Abstract
Context
The effects of maternal subclinical hypothyroidism on pregnancy outcomes are not clear.
Objective
We aimed to assess potential associations between maternal thyrotropin ...(thyroid-stimulating hormone TSH) levels in pregnancy and obstetric and perinatal outcomes.
Design
Retrospective cohort study.
Setting
Tertiary academic medical center.
Patients
Women aged ≥18 years with a singleton gestation and no known thyroid disease seen for prenatal care at Boston Medical Center from January 1, 2003 through May 22, 2014, and their fetuses and infants were included.
Main Outcome Measures
Risk ratios of adverse obstetric and perinatal outcomes.
Results
A total of 8,413 pregnant women (mean age 29.1 years, 15% white, 60% black, 13% Hispanic) and their fetuses and infants (mean gestational age at birth 38.5 weeks, 52% male, mean birth weight 3.2 kg) were included in the analyses. The median (interquartile range) TSH level was 1.06(0.62–1.60) mIU/L, and 130 women (1.6%) had TSH > 4 mIU/L. Maternal TSH levels > 4 mIU/L were associated with increased risks of prematurity (risk ratio RR 2.17 95% confidence interval 1.15–4.07 P = .016) and neonatal respiratory distress syndrome (RDS) (RR 2.83 95% confidence interval 1.02–7.86 P = .046) compared to TSH levels ≤ 4 mIU/L. Although not statistically significant, TSH levels > 4 mIU/L were also associated with increased RRs for fetal loss, preeclampsia/eclampsia, and low birth weight. TSH levels > 4 mIU/L were not associated with preterm labor, placental abruption, cesarean section, gestational hypertension or diabetes, or neonatal intensive care unit admission.
Conclusion
Maternal serum TSH concentration > 4 mIU/L in pregnancy was associated with approximately 2-fold increased risks of prematurity and RDS in offspring. Elevated TSH was also associated with statistically non-significant increases in the risk of fetal loss, preeclampsia/eclampsia, and low birth weight.
It is estimated that 50,000-60,000 pregnant people in the United States (US) experience severe maternal morbidity (SMM). SMM includes life-threatening conditions, such as acute myocardial infarction, ...acute renal failure, amniotic fluid embolism, disseminated intravascular coagulation, or sepsis. Prior research has identified both rising rates through 2014 and wide racial disparities in SMM. While reducing maternal death and SMM has been a global goal for the past several decades, limited progress has been made in the US in achieving this goal. Our objectives were to examine SMM trends from 1998-2018 to identify factors contributing to the persistent and rising rates of SMM by race/ethnicity and describe the Black non-Hispanic/White non-Hispanic rate ratio for each SMM condition. We used a population-based data system that links delivery records to their corresponding hospital discharge records to identify SMM rates (excluding transfusion) per 10, 000 deliveries and examined the trends by race/ethnicity. We then conducted stratified analyses separately for Black and White birthing people. While the rates of SMM during the same periods steadily increased for all racial/ethnic groups, Black birthing people experienced the greatest absolute increase compared to any other race/ethnic group going from 69.4 in 1998-2000 to 173.7 per 10,000 deliveries in 2016-2018. In addition, we found that Black birthing people had higher rates for every individual condition compared to White birthing people, with rate ratios ranging from a low of 1.11 for heart failure during surgery to a high of 102.4 for sickle cell anemia. Obesity was not significantly associated with SMM among Black birthing people but was associated with SMM among White birthing people aRR 1.18 (95% CI: 1.02, 1.36). An unbiased understanding of how SMM has affected different race/ethnicity groups is key to improving maternal health and preventing SMM and mortality among Black birthing people. SMM needs to be addressed as both a medical and public health challenge.
Racial/ethnic minorities living with HIV and behavioral health co-morbidities are more likely to be disengaged from HIV primary care. Peer programs have been effective in HIV outreach and prevention ...but effectiveness of such programs for retention in care and viral suppression is understudied. Subjects (
n
= 348) were randomized in equal allocation to a peer navigation and education intervention versus standard clinical care at three urban clinics in the United States. The intervention group received seven structured interventions plus weekly contact to address medical and social needs. Primary outcomes included time-to-first 4-month gap in HIV care and viral suppression up to 12 months of follow-up. Intention-to-treat analysis showed no difference between groups on 4-month gap in HIV primary care, but subgroup analysis showed a suggestive effect of the peer intervention in reducing gaps in care among stably housed subjects. Fully compliant subjects in the peer intervention experienced significantly fewer 4-month gaps in HIV primary care (
p
< 0.0001). Those in the peer group who had more clinical face-to-face encounters in the first 3 months were also significantly more likely to have better retention in care (
p
= 0.04). There were no significant differences between any study subgroups in viral suppression at 12 months. Peer interventions may improve retention in primary care among subgroups of people living with HIV from racial/ethnic minority communities, although such improved retention may not increase viral load suppression. Attending and completing structured educational sessions along with early, intensive contact with peers could improve retention in HIV primary care for patients. Future peer programs should consider training on housing referral systems to help increase retention for patients who are not stably housed. clinicaltrials.gov registration number: NCT01616940.
Chronic obstructive pulmonary disease (COPD) is characterized by an incompletely reversible limitation in airflow. A physiological variable--the forced expiratory volume in one second (FEV1)--is ...often used to grade the severity of COPD. However, patients with COPD have systemic manifestations that are not reflected by the FEV1. We hypothesized that a multidimensional grading system that assessed the respiratory and systemic expressions of COPD would better categorize and predict outcome in these patients.
We first evaluated 207 patients and found that four factors predicted the risk of death in this cohort: the body-mass index (B), the degree of airflow obstruction (O) and dyspnea (D), and exercise capacity (E), measured by the six-minute-walk test. We used these variables to construct the BODE index, a multidimensional 10-point scale in which higher scores indicate a higher risk of death. We then prospectively validated the index in a cohort of 625 patients, with death from any cause and from respiratory causes as the outcome variables.
There were 25 deaths among the first 207 patients and 162 deaths (26 percent) in the validation cohort. Sixty-one percent of the deaths in the validation cohort were due to respiratory insufficiency, 14 percent to myocardial infarction, 12 percent to lung cancer, and 13 percent to other causes. Patients with higher BODE scores were at higher risk for death; the hazard ratio for death from any cause per one-point increase in the BODE score was 1.34 (95 percent confidence interval, 1.26 to 1.42; P<0.001), and the hazard ratio for death from respiratory causes was 1.62 (95 percent confidence interval, 1.48 to 1.77; P<0.001). The C statistic for the ability of the BODE index to predict the risk of death was larger than that for the FEV1 (0.74 vs. 0.65).
The BODE index, a simple multidimensional grading system, is better than the FEV1 at predicting the risk of death from any cause and from respiratory causes among patients with COPD.
Employment is particularly beneficial for persons living with HIV (PLWH). However, PLWH experiencing internalized stigma or anticipating that they may experience stigma may be less likely to seek ...employment due to additional barriers associated with HIV. The purpose of this study was to understand the associations between internalized and anticipated stigma and employment barriers for PLWH. Adjusted models suggest that greater anticipated stigma was related to increased employment barriers (beta = 0.12, p = 0.04). Mental and physical health functioning also positively predicted employment barriers (beta = -0.18, p <0.001; beta = -0.40, p <0.001, respectively). Employment among PLWH has beneficial impacts on HIV-related health outcomes. This study suggests that anticipated stigma may limit and individual's willingness to seek out employment, or may cause them to leave employment. Internalized stigma may not play as large of a role in employment as anticipated stigma for PLWH. HIV-related stigma reduction interventions focused on community-level and employers are essential to improve employment opportunities for PLWH.
A variety of wearable monitors are available for objectively assessing physical activity but there is a lack of established values for the activity intensity of MotionWatch8 (MW8) and a similar lack ...of studies on comparability across devices. Our study aimed to establish activity intensity cutpoints for the MW8 accelerometer in children, which are necessary to determine whether they are meeting physical activity guidelines. Children (n = 39, ages 9-13 years) were asked to wear two different accelerometers (MW8 and ActiGraph) simultaneously on the same dominant wrist as they performed different activities designed to mimic activities of variable intensity that a child might perform in a free-living environment. Linear regression and receiver operating characteristic (ROC) curves were performed to assess sensitivity and specificity of the identified MW8 intensity cutpoints compared to established ActiGraph cutpoints. Mean values for each activity were positively correlated using the MW8 and ActiGraph monitors (r = 0.85, p<0.001). The optimal cutpoints for differentiating sedentary from light physical activity, light from moderate, and moderate from vigorous activity were less than or equal to32 counts, greater than or equal to 371.5 counts, and greater than or equal to 859.5 counts per 30 seconds, respectively. Our study demonstrated the ability of MW8 to discriminate different intensity activities and provided the first cutoff values for researchers using the MW8 to measure physical activity patterns among children.
Over the past 10 years, identification of Autism Spectrum Disorder (ASD) risk has dramatically increased due to the wide-spread implementation of screening programs; yet, there is limited ...understanding about parent perceptions and experiences during the time period when risk is identified, but prior to receiving a formal diagnosis—a period that can last months to years given the long wait-lists for formal ASD evaluations. The current study aimed to examine parent perceptions of family impact (i.e., the impact their child’s behaviors have on the family) between the time of risk-identification and formal diagnosis among 277 children identified as at-risk for ASD through screening positive in primary care. We aimed to compare family impact among those whose child met diagnostic criteria for ASD and those who did not. Parents of children who received a non-ASD diagnosis reported a higher baseline level of family impact (F1, 274 = 5.82,
p
= .017); however, perceived difficult child behavior was a stronger predictor of family impact (t6 = 13.11,
p
< .001) than later diagnostic group (
t
6 = − 2.10,
p
= .037), and child functioning did not predict family impact (
t
6 = -0.31,
p
= .76). These results suggest that in this population, perceived difficult child behavior is a stronger predictor of family impact than later diagnostic category and should be considered an important factor in family support.
Abstract
STUDY QUESTION
Do women with polycystic ovary syndrome (PCOS) have a greater risk of adverse pregnancy complications (gestational diabetes, preeclampsia, cesarean section, placental ...abnormalities) and neonatal outcomes (preterm birth, small for gestational age, prolonged delivery hospitalization) compared to women without a PCOS diagnosis and does this risk vary by BMI, subfertility and fertility treatment utilization?
SUMMARY ANSWER
Deliveries to women with a history of PCOS were at greater risk of complications associated with cardiometabolic function, including gestational diabetes and preeclampsia, as well as preterm birth and prolonged length of delivery hospitalization.
WHAT IS KNOWN ALREADY
Prior research has suggested that women with PCOS may be at increased risk of adverse pregnancy outcomes. However, findings have been inconsistent possibly due to lack of consistent adjustment for confounding factors, small samples size and other sources of bias.
STUDY DESIGN, SIZE, DURATION
Massachusetts deliveries among women ≥18 years old during 2013–2017 from state vital records linked to hospital discharges, observational stays and emergency department visits were linked to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) and the Massachusetts All-Payers Claims Database (APCD).
PARTICIPANTS/MATERIALS, SETTING, METHODS
PCOS was identified by ICD9 and ICD10 codes in APCD prior to index delivery. Relative risks (RRs) and 95% CI for pregnancy and delivery complications were modeled using generalized estimating equations with a log link and a Poisson distribution to take multiple cycles into account and were adjusted a priori for maternal age, BMI, race/ethnicity, education, plurality, birth year, chronic hypertension and chronic diabetes. Tests for homogeneity investigated differences between maternal pre-pregnancy BMI categories (<30, ≥30, <25 and ≥25 kg/m2) and between non-infertile deliveries and deliveries that used ART or had a history of subfertility (defined by birth certificates, SART CORS records, APCD or hospital records).
MAIN RESULTS AND THE ROLE OF CHANCE
Among 91 825 deliveries, 3.9% had a history of PCOS. Women with a history of PCOS had a 51% greater risk of gestational diabetes (CI: 1.38–1.65) and a 25% greater risk of preeclampsia (CI: 1.15–1.35) compared to women without a diagnosis of PCOS. Neonates born to women with a history of PCOS were more likely to be born preterm (RR: 1.17, CI: 1.06–1.29) and more likely to have a prolonged delivery hospitalization after additionally adjusting for gestational age (RR: 1.23, CI: 1.09–1.40) compared to those of women without a diagnosis of PCOS. The risk for gestational diabetes for women with PCOS was greater among women with a pre-pregnancy BMI <30 kg/m2.
LIMITATIONS, REASONS FOR CAUTION
PCOS was defined by ICD documentation prior to delivery so there may be women with undiagnosed PCOS or PCOS diagnosed after delivery included in the unexposed group. The study population is limited to deliveries within Massachusetts among most private insurance payers and inpatient or observational hospitalization in Massachusetts during the follow-up window, therefore there may be diagnoses and or deliveries outside of the state or outside of our sample that were not captured.
WIDER IMPLICATIONS OF THE FINDINGS
In this population-based study, women with a history of PCOS were at greater risk of pregnancy complications associated with cardiometabolic function and preterm birth. Obstetricians should be aware of patients’ PCOS status and closely monitor for potential pregnancy complications to improve maternal and infant perinatal health outcomes.
STUDY FUNDING/COMPETING INTEREST(S)
This work was supported by the NIH (R01HD067270). S.A.M. receives grant funding from NIH, AbbVie and the Marriot Family Foundation; payment/honoraria from the University of British Columbia, World Endometriosis Research Foundation and Huilun Shanghai; travel support for attending meetings for ESHRE 2019, IASP 2019, National Endometriosis Network UK meeting 2019; SRI 2022, ESHRE 2022; participates on the data safety monitoring board/advisory board for AbbVie, Roche, Frontiers in Reproductive Health; and has a leadership role in the Society for Women’s Health Research, World Endometriosis Research Foundation, World Endometriosis Society, American Society for Reproductive Medicine and ESHRE. The other authors have no conflicts of interest.
TRIAL REGISTRATION NUMBER
N/A.
People with HIV with co-occurring substance use and mental health diagnoses who are unstably housed have poorer outcomes for retention in care and viral suppression. Navigation models are a potential ...strategy to help this vulnerable population obtain the necessary medical and non-medical services across multiple service systems. The Health Resources and Services Administration's Special Projects of National Significance: "Building a Medical Home for Multiply-Diagnosed HIV-positive Homeless Populations initiative 2012-2017 found that navigation models may be an effective intervention to support people with HIV with unstable housing improve HIV health outcomes. However, there is limited information about the mechanisms by which this intervention works. In this article, we explore the participant and program factors for achieving stable housing at 6 months and how these factors influence HIV health outcomes. This was a prospective study of 471 unstably housed people with HIV enrolled in a navigation intervention across nine sites in the United Stated from 2013-2017. All sites provided HIV primary medical care. Eight sites were located in urban areas and one site served a predominantly rural population. Two sites were federally qualified health centers, three were city or county health departments, one site was a comprehensive HIV/AIDS service organization, and three sites were outpatient or mobile clinics affiliated with a university -based or hospital system. Data were collected via interview and medical chart review at baseline, post 6 and 12 months. Type and dose of navigation activities were collected via a standardized encounter form. We used a path analysis model with housing stability at 6 months as the mediator to examine the direct and indirect effects of participant's socio-demographics and risk factors and navigation on viral suppression and retention in care at 12 months. Housing stability at 6 months was associated with male gender, younger age, viral suppression at baseline, having a lower risk for opiate use, recent homelessness, lower risk of food insecurity, and a longer length of time living with HIV. Participants who increased self-efficacy with obtaining help by 6 months had significantly higher odds of achieving housing stability. Stable housing, fewer unmet needs, moderate to high risk for opiate use, and viral suppression at baseline had a direct effect on viral suppression at 12 months. The intensity of navigation contact had no direct effect on housing stability and a mixed direct effect on viral suppression. Recent diagnosis with HIV, women, greater social support, increased self-efficacy and higher intensity of navigation contact had a direct effect on improved retention in HIV primary care at 12 months. In this sample of people with HIV who are experiencing homelessness, housing stability had a significant direct path to viral suppression. Navigation activities did not have a direct effect on the path to housing stability but were directly related to retention in care. These results identify key populations and factors to target resources and policies for addressing the health and social unmet needs of people with HIV to achieve housing stability and HIV health outcomes.
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