Melissa A. Plegue

Factors associated with vulvodynia incidence.

OBJECTIVE: To assess incidence rates of and risk factors for vulvodynia. METHODS: We conducted a longitudinal population-based study of women in southeast Michigan (Woman-to-Woman Health Study) using a validated survey-based screening test for vulvodynia that was repeated at 6-month intervals over 30 months. Unadjusted incidence rates were determined using Poisson models. Demographic and symptom-related risk factors for incidence were assessed using discrete time survival analysis. RESULTS: Women who screened negative for vulvodynia at baseline and were followed through at least one additional survey (n=1,786) were assessed for onset of vulvodynia. The incidence rate was 4.2 cases per 100 person-years, and rates per 100 person-years were greater in women who were younger (7.6 cases per 100 person-years at age 20 years, compared with 3.3 cases per 100 person-years at age 60 years), Hispanic (9.5 cases per 100 person-years), married, or living as married (4.9 cases per 100 person-years); had reported symptoms of vulvar pain but did not meet vulvodynia criteria on the initial survey (11.5 cases per 100 person-years); or had reported past symptoms suggesting a history of vulvodynia (7.5 cases per 100 person-years). Increased risk of new-onset vulvodynia also included baseline sleep disturbance, chronic pain in general, specific comorbid pain disorders, and specific comorbid psychological disorders. CONCLUSIONS: The incidence rates of vulvodynia differ by age, ethnicity, and marital status. Onset is more likely among women with previous symptoms of vulvodynia or those with intermediate symptoms not meeting criteria for vulvodynia and among those with pre-existing sleep, psychological, and comorbid pain disorders. This suggests vulvodynia is an episodic condition with a potentially identifiable prodromal phase. LEVEL OF EVIDENCE: II

Impact of an Electronic Health Record (EHR) Reminder on Human Papillomavirus (HPV) Vaccine Initiation and Timely Completion.

Background: The initiation and timely completion of the human papillomavirus (HPV) vaccine in young women is critical. We compared the initiation and completion of the HPV vaccine among women in 2 community-based networks with electronic health records: 1 with a prompt and reminder system (prompted cohort) and 1 without (unprompted cohort). Methods: Female patients aged 9 to 26 years seen between March 1, 2007, and January 25, 2010, were used as the retrospective cohort. Patient demographics and vaccination dates were extracted from the electronic health records. Results: Patients eligible for the vaccine included 6019 from the prompted cohort and 9096 from the unprompted cohort. Mean age at initiation was 17.3 years in the prompted cohort and 18.1 years in the unprompted cohort. Significantly more (P < .001) patients initiated the vaccine in the prompted cohort (34.9%) compared with the unprompted cohort (21.5%). African Americans aged 9 to 18 years with ≥3 visits during the observation period were significantly more likely to initiate in the prompted cohort (P < .001). The prompted cohort was significantly more likely (P < .001) to complete the vaccine series in a timely manner compared with the unprompted cohort. Conclusion: More patients aged 9 to 26 years initiated and achieved timely completion of the HPV vaccine series in clinics using an electronic health record system with prompts compared with clinics without prompts.

Treatment adherence among adolescents with epilepsy: What really matters?

Treatment adherence is often suboptimal among adolescents with epilepsy. However, knowledge is lacking regarding factors that affect adherence. Empirical studies and theories of human development suggest that self-management skills, self-efficacy, and sense of control are related to adherence. Eighty-eight adolescents with epilepsy, and their parents, completed standardized measures assessing epilepsy knowledge and expectations, treatment self-management, sense of control, and self-efficacy. Better self-reported parent adherence was correlated with greater epilepsy knowledge/expectations (p<0.001) and more medications (p = 0.042). Better self-reported adolescent adherence was correlated with fewer siblings (p = 0.003) and higher adolescent epilepsy knowledge/expectations (p<0.001). Greater adolescent epilepsy knowledge/expectations correlated with parent self-reported adherence (p<0.001), Powerful others locus of control (p = 0.008), and adolescent/parent discordance regarding epilepsy knowledge/expectations (p<0.001). Interventions that enhance adolescents knowledge of epilepsy and their treatment plan, while ensuring that teens and parents are in agreement with regard to epilepsy treatment, might contribute to better adherence.

U.S. Medical Schools’ Compliance With the Americans with Disabilities Act: Findings From a National Study

Purpose Physician diversity improves care for underserved populations, yet there are few physicians with disabilities. The authors examined the availability of technical standards (TSs) from U.S. medical schools (MD- and DO-granting) and evaluated these relative to intent to comply with the Americans with Disabilities Act (ADA). Method Document analysis was conducted (2012–2014) on U.S. medical schools’ TSs for hearing, visual, and mobility disabilities. Primary outcome measures were ease of obtaining TSs, willingness to provide reasonable accommodations, responsibility for accommodations, and acceptability of intermediaries or auxiliary aids. Results TSs were available for 161/173 (93%) schools. While 146 (84%) posted these on their Web sites, 100 (58%) were located easily. Few schools, 53 (33%), had TSs specifically supporting accommodating disabilities; 79 (49%) did not clearly state policies, 6 (4%) were unsupportive, and 23 (14%) provided no information. Most schools, 98 (61%), lacked information on responsibility for providing accommodations, 33 (27%) provided accommodations, and 10 (6%) had students assume some responsibility. Approximately 40% allowed auxiliary aids (e.g., motorized scooter), but < 10% allowed intermediaries (e.g., sign language interpreter). Supportive schools were more likely to allow accommodations (P < .001), assume responsibility for accommodations (P < .001), and accept intermediaries (P < .002). DO-granting schools were more supportive for students with mobility disabilities. Conclusions Most medical school TSs do not support provision of reasonable accommodations for students with disabilities as intended by the ADA. Further study is needed to understand how schools operationalize TSs and barriers to achieving ADA standards.

Inadequate Hydration, BMI, and Obesity Among US Adults: NHANES 2009–2012

PURPOSE Improving hydration is a strategy commonly used by clinicians to prevent overeating with the goal of promoting a healthy weight among patients. The relationship between weight status and hydration, however, is unclear. Our objective was to assess the relationship between inadequate hydration and BMI and inadequate hydration and obesity among adults in the United States. METHODS Our study used a nationally representative sample from the National Health and Nutrition Examination Survey (NHANES) 2009 to 2012, and included adults aged 18 to 64 years. The primary outcome of interest was body mass index (BMI), measured in continuous values and also categorized as obese (BMI ≥30) or not (BMI <30). Individuals with urine osmolality values of 800 mOsm/kg or greater were considered to be inadequately hydrated. Linear and logistic regressions were performed with continuous BMI and obesity status as the outcomes, respectively. Models were adjusted for known confounders including age, race/ethnicity, sex, and income-to-poverty ratio. RESULTS In this nationally representative sample (n = 9,528; weighted n = 193.7 million), 50.8% were women, 64.5% were non-Hispanic white, and the mean age was 41 years. Mean urine osmolality was 631.4 mOsm/kg (SD = 236.2 mOsm/kg); 32.6% of the sample was inadequately hydrated. In adjusted models, adults who were inadequately hydrated had higher BMIs (1.32 kg/m2; 95% CI, 0.85–1.79; P <.001) and higher odds of being obese (OR = 1.59; 95% CI, 1.35–1.88; P <.001) compared with hydrated adults. CONCLUSION We found a significant association between inadequate hydration and elevated BMI and inadequate hydration and obesity, even after controlling for confounders. This relationship has not previously been shown on a population level and suggests that water, an essential nutrient, may deserve greater focus in weight management research and clinical strategies.

An Evaluation of Cerebral and Systemic Predictors of 18-Month Outcomes for Neonates With Hypoxic Ischemic Encephalopathy

Amplitude-integrated EEG (aEEG) is a commonly used predictor of outcome after hypoxic ischemic encephalopathy. Cerebral and systemic near-infrared spectroscopy and acute kidney injury might also have prognostic value. The authors monitored neonates with aEEG, cerebral and systemic near-infrared spectroscopy during therapeutic hypothermia, assigned an acute kidney injury stage, and measured neurodevelopmental outcome. For 18 infants, cerebral near-infrared spectroscopy variables did not differentiate between those with favorable (n = 13) versus adverse (death or moderate-severe disability; n = 5) 18-month outcomes. However, systemic rSO2 variability was higher during hours 48-72 of cooling among those with favorable outcomes (.02 < P < .03). Mean aEEG amplitude during hours 24 to 48 of cooling was higher among those with good outcomes (.027 < P < .032). The aEEG lower margin was also higher during hours 12 to 48 for those with good outcomes (.014 < P < .035). Acute kidney injury did not predict outcome (P > .05). aEEG is a useful prognostic tool for outcomes after neonatal hypoxic ischemic encephalopathy, but the role of near-infrared spectroscopy in the hypothermia-treated population remains uncertain.

Remission, Relapse, and Persistence of Vulvodynia: A Longitudinal Population-Based Study

BACKGROUND Vulvodynia has been considered to be a chronic disorder. We sought to estimate the probability of and risk factors for remission, relapse, and persistence among women screening positive for vulvodynia. METHODS Survey-based assessment in a longitudinal population-based study of women (the Woman to Woman Health Study) who screened positive for vulvodynia and completed at least four follow-up surveys. Outcome measures included remission without relapse, relapse (after remission), and persistence of a positive vulvodynia screen. Multinomial regression was used to assess factors associated with outcomes. RESULTS Of 441 women screening positive for vulvodynia during the study, 239 completed 4 additional surveys. Of these, 23 (9.6%) had consistently positive vulvodynia screens, 121 (50.6%) remitted without relapse, and 95 (39.7%) relapsed following remission. Overall, factors associated with both relapse and persistence (compared with remission alone) included increased severity of pain ever (p < 0.001) or after intercourse (p = 0.03), longer duration of symptoms (p ≤ 0.001), and screening positive for fibromyalgia (p < 0.001). Factors associated with persistence (but not relapse) included more severe symptoms with intercourse (p = 0.001) and pain with oral sex (p = 0.003) or partner touch (p = 0.04). Factors associated with relapse (but not persistence) included having provoked pain (p = 0.001) or screening positive for interstitial cystitis (p = 0.05) at first positive vulvodynia screen. Demographic characteristics, age at pain onset, and whether vulvodynia was primary or secondary did not predict outcome. CONCLUSION Remission of vulvodynia symptoms is common with approximately half of remitters experiencing a relapse within 6-30 months. Persistence without remission is the exception rather than the rule. Pain history and comorbid conditions were associated with the more severe outcomes of relapse and/or persistence compared with those who remitted only. These findings provide further support that vulvodynia is heterogeneous and often occurs in an episodic pattern.

Impact of hands-on care on infant sleep in the neonatal intensive care unit

Sleep disruption is increasingly recognized in hospitalized patients. Impaired sleep is associated with measureable alterations in neurodevelopment. The neonatal intensive care unit (NICU) environment has the potential to affect sleep quality and quantity. We aimed: (i) to determine the frequency and duration of hands‐on care, and its impact on sleep, for NICU patients; and (ii) to assess the incidence of respiratory events associated with handling for a cohort of sick neonates.

Impact of family history assessment on communication with family members and health care providers: A report from the Family Healthware™ Impact Trial (FHITr)

OBJECTIVE This study examines the impact of Family Healthware™ on communication behaviors; specifically, communication with family members and health care providers about family health history. METHODS A total of 3786 participants were enrolled in the Family Healthware™ Impact Trial (FHITr) in the United States from 2005-7. The trial employed a two-arm cluster-randomized design, with primary care practices serving as the unit of randomization. Using generalized estimating equations (GEE), analyses focused on communication behaviors at 6month follow-up, adjusting for age, site and practice clustering. RESULTS A significant interaction was observed between study arm and baseline communication status for the family communication outcomes (ps<.01), indicating that intervention had effects of different magnitude between those already communicating at baseline and those who were not. Among participants who were not communicating at baseline, intervention participants had higher odds of communicating with family members about family history risk (OR=1.24, p=0.042) and actively collecting family history information at follow-up (OR=2.67, p=0.026). Family Healthware™ did not have a significant effect on family communication among those already communicating at baseline, or on provider communication, regardless of baseline communication status. Greater communication was observed among those at increased familial risk for a greater number of diseases. CONCLUSION Family Healthware™ prompted more communication about family history with family members, among those who were not previously communicating. Efforts are needed to identify approaches to encourage greater sharing of family history information, particularly with health care providers.

Presence of Spontaneous Pain and Comorbid Pain Conditions Identifies Vulvodynia Subgroups.

Objective The aims of the study were to define the heterogeneity of vulvodynia by determining data-driven subgroups within the vulvodynia diagnosis using exploratory cluster analysis and to characterize the subgroups identified. Materials and Methods Included were participants in the longitudinal population-based study of vulvodynia in southeast Michigan who screened positive for vulvodynia at least once during the study. A cluster analysis using variables reflecting vulvar pain characteristics and comorbid pain conditions was conducted. Variables reflecting best separation of clusters were used to assign participants to subgroup categories. Demographic, psychiatric, general health, and other vulvar pain characteristics were summarized for each subgroup, followed by multinomial regression and pairwise comparisons of subgroups on these factors. Results Of 441 women screening positive for vulvodynia during the course of the study, 393 were eligible on the basis of data requirements. Cluster analysis suggested that best subgroup separation was based on the following 2 variables: (1) presence or absence of spontaneous vulvar pain and (2) presence or absence of other comorbid pain conditions. Subgroups did not differ by age or ethnicity. The subgroup having spontaneous pain and other comorbid conditions demonstrated greatest morbidity in general health measures, psychiatric disorders, and other vulvar pain measures. Primary versus secondary vulvodynia did not vary between subgroups and did not assist in subgroup separation in the cluster analysis. Discussion Subgroups based on exploratory cluster analysis demonstrated that presence of spontaneous pain and the presence of comorbid pain conditions resulted in best separation of groups. Presence of both spontaneous pain and other comorbid pain conditions identified the group with greatest morbidity.