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Rheumatic diseases affect women during their reproductive years. Many women with rheumatic diseases become pregnant; some undergo pregnancy termination. However, there are no official guidelines on pregnancy termination in patients with rheumatic diseases. This work provides an overview of factors that health care professionals must consider. We highlight areas that require further studies and the importance of pregnancy planning and contraception counseling. Patients with rheumatic diseases need to be informed of adverse maternal and fetal outcomes of pregnancy to make informed reproductive decisions and reduce the need for pregnancy terminations., (© 2021 American College of Rheumatology.)

Importance: Adolescents have been thought to be low in susceptibility to COVID-19 compared with older adults. Data regarding incidence and risk of COVID-19 are needed to convey risk of infection and inform prevention messaging, especially because US states such as Florida are recommending against vaccinating individuals ages 5 to 17 years and because more infections among adolescents could signal potentially higher incidence of long COVID., Objective: To compare incidence rates and relative risk of infection among US adolescents and youth with those of older adults for wild-type SARS-CoV-2., Design, Setting, and Participants: This cross-sectional study included persons living in 19 US states that experienced surges from the start of the pandemic through fall 2020. Participants were all individuals reported as cases on state health department websites for the age groups and states studied. Age groups included adolescents (ages 10 to 19 years), youth (ages 15 to 24 years or 18 to 24 years), adolescents and youth combined (ages 10 to 24 years), and older adults (either age 60 years or 65 years and older), with age thresholds dependent on individual state data. Data were analyzed between June 2021 and January 2022., Main Outcomes and Measures: Incidence rates for the wild-type SARS-CoV-2 strain; the relative risk of infection in adolescents and youth compared with older adults, based on the incidence rate ratio (IRR)., Results: In 16 of 19 states, the IRR of COVID-19 infection in adolescents and youth was significantly greater than in older adults. For example, in Florida, the incidence rate in adolescents and youth was 0.055 compared with 0.028 in older adults-adolescents and youth had 1.94 times the risk of contracting COVID-19 compared with older adults (IRR, 1.94; 95% CI, 1.92-1.95)., Conclusions and Relevance: Results from this cross-sectional study with US data were contrary to studies from Asia and Europe indicating lower susceptibility of adolescents than older adults. Our findings with the wild-type strain were consistent with findings reported in the UK for the Delta variant and underscored that even with the wild-type lineage, incidence among adolescents and youth exceeded that in older adults.

Objective: Our study assessed the rate of new and recurrent Chlamydia trachomatis and Neisseria gonorrhoeae infections in the third trimester at an adolescent obstetrics clinic., Method: Between October 2016 and June 2020, routine third-trimester screening for C. trachomatis and N. gonorrhoeae was implemented according to new Canadian recommendations. Urine nucleic acid amplification was performed. Patient records were reviewed retrospectively, and demographic data; pregnancy and delivery characteristics; and information on screening at presentation to care, third-trimester screening (33-38 weeks), and other STI testing was recorded., Results: A total of 115 adolescents (mean age 17.90 ± 1.43 y) with 125 pregnancies presented for care. Twenty-three pregnancies were excluded (12 transferred out and 11 experienced a pregnancy loss). At presentation, screening was performed in 100 of 102 pregnancies: 64 of 100 at <13 weeks, 32 of 100 at 13-27 weeks, and 4 of 100 at 28-30 weeks. Nine tested positive for C. trachomatis and none tested positive for N. gonorrhoeae. In the third trimester, there were 3 positive C. trachomatis tests, but all were indicated: test of cure was due for 1 patient, 1 patient had a new sexual partner, and 1 patient presented with symptoms. The remaining 89 of 102 pregnancies were screened (with no other indication) and none were positive for C. trachomatis or N. gonorrhoeae. Ten patients could not be sampled (5 missed, 4 pre-term deliveries, and 1 non-compliant with testing)., Conclusion: No cases of C. trachomatis or N. gonorrhoeae infection were identified on third-trimester screening in our study. Adolescent obstetrics providers implementing Canadian screening guidelines may want to monitor their screening results to determine whether their yield warrants universal implementation., (Copyright © 2021. Published by Elsevier Inc.)

Purpose: There has been considerable controversy regarding susceptibility of adolescents (10-19 years) and youth (15-24 years) to COVID-19. However, a number of studies have reported that adolescents are significantly less susceptible than older adults. Summer 2020 provided an opportunity to examine data on prevalence since after months of lockdowns, with the easing of restrictions, people were mingling, leading to surges in cases., Methods: We examined data from Departments of Health websites in six U.S. states experiencing surges in cases to determine prevalence of COVID-19, and two prevalence-related measures, in adolescents and youth as compared to older adults. The two other measures related to prevalence were: (Percentage of cases observed in a given age group) ÷ (percentage of cases expected based on population demographics); and percentage deviation, or [(% observed-% expected)/ % expected] x 100., Results: Prevalence of COVID-19 for adolescents and for youth was significantly greater than for older adults (p < .00001), as was percentage observed ÷ percentage expected (p < .005). The percentage deviation was significantly greater in adolescents/youth than in older adults (p < 0.00001) when there was an excess of observed cases over what was expected, and significantly less when observed cases were fewer than expected (p< 0.00001)., Conclusions: Our results are contrary to previous findings that adolescents are less susceptible than older adults. Possible reasons for the findings are suggested, and we note that public health messaging targeting adolescents and youth might be helpful in curbing the pandemic. Also, the findings of the potential for high transmission among adolescents and youth, should be factored into decisions regarding school reopening., Competing Interests: The authors have declared no competing interests exist.

Objective: To assess if pregnancies among women with Addison's disease (AD) are at higher risk of adverse maternal and neonatal outcomes., Design: Population-based retrospective cohort study., Setting/population: All births in the United States' Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 2003 to 2011., Methods: Baseline characteristics were compared between women with AD and those without, and prevalence over time was measured. Logistic regression was used to estimate the effect of AD on maternal and neonatal outcomes by calculating the crude and adjusted odds ratios (OR) and corresponding 95% confidence intervals (95% CI)., Results: We calculated a prevalence of AD in pregnancy of 5.5/100 000, increasing from 5.6 to 9.6/100 000 (P = 0.0001) over the 9-year study period. Compared with women without AD, women with AD were more likely to deliver preterm (OR 1.50, 95% CI 1.16-1.95), deliver by caesarean section (OR 1.32, 95% CI 1.08-1.61), have impaired wound healing (OR 4.28, 95% CI 2.55-7.18), develop infections (OR 2.44, 95% CI 1.66-3.58) and develop thromboembolism (OR 5.21, 95% CI 2.15-12.63), require transfusions (OR 6.69, 95% CI 4.69-9.54), and have prolonged postpartum hospital admissions (OR 5.71, 95% CI 4.37-7.47). Maternal mortality was significantly higher than in the comparison group (OR 22.30, 95% CI 6.82-72.96). Congenital anomalies (OR 3.62, 95% CI 2.05-6.39) and small-for-gestational age infants (OR 1.78, 95% CI 1.15-2.75) were more likely in these pregnancies., Conclusions: Addison's disease significantly increases the risk of severe adverse maternal and neonatal outcomes, so pregnant women with AD are best managed in tertiary-care centres., Tweetable Abstract: Pregnancies complicated by Addison's disease have an increased risk of adverse maternal and neonatal outcomes., (© 2016 Royal College of Obstetricians and Gynaecologists.)

Objective: Currently, no ACOG guidelines address the issue of the optimal timing of delivery in placenta previa. Though there is an increased risk of neonatal morbidity and mortality when electively delivered preterm, it is unclear whether adverse neonatal outcomes exist when these pregnancies make it beyond term. By comparing neonatal outcomes amongst pregnancies with placenta previa versus those from cesarean for another indication at term, the objective of this study was to determine whether placenta previa is an independent risk factor for adverse neonatal outcomes at term., Methods: We conducted a population-based cohort-study using the CDC's Linked Birth-Infant Death data from the United States. The effect of placenta previa on the risk of adverse neonatal outcomes was estimated using unconditional logistic regression analysis, adjusting for relevant confounders., Results: Our cohort consisted of 3,550,842 deliveries meeting inclusion criteria. The incidence of placenta previa at term was 1.3/1000 (n = 4,492), accounting for 40.6% of all previa cases. Relative to cesareans for other indications, pregnancies with placenta previa had an increased risk of IUGR 3.20 [2.50-4.10], SGA 2.70 [2.45-2.97], respiratory distress 3.82 [2.91-5.00], prolonged ventilation 3.41 [2.70-4.32] and neonatal anemia 6.87 [4.43-10.65]. Rates of meconium aspiration syndrome, seizures, birth injury and overall infant mortality do not appear to be affected by this condition., Conclusion: Relative to cesareans for other indications, placenta previa is associated with increased morbidity, but not mortality, at term. This information might be helpful in the development of future guidelines, which are currently needed to guide and standardize clinical practice regarding the optimal timing of delivery in placenta previa.

Psychological maltreatment (PM) is a wide-spread form of child maltreatment, both in high-risk and maltreating parents, yet there are no intervention programs that target it directly. In this study, the content of parenting programs for high-risk and maltreating parents was assessed to determine whether the program manuals include content on PM. Nine evidence-based group parenting programs for high-risk or maltreating parents (e.g., included in the SAMHSA or a comparable model program registry) were identified. Program manuals were rated for whether they included content on 18 types of psychological maltreatment (PM). Only one type of PM was rated as being included in all nine programs. Not one of the remaining PM types was rated as being included in more than four programs; and many of the PM types were not rated as being included in any program manual. Therefore, existing parenting program manuals do not contain content related to many forms of psychological maltreatment.

Objectives: Neuroendocrine tumors demonstrate heterogeneous behavior based on the site of origin and histology. This study aimed to delineate prognostic clinicopathologic features in patients with metastatic midgut carcinoid., Methods: All patients underwent resection of the primary tumor in the setting of metastatic disease. Survival was measured from the date of primary tumor resection and calculated by Kaplan-Meier estimation. Clinical data include age, sex, serum biomarkers, primary tumor size, Ki-67 index, and the performance of hepatic cytoreductive procedure. Serially collected serum biomarkers were considered as mean values within periods relative to primary resection: preoperative, 0 to 1 year postoperative, and years 1 to 5 postoperative. Log-rank comparisons were used to assess the prognostic value of the aforementioned features., Results: Forty-nine patients (21 men) with metastatic midgut carcinoid who underwent primary tumor resection were identified. Median survival was 121 months. The overall 5-year survival rate was 83%. Age higher than 65 years (P = 0.01) and late postoperative chromogranin A (CgA; P = 0.02) were associated with decreased survival., Conclusions: This study highlights the favorable prognosis of patients with metastatic small bowel carcinoid in a multidisciplinary treatment program. Among other factors, elevated postoperative CgA is associated with decreased survival. The significance of increased CgA over time underlies the importance of longitudinal follow-up for these patients.

We investigated whether human subjects' ability to identify the direction of a brief pulse of coherent motion in a random-dot pattern (RDP) was influenced by: (a) maintaining in working memory the direction of motion of an RDP previously presented far from the pulse (feature-based working memory or FBWM, Experiment 1), (b) attending to the direction of an RDP co-occurring with but far from the pulse (feature-based attention or FBA, Experiment 2), and (c) both FBWM and FBA acting simultaneously (Experiment 3). In the first two experiments, pulse direction identification performance was higher when the remembered direction (FBWM) or the direction of the concurrently attended RDP (FBA) matched the pulse direction than when it was opposite. In Experiment 3, performance was highest when both the remembered and the attended directions matched the pulse direction (combined effects of FBWM and FBA), it was intermediate when only one of them matched the pulse direction, and it was lowest when neither matched the pulse direction. Our results demonstrate that both feature-based working memory and feature-based attention can individually modulate the perception of motion direction and that when acting together they produce an even larger modulation.

This study assessed the utility of the Child Sexual Behavior Inventory (CSBI) in a child welfare sample. In this study, 97 children from ages 10 to 12 from either foster boarding homes or a residential treatment center participated. Researchers interviewed foster parents or primary therapists about children's sexual behavior, traumatic events, clinical symptoms, and their attitudes toward the child. Findings revealed that problematic sexualized behaviors were more prevalent in the residential treatment center (RTC) sample than they were in a normative sample. The pattern of associations between sexual behavior problems, traumatic events, and clinical syndromes in both the RTC and the foster boarding home (FBH) samples was similar to what has been found in samples in which biological custodial parents were the respondents. Analyses comparing youth who met the criterion for having problematic sexualized behaviors and youth who did not meet the criterion revealed that the two groups differed on clinical symptoms, prior traumatic events, and negative reports by caregivers. Results confirm the utility of the CSBI measure for this population and highlight several important clinical and programmatic concerns for addressing problematic sexual behavior in children in the child welfare system.

This study assessed continuity of problematic sexualized behaviors (PSB) over a 1-year period. Ninety-seven 10-12-year-olds in either foster boarding homes or a residential treatment center participated at Time 1. Twelve months later, 78 youth were available for a second data collection assessment. At both data collection phases, researchers interviewed foster parents or primary therapists about the youths' sexual behavior. Findings revealed significant continuity in PSB over time, with children who at Time 1 exhibited PSB significantly more likely to exhibit PSB at Time 2. The reverse was also true in that the absence of PSB at Time 1 was associated with the absence of PSB at Time 2. In addition, a subset of specific PSB behaviors was noted to be most stable, although this varied across the groups. Youth with PSB exhibited several patterns of persistence in specific behaviors over time, including continuity, a mix of continuity and change, and complete discontinuity. The persistence of PSB over time was most true for the children living in a residential treatment center, the more disturbed group studied. We conclude that the persistence of PSB is more likely when the child has other problematic behaviors.

Forty-eight of 52 (92%) agencies contracted with the New York City Administration for Children's Services (ACS) responded to a survey about problematic sexualized behaviors (PSB) of children in different levels of care within the child welfare system. Results revealed that almost all agencies reported PSB within their foster boarding home and residential treatment centers. A majority of agencies perceived PSB to be a significant problem for which staff and families were not sufficiently trained. These findings highlight many avenues for advocacy, clinical intervention, and staff development.

This article documents the risk factors and high incidence of psychopathology among children in out-of-home placements. A framework and guiding principles for mental health service delivery are described that are consistent with the clinical needs of children in care and the child welfare goal of permanency.

Objective: To evaluate the frequency of home health agency referrals (HHRs) by internists and family physicians., Design: Telephone survey of a randomly selected, nationally representative, stratified physician sample., Participants and Setting: One thousand one hundred sixty-one interviews with 576 family physicians and 585 internists selected from the American Medical Association Physician Masterfile., Main Results: Most respondents (88%) reported making HHRs (mean for those making HHRs = 43/year). Physicians with > or = 48 annual HHRs (n = 315) reported a mean of 2.6 hours/week in home care telephone management and 2.1 hours/week on related paperwork. Rural internists and family physicians (n = 230) reported less availability of several types of non-physician home health services than non-rural respondents (n = 931), yet rural physicians were more likely to refer patients to home health agencies. Using multivariate linear regression, the reported frequency of HHRs was significantly related to rural practice location, number of home-bound patients, proportion of geriatric patients, number of house calls, graduation from a U.S. or Canadian medical school, physician knowledge of community resources, and physician experience either as a medical director, a member of the board of directors, or a consultant for a home health agency., Conclusions: Internists and family physicians who work at least 10 hours per week in ambulatory care report making approximately three home health agency referrals per month and spending substantial amounts of time coordinating home health agency care. Despite reporting less availability of many home health agency services, rural physicians report greater involvement than non-rural physicians in the delivery of home care.

Background: Over the past decade, while physician home visiting has continued to decline, the home care industry has been experiencing dramatic growth. In response, several major physician organizations have been encouraging increased physician education and involvement in home care and urging related health policy changes. This study provides the first in-depth, nationally representative descriptive data on the current home visiting practice and related attitudes of physicians., Methods: Data were gathered through a structured 15-minute telephone survey, consisting of 141 items covering physician's general practice, personal home visiting practice, interaction with other home care providers, and attitudes regarding home care issues. Subjects were a nationally representative, randomly selected sample of 2200 family practice physicians (FPs) and internal medicine physicians (IMs) currently in active practice with at least 10 hours per week of professional time spent in ambulatory care., Results: Sixty-five percent of eligible participants completed the survey. Of all physicians surveyed, 65% of FPs and 44% of IMs reported that they may make house calls (P less than .001). Mean number of visits per year was 21.2 (median, 10) for FPs, and it was 15.7 (median, 6) for IMs. Physicians in rural practice were more likely to make home visits (P less than .001). Physician attitudes related to home care reflect a strong dissatisfaction with reimbursement, but positive opinions about the use of other home care professionals and the importance of home visits for selected patients. Logistic regression analysis comparing home-visiting physicians with non-visiting physicians allowed for prediction of the correct classification 73% of the time, and it revealed six variables that were significant predictors of home visiting. The strongest of these predictors were the physician's positive attitude regarding the importance of home visits for selected patients and his or her perception of having time available for home visits. Other significant variables predictive of home visiting were family practice specialty, rural location of practice, greater numbers of referrals to home care agencies, and, interestingly, dissatisfaction with reimbursement., Conclusions: Although the great majority (over 75%) of FPs and IMs still regard the physician home visit as important for the care of selected patients, only about half report making one or more home visits within a 12-month period. Family physicians generally report a greater involvement in home care than do IMs. Physician reimbursement for home visits is perceived to be inadequate, and almost half (45%) indicate that they would do more home visits if reimbursement were increased. Most physicians (over 80%) have the opinion that home care agencies should be used more.

This paper addresses some enduring issues concerning prevention of environmental and occupational cancer. The first part reviews methodological problems of estimating cancer risks and outlines some research priorities. The second part documents countervailing trends in chemical production during the past two decades, noting the doubling of some synthetic organic human carcinogens and the leveling off of some heavy metal carcinogens. The final section details recent increases in site-specific causes of cancer mortality for men old enough to have developed workplace cancers (ages 35 to 84), considering those cancers that have been linked with exposures to toxic chemicals and to cigarette smoking. This paper points out that Doll and Peto's (1981) analysis of U.S. cancer trends does not indicate some important increases in older males; they conclude that apart from cigarette smoking, there is no generalized increase in cancer for persons up to age 64. In fact, there has been a sharp reduction in cancer mortality for those under age 45. This reduction more than offsets increases in some cancers for those ages 45 to 65. Men ages 55 to 84 have experienced major increases in mortality for certain cancers plausibly associated with occupational exposures, including cancers of the brain, lung, and multiple myeloma. These older age groups have potentially sustained longer workplace exposures to carcinogens, some of which have 25-year or greater latencies. Changes in infectious diseases, workplace exposures, diagnostic trends, environment, and nutrition require further study.

The term "clonal succession" was proposed 20 years ago by Kay to characterize the release of stem cells from their primary pool, followed by the expansion of each cell to a clone and the succession of new clones as the mature cells of each clone are lost because of their finite life span. The authors point out that the events described by Kay as clonal succession are necessary features of hemopoietic proliferation. Clonal succession is equivalent to the universally recognized existence of a self-replicating primary stem cell pool that continuously supplies cells for amplification and maturation to subsequent compartments. The authors object to the term "clonal succession" because it has been used by a number of investigators to characterize specific schemes rather than the general aspects of hemopoietic proliferation, thus leading to confusion. They suggest that the descriptive term, "continuous release of stem cells for differentiation," would be preferable to the use or misuse of "clonal succession."

Analysis of controlled and uncontrolled published papers in clinical cancer therapy has revealed differences in patient data handling, which may reflect both the inherent biases of patient selection for uncontrolled studies and the primary purpose of such studies. A distinction between drug-data oriented research and patient oriented research was advanced to explain these results. If comparable results are to be developed, we urge controlled trials at all phases of treatment development.

Two hundred thirty-nine patients with microscopically proven, inoperable bronchogenic carcinoma were allocated at random to receive twice weekly I.M. injections of either methotrexate at "high dose" of 0.06 mg/kg/dose or methotrexate at "low dose" of 0.2 mg/kg or visually indistinguishable placebo in the same volume of 0.1 ml/kg for four months. Twelve patients were invalidated for procedural reasons. Objective response (greater than or equal to 50% tumor regression) was dose-related with 21% of 48 patients with measurable disease on high -ose, 11% of 37 patients on low dose, and 6% of 32 patients on placebo. Corresponding response rates for epidermoid carcinoma were 35% of 23 patients, 9% of 11 patients, and 0 of 13 patients. Responders in the two treatment groups had a three to four fold increase of median survival (p less than .05). Non-responders on high and low dose methotrexate lived as long as patients on placebo. Leukopenic patients in all three treatment groups lived substantially longer than patients without leukopenia less than 4,500/mm3, irrespective of presence or absence of objective response. All three regimens were well tolerated. None of the patients had life-threatening toxicity. It is concluded that methotrexate at "high dose" is a potentially useful drug for temporary palliation of epidermoid carcinoma of the lung.