While fluoride has been added to drinking water and dental products for decades in order to prevent tooth decay, there are growing concerns about its potential toxicity. Given that fluoride is ...primarily excreted in urine, an important question that has not been examined is whether among those whose drinking water is fluoridated, impaired renal function is associated with higher levels of circulating fluoride.
To examine the association between drinking water and plasma fluoride and its modification by renal function. Design, Setting, and Participants: Participants in the National Health and Nutrition Examination Survey (NHANES) between 2013 and 2016 with measures of fluoride in plasma and drinking water and renal function. These measures were only available in adolescent age 12–19 years.
Plasma fluoride levels and their modification by strata of renal function, measured by the estimated glomerular filtration rate (eGFR).
Among 1841 healthy adolescents, a 10 ml/min/1.73 m (Penman et al., 1997) lower eGFR and a 1 mg/L higher drinking water fluoride concentration were associated with a 0.02 (95%CI -0.02, −0.03) umol/L and 0.23 (95%CI 0.15,0.30) umol/L higher adjusted plasma fluoride level, respectively. The association of water and plasma fluoride levels was most robust among those with lower renal function (multiplicative interaction p value < 0.001). For adolescents in the lowest eGFR quartile, a 1 mg/L higher drinking water fluoride concentration was associated with a 0.35 (95%CI 0.21,0.48) umol/L higher plasma fluoride level, compared to 0.20 (95%CI 0.14,0.26) umol/L in the highest eGFR quartile. Restriction to those with measurable plasma fluoride levels yielded similar results.
Water fluoridation results in higher plasma fluoride levels in those with lower renal function. How routine water fluoridation may affect the many millions of Americans with Chronic Kidney Disease, who are particularly susceptible to heavy metal and mineral accumulation, needs to be further investigated.
•Given that fluoride is excreted by the kidneys, lower kidney function is associated with higher fluoride levels in blood.•Among healthy individuals, water fluoridation associates with higher fluoride levels in blood for those with lower kidney function.•Whether routine water fluoridation may adversely affect those with Chronic Kidney Disease requires further study.
To study the reason(s) why insured patients discontinue in vitro fertilization (IVF) before achieving a live birth.
Cross-sectional study.
Private academically affiliated infertility center.
A total ...of 893 insured women who had completed one IVF cycle but did not return for treatment for at least 1 year and who had not achieved a live birth were identified; 312 eligible women completed the survey.
None.
Reasons for treatment termination.
Two-thirds of the participants (65.2%) did not seek care elsewhere and discontinued treatment. When asked why they discontinued treatment, these women indicated that further treatment was too stressful (40.2%), they could not afford out-of-pocket costs (25.1%), they had lost insurance coverage (24.6%), or they had conceived spontaneously (24.1%). Among those citing stress as a reason for discontinuing treatment (n = 80), the top sources of stress included already having given IVF their best chance (65.0%), feeling too stressed to continue (47.5%), and infertility taking too much of a toll on their relationship (36.3%). When participants were asked what could have made their experience better, the most common suggestions were evening/weekend office hours (47.4%) and easy access to a mental health professional (39.4%). Of the 34.8% of women who sought care elsewhere, the most common reason given was wanting a second opinion (55.7%).
Psychologic burden was the most common reason why insured patients reported discontinuing IVF treatment. Stress reduction strategies are desired by patients and could affect the decision to terminate treatment.
Advance care planning (ACP) is important to improving end-of-life care. Few studies have examined the impact of primary care physician (PCP) involvement in ACP.
To determine whether complete ACP, ...defined as health care proxy (HCP), provider orders for life-sustaining treatment (POLST), and documented goals-of-care (GOC) conversations, would occur earlier when the PCP was involved in POLST and/or GOC conversations.
Charts of deceased patients from 2015 to 2017 in a U.S. academic primary care practice were reviewed. Demographic factors, mortality risk scores, palliative care involvement, and visits within the last year of life to PCPs and specialists were collected. Poisson models with robust variance estimators were used to estimate the likelihood of PCP involvement being associated with earlier complete ACP after adjusting for confounders and accounting for clustering by PCP. Due to high rates of HCP documentation at the institution, 10 patients without HCP were excluded from the review.
Of 403 decreased patients, 71 (18%) met criteria for complete ACP and 214 (53%) had HCP only; the remaining 118 patients had partial (2/3 components) ACP. Of the 71 patients with complete ACP, 40.1% had ACP earlier than three months of death (early) and 59.2% had ACP within three months of death (late). PCP involvement was associated with early ACP compared with late ACP and HCP only for both PCP completion of the POLST (risk ratio RR: 4.7; 95% confidence interval CI: 1.3-17.1) and for PCP documentation of GOC conversation (RR: 4.6; 95% CI: 1.2-17.1) after adjustment for clustering by PCP and other relevant variables.
This retrospective cohort study suggests that PCP involvement in ACP correlates with earlier completion. This finding highlights the importance of educating and encouraging PCPs on completing ACP with their patients.
Introduction
High‐quality health systems rely on care that centers on patient preferences. Realization of patient preferences can improve the birth experience. However, in the dynamic setting of ...birth, birth preferences can diverge from what is medically indicated. Through studying women and birthing peoples' experiences of unplanned labor procedures, we aimed to identify ways in which practitioners can support women and birthing people through unexpected or unwanted aspects of their delivery. Specifically, we focused on labor induction.
Methods
In one large US academic center, women and birthing people participated in prenatal and postpartum surveys regarding their desires, expectations, and experiences of labor induction. From April to November 2021, participants were eligible if they showed discordance between having labor induction and whether it was initially wanted or expected. Interviews focused on attitudes toward birth preferences and outcomes, with attention to discordances. We analyzed interviews through a modified grounded theory approach.
Results
Of 22 participants, our sample was predominantly white (91%). Participants in this sample reported discordance between wanting and experiencing (73%) and/or expecting and experiencing (54%) an induction. We identified two themes: “Discordance without mitigation is perceived as a negative experience” and “Practitioner interaction can buffer against negative experience” which includes three ways in which participants prefer support in instances of discordance: preparation, communication, and care and comfort. These methods of support foster patient autonomy and can lead to positive patient experiences.
Conclusions
While medical systems should work to support patient preferences, our results suggest that patients can still have positive birth experiences, even when preferences are not fulfilled. Early practitioner preparation, positive communication, and responsive care and comfort may help to improve patient birth experience when challenges arise.
Evidence from both animal and human studies suggests that exposure to phthalates may be associated with adverse female reproductive outcomes.
We evaluated the associations between urinary ...concentrations of phthalate metabolites and outcomes of assisted reproductive technologies (ART).
This analysis included 256 women enrolled in the Environment and Reproductive Health (EARTH) prospective cohort study (2004-2012) who provided one to two urine samples per cycle before oocyte retrieval. We measured 11 urinary phthalate metabolites mono(2-ethylhexyl) phthalate (MEHP), mono(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP), mono(2-ethyl-5-oxohexyl) phthalate (MEOHP), mono(2-ethyl-5-carboxypentyl) phthalate (MECPP), mono-isobutyl phthalate (MiBP), mono-n-butyl phthalate (MBP), monobenzyl phthalate (MBzP), monoethyl phthalate (MEP), monocarboxyisooctyl phthalate (MCOP), monocarboxyisononyl phthalate (MCNP), and mono(3-carboxypropyl) phthalate (MCPP). We used generalized linear mixed models to evaluate the association of urinary phthalate metabolites with in vitro fertilization (IVF) outcomes, accounting for multiple IVF cycles per woman.
In multivariate models, women in the highest as compared with lowest quartile of MEHP, MEHHP, MEOHP, MECPP, ΣDEHP (MEHP + MEHHP + MEOHP + MECPP), and MCNP had lower oocyte yield. Similarly, the number of mature (MII) oocytes retrieved was lower in the highest versus lowest quartile for these same phthalate metabolites. The adjusted differences (95% CI) in proportion of cycles resulting in clinical pregnancy and live birth between women in the fourth versus first quartile of ΣDEHP were -0.19 (-0.29, -0.08) and -0.19 (-0.28, -0.08), respectively, and there was also a lower proportion of cycles resulting in clinical pregnancy and live birth for individual DEHP metabolites.
Urinary concentrations of DEHP metabolites were inversely associated with oocyte yield, clinical pregnancy, and live birth following ART.
Hauser R, Gaskins AJ, Souter I, Smith KW, Dodge LE, Ehrlich S, Meeker JD, Calafat AM, Williams PL, for the EARTH Study Team. 2016. Urinary phthalate metabolite concentrations and reproductive outcomes among women undergoing in vitro fertilization: results from the EARTH study. Environ Health Perspect 124:831-839; http://dx.doi.org/10.1289/ehp.1509760.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
To compare the representation of women in obstetrics and gynecology department-based leadership to other clinical specialties while accounting for proportions of women in historical residency ...cohorts.
This was a cross-sectional observational study. The gender of department-based leaders (chair, vice chair, division director) and residency program directors was determined from websites of 950 academic departments of anesthesiology, diagnostic radiology, general surgery, internal medicine, neurology, obstetrics and gynecology, pathology, pediatrics, and psychiatry. Each specialty's representation ratio-proportion of leadership roles held by women in 2013 divided by proportion of residents in 1990 who were women-and 95% confidence interval (CI) were calculated. A ratio of 1 indicates proportionate representation.
Women were significantly underrepresented among chairs for all specialties (ratios 0.60 or less, P≤.02) and division directors for all specialties except anesthesiology (ratio 1.13, 95% CI 0.87-1.46) and diagnostic radiology (ratio 0.97, 95% CI 0.81-1.16). The representation ratio for vice chair was below 1.0 for all specialties except anesthesiology; this finding reached statistical significance only for pathology, pediatrics, and psychiatry. Women were significantly overrepresented as residency program directors in general surgery, anesthesiology, obstetrics and gynecology, and pediatrics (ratios greater than 1.19, P≤.046). Obstetrics and gynecology and pediatrics had the highest proportions of residents in 1990 and department leaders in 2013 who were women.
Despite having the largest proportion of leaders who were women, representation ratios demonstrate obstetrics and gynecology is behind other specialties in progression of women to departmental leadership. Women's overrepresentation as residency program directors raises concern because education-based academic tracks may not lead to major leadership roles.
Prior work shows that ads related to abortion services often feature crisis pregnancy centers instead of abortion providers. We investigated whether a change in Google's advertising policy that ...required advertisers to disclose whether they provided abortion services increased the proportion of ads facilitating abortion self-referral.
We used a standardized protocol to search online for abortion services before, during, and after the policy change; we performed searches in August 2016 to June 2017, June 2019, and October 2019, respectively, using Google, Bing, and Yahoo search engines. We performed searches for the 25 most populous U.S. cities and the 43 state capitals not already included. We classified up to the first 5 ads as facilitating abortion referral, hindering abortion referral, or providing neutral content. We compared search engine results using a chi-square test.
Among ads returned by Google, those shown after the policy change were significantly more likely to facilitate abortion self-referral (66.7% vs. 44.2%; p = 0.003) and slightly less likely to hinder abortion self-referral (33.3% vs. 40.6%; p = 0.33) compared to before the change. These findings were reversed for ads shown by Bing and Yahoo; ads returned after the change were significantly less likely to facilitate abortion self-referral (24.6% vs. 32.8%; p = 0.01) and significantly more likely to hinder self-referral (28.3% vs. 21.6%; p = 0.03) compared to before the change.
A policy requiring advertisers to disclose whether they provide abortion services was associated with increasing the proportion of ads facilitating self-referral. Similar policies should be considered by all search engines.
OBJECTIVE:To characterize the cohort who may become senior leaders in obstetrics and gynecology by examining the gender and subspecialty of faculty in academic department administrative and ...educational leadership roles.
METHODS:This is an observational study conducted through web sites of U.S. obstetrics and gynecology residency programs accredited in 2012–2013.
RESULTS:In obstetrics and gynecology departmental administrative leadership roles, women comprised 20.4% of chairs, 36.1% of vice chairs, and 29.6% of division directors. Among educational leaders, women comprised 31.9% of fellowship directors, 47.3% of residency directors, and 66.1% of medical student clerkship directors. Chairs were most likely to be maternal–fetal medicine faculty (38.2%) followed by specialists in general obstetrics and gynecology (21.8%), reproductive endocrinologists (15.6%), and gynecologic oncologists (14.7%). Among chairs, 32.9% are male maternal–fetal medicine specialists. Family planning had the highest representation of women (80.0%) among division directors, whereas reproductive endocrinology and infertility had the lowest (15.8%). The largest proportion of women chairs, vice chairs, residency program directors, and medical student clerkship directors were specialists in general obstetrics and gynecology.
CONCLUSION:Women remained underrepresented in the departmental leadership roles of chair, vice chair, division director, and fellowship director. Representation of women was closer to parity among residency program directors, in which women held just under half of positions. Nearly one in three department chairs was a male maternal–fetal medicine specialist. Compared with subspecialist leaders, specialist leaders in general obstetrics and gynecology were more likely to be women.
LEVEL OF EVIDENCE:II
Background
The copper intrauterine device (Cu‐IUD) is a highly effective method of contraception that can also be used for emergency contraception (EC). It is the most effective form of EC, and is ...more effective than other existing oral regimens also used for EC. The Cu‐IUD provides the unique benefit of providing ongoing contraception after it is inserted for EC; however, uptake of this intervention has been limited. Progestin IUDs are a popular method of long‐acting, reversible contraception. If these devices were also found to be effective for EC, they would provide a critical additional option for women. These IUDs could not only provide EC and ongoing contraception, but additional non‐contraceptive benefits, including a reduction in menstrual bleeding, cancer prevention, and pain management.
Objectives
To examine the safety and effectiveness of progestin‐containing IUDs for emergency contraception, compared with copper‐containing IUDs, or compared with dedicated oral hormonal methods.
Search methods
We considered all randomized controlled trials and non‐randomized studies of interventions that compared outcomes for individuals seeking a levonorgestrel IUD (LNG‐IUD) for EC to a Cu‐IUD or dedicated oral EC method. We considered full‐text studies, conference s, and unpublished data. We considered studies irrespective of their publication status and language of publication.
Selection criteria
We included studies comparing progestin IUDs with copper‐containing IUDs, or oral EC methods for emergency contraception.
Data collection and analysis
We systematically searched nine medical databases, two trials registries, and one gray literature site. We downloaded all titles and s retrieved by electronic searching to a reference management database, and removed duplicates. Three review authors independently screened titles, s, and full‐text reports to determine studies eligible for inclusion. We followed standard Cochrane methodology to assess risk of bias, and analyze and interpret the data. We used GRADE methodology to assess the certainty of the evidence.
Main results
We included only one relevant study (711 women); a randomized, controlled, non‐inferiority trial comparing LNG‐IUDs to Cu‐IUDs for EC, with a one‐month follow‐up. With one study, the evidence was very uncertain for the difference in pregnancy rates, failed insertion rates, expulsion rates, removal rates and the difference in the acceptability of the IUDs. There was also uncertain evidence suggesting the Cu‐IUD may slightly increase rates of cramping and the LNG‐IUD may slightly increase bleeding and spotting days.
Authors' conclusions
This review is limited in its ability to provide definitive evidence regarding the LNG‐IUD’s equivalence, superiority, or inferiority to the Cu‐IUD for EC. Only one study was identified in the review, which had possible risks of bias related to randomization and rare outcomes.
Additional studies are needed to provide definitive evidence related to the effectiveness of the LNG‐IUD for EC.
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