"I mean, I didn't really have a choice of anything:" How incarceration influences abortion decision-making and precludes access in the United States.

OBJECTIVE: To understand how the punitive, rights-limiting, and racially stratified environment of incarceration in the United States (US) shapes the abortion desires, access, and pregnancy experiences of pregnant women, transgender men, and gender non-binary individuals. METHODS: From May 2018-November 2020, we conducted semi-structured, qualitative interviews with pregnant women in prisons and jails in an abortion supportive and an abortion restrictive state. Interviews explored whether participants considered abortion for this pregnancy; attempted to obtain an abortion in custody; whether and how incarceration affected their thoughts about pregnancy, birth, parenting, and abortion; and options counseling and prenatal care experiences, or lack thereof, in custody. RESULTS: The conditions of incarceration deeply shaped our 39 participants' abortion and pregnancy decisions, with some experiencing pregnancy continuation as punishment. Four themes emerged: (1) medical providers' overt obstruction of desired abortions; (2) participants assuming that incarcerated women had no right to abortion; (3) carceral bureaucracy constraining abortion access; and (4) carceral conditions made women wish they had aborted. Themes were similar in supportive and restrictive states. CONCLUSIONS: Incarceration shaped participants' thoughts about pregnancy and their abilities to access abortion, consider whether abortion was an attainable option, and make pregnancy-related decisions. These subtle carceral control aspects presented more frequent barriers to abortion than overt logistical ones. The carceral environment played a more significant role than the state's overall abortion climate in shaping abortion experiences. Incarceration constrains and devalues reproductive wellbeing in punitive ways that are a microcosm of broader forces of reproductive control in US society.

A Retrospective Study of the Adjunctive Use of Gabapentin With Benzodiazepines for the Treatment of Benzodiazepine Withdrawal.

Benzodiazepine withdrawal is a widespread problem with potentially severe and deadly consequences. Currently, the only medications available for treating benzodiazepine withdrawal are short-acting and long-acting benzodiazepines. Identifying other drugs to help in treating benzodiazepine withdrawal is necessary. Gabapentin, an anxiolytic drug that is also used off-label to treat alcohol withdrawal, is a potential candidate for modulating benzodiazepine withdrawal. Using electronic records from a large inpatient psychiatric facility, a retrospective study of 172 patients presenting with benzodiazepine withdrawal was conducted to determine if the coincidental use of gabapentin for other medical conditions was associated with better outcomes of benzodiazepine withdrawal (N=57 gabapentin, N=115 no gabapentin). The primary outcomes were hospital length of stay and total amount of benzodiazepines given (lorazepam milligram equivalent). In this retrospective analysis of electronic medical record data, the patients experiencing benzodiazepine withdrawal who received gabapentin as an adjunct to the use of benzodiazepines were administered a smaller amount of benzodiazepines and had a shorter length of hospital stay relative to the comparison group who did not receive adjunctive gabapentin. These results suggest the potential use of gabapentin as an adjunct to the use of benzodiazepines for treating benzodiazepine withdrawal. The limitations of this study included a small sample size and variability in medication management strategies across the sample.

Efficacy of Thin and Ultrathin Descemet Stripping Automated Endothelial Keratoplasty and Influence of Graft Thickness on Postoperative Outcomes: Systematic Review and Meta-analysis.

PURPOSE: To conduct a systematic review and meta-analysis on the efficacy of thin and ultrathin Descemet stripping automated endothelial keratoplasty (T-DSAEK and UT-DSAEK, with graft thickness <130 and <100 µm, respectively), depending on graft thickness. DESIGN: Systematic review and meta-analysis. METHOD: PubMed, Cochrane Library, Embase, ClinicalTrials.gov, and ScienceDirect databases were searched until October 1, 2021. We computed random-effect meta-analysis on postoperative outcomes of T/UT-DSAEK, stratified by graft thickness (<80 µm, 80-100 µm, and 100-130 µm). The main postoperative outcome was visual acuity (logarithm of the minimum angle of resolution [logMAR]). Secondary outcomes were pachymetry (µm), endothelial cell count (cell/mm2), spherical equivalent (diopter [D]), rebubbling rate (%), and rejection rate (%). Meta-regressions compared postoperative outcomes depending on graft thickness and search for putative confusion factors. RESULTS: We included 47 articles for a total of 2141 eyes of 2040 patients. T/UT-DSAEK globally improved visual acuity (effect size = -0.38 logMAR [95% confidence interval {CI} -0.46 to -0.30 logMAR]), without difference depending on graft thickness. Overall, pachymetry improved (-60.6 µm [95% CI -101 to -19.7 µm]), endothelial cell count decreased (-1039 cells/mm2 [95% CI -1209 to -868 cells/mm2), spherical equivalent resulted in a hyperopic shift (0.74 D [95% CI -0.50 to 1.97 D), the graft rejection rate was 0.2% (95% CI -0.1% to 0.4%), and the rebubbling rate was 8.7% (95% CI 6.8%-10.5%). Grafts >100 µm induced a hyperopic shift. Metaregressions did not demonstrate differences between the 3 groups (<80 µm, 80-100 µm, or 100-130 µm) in any outcomes. CONCLUSION: All T/UT-DSAEK thickness groups provided similar visual acuity, pachymetry, endothelial cell count, rejection rate, and rebubbling rate regardless of graft thickness. A hyperopic shift was induced by grafts >100 µm.

Management of Transected Invasive Melanoma: A Single Institution Retrospective Review.

BACKGROUND: Deep transection of invasive melanoma precludes accurate measurement of Breslow depth, which may affect tumor staging. OBJECTIVE: To determine the frequency of upstaging of transected invasive melanomas after excision, characterize the impact on National Comprehensive Cancer Network (NCNN)-recommended treatment, and determine predictors of subsequent upstaging. MATERIALS AND METHODS: A retrospective review of invasive melanomas between January 2017 and December 2019 at a single institution. Deeply transected biopsy reports were compared with subsequent excisions to calculate the frequency of upstaging. RESULTS: Three hundred sixty (49.6%) of 726 invasive melanomas identified were transected. Forty-nine (13.6%) transected tumors had upstaging that would have altered NCCN-recommended management. "Broadly" transected tumors had upstaging that would have resulted in a change in the management in 5/23 cases (21.7%) versus 2/41 cases (4.9%) for "focally" transected tumors (p = .038). Breslow depth increased by 0.59 mm on average for "broad" transection versus 0.06 mm for "focal" transection (p =< .01). Of the 89 transected pT1a melanomas, specimens with gross residual tumor or pigment after biopsy were upstaged in 8/17 (47.1%) of cases versus 5/72 (6.9%) of specimens without (p =< .01). CONCLUSION: Upstaging of deeply transected invasive melanomas that would alter NCCN-recommended management occurred in 13.6% of cases. Broad transection and gross residual tumor or pigment after biopsy predicted higher likelihood of upstaging.

Female permanent contraception policies and occurrence at a sample of U.S. prisons and jails.

OBJECTIVE(S): Incarcerated individuals have an unmet need for contraception, yet have also been subject to coercive permanent contraception practices. Data do not exist on prison and jail policies around access to permanent contraception or how often it occurs among women in custody. We sought to describe permanent and reversible contraception policies at U.S carceral institutions and the frequency of these procedures. STUDY DESIGN: We surveyed a convenience sample of 22 state prison systems and 6 county jails from 2016 to 2017 about female permanent contraception and reversible contraception policies. In addition, 10 prisons and 4 jails reported 6 months of monthly data on the number of postpartum permanent contraception procedures performed on women who gave birth in custody. We analyzed results for descriptive statistics. RESULTS: Eleven prisons (50%) and 5 jails (83%) permitted female permanent contraception; 7 of these prisons and 3 of these jails allowing permanent contraception did not have a written policy about it. Six prisons and no jails provided access to permanent but not reversible contraception. Over 6 months, 3 women from 2 prisons and 4 women at 2 jails received postpartum permanent contraception. CONCLUSION(S): The majority of prisons and jails in our study allowed incarcerated women to have permanent contraception in custody, often without formalized policies in place. Postpartum permanent contraception occurred during the study period. Given the inherent lack of autonomy of incarceration and history of sterilization abuses in this marginalized group, policy-makers should advance policies that avoid coercive permanent contraception and increase access to reversible contraception in carceral settings. IMPLICATIONS: Many carceral institutions permit women to undergo permanent contraception but provide no access to reversible contraception; this practice raises concern for compromised autonomy and further reproductive marginalization of a group with limited access to quality reproductive health care.

Abortion Access for Incarcerated People: Incidence of Abortion and Policies at U.S. Prisons and Jails.

OBJECTIVE: To understand abortion incidence among incarcerated people and the relation to prison and jail pregnancy policies. METHODS: We collected abortion numbers and policy data from convenience sample of 22 state prison systems, all Federal Bureau of Prisons sites, and six county jails that voluntarily reported monthly, aggregate pregnancy outcomes for 12 months in 2016-2017. Sites also completed a baseline survey of institution characteristics and pregnancy policies, including abortion. We reported facility policies and abortion incidence according to state-level abortion characteristics. RESULTS: Only half of state prisons in the study allowed abortion in both the first and second trimesters, and 14% did not allow abortion at all. Of the 19 state prisons permitting abortion, two thirds required the incarcerated woman to pay. Four jails of the six study jails (67%) allowed abortions in the first and second trimesters, and 25% of those required the incarcerated woman to pay for the procedure. The three prisons and two jails that did not allow abortions were in states considered hostile to abortion access. In the state and federal prisons studied, 11 of the 816 pregnancies (1.3%) that ended during the study time period were abortions. Of the 224 pregnancies that ended at study jails, 33 were abortions (15%), with more than half of those (55%) occurring in the first trimester. The abortion ratio (proportion of pregnancies ending in abortion) was 1.4% for prisons and 18% for jails. CONCLUSION: Although some incarcerated individuals have abortions, many prisons and jails have restrictive policies surrounding abortion, either through self-payment requirements or explicit prohibition. Findings from this study should prompt further inquiry into abortion incidence in these settings and address interventions to ensure incarcerated people, in accordance with legal requirements and health equity, have access to abortion.

Efficacy of Closed Incision Negative Pressure Wound Therapy on Abdominal Donor Site After Free Flap Breast Reconstruction.

INTRODUCTION: Negative pressure wound therapy (NPWT) has been used to treat acute and chronic wounds in a variety of scenarios. Specifically, in autologous breast reconstruction, studies investigating the use of closed incision NPWT (ciNPWT) in breast surgery are lacking. OBJECTIVE: The aim of this study was to analyze the use of ciNPWT at the abdominal donor site following deep inferior epigastric perforator (DIEP) flap breast reconstruction. MATERIALS AND METHODS: A retrospective cohort study was conducted over a 15-month period including patients who underwent abdominally based microsurgical breast reconstruction. Patients were divided into 2 groups: (1) a control group that underwent standard abdominal donor site closure and (2) an experimental group that underwent standard abdominal donor site closure plus ciNPWT. Groups were compared in terms of demographic characteristics, perioperative variables, and abdominal donor site complications. RESULTS: A total of 42 patients were identified. Of these, 18 were included in the control group and 24 in the ciNPWT group. No cases of seroma, abdominal bulge, or abdominal hernia were reported. Wound dehiscence developed in 2 patients (11.1%) in the control group and in 3 patients (12.5%) in the experimental group (P = 1.000). One patient (5.6%) in the control group had an infection of the donor site compared with none in the ciNPWT group (P = .429). Interestingly, 3 patients developed hyperpigmentation where the ciNPWT plastic drape was placed. CONCLUSIONS: The use of ciNPWT on the abdominal donor site following DIEP flap breast reconstruction did not lower the incidence of wound dehiscence and wound infection. Different approaches are needed to decrease the incidence of donor site complications in abdominally based postmastectomy breast reconstruction.

Breastfeeding in Incarcerated Settings in the United States: A National Survey of Frequency and Policies.

Objectives: To assess the existence of prison and jail policies and practices that allow incarcerated women to breastfeed while in custody, and prevalence of women in custody who pumped human milk for their infants. Methods: We surveyed 22 state prison systems and 6 county jails from 2016 to 2017 about policies related to breastfeeding and other programs for pregnant and parenting women in custody. In addition, 11 prisons and 5 jails reported 6 months of monthly, prospective data on the number of women pumping human milk, as well as information on placement of infants born to women in custody. Results: Eleven prisons and five jails had policies that supported the practice of expressed milk, either through pumping or breastfeeding. Over 6 months at these sites that allowed lactation, there were 207 women who gave birth in the prisons and an average of 8 women/month who pumped human milk; at the jails, there were 67 women who gave birth and an average of 6 women/month who pumped human milk. Most infants born to women in custody were placed in the care of a family member. Conclusions: Breastfeeding and the provision of human milk are critical public health issues. Our data show inconsistent implementation of policies and practices supportive of breastfeeding in prisons and jails. However, there are institutions in the United States that are supportive of incarcerated women's breastfeeding and lactation needs. Further research is needed to identify the barriers and facilitators associated with implementing supportive breastfeeding policies and practices in the carceral system.

Quantifying Patient Portal Use: Systematic Review of Utilization Metrics.

BACKGROUND: Use of patient portals has been associated with positive outcomes in patient engagement and satisfaction. Portal studies have also connected portal use, as well as the nature of users' interactions with portals, and the contents of their generated data to meaningful cost and quality outcomes. Incentive programs in the United States have encouraged uptake of health information technology, including patient portals, by setting standards for meaningful use of such technology. However, despite widespread interest in patient portal use and adoption, studies on patient portals differ in actual metrics used to operationalize and track utilization, leading to unsystematic and incommensurable characterizations of use. No known review has systematically assessed the measurements used to investigate patient portal utilization. OBJECTIVE: The objective of this study was to apply systematic review criteria to identify and compare methods for quantifying and reporting patient portal use. METHODS: Original studies with quantifiable metrics of portal use published in English between 2014 and the search date of October 17, 2018, were obtained from PubMed using the Medical Subject Heading term "Patient Portals" and related keyword searches. The first search round included full text review of all results to confirm a priori data charting elements of interest and suggest additional categories inductively; this round was supplemented by the retrieval of works cited in systematic reviews (based on title screening of all citations). An additional search round included broader keywords identified during the full-text review of the first round. Second round results were screened at abstract level for inclusion and confirmed by at least two raters. Included studies were analyzed for metrics related to basic use/adoption, frequency of use, duration metrics, intensity of use, and stratification of users into "super user" or high utilizers. Additional categories related to provider (including care team/administrative) use of the portal were identified inductively. Additional analyses included metrics aligned with meaningful use stage 2 (MU-2) categories employed by the US Centers for Medicare and Medicaid Services and the association between the number of portal metrics examined and the number of citations and the journal impact factor. RESULTS: Of 315 distinct search results, 87 met the inclusion criteria. Of the a priori metrics, plus provider use, most studies included either three (26 studies, 30%) or four (23 studies, 26%) metrics. Nine studies (10%) only reported the patient use/adoption metric and only one study (1%) reported all six metrics. Of the US-based studies (n=76), 18 (24%) were explicitly motivated by MU-2 compliance; 40 studies (53%) at least mentioned these incentives, but only 6 studies (8%) presented metrics from which compliance rates could be inferred. Finally, the number of metrics examined was not associated with either the number of citations or the publishing journal's impact factor. CONCLUSIONS: Portal utilization measures in the research literature can fall below established standards for "meaningful" or they can substantively exceed those standards in the type and number of utilization properties measured. Understanding how patient portal use has been defined and operationalized may encourage more consistent, well-defined, and perhaps more meaningful standards for utilization, informing future portal development.

Pregnancy Prevalence and Outcomes in 3 United States Juvenile Residential Systems.

STUDY OBJECTIVE: To describe the number of admissions of pregnant adolescents to US juvenile residential systems (JRS) and the outcomes of pregnancies that ended while in custody. DESIGN: Prospective study. SETTING: Three nonrandomly selected JRS in 3 US states. PARTICIPANTS: Designated reporter at each JRS reporting aggregate data on various pregnant admissions, outcomes, and systems' policies. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Monthly number of pregnant people admitted, pregnant people at the end of the month, births, preterm births, cesarean deliveries, miscarriages, induced abortions, ectopic pregnancies, maternal and newborn deaths, and administrative policies. RESULTS: There were 71 admissions of pregnant adolescents reported over 12 months from participating JRS. At the time of the census, 6 of the 183 female adolescents (3.3%) were pregnant. Eight pregnancies ended while in custody. Of these, 1 pregnancy was a live full-term birth, 4 were miscarriages, and 3 were induced abortions. There were no newborn deaths or maternal deaths. Administrative policies and services varied among the JRS. For example, all JRS had a prenatal care provider on-site, whereas 2 JRS helped cover the costs of abortions. CONCLUSION: To our knowledge, this study is the first to report the estimates of pregnancy and pregnancy outcomes among justice-involved youth in JRS. Our findings indicate that there are pregnant adolescents in JRS and most return to their communities while pregnant, highlighting the importance of continuity of care. More work is needed to understand the complexities of health care needs of justice-involved pregnant youth during and after their incarceration.

Pregnancy Prevalence and Outcomes in U.S. Jails.

OBJECTIVE: To describe the number of admissions of pregnant people to U.S. jails and the outcomes of pregnancies that end in custody. METHODS: We prospectively collected pregnancy data from six U.S. jails, including the five largest jails, on a monthly basis for 12 months. Jails reported de-identified, aggregate numbers of pregnant people admitted, births, preterm births, cesarean deliveries, miscarriages, induced abortions, ectopic pregnancies, and maternal and newborn deaths. RESULTS: There were 1,622 admissions of pregnant people in 12 months in the selected jails. The highest 1-day count of pregnant people at a single jail was 65. The majority of these admissions involved the release of a pregnant person. Of the 224 pregnancies that ended in jail, 144 (64%) were live births, 41 (18%) were miscarriages, 33 (15%) were induced abortions, and four were ectopic (1.8%). One third of the births were cesarean deliveries and 8% were preterm. There were two stillbirths, one newborn death, and no maternal deaths. CONCLUSION: About 3% of admissions of females to U.S. jails are of pregnant people; extrapolating study results to national female jail admission rates suggests nearly 55,000 pregnancy admissions in 1 year. It is feasible to track pregnancy statistics about this overlooked group.

Opioid use disorder incidence and treatment among incarcerated pregnant women in the United States: results from a national surveillance study.

BACKGROUND AND AIMS: The established standard care in pregnancy is medication for opioid use disorder (MOUD); however, many institutions of incarceration do not have MOUD available. We aimed to describe the number of incarcerated pregnant women with opioid use disorder (OUD) in the United States and jails' and prisons' MOUD in pregnancy policies. DESIGN: Epidemiological surveillance study of 6 months of outcomes of pregnant, incarcerated women with OUD and cross-sectional survey of institutional policies. SETTING: United States. PARTICIPANTS: Twenty-two state prison systems and six county jails. MEASUREMENTS: The number of pregnant women with OUD admitted and treated with methadone, buprenorphine or withdrawal; policies on provision of MOUD and withdrawal in pregnancy. FINDINGS: Twenty-six per cent of pregnant women admitted to prisons and 14% to jails had OUD. One-third were managed through withdrawal. The majority who were prescribed MOUD were on methadone (78%, prisons; 81%, jails), not buprenorphine. While most sites (n = 18 prisons, n = four jails) continued pre-incarceration MOUD in pregnancy, very few initiated in custody (n = four prisons; n = two jails). Two-thirds of prisons and three-quarters of jails providing MOUD in pregnancy discontinued it postpartum. CONCLUSIONS: In this sample of US prisons and jails, one-third required pregnant women with opioid use disorder to go through withdrawal, contrary to medical guidelines. More women were prescribed methadone than buprenorphine, despite the fewer regulatory barriers on prescribing buprenorphine. Most sites stopped medication for opioid use disorder postpartum, signaling prioritization of the fetus, not the mother. Pregnant incarcerated women with opioid use disorder in the United States frequently appear to be denied essential medications and receive substandard medical care.

Pregnancy Outcomes in US Prisons, 2016-2017.

OBJECTIVES: To collect national data on pregnancy frequencies and outcomes among women in US state and federal prisons. METHODS: From 2016 to 2017, we prospectively collected 12 months of pregnancy statistics from a geographically diverse sample of 22 state prison systems and the Federal Bureau of Prisons. Prisons reported numbers of pregnant women, births, miscarriages, abortions, and other outcomes. RESULTS: Overall, 1396 pregnant women were admitted to prisons; 3.8% of newly admitted women and 0.6% of all women were pregnant in December 2016. There were 753 live births (92% of outcomes), 46 miscarriages (6%), 11 abortions (1%), 4 stillbirths (0.5%), 3 newborn deaths, and no maternal deaths. Six percent of live births were preterm and 30% were cesarean deliveries. Distributions of outcomes varied by state. CONCLUSIONS: Our study showed that the majority of prison pregnancies ended in live births or miscarriages. Our findings can enable policymakers, researchers, and public health practitioners to optimize health outcomes for incarcerated pregnant women and their newborns, whose health has broad sociopolitical implications.

Nephrologic Impact of Hurricanes Katrina and Rita in Areas Not Directly Affected.

Hurricanes Katrina and Rita resulted in enormous loss of life and disrupted the delivery of health care in areas affected by them. In causing mass movements of patients, natural disasters can overwhelm the resources of nephrology communities in areas not suffering direct damage. The following largely personal account evaluates the impact these hurricanes had upon the nephrology community, patients and health care providers alike, in areas not directly affected by the storms. Mass evacuation of hundreds of dialysis patients to surrounding areas overwhelmed the capacity of local hemodialysis centers. Non-availability of medical records in patients arriving without a supply of their routine medications led to confusion and sub-optimal treatment of conditions such as hypertension and congestive heart failure. Availability of cadaveric organs for transplantation was reduced in the surrounding areas, as the usual lines of communication and transportation were severed for several weeks. All of these issues led to prolong waiting times for patients on the transplant list. The hurricanes severely disrupted usual supply lines of medications to hospitals; certain rare conditions may be seen in higher numbers as a result of the shortages induced. We present the interesting surge in cases of acute kidney injury secondary to use of intravenous immune globulin.