A mixed-methods evaluation of an HIV pre-exposure prophylaxis educational intervention for healthcare providers in a NYC safety-net hospital-based obstetrics and gynecology clinic.

Cisgender women and transgender men are less likely to be assessed for PrEP eligibility, prescribed PrEP, or retained in PrEP care. Thus, this pilot PrEP educational intervention was tailored for healthcare providers (HCPs) in obstetrics/gynecology who provide care to cisgender women and transgender men in an academically-affiliated, public hospital women's health clinic. The three-lecture educational curriculum designed for HCPs focused on PrEP eligibility and counseling, formulations and adherence, and prescription and payment assistance programs. Pre- and post-intervention surveys assessed HCP knowledge and barriers to PrEP counseling and prescription. Among n = 49 participants (mean age = 32.8 years; 85.7% cisgender women, mean years practicing = 4.2 years) pre-intervention, 8.7% had prior PrEP training and 61.2% felt very/somewhat uncomfortable prescribing PrEP. Post-intervention, knowledge of PrEP contraindications, eligibility, follow-up care, and assistance programs all increased. HCPs identified key barriers to PrEP care including lack of a dedicated PrEP navigator, culturally and linguistically appropriate patient materials on PrEP resources/costs, and PrEP-related content integrated into EHRs. Ongoing PrEP educational sessions can provide opportunities to practice PrEP counseling, including information on financial assistance. At the institutional level, incorporating PrEP screening in routine clinical practice via EMR prompts, facilitating PrEP medication monitoring, and enhancing telehealth for follow-up care could enhance PrEP prescription.

Association of Antenatal Housing Instability with Perinatal Care Utilization and Outcomes.

Background: Social determinants of health are important contributors to maternal and child health outcomes. Limited existing research examines the relationship between housing instability during pregnancy and perinatal care utilization. Our objective was to evaluate whether antenatal housing instability is associated with differences in perinatal care utilization and outcomes. Materials and Methods: Participants who were surveyed during their postpartum hospitalization were considered to have experienced housing instability if they answered affirmatively to at least one of six screening items. The primary outcome was adequacy of prenatal care measured by the Adequacy of Prenatal Care Utilization index. Maternal, neonatal, and postpartum outcomes, including utilization and breastfeeding, were also collected as secondary outcomes. Multivariable logistic regression models were adjusted for sociodemographic and clinical covariates. Results: In this cohort (N = 490), 11.2% (N = 55) experienced housing instability during pregnancy. Participants with unstable housing were more likely to have inadequate prenatal care (17.3% vs. 3.9%; odds ratio [OR] 5.11, 95% confidence interval [CI] 2.15-12.14, p < 0.001), but findings were not significant after adjustment (aOR 1.72, 95% CI 0.55-5.41, p = 0.35). Similarly, postpartum visit attendance was lower for individuals with unstable housing (79.6% vs. 91.2%), but there was no difference in the odds of the postpartum visit attendance after adjustment (OR 0.69, 95% CI 0.29-1.66, p = 0.14). Conclusions: There were no statistically significant association with the maternal, neonatal, and other postpartum secondary outcomes. Housing instability appears to be a risk marker that is related to other social determinants of health. Given the range of housing instability experiences, future research must account for specific types and degrees of housing instability and their potential perinatal consequences.

Vaginal and Extra-Vaginal Bacterial Colonization and Risk for Incident Bacterial Vaginosis in a Population of Women Who Have Sex With Men.

BACKGROUND: Bacterial vaginosis (BV) is a common cause of vaginal discharge and associated with vaginal acquisition of BV-associated bacteria (BVAB). METHODS: We used quantitative polymerase chain reaction assays to determine whether presence or concentrations of BVAB in the mouth, anus, vagina, or labia before BV predict risk of incident BV in 72 women who have sex with men. RESULTS: Baseline vaginal and extra-vaginal colonization with Gardnerella spp, Megasphaera spp, Sneathia spp, BVAB-2, Dialister sp type 2, and other BVAB was more common among subjects with incident BV. CONCLUSIONS: Prior colonization with BVAB is a consistent risk for BV.

Management of Pelvic Organ Prolapse in the Adult Congenital Genitourinary Patient.

OBJECTIVES: To assess and present our experience with the management and outcomes of female pelvic organ prolapse in the adult congenital genitourinary patient population. METHODS: Retrospective review of our adult congenital GU patients with spina bifida with a documented Pelvic Organ Prolapse Quantification exam (POP-Q) from 2006 - 2021 was undertaken. Spina bifida lesion level, bladder management method, prolapse stage and component, and obstetric history were reviewed. Outcomes of treated patients are from most recent follow up. RESULTS: 37 congenital GU patients were identified. 26 (70%) were nulliparous with many showing advanced prolapse, defined as stage 2 or greater. By POP-Q, only 22% were stage 0, indicating no prolapse. 68% had advanced prolapse, with one case of complete procidentia despite no pregnancy history. The dominant prolapse compartment in advanced prolapse patients regardless of parity was apical, or cervical (47%). 16 had symptomatic prolapse, most with vaginal bulge or noticing bulge with catheterization. 6 patients underwent surgery with 2 vaginal hysterectomy and uterosacral suspensions and 1 sacrocolpopexy with mesh. Due to elongated cervix with protrusion, 3 patients underwent cervical shortening as their primary prolapse intervention. 4 of the patients saw a decrease in POP-Q score post-operatively with 2 patients still pending follow-up. CONCLUSIONS: Congenital GU patients may have more advanced prolapse at younger ages and nulliparity and are frequently apical dominant. A variety of surgical options can provide meaningful improvement in the symptomatic patient.

Trends and Risk Markers for Severe Maternal Morbidity and Other Obstetric Complications.

Background: Studies of obstetric quality of care have almost exclusively focused on severe maternal morbidity (SMM) and have rarely examined more common complications. Methods: This 2016-2018 retrospective, population-based cohort study analyzed maternal delivery outcomes at 127 Illinois hospitals. International Classification of Disease (ICD)-10 Revision codes were used to describe the incidence of SMM and route-specific complications. Poisson regression models were used to estimate the association of maternal sociodemographic, clinical, and hospital characteristics with the likelihood of coded complications. Results: Among 421,426 deliveries, the SMM rate was 1.4% overall, 0.4% for vaginal, and 2.8% for cesarean delivery. Other complications were documented for 6.9% of women with vaginal and 10.0% of women with cesarean deliveries. While SMM rates were stable, vaginal delivery complications increased 5.9% from 2016 to 2018 and cesarean delivery complications increased 13.8%. Patient age, minority race and ethnicity, high poverty level, and preexisting and pregnancy-related clinical conditions were significantly associated with each complication outcome. Higher hospital delivery volume was associated with higher route-specific complications. Conclusion: SMM significantly underestimates the incidence of maternal complications. Complicated deliveries have much higher charges and length of stay, although ICD-10 coding intensity may influence incidence. New outcome measures based on more detailed clinical data and linked antepartum and postpartum care will be necessary to improve obstetric quality of care measurement.

Genetic Variation in Toll-Like Receptor 5 and Colonization with Flagellated Bacterial Vaginosis-Associated Bacteria.

Bacterial vaginosis (BV) is a vaginal dysbiotic condition linked to negative gynecological and reproductive sequelae. Flagellated bacteria have been identified in women with BV, including Mobiluncus spp. and BV-associated bacterium-1 (BVAB1), an uncultivated, putatively flagellated species. The host response to flagellin mediated through Toll-like receptor 5 (TLR5) has not been explored in BV. Using independent discovery and validation cohorts, we examined the hypothesis that TLR5 deficiency-defined by a dominant negative stop codon polymorphism, rs5744168-is associated with an increased risk for BV and increased colonization with flagellated bacteria associated with BV (BVAB1, Mobiluncus curtisii, and Mobiluncus mulieris). TLR5 deficiency was not associated with BV status, and TLR5-deficient women had decreased colonization with BVAB1 in both cohorts. We stimulated HEK-hTLR5-overexpressing NF-κB reporter cells with whole, heat-killed M. mulieris or M. curtisii and with partially purified flagellin from these species; as BVAB1 is uncultivated, we used cervicovaginal lavage (CVL) fluid supernatant from women colonized with BVAB1 for stimulation. While heat-killed M. mulieris and CVL fluid from women colonized with BVAB1 stimulate a TLR5-mediated response, heat-killed M. curtisii did not. In contrast, partially purified flagellin from both Mobiluncus species stimulated a TLR5-mediated response in vitro We observed no correlation between vaginal interleukin 8 (IL-8) and flagellated BVAB concentrations among TLR5-sufficient women. Interspecies variation in accessibility of flagellin recognition domains may be responsible for these observations, as reflected in the potentially novel flagellin products encoded by Mobiluncus species versus those encoded by BVAB1.

Using Electronic Health Record and Administrative Data to Analyze Maternal and Neonatal Delivery Complications.

BACKGROUND: Obstetric quality of care measures have largely focused on severe maternal morbidity (SMM), with little consensus about measures of less severe but more prevalent delivery and neonatal complications. This study analyzes risk-adjusted maternal and neonatal outcomes using both ICD-10 coding and electronic health record (EHR) data. METHODS: Complication rates at seven health system hospitals from January 2016 to August 2019 were analyzed. EHR data and ICD-10 codes were used to identify the incidence of SMM as well as other route-specific maternal and neonatal complications. Researchers tested the association of maternal sociodemographic and clinical risk markers with the likelihood of maternal and neonatal complications using multiple logistic and Poisson regression. RESULTS: Among 42,681 deliveries, the SMM rate was 1.3%, and other complication rates were 12.9% for vaginal and 19.7% for cesarean deliveries. The neonatal complication rate was 20.2%. Risk factors for all complications included multiple gestation and hypertensive disorders of pregnancy. Risk factors for SMM included nulliparity, cesarean delivery, and preexisting conditions; risks for neonatal complications included academic medical center admission, cesarean delivery, higher maternal body mass index, and preterm birth. There were significant racial disparities in maternal and neonatal outcomes. CONCLUSION: This study is among the first to combine EHR and administrative discharge data to describe a wide range of maternal and neonatal birth outcomes, including associations with established risk factors. Although SMM was rare, route-specific and neonatal complications were much more common and may offer a better focus for obstetric quality improvement efforts.

Today's Students, Tomorrow's Physicians: Opinions on Enacted and Prospective Health Care Policies.

Future physicians will be key stakeholders in the formation, implementation, and success of health care policies enacted during their careers, though little is known of their opinions of enacted and proposed policies since the 2016 U.S. presidential election. This study aimed to understand the opinions of medical students related to policies including, but not limited to, protections for people with pre-existing conditions, a public option on the private exchange, and single-payer health care. Online surveys were completed by 1,660 medical students at 7 U.S. medical schools between October 2017 and November 2017. The authors used multiple logistic regression to examine associations between student characteristics and support of policies. In total, 1,660 of 4,503 (36.9%) eligible medical students completed the survey. A majority of respondents identified 4 extant Affordable Care Act policies as important, including its protections for patients with pre-existing conditions (95.3%) and Medicaid expansion (77.8%). With respect to prospective reforms, 82.6% supported a public insurance option, and 70.5% supported a single-payer health care system. Only 2.2% supported reducing funding for Medicaid. Although views varied by sex, anticipated specialty, and political affiliation, medical students largely supported prospective policies that would expand insurance coverage and access to health care.

Looking to the Future: Medical Students' Views on Health Care Reform and Professional Responsibility.

PURPOSE: Although medical students will influence the future U.S. health care system, their opinions on the Patient Protection and Affordable Care Act (ACA) have not been assessed since the 2016 presidential election and elimination of key ACA provisions. Understanding medical students' views on health care policy and professional obligations can provide insight into issues that will be shaped by the next generation of physicians. METHOD: From October 2017 to November 2017, the authors conducted an electronic survey of medical students from seven U.S. institutions to elicit opinions regarding the ACA and their professional responsibility to address health policy. Participant demographics and responses were tabulated, and multiple logistic regression models were used to assess the associations of demographic characteristics with student opinions. RESULTS: Completed surveys were returned by 1,660/4,503 (36.9%) eligible medical students. Respondent demographics were similar to national estimates. In total, 89.1% (1,475/1,660) supported the ACA, and 82.0% (1,362/1,660) reported that they understood the health care law. Knowledge of the law's provisions was positively associated with support for the ACA (P < .001). Most students (85.8%; 1,423/1,660) reported addressing health policy to be a professional responsibility. Political affiliation was consistently associated with student opinions. CONCLUSIONS: Most medical students support the ACA, with greater levels of support among medical students who demonstrated higher levels of objective knowledge about the law. Furthermore, students indicated a professional responsibility to engage in health policy, suggesting that tomorrow's physicians are likely to participate in future health care reform efforts.

Diffusion tensor imaging provides an insight into the microstructure of meningiomas, high-grade gliomas, and peritumoral edema.

OBJECTIVE: Fractional anisotropy (FA) is a measure for the degree of microstructural organization. Several studies have used FA values to assess microstructural organization of brain tumors and peritumoral edema. The purpose of our study was to validate FA and apparent diffusion constant (ADC) values in the diagnosis of meningiomas versus high-grade glial tumors, with the focus on the ability of diffusion tensor imaging (DTI) to reveal tumor ultrastructure. Our hypothesis was that FA and ADC values significantly differ between high-grade gliomas and meningiomas, and in the peritumoral edema. METHODS: Diffusion tensor imaging values were obtained from 20 patients with meningiomas (21 tumors) and 15 patients with high-grade gliomas. Regions of interest were outlined in FA and ADC maps for solid-enhancing tumor tissue and peritumoral edema. Fractional anisotropy and ADC values were normalized by comparison to normal-appearing white matter (NAWM) in the contralateral hemisphere. Differences between meningiomas and high-grade gliomas were statistically analyzed. RESULTS: Meningiomas showed a significantly higher FA tumor/FA NAWM ratio (P = 0.0001) and lower ADC tumor/ADC NAWM ratio (P = 0.0008) compared to high-grade gliomas. On average, meningiomas also showed higher FA values in peritumoral edema than high-grade gliomas (P = 0.016). Apparent diffusion constant values of peritumoral edema for the 2 tumor groups did not differ significantly (P = 0.5). CONCLUSIONS: Diffusion tensor imaging can be used to reveal microstructural differences between meningiomas and high-grade gliomas and may contribute toward predicting the histopathology of intracranial tumors. We advocate that diffusion tensor imaging should be included in the standard imaging protocol for patients with intracranial tumors.