive values (PPVs), and negative predictive values were computed following abstractor adjudication. RESULTS: The high PPV for the Perl-based algorithms to classify CNS tumors (PPV > 98%) and prostate cancer (PPV > 99%) supports this approach to classify malignancies for cancer surveillance operations, mediated by a hand-reviewed semiautomated process to increase sensitivity by capturing ungraded cancers. Early detection was pronounced where 33.6% and 50.7% of malignant records retained a CNS WHO grade of II or a Gleason score of 6, respectively. Sensitivity metrics met criteria (> 75%) for brain (79.9%, 95% CI, 73.0 to 85.7) and prostate (96.7%, 95% CI, 94.9 to 98.0) cancers. CONCLUSION: Semiautomated, document-based text classification using Perl coding successfully leveraged identification of WHO and Gleason grades to classify pathology records for CNS tumors and prostate cancer. The process is recommended for data quality initiatives to support cancer reporting functions, epidemiology, and research.

Development and Evaluation of Perl-Based Algorithms to Classify Neoplasms From Pathology Records in Synoptic Report Format.

PURPOSE: Synoptic reporting provides a mechanism for uniform and structured pathology diagnostics. This paper demonstrates the functionality of Perl alternation and grouping expressions to classify electronic pathology reports generated from military treatment facilities. Eight Perl-based algorithms are validated to classify malignant melanoma, Hodgkin lymphoma, non-Hodgkin lymphoma, leukemia, and malignant neoplasms of the breast, ovary, testis, and thyroid. METHODS: Case finding cohorts were developed using diagnostic codes for neoplasm groups and matched by unique identifiers to obtain pathology records. Preprocessing techniques and Perl-based algorithms were applied to classify records as malignant, in situ, suspect, or nonapplicable, followed by a hand-review process to determine the accuracy of the algorithm classifications. Interrater reliability, sensitivity, specificity, positive predictive values, and negative predictive values were computed following abstractor adjudication. RESULTS: The specificity of the Perl-based algorithms was consistently high, over 98%. Very few benign results were classified as malignant or in situ by the Perl-based algorithms; the leukemia algorithm classification was the only group to demonstrate a positive predictive value below 95%, at 91.9%. Three algorithm classification groups demonstrated a sensitivity of < 80%, including malignant neoplasm of the ovary (33.3%), leukemia (52.8%), and non-Hodgkin lymphoma (62.9%). The pathology records for these results included substantial linguistic variation. CONCLUSION: This paper contextualizes the utility and value of an algorithm logic built around synoptic reporting to identify neoplasms from electronic pathology results. The major strength includes the application of Perl-based coding in SAS, an accessible software application, to develop highly specific algorithms across institutional variation in diagnostic documentation.

Cardiothoracic Surgical Volume Within the Military Health System: Fiscal Years 2007 to 2017.

BACKGROUND: Cardiothoracic surgical services have been provided at 7 military treatment facilities over the past decade. Accurate case volume data for adult cardiac and general thoracic surgical service lines in the Military Health System is unknown. METHODS: We queried the Military Health System Data Repository for adult cardiac and general thoracic cases performed at military treatment facilities in the Military Health System and surrounding purchased care markets for fiscal years 2007 to 2017. Cases were filtered and classified into major cardiac and major general thoracic categories. Five military treatment facility markets had sufficient cardiac case data to perform cost analysis. RESULTS: Institutional major cardiac case volume was low across the Military Health System with less than 100 cardiopulmonary bypass cases per year (range, 17-151 cases per year) performed most years at each military treatment facility. Similarly, general thoracic surgical case volume was universally low, with less than 30 anatomic lung resections (range, 0-26) and fewer than 5 esophageal resections (range, 0-4) performed at each military treatment facility annually. Cost analysis revealed that provision of cardiac surgical services is significantly more expensive at most military treatment facilities compared with their surrounding purchased care markets. CONCLUSIONS: Adult cardiac and general thoracic surgical volume within the Military Health System is low across all institutions and inadequate to provide clinical readiness for active-duty surgeons. Recapture of major cases from the purchased care market is unlikely and would not significantly increase military treatment facility or individual surgeon case volume.

Universal Healthcare Coverage Does Not Ensure Adherence to Initial Colorectal Cancer Screening Guidelines.

INTRODUCTION: Colorectal cancer is the second leading cause of cancer deaths in the USA, and screening tests are underutilized. The aim of this study was to determine the proportion of individuals at average risk who utilized a recommended initial screening test in a universal healthcare coverage system. MATERIALS AND METHODS: This is a retrospective cohort study of active duty and retired military members as well as civilian beneficiaries of the Military Health System. Individuals born from 1960 to 1962 and eligible for full benefits on their 50th birthday were evaluated. Military rank or rank of benefits sponsor was used to determine socioeconomic status. Adherence to the U.S. Preventive Services Task Force guidelines for initial colorectal cancer screening was determined using "Current Procedural Terminology" and "Healthcare Common Procedure Coding System" codes for colonoscopy, sigmoidoscopy, fecal occult blood test, and fecal immunohistochemistry test. Average risk individuals who obtained early screening ages 47 to 49 were also identified. RESULTS: This study identified 275,665 individuals at average risk. Of these, 105,957 (38.4%) adhered to screening guidelines. An additional 19,806 (7.2%) individuals were screened early. Colonoscopy (82.7%) was the most common screening procedure. Highest odds of screening were associated with being active duty military (odds ratio [OR] 3.63, 95% confidence interval [CI] 3.43 to 3.85), having highest socioeconomic status (OR 2.37, 95% CI 2.31 to 2.44), and having managed care insurance (OR 4.36, 95% CI 4.28 to 4.44). CONCLUSIONS: Universal healthcare coverage does not ensure initial colorectal cancer screening utilization consistent with guidelines no does it eliminate disparities.

"Making It Work": A Preliminary Mixed Methods Study of Rural Trauma Care Access and Resources in New Mexico.

Introduction Patients in the rural western United States face challenges accessing trauma and surgical services and are more likely to succumb to their injuries. New Mexico, a rural and medically underresourced state, is a salient space to study these disparities. We examine how travel distance from trauma centers impacts injured patient outcomes and describe care delivery obstacles. Materials and Methods We conducted an explanatory mixed methods study by creating geospatial maps of New Mexico's trauma data, incorporating linear regression analyses on patient outcomes as a function of estimated travel distance from trauma centers. We also conducted qualitative semi-structured interviews with trauma providers to illuminate and provide context for the geospatial findings utilizing a systematic, collaborative, iterative transcript analysis process. We constructed a conceptual framework describing rural trauma care delivery obstacles. Results Geospatial analyses revealed that most New Mexicans face long travel times to trauma centers. Comparing regression analyses using different data sources suggests that solely hospital-derived data may undercount rural trauma deaths. Interviews with 10 providers suggest that elements that may contribute to these findings include on-the-ground resource-based challenges and those related to broader healthcare systems-based issues. Our conceptual framework denotes how these elements collectively may impact rural trauma outcomes and proposes potential solutions. Conclusions In addressing rural patients' needs, healthcare policy decision-makers should ensure that their datasets are comprehensive and inclusive. They must also take into account the particular challenges of underserved rural patients and providers who care for them by eliciting their perspectives, as presented in our conceptual framework.

Medical Student Values Inform Career Plans in Service & Surgery-A Qualitative Focus Group Analysis.

BACKGROUND: Diversifying the surgical workforce is a critical component of improving care for underserved patients. To recruit surgeons from diverse backgrounds, we must understand how medical students choose their specialty. We investigate how preclinical students contemplate entering a surgical field. MATERIALS AND METHODS: We conducted semistructured focus groups during two iterations of a seminar class called Service Through Surgery. Discussion goals included identifying student values and assessing how they inform early career decisions. We used a systematic, collaborative, and iterative process for transcript analysis, including developing a codebook, assessing inter-rater reliability, and analyzing themes. RESULTS: Twenty-four preclinical medical students from diverse backgrounds participated in seven focus groups; most were women (16; 67%), in their first year of medical school (19; 79%), and interested in surgery (17; 71%). Participants ranked professional fulfillment, spending time with family, and serving their communities and/or underserved populations among their most important values and agreed that conducting groundbreaking research, working long hours, and finding time for leisure activities were the least important. We constructed a framework to describe student responses surrounding their diverse visions for service in future surgical careers through individual doctoring interactions, roles in academia, and broader public service. CONCLUSIONS: Our framework provides a basis for greater understanding and study of the ways in which preclinical medical students think about their personal values and visions for service in potential future surgical careers. This research can guide early interventions in medical education to promote diversity and care for the underserved in surgery.

Blood lead level surveillance among pediatric beneficiaries in the Military Health System, 2010-2017.

The EpiData Center (EDC) has provided routine blood lead level (BLL) surveillance for Department of Defense (DoD) pediatric beneficiaries since 2011. Data for this study were collected and compiled from raw laboratory test records obtained from the Composite Health Care System Health Level 7 (HL7)-formatted chemistry data, allowing an overview of the number of tests performed and the number of elevated results. Between 2010 and 2017, there were 177,061 tests performed among 162,238 pediatric beneficiaries tested. Using only the highest test result per year for each individual, 169,917 tests were retained for analysis, of which 1,334 (0.79%) test results were considered elevated. The percentage of children with elevated BLLs generally decreased over the time period for children of every service affiliation. All tests throughout this time frame were evaluated using current standards and the protocol followed by the Centers for Disease Control and Prevention and the Department of the Navy (DON). The adoption of a standardized BLL surveillance methodology across the DoD supports a cohesive approach to an evolving public health surveillance topic.

Service through surgery: A quasi-experimental comparison study on the impact of a preclinical seminar course on diverse mentorship and attitudes towards the underserved.

BACKGROUND: Increased surgical workforce diversity diminishes health disparities. METHODS: Researchers recruited and nonrandomly enrolled participants into intervention and comparison groups for a quasi-experimental study of the impact of a seminar course on student exposure to diverse mentorship and service through surgery. All metrics were analyzed with chi-squared and paired t-tests. RESULTS: 109 students participated (34 intervention, 75 comparison). There were significant differences in the percentage of participants that newly met a surgeon of their race (intervention, comparison: 100%, 25%), their race and gender (80%, 21%), their religion (23%, 9%), and who completed health disparities research (90%, 45%, p-value for all <0.05). There was a nonsignificant change in participants' attitudes towards underserved populations in intervention and comparison groups. CONCLUSIONS: This preclinical surgery seminar course increased exposure of underrepresented students to surgeons from diverse backgrounds and may impact student attitudes towards the underserved. This class represents a replicable model for increasing mentorship.

Anorexia nervosa in identical triplets.

The cause of anorexia nervosa (AN) is unclear, but is likely multifactorial, including psychological, familial, environmental, societal, genetic, and other biological factors. This case report of identical 12-year-old female triplets simultaneously concordant for AN illustrates the importance of addressing all these components in evaluation and treatment, and the difficulty of determining the relative importance of each factor in the cause of an individual's eating disorder. An overly close relationship and competitiveness between the girls, treated at times as a triplet group rather than as individuals, as well as stressful family dynamics, were probably important antecedents to the girls' AN. The girls encouraged each other and competed to lose weight. Brief individual and family psychotherapy, parent counseling, nutritional counseling, and psychoeducation led to successful treatment. The triplets were encouraged in treatment to compete with and encourage each other to obtain treatment goals, including eating more healthily and achieving healthy weights. A literature review of AN twins studies is also presented, as these studies add to our understanding of the relative importance of shared genes and shared environment in the development of AN. These studies also add insight into treating individuals from families with multiple affected relatives.