Maqdooda Merchant

Neisseria gonorrhea and Chlamydia trachomatis Screening at Intrauterine Device Insertion and Pelvic Inflammatory Disease

OBJECTIVE: To evaluate the relationship between Neisseria gonorrhea and Chlamydia trachomatis screening strategies and risk of pelvic inflammatory disease (PID) after intrauterine device (IUD) insertion. METHODS: We conducted a retrospective cohort study of all IUD insertions at Kaiser Permanente Northern California from January 2005 to August 2009. The PID incidence within 90 days after insertion was compared among women who were and were not screened for N gonorrhea and C trachomatis. The study was powered for equivalence with a PID risk difference of −0.006 to 0.006 between two groups considered to be clinically insignificant. Risk difference was calculated by subtracting the proportion of females with PID in one screening group from the proportion of females with PID in the comparison screening group. RESULTS: Of 57,728 IUD insertions, 47% were unscreened within 1 year of insertion; of screened women, 19% were screened on the same day. The overall risk of PID was 0.54% (95% confidence interval [CI] 0.48–0.60%). Nonscreening had an equivalent risk of PID as any screening (risk difference −0.0034, 95% CI −0.0045 to −0.0022), and same-day screening was equivalent to prescreening (risk difference −0.0031, 95% CI −0.0049 to −0.0008). The equivalence persisted when adjusted for age and race and when stratified by age younger than 26 years and older than 26 years. CONCLUSION: The risk of PID in women receiving IUDs was low. These results support IUD insertion protocols in which clinicians test women for N gonorrhea and C trachomatis based on risk factors and perform the test on the day of insertion. These findings have potential to reduce barriers to IUD use for women seeking highly effective, long-term, reversible contraception. LEVEL OF EVIDENCE: II

Does increased experience with laparoscopic cholecystectomy yield more complex bile duct injuries

BACKGROUND Two decades since the advent of laparoscopic cholecystectomy, the rate of bile duct injuries still remains higher than in the open cholecystectomy era. METHODS The rate and complexity of bile duct injuries was evaluated in 83,449 patients who underwent laparoscopic cholecystectomy between 1995 and 2008 in the Kaiser Permanente Northern California system. Fifty-six surgeons who performed a laparoscopic cholecystectomy in the past were surveyed to determine factors that predispose to bile duct injuries. RESULTS The overall incidence of bile duct injuries was .10%; 59.5% of the 84 injuries were cystic duct leaks. Incidence varied slightly from .10% (1995-1998) to .08% (1999-2003) and .12% (2004-2008). There was a trend toward more proximal injuries (injury <2 cm from the bifurcation: 14.3% to 44.4% to 50.0% of major injuries). The misinterpretation of anatomy was cited by 92.9% of surgeons as the primary cause of bile duct injuries; 70.9% cited a lack of experience as a contributing factor. CONCLUSIONS Laparoscopic cholecystectomy has an overall low risk of bile duct injuries; the rate remains constant, but injury complexity may have increased over time.

Asymmetric dimethylarginine and coronary artery calcium scores are increased in patients infected with human immunodeficiency virus.

OBJECTIVE Patients infected with human immunodeficiency virus (HIV) have an increased risk for cardiovascular events and mortality. Elevated concentrations of asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase, are associated with increased subclinical atherosclerosis and cardiovascular events. The objective of this study was to determine whether plasma ADMA levels are increased in patients infected with HIV and whether this is associated with cardiovascular risk factors, inflammatory/thrombotic biomarkers, and elevated coronary artery calcium scores (CACS). METHODS HIV-infected patients and control patients were recruited in a case-control study. Medical history and laboratory measurements including plasma ADMA and biomarkers for inflammation and thrombosis such as C-reactive protein (CRP), fibrinogen, and homocysteine were obtained in both cohorts. Using multidetector computed tomography, CACS were measured in Agatston Units (AU). Bivariate differences between HIV-infected and control patients were analyzed. RESULTS HIV-infected patients (n=37, male=27, age=45 years) had significantly higher concentrations of ADMA (0.40±0.10 μmol/l) compared to a similarly matched cohort of non-HIV-infected patients (n=43, male=27, age=45 years), (0.35±0.07 μmol/l, p=0.03). There were no significant differences in CRP, homocysteine, and fibrinogen between the two cohorts. However, HIV-infected patients had a higher CACS distribution compared to control patients [0.0 (8.5) vs. 0.0 (0.0) AU, p=0.01]. In a multivariable regression analysis HIV-infected patients with a relative CACS of 75-90% for age and gender had the highest ADMA concentrations (0.48±0.09 μmol/l, p=0.04) among all CACS subgroups. CONCLUSION HIV-infected patients have significantly higher ADMA concentrations compared to control patients. In addition, increased CACS was associated with elevated ADMA concentrations. Thus, increased ADMA levels appear to be associated with the presence of subclinical atherosclerosis in HIV-infected patients.

Contribution of Demographic and Behavioral Factors on the Changing Incidence Rates of Oropharyngeal and Oral Cavity Cancers in Northern California

Background: It is unknown to what extent patient demographics, smoking, and alcohol use have contributed to changes in oropharyngeal and oral cavity cancer incidence rates. Methods: We performed a cohort study of Kaiser Permanente healthplan members, ages 20 to 89, for years 1995–2010 (n = 2.2 million annual members). Poisson Regression models estimated calendar trends in cancer rates both adjusted for and stratified by age, sex, smoking, and alcohol abuse history. Results: We identified 1,383 human papillomavirus (HPV)–related and 1,344 HPV-unrelated oral cavity and oropharyngeal cancer cases. With adjustment for age and sex, HPV-related cancer incidence rates increased 3.8% per year (P < 0.001) between 1995 and 2010, whereas rates for HPV-unrelated cancers decreased 2.4% per year (P < 0.001). For years 2007 to 2010, with additional adjustment for smoking and alcohol abuse, results were nonsignificant, but similar in magnitude. The increasing rates for HPV-related cancers were more prominent among nonsmokers (+14.5%) compared with smokers (−2.5%; P-interaction = 0.058). The decreased rates for HPV-unrelated sites were more prominent among those ≥60 years (−11.0%) compared with those <60 years (+16.8%; P-interaction = 0.006), among smokers (−9.7%) compared with nonsmokers (+8.4%; P-interaction = 0.055), and among those with an alcohol abuse history (−20.4%) compared with those without a history (+5.8%; P-interaction = 0.009). Conclusions: The observed increasing HPV-related cancer rates are most evident among nonsmokers, whereas the decreasing HPV-unrelated cancer rates are least evident among younger individuals, nonsmokers, and those without an alcohol abuse history. Impact: Continued vigilance for oropharyngeal and oral cavity cancer is warranted, including among those without traditional risk factors such as smoking and alcohol abuse. Cancer Epidemiol Biomarkers Prev; 24(6); 978–84. ©2015 AACR.

Reproductive health outcomes of insured adolescent and adult women who access oral levonorgestrel emergency contraception.

OBJECTIVE: To assess the level of risk for adolescents and women who seek emergency contraception through various clinical routes and the opportunities for improved care provision. METHODS: This study looked at a retrospective cohort to assess contraception and other reproductive health outcomes among adolescents and women aged 15–44 years who accessed oral levonorgestrel emergency contraception through an office visit or the call center at Kaiser Permanente Northern California from 2010 to 2011. RESULTS: Of 21,421 prescriptions, 14,531 (67.8%) were accessed through the call center. In the subsequent 12 months, 12,127 (56.6%) adolescents and women had short-acting contraception (pills, patches, rings, depot medroxyprogesterone) dispensed and 2,264 (10.6%) initiated very effective contraception (intrauterine contraception, implants, sterilization). Initiation of very effective contraception was similar for adolescents and women who accessed it through the call center—1,569 (10.8%) and office visits—695 (10.1%) (adjusted odds ratio [OR] 1.02, 95% confidence interval [CI] 0.93–1.13). In the subsequent 6 months, 2,056 (9.6%) adolescents and women became pregnant. Adolescents and women who accessed emergency contraception through the call center were less likely to become pregnant within 3 months of accessing emergency contraception than woman who accessed it through office visits (adjusted OR 0.82, 95% CI 0.72–0.94); however, they were more likely to become pregnant within 4–6 months (adjusted OR 1.37, 95% CI 1.16–1.60). Among adolescents and women who were tested for chlamydia and gonorrhea, 689 (7.8%) and 928 (7.9%) were positive in the 12 months before and after accessing emergency contraception, respectively. CONCLUSION: Protocols to routinely address unmet needs for contraception at every call for emergency contraception and all office visits, including visits with primary care providers, should be investigated. LEVEL OF EVIDENCE: II

The Impact of a Tertiary Care Vaginitis Clinic on Prescription Antimicrobials and Health Care Utilization [14M]

INTRODUCTION: To evaluate the impact of a tertiary care vaginitis clinic with standardized protocols on health care utilization and prescription antifungal and antimicrobials for vaginitis-related concerns. METHODS: A retrospective analysis of electronic medical records of women with complaints of vaginitis attending a tertiary care vaginitis clinic (VC) in an integrated healthcare system. Women had vaginal microscopy, vaginal pH, an amine test, and vaginal mycology cultures at the index VC visit. Vulvovaginal candidiasis diagnoses required a positive mycology culture and bacterial vaginosis required 3 of 4 Amsels criteria. Records were analyzed to compare the number of vaginitis-related encounters (clinic and telephone), fluconazole, and metronidazole (oral and vaginal) prescriptions in the 12 months before and the 12 months after the index VC visit. RESULTS: Out of 207 women identified over an 18 month time frame, age range 16–77 years (mean 38.5 years), 71.5% had at least 1 vaginitis-related encounter in the 12 months before the index VC visit; 47.3% in the 12 months after. The mean number of visits dropped from 2.06 to 0.98 (P<.0001, paired t test). The number of women with at least one fluconazole prescription and one metronidazole prescription decreased from 53.6% to 43.0% and 39.6%–18.8% respectively (P<.0001, paired t test). CONCLUSION: Attending a tertiary care vaginitis clinic resulted in a statistically significant reduction in vaginitis-related encounters and both fluconazole and metronidazole prescriptions for 12 months. A standardized vaginitis clinic may help reduce the burden of inappropriate diagnosis and treatment of vaginitis.

Comparison of Intrauterine Device Expulsion Rates After Aspiration Abortion or Interval Insertion

INTRODUCTION: Twenty-two percent of all pregnancies in the United States result in termination, reflecting the need for more robust contraception. The intrauterine device (IUD) is highly effective and reversible although underused in the United States compared with other countries. Several institutions in the United States insert IUDs immediately after abortions with success despite international research that suggests a higher rate of expulsion. OBJECTIVE: To compare the rate of IUD expulsion in immediate postabortion insertion compared with interval insertion. METHODS: A retrospective cohort study was performed to ascertain complications after immediate compared with interval IUD placement after first-trimester aspiration abortions between April 1, 2006, and September 30, 2011, at all Kaiser Permanente Northern California facilities. The primary outcome was the rate of expulsion within 90 days of IUD insertion. Secondary outcomes included rates of uterine perforation, upper genital tract infection, and early removal of IUD. Statistical analysis used &khgr;2 and t test comparisons. Logistic regression was performed for multiple variable analysis. RESULTS: Four hundred forty-seven women with same-day insertions were compared with 316 women with interval insertions. The overall rate of expulsion was low with no statistically significant differences seen between cohorts at 4.1% and 1.7%, respectively (P<.073). Secondary outcome rates were all low. In multivariate analysis, African American race was noted to be an independent risk factor for expulsion with an odds ratio of 3.95. CONCLUSION: In a diverse, American population, levonorgestrel or Cu-T IUD insertion immediately after first-trimester abortion appears to be safe with no significant increase in rates of expulsion or other complications when compared with interval insertion.

Does Antidepressant Exposure in Pregnancy Affect Maternal Serum Markers for Aneuploidy

INTRODUCTION: The objective of this study was to examine the effect of maternal antidepressant exposure on first- and second-trimester maternal serum markers for aneuploidy. METHODS: We conducted a 10-year retrospective cohort study within a large health care organization. Pregnant women diagnosed with depression who underwent serum screening for aneuploidy were identified. Antidepressant exposure was defined by a filled prescription. Levels of pregnancy-associated plasma protein-A, alpha-fetoprotein, estriol, inhibin, and second-trimester human chorionic gonadotropin (hCG) were obtained, expressed as multiples of the mean. We compared levels of serum analytes between women who were and were not exposed to antidepressants. Using recorded Patient Health Questionnaire scores, we assessed depression severity as a confounder. RESULTS: Antidepressant exposure occurred in 52% of 19,186 pregnancies. Mean inhibin levels were significantly higher in the unexposed group (1.124 multiples of the median compared with 1.084 multiples of the median, P=.003) as were mean hCG levels (1.188 multiples of the median compared with 1.165 multiples of the median, P=.007). Mean estriol levels were lower in the unexposed group (1.005 multiples of the median compared with 1.015 multiples of the median, P=.030). There were no statistically significant differences in the mean values of pregnancy-associated plasma protein-A or alpha-fetoprotein. In bivariate analyses, there were no interactions between analyte values and depression severity. There were no significant differences in the proportion of patients with one or more abnormal level of serum analytes between exposed and unexposed groups. CONCLUSION: Antidepressant exposure affects mean levels of inhibin, hCG, and estriol. As a result of our large number of participants, small differences could be detected. Further research is necessary to determine if such differences are of clinical significance.

OC09.06: Incidence of stillbirth after viability in a large, unselected cohort of monochorionic twin pregnancies

Objectives: The objective of our study was to determine the incidence of stillbirth in monochorionic twin pregnancies after 24 0/7 weeks gestational age in a large, unselected cohort of monochorionic (MC) twins. In addition, we sought to explore the added risk factor of twin-to-twin transfusion syndrome (TTTS) in this cohort. Methods: We completed a retrospective cohort study of all MC twin pregnancies in the Kaiser Northern California (KPNC) population delivered between 1996 and 2003. All twin placentas were submitted to pathology during this time frame, and chorionicity was confirmed by placental pathology. Pregnancies were excluded if delivery or termination occurred prior to 24 0/7 weeks’ gestation, birth data was unavailable or chorionicity could not be confirmed. The incidence of stillbirth, TTTS and outcomes for liveborn twins were assessed by database search and chart review. Results: From 1996–2003, 646 monochorionic twin sets were cared for and delivered by KPNC and 594 of these pregnancies met criteria for inclusion. Thirteen pregnancies resulted in the demise of both twins and 26 pregnancies resulted in the demise of a single twin, thus 4.4% of all infants delivered after 24 0/7 weeks’ gestation were stillborn (52/1188). 9.1% of MC pregnancies were affected by TTTS (54/594) and 25.9% of the TTTS pregnancies resulted in intrauterine fetal demise (IUFD) of at least one twin (14/54) compared to 4.6% of non-TTTS pregnancies (25/540). The RR for fetal demise after 24 weeks’ gestation in MC twins affected by TTTS is 4.86 (CI 2.86–8.59). Conclusions: In our study population, one in every fifteen MC twin pregnancies resulted in a post-viability IUFD of at least one twin. This incidence of IUFD appears higher than that of the general population, affirming the results of previous studies. Families should be counseled about these pregnancy prognoses and further prospective studies should be done to assess the optimal gestational age for delivery to potentially prevent these outcomes.