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BACKGROUND: The U.S. Preventive Services Task Force (USPSTF) modified breast cancer screening guidelines in November 2009. The impact has been studied among privately and Medicare insured populations, but not among universally insured women. MATERIALS AND METHODS: This study compared the proportion of TRICARE beneficiaries aged 40–64 receiving mammograms from fiscal years 2006 to 2015 using an interrupted time series analysis to determine the impact of the 2009 USPSTF guideline changes. Stratified analyses evaluated differences by age (ages 40–49, 50–64), race, care setting, beneficiary type, and military status. RESULTS: The proportion of women receiving mammograms increased from October 2005 through September 2009. A small, but significant decrease of 65–66 fewer women screened per 10,000 occurred in the first quarter of 2010 (October 1 to December 31) following the screening guideline update publication. The proportion screened then remained unchanged through 2015. Comparative analysis revealed no differences in impact between age groups, blacks and whites, or military dependents and active-duty/retirees. CONCLUSIONS: This study determined that the USPSTF guideline updates had a small, but immediate and lasting impact that was not different across age groups, beneficiary type, or race. No racial disparities in the proportion screened or in the impact of the guideline change were noted in our universally insured population.

Women in the military have a high rate of unintended pregnancies, which is an issue both personally and with respect to the warfighting mission. One strategy to help servicewomen achieve family planning goals includes increasing education about and access to contraception. Research suggests that preference-sensitive decisions about contraceptives benefit from shared decision-making, and decision aids have been shown to facilitate this patient-centered approach. In this article, we describe the process by which we enhanced an existing evidence-based tool to meet the needs of military servicewomen and created Decide + Be Ready, a contraceptive decision-making mobile application. After extensive research into challenges faced by servicewomen with respect to contraceptive knowledge and access, we developed content for the decision aid and determined that a mobile app format would provide the privacy and convenience needed. Our team developed a prototype that, in collaboration with the Defense Health Agency Connected Health Branch, was tested with servicewomen and providers. User feedback shaped the final version, which can be accessed free from the App Store and Google Play. Early implementation has demonstrated patient and provider satisfaction. Obstacles to full implementation of Decide + Be Ready remain within the Military Health System. We lay out a roadmap for dissemination, implementation, and evaluation and explore the applications of the decision aid for health professions education in the realm of shared decision-making. Finally, we recommend consideration of decision aids for other health care decisions as a way to achieve patient-centered care, improve health outcomes, and potentially reduce costs.

Shared decision making, a collaborative approach between patient and provider that considers the patient's values and preferences in addition to the scientific evidence, is a complex clinical activity that has not realized its full potential. Gaps in education and training have been cited as barriers to shared decision making, and evidence is inconsistent on effective educational interventions. Because individual agents with their own social and behavioral contexts co-construct a shared decision, the educational approach may need to consider the role of patient agency and sociocultural influences. To address the inherent complexity in shared decision making, the authors identified cultural historical activity theory (CHAT) as a framework for analysis. Although certainly not the only relevant theory, CHAT offers an appropriate lens through which the multivoiced nature of shared decision making can be more clearly appreciated. In this article, the authors demonstrate the application of CHAT as a lens for researchers and educators to examine the complexity of shared decision making. The fictitious case presented in this article describes the use of CHAT with a patient who experiences 2 clinical encounters; during the second, shared decision making takes place. Elements of the case are threaded through the article, demonstrating a sample analysis of the interacting activity systems of the patient and physician and highlighting inherent tensions and contradictions. The authors propose CHAT as a tool for future research around the role of agency in shared decision making and other complex topics and as a framework for design of novel instructional strategies. Although not applicable to all topics and settings, CHAT has significant potential within health professions education.

Introduction Postpartum depression (PPD) is a common perinatal complication. Risk factors previously found to correlate with PPD in civilians include prenatal depression, childcare stress, limited social support, difficult infant temperament, and maternity blues. Previously identified risk factors in military spouses include spouse deployment/redeployment cycles. It is unclear if these previously identified risk factors are also a risk factor for AD women or if the additional stressors associated with being on active duty (AD) are risk factors for PPD. The purpose of this review is to determine if civilian risk factors have been found to put AD women at risk for PPD and to identify unique risk factors for PPD in AD women. Materials and Methods A scoping literature review was performed using PubMed, Defense Technical Information Center, and PsychINFO. The searches were conducted using relevant medical subject headings and keywords. The inclusion criteria included articles published since 1948 (the year women were legally allowed to join the military) that reference risk factors for postpartum/peripartum depression in AD women serving in the U.S. military. The following exclusion criteria were also applied: in a language other than English, opinion papers, and/or not published in a peer-reviewed journal. Articles meeting criteria were evaluated and mapped to stressors previously identified in the literature for civilian and military spouses with PPD with novel stressors identified as mapping outside this framework. Results Only two articles met the inclusion criteria. The first study included 87 AD women. The second study, a cohort study between 2001 and 2008, included 1660 AD women. Unique risk factors identified in AD women include previous deployments, serving in the Army, smoking status, alcohol use, and low self-esteem. Conclusions Few studies have investigated the risk factors for PPD in AD women. It appears that AD women share many risk factors, or variants of those risk factors, for PPD as their civilian and AD spouse counterparts, but there are also unique risks to consider. More work is needed to improve screening and prevention efforts.

The Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient advocacy representatives, developed a recommendation for counseling midlife women aged 40 to 60 years with normal or overweight body mass index (BMI; 18.5 to 29.9 kg/mThe WPSI developed this recommendation after evaluating results of a systematic review of the effectiveness and harms of interventions to prevent weight gain and obesity in women aged 40 to 60 years without obesity. Seven randomized clinical trials including 51 638 participants and using various counseling and behavioral interventions were included. Trials indicated favorable weight changes with interventions that were statistically significantly different from control groups in 4 of 5 trials of counseling, but not in 2 trials of exercise. Few harms were reported.The WPSI recommends counseling midlife women aged 40 to 60 years with normal or overweight BMI (18.5 to 29.9 kg/m

Introduction The Coronavirus (COVID-19) pandemic has presented a myriad of organizational and institutional challenges. The Uniformed Services University of the Health Sciences, like many other front line hospitals and clinics, encountered a myriad of challenges in fostering and sustaining the education of students enrolled at the nation’s only military medical school. Critical to the function of any academic medical institution, but particularly one devoted to the training of future physicians for the Military Health System, was the ability to rapidly adapt, modify, and create new means of keeping medical students engaged in their core curricula and progressing toward full and timely attainment of established educational goals and objectives. Methods This article highlights some of the particular challenges faced by faculty and students during the first 6 months of the COVID-19 pandemic and describes how they were managed and/or mitigated. Results Six key “lessons learned” were identified and summarized in this manuscript. These lessons may be applicable to other academic institutions both within and outside of the Military Health System. Conclusions Recognizing and embracing these key tenets of academic change management can accelerate the generation of a cohesive, organizational response to the next pandemic or public health crisis.

Objective This study examines whether children delivered by repeat cesarean section experience higher incidences of otitis media, respiratory infections, and allergic diseases than children delivered by vaginal birth after cesarean section (VBAC) in the Military Health System. Study Design This is a retrospective cohort study from the Military Health System Data Repository of women who underwent repeat cesarean section or VBAC between 2006 and 2012 and their offspring through 2014. Results About 11,659 infants with 2 years of follow-up were identified. Infants delivered by VBAC had lower odds of developing respiratory illness (P Conclusion Emerging data regarding early childhood health are additional factors that can influence the mother’s decision on mode of birth after a primary cesarean section.

OBJECTIVE: To systematically review the effectiveness of telehealth interventions for improving obstetric and gynecologic health outcomes.

Objective Potentially avoidable maternity complications (PAMCs) have been validated as an indicator of access to quality prenatal care. African-American mothers have exhibited a higher incidence of PAMCs, which has been attributed to unequal health coverage. The objective of this study was to assess if racial disparities in the incidence of PAMCs exist in a universally insured population. Study Design PAMCs in each racial group were compared relative to White mothers using multivariate logistic regression. Stratified subanalyses assessed for adjusted differences in the odds of PAMCs for each racial group within direct versus purchased care. Results A total of 675,553 deliveries were included. Among them, 428,320 (63%) mothers were White, 112,170 (17%) African-American, 37,151 (6%) Asian/Pacific Islanders, and 97,912 (15%) others. African-American women (adjusted odds ratio [aOR]: 1.05, 95% CI: 1.02–1.08) were more likely to have PAMCs compared with White women, and Asian women (aOR: 0.92, 95% CI: 0.89–0.95) were significantly less likely to have PAMCs compared with White women. On stratified analysis according to the system of care, equal odds of PAMCs among African-American women compared with White women were realized within direct care (aOR: 1.03, 95% CI: 1.00–1.07), whereas slightly higher odds among African-American persisted in purchased (aOR: 1.05, 95% CI: 1.01–1.10). Conclusion Higher occurrence of PAMCs among minority women sponsored by a universal health coverage was mitigated compared with White women. Protocol-based care as in the direct care system may help overcome health disparities.

Introduction The U.S. Preventive Services Task Force (USPSTF) modified their screening guidelines for breast cancer in November 2009. Previous studies evaluated the impact of these guideline changes among privately and Medicare insured populations. Women in the military form a unique population exposed to many social, environmental, and occupational hazards that may increase breast cancer incidence. By evaluating mammography screening rates among women in the military before and after the USPSTF guideline changes, this study evaluated the impact of the USPSTF breast cancer guideline change on screening mammography use within the military population and determined whether current guidelines were followed for this high-risk population with universal health care access. Materials and methods This study evaluated the impact of the 2009 guideline changes among the population of universally insured military servicewomen, comparing the proportion of active duty women aged 40 to 64 receiving mammograms from fiscal years 2006 to 2015 using an interrupted time series analysis. Stratified analyses evaluated differences by age (aged 40–49, 50–64), race, military branch, and rank. This research is considered exempt by the Uniformed Services University Institutional Review Board. Results The proportion of insured military servicewomen receiving mammograms increased from October 2005 through September 2009. A significant decrease occurred in the first quarter of 2010 following the publication of the screening guideline update. From this new baseline, the proportion of women screened increased again through September 2015. Comparative analyses showed more pronounced effects both immediately and over time among the women aged 50 to 64 compared to those aged 40 to 49 years and among older enlisted women compared with their officer counterparts. The patterns were near identical in all subgroups; however, no changes in rate were evident among Air Force and black servicewomen aged 50 to 64 and Army and Navy/Marine Corps servicewomen aged 40 to 49 years. No racial disparities in screening or impact were noted. Conclusions The USPSTF guidelines had differential impacts among some subpopulations. While older women, aged 50 to 64 years, had a greater temporary reduction immediately after the guideline change, younger women aged 40 to 49 years had a longer-term reduction in screening following the guideline changes. No racial disparities in the proportion screened or in the impact of the guideline change were noted in this population with universal health coverage. The lack of Department of Defense standard breast cancer screening guidelines was evident from the different patterns of mammography utilization observed among military branches. To completely understand the impact of the updated screening guidelines, future studies must incorporate research focusing on changes in breast cancer morbidity and mortality as well as updated cost-benefit analyses.

INTRODUCTION Incomplete or inadequate provision of contraceptive services to servicewomen can have a profound impact on military health, readiness, and financial outcomes. This study examined the reproductive health practices and perceptions among family medicine physicians caring for servicewomen. MATERIALS AND METHODS We conducted an anonymous survey of 568 registered attendees at the March, 2018 Uniformed Services Academy of Family Physicians annual meeting. The response rate was 52.8% and 69% of responders met inclusion criteria. RESULTS Our sample of family medicine physicians was 58.3% male and 85.3% Caucasian. In all, 18.3% were current residents, 42.9% graduated between 2008 and 2017, and 38.7% graduated before 2008. A previous deployment was reported by 55.1%.Among physicians with a deployment history, 20.8% reported difficulty prescribing contraception during deployment because they were unable to obtain a patient's desired method, 2.6% reported servicewomen not accessing contraception because of fear and stigma associated with sexual activity in the deployed setting, and 22.1% reported problems with both factors.Among physicians performing pre-deployment and other readiness visits for active duty servicewomen, 17.4% reported not discussing contraception at these encounters because of competing priorities and 1.5% because of ethical/religious concerns. Physicians who could offer more rapid access to subdermal implants (within 2 weeks) were more likely to discuss contraception (87.0% versus 64.7%, p = 0.005).When discussing the use of contraception in the deployed environment, 15.8% of physicians would not prescribe oral contraceptives, 12.3% would not prescribe intrauterine methods, and 14.3% would not prescribe subdermal implants. Physicians who previously deployed were more likely to report they would offer oral contraceptives (91% versus 75.0%, OR 3.4 [95% CI 1.44-8.48], p = 0.002) for women in the deployed setting compared to those who have not deployed. More timely (

Background Expectant mothers who are beneficiaries of TRICARE (universal insurance to United States Armed Services members and their dependents) can choose to receive care within direct (salary-based) or purchased (fee-for-service) care systems. We sought to compare frequency of intrapartum obstetric procedures and outcomes such as severe acute maternal morbidity (SAMM) and common postpartum complications between direct and purchased care systems within TRICARE. Methods TRICARE (2006-2010) claims data were used to identify deliveries. Patient demographics, frequency of types of delivery (noninstrumental vaginal, cesarean, and instrumental vaginal), comorbid conditions, SAMM, and common postpartum complications were compared between the two systems of care. Multivariable models adjusted for patient clinical/demographic factors determined the odds of common complications and SAMM complications in purchased care compared with direct care. Results A total of 440 138 deliveries were identified. Compared with direct care, purchased care had higher frequency (30.9% vs 25.8%, P

The increasing prevalence of maternal obesity around the world has significant implications for the short- and long-term health outcomes of both mother and child. This public health crisis requires a multidisciplinary effort to begin to address the complex and far-reaching impacts. There is a critical need for health-care providers to understand how to care for pregnant patients who are obese in order to optimize outcomes during the pregnancy and positively influence subsequent pregnancies and the future health of the offspring. Even more important, everyone—from front-line providers to leaders to researchers to leaders of health-care systems—must be familiar with the evidence for preventive interventions that are most effective. This chapter focuses on the role of the clinician in caring for the obese gravida but highlights important gaps that need to be filled by basic and clinical science and health services research. Because many women with polycystic ovarian syndrome also have an elevated body mass index, this chapter also includes a special section addressing the issues unique to PCOS in pregnancy, in both obese and normal-weight women.

The diagnostic error crisis suggests a shift in how we view clinical reasoning and may be vital for transforming how we view clinical encounters. Building upon the literature, we propose clinical reasoning and error are context-specific and proceed to advance a family of theories that represent a model outlining the complex interplay of physician, patient, and environmental factors driving clinical reasoning and error. These contemporary social cognitive theories (i.e. embedded cognition, ecological psychology, situated cognition, and distributed cognition) can emphasize the dynamic interactions occurring amongst participants in particular settings. The situational determinants that contribute to diagnostic error are also explored.

To determine if additional children attending primary care clinics in moderate-altitude areas would screen positive for anemia if the hemoglobin cutoff were modified for altitude.This cross-sectional study evaluated children aged 11-19 months of age who had a screening hemoglobin conducted between January 2011 and December 2017 at 4 moderate-altitude (1726-2212 m) and 8 low-altitude (1-20 m) US military clinics. The primary outcome was anemia prevalence (hemoglobin11 g/dL) in moderate-altitude and low-altitude groups, before and after applying the current World Health Organization model for altitude-based hemoglobin modification. Groups were compared with prevalence ORs adjusted for age, sex, weight-for-length percentile, and parental military rank, and the false-negative proportion was calculated for children with anemia at moderate altitude.Before altitude modification, anemia prevalence was 4.4% in the moderate-altitude group (n = 1488) and 16.8% in the low-altitude group (n = 7090) (prevalence OR, 0.23; 95% CI, 0.17-0.29). After applying the World Health Organization model, anemia prevalence in the moderate-altitude group increased to 14.7% (prevalence OR, 0.82; 95% CI, 0.70-0.97). Nonapplication of the model at moderate altitude resulted in a false-negative proportion of 0.70 (95% CI, 0.63-0.76).Nonuse of the World Health Organization altitude-based modification model for hemoglobin may result in a large percentage of US children with anemia at moderate altitude screening falsely negative for anemia. Although ancestry disparities in altitude acclimatization may limit universal application of the current World Health Organization model, the existing standard of care may leave children at moderate altitude at risk for complications from iron deficiency anemia.

Introduction As a research methodology, phenomenology is uniquely positioned to help health professions education (HPE) scholars learn from the experiences of others. Phenomenology is a form of qualitative research that focuses on the study of an individual’s lived experiences within the world. Although it is a powerful approach for inquiry, the nature of this methodology is often intimidating to HPE researchers. This article aims to explain phenomenology by reviewing the key philosophical and methodological differences between two of the major approaches to phenomenology: transcendental and hermeneutic. Understanding the ontological and epistemological assumptions underpinning these approaches is essential for successfully conducting phenomenological research. Purpose This review provides an introduction to phenomenology and demonstrates how it can be applied to HPE research. We illustrate the two main sub-types of phenomenology and detail their ontological, epistemological, and methodological differences. Conclusions Phenomenology is a powerful research strategy that is well suited for exploring challenging problems in HPE. By building a better understanding of the nature of phenomenology and working to ensure proper alignment between the specific research question and the researcher’s underlying philosophy, we hope to encourage HPE scholars to consider its utility when addressing their research questions.

Background: Shared decision making is critical to patient-centered care and yet there is limited consensus on effective teaching approaches for training physicians in this domain. As a collaborative process in which the patient and physician co-create a decision, patient and relational agency may be important contributors and studies with patient-reported outcomes may identify successful approaches and determine gaps in pedagogy. The authors conducted a systematic review of educational interventions for shared decision making, focusing on patient-reported outcomes and consideration of agency. Methods: Ovid MEDLINE, Embase, and Web of Science were searched for studies describing educational interventions with patient-level outcomes published between January 2000 and January 2020. Articles were excluded if they were not in English, included only patient interventions, or reported only physician outcomes. Quality assessment was performed using the Medical Education Research Study Quality Instrument (MERSQI). Data about the educational methods used were extracted and included studies were assessed for quality. Thematic analysis was performed to identify the potential role of agency. Results: 26 articles were identified describing 17 unique studies. Educational interventions were diverse in duration and content, with multiple components. Three-quarters of studies used role play or simulated patients and 82% included tools to facilitate shared decisions. Although no articles explicitly discussed facilitating agency as a component of the intervention or as an outcome, one qualitative study demonstrated themes of patient and relational agency. Conclusions: Educational interventions included small group discussion, decision aids, role play, and simulated patients, and improved a range of patient outcomes, but our study included only studies including practicing physicians, limiting applicability to trainees and other health care providers. Interventions have not included explicit instructional design around agency, but qualitative analyses demonstrated interventions may facilitate agency and shared decision making. Future instructional strategies should consider the complexity inherent in co-constructing decisions.

Introduction Surveillance systems have become a valuable tool to capture epidemiological data at multi-sport events, with findings serving to predict and prevent injury, reduce illness, and guide efficient utilization of medical resources. In 2016, the first injury and illness surveillance tool for the Department of Defense (DoD) Warrior Games was established to inform the required medical footprint. The purpose of this paper is to describe the methods and findings from the 2016 DoD Warrior Games surveillance system, which included a database of injuries and illness. Materials and Methods A total of 245 wounded warrior (WW) athletes were followed over 19 days, to include train-up and competition periods, as they competed for their respective teams of Army, Navy, Air Force, Marines, Special Operations, and United Kingdom. Medical personnel recorded injuries and illnesses treated utilizing a standardized surveillance form and data were entered into a daily tracker to examine patterns or areas for prevention. Reports included sex, age, event discipline, previous injury or illness, reason for presentation, and treatment provided. Results From June 3 to June 21, 2016, 114 individual encounters were recorded on the standard form and entered into the surveillance database. Athletes accounted for 67% of all encounters. Illness accounted for 30.7% of all visits, while injuries accounted for 69.2%. The incident proportion of injuries in athletes was 23.3 injuries per 100 athletes (95% CI 17.6, 30.1) and incident rate of 12.2 injuries per 1000 athlete days. Integrative medicine treatments including acupuncture, osteopathic manipulative treatment (OMT), massage therapy, and gua sha accounted for the largest forms of treatment (31%). Conclusions From the surveillance data, staff levels and treatment supplies can be adjusted. In addition an improved surveillance tool can be created. Continuous surveillance is required to provide information on trends in injury and illness to support prevention strategies.

Background Gastroesophageal reflux disease is a common condition in pregnancy and is often managed with medications. Specific medications have been linked to osteoporosis and fragility fracture in older adults. This study assessed whether maternal use of antireflux medications is associated with early childhood fracture. Methods TRICARE beneficiaries during pregnancy were retrospectively identified using the Military Health System Data Repository and pharmacy data. Mother and infant data were linked; children with continuous enrollment for the first 5 years of life were included. Differences in the children's fracture risk were analyzed through multivariate analysis, adjusting for region, rank, and military branch of service. Results A total of 378 150 patients comprised the final cohort with 3.3% (n = 12 479) prescribed antireflux medications during pregnancy. A significant decrease in fracture rate was found among children of women who were prescribed antireflux medications during pregnancy compared with those who were not (0.8% vs 1.2%, RR = 0.70, 95% CI 0.58-0.85). There was no difference in fracture risk between histamine type 2 receptor antagonists and proton pump inhibitors. A significantly increased fracture incidence was seen in pregnancies with multiple gestations (RR = 1.38, 95% CI 1.04-1.85). There was no identified difference in fracture risk for women with gestational diabetes, preeclampsia, preterm or low birthweight, chronic hypertension, induction, or breech presentation when compared to women without these conditions. Conclusions We found no increase in early childhood fracture risk with maternal antireflux medication use. This suggests that prenatal exposure to antireflux medications does not affect fetal bones to a clinically significant extent.

"Cascade testing" refers to the performance of genetic counseling and testing in blood relatives of individuals who have been identified with specific genetic mutations. Testing protocols and other interventions may save lives and improve health and quality of life for these family members. Obstetrician-gynecologists should know who is eligible for cascade testing and should use all available resources to ensure that cascade testing is offered and occurs in a timely manner. Despite the clear health benefits for specific populations and individuals, obstetrician-gynecologists should be aware of the potential barriers to cascade testing and should know which options can help patients overcome those barriers. Such barriers, however, may be overcome with health care provider awareness and participation in local and state initiatives to improve implementation of cascade testing. Resources (available within federal and state agencies, professional societies, and in advocacy and community groups) are critical to the successful implementation of cascade testing. This Committee Opinion focuses specifically on cascade testing and the role of the obstetrician-gynecologist in clinical and public health efforts to increase identification of women with hereditary cancer syndromes.

Objective To determine the proportion and characteristics of US servicewomen who were prescribed contraception between 2008 and 2013 and to estimate the prevalence of contraceptive utilization among women who deployed during the surveillance period. Study design This is a descriptive study of all servicewomen of child-bearing potential serving in the active component of the US armed forces at any time between 2008 and 2013. We estimated contraceptive utilization status using pharmacy, procedural and diagnostic codes as recorded in the Defense Medical Surveillance System and Pharmacy Data Transaction Service. Estimates of contraceptive utilization were compared by demographic and military variables, including deployment status. Poisson regression with robust error variance was used to estimate adjusted prevalence ratios and 95% confidence intervals. Results Among eligible servicewomen (N=375,847), 68.7% received at least one form of contraception during the surveillance period. Contraceptive methods included short acting only (55.6%), long-acting (11.9%), permanent (1.0%) and barrier methods (0.2%). An additional 8.2% received counseling services only without an associated procedure or prescription. After adjusting by several demographic variables, receipt of contraception was highest among women aged 25–29 years and lowest among those aged 17–19 and 45–49 years. Receipt of any contraception was similar across racial/ethnic groups, although Hispanic and black, non-Hispanic women were more likely to receive long-acting reversible contraception. Of those who deployed (N=131,597), 53.6% received contraception before or during their deployment, with 7.9% using long-acting contraception. Conclusion US servicewomen utilize contraception at high levels, with few demographic disparities. Gaps still exist, especially among the youngest women and around the time of deployment. Implications US servicewomen are prescribed contraception at high levels, but utilization is lower in the youngest servicewomen and around the time of deployment. Such data provide opportunities for development and evaluation of interventions designed to improve access to contraceptive services for all servicewomen and to reduce the rate of unintended pregnancy.

Objective To assess current practice, advise minimum standards, and identify educational gaps relevant to genetic screening, counseling, and testing of women affected by gynecologic cancers. Methods The Society of Gynecologic Oncology (SGO) organized a multidisciplinary summit that included representatives from the American College of Obstetricians and Gynecologists (ACOG), the American Society Clinical Oncology (ASCO), the National Society of Genetic Counselors (NSGC), and patient advocacy groups, BrightPink and Facing our Risk of Cancer Empowered (FORCE). Three subject areas were discussed: care delivery models for genetic testing, barriers to genetic testing, and educational opportunities for providers of genetic testing. Results The group endorsed current SGO, National Comprehensive Cancer Network (NCCN), and NSGC genetic testing guidelines for women affected with ovarian, tubal, peritoneal cancers, or DNA mismatch repair deficient endometrial cancer. Three main areas of unmet need were identified: timely and universal genetic testing for women with ovarian, fallopian tube, and peritoneal cancers; education regarding minimum standards for genetic counseling and testing; and barriers to implementation of testing of both affected individuals as well as cascade testing of family members. Consensus building among all stakeholders resulted in an action plan to address gaps in education of gynecologic oncology providers and delivery of cancer genetics care.

Condition Definition SCT is a heterozygotic carrier state in which an individual has one copy of the normal HbA gene and one copy of the HbS variant. Commercial tests for SCT have been available since the early 1970s. The sickle solubility test qualitatively detects the presence of HbS by precipitating sickle hemoglobin in the presence of an oxygen depleting reagent. With a sensitivity approaching 99% and a specificity of 100%, sickle solubility provides an accurate screening method. The hemoglobin electrophoresis test is a confirmatory test that quantifies the percentage of HbS and is therefore able to distinguish among the HbS disorders, such as SCT or sicklecell disease. According to the 59th Clinical Lab Flight at Joint Base San Antonio-Lackland, Texas (oral communication, November 2013), the U.S. Air Force (USAF) spends $4.86 on the sickle solubility test and $9.41 on the hemoglobin electrophoresis test.

To determine if racial differences exist in receipt of minimally invasive hysterectomy (defined as total vaginal hysterectomy [TVH] and total laparoscopic hysterectomy [TLH]) compared with an open approach (total abdominal hysterectomy [TAH]) within a universally insured patient population.Retrospective data analysis (Canadian Task Force classification II-2).The 2006-2010 national TRICARE (universal insurance coverage to US Armed Services members and their dependents) longitudinal claims data.Women aged 18 years and above who underwent hysterectomy stratified into 4 racial groups: white, African American, Asian, and "other."Receipt of hysterectomy (TAH, TVH, or TLH).We used risk-adjusted multinomial logistic regression models to determine the relative risk ratios of receipt of TVH and TLH compared with TAH in each racial group compared with referent category of white patients for benign conditions. Among 33 015 patients identified, 60.82% (n = 20 079) were white, 26.11% (n = 8621) African American, 4.63% (n = 1529) Asian, and 8.44% (n = 2786) other. Most hysterectomies (83.9%) were for benign indications. Nearly 42% of hysterectomies (n = 13 917) were TAH, 27% (n = 8937) were TVH, and 30% (n = 10 161) were TLH. Overall, 36.37% of white patients received TAH compared with 53.40% of African American patients and 51.01% of Asian patients (p .001). On multinomial logistic regression analyses, African American patients were significantly less likely than white patients to receive TVH (relative risk ratio [RRR], .63; 95% confidence interval [CI], .58-.69) or TLH (RRR, .65; 95% CI, .60-.71) compared with TAH. Similarly, Asian patients were less likely than white patients to receive TVH (RRR, .71; 95% CI, .60-.84) or TLH (RRR, .69; 95% CI, .58-.83) compared with TAH. Analyses by benign indications for surgery showed similar trends.We demonstrate that racial minority patients are less likely to receive a minimally invasive surgical approach compared with an open abdominal approach despite universal insurance coverage. Further work is warranted to better understand factors other than insurance access that may contribute to racial differences in surgical approach to hysterectomies.

Background/Objectives Infection with varicella zoster virus (VZV) produces lifelong immunity, but duration of post-vaccination immunity has not been established. The purpose of this study is to determine if a difference exists in the long-term seropositivity of anti-VZV antibodies in a cohort of young adults who were vaccinated against varicella as compared to a similar cohort with a history of chickenpox disease, and to determine which variables best predict waning seropositivity following varicella vaccination. Methods This retrospective cohort study captures immunization and serology data from approximately 10,000 recruits who entered basic military training between January 1, 2008, and December 31, 2015, and who have childhood immunization records in the Air Force Aeromedical Services Information Management System. Varicella vaccine immunogenicity was determined relative to the immunogenicity of chickenpox disease, as measured by multiplex flow immunoassay. Among vaccine recipients, waning seroimmunity was modeled and adjusted for several important covariates. Results Basic military trainees who received varicella vaccine in childhood were 24% less likely to be seropositive to VZV than trainees who were exempt from vaccine due to a history of chickenpox disease. There was no significant difference in seropositivity between male and female trainees. The odds of a vaccinated trainee being seropositive to VZV decreased by 8% with each year elapsed since vaccination. Seroprevalence declined below estimated herd immunity thresholds in vaccinated trainees born after 1994, and in the cohort as a whole for trainees born after 1995. Conclusion Despite prior vaccination, seroimmunity in a large cohort of young adults unexposed to wild-type VZV failed to meet the estimated threshold for herd immunity. If vaccination in accordance with the current US VZV vaccination schedule is inadequate to maintain herd immunity, young adults not previously exposed to wild-type VZV may be at increased risk for varicella outbreaks.

INTRODUCTION:The objective of this study was to determine whether outcomes of mothers and children at five years vary after cesarean versus vaginal delivery.METHODS:TRICARE (universal insurance coverage to all members of US Armed Services and their dependents) data was used to identify mother-infant

Background The U.S. Air Force Academy is an undergraduate institution that educates and trains cadets for military service. Following the arrival of 1376 basic cadet trainees in June 2009, surveillance revealed an increase in cadets presenting with respiratory illness. Specimens from ill cadets tested positive for novel influenza A (H1N1 [nH1N1])–specific ribonucleic acid (RNA) by real-time reverse transcriptase–polymerase chain reaction. Purpose The outbreak epidemiology, control measures, and nH1N1 shedding duration are described. Methods Case patients were identified through retrospective and prospective surveillance. Symptoms, signs, and illness duration were documented. Nasal-wash specimens were tested for nH1N1-specific RNA. Serial samples from a subset of 53 patients were assessed for presence of viable virus by viral culture. Results A total of 134 confirmed and 33 suspected cases of nH1N1 infection were identified with onset date June 25–July 24, 2009. Median age of case patients was 18 years (range, 17–24 years). Fever, cough, and sore throat were the most commonly reported symptoms. The incidence rate among basic cadet trainees during the outbreak period was 11%. Twenty-nine percent (31/106) of samples from patients with temperature Conclusions In the nH1N1 outbreak under study, the number of cases peaked 48 hours after a social event and rapidly declined thereafter. Almost one quarter of samples obtained 7 days from illness onset contained viable nH1N1 virus. These data may be useful for future investigations and in scenario planning.

We conducted a systematic review to estimate benefits and harms of the choice of timing of induction or elective cesarean delivery based on estimated fetal weight or gestational age in women with gestational diabetes mellitus (GDM).An electronic literature search was performed using MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature, and The Cochrane Central Register of Controlled Trials from inception to January 2007.Two investigators independently reviewed titles and abstracts, assessed article quality, and abstracted data. Maternal outcomes included cesarean delivery and operative vaginal delivery. Neonatal outcomes included birth weight, macrosomia, large for gestational age, shoulder dystocia, birth trauma, neonatal intensive care admissions, and perinatal mortality.Five studies met our inclusion criteria: one randomized controlled trial (RCT) and four observational studies. The RCT (n=200) compared the effect of labor induction at term with expectant management. The proportion of newborns with birth weight greater than the 90th percentile was significantly greater in the expectant-management group (23% compared with 10% with active induction, P=.02); there were no significant differences in rates of cesarean delivery, shoulder dystocia, neonatal hypoglycemia, or perinatal deaths. The four observational studies suggest a potential reduction in macrosomia and shoulder dystocia with labor induction and cesarean delivery for estimated fetal weight indications, but there was insufficient evidence to assess other clinical outcomes.Active rather than expectant management of labor at term for women with GDM may reduce rates of macrosomia and related complications. Further RCTs and observational studies with a broader range of outcomes are needed for sufficient evidence to inform clinical practice.

CONTEXT. Hydroxyurea is the only approved medication for the treatment of sickle cell disease in adults; there are no approved drugs for children. OBJECTIVE. Our goal was to synthesize the published literature on the efficacy, effectiveness, and toxicity of hydroxyurea in children with sickle cell disease. METHODS. Medline, Embase, TOXLine, and the Cumulative Index to Nursing and Allied Health Literature through June 2007 were used as data sources. We selected randomized trials, observational studies, and case reports (English language only) that evaluated the efficacy and toxicity of hydroxyurea in children with sickle cell disease. Two reviewers abstracted data sequentially on study design, patient characteristics, and outcomes and assessed study quality independently. RESULTS. We included 26 articles describing 1 randomized, controlled trial, 22 observational studies (11 with overlapping participants), and 3 case reports. Almost all study participants had sickle cell anemia. Fetal hemoglobin levels increased from 5%–10% to 15%–20% on hydroxyurea. Hemoglobin concentration increased modestly (∼1 g/L) but significantly across studies. The rate of hospitalization decreased in the single randomized, controlled trial and 5 observational studies by 56% to 87%, whereas the frequency of pain crisis decreased in 3 of 4 pediatric studies. New and recurrent neurologic events were decreased in 3 observational studies of hydroxyurea compared with historical controls. Common adverse events were reversible mild-to-moderate neutropenia, mild thrombocytopenia, severe anemia, rash or nail changes (10%), and headache (5%). Severe adverse events were rare and not clearly attributable to hydroxyurea. CONCLUSIONS. Hydroxyurea reduces hospitalization and increases total and fetal hemoglobin levels in children with severe sickle cell anemia. There was inadequate evidence to assess the efficacy of hydroxyurea in other groups. The small number of children in long-term studies limits conclusions about late toxicities.

The announcement of the Precision Medicine Initiative was an important step towards establishing the use of genomic information as part of the wider practice of medicine. The US military has been exploring the role that genomic information will have in health care for service members (SMs) and its integration into the continuum of military medicine. An important part of the process is establishing robust protections to protect SMs from genetic discrimination in the era of exome/genome sequencing.

Overweight and obesity are associated with multiple maternal and fetal complications, including gestational diabetes mellitus, hypertensive disorders of pregnancy, macrosomia (infant weighing more than 4,000 g), and cesarean delivery. The preconception period is a critical time frame to address overweight and obesity in reproductive-aged women. Preconception care should include education about the effect of obesity on pregnancy outcomes, long-term health of the offspring, clinical evaluation for comorbid conditions, assessment of the patient’s readiness for change, and guidance on safe and effective interventions to achieve a healthy weight prior to conception. Current gaps in our knowledge include the identification of the most effective lifestyle strategies to promote a healthy weight prior to pregnancy and the development of policies to improve the dissemination of patient-centered preconception care.

Overweight and obesity are risk factors for several labor and postpartum complications, including macrosomia, shoulder dystocia, and cesarean delivery. Anesthesia and surgical intervention also present unique challenges, but research has provided new insights on how to reduce complications in these two areas. Providers can use currently available evidence to counsel patients, and this conversation should begin during the prenatal period. Further research is needed to address the gaps in our understanding of the most effective methods of delivery and postpartum care for overweight and obese women.

Clinical experts have expressed concern about underutilization of sickle cell disease (SCD) therapies, including hydroxyurea, prophylactic antibiotics, iron chelation, bone marrow transplantation, pain management during vaso-occlusive crisis, and receipt of routine ambulatory health care. We synthesized studies that identified barriers to and interventions to improve appropriate use of these therapies. Of the 48 studies included in our review, 35 identified therapeutic barriers or facilitators, and 13 evaluated interventions to improve use of therapies. Consistently identified barriers to appropriate pain management were negative provider attitudes and lack of provider knowledge. Four of 9 pain management interventions improved direct measures of pain management quality, while 5 improved indirect measures. One intervention improved receipt of routine ambulatory care. We concluded that interventions to improve pain management in SCD can be effective and should address providers' negative attitudes and knowledge and that more intervention studies are needed to improve receipt of recommended SCD therapies.

Little is known about the comparative risks and benefits of medical treatments for gestational diabetes mellitus (GDM). We conducted a systematic review of randomized controlled trials and observational studies of maternal and neonatal outcomes in women with GDM treated with oral diabetes agents compared with all types of insulin.We searched four electronic databases from inception through January 2007. Terms for GDM, insulins, and oral hypoglycemic agents were used in the search. Two investigators independently reviewed titles and abstracts, performed data abstraction on full articles, and assessed study quality.Articles were excluded if they had no comparison group or did not use a standard diagnosis of GDM (3-hour, 100-g oral glucose tolerance test or 2-hour, 75-g oral glucose tolerance test). Nine studies met our inclusion criteria, four randomized controlled trials (n=1,229 participants) and five observational studies (n=831 participants). Data were abstracted on study characteristics, gestational age at treatment, medication dosage, and length of follow-up. Outcomes included glycemic control, infant birth weight, neonatal hypoglycemia, and congenital anomalies.Two trials compared insulin to glyburide; one trial compared insulin, glyburide, and acarbose; and one trial compared insulin to metformin. No significant differences were found in maternal glycemic control or cesarean delivery rates between the insulin and glyburide groups. A meta-analysis showed similar infant birth weights between women treated with glyburide and women treated with insulin (mean difference -93 g) (95% confidence interval -191 to 5 g). There was a higher proportion of infants with neonatal hypoglycemia in the insulin group (8.1%) compared with the metformin group (3.3%) (P=.008). The rate of congenital malformations did not differ between pregnancies treated with insulin and those treated with oral agents. Observational studies were limited by selection bias and confounding.No substantial maternal or neonatal outcome differences were found with the use of glyburide or metformin compared with use of insulin in women with GDM.

Hydroxyurea is the only approved drug for treatment of sickle cell disease.To synthesize the published literature on the efficacy, effectiveness, and toxicity of hydroxyurea when used in adults with sickle cell disease.MEDLINE, EMBASE, TOXLine, and CINAHL were searched through 30 June 2007.Randomized trials, observational studies, and case reports evaluating efficacy and toxicity of hydroxyurea in adults with sickle cell disease, and toxicity studies of hydroxyurea in other conditions that were published in English.Paired reviewers abstracted data on study design, patient characteristics, and outcomes sequentially and did quality assessments independently.In the single randomized trial, the hemoglobin level was higher in hydroxyurea recipients than placebo recipients after 2 years (difference, 6 g/L), as was fetal hemoglobin (absolute difference, 3.2%). The median number of painful crises was 44% lower than in the placebo group. The 12 observational studies that enrolled adults reported a relative increase in fetal hemoglobin of 4% to 20% and a relative reduction in crisis rates by 68% to 84%. Hospital admissions declined by 18% to 32%. The evidence suggests that hydroxyurea may impair spermatogenesis. Limited evidence indicates that hydroxyurea treatment in adults with sickle cell disease is not associated with leukemia. Likewise, limited evidence suggests that hydroxyurea and leg ulcers are not associated in patients with sickle cell disease, and evidence is insufficient to estimate the risk for skin neoplasms, although these outcomes can be attributed to hydroxyurea in other conditions.Only English-language articles were included, and some studies were of lower quality.Hydroxyurea has demonstrated efficacy in adults with sickle cell disease. The paucity of long-term studies limits conclusions about toxicity.

To examine the natural history of fetal position throughout pregnancy and the likelihood for nonvertex delivery.We examined fetal positions at 15-22 weeks, at 31-35 weeks, and at delivery using data from the Routine Antenatal Diagnostic Imaging with Ultrasound trial. Characteristics of women with nonvertex and vertex presentation at delivery were compared. Multivariable logistic regression analysis was performed to determine risk factors for nonvertex presentation at delivery, and odds ratios were calculated for those risk factors found to be statistically significantly associated with nonvertex presentation.Data for 7,045 women who underwent routine prenatal ultrasound examinations were analyzed. We found no association between nonvertex presentation at 15-22 and at 31-35 weeks of gestation. A nonvertex fetus at 35 weeks had a 45% chance of spontaneous version by delivery. Multivariable logistic regression analysis found that multiparous women had half of the risk of nonvertex presentation as nulliparous women. Smoking during pregnancy (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.10-1.96), low volume of amniotic fluid at 31-35 weeks (OR 3.74, 95% CI 1.85-7.53), and fundal position of the placenta at late ultrasound examination (OR 1.85, 95% CI 1.23-2.78) were all associated with significant increases in the risk of nonvertex position at delivery.Spontaneous version of a nonvertex fetus at 35 weeks of gestation is still likely.