Initiation of Sexual Intercourse and Safe Sex Practices: An Evidence-Based Replication of Reducing the Risk

Purpose and Background: This study aimed to (1) identify predictors of initiation of sexual intercourse before program implementation, and (2) assess the one-year impact of Reducing the Risk (RTR) on the delay of sexual intercourse initiation and safe sex practices among a predominantly Latino sample of 9th graders in Tulare County. RTR is an evidence-based program designed to delay initiation of adolescent sexual intercourse, and increase safe practices among those who are already sexually active. The program was implemented in Tulare County; whose average teen birth rate for 2009-2011 was 60.2 per 1,000 teens aged 15-19. Methods: Baseline and one-year follow-up data were collected on 390 students, beginning in their 9th grade year (53% female, 72.2% Latino/Hispanic). Students participated in a school-based pregnancy prevention program (RTR) and answered questions on HIV/STIs knowledge, attitudes about abstinence and teen pregnancy, parent communication, sexual intercourse, and safe sex practices. Results: Over one in eight students were sexually active at baseline. Overall, students reported long-term increases in HIV/STI knowledge and parent communication, decreases in intentions to have sexual intercourse and positive attitudes about teen pregnancy. Controlling for baseline differences, sexually active students reported fewer positive attitudes about abstinence. Conclusion: RTR may be more effective in preventing pregnancy and HIV/STIs among students who are not yet sexually active. Further, RTR does appear to successfully impact students who have already initiated sexual intercourse decisions to practice safe sex; however, not to become abstinent

Assessing the association of county-level structural racism and social and economic deprivation with women’s prenatal care utilization and adverse birth outcomes

There is a growing body of research showing community- and state-level indicators of structural racism and social and economic deprivation are associated with prenatal care utilization and adverse birth outcomes among African American women. However, even after controlling for individual characteristics and community poverty, racial inequities in prenatal care utilization and adverse birth outcomes are still present. There is limited research on the effect of structural racism and social and economic deprivation when measured at the county-level on adverse birth outcomes. This study contributes to previous research by using a novel conceptualization and measurement of structural racism and social and economic deprivation to better understand racial inequities in prenatal care utilization and adverse birth outcomes. Cross-sectional birth record data (2009-2013) from women residing in California (n= 531,170) were linked to county-level data gathered from the American Community Survey (2009-2013) to conduct multilevel analyses. This study was guided by the ecosocial theory and was centered on examining the association of exposures to structural racism (e.g., residential segregation and African American and White ratios in political participation) and embodied racial inequities in adverse birth outcomes between African American and White women through two mediated pathways: (1) social and economic deprivation, and (2) prenatal care utilization. Outcome variables in this study were infants’ birth weight (measured in grams) and gestational age (measured in weeks). Women receiving less than adequate prenatal care (i.e., initiating prenatal care after the first trimester and attending 79% or less of recommended appointments) served as a secondary outcome variable. Structural racism was measured by residential segregation indices (i.e., dissimilarity, isolation, and concentration) and African American and White ratios in the number of persons incarcerated for felonies and in board of supervisor positions at the county-level. Social and economic deprivation was measured by two African American to White ratios: in having a professional and/or management job, and in having a high school diploma or higher at the county-level. Chapters 4 and 5 are two papers included in this dissertation that sought to answer the following research questions: (1) Are both traditional and novel indicators of county-level structural racism associated with adverse birth outcomes among African American and White women?; (2) Do both traditional and novel measures of county-level structural racism account for racial inequities seen in adverse birth outcomes among African American and White women?; and (3) Do county-level indicators of social and economic deprivation account for racial inequities seen in African American and White women’s prenatal care utilization? Among women included in the study sample, African American women birthed infants of lower average birth weight and earlier average gestational age, with corresponding higher percentages of infants meeting criteria for low birth weight and preterm birth in comparison to White women. Additionally, African American women, compared to White women, were more likely to have less than adequate prenatal care utilization. Traditional indicators of structural racism (i.e., isolation and dissimilarity) were associated with African American and White women’s infants’ birth weight and gestational age, after controlling for individual characteristics and county-level poverty. There was a significant interaction between race (i.e., African American) and traditional indicators of structural racism (i.e., isolation) with infants’ gestational age, where African American women who lived in counties with high isolation birthed infants at earlier gestational ages. The main effect of race on infants’ birth weight and gestational age remained significant across all models. Novel indicators of structural racism were associated with infants’ birth weight among both African American and White women. There were no statistically significant interactions between race and novel indicators of structural racism with infants’ birth weight. Only one indicator of social and economic deprivation was associated with women’s prenatal care utilization, adjusting for individual characteristics and county-level poverty. Findings indicate increasing the number of African Americans by one to every 100 Whites in professional jobs at the county-level, increased women’s likelihood of having less than adequate prenatal care by 1.03 odds. Race remained significant after accounting for individual-level factors and county poverty; however, there were no significant interactions between race and African American to White ratios in professional jobs. Findings from this study highlight the utility of county-level measures of structural racism and social and economic deprivation in understanding factors related to prenatal care utilization and adverse birth outcomes among African American and White women. Future studies should examine more comprehensive approaches to measure structural racism and social and economic deprivation to better understand the structural influences affecting racial inequities in prenatal care utilization and adverse birth outcomes

Transitioning HIV-infected adolescents to adult care at 14 clinics across the United States: Using adolescent and adult providers’ insights to create multi-level solutions to address transition barriers

HIV-infected adolescents have disproportionately low rates of care retention and viral suppression. Approximately half disengage from care while transitioning to adult clinics, in part due to fragmented care systems and lack of streamlined protocols. We conducted 58 qualitative interviews with social service and health care providers across 14 Adolescent Trials Network clinics (n=28) and 20 adult clinics that receive transitioning adolescents (n=30) from August 2015 – June 2016. We used the constant comparative approach to examine processes, barriers, and facilitators of adult care transition. Transition barriers coalesced around three levels. Structural: insurance eligibility, transportation, and HIV-related stigma; Clinical: inter-clinic communication, differences in care cultures, and resource/personnel limitations; and Individual: adolescents’ transition readiness and developmental capacity. Staff-initiated solutions (e.g., grant-funded transportation) were often unsustainable and applied individual-level solutions to structural-level barriers. Comprehensive initiatives, which develop collaborative policies and protocols that support providers’ ability to match the solution and barrier level (i.e., structural-to-structural), are sorely needed. These initiatives should also support local systematic planning to facilitate inter-clinic structures and communication. Such approaches will help HIV-infected adolescents transition to adult care and improve long-term health outcomes

2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/154675/1/art41191.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154675/2/art41191_am.pd

Infant Outcomes Following Maternal Infection With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): First Report From the Pregnancy Coronavirus Outcomes Registry (PRIORITY) Study.

Infant outcomes after maternal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are not well described. In a prospective US registry of 263 infants, maternal SARS-CoV-2 status was not associated with birth weight, difficulty breathing, apnea, or upper or lower respiratory infection through 8 weeks of age

Clinical Presentation of Coronavirus Disease 2019 (COVID-19) in Pregnant and Recently Pregnant People.

OBJECTIVE: To describe the clinical presentation, symptomology, and disease course of coronavirus disease 2019 (COVID-19) in pregnancy. METHODS: The PRIORITY (Pregnancy CoRonavIrus Outcomes RegIsTrY) study is an ongoing nationwide prospective cohort study of people in the United States who are pregnant or up to 6 weeks postpregnancy with known or suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We analyzed the clinical presentation and disease course of COVID-19 in participants who tested positive for SARS-CoV-2 infection and reported symptoms at the time of testing. RESULTS: Of 991 participants enrolled from March 22, 2020, until July 10, 2020, 736 had symptoms of COVID-19 at the time of testing; 594 tested positive for SARS-CoV-2 infection and 142 tested negative in this symptomatic group. Mean age was 31.3 years (SD 5.1), and 37% will nulliparous. Ninety-five percent were outpatients. Participants who tested positive for SARS-CoV-2-infection were a geographically diverse cohort: 34% from the Northeast, 25% from the West, 21% from the South, and 18% from the Midwest. Thirty-one percent of study participants were Latina, and 9% were Black. The average gestational age at enrollment was 24.1 weeks, and 13% of participants were enrolled after pregnancy. The most prevalent first symptoms in the cohort of patients who tested positive for SARS-CoV-2 infection were cough (20%), sore throat (16%), body aches (12%), and fever (12%). Median time to symptom resolution was 37 days (95% CI 35-39). One quarter (25%) of participants who tested positive for SARS-CoV-2 infection had persistent symptoms 8 or more weeks after symptom onset. CONCLUSION: COVID-19 has a prolonged and nonspecific disease course during pregnancy and in the 6 weeks after pregnancy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT04323839

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570