Search

Background High rates of unplanned pregnancy and low rates of contraception use are reported among women with sickle cell disease (SCD). Pregnancy in women with SCD is high risk and unintended pregnancies limit opportunities to provide indicated preconception care and counseling. Contraceptive use in women with SCD is complicated by a lack of disease-specific data about treatment risks and benefits. The purpose of this study was to describe, for the first time in the U.S. context, contraceptive use, knowledge and preferences in adult cohort of women with SCD. Materials and Methods A single-center survey study of women with SCD of reproductive age from our Center's adult and pediatric sickle cell centers. Results Seventy-eight women ages 28-65 years (median 33.5 years, IQR 16) completed surveys. Seventy-three percent of respondents had an average of 2.5 pregnancies (S.D. 1.22) and of these, 58% reported being pregnant when they did not want to be pregnant at least once. The most common forms of contraception used were condoms (87%), birth control pills (46%), medroxyprogesterone (44%) and withdrawal (44%). Twenty-two percent of subjects reported using a long-acting reversible form of contraception and 21% reported a tubal ligation or partner vasectomy. Respondents demonstrated low knowledge of the efficacy of contraceptive options and over-estimated the risk of pregnancy with the IUD, implant. Contraceptive priorities included pregnancy prevention, decreasing HIV transmission and effects on SCD symptoms. Conclusions Women with SCD have high rates of unintended pregnancy, low knowledge of contraceptive efficacy and low use of long-acting reversible contraception.

Background The creatinine-based CKD EPI equation is the most widely used method to estimate glomerular filtration rate (eGFRcr) in clinical practice. Here, we focus on African American (AA) participants to determine whether the race eGFRcr calibration factor contributes to poor accuracy and bias in AAs living with HIV. Methods Annually, we measured GFR by iohexol disappearance from plasma (iGFR) and serum concentrations of creatinine and cystatin C. We calculated eGFRcr and the creatinine-cystatin C combination equation (eGFRcr-cys) with and without race adjustment. We used multilevel mixed models to account for the within-visit linked structure of the multiple GFR measures, further nested within repeated observations for individuals. We examined the association between lean mass, HIV status, and eGFRcr bias in a subset with body composition measures. Results 207 HIV-positive and 107 HIV-negative AA participants contributed 781 and 376 study visits, respectively, with valid measures of iGFR, creatinine, and cystatin C. Among PLWH, omitting the race adjustment (compared with retaining it) changed average eGFRcr bias from 9.1 to -3.9 ml/min/1.73 m2. Moreover, estimation accuracy improved significantly when race adjustment was omitted rather than retained: 86% vs. 78% for eGFRcr (P

Background Reducing HIV incidence requires addressing persistent racial/ethnic disparities in HIV burden. Our goal was to evaluate preexposure prophylaxis (PrEP) delivery, overall and relative to community need, among 7 clinical sites participating in a health department-led demonstration project to increase PrEP in Baltimore city, MD. Methods PrEP care continuum stages (screened, indicated, referred, linked, evaluated, prescribed) were examined among HIV-negative individuals receiving services at participating sites between September 30, 2015 and September 29, 2019. Community need was defined using information on new HIV diagnoses (2016-2018). Differences in care continuum progression by demographics/priority population and comparison of demographic compositions between care continuum stages and new HIV diagnoses were examined using modified Poisson regression and χ2 tests, respectively. Results Among 25,886 PrEP-screened individuals, the majority were non-Hispanic (NH) black (81.1%, n = 20,998), cisgender male (61.1%, n = 15,825), and heterosexual (86.7%, n = 22,452). Overall, 31.1% (n = 8063) were PrEP-indicated; among whom, 56.8% (n = 4578), 15.6% (n = 1250), 10.8% (n = 868), and 9.0% (n = 722) were PrEP-referred, linked, evaluated, and prescribed, respectively. Among 2870 men who have sex with men (MSM), 18.7% (n = 538) were PrEP-prescribed. Across all groups, the highest attrition was between PrEP-referred and PrEP-linked. NH-black race (vs. NH-white) was independently associated with lower likelihood of PrEP prescription (aPR, 0.89; 95% confidence interval, 0.81 to 0.98 controlling for age/gender). Relative to the demographic composition of new HIV diagnoses, fewer NH-blacks (80.2% vs. 54.3%) and more NH-whites (10.7% vs. 30.3%) and MSM were PrEP prescribed (55.2% vs. 74.5%). Conclusions This project showed promise delivering PrEP referrals and prescriptions overall and to MSM. Substantial improvement is needed to improve linkage overall and to decrease disparities in PrEP prescriptions among NH-blacks. Future work should focus on addressing service gaps that hinder PrEP utilization.

BackgroundMultisystem inflammatory syndrome in children (MIS-C) is a severe clinical phenotype of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection that remains poorly understood.MethodsHospitalized children ResultsThe median ages for those with and without MIS-C were 8.7 years (interquartile range [IQR], 5.5–13.9) and 2.2 years (IQR, 1.1–10.5), respectively (P = .18), and nasopharyngeal levels of SARS-CoV-2 RNA did not differ significantly between the 2 groups (median 63 848.25 copies/mL versus 307.1 copies/mL, P = .66); 75% of those with MIS-C were antibody positive compared with 44% without (P = .026). Levels of 14 of 37 cytokines/chemokines (interleukin [IL]-1RA, IL-2RA, IL-6, IL-8, tumor necrosis factor-α, IL-10, IL-15, IL-18, monocyte chemoattractant protein [MCP]-1, IP-10, macrophage-inflammatory protein [MIP]-1α, MCP-2, MIP-1β, eotaxin) were significantly higher in children with MIS-C compared to those without, irrespective of age or sex (false discovery rate ConclusionsThe distinct pattern of heightened cytokine/chemokine dysregulation observed with MIS-C, compared with acute COVID-19, occurs across the pediatric age spectrum and with similar levels of nasopharyngeal SARS-CoV-2 RNA.

We determine the association between use of specific cephalosporins and macrolides and hospital length of stay in patients with sickle cell disease (SCD) who are admitted with acute chest syndrome, and determine treatment risk factors for acute chest syndrome-related 30-day readmission.Patients admitted to 48 US hospitals within the Pediatric Health Information System between January 2008 and December 2016 with associated International Classification of Diseases, Ninth Revision (ICD-9) or ICD-10 diagnoses of SCD and acute chest syndrome were included. Primary outcomes were hospital length of stay and acute chest syndrome-related and all-cause 30-day readmission. Data were analyzed with t tests, ANOVA, and bivariable and multivariable linear and logistic regressions.In 21,126 visits (representing 8,856 patients), median age was 11.2 years (interquartile range 6.1 to 16.5 years), 53.5% were male patients, and 77.2% had hemoglobin SS genotype. Median length of stay was 4 days (interquartile range 2 to 6 days; mean 4.76 days [SD 4.62 days]). Ceftriaxone alone (length of stay 4.75 days [SD 4.66 days]; P.001) or the combination of ceftriaxone and azithromycin (length of stay 4.84 days [SD 4.74 days]; P.001) was associated with the shortest length of stay and a reduced risk of acute chest syndrome-related readmission (ceftriaxone odds ratio [OR] 0.31; 95% confidence interval [CI] 0.27 to 0.35; ceftriaxone+azithromycin OR 0.20; 95% CI 0.17 to 0.24). Albuterol (OR 0.97; 95% CI 0.96 to 0.98) and RBC transfusion (OR 0.60; 95% CI 0.43 to 0.83) were also associated with decreased rates of acute chest syndrome-related 30-day readmission. All-cause 30-day readmission rate was 16.7% (95% CI 16.2% to 17.3%).Guideline-compliant therapy for acute chest syndrome could preferentially include ceftriaxone and azithromycin. All-cause 30-day readmission for acute chest syndrome is lower than that reported for all-cause readmissions for SCD and more consistent with rates of readmission for pneumonia in the general population.

Supplemental Digital Content is available in the text., OBJECTIVES: To assess the effectiveness of a chaplain patient navigator in improving outcomes and reducing costs in the ICU setting. DESIGN: A randomized controlled trial at a large, urban, academic community hospital in Baltimore, Maryland. SETTING/PATIENTS: All patients admitted to the Johns Hopkins Bayview Medical Center Cardiac and Medical ICUs between March 2015 and December 2015. INTERVENTIONS: Patients in the intervention group were assigned a chaplain patient navigator to facilitate communication, offer support, and setup multidisciplinary family meetings. MEASUREMENTS AND MAIN RESULTS: The primary outcomes were hospital and ICU length of stay. Secondary outcomes included total and ICU charges, 60- and 90-day readmission rates, and the number of palliative care consults. For all outcomes, patients were included in the intention-to-treat analyses only if they remained in the ICU greater than 24 hours. In total, 1,174 were randomly assigned to “usual care” (n = 573) or to the intervention (n = 601). In the intervention group, 44.8% (269/601) had meetings within 24 hours of admission and, of those patients, 32.8% (88/268) took part in the larger multidisciplinary family meeting 2–3 days later. The intervention group had longer mean adjusted hospital length of stay (7.78 vs 8.63 d; p ≤ 0.001) and mean ICU length of stay (3.65 vs 3.87 d; p = 0.029). In addition, they had greater total and ICU charges. There were no differences in other outcomes. Of note, only differences in total and ICU charges remained when controlling for case-mix index, which were greater in the intervention group. CONCLUSIONS: Although the chaplain patient navigator anecdotally enhanced communication, our study found an increase in hospital and ICU length of stay as well as cost. Since other studies have shown benefits in some clinical outcomes, projects focused on patient navigators may learn lessons from our study in order to better prioritize family meetings, gather indicators of communication quality, and identify the optimal patient navigator operational context.

The objective of this evaluation was to assess the use of public health detailing in a pilot program to increase Expedited Partner Therapy (EPT) uptake among community-based providers in two Maryland jurisdictions. Public health detailing is a method designed to raise awareness and increase implementation of evidence-based clinical practices by delivering educational content via one-on-one meetings with providers. EPT is a voluntary clinical practice of treating all sexual partners of patients diagnosed with STIs by prescribing medications without the provider first examining said sexual partners. The aim of EPT is to prevent STI reinfection and reduce further transmission. From April 2017 to March 2019, detailers visited community-based health care practice sites to conduct EPT detailing with providers. The effectiveness of this program was evaluated by comparing provider responses from pre- to post-detailing surveys, administered six months after detailing. Survey responses assessed EPT awareness and practices, barriers to implementation, and satisfaction with detailing. The proportion of providers (170) aware of EPT for treating chlamydia and gonorrhea increased from 61.7% (114) to 99.4% (169) (p-value

Young people aged less than 25 years bear the highest burden of sexually transmitted infections (STIs) in the United States. Here we sought to characterize patients aged 15–24 compared with patients ≥age 25 utilizing a database of first visits to two STI clinics in Baltimore, USA from 2011 to 2016. Acute STI (aSTI) was defined as gonorrhea (GC), trichomonas, or early syphilis (ES) in women and non-gonococcal urethritis, GC, Chlamydia (CT), and ES in men. Proportions were compared using the Chi square test and logistic regression was used to assess aSTI predictors in younger versus older groups, stratified by gender. Fifteen thousand four hundred and sixty-three first visits for patients

PURPOSE: To characterize female pediatric and adolescent patients seen for fertility preservation consultation at an academic medical center and to describe the association between demographic or clinical factors and the use of fertility preservation treatment (FPT). METHODS: This is a retrospective chart analysis of female pediatric and adolescent patients seen for fertility preservation consultation at an academic fertility center over a 14-year period from 2005 to 2019. RESULTS: One hundred six females aged 3–21 years were seen for fertility preservation consultation with a mean age of 16.6 years. Diagnoses included hematologic malignancies (41.5%), gynecologic malignancies (9.4%), other malignancies (31.1%), non-malignant hematologic disease (14.2%), and non-malignant conditions (3.8%). Overall, 64.2% of subjects pursued fertility preservation, including oocyte cryopreservation (35.8%) and ovarian tissue cryopreservation (23.6%). Overall, age, minority race, diagnosis, time since diagnosis, and median household income were not significantly associated with odds of completing an FPT procedure. Among all patients, those who underwent gonadotoxic therapy prior to consultation had a lower odds of receiving FPT (OR= 0.24, 95% CI 0.10–0.55). Among patients without chemotherapy exposure, no factors were associated with FPT. CONCLUSIONS: Among pediatric and adolescent patients at an academic center undergoing a fertility preservation consultation, there were no socioeconomic or clinical barriers to FPT use in those who had not yet undergone gonadotoxic therapy. The only factor that was negatively associated with odds of pursuing FPT was prior chemotherapy exposure. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s10815-021-02286-y.

Background: The creatinine-based CKD EPI equation is the most widely used method to estimate glomerular filtration rate (eGFRcr) in clinical practice. The eGFRcr adjusts for sex, age, and race (Black vs non-Black) and was derived and validated in aggregated datasets from US-based research studies in which GFR was measured directly. However, in prior work, we found eGFRcr performed worse in people living with HIV (PLWH) compared to HIV negative counterparts which may be due to differences in muscle mass, the major source of creatinine. Here, we focus on African American (AA) participants to determine whether the race eGFRcr calibration factor contributes to poor accuracy and bias in AAs living with HIV. Methods: Beginning in 2010, we enrolled and followed an AA cohort of PLWH and HIV-negative participants in Baltimore Maryland. Annually, we measured GFR by iohexol disappearance from plasma (iGFR) and serum concentrations of creatinine and cystatin C. This analysis was restricted to AA participants. We calculated eGFRcr and the creatinine-cystatin C combination equation (eGFRcr-cys) with and without race adjustment. Accuracy was defined as the fraction of eGFR values within +/- 30% of iGFR. Bias was defined as eGFR minus iGFR, with positive and negative values representing overestimation and underestimation of iGFR, respectively. We used multilevel mixed models to account for the within-visit linked structure of the multiple GFR measures, further nested within repeated observations for individuals. We examined the association between lean mass, HIV status, and eGFRcr bias in a subset with body composition measures. Findings: 207 HIV-positive and 107 HIV-negative AA participants contributed 781 and 376 study visits, respectively, with valid measures of iGFR, creatinine, and cystatin C. Among PLWH, omitting the race adjustment (compared with retaining it) changed average eGFRcr bias from 9.1 to -3.9 ml/min/1.73 m2. Moreover, estimation accuracy improved significantly when race adjustment was omitted rather than retained: 86% vs. 78% for eGFRcr (P

OBJECTIVE To determine if neonatal serum biomarkers representing different pathways of injury differ for cases of HIE of unknown cause to gain insight into timing and mechanism of injury. STUDY DESIGN In this cohort of all neonates with HIE admitted to our NICU, newborns with sentinel events were compared to those without during the 1st 3 days of life. Discard neonatal blood during the 1st 3 days of life was used for analysis. RESULTS Of 277 babies with HIE treated with whole-body hypothermia, 190 (68.6%) had blood available for biomarker analysis. 71 (37.4%) were born within our system, and 119 (62.6%) were transferred in from outside hospitals. Of these babies, 77 (40.5%) had a sentinel event and 113 (59.6%) had no sentinel event. Although the degree of metabolic acidosis was similar, repeated measures analysis showed that during the initial 3 days of life neonates born with HIE in the absence of sentinel events had 41.4% decreased VEGF (p=0.027) and 62.5% increased IL-10 serum concentrations (p=0.005). CONCLUSION These changes indicate that neonatal HIE in the absence of sentinel events is not related to an unrecognized acute intrapartum event and is possibly related to chronic hypoxia of lower severity or recovery from a remote event.

Background Pulmonary arterial hypertension (PAH) is a fatal disease that results from cardio-pulmonary dysfunction with the pathology largely unknown. Insulin-like growth factor binding protein 2 (IGFBP2) is an important member of the insulin-like growth factor family, with evidence suggesting elevation in PAH patients. We investigated the diagnostic and prognostic value of serum IGFBP2 in PAH to determine if it could discriminate PAH from healthy controls and if it was associated with disease severity and survival. Methods Serum IGFBP2 levels, as well as IGF1/2 levels, were measured in two independent PAH cohorts, the Johns Hopkins Pulmonary Hypertension program (JHPH, N = 127), NHLBI PAHBiobank (PAHB, N = 203), and a healthy control cohort (N = 128). The protein levels in lung tissues were determined by western blot. The IGFBP2 mRNA expression levels in pulmonary artery smooth muscle cells (PASMC) and endothelial cells (PAEC) were assessed by RNA-seq, secreted protein levels by ELISA. Association of biomarkers with clinical variables was evaluated using adjusted linear or logistic regression and Kaplan-Meier analysis. Results In both PAH cohorts, serum IGFBP2 levels were significantly elevated (p p Conclusions IGFBP2 protein expression was increased in the PAH lung, and secreted by PASMC. Elevated circulating IGFBP2 was associated with PAH severity and mortality and is a potentially valuable prognostic marker in PAH.