Search

Background The goal of risk-appropriate maternal care is for high-risk pregnant women to receive specialized obstetrical services in facilities equipped with capabilities and staffing to provide care or transfer to facilities with resources available to provide care. In the United States, geographic access to critical care obstetrics varies. It is unknown whether this variation in proximity to critical care obstetrics differs by race, ethnicity, and region. Objective We examined the geographic access, defined as residence within 50 miles of a facility capable of providing risk-appropriate critical care obstetrics services for women of reproductive age, by distribution of race and ethnicity. Study Design Descriptive spatial analysis was used to assess geographic distance to critical care obstetrics for women of reproductive age by race and ethnicity. Data were analyzed geographically: nationally, by the Department of Health and Human Services regions, and by all 50 states and the District of Columbia. Dot density analysis was used to visualize geographic distributions of women by residence and critical care obstetrics facilities across the United States. Proximity analysis defined the proportion of women living within an approximate 50-mile radius of facilities. Source data included the 2015 American Community Survey from the United States Census Bureau and the 2015 American Hospital Association Annual Survey. Results Geographic access to critical care obstetrics was the greatest for Asian and Pacific Islander women of reproductive age (95.8%), followed by black (93.5%), Hispanic (91.4%), and white women of reproductive age (89.1%). American Indian and Alaska Native women had more limited geographic access (66%) in all regions. Visualization of proximity to critical care obstetrics indicated that facilities were predominantly located in urban areas, which may limit access to women in frontier or rural areas of states including nationally recognized reservations where larger proportions of white women and American Indian and Alaska Native women reside, respectively. Conclusion Disparities in proximity to critical care obstetrics exist in rural and frontier areas of the United States, which affect white women and American Indian and Alaska Native women, primarily. Examining insurance coverage, interstate hospital referral networks, and transportation barriers may provide further insight into critical care obstetrics accessibility. Further exploring the role of other equity-based measures of access on disparities beyond geography is warranted.

Objective To compare the risk of preeclampsia among spontaneously conceived pregnancies to those after hyperestrogenic ovarian stimulation (hyperestrogenic OS) with and without assisted reproductive technology (ART), and stimulation with non-hyperestrogenic aromatase inhibitor stimulation (non-hyperestrogenic OS). Methods Live-born singleton deliveries among women 20-49 years were identified in the 2004-2012 Truven Health MarketScan Commercial Claims and Encounters Databases using ICD-9 and CPT codes. Maternal characteristics were compared using Chi squared and Fisher exact tests. We performed multilevel multivariable logistic regression, controlling for maternal age, parity, comorbid conditions, and region of delivery, and calculated adjusted odds ratios (aOR) and 95 % confidence intervals for mild and severe preeclampsia. Results 1,014,526 spontaneously conceived, 6881 hyperestrogenic OS with ART, 27,516 hyperestrogenic OS without ART, and 2117 non-hyperestrogenic OS pregnancies were identified. The adjusted odds of developing preeclampsia were increased for deliveries after hyperestrogenic OS with ART (mild preeclampsia aOR 1.42, 1.24-1.62; severe preeclampsia aOR 1.83, 1.59-2.11) and without ART (mild preeclampsia aOR 1.32, 1.24-1.42; severe preeclampsia aOR 1.53, 1.41-1.66). Adjusted odds of preeclampsia were similar between spontaneously conceived and non-hyperestrogenic OS pregnancies. Conclusions for Practice Risk of preeclampsia after ART may in part be related to supraphysiologic estrogen associated with hyperestrogenic OS.

BACKGROUND: There is limited information on the patterns and trends of contraceptive use among women living with HIV, compared with noninfected women in the United States. Further, little is known about whether antiretroviral therapy correlates with contraceptive use. Such information is needed to help identify potential gaps in care and to enhance unintended pregnancy prevention efforts. OBJECTIVE: We sought to compare contraceptive method use among HIV-infected and noninfected privately insured women in the United States, and to evaluate the association between antiretroviral therapy use and contraceptive method use. STUDY DESIGN: We used a large US nationwide health care claims database to identify girls and women ages 15–44 years with prescription drug coverage. We used diagnosis, procedure, and National Drug Codes to assess female sterilization and reversible prescription contraception use in 2008 and 2014 among women continuously enrolled in the database during 2003 through 2008 or 2009 through 2014, respectively. Women with no codes were classified as using no method; these may have included women using nonprescription methods, such as condoms. We calculated prevalence of contraceptive use by HIV infection status, and by use of antiretroviral therapy among those with HIV. We used multivariable polytomous logistic regression to calculate unadjusted and adjusted odds ratios and 95% confidence intervals for female sterilization, long-acting reversible contraception, and short-acting hormonal contraception compared to no method. RESULTS: While contraceptive use increased among HIV-infected and noninfected women from 2008 through 2014, in both years, a lower proportion of HIV-infected women used prescription contraceptive methods (2008: 17.5%; 2014: 28.9%, compared with noninfected women (2008: 28.8%; 2014: 39.8%, P < .001 for both). Controlling for demographics, chronic medical conditions, pregnancy history, and cohort year, HIV-infected women compared to HIV-noninfected women had lower odds of using long-acting reversible contraception (adjusted odds ratio, 0.67; 95% confidence interval, 0.52–0.86 compared to no method) or short-acting hormonal contraception method (adjusted odds ratio, 0.59; 95% confidence interval, 0.50–0.70 compared to no method). In 2014, HIV-infected women using antiretroviral therapy were significantly more likely to use no method (76.8% vs 64.1%), and significantly less likely to use short-acting hormonal contraception (11.0% vs 22.7%) compared to HIV-infected women not using antiretroviral therapy. Those receiving antiretroviral therapy had lower odds of using short-acting hormonal contraception compared to no method (adjusted odds ratio, 0.45; 95% confidence interval, 0.32–0.63). There was no significant difference in female sterilization by HIV status or antiretroviral therapy use. CONCLUSION: Despite the safety of reversible contraceptives for women with HIV, use of prescription contraception continues to be lower among privately insured HIV-infected women compared to noninfected women, particularly among those receiving antiretroviral therapy.

Objective To assess trends and outcomes of assisted hatching among assisted reproductive technology (ART) cycles. Design Retrospective cohort analysis using National ART Surveillance System (NASS) data. Setting U.S. fertility centers reporting to NASS. Patient(s) Fresh autologous noncanceled ART cycles conducted from 2000–2010. Intervention(s) None. Main Outcome Measure(s) Implantation, clinical pregnancy, live-birth, miscarriage, multiple gestation. Result(s) Assisted hatching use statistically significantly increased in absolute number (from 25,724 to 35,518 cycles), percentages of day-3 (from 50.7% to 56.3%) and day-5 transfers (from 15.9% to 22.8%), and percentage of transfers among women ≥38 years (from 17.8% to 21.8%) or women with ≥2 prior ART cycles and no live birth(s) (from 4.3% to 7.4%). Both day-3 and day-5 cycles involving assisted hatching were associated with lower odds of implantation (adjusted odds ratios [aOR] 0.7 and 0.6, respectively), clinical pregnancy (aOR 0.8 and 0.7, respectively), live birth (aOR 0.8 and 0.7, respectively), and increased odds of miscarriage (aOR 1.4 and 1.4, respectively), as compared with cycles without assisted hatching. Assisted hatching was associated with lower odds of multiple gestation in day-5 cycles (aOR 0.8). In cycles for women with a "poor prognosis," the association of assisted hatching with pregnancy outcomes was not statistically significant. Conclusion(s) Assisted hatching use had an increasing trend but was not associated with improved pregnancy outcomes, even in poor-prognosis patients. Prospective studies are needed to identify the patients who may benefit from assisted hatching.

OBJECTIVE: To calculate incidence of postpartum venous thromboembolism by week after delivery and to examine potential risk factors for venous thromboembolism overall and at different times during the postpartum period. METHODS: A deidentified health care claims information database from employers, health plans, hospitals, and Medicaid programs across the United States was used to identify delivery hospitalizations among women aged 15–44 years during the years 2005–2011. International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedure codes were used to identify instances of venous thromboembolism and associated characteristics and conditions among women with recent delivery. Incidence proportions of venous thromboembolism by week postpartum through week 12 were calculated per 10,000 deliveries. Logistic regression was used to calculate odds ratios for selected risk factors among women with postpartum venous thromboembolism and among women with venous thromboembolism during the early or later postpartum periods. RESULTS: The incidence proportion of postpartum venous thromboembolism was highest during the first 3 weeks after delivery, dropping from nine per 10,000 during the first week to one per 10,000 at 4 weeks after delivery and decreasing steadily through the 12th week. Certain obstetric procedures and complications such as cesarean delivery, preeclampsia, hemorrhage, and postpartum infection conferred an increased risk for venous thromboembolism (odds ratios ranging from 1.3 to 6.4), which persisted over the 12-week period compared with women without these risk factors. CONCLUSION: Risk for postpartum venous thromboembolism is highest during the first 3 weeks after delivery. Women with obstetric complications are at highest risk for postpartum venous thromboembolism, and this risk remains elevated throughout the first 12 weeks after delivery.

To examine trends in severe maternal morbidity from 2008 to 2012 in delivery and postpartum hospitalizations among pregnancies conceived with or without assisted reproductive technology (ART).In this retrospective cohort study, deliveries were identified in the 2008-2012 Truven Health MarketScan Commercial Claims and Encounters Databases. Severe maternal morbidity was identified using International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes and Current Procedural Terminology codes. Rate of severe maternal morbidity was calculated for ART and non-ART pregnancies. We performed multivariable logistic regression, controlling for maternal characteristics, and calculated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for severe morbidity. Additionally, a propensity score analysis was performed between ART and non-ART deliveries.Of 1,016,618 deliveries, 14,761 (1.5%) were identified as pregnancies conceived with ART. Blood transfusion was the most common severe morbidity indicator for ART and non-ART pregnancies. For every 10,000 singleton deliveries, there were 273 ART deliveries or postpartum hospitalizations with severe maternal morbidity compared with 126 for non-ART (P.001). For ART singleton deliveries, the rate of severe morbidity decreased from 369 per 10,000 deliveries in 2008 to 219 per 10,000 deliveries in 2012 (P=.025). Odds of severe morbidity were increased for ART compared with non-ART singletons (adjusted OR 1.84, 95% CI 1.63-2.08). Among multiple gestations, there was no significant difference between ART and non-ART pregnancies (rate of severe morbidity for ART 604/10,000 and non-ART 539/10,000 deliveries, P=.089; adjusted OR 1.04, 95% CI 0.91-1.20). Propensity score matching agreed with these results.Singleton pregnancies conceived with ART are at increased risk for severe maternal morbidity; however, the rate has been decreasing since 2008. Multiple gestations have increased risk regardless of ART status.

Background Migraine with aura and combined hormonal contraceptives are independently associated with an increased risk of ischemic stroke. However, little is known about whether there are any joint effects of migraine and hormonal contraceptives on risk of stroke. Objective We sought to estimate the incidence of stroke in women of reproductive age and examine the association among combined hormonal contraceptive use, migraine type (with or without aura), and ischemic stroke. Study Design This study used a nationwide health care claims database and employed a nested case-control study design. Females ages 15-49 years with first-ever stroke during 2006 through 2012 were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification inpatient services diagnosis codes. Four controls were matched to each case based on age. Migraine headache with and without aura was identified using inpatient or outpatient diagnosis codes. Current combined hormonal contraceptive use was identified using the National Drug Code from the pharmacy database. Conditional logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals of ischemic stroke by migraine type and combined hormonal contraceptive use. Results From 2006 through 2012, there were 25,887 ischemic strokes among females ages 15-49 years, for a cumulative incidence of 11 strokes/100,000 females. Compared to those with neither migraine nor combined hormonal contraceptive use, the odds ratio of ischemic stroke was highest among those with migraine with aura using combined hormonal contraceptives (odds ratio, 6.1; 95% confidence interval, 3.1–12.1); odds ratios were also elevated for migraine with aura without combined hormonal contraceptive use (odds ratio, 2.7; 95% confidence interval, 1.9–3.7), migraine without aura and combined hormonal contraceptive use (odds ratio, 1.8; 95% confidence interval, 1.1–2.9), and migraine without aura without combined hormonal contraceptive use (odds ratio, 2.2; 95% confidence interval, 1.9–2.7). Conclusion The joint effect of combined hormonal contraceptives and migraine with aura was associated with a 6-fold increased risk of ischemic stroke compared with neither risk factor. Use of combined hormonal contraceptives did not substantially further increase risk of ischemic stroke among women with migraine without aura. Determining migraine type is critical in assessing safety of combined hormonal contraceptives among women with migraine.

This research was an investigation into four challenges purported to confront cross-sex friends. One hundred and thirty eight individuals (females = 86, males = 52) completed two surveys designed to explore the extent to which the “sexual,” “emotional bond,” “audience,” and “equality” challenges were present in their cross-sex friendships. Over 98% of the participants were heterosexual, 99% were Caucasian, and approximately 5% were Hispanic. Data gathered from the first survey were analyzed using a three-way analysis of variance, with gender, type of friendship, and romantic status as the independent variables, and three of the four challenges as the dependent variables. The first survey also included open-ended questions designed to explore the nature and existence of the challenges. The second survey was in a diary format. Respondents kept a frequency count for three weeks of discussions they had with their cross-sex friend concerning the challenges, and thoughts that they had as individuals concerning those challenges. Results from both surveys indicate that though the challenges exist and have powerful effects on a small percentage of individuals in cross-sex friendships, for the majority of participants the challenges are not perceived as salient.

Because of the task and social pressures involved in doing a dissertation, a significant percentage of graduate students never complete it. This essay describes a procedure that communication departments, advisors, and graduate students can utilize to help students cope with the task and social pressures that accompany working on a dissertation, and is written from the phenomenological perspective of two recent PhDs who went through the process of completing their dissertations together. Being and having a dissertation partner supplements the advisor's role by providing task support in the form of weekly meetings and social support in the form of empathy and companionship. Suggestions are made concerning how this procedure might be incorporated into PhD programs so as to lessen the number of individuals who never complete their dissertations.

Background Transmitted HIV-1 drug resistance can compromise initial antiretroviral therapy (ART); therefore, its detection is important for patient management. The absence of drug-associated selection pressure in treatment-naïve persons can cause drug-resistant viruses to decline to levels undetectable by conventional bulk sequencing (minority drug-resistant variants). We used sensitive and simple tests to investigate evidence of transmitted drug resistance in antiretroviral drug-naïve persons and assess the clinical implications of minority drug-resistant variants. Methods and Findings We performed a cross-sectional analysis of transmitted HIV-1 drug resistance and a case-control study of the impact of minority drug resistance on treatment response. For the cross-sectional analysis, we examined viral RNA from newly diagnosed ART-naïve persons in the US and Canada who had no detectable (wild type, n = 205) or one or more resistance-related mutations (n = 303) by conventional sequencing. Eight validated real-time PCR-based assays were used to test for minority drug resistance mutations (protease L90M and reverse transcriptase M41L, K70R, K103N, Y181C, M184V, and T215F/Y) above naturally occurring frequencies. The sensitive real-time PCR testing identified one to three minority drug resistance mutation(s) in 34/205 (17%) newly diagnosed persons who had wild-type virus by conventional genotyping; four (2%) individuals had mutations associated with resistance to two drug classes. Among 30/303 (10%) samples with bulk genotype resistance mutations we found at least one minority variant with a different drug resistance mutation. For the case-control study, we assessed the impact of three treatment-relevant drug resistance mutations at baseline from a separate group of 316 previously ART-naïve persons with no evidence of drug resistance on bulk genotype testing who were placed on efavirenz-based regimens. We found that 7/95 (7%) persons who experienced virologic failure had minority drug resistance mutations at baseline; however, minority resistance was found in only 2/221 (0.9%) treatment successes (Fisher exact test, p = 0.0038). Conclusions These data suggest that a considerable proportion of transmitted HIV-1 drug resistance is undetected by conventional genotyping and that minority mutations can have clinical consequences. With no treatment history to help guide therapies for drug-naïve persons, the findings suggest an important role for sensitive baseline drug resistance testing., Using real-time PCR to detect HIV resistance mutations present at low levels, Jeffrey Johnson and colleagues investigate prevalence and clinical implications of minority transmitted mutations., Editors' Summary Background Since the mid-1990s, several powerful antiretroviral drug combinations have been developed that have greatly improved the prognosis of HIV infection. All antiretroviral therapy (ART) regimens combine drugs that act against HIV in different ways (so-called different drug classes). Multiple drugs are necessary because HIV continually accumulates random changes (mutations) in its genetic material (genome). Some of these mutations make HIV resistant to individual antiretroviral drugs, so a mixture of drugs is needed to keep the virus in check. However, the efficacy of ART (which itself selects for drug-resistant variants by giving them a growth advantage over drug-sensitive variants) is substantially reduced when these variants account for more than about 20% of the viruses in an infected person. This level of variant virus can be detected in blood samples with a technique called bulk sequencing. In North America and Europe, where ART has been widely used for many years, around 20% of HIV-infected people who have taken ART themselves develop this level of drug-resistant virus, which can be transmitted by the same routes as nonresistant HIV (typically unprotected sexual intercourse or needle sharing). In such cases, the person acquiring drug-resistant HIV may experience treatment failure when drugs later fail to work against the resistant virus. In these countries, therefore, resistance testing by bulk sequencing is done routinely before ART is initiated to decide which antiviral drugs are likely to be effective. Why Was This Study Done? Several years usually elapse between the time a person becomes infected with HIV and the time he or she starts ART. During this time, the absence of selection pressure from antiviral drugs means that transmitted drug-resistant variants tend to decline to levels undetectable by bulk sequencing. These “minority drug-resistant variants” can be detected using other more sensitive tests but it is not known what proportion of HIV-infected people who have never taken ART carry minority drug-resistant variants (the “prevalence” of these variants). It is also unknown whether the presence of minority drug-resistant variants reduces the success of ART. In this paper, the researchers first report a “cross-sectional” study in North America using a sensitive assay to determine the prevalence of minority drug-resistant viruses among HIV-infected people who had never received ART. They then investigate whether minority drug-resistant variants have any impact on the effectiveness of ART in a “case-control” study. What Did the Researchers Do and Find? In their cross-sectional study, the researchers used a highly sensitive test for detecting mutations (called a real-time PCR-based assay) to look for low levels of viruses carrying any of eight major drug-resistance mutations in people with newly diagnosed HIV infection who reported no prior treatment with ART. Seventeen percent of the people who had only wild-type (nonmutated) virus by bulk sequencing (205 participants) were found, in fact, to carry low levels of virus variants with 1–3 drug-resistance mutations; 2% of them carried viruses resistant to two different drug classes (called multi-drug resistance). Among the people with resistance mutations detected by bulk sequencing (303 participants), 10% had at least one additional minority drug-resistant variant, often a viral variant that was resistant to a drug class different from that detected by bulk sequencing. In the case-control study, the researchers used their sensitive assays to measure the levels of viruses containing any of the three most common drug resistance mutations likely to affect viral responses to the antiretroviral drugs efavirenz and lamivudine in 316 people just before they started their first HIV treatment, which included these drugs. Of people for whom ART failed, 7% were infected with minority drug-resistant virus variants at baseline compared with only 0.9% of people for whom ART worked; this difference was statistically significant. What Do These Findings Mean? The findings of the cross-sectional study indicate that conventional bulk sequencing fails to detect a large proportion of transmitted HIV drug resistance and suggest that the transmission of drug-resistant variants from infectious ART-experienced people to ART-naïve individuals might not be uncommon. The findings of the case-control study suggest that the minority drug-resistant HIV variants may have clinical consequences. That is, the presence of such variants in individuals who have not previously taken ART may reduce the efficacy of some ART regimens. However, the number of participants meeting the criteria for analysis in the cross-sectional study was limited, and the association between minority resistance and treatment failure may have been influenced by other factors. Taken together, these findings suggest that, to ensure that first-line ART is as effective as possible, greater efforts should be made to prevent HIV transmission, whether from ART-experienced or ART-naive people. However, because data on minority drug-resistant virus are limited, more studies— particularly with recent populations—are needed before testing for these variants can be considered appropriate in the clinical management of newly diagnosed HIV infection. Additional Information. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050158. This study is further discussed in a PLoS Medicine Perspective by Steven G. Deeks Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS HIV InSite has comprehensive information on all aspects of HIV/AIDS, including links to fact sheets (in English, French, and Spanish) about antiretrovirals and information on genetic testing for HIV drug resistance NAM, a UK registered charity, provides information about all aspects of HIVand AIDS, including fact sheets on types of HIV drug, drug resistance, and resistance tests (in English, Spanish, French, Portuguese, and Russian) The US Centers for Disease Control and Prevention provides information on HIV/AIDS and on treatment (in English and Spanish)

In the absence of an effective vaccine, HIV continues to spread globally, emphasizing the need for novel strategies to limit its transmission. Pre-exposure prophylaxis (PrEP) with antiretroviral drugs could prove to be an effective intervention strategy if highly efficacious and cost-effective PrEP modalities are identified. We evaluated daily and intermittent PrEP regimens of increasing antiviral activity in a macaque model that closely resembles human transmission.We used a repeat-exposure macaque model with 14 weekly rectal virus challenges. Three drug treatments were given once daily, each to a different group of six rhesus macaques. Group 1 was treated subcutaneously with a human-equivalent dose of emtricitabine (FTC), group 2 received orally the human-equivalent dosing of both FTC and tenofovir-disoproxil fumarate (TDF), and group 3 received subcutaneously a similar dosing of FTC and a higher dose of tenofovir. A fourth group of six rhesus macaques (group 4) received intermittently a PrEP regimen similar to group 3 only 2 h before and 24 h after each weekly virus challenge. Results were compared to 18 control macaques that did not receive any drug treatment. The risk of infection in macaques treated in groups 1 and 2 was 3.8- and 7.8-fold lower than in untreated macaques (p = 0.02 and p = 0.008, respectively). All six macaques in group 3 were protected. Breakthrough infections had blunted acute viremias; drug resistance was seen in two of six animals. All six animals in group 4 that received intermittent PrEP were protected.This model suggests that single drugs for daily PrEP can be protective but a combination of antiretroviral drugs may be required to increase the level of protection. Short but potent intermittent PrEP can provide protection comparable to that of daily PrEP in this SHIV/macaque model. These findings support PrEP trials for HIV prevention in humans and identify promising PrEP modalities.

Backgroud In our previous work, oral chemoprophylaxis with tenofovir disoproxil fumarate (TDF) provided partial protection in rhesus macaques against repeated low-dose (RL) intrarectal SHIV162p3 exposure. Methods Here, we make a direct comparison of these previous findings with data generated using a single high (SH)-dose challenge strategy. Results All 5 (100%) control macaques were infected after a SH challenge and only three of five (60%) TDF-treated macaques became infected. The remaining two TDF-treated macaques remained virus-negative and were susceptible to virus infection upon re-challenge in the absence of oral TDF. Thus, two of five (40%) TDF-treated macaques were protected by the pre-exposure chemoprophylaxis regimen. By comparison with the RL challenge system, only one of four (25%) of TDF-treated macaques were protected from infection, whereas four of four (100%) control macaques became infected using RL challenges. Conclusion Taken together, these findings indicate that the stringency of the RL challenge model for testing antiretroviral interventions is not lower and possibly greater than that of the SH challenge model.

On 12 January 2010, a 7.0-magnitude earthquake devastated the island nation of Haiti, leading to the world's largest humanitarian effort in over 6 decades. The catastrophe caused massive destruction of homes and buildings and overwhelmed the Haitian health care system. The United States responded immediately with a massive relief effort, sending U.S. military forces and civilian volunteers to Haiti's aid and providing a tertiary care medical center aboard the USNS COMFORT hospital ship. The COMFORT offered sophisticated medical care to a geographically isolated population and helped to transfer resource-intensive patients from other treatment facilities. Working collaboratively with the surgical staff, ancillary services, and nursing staff, internists aboard the COMFORT were integral to supporting the mission of the hospital ship and provided high-level care to the casualties. This article provides the perspective of the U.S. Navy internists who participated in the initial response to the Haitian earthquake disaster onboard the COMFORT.