Elective Joint Replacement Among Medicaid Beneficiaries: Utilization and Postoperative Adverse Events by Racial and Ethnic Groups.

Hip and knee replacement have been marked by racial and ethnic disparities in both utilization and postoperative adverse events among Medicare beneficiaries, but limited knowledge exists regarding racial and ethnic differences in joint replacement care among Medicaid beneficiaries. To close this gap, this study used Medicaid claims in 2018 and described racial and ethnic differences in the utilization and postoperative adverse events of elective joint replacements among Medicaid beneficiaries. Among the 2,260,272 Medicaid beneficiaries, 5987 had an elective joint replacement in 2018. Asian (0.05%, 95% confidence interval [CI]: 0.03%-0.07%) and Hispanic beneficiaries (0.12%, 95% CI: 0.07%-0.18%) received joint replacements less frequently than American Indian and Alaska Native (0.41%, 95% CI: 0.27%-0.55%), Black (0.33%, 95% CI: 0.19%-0.48%), and White (0.37%, 95% CI: 0.25%-0.50%) beneficiaries. Black patients demonstrated the highest probability of 90-day emergency department visits (34.8%, 95% CI: 32.7%-37.0%) among all racial and ethnic groups and a higher probability of 90-day readmission (8.0%, 95% CI: 6.9%-9.0%) than Asian (3.4%, 95% CI: 0.7%-6.0%) and Hispanic patients (4.4%, 95% CI: 3.4%-5.3%). These findings indicate evident disparities in postoperative adverse events across racial and ethnic groups, with Black patients demonstrating the highest probability of 90-day emergency department visits. This study represents an initial exploration of the racial and ethnic differences in joint replacement care among Medicaid beneficiaries and lay the groundwork for further investigation into contributing factors of the observed disparities.

Association between Weight for Length and the Severity of Respiratory Morbidity in Preterm Infants.

Association Between Weight for Length and the Severity of Respiratory Morbidity in Preterm Infants. OBJECTIVE: To determine whether higher weight-to-length z-scores after 32 weeks of gestation are associated with higher pulmonary scores (PSs) in preterm infants requiring respiratory support using a prospective observational study. METHODS: Infants born at <30 weeks, with a post-menstrual age (PMA) of 30-33 weeks, were enrolled. The infant's weight, length, and head circumference were measured weekly. Data on calories/kg/d, protein g/kg/d, weight-for-length percentiles, z-scores, and BMI at 33 through 40 weeks PMA were collected. The PS was calculated. RESULTS: We analyzed 91 infants. The mean gestational age was 26.9 ± 1.7 weeks. The mean birthweight was 0.898 ± 0.238 kgs. They were predominantly African American (81.3%) and girls (56%). Postnatal steroids were administered in 26.4% of the infants. The mean duration of invasive ventilation was 19.23 days ± 28.30 days. There was a significant association between the PS and W/L z-score (p < 0.0001). For every one-unit increase in W/L z-score, the PS increased by 0.063. There was a significant association between the PS and W/L percentile (p = 0.0017), as well as BMI (p ≤ 0.0001). For every unit increase in W/L percentile, the PS increased by 0.002, and for a unit increase in BMI, the PS increased by 0.04. The association remained significant after postnatal steroid use, sex, and corrected and birth gestational ages were included in the regression analysis. Nutrition did not affect the anthropometric measurements. CONCLUSIONS: Our study is the first to demonstrate that a higher BMI and W/L may adversely affect the respiratory severity in preterm infants. Studies with larger sample sizes are needed to confirm our findings.

State- and County-Level Geographic Variation in Opioid Use Disorder, Medication Treatment, and Opioid-Related Overdose Among Medicaid Enrollees.

Importance: The opioid crisis disproportionately affects Medicaid enrollees, yet little systematic evidence exists regarding how prevalence of and health care utilization for opioid use disorder (OUD) vary across geographical areas. Objectives: To characterize state- and county-level variation in claims-based prevalence of OUD and rates of medication treatment for OUD and OUD-related nonfatal overdose among Medicaid enrollees. Design, Setting, and Participants: This cross-sectional study used data from the Transformed Medicaid Statistical Information System Analytic Files from January 1, 2016, to December 31, 2018. Participants were Medicaid enrollees with or without OUD in 46 states; Washington, DC; and Puerto Rico who were aged 18 to 64 years and not dually enrolled in Medicare. The analysis was conducted between September 2022 and April 2023. Exposure: Calendar-year OUD prevalence. Main Outcomes and Measures: The main outcomes were claims-based measures of OUD prevalence and rates of medication treatment for OUD and opioid-related nonfatal overdose. Individual records were aggregated at the state and county level, and variation was assessed within and across states. Results: Of the 76 390 817 Medicaid enrollee-year observations included in our study (mean [SD] enrollee age, 36.5 [1.6] years; 59.0% female), 2 280 272 (3.0%) had a claims-based OUD (mean [SD] age, 38.9 [3.6] years; 51.4% female). Of enrollees with OUD, 41.2% were eligible due to Medicaid expansion, 46.4% had other substance use disorders, 55.8% had mental health conditions, 55.2% had claims indicating some form of OUD medication, and 5.8% had claims indicating an overdose during a calendar year. Claims-based outcomes exhibited substantial variation across states: OUD prevalence ranged from 0.6% in Arkansas and Puerto Rico to 9.7% in Maryland, rates of OUD medication treatment ranged from 17.7% in Kansas to 82.8% in Maine, and rates of overdose ranged from 0.3% in Mississippi to 10.5% in Illinois. Pronounced variation was also found within states (eg, OUD prevalence in Maryland ranged from 2.2% in Prince George's County to 21.6% in Cecil County). Conclusions and Relevance: In this cross-sectional study of Medicaid enrollees from 2016 to 2018, claims-based prevalence of OUD and rates of OUD medication treatment and opioid-related overdose varied substantially across and within states. Further research appears to be needed to identify important factors influencing this variation.

Transretroperitoneal Pedicled Omental Flap for Coverage of Traumatic Sacral Defect: A Case Report.

The greater omentum is a reliable choice for salvage soft-tissue reconstruction. Benefits include consistent anatomy, long pedicle length, and a high concentration of lymphatic tissue that is resistant to infection. We report the case of a 46-year-old man with a complex traumatic sacral wound resulting in severe limitation of reconstructive options. A pedicled greater omentum flap was transposed through the retroperitoneum via the lumbosacral triangle, resulting in durable soft-tissue coverage.

The Spillover Effect of the Medicare Mandatory Bundled Payment Program on Joint Replacement Outcomes: Analysis of Patients with Commercial Insurance and Medicare Advantage.

BACKGROUND: To improve the value and efficiency of care among traditional Medicare enrollees, the Centers for Medicare & Medicaid Services has implemented alternative payment models designed to control health-care spending and improve quality. These models may affect care beyond traditional Medicare enrollees, "spilling over" into other populations. Established in April 2016, the Medicare mandatory bundled payment program, called the Comprehensive Care for Joint Replacement (CJR) model, holds hospitals accountable for spending and quality of care for traditional Medicare joint-replacement patients during care episodes that span from the index hospitalization to 90 days post-discharge. We assessed the extent to which the CJR model was associated with outcomes for patients enrolled in commercial insurance and Medicare Advantage plans. METHODS: With use of Health Care Cost Institute claims data from 2012 through 2017, we assessed the association of the CJR model with total expenditures, discharges to institutional post-acute care, and readmissions among commercial insurance and Medicare Advantage joint-replacement patients. The exposure variable was the implementation of the CJR model in 67 randomly selected metropolitan statistical areas compared with 103 similar areas without CJR implementation. We utilized difference-in-differences models to estimate the spillover effects of the CJR model by comparing outcomes between these areas before and after CJR implementation. RESULTS: The study included 174,893 joint-replacement episodes of care in commercial insurance enrollees and 202,070 episodes in Medicare Advantage enrollees. Among both commercial insurance and Medicare Advantage enrollees, CJR implementation was associated with no meaningful changes in total episode expenditures, discharges to institutional post-acute care, or readmissions. CONCLUSIONS: We found no evidence for spillover effects of the CJR model on commercial insurance and Medicare Advantage patients, suggesting that alternative payment models targeting traditional Medicare patients may have limited effects on the cost and quality of care for patients outside of the traditional Medicare system.

Renal vein injuries: a 10-year, single institution experience with a rare injury following blunt abdominal trauma.

PURPOSE: To determine the incidence, injury type, injury associations, and management of patients with renal vein injuries following trauma. METHODS: This is a 10-year single-center retrospective observational study of patients with renal vein injuries identified on admission abdominopelvic CT following trauma. Our institutional trauma registry and radiology information system (RIS) was used to identify patients with renal vein injuries. The medical records and imaging exams were reviewed to determine venous injury type, associated injuries, management, and outcomes. RESULTS: Fifteen (15) patients with renal vein injuries (N = 9 right side) were identified out of 36,077 trauma evaluations, for an overall incidence of 0.042%. Eight (53.3%) were male with a mean age of 36.3 years (range 9-67 years) and a mean Injury Severity Score (ISS) of 32 (range 13-57). The most common imaging findings were pseudoaneurysm formation with or without intimal injury and intraluminal thrombus seen in 86.7% of the cohort. Twelve patients (80.0%) had other acute traumatic renal findings, most commonly an ipsilateral grade 4 or higher renal injury. Angiography was performed in 6 patients (40.0%), however no patients received renal vein specific endovascular evaluation, endovascular treatment, or surgical treatment of their renal vein injuries. Three patients were treated with long-term anticoagulation, of which one received an IVC filter. There were no known renal vein injury specific mortalities. CONCLUSIONS: Renal vein injuries are an extremely rare entity but can be detected on admission CT. The most common injury patterns include an intimal injury with intraluminal thrombus and pseudoaneurysm in combination with an intimal injury and intraluminal thrombus. Conservative, nonoperative management was successfully employed in all cases with no renal vein specific mortalities.

Predicting vaginal birth after previous cesarean: Using machine-learning models and a population-based cohort in Sweden.

INTRODUCTION: Predicting a woman's probability of vaginal birth after cesarean could facilitate the antenatal decision-making process. Having a previous vaginal birth strongly predicts vaginal birth after cesarean. Delivery outcome in women with only a cesarean delivery is more unpredictable. Therefore, to better predict vaginal birth in women with only one prior cesarean delivery and no vaginal deliveries would greatly benefit clinical practice and fill a key evidence gap in research. Our aim was to predict vaginal birth in women with one prior cesarean and no vaginal deliveries using machine-learning methods, and compare with a US prediction model and its further developed model for a Swedish setting. MATERIAL AND METHODS: A population-based cohort study with a cohort of 3116 women with only one prior birth, a cesarean, and a subsequent trial of labor during 2008-2014 in the Stockholm-Gotland region, Sweden. Three machine-learning methods (conditional inference tree, conditional random forest and lasso binary regression) were used to predict vaginal birth after cesarean among women with one previous birth. Performance of the new models was compared with two existing models developed by Grobman et al (USA) and Fagerberg et al (Sweden). Our main outcome measures were area under the receiver-operating curve (AUROC), overall accuracy, sensitivity and specificity of prediction of vaginal birth after previous cesarean delivery. RESULTS: The AUROC ranged from 0.61 to 0.69 for all models, sensitivity was above 91% and specificity below 22%. The majority of women with an unplanned repeat cesarean had a predicted probability of vaginal birth after cesarean >60%. CONCLUSIONS: Both classical regression models and machine-learning models had a high sensitivity in predicting vaginal birth after cesarean in women without a previous vaginal delivery. The majority of women with an unplanned repeat cesarean delivery were predicted to succeed with a vaginal birth (ie specificity was low). Additional covariates combined with machine-learning techniques did not outperform classical regression models in this study.

Kidney Histopathology and Prediction of Kidney Failure: A Retrospective Cohort Study.

RATIONALE & OBJECTIVE: The use of kidney histopathology for predicting kidney failure is not established. We hypothesized that the use of histopathologic features of kidney biopsy specimens would improve prediction of clinical outcomes made using demographic and clinical variables alone. STUDY DESIGN: Retrospective cohort study and development of a clinical prediction model. SETTING & PARTICIPANTS: All 2,720 individuals from the Biopsy Biobank Cohort of Indiana who underwent kidney biopsy between 2002 and 2015 and had at least 2 years of follow-up. NEW PREDICTORS & ESTABLISHED PREDICTORS: Demographic variables, comorbid conditions, baseline clinical characteristics, and histopathologic features. OUTCOMES: Time to kidney failure, defined as sustained estimated glomerular filtration rate ≤ 10mL/min/1.73m2. ANALYTICAL APPROACH: Multivariable Cox regression model with internal validation by bootstrapping. Models including clinical and demographic variables were fit with the addition of histopathologic features. To assess the impact of adding a histopathology variable, the amount of variance explained (r2) and the C index were calculated. The impact on prediction was assessed by calculating the net reclassification index for each histopathologic variable and for all combined. RESULTS: Median follow-up was 3.1 years. Within 5 years of biopsy, 411 (15.1%) patients developed kidney failure. Multivariable analyses including demographic and clinical variables revealed that severe glomerular obsolescence (adjusted HR, 2.03; 95% CI, 1.51-2.03), severe interstitial fibrosis and tubular atrophy (adjusted HR, 1.99; 95% CI, 1.52-2.59), and severe arteriolar hyalinosis (adjusted HR, 1.53; 95% CI, 1.14-2.05) were independently associated with the primary outcome. The addition of all histopathologic variables to the clinical model yielded a net reclassification index for kidney failure of 5.1% (P < 0.001) with a full model C statistic of 0.915. Analyses addressing the competing risk for death, optimism, or shrinkage did not significantly change the results. LIMITATIONS: Selection bias from the use of clinically indicated biopsies and exclusion of patients with less than 2 years of follow-up, as well as reliance on surrogate indicators of kidney failure onset. CONCLUSIONS: A model incorporating histopathologic features from kidney biopsy specimens improved prediction of kidney failure and may be valuable clinically. Future studies will be needed to understand whether even more detailed characterization of kidney tissue may further improve prognostication about the future trajectory of estimated glomerular filtration rate.

Calorie intake is associated with weight gain during transition phase of nutrition in female extremely low birth weight infants.

We sought to determine whether there are sex-based differences in the requirements for calories or protein for optimal growth during the transition phase (TP) when an extremely low birth weight (ELBW) infant, defined as a preterm infant with a birth weight of < 1000 g, is progressing from parenteral to enteral feeds. A retrospective review of ELBW infants born from 2014 to 2016 was performed at a tertiary NICU. Infants with necrotizing enterocolitis, short bowel syndrome, or chromosomal anomalies were excluded. TP was defined as the period when the infant's enteral feeds were increased from 30 up to 120 ml/kg/day while weaning parenteral nutrition (PN). Effects of sex and protein-calorie intake on the change in growth parameters from the beginning to the end of TP were analyzed. Pre-TP growth percentiles and calorie and protein intake were similar in both sexes. There was a significant (r = 0.22, p = 0.026) correlation of total calorie intake with a change in weight percentiles (wt.pc) for the whole group, but on sex-specific analysis, this correlation was more robust and significant only in girls (r = 0.28, p = 0.015). Protein intake did not correlate with the changes in wt.pc in either sex. Despite a similar intake of calories and protein during the TP, we found a significant decrease in wt.pc only in girls. More extensive studies are needed to understand the sex-based differences in caloric needs and metabolic rate in ELBW infants.

Bibliometric and authorship trends over a 30 year publication history in two representative US sports medicine journals.

Bibliometric studies are important to understand changes and improvement opportunities in academia. This study compared bibliometric trends for two major sports medicine/arthroscopy journals, the American Journal of Sports Medicine® (AJSM®) and Arthroscopy® over the past 30 years. Trends over time and comparisons between both journals were noted for common bibliometric variables (number of authors, references, pages, citations, and corresponding author position) as well as author gender and continental origin. Appropriate statistical analyses were performed. A p < 0.001 was considered statistically significant. One representative year per decade was used. There were 814 manuscripts from AJSM® and 650 from Arthroscopy®. For AJSM® the number of manuscripts steadily increased from 86 in 1986 to 350 in 2016; for Arthroscopy® the number of manuscripts increased from 73 in 1985/1986, to 267 in 2006, but then dropped to 229 in 2016. There were significant increases in all bibliometric variables, except for the number of citations which decreased in Arthroscopy®. There were significant differences in manuscript region of origin by journal (p = 0.000002). Arthroscopy® had a greater percentage of manuscripts from Asia than AJSM® (19.3% vs 11.5%) while AJSM® had a greater percentage from North America (70.3% vs 59.2%); both journals had similar percentages from Europe (18.2% for AJSM® and 21.6% for Arthroscopy®). For AJSM® the average percentage of female first authors was 13.3%, increasing from 4.7% in 1986 to 19.3% in 2016; the average percentage of female corresponding authors was 7.3%. For Arthroscopy®, the average percentage of female first authors was 8.1%, increasing from 2.8% in 1985/1986 to 15.7% in 2016 (p = 0.00007). In conclusion, AJSM® and Arthroscopy® showed an increase in most variables analyzed. Although Arthroscopy® is climbing at a higher rate than AJSM® for female authors, AJSM® has an overall greater percentage of female authors.

Surgical Management of Pelvic Organ Prolapse in Ethiopian Women: What Is the Preferred Approach?

OBJECTIVES: The aim of this study was to determine the most effective approach to surgical repair of pelvic organ prolapse for Ethiopian women and to characterize this population. METHODS: This is a prospective cohort study of women presenting for prolapse repair. Demographics and assessments of prolapse were obtained preoperatively. Information surrounding the surgical encounter was collected. The same anatomic and symptomatic measures were ascertained postoperatively. Information regarding surgical complications was collected. RESULTS: Two hundred thirty-three women with stage III or IV prolapse underwent surgical prolapse repair between March 2015 and November 2017. Seventy-eight of these women participated with a median length of follow-up of 255 days. All of the sacrocolpopexy patients (n = 21) and 56 of 57 vaginal repair patients had follow-up anatomic data. Anatomic failure as defined by Pelvic Organ Prolapse-Quantification (Ba, C, or Bp > 0) occurred in 0% (0/21) of sacrocolpopexy patients and 34% (19/56) of vaginal repair patients (P = 0.005). Symptomatic failure, as defined by self-reported recurrence of vaginal bulge, occurred in 0% (0/21) of sacrocolpopexy patients and 23% (13/56) of vaginal repair patients (P = 0.015). A global assessment of improvement (worse, same, or improved) revealed that 100% (21/21) of sacrocolpopexy patients reported improvement, whereas 91% (50/55) of vaginal repair patients reported improvement, 7% (4/55) reported being the same, and 2% (1/55) reported being worse. There were 2 intraoperative complications and 3 postoperative complications. There were no cases of mesh erosion. CONCLUSIONS: Although both vaginal and abdominal routes of prolapse surgery seem to be safe, an abdominal approach with mesh augmentation may be the preferred surgical repair in Ethiopian women.

Rapid actions of anti-Müllerian hormone in regulating synaptic transmission and long-term synaptic plasticity in the hippocampus.

Anti-Müllerian hormone (Amh) is a peptide factor that is known to regulate sexual differentiation and gonadal function in mammals. Although Amh is also suggested to be associated with cognitive development and function in the postnatal brain, little is known about its expression or direct effects on neuronal activities in the hippocampus. Therefore, we assessed Amh and its receptor expression in the hippocampus of male and female mice using PCR, Western blot, and immunofluorescence staining. While Amh-specific receptor expression was comparable between males and females, mRNA and protein levels of Amh were higher in females than those of males. Electrophysiological recordings on acute hippocampal slices showed that exogenous Amh protein addition increased synaptic transmission and long-term synaptic plasticity at the Cornu Ammonis (CA) 3-CA1 synapses. Amh exposure also increased the excitatory postsynaptic potential at CA1 synapses. Our findings support direct and rapid actions of Amh as a paracrine and/or autocrine factor in regulating hippocampal neuronal activities. Data provide functional evidence of Amh-mediated postsynaptic modulation of synaptic transmission and Amh-regulated long-term synaptic plasticity in the hippocampus. These results suggest a potential role of Amh in learning and memory, and a possible cause of the sex differences in cognitive development and function.

Intrauterine fluid instillation to confirm tubal occlusion after transcervical permanent contraception: A pilot study.

OBJECTIVES: To determine if women with tubal patency experience more fluid loss compared to those with bilateral tubal occlusion following intrauterine instillation of fluid via a balloon catheter. STUDY DESIGN: In this prospective cohort pilot study, we enrolled women with prior Essure® procedures and healthy controls from September 2016 to July 2017. We excluded women using an implant or intrauterine device, or with a prior cesarean delivery or permanent contraception procedures other than Essure®. An infusion pump delivered saline via balloon catheter under continuous pressure monitoring. After one minute, we withdrew the fluid and recorded volumes in and out. Subjects then underwent hysterosalpingogram for evaluation of tubal patency. We conducted crude analyses with t-tests and sensitivity analyses. RESULTS: We recruited 23 participants; ten provided analyzable data in each group. Hysterosalpingogram confirmed patency in all control and occlusion in all post-Essure® subjects in the analysis group. We found the median volume of saline lost among control subjects [7.8 mL (7.4, 8.4)] larger than post-Essure® participants [2.2 mL (2.0, 3.8), p < 0.01]. While 50% of control subjects tolerated the full 10 mL of fluid instillation, none of the post-Essure® subjects tolerated this volume (p = 0.03). A combination of saline loss ≤4 mL and participant intolerance of the full 10 mL volume yielded sensitivity of 0.80 (95% CI: 0.57, 1.00) and specificity of 1.00 for bilateral tubal occlusion. CONCLUSION: Instillation of a fixed volume into the uterus may discriminate between women with tubal patency and occlusion following permanent contraception procedures with high specificity and adequate sensitivity. These findings should be validated in larger, more diverse study populations. IMPLICATIONS: Confirmation of tubal occlusion following permanent contraception with an office-based approach could improve acceptability of transcervical approaches. The recent removal of Essure® from the U.S. market increases the need for novel transcervical procedures and occlusion verification methods.

Comparing cervical mucus changes in response to an oral progestin or oestrogen withdrawal in ovarian-suppressed women: a clinical pilot.

Purpose: Prior studies evaluating the effect of administered progestogens on peak cervical mucus have not controlled for the influence of endogenous hormones. To address this, we treated women with a gonadotropin-releasing hormone (GnRH) agonist to suppress the hypothalamus-pituitary-ovarian (HPO) axis and used transdermal oestradiol replacement to stimulate peak cervical mucus and then evaluated the effects of an oral progestin or oestradiol withdrawal. Materials and methods: We used a crossover design to examine cervical mucus changes in women receiving transdermal oestradiol replacement following intramuscular administration of leuprolide acetate. After increasing oestradiol patches to mid-cycle levels, subjects were assigned to either 0.35 mg oral norethindrone with continuation of the patches (NET) or oestradiol withdrawal by patch removal (E2WD). We collected serum and cervical mucus samples at 0, 2, 4, 6, 22 and 24 h following the intervention. Results: We analysed 12 cycles (6 NET, 6 E2WD) from three subjects. Baseline cervical mucus scores were favourable to sperm penetration [NET median 11, interquartile range (9-12), E2WD 13 (12-13)]. Two hours after removal of oestradiol patch or administration of norethindrone, cervical mucus scores declined [NET 8.5 (4-9), E2WD 10.5 (10-12)]. Low cervical mucus scores persisted at 24 h with NET [8.0 (7-8)] but not E2WD [10.5 (8-11)]. Conclusions: We observed a rapid decline in cervical mucus Insler scores following administration of a single dose of oral norethindrone, and scores remained lower and unfavourable through 24 h. Oestradiol withdrawal did not result in similar unfavourable changes.

Total body necrotizing fasciitis.

Necrotizing fasciitis is uncommon in the United States. Despite medical advances, its mortality rate has remained unchanged over the past 20 years at 25% to 35%. Risk scoring tools have been created but often fall short when used in the clinical setting. We present a case of an elderly woman with necrotizing fasciitis but with extensive intraparenchymal air that is undocumented in the literature. Imaging demonstrated significant air collections originating from an infection on the right foot that extended through the body, including the cranial vault. Despite aggressive resuscitative efforts, the patient was not considered a surgical candidate and ultimately died. Using a scoring tool for our patient suggested a low probability of infection, demonstrating that clinical suspicion should take precedence over any test or scoring system.

The role of environmental factors and lifestyle on male reproductive health, the epigenome, and resulting offspring.

Many environmental and genetic variables affect male reproductive health. Some of these factors, however, interfere not only with fertility, but also the non-genomic materials within spermatozoa that can cause phenotypic changes in the offspring, and in some cases, multiple generations. This intergenerational and transgenerational inheritance is due to epigenetic modifications, which is a complex adjunct to traditional Mendelian genetics whose influence on a wide range of human diseases is an active area of research. As the epigenome is a gestalt of individual exposures to the world, ongoing research is evaluating the scope of environmental impacts on the epigenome, as well as its mechanisms for adjusting the phenotypic expression of the organism without changing the code itself. Of particular interest is how these traits are passable to subsequent generations. This article will cover the latest data concerning how the overall quality of nutrition and lifestyle of an individual has been demonstrated to have a significant effect on male reproductive health, and how the accumulation of these modifications are risk factors for the health of their offspring.

Mindfulness-Based Group Cognitive Behavior Therapy for Provoked Localized Vulvodynia: A Randomized Controlled Trial.

OBJECTIVE: The aim of the study was to compare the effectiveness of mindfulness-based group cognitive behavior therapy (M-gCBT) versus education support group therapy for the pain and distress associated with provoked localized vulvodynia. MATERIALS AND METHODS: Participants were randomized to M-gCBT or education support group therapy. Mindfulness-based group cognitive behavior participants attended 8 weekly sessions. Education support group participants received 8 weeks of online education with 3 in-person group visits. Vaginal insertion pain (tampon test) was the primary outcome. Secondary outcomes (Generalized Anxiety Disorder 7, Beck's Depression Index, Female Sexual Distress Scale, Female Sexual Function Index, and Pain Catastrophizing) were administered before intervention and at the completion of the study period, 3 months, and 6 months. Sample size was based on the ideal number for group dynamics of 6 to 12 participants per group. RESULTS: Participants were enrolled from August 1, 2016, to January 30, 2017. Thirty-two participants were enrolled and 31 were randomized: 14 to M-gCBT and 17 to education support. Baseline characteristics did not differ significantly. Vaginal insertion pain decreased in both groups but was not statistically different between groups (difference of 1.23; 95% CI = -0.52 to 2.98). At 6 months, participants in the M-gCBT group showed statistically significant improvement in the Female Sexual Function Index, Generalized Anxiety Disorder 7, and Beck's Depression Index compared with the education support group. CONCLUSIONS: Mindfulness-based group cognitive behavior and education support group therapy are effective in reducing pain and distress. However, women in the M-gCBT program showed greater improvement in certain secondary outcomes, indicating that M-gCBT may offer some advantages in reducing distress associated with provoked localized vulvodynia.

Predictors for follow-up among postpartum patients enrolled in a clinical trial.

OBJECTIVE: To identify risk factors for failure to attend postpartum follow-up within 3 months of delivery, including social support, intrinsic motivation, insurance type and prenatal care attendance. STUDY DESIGN: This planned secondary analysis is derived from a randomized controlled trial of patients intending intrauterine device (IUD) use following their delivery (n=197). Subjects were postpartum from a vaginal or cesarean birth at ≥32 weeks' gestation. We obtained baseline demographics and certainty about their plan to receive a postpartum IUD. We administered validated scales for social support and intrinsic motivation at enrollment. We then reviewed health records for prenatal visits and any postpartum visit by 3 months and performed logistic regression to assess for predictors of follow-up. RESULTS: A total of 38/197 subjects (19.3%) failed to attend any postpartum visit by 3 months. Subjects who failed to follow up were more likely to have Medicaid versus private insurance (92% versus 8%, p<.01). Income <$50,000, no car, younger age, unplanned pregnancy, unemployment, multiple children, missed prenatal visits and late initiation of prenatal care were also associated with failure to follow up. Higher scores for social support and goal-directed motivation were not significantly associated with follow-up. CONCLUSIONS: In our cohort, we found that one in five participants did not attend a postpartum visit by 3 months. Several socioeconomic indicators are associated with loss to follow-up, most notably Medicaid insurance. Having high motivation and social support is not sufficient to predict successful follow-up. IMPLICATIONS: The main predictors for not attending a postpartum visit are Medicaid insurance or limited prenatal care, and not social support or intrinsic motivation. Interventions to improve postpartum contraception uptake should focus efforts on provision of immediate postpartum contraception for this population.

Modeling Amorphous Microporous Polymers for CO2 Capture and Separations.

This review concentrates on the advances of atomistic molecular simulations to design and evaluate amorphous microporous polymeric materials for CO2 capture and separations. A description of atomistic molecular simulations is provided, including simulation techniques, structural generation approaches, relaxation and equilibration methodologies, and considerations needed for validation of simulated samples. The review provides general guidelines and a comprehensive update of the recent literature (since 2007) to promote the acceleration of the discovery and screening of amorphous microporous polymers for CO2 capture and separation processes.

Ionic-Functionalized Polymers of Intrinsic Microporosity for Gas Separation Applications.

Ionic-functionalized microporous materials are attractive for energy-efficient gas adsorption and separation processes and have shown promising results in gas mixtures at pressure ranges and compositions that are relevant for industrial applications. In this work, we studied the influence of different counterions (Li+, Na+, K+, Rb+, and Mg2+) on the porosity, carbon dioxide (CO2) gas adsorption, and selectivity in ionic-functionalized PIM-1 (IonomIMs), a polymer belonging to the class of linear and amorphous microporous polymers known as polymers of intrinsic microporosity (PIMs). It was found that an increase in the concentration of ionic groups led to a decrease in the free volume, resulting in a less porous polymer framework, and Mg2+-functionalized IonomIMs exhibited a relatively larger porosity compared to other IonomIMs. The CO2 adsorption capacity was affected by the different counterions for IonomIM-1, and a higher loading capacity for pure CO2 was observed for Mg2+. Furthermore, the IonomIMs showed an enhanced CO2 selectivity in CO2/CH4 and CO2/N2 gas mixtures at conditions used in pressure swing adsorption and vacuum swing adsorption applications. It was also observed that the concentration of ionic groups plays a vital role in changing the CO2 gas adsorption and selectivity.