The Challenge of Maintaining our Physician-Scientist Workforce (Rare Breed/Endangered Species): Epidemiology & Anecdotes

As part of the mini-symposium entitled The Challenge of Maintaining our Physician-Scientist Workforce, Dr. Moore Simas discusses the epidemiology of physician scientists in the modern era with a focus on specialty-based and demographic issues

PPODS: Pregnancy and Postpartum Observational Dietary Study

An important contributor to weight gain among young women is postpartum weight retention; however, interventions aimed at promoting weight loss among post-partum women have generally been unsuccessful. This presentation will include an overview of a recently funded translational research project designed to evaluate whether associations among dietary consumption of saturated fat, fat deposition and weight loss observed in mice, can be observed in human subjects during pregnancy and the postpartum period

Why pregnant women with depression often slip through the cracks

One in seven women experience depression during pregnancy and after they give birth. This article explains how a model the authors created in Massachusetts to ensure that women with depression get the help they need is being implemented in other states

Addressing Perinatal Depression in the Outpatient Obstetric Setting

Presentation will discuss: (1) barriers that OB/Gyn providers and support staff encounter in recognizing depression and engaging perinatal women in treatment, (2) strategies to overcome barriers to treatment and (3) the development of interventions aimed at improving treatment entry and follow-up

BMI, Gestational Weight Gain and Angiogenic Biomarker Profiles for Preeclampsia Risk

Objective: In May 2009, after considering short and long-term maternal/child outcomes, the Institute of Medicine (IOM) revised recommendations for gestational weight gain (GWG); however preeclampsia was dismissed due to insufficient evidence. Our objective was to evaluate preeclampsia risk by angiogenic-biomarker profile by both BMI and GWGadherence. Given numerous studies showing adipose tissue\u27s ability to stimulate angiogenesis, we hypothesized that overweight/obese (OW-OB) women and over-gainers (OG) would have altered angiogenic profiles as compared to underweight/normal-weight (UN) women and under-/appropriate-gainers (U-AG), respectively. Methods: Between 5/04-1/06, serial serum specimens collected from 94 women at high preeclampsia risk between 22-36 weeks. Soluble fms-like tyrosine kinase-1 (sFlt1), placental growth factor (PlGF) and soluble endoglin (sEng) measured by ELISA. BMI and GWG adherence categories determined by 1990 IOM recommendations. Within-women correlation and right-skewness handled by estimating linear mixed models for ln-transformed biomarkers and then exponentiating on ln scale (i.e.geometric means). T-test compared means in 3 windows. Results: Analytic sample included 82 subjects (342 specimens) without multiples or pregnancy-related hypertension diagnosis. Mean sFlt1 lower in all windows in OW-OB compared to U-N - significant only at 22-26wks [506.2 (95% CI 438.1-584.9) vs 745.5 (95% CI 595.9-932.6) p=0.04] and in OG compared to U-AG with significant comparisons (p=0.05) [22-26wks: 492.1 (95% CI 420.1-576.3) vs 691.3 (95% CI 574.0-832.6); 27-30 wks: 570.1 (95% CI 488.1-665.9) vs 788.8 (95% CI 656.8-947.4)]. Mean PIGF lower in all windows in OW-OB compared to U-N [22-26wks: 430.5 (95% CI 359.0-516.3) vs 588.6 (95% CI 444.3-779.7) p=0.06; 27-30wks: 475.8 (95% CI 398.7-567.8) vs 811.8 (95% CI 614.3-1072.9) p=0.005; 31-36wks: 428.5 (95% CI 358.0-513.0) vs 724.6 (95% CI 548.5-957.1) p=0.01] and in OG compared to U-AG with no significant comparisons. Mean ratio [(sFlt1+sEng):PIGF] trended higher in OW-OB compared to U-N women at 27-30 and 31-36 wks and in OG compared to UAG at 31-36wks; however no windows with significant comparisons. Conclusion: Findings suggest trends that OW-OB BMI and excessive GWG associated with angiogenic biomarker profiles consistent with higher preeclampsia risk. Exploratory study limited by small numbers. BMI and GWG as potentially modifiable factors merit furtherinvestigation for preeclampsia risk alteration. Presented at the Society of Gynecologic Investigation 2011 Annual Meeting, March 2011, Miami Beach, Florida

Obstetric Interventions: Assessment of Differential Practices by Race/Ethnicity

Cesarean sections constitute approximately 30% of the over 4 million live births a year in the United States, and a rising number of primary cesarean sections contribute significantly to the overall rate. Studies suggest that the rate of primary cesarean section is disproportionately higher among non-white women, even when controlling for demographic, behavioral and medical risk factors. Our study investigates the interrelationships between racial/ethnic characteristics and obstetric interventions among low risk pregnancies. We included nulliparous women with full term, singleton pregnancies and fetus in vertex presentation who delivered at UMass between April 2006 and March 2011. We excluded non-live births, women with antepartum complications or pre-labor indications for cesarean, and cases with unspecified race or missing data. Our sample consisted of 4,483 subjects, of which 7% were black, 70% white, 4% Asian, and 17% Hispanic. 74% had spontaneous vaginal deliveries, 9% had operative vaginal deliveries, and 17% had cesarean sections. 40% of the indications for cesarean were related to fetal distress, 25% to first stage labor, and 34% to second stage labor. Average maternal age was 26.2, average BMI was 24.9, average birth weight was 3381g, and average gestational age at delivery was 39.7 weeks; there were no significant differences in these variables across racial groups. We examined racial/ethnic differences in mode of delivery (spontaneous vaginal, operative vaginal and cesarean) using logistic regression models while adjusting for maternal age, BMI, and birth weight. We found that Asian women were more likely than white women to undergo cesarean section compared with spontaneous vaginal delivery (OR 1.49, 95% CI (1.02, 2.17)). We also found that Black women were more likely than white women to undergo cesarean section compared with spontaneous vaginal delivery (OR 1.43, 95% CI 1.07, 1.91)). This may warrant further investigation of racial differences in risk adjusted primary cesarean rates

Gestational Weight Gain Prior to Glucola and Risk of Gestational Diabetes Mellitus

Background: Gestational diabetes mellitus (GDM) complicates 4–7% of U.S. pregnancies. Diabetes and obesity rates are consistently higher in Hispanics compared to non-Hispanic whites. Early-to-mid gestational weight gain (GWG) has been thought to be associated with GDM risk; however, the Institute of Medicine (IOM) found insufficient evidence when re-examining GWG guidelines in 2009. Objective: To investigate associations of GWG adherence per 2009 IOM guidelines prior to 1-hr 50g Glucose Tolerance Test (GTT), or glucola, with GDM diagnoses in Latinas. Methods: The study is a retrospective chart review of all Hispanic women delivered by UMass Memorial faculty between 4/1/06-3/31/11 and received prenatal care at faculty-resident practices (n=1163). Pre-pregnancy weight and height, weight and gestational age (GA) most proximate to glucola and 100g GTT where appropriate, lab results and relevant demographics were abstracted. Weight gain was categorized as inadequate, appropriate or excessive according to 2009 IOM Guidelines with adjustment for gestational age. Mean and standard deviation (SD) and frequency measures reported for continuous and categorical variables, respectively. Comparisons were evaluated with chi-squared tests with statistical significance set at p\u3c0.05. Results: Data for 1115 subjects was analyzed. Preliminary cohort was mean age 25.3 years (sd±6.0), mean gravidity 2.8 (sd±1.8) and 72.1% English and 26.4% Spanish-speaking. Eleven subjects excluded for pregestational diabetes. BMI calculable for 858 subjects (5.4% underweight, 40.3% normal, 26.0% overweight and 28.3% obese); 70 subjects missing GWG prior to glucola. Seven hundred eighty-eight subjects had complete data, on which remainder of analyses were performed. By 2009 IOM guidelines, 174 (22.1%), 193 (24.5%) and 421 (53.4%) gained inadequately, appropriately and excessively as per BMI criteria, respectively. Overall, 86 of 788 diagnosed with GDM (10.9%). According to weight gain adherence, 14 of 174 (8.0%) inadequate-gainers, 20 of 193 (10.4%) appropriate-gainers and 52 of 421 (12.4%) excessive-gainers were diagnosed with GDM. Of subjects with GDM diagnosis (n=86), 16.3%, 23.3% and 60.5% were inadequate, appropriate and excessive-gainers, respectively. Compared to appropriate gainers, the crude odds ratio and 95% CI for GDM diagnosis was 1.22 (0.71-2.11) for excessive-gainers and 0.76 (0.37-1.55) for inadequate-gainers. No statistically significant association between pre-glucola GWG and GDM detected (p=0.3). Conclusion: The rate of GDM in this cohort of Latina women is almost double that of the general population. Though no statistically significant association was identified, the majority of patients diagnosed with GDM were classified as excessive-gainers as per pre-glucola GWG adherence. The trend warrants further evaluation of this population at increased risk for GDM as well as analysis within high-risk subgroups

HPV Vaccine Reminders at the Point of Service: Efficacy and Missed Opportunities. A Claims Based Study within One Health Plan

Introduction: Our objective is to assess HPV vaccine series completion rates, whether on-screen Point of Service reminders (POS) make a difference, and missed opportunities for reminders to have an effect. Methods: Retrospective, claims-based study of females aged 9-26 receiving an initial dose of HPV vaccine during 2 periods: before (period 1) and after (period 2) implementation of a POS reminder system in 1(“Change Group”) of 2 physician groups using EHRs for both periods. Completion rates, and missed opportunities during eligible periods were calculated for those with continuous enrollment in the health plan investigated. Results: Completion rates within 1 year of the 1st dose were Period 1: 47% Change Group vs. 46% Control Group (p=0.847). Period 2: 50% Change group vs. 57% Control Group (p=0.158). No significant improvement occurred between the 2 periods in either group. Differences in 1 year completion rates by specialty of initiating provider or age group (≥18) were not significant. During period 2, among those with continuous insurance plan enrollment in the Change Group, 43 patients received 1 dose and 46 received 2 doses. Of those receiving 1 dose, 30 (70%) had a visit to the same group within an eligible time period (median # visits: 2, range 1-20); of those completing 2 doses, 4 (9%) had a visit to the same group within an eligible period (median # visits: 1, range: 1-3). Among those receiving 1 dose, 25 (58%) had a visit to the same group and same specialty as the initial dose (median # visits: 1, range 1-8); for those having received 2 doses, 3 (6%) had a subsequent visit to same group and specialty (median # visits: 1, range 1-3). Conclusion: POS reminder systems was not associated with improved completion rates. POS reminders are limited by infrequent visits among non-completers in an eligible period

Racial and ethnic differences in primary, unscheduled cesarean deliveries among low-risk primiparous women at an academic medical center: a retrospective cohort study

BACKGROUND: Cesarean sections are the most common surgical procedure for women in the United States. Of the over 4 million births a year, one in three are now delivered in this manner and the risk adjusted prevalence rates appear to vary by race and ethnicity. However, data from individual studies provides limited or contradictory information on race and ethnicity as an independent predictor of delivery mode, precluding accurate generalizations. This study sought to assess the extent to which primary, unscheduled cesarean deliveries and their indications vary by race/ethnicity in one academic medical center. METHODS: A retrospective, cross-sectional cohort study was conducted of 4,483 nulliparous women with term, singleton, and vertex presentation deliveries at a major academic medical center between 2006-2011. Cases with medical conditions, risk factors, or pregnancy complications that can contribute to increased cesarean risk or contraindicate vaginal birth were excluded. Multinomial logistic regression analysis was used to evaluate differences in delivery mode and caesarean indications among racial and ethnic groups. RESULTS: The overall rate of cesarean delivery in our cohort was 16.7%. Compared to White women, Black and Asian women had higher rates of cesarean delivery than spontaneous vaginal delivery, (adjusted odds ratio {AOR}: 1.43; 95% CI: 1.07, 1.91, and AOR: 1.49; 95% CI: 1.02, 2.17, respectively). Black women were also more likely, compared to White women, to undergo cesarean for fetal distress and indications diagnosed in the first stage as compared to the second stage of labor. CONCLUSIONS: Racial and ethnic differences in delivery mode and indications for cesareans exist among low-risk nulliparas at our institution. These differences may be best explained by examining the variation in clinical decisions that indicate fetal distress and failure to progress at the hospital-level

Trajectories of Weight for Length Growth for Infants During the First Year of Life

Background: Childhood obesity is a major public health problem. Studies of patterns of child growth contributing to the development of obesity are scarce, particularly in infancy. Group based trajectory analyses among infants are a novel procedure that may help characterize subgroups of infants with similar longitudinal growth profiles. Objective: To identify trajectories of weight for length growth during the first year of life. Methods: Subjects were singleton infants and their mothers (N=90 mother-infant pairs) who participated in the Pregnancy and Postpartum Observational Dietary Study. Women completed assessments throughout their infant\u27s first year of life and included sociodemographic characteristics and feeding behaviors. Infant weight for length measures from birth to 12 months were abstracted from pediatric office records. Weight for length percentiles were calculated according to the World Health Organization guidelines for infants. Group-based trajectory analysis was done to identify subgroups of infants with similar growth profiles. Results: Infants were from mother’s with average of 28 years (SD=5.2), 70.0% White, 60.0% high-school educated and 63.2% had two or more children. Over half of mothers introduced solid foods to their infants by 6 months of age (63.2%) and about one third self-reported breast feeding at 12 months post-partum (31.9%). Three growth trajectories were identified: a low and stable growth group (38.3%), a rapid growth group (35.0%) and a moderate growth group (26.7%). Maternal and feeding variables were all similar across the three infant growth trajectory groups (p\u3e0.05). Conclusion: Trajectory models suggested three patterns of infant growth. If replicated, future studies can help identify and subsequently target modifiable risk factors associated with rapid infant growth trajectories