Hypertension: Are Current Guidelines Inclusive of Sex and Gender?

Background: Hypertension (HTN) accounts for one in five deaths of American women. Major societies worldwide aim to make evidence-based recommendations for HTN management. Sex- or gender-based differences exist in epidemiology and management of HTN; in this study, we aimed to assess sex- and gender-based language in major society guidelines. Materials and Methods: We reviewed HTN guidelines from four societies: the American College of Cardiology (ACC), the American College of Emergency Physicians (ACEP), the European Society of Cardiology (ESC), and the Eighth Joint National Committee (JNC8). We quantified the sex- and gender-based medicine (SGBM) content by word count in each guideline as well as identified the gender of guideline authors. Results: Two of the four HTN guidelines (ACC, ESC) included SGBM content. Of these two guidelines, there were variations in the quantity and depth of content coverage. Pregnancy had the highest word count found in both guidelines (422 words in ACC and 1,523 words in ESC), which represented 2.45% and 3.04% of the total words in each guideline, respectively. There was minimal coverage, if any, of any other life periods. The number of women authors did not impact the SGBM content within a given guideline. Conclusions: Current HTN management guidelines do not provide optimal guidance on sex- and gender-based differences. Inclusion of sex, gender identity, hormone therapy, pregnancy and lactation status, menopause, and advanced age in future research will be critical to bridge the current evidence gap. Guideline writing committees should include diverse perspectives, including cisgender and transgender persons from diverse racial and ethnic backgrounds.

The Proportion of Women Authors and the Inclusion of Sex and Gender Content Among the American College of Cardiology Clinical Practice Guidelines, 2008-2018.

Background: Sex and gender, two important factors affecting health care, should be routinely taken into consideration in clinical practice. Members of the Sex and Gender Health Collaborative Scholarship Committee reviewed clinical guidelines published by the American College of Cardiology (ACC) from 2008 to 2018 to determine if the number of women authors on the writing committee influenced the presence of sex- and gender-specific content and recommendations in each guideline. Methods: We reviewed 33 ACC clinical guidelines from 2008 to 2018 and determined the number of women authors on the writing committee for each guideline. We then reviewed each guideline to identify specific content on sex and/or gender differences as it pertained to the guideline's subject cardiac condition. Results: The median proportion of women authors among the 33 ACC guidelines was 22.2% (interquartile range 4.4-81.1). Only two guidelines (6%) had writing committees with >50% women authors. Overall, 25 of 33 guidelines (75.8%) contained sex and gender content; however, the depth and detail of the sex and gender content varied widely among guidelines. The proportion of women authors was not associated with the presence of sex- and gender-specific content. Conclusions: Our findings demonstrate continued gender disparities in authorship, and changes should be made to increase the inclusion of women in clinical practice guideline writing committees. We propose selecting a sex and gender champion for guideline writing committees and/or including a specific section on sex- and gender-related content in each guideline to ensure inclusion of sex- and gender-specific recommendations in clinical guidelines.

'I feel like a person has a right to use a product to protect themselves ': a qualitative study of the risk-benefit calculus on women's contraceptive use and choice.

Background Reducing pregnancy risk requires a multidimensional approach to sexual and reproductive health product development. The purpose of this analysis is to identify, compare, and contrast women's pre-use beliefs and attitudes about three different forms of contraceptives: intravaginal rings; spermicide in conjunction with condoms; and oral contraceptive pills - and explore how those attitudes and beliefs, along with actual method-use experience, may affect potential choices in contraceptive method moving forward. The relationship of beliefs and attitudes to their risk-benefit calculations when using these methods was also considered.? METHODS: Women used one or more contraceptive methods, each for 3-6 months. Qualitative data from individual in-depth interviews completed after each 3-month use period were analysed using a summary matrix framework. Data were extracted and summarised into themes. Each woman's experiences were compared among the methods she used; comparisons were also made across participants. RESULTS: The data consist of 33 90-120 min in-depth qualitative interviews from 16 women aged 20-34 years, in which they discussed various elements of their method use experience. One prominent theme was identified: the influence of attitudes and beliefs on the risk-benefit calculus. There were six key elements within the theme: pregnancy prevention; dosing and the potential for user error; side-effects; familiarity; disclosure; and sexual partnerships. CONCLUSIONS: Women weighed perceived risks and benefits in their decision-making and, ultimately, their contraception choices. Understanding women's beliefs and attitudes that contribute to a calculation of risk-benefit can inform the development of sexual and reproductive health products.

A Qualitative Study of the Contraceptive Effect on Women's Sexual Experiences: Beyond Hormonal Effects.

OBJECTIVE: To elucidate the effects of the intravaginal ring, oral contraceptive pill (OCP), and spermicide plus condom on women's sexual experiences through an in-depth understanding of the physical characteristics of these contraceptive methods. METHODS: We conducted qualitative in-depth interviews with women (aged 18-45 years) who used up to three contraceptive methods (intravaginal ring, OCP, and spermicide plus condom). Women completed in-depth interviews after each 3-month use period. We used a summarized matrix framework and thematic content analysis to explore how each method affected participants' sexual experiences. RESULTS: Sixteen women completed interviews, yielding 33 transcripts. Women reported physical effects on their sexual experiences while using the intravaginal ring and spermicide plus condom. The OCP was often discussed as lacking these physical effects. Discussion themes included product administration (eg, navigating intravaginal ring removal) and physical product awareness (eg, spermicide as a lubricant). From these experiences, women often altered and individualized their use and subsequent opinions of the contraceptive method. CONCLUSION: The range of contraceptive effects on women's sexual experiences shape their use and opinions of the product, leading to either increased motivation and consistent use or poor adherence and discontinuation. Awareness of these individualized experiences can help providers better understand and guide their patients towards successful contraceptive use.

Management of uncommon disorders in pregnancy: Von Hippel-Lindau disease, Gitelman syndrome, and Nutcracker syndrome.

Uncommon renal disorders in pregnancy can be challenging to manage given limited evidence in the literature to guide management. We present a series of three uncommon renal disorders in pregnancy: Von Hippel-Lindau disease, Gitelman syndrome, and Nutcracker syndrome. Previously published case reports with differing outcomes offer some guidance to the management of these disorders in pregnancy. In this case series, we address the management of these syndromes during pregnancy and discuss the maternal and fetal outcomes. All three of our patients had good maternal and fetal outcomes, which will contribute to current data on maternal and fetal outcomes in these rare diseases, which is limited.

Obstructive sleep apnea in pregnancy is associated with adverse maternal outcomes: a national cohort.

OBJECTIVE: Pregnancy and the obesity epidemic impacting women of reproductive age appear to predispose women to obstructive sleep apnea (OSA) in pregnancy. The aim of this study is to examine the association between OSA and adverse maternal outcomes in a national cohort. METHODS: The National Perinatal Information Center in the US was used to identify women with a delivery discharge diagnosis of OSA from 2010 to 2014. We used the International Classification of Diseases, ninth Revision to classify OSA diagnosis and maternal outcomes. MEASUREMENTS: The sample consisted of 1,577,632 gravidas with a rate of OSA of 0.12% (N = 1963). There was a significant association between OSA and preeclampsia (adjusted odds ratio (aOR) 2.22, 95% confidence interval (CI) 1.94-2.54), eclampsia (aOR 2.95, 1.08-8.02), and gestational diabetes (aOR 1.51, 1.34-1.72) after adjusting for a comprehensive list of covariates which includes maternal obesity. OSA status was also associated with a 2.5-3.5-fold increase in risk of severe complications such as cardiomyopathy, congestive heart failure, and hysterectomy. Length of hospital stay was significantly longer (5.1 + 5.6 vs 3.0 + 3.0 days, p < 0.001) and odds of an admission to an intensive care unit higher (aOR 2.74, 2.36-3.18) in women with OSA. CONCLUSIONS: Compared to pregnant women without OSA, pregnant women with OSA have a significantly higher risk of pregnancy-specific complications such as gestational hypertensive conditions and gestational diabetes, and rare medical and surgical complications such as cardiomyopathy, pulmonary edema, congestive heart failure, and hysterectomy. OSA diagnosis was also associated with a longer hospital stay and significantly increased odds for admission to the intensive care unit.

Restless Legs Symptoms and Pregnancy and Neonatal Outcomes.

PURPOSE: Restless legs syndrome (RLS) is a commonly occurring neurologic disorder that affects up to one third of women during pregnancy. RLS has been associated with increased sympathetic tone in the nonpregnant population. We examined whether a RLS surrogate is associated with a higher prevalence of pregnancy and neonatal outcomes. METHODS: Data were analyzed from a cross-sectional survey of 1000 women interviewed soon after delivery by using an RLS surrogate question. Women were asked how frequently (0 = none, 1 = rarely [<1 time/week], 2 = sometimes [1-2 times/week], 3 = frequently [3-4 times/week], and 4 = always [5-7 times/week]) they had "experienced jumpy or jerky leg movements" in the last 3 months of pregnancy. Clinical charts were reviewed to obtain relevant demographic and clinical data, including the presence of gestational hypertensive disorders and neonatal outcomes at birth. Subjects who "always" experienced RLS were compared with subjects experiencing symptoms less frequently or not at all with respect to prevalence of gestational hypertensive disorder. FINDINGS: The mean ([SD]) age, prepregnancy body mass index (BMI), and BMI at delivery were 29.0 (6.1) years, 26.1 (6.2) kg/m(2), and 32.0 (6.3) kg/m(2), respectively. The overall prevalence of the RLS surrogate (jumpy or jerky leg movements) was 35.5% with the following distribution on a Likert scale: score 1 = 6.4%; score 2 = 10.2%; score 3 = 8.1%; and score 4 = 10.8%. Chronic hypertension was present in 2.1%, pregnancy-induced hypertension in 9.5%, and preeclampsia in 4.5% of respondents. Subjects who reported "always" having sensations of jumpy or jerky legs were more likely to have gestational hypertensive disorders compared with those who reported less frequent occurrence of the symptoms. Adjusted odds ratios were 3.74 (95% CI, 1.31-10.72; P = 0.014) for chronic hypertension; 1.26 (95% CI, 0.65-2.46; P = 0.487) for pregnancy-induced hypertension; and 2.15 (95% CI, 0.97-4.75; P = 0.060) for preeclampsia. There was a significant association between leg movement score and neonatal birth weight (coefficient, -149.5 g [95% CI, -276.9 to -22.5]; P = 0.005) and gestational age at birth (-0.7 week [95% CI, -1.1 to -0.2]; P = 0.021) that persisted after adjusting for preeclampsia, diabetes, and smoking. IMPLICATIONS: A higher frequency of jumpy or jerky leg symptoms, a proxy for RLS during pregnancy, was associated with a higher likelihood of gestational hypertensive disorders and neonatal outcomes such as gestational age at birth and birth weight. These findings may affect RLS treatment decisions during pregnancy.

An assisted living facility curriculum to introduce geriatrics to first-year medical students.

Many U.S. medical schools have developed curricula in geriatric medicine to address the growing older adult population. At our university, the authors have integrated an assisted living facility (ALF) program into a required first-year clinical skills course. During the 2011 to 2012 academic year, an electronic survey was distributed to 109 first-year medical students prior to and after the program. Eighty-eight percent and 85% of students completed the pre- and postintervention survey, respectively. Students reported a positive attitude toward caring for older adults (92.5% post- vs. 80.2% preintervention), an understanding of the medical and social needs of older adults (89.2% post- vs. 38.5% preintervention), an acquisition of the skills to assess the health of older adults (71% post- vs. 14.5% preintervention), and an understanding of ALFs as nonmedical supportive housing (92.5% post- vs. 70.8% preintervention). The authors' curriculum offers an innovative method to integrate geriatrics education early in medical education and to involve medical students in their community.

Contraceptive use in women undergoing bariatric surgery.

INTRODUCTION: Contraceptive counselling in women undergoing bariatric surgery is crucial due to increased risk of foetal growth restriction postoperatively. We evaluate if women undergoing bariatric surgery are being counselled about and using contraception. METHODS: A 36-question survey was sent electronically to patients at the Miriam Hospital Bariatric Center in Providence, Rhode Island. RESULTS: Of the thirty-five women included in our study, 85.7% and 80% reported receiving contraceptive counselling and advice to avoid pregnancy in the 12-24 months following surgery, respectively. Only 65.7% were using contraception. More women using contraception reported receiving counselling (95.7% vs. 66.7%) and knew to avoid pregnancy postoperatively (82.6% vs. 75%) than women not using contraception. Contraceptive use declined over time following surgery. CONCLUSION: We have identified an important opportunity for healthcare providers to promote ongoing compliance with contraception for women undergoing bariatric surgery.

Infective endocarditis complicated by aortic graft infection and osteomyelitis: case report and review of literature.

Primary aortic graft infection early after aortic graft insertion is well described in the literature. Here, we present a unique case of late aortic graft infection 5 years after insertion secondary to mitral valve endocarditis, resulting from cellulitis in a patient with severe venous varicosities. A 63-year-old male presented for severe low back pain, constipation, and low-grade fever. An abdominal computed tomography scan with oral and intravenous contrast showed a normal spine and urinary tract. Blood and urine cultures, done at the same time, grew Staphylococcus aureus. A transesophageal echocardiogram confirmed the diagnosis of endocarditis. Subsequently, a gallium scan showed increased uptake in the vertebral bodies, aortic graft, left patella, and left ankle. After 3 months of antibiotic therapy, the patient's low back pain resolved with normalization of his laboratory values. He remained free of infection at a 2-year follow-up. We reviewed the literature concerning the atypical presentation of infective endocarditis, with a focus on distant metastases at initial presentation, such as osteomyelitis and aortic graft infection, as well as the different treatment modalities. This report describes successful medical treatment with intravenous followed by oral antibiotics for an infected endovascular graft without any surgical intervention.

Thymic involution in pregnancy: a universal finding?

The thymus is a lymphatic organ that plays a vital role in the development of immunity in childhood. The thymus involutes during periods of stress and may acutely decrease in size but usually recovers to its normal size. The thymus also involutes during pregnancy, a process that is possibly hormonally mediated and thought to be necessary for fetal survival. This report describes two pregnant patients with signs and symptoms suggestive of pulmonary embolism who were incidentally found to have thymic enlargement on computed tomography. Follow-up imaging postpartum in both cases demonstrates a significant reduction in thymus size, suggesting thymic hyperplasia. Both patients delivered healthy babies at term. Thymic involution does not universally occur in pregnancy, challenging the theory of its necessity to fetal survival.

Teaching communication and compassionate care skills: an innovative curriculum for pre-clerkship medical students.

BACKGROUND: Physicians require communications training to improve effective and compassionate care. Clinicians discuss challenging communication issues in existing hospital "Schwartz Rounds." AIMS: To improve communication skills, the Warren Alpert Medical School of Brown University designed "Schwartz Communication Sessions" for the mandatory 2-year pre-clerkship Doctoring course. Alongside learning interviewing, physical examination, and professionalism skills, the new Schwartz curriculum provides medical students with the rationale and proficiency for effective communication with patients, families and the healthcare team. METHODS: First-year students experience a graduated curriculum of three sessions on themes such as empathy and professionalism using innovative methods. Sessions highlight cases and videos depicting successful and ineffective interactions, large and small group discussions, role play and skills practice, guest patient presentations, and multi-disciplinary panels. The second-year students' session focuses on communications with challenging patients. RESULTS: Students and faculty rate the sessions highly on effectiveness of enhancing communication skills, gaining perspective in healthcare communication, and appreciating the complexities of healthcare situations. Expansion of the program using case-based sessions for clerkship students is planned for a continuous and graduated experience. CONCLUSIONS: Integrating a pre-clerkship communications curriculum may help improve future physicians' interactions with patients and families. Implications of this curriculum for medical education are discussed.

Timing of conception for pregnant women returning to jail.

Approximately 6% to 10% of women entering jails are pregnant. Women entering jail are often poor, medically underserved, and at high risk for substance abuse and unplanned pregnancies. We hypothesize that many women who are pregnant when entering jail have had a prior incarceration and conceived soon after release. We reviewed charts of 269 pregnant women entering the Rhode Island jail between August 1997 and November 2002. Of these women, 52.4% had prior incarcerations. In addition, 117 women conceived within 1 year of a prior release (50% within 90 days, 24% within 91 to 180 days, and 26% more than 180 days postrelease). Women who conceived within 90 days were more likely to be incarcerated for more than 30 days while pregnant than women who conceived after 90 days (relative risk 2.38; 95% confidence interval 1.12 to 5.07). Providing contraceptive services at the time of release may help decrease the number of women who enter jail pregnant.

Treatment of menopausal symptoms.

Vasomotor symptoms affect the majority of postmenopausal women. Given the risks of hormone replacement therapy, alternative treatments for hot flashes have emerged over recent years. This article will review currently available treatments for hot flashes, including hormonal and non-hormonal therapies.

Hermansky-Pudlak syndrome in the peripartum period.

Hermansky-Pudlak syndrome (HPS) is a disease characterized by the triad of oculocutaneous albinism, bleeding diathesis and organ failure secondary to lysosomal accumulation of ceroid lipofuscin. We report the case of a pregnant woman with HPS who had a successful vaginal delivery with the administration of desmopressin.