Alicia Roston

Staying on track: a cluster randomized controlled trial of automated reminders aimed at increasing human papillomavirus vaccine completion.

OBJECTIVES To evaluate whether automated reminders increase on-time completion of the three-dose human papillomavirus (HPV) vaccine series. METHODS Ten reproductive health centers enrolled 365 women aged 19-26 to receive dose one of the HPV vaccine. Health centers were matched and randomized so that participants received either routine follow-up (control) or automated reminder messages for vaccine doses two and three (intervention). Intervention participants selected their preferred method of reminders - text, e-mail, phone, private Facebook message, or standard mail. We compared vaccine completion rates between groups over a period of 32 weeks. RESULTS The reminder system did not increase completion rates, which overall were low at 17.2% in the intervention group and 18.9% in the control group (p=0.881). Exploratory analyses revealed that participants who completed the series on-time were more likely to be older (OR=1.15, 95% CI 1.01-1.31), report having completed a four-year college degree or more (age-adjusted OR=2.51, 95% CI 1.29-4.90), and report three or more lifetime sexual partners (age-adjusted OR=3.45, 95% CI 1.20-9.92). CONCLUSIONS The study intervention did not increase HPV vaccine series completion. Despite great public health interest in HPV vaccine completion and reminder technologies, completion rates remain low.

Assessing the extent of provision of comprehensive medical care management for female sexual assault patients in US hospital emergency departments

To describe medical services provided to sexual assault patients in US emergency departments and to identify the percentage of hospitals always providing the 10 elements of comprehensive medical care management (CMCM).

Doulas as facilitators: the expanded role of doulas into abortion care

The involvement of a lay support person, known as a doula, in the labour process is a long-standing practice across different cultures and traditions. A great body of literature exists evaluating the effect of a support layperson within the labour process on maternal and neonatal outcomes. This literature demonstrates a positive association between doula support and decreased labour time, oxytocin utilisation, Caesarean section rates and need for epidural/anaesthesia.1 Given the varied benefits afforded to women through doula support at the time of labour, the authors believe that womens health providers should consider the potential role that continuous lay person support could play at other physically and emotionally challenging moments in womens lives. One such setting in which doula support would be highly beneficial is in abortion care. Abortion is a stressful event regardless of a womans circumstances. Unlike pregnancy in which women can accustom themselves for the forthcoming delivery over a period of time, the decision to terminate pregnancy often leaves little time for reflection. Also unlike pregnancy, women often obtain abortion services from medical caregivers with whom they have had no prior relationship. While these and other differences clearly exist between labour and pregnancy termination, many benefits afforded by the presence of a doula during labour would likely translate well into abortion care. One example of the way in which doula involvement would naturally benefit …

Effect of previous induced abortions on postabortion contraception selection

OBJECTIVE The objective was to compare contraceptive method selection in women undergoing their first pregnancy termination versus women undergoing repeat pregnancy termination in an urban abortion clinic. We hypothesized that women undergoing repeat abortions will select highly effective contraceptives (intrauterine device, subdermal implant, tubal ligation) more often than patients undergoing their first abortion. STUDY DESIGN We conducted a retrospective analysis of all women undergoing first-trimester surgical abortion at John H. Stroger, Jr., Hospital of Cook County from October 1, 2009, to October 31, 2011. We compared contraceptive method selection in the postabortion period after receipt of contraceptive counseling for 7466 women, stratifying women by history of no prior abortion versus one or more abortions. RESULTS Of the 7466 women, 48.6% (3625) had no history of previous abortion. After controlling for age, race and number of living children, women with a history of abortion were more likely to select a highly effective method [odds ratio (OR) 1.19, 95% confidence interval (CI) 1.06-1.33]. Most significantly, having living children was the strongest predictor of a highly effective method with an OR of 3.17 (95% CI 2.69-3.75). CONCLUSIONS In women having a first-trimester abortion, the factors most predictive of selecting a highly effective method for postabortion contraception include history of previous abortion and having living children. The latter holds true independent of abortion history. IMPLICATIONS This paper is unique in its ability to demonstrate the high interest in highly effective contraceptive selection in high-risk, low-income women with prior abortion history. Efforts to integrate provision of highly effective methods of contraception for postabortion care are essential for the reduction of future unintended pregnancies.

Detection of gynecologic cancers in indigent women in an urban inner-city hospital

Objective Access to care is a major concern for impoverished urban communities in the United States, whereas early detection of gynecologic malignancies significantly influences ultimate survival. Our goal was to compare the stage at detection of common gynecologic cancers at an urban county hospital with national estimates, and to describe the demographic and socioeconomic characteristics of this population. Methods All new patients presenting to the John H. Stroger, Jr. Hospital of Cook County gynecologic oncology clinic from January 1, 2008, to December 31, 2009, were reviewed under an institutional review board–approved protocol. Patients receiving primary treatment at the institution during these dates were included for analysis. We used χ2 tests to compare the institution’s stage distributions to national estimates. Results Two hundred nineteen patients met inclusion criteria over the 2-year study period. Racial and ethnic minorities represented 72.5% of the population. Of the 219 patients, 56.1% (123/219) were uninsured and 37.9% (83/219) were covered by Medicaid or Medicare. We identified 97 (43.9%) cervical, 95 (43%) uterine, and 29 (13.1%) ovarian cancers, including 2 synchronous primaries. Compared to the National Cancer Data Base, women with uterine cancer at our institution were significantly more likely to present with later-stage disease (P < 0.05), whereas cervical cancer and ovarian cancer stage distributions did not differ significantly. Conclusions Compared to national trends, women with uterine cancer presenting to an urban tertiary care public hospital have significantly more advanced disease, whereas those with cervical cancer do not. Nationally funded cervical cancer screening is successful but does not address all barriers to accessing gynecologic cancer care. Promotion of public education of endometrial cancer symptoms may be a vital need to impoverished communities with limited access to care.

Methotrexate: An Appropriate Treatment for Ectopic Pregnancy in an Inner-City Population?

INTRODUCTION: To assess the success of methotrexate in treating ectopic pregnancy in a disadvantaged inner-city population. METHODS: A retrospective chart review (n=81) was conducted on patients who received methotrexate for ectopic pregnancy at Cook County Hospital between January 2006 and December 2011. Data collected included demographics, relative contraindications to methotrexate, clinical presentation, and details of treatment, including patient compliance parameters. Our primary outcome was successful completion of medical therapy, defined as a documented serum &bgr;-human chorionic gonadotropin of less than 5 or a negative urine pregnancy test. Multivariable analysis was used to determine variables predictive of treatment success, treatment failure, and patient compliance with follow-up. RESULTS: Medical management alone was successful in 29.6% (24/81) of our patients. However, only 14.8% (12/81) of patients adhered to the recommended follow-up schedule. No variables were predictive of treatment success, treatment failure, or patient compliance with follow-up. Of those who followed up, 17.2% (5/29) ultimately required surgical treatment, only one for a ruptured ectopic pregnancy (3.4%). Median duration to successful completion of medical therapy was 37 days (range 14–118 days) and 5.5 visits (range three to 13). Median follow-up for those who were lost before completing treatment was 22 days (range 0–92 days) and 3.5 visits (range zero to 12). CONCLUSIONS: In a disadvantaged inner-city population, only 29.6% of patients who received methotrexate for treatment of ectopic pregnancy successfully completed medical therapy. Patient compliance with follow-up was poor, and successful treatment required a median of 37 days. Sustained follow-up is difficult for this population and should be considered when recommending a treatment modality.

Cervical intraepithelial neoplasia and cancer in women 35 years and older

Objective To evaluate the distribution of abnormal cytohistopathology among low-income women 35 years and older compared with women younger than 35 years. Materials and Methods This was a retrospective analysis of the 896 women who presented to the dysplasia clinic at an urban, public, tertiary care hospital with abnormal cervical cytology from September 23, 2008, to September 23, 2010. Statistical comparisons were made using t, &khgr;2, and Wilcoxon rank sum tests. Results Of the 896 patients, 460 (51%) were aged 35 years or older. Among the women 35 years and older, 56% had negative/benign histologic findings compared with 45% in women younger than 35 years. Conversely, women 35 years and older had lower rates of cervical intraepithelial neoplasia 1 (14%) than women younger than 35 years (30%). However, the prevalence of cancer diagnosis, per colposcopy, increased significantly with age, affecting 6% of women aged 50 years or older, 2% of women aged 35 to 49 years, and 1% of women younger than 35 years (p = .0008). Conclusions Women older than 35 years with abnormal cytology demonstrated increased severity of cervical intraepithelial neoplasia on histology compared with younger women. Although women younger than 35 years were more likely to have transient human papillomavirus infections, a very high prevalence of severe cervical intraepithelial neoplasia and cancer was identified among women aged 35 years and older. Careful evaluation and follow-up must be performed for this group of women who may have previously been considered by some clinicians to be low risk on the basis of their age.

Insufficient endometrial biopsy results in women with abnormal uterine bleeding.

INTRODUCTION: The objectives of this study were to evaluate factors and outcomes associated with insufficient endometrial biopsy in low-income women with abnormal uterine bleeding. METHODS: A retrospective review of women undergoing endometrial biopsy for abnormal uterine bleeding at John H. Stroger Hospital from January 1 to June 30, 2011, was performed. The primary outcome was rates and factors associated with insufficient sampling. Secondary outcomes evaluated insufficient biopsy follow-up patterns. &khgr;2 analyses were used to evaluate associations with insufficient biopsy. RESULTS: Of 506 patients identified as having undergone endometrial biopsy for abnormal uterine bleeding, 19.8% had insufficient results (n=100). The rate of insufficiency was 31.7% among postmenopausal women compared with 14.2% in peri- and premenopausal women (P<.001). Of the 100 women with insufficient results, 17 were lost to follow-up and 10 had resolution of symptoms. Follow-up endometrial biopsy or curettage was performed for 42 women, in which 14 (31.7%) had a subsequent insufficient result. For six of these women (42.9%), this second insufficient result was followed by ultrasonography. An additional 22 women received ultrasound examinations after their initial insufficient endometrial biopsy. Of the combined 28 women receiving ultrasound examinations, nine (32.1%) had an endometrial stripe of less than 4 mm indicating an endometrial biopsy was never warranted. CONCLUSIONS: Insufficient sampling is common amongst postmenopausal women. Ultrasonography may be used to identify appropriate candidates for endometrial biopsy in this group, thereby decreasing insufficient biopsies and preventing unnecessary sampling. The high rate of insufficient results subsequently warrants reassessment of the model of care provided to postmenopausal women presenting with abnormal uterine bleeding.

Endometrial Biopsy Results in Women With Abnormal Uterine Bleeding: A County Hospital Experience

INTRODUCTION: The objective of this study was to evaluate the endometrial biopsy patterns in an indigent population of women with abnormal uterine bleeding. METHODS: A retrospective chart review was performed from January 1 to June 30, 2011, of women undergoing endometrial biopsy for abnormal uterine bleeding at John H. Stroger Hospital. Primary outcomes were to detect the rate of benign endometrium, insufficient samples, polyps, inflammation, all types of hyperplasia, and carcinoma within this group. RESULTS: Five hundred seven patients were identified as having undergone endometrial biopsy for abnormal uterine bleeding. The mean age was 48.6 years (±9.5, 22.7–79.9) and average body mass index was 32.6 kg/m2 (±8.8, 15.0–74.7). Of the 472 patients for whom we had a documented menstrual status, 47.9% were premenstrual, 22.7% perimenopausal, and 29.3% postmenopausal. In our sample, 55.2% of women had benign pathology (n=280), 10.5% inflammation (n=53), 8.1% polyps (n=41), 4.3% hyperplasia (n=22), and 2.2% had carcinoma (n=11). In those with hyperplasia, 3.9% (n=20) had simple hyperplasia and less than 1% (n=2) had complex hyperplasia with atypia; no women had simple hyperplasia with atypia or complex hyperplasia without atypia. The percentage of women within the cohort requiring surgical intervention for complex hyperplasia with atypica or carcinoma was 2.5%. Insufficient results were noted in 19.7% of the samples. Within this sample, 31.2% were postmenopausal women (n=43). CONCLUSIONS: The most common group presenting with abnormal bleeding was premenstrual women with the majority of pathology resulting as benign, including polyps and inflammation. The rates of hyperplasia and carcinoma in this population of women appear comparable to general reports in the literature.

Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae in an urban public hospital pregnancy termination clinic

This study is a follow-up observational study to assess the prevalence of chlamydia (CT) and gonorrhea (GC) among women who undergo a first-trimester surgical termination in a large public, urban hospital-based termination clinic, and to compare the rates to previously published data. We conducted a retrospective chart review on 4197 patients who underwent CT and GC testing before an elective, first-trimester surgical termination between 1 June 2014 and 31 May 2015. The prevalence rates were calculated and compared by chi square tests to previously published data from 1 January 2006 to 30 June 2006 from the same publicly-funded pregnancy termination clinic. Our study population comprised mostly of African Americans (86.8%), and more than half were aged less than 25 years. The overall prevalence of CT in our population was 9.6%, which was significantly different to the prevalence of 11.4% in 2006 (p value = 0.03). The overall prevalence of GC in our population was 1.9%, which was not significantly different to the prevalence of 2.6% in 2006. To conclude, this study demonstrates the high prevalence rate of CT-positive and GC-positive patients in our publicly-funded pregnancy termination clinic. The prevalence of infection with CT and GC in our study is higher than in other family planning clinics. Regular screening of all patients who undergo induced termination in pregnancy termination clinics can provide a valuable opportunity for physicians to counsel patients about sexually transmitted infection prevention and treatment prior to the procedure or distribution of medications.