relyplot examines reliability of predicted risks following a logistic model. It creates categories of predicted risk, divided either into fractions, e.g. tenths, or any number of equal size groups (percentiles). It then calculates proportions of observed events among subjects within similar predictive probability categories. These proportions are plotted against a diagonal line for perfect fit (observed=predicted). Deviations from the line indicate worse prediction in those categories. relyplot can be repeated on a new sample using logistic regression estimates from another sample.

stkap graphs the Kaplan-Meier survivor function by categories of one or more nominal X variables adjusted for covariates. The only difference between this and sts graph is the covariates are centered by default based on the observations used in the analysis, or can be set to specified values. If the adjust option is not specified, stkap reduces to unadjusted KM plots; You must have stset your data before using this command.

OBJECTIVETo evaluate whether contraceptive insurance coverage for women who present for an abortion is associated with obtaining long-acting reversible contraception or depot medroxyprogesterone acetate (DMPA) on the day the abortion is completed.METHODSWe conducted a prospective cohort study of women presenting for medical or surgical abortion at a single health center in North Carolina. Eligible women were 18 years or older and fluent in English or Spanish. Data were from participant questionnaires, medical charts, and financial records. Our main exposure was whether the woman had insurance coverage for contraception at clinic intake. Our primary outcome was receiving DMPA, an intrauterine device, or a contraceptive subdermal implant on the same day of their surgical abortion or at the visit that determined their medication abortion was complete. We used univariable, bivariable, and multivariable analysis to report our findings.RESULTSFive hundred seventy-five women enrolled in our cohort between September 2015 and April 2016. One hundred twenty-eight (22%) had insurance coverage and 447 (78%) did not. In the group with insurance coverage for contraception, 38% (49/128) received a long-acting reversible contraception method or DMPA compared with 7% (33/447) in the group without insurance coverage for contraception. After adjusting for confounding, women with contraceptive coverage were more than five times as likely to receive immediate postabortion contraception with one of these methods compared with women without coverage (relative risk 5.6, 95% confidence interval 3.8-8.3).CONCLUSIONWomen with contraceptive insurance coverage on the day of their abortion were more likely to leave the abortion clinic with an intrauterine device or implant in place or receive DMPA injection compared with women without coverage.

powerclus calculates sample size and number of clusters for cluster sampled studies, correcting for any intraclass correlation. powerclus uses the estimates from the power command, which must precede it. This is an update from the program samppclus which worked with sampsi.

OBJECTIVE:To estimate variation in the use of neoadjuvant chemotherapy by high volume hospitals and to determine the association between hospital utilization of neoadjuvant chemotherapy and survival. METHODS:We identified incident cases of stage IIIC or IV epithelial ovarian cancer in the National Cancer Database from 2006 to 2012. Inclusion criteria were treatment at a high volume hospital (>20 cases/year) and treatment with both chemotherapy and surgery. A logistic regression model was used to predict receipt of neoadjuvant chemotherapy based on case-mix predictors (age, comorbidities, stage etc). Hospitals were categorized by the observed-to-expected ratio for neoadjuvant chemotherapy use as low, average, or high utilization hospitals. Survival analysis was performed. RESULTS:We identified 11,574 patients treated at 55 high volume hospitals. Neoadjuvant chemotherapy was used for 21.6% (n=2494) of patients and use varied widely by hospital, from 5%-55%. High utilization hospitals (n=1910, 10 hospitals) had a median neoadjuvant chemotherapy rate of 39% (range 23-55%), while low utilization hospitals (n=2671, 14 hospitals) had a median rate of 10% (range 5-17%). For all ovarian cancer patients adjusting for clinical and socio-demographic factors, treatment at a hospital with average or high neoadjuvant chemotherapy utilization was associated with a decreased rate of death compared to treatment at a low utilization hospital (HR 0.90 95% CI 0.83-0.97 and HR 0.85 95% CI 0.75-0.95). CONCLUSIONS:Wide variation exists in the utilization of neoadjuvant chemotherapy to treat stage IIIC and IV epithelial ovarian cancer even among high volume hospitals. Patients treated at hospitals with low rates of neoadjuvant chemotherapy utilization experience decreased survival.

OBJECTIVE:To determine whether deep-infiltrating endometriosis (DE) carries an increased risk of appendiceal endometriosis (AppE) as compared with superficial endometriosis or no endometriosis.METHODS:In a retrospective study, data were obtained by chart review of an internal database for women who underwent coincidental appendectomy during benign gynecologic surgery between July 2009 and February 2014 at a tertiary referral center in the USA. Univariate, bivariate, and regression analyses were performed. The primary exposure was surgically documented endometriosis (DE, superficial, or no endometriosis). The primary outcome was AppE.RESULTS:Endometriosis was diagnosed for 151 (38.2%) of 395 women; 82 (54.3%) had DE. The prevalence of AppE was 13.2% (52/395) overall; 8 (11.6%) of 69 women with superficial endometriosis and 32 (39.0%) of 82 with DE were affected. Frequency of AppE was increased among women with DE, abnormal appendix appearance, and surgical indication (all P<0.001). Women with DE had a 5.9-fold (95% confidence interval [CI] 2.9-11.9) higher risk of AppE compared with women without endometriosis, controlling for appendiceal appearance and surgical indication, and a 2.7-fold (95% CI 1.2-6.2) higher risk of AppE compared with those with superficial endometriosis.CONCLUSION:Women with DE have increased risk of AppE. Coincidental appendectomy should form part of complete endometriosis excision for these patients.

lintrend examines the linearity assumption for an ordinal or interval X variable against category means of a continuous outcome or the logodds of a binary outcome; default prints means or logodds, and a test for linear trend (based on linear or logistic regression); optionally a graph is printed of the means (for a continuous Y) or logodds for a binary Y.

ObjectiveTo determine the feasibility and acceptability of inserting the levonorgestrel intrauterine system, LNG 52 mg IUS (LNG IUS), at 2 weeks postpartum.Study designThis prospective study of feasibility and patient acceptability recruited women interested in a postpartum LNG IUS and placed the LNG IUS under ultrasound guidance on days 14–20 postpartum. We determined feasibility by our ability to recruit and insert the LNG IUS in our predetermined sample size of 50 women. We measured our primary acceptability outcome at 6 months postpartum with the question: “Would you recommend Mirena placement at 2 weeks postpartum to a friend?” Other outcomes included expulsion and pain. The three study visits consisted of (1) insertion visit (14–20 days postpartum), (2) standard postpartum visit with a string check (6 weeks postpartum) and (3) research visit with sonography and assessment of the primary outcome (6 months postpartum).ResultsWe enrolled 50 women over 8 months, all of whom received LNG IUS. Forty-three of the 50 (86%) provided follow-up data for the primary outcome. Of those, 93% (40/43) would recommend 2-week LNG IUS insertion to a friend, and 86% (37/43) continued using their LNG IUS at the conclusion of the 6-month visit. There were two partial expulsions; one was symptomatic. There were no uterine perforations.ConclusionsLNG IUS inserted at 2 weeks postpartum is feasible and acceptable to patients. These results offer evidence to support intrauterine contraception insertion prior to the onset of ovulation and at a potentially more convenient time point in the postpartum period.ImplicationsThis study supports offering the LNG IUS beginning on the 14th postpartum day. The 4% expulsion rate is consistent with the rate of interval insertion and lower than immediate postplacental insertion. Additional research is needed to ensure a low risk of adverse events with other brands of intrauterine contraception.

Objectives This study aimed to measure the incidence and identify predictors of postpartum visit non-attendance, using medical records of women who received prenatal care and went on to deliver live births at Montefiore Hospital in 2013. Methods Pearson’s Chi square tests were used to assess the association between maternal demographics, insurance status, and delivery information with non-attendance of a postpartum visit. Logistic regression and modified Poisson regression models were then used to identify statistically significant predictors of postpartum visit non-attendance. Results We found that one-third of all women who attended a prenatal visit at Montefiore Hospital did not return for a postpartum visit. Variables significantly associated with non-attendance include having Medicaid or no insurance (RR 1.4, 95 % CI 1.2–1.6), being Hispanic or Latino (RR 1.2, 95 % CI 1.1–1.3), having a vaginal delivery (RR 1.2, 95 % CI 1.1–1.4), and age <20 years (RR 0.77, 95 % CI 0.64–0.92). Conclusions for Practice We conclude that the risk of postpartum visit non-attendance disproportionately impacts socially and economically vulnerable patients who are: younger, part of a minority ethnic background, and depend on state funded health insurance. Our results highlight the disparity in access to postpartum care and the importance of identifying barriers to attendance as well as developing creative strategies of providing postpartum care outside of the traditional postpartum visit framework.

Study Objective: To compare immediate postpartum insertion of the contraceptive implant to placement at the 6-week postpartum visit among adolescent and young women.Design: Non-blinded, randomized controlled trial.Setting and Participants: Postpartum adolescents and young women ages 14-24 years who delivered at an academic tertiary care hospital serving rural and urban populations in North Carolina. Interventions: Placement of an etonogestrel-releasing contraceptive implant before leaving the hospital postpartum, or at the 4-6 week postpartum visit.Main Outcome Measures: Contraceptive implant use at 12 months postpartum.Results: Ninety-six participants were randomized into the trial. Data regarding use at 12 months were available for 64 participants, 37 in the immediate group and 27 in the 6-week group. There was no difference in use at 12 months between the immediate group and the 6week group (30 of 37, 81% vs 21 of 27, 78%; P =.75). At 3 months, the immediate group was more likely to have the implant in place (34 of 37, 92% vs 19 of 27, 70%; P =.02).Conclusion: Placing the contraceptive implant in the immediate postpartum period results in a higher rate of use at 3 months postpartum and appears to have similar use rates at 12 months compared with 6-week postpartum placement. Providing contraceptive implants to adolescents before hospital discharge takes advantage of access to care, increases the likelihood of effective contraception in the early postpartum period, appears to have no adverse effects on breastfeeding, and might lead to increased utilization at 1 year postpartum.

To determine factors associated with peri-operative blood transfusion after minimally invasive myomectomy.

INTRODUCTION AND HYPOTHESIS:Urinary incontinence is common amongst Chinese immigrants. These women are a rapidly growing population in the USA who require unique assessment tools due to language barriers. Presently, there are no Chinese language surveys to assess knowledge of urinary incontinence. Our goal was to translate and validate a urinary incontinence knowledge survey from English into Chinese.METHODS:The English language Urinary Incontinence Quiz (UIQ) developed and validated by Branch et al. for the Educational Demonstration of Urinary Continence Assessment and Treatment for the Elderly program assesses general knowledge of urinary incontinence as a disease entity. We translated it into Chinese using the forward translation/back translation technique. The Chinese and English versions were then administered to bilingual volunteers in a nonrandomized order during a single encounter. Their responses were analyzed using Cohen's kappa coefficient to establish the validity of the translated knowledge survey.RESULTS:Minimal reconciliation was needed in construction of the Chinese survey. Minor English grammatical corrections were made to the back-translated English survey. One question testing two knowledge concepts was separated into two questions to allow clear testing of both concepts individually. Twenty-one bilingual participants performed the validity testing. Over 50% (8 out of 15) of the questions showed nearly perfect agreement with a kappa coefficient >0.80, 5 out of the 15 questions showed substantial agreement with kappa coefficients between 0.61 and 0.8 and two questions showed moderate agreement with kappa coefficients between 0.4 and 0.6.CONCLUSIONS:We validated a translation of the UIQ for assessment of urinary incontinence knowledge in Chinese-speaking immigrants to the USA.

OBJECTIVE: To compare intrauterine device (IUD) use at 6 months postpartum among women who underwent intracesarean delivery (during cesarean delivery) IUD placement compared with women who planned for interval IUD placement 6 or more weeks postpartum. METHODS: In this nonblinded randomized trial, women who were undergoing a cesarean delivery and desired an IUD were randomized to intracesarean delivery or interval IUD placement. The primary outcome was IUD use at 6 months postpartum. A sample size of 112 (56 in each group) was planned to detect a 15% difference in IUD use at 6 months postpartum between groups.RESULTS: From March 2012 to June 2014, 172 women were screened and 112 women were randomized into the trial. Baseline characteristics were similar between groups. Data regarding IUD use at 6 months postpartum were available for 98 women, 48 and 50 women in the intracesarean delivery and interval groups, respectively. A larger proportion of the women in the intracesarean delivery group were using an IUD at 6 months postpartum (40/48 [83%]) compared with those in the interval group (32/50 [64%], relative risk 1.3, 95% confidence interval 1.02-1.66). Among the 56 women randomized to interval IUD insertion, 22 (39%) of them never received an IUD; 14 (25%) never returned for IUD placement, five (9%) women declined an IUD, and three (5%) had a failed IUD placement.CONCLUSION: Intrauterine device placement at the time of cesarean delivery leads to a higher proportion of IUD use at 6 months postpartum when compared with interval IUD placement.

OBJECTIVE: To examine the influence of mechanical bowel preparation on surgical field visualization during laparoscopic hysterectomy.METHODS: The study's primary outcome was the percentage of operations rated "good" or "excellent" in terms of surgical field visualization at the outset of the case by the primary surgeon. Additional measures included assessment of visualization during the case and patient perioperative comfort. The study was powered to detect a 20% absolute difference in the proportion of cases rated as "good" or "excellent."RESULTS: Seventy-three patients were assigned to mechanical bowel preparation and 73 to no mechanical bowel preparation. The groups were comparable regarding patient and surgery characteristics. No differences were found for this rating between groups (mechanical bowel preparation, 64 of 73 patients [87.7%], compared with no mechanical bowel preparation, 60 of 73 patients [82.2%], P=.36). Surgeons guessed patient assignment correctly 59% of the time (42 of 71 patients) with mechanical bowel preparation and 55% of the time (41 of 75 patients) with no mechanical bowel preparation.CONCLUSION: Mechanical bowel preparation is well-tolerated but does not influence surgical field visualization for laparoscopic hysterectomy.

Our objective was to estimate the prevalence and sociodemographic factors associated with anticholinergic medication use by adult women for overactive bladder (OAB) in the United States.

ObjectiveSubdermal contraceptive implant continuation has not been well studied in Africa. We conducted a secondary data analysis to compare baseline characteristics of Kenyan women who continued to use the subdermal implant at 12 months to those who did not.Study DesignKenyan women aged 18–24 years who presented to a family planning clinic for short-acting hormonal contraception were offered a two-rod subdermal implant instead. Participants were followed for 12 months after initiation of their contraceptive method. Statistical analysis included Pearson's chi-square or Fisher's exact tests for comparisons of proportions. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated to determine factors associated with continuation.ResultsEighty-six (89%) of the 97 women who chose the implant were followed for 12 months. Of these women, 68 (79%) continued to use the implant. None of the factors we examined had a statistically significant association with continued use of the implant. Duration of intended use was the only strong factor; 83% of women with 3+ years of need continued using the implant, compared to 56% of those with shorter needs (Risk ratio = 1.48, 95% CI = 0.94–2.31). No substantive continuation differences were found when comparing other participant characteristics including months with their current partner, personal desire and partner preference for future children, previous use of modern birth control and other factors.ConclusionHigh implant continuation rates were noted regardless of previous use of modern birth control, partner preference for children or baseline concern for menstrual change.ImplicationsContraceptive use in Africa continues to focus on short-acting contraceptives despite the proven superior efficacy of long-acting reversible contraceptives in other settings. The high subdermal implant continuation among Kenyan women in this prospective study, regardless of baseline characteristics, supports the need for increasing access and future research in this population.

OBJECTIVE:Significant deficiencies exist in the communication of prognosis for patients requiring prolonged mechanical ventilation after acute illness, in part because of clinician uncertainty about long-term outcomes. We sought to refine a mortality prediction model for patients requiring prolonged ventilation using a multicentered study design. DESIGN:Cohort study. SETTING:Five geographically diverse tertiary care medical centers in the United States (California, Colorado, North Carolina, Pennsylvania, and Washington). PATIENTS:Two hundred sixty adult patients who received at least 21 days of mechanical ventilation after acute illness. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:For the probability model, we included age, platelet count, and requirement for vasopressors and/or hemodialysis, each measured on day 21 of mechanical ventilation, in a logistic regression model with 1-yr mortality as the outcome variable. We subsequently modified a simplified prognostic scoring rule (ProVent score) by categorizing the risk variables (age 18-49, 50-64, and ≥65 yrs; platelet count 0-150 and >150; vasopressors; hemodialysis) in another logistic regression model and assigning points to variables according to β coefficient values. Overall mortality at 1 yr was 48%. The area under the curve of the receiver operator characteristic curve for the primary ProVent probability model was 0.79 (95% confidence interval 0.75-0.81), and the p value for the Hosmer-Lemeshow goodness-of-fit statistic was .89. The area under the curve for the categorical model was 0.77, and the p value for the goodness-of-fit statistic was .34. The area under the curve for the ProVent score was 0.76, and the p value for the Hosmer-Lemeshow goodness-of-fit statistic was .60. For the 50 patients with a ProVent score >2, only one patient was able to be discharged directly home, and 1-yr mortality was 86%. CONCLUSION:The ProVent probability model is a simple and reproducible model that can accurately identify patients requiring prolonged mechanical ventilation who are at high risk of 1-yr mortality.

Study Objective To estimate the effect of body mass index (BMI) on several outcomes in laparoscopic hysterectomy, in particular in the extremes of obesity. Design Retrospective cohort study (Canadian Task Force classification II-3). Setting Tertiary-care university-based teaching hospital. Patients Eight hundred thirty-four patients who underwent laparoscopic hysterectomy from January 2007 to October 2011. Intervention Laparoscopic hysterectomy for benign indications. Measurements and Main Results Demographic, operative, and postoperative data were abstracted from medical records. The primary outcome was a composite index score that took into account operative time, nonsurgical operating room time, estimated blood loss, length of hospital stay, number of complications, and severity of complications according to the Dindo-Clavien classification. We individually examined elements of the composite index as a secondary outcome. Models were developed to assess the association of BMI with the composite index score and the components of the index, controlling for age, presence of diabetes, tobacco use, surgeon, type of hysterectomy (total vs supracervical), use of robotics, uterine weight, number of additional procedures performed, presence of adhesions requiring lysis, and deeply infiltrating endometriosis as potential confounders. Mean (SD) BMI was 31.4 (8.1). Mean (SD) uterine weight was 345 (388) g. Mean operative time was 150 (61) minutes. Increasing BMI was associated with a worse composite score (p < .01); longer operative time (p = .03), nonsurgical operating room time (p = .02), and total operating room time (p < .01); greater estimated blood loss (p < .01); and complication severity (p = .01). Conclusion These data suggest that there is a significant association of BMI with surgical outcomes in laparoscopic hysterectomy, and the effect is most pronounced in the morbidly obese. These patients may stand to gain the greatest differential benefit from a laparoscopic approach to surgery. However, they should be properly counseled about the challenge that obesity poses to the operation.

HUMAN GENOME RESEARCH DEPENDS upon participants who donate genetic samples, but few studies have explored in depth the motivations of genetic research donors. This mixed methods study examines telephone interviews with 752 sample donors in a U.S. genetic epidemiology study investigating colorectal cancer. Quantitative and qualitative results indicate that most participants wanted to help society, and that many also wanted information about their own health, even though such information was not promised. Qualitative analysis reveals that donors believed their samples contributed to a scientific "common good"; imagined samples as information rather than tissues; and often blurred distinctions between research and diagnostic testing of samples. Differences between African American and White perspectives were distinct from educational and other possible explanatory factors.