Impact of Clinic Closures on Women Obtaining Abortion Services After Implementation of a Restrictive Law in Texas

Objectives. To evaluate the additional burdens experienced by Texas abortion patients whose nearest in-state clinic was one of more than half of facilities providing abortion that had closed after the introduction of House Bill 2 in 2013.Methods. In mid-2014, we surveyed Texas-resident women seeking abortions in 10 Texas facilities (n = 398), including both Planned Parenthood–affiliated clinics and independent providers that performed more than 1500 abortions in 2013 and provided procedures up to a gestational age of at least 14 weeks from last menstrual period. We compared indicators of burden for women whose nearest clinic in 2013 closed and those whose nearest clinic remained open.Results. For women whose nearest clinic closed (38%), the mean one-way distance traveled was 85 miles, compared with 22 miles for women whose nearest clinic remained open (P ≤ .001). After adjustment, more women whose nearest clinic closed traveled more than 50 miles (44% vs 10%), had out-of-pocket expenses greater than $100 (32% vs 20%), had a frustrated demand for medication abortion (37% vs 22%), and reported that it was somewhat or very hard to get to the clinic (36% vs 18%; P < .05).Conclusions. Clinic closures after House Bill 2 resulted in significant burdens for women able to obtain care.Since 2010, US states have enacted nearly 300 abortion restrictions, with 51 new restrictions passed in the first half of 2015 alone.1 Of note is the increase in laws that make it more difficult to provide abortion services by imposing expensive or logistically difficult requirements on facilities and clinicians, which are often referred to as Targeted Regulation of Abortion Provider (TRAP) laws. In the summer of 2013, Texas passed House Bill 2 (HB2), a TRAP law that restricted abortion services in 4 ways: (1) physicians performing abortions must have admitting privileges at a hospital within 30 miles of the facility, (2) medication abortion must be administered according to the mifepristone label approved by the Food and Drug Administration (with some dosage exceptions), (3) most abortions at or after 20 weeks “postfertilization” are banned, and (4) all abortions must be performed in facilities meeting the requirements of an ambulatory surgical center (ASC).2 The first 3 provisions of HB2 were enforced by November 1, 2013; the ASC requirement is currently enjoined pending a US Supreme Court decision, as is the admitting privileges requirement as it applies to 2 Texas facilities.Eight of the 41 Texas facilities providing abortion care in April 2013 closed or stopped providing abortion services after the introduction of the HB2 bill.3 Eleven more facilities closed or stopped providing abortions when HB2 was enforced, primarily because physicians experienced barriers to obtaining hospital admitting privileges.3 Although some clinics were able to reopen once physicians successfully obtained admitting privileges, still others closed, resulting in 19 licensed facilities providing abortions in Texas by July 2014—a 54% reduction in the number of facilities since April 2013.4Recent studies have reported the effects of state-level abortion restrictions on abortion rates, out-of-state travel for abortion, and the consequences for women of being denied a wanted abortion because of clinic gestational age limits, but less is known about the burdens that women experience as a result of clinic closures.5–9 Evaluating the impact of a substantially reduced number of abortion clinics in Texas on hardships experienced by women who are in need of abortion services is essential to determining the constitutionality of HB2, as the legal thresholds for abortion restrictions center upon the magnitude and nature of these burdens on women.10 However, such an evaluation presents a number of methodological challenges. Documenting the experiences of women who were unable to obtain a wanted abortion because of insurmountable hardship is difficult, primarily because those are the very women who were unable to reach an abortion clinic where they might be enrolled in a study.11,12 Indeed, the 13% decline in abortions performed in Texas during the first 6 months after HB2 went into effect gives an indication of the law’s impact.3In addition, HB2 affected women who were able to obtain an abortion. These women include those who were directly affected by the closure of the clinic they would have used, as well as women whose nearest or preferred clinic did not close, but who nevertheless were burdened by the law through discontinued offering of medication abortion, longer wait times for appointment availability, or higher costs of the procedure at one of the remaining facilities.In this study, we assess the impact of HB2 on women who obtained an abortion after the law was implemented. With survey data collected from a sample of women who obtained an abortion in Texas in 2014, we compared the experiences of women whose nearest clinic closed with those of women whose nearest clinic remained open. Through this comparison, we sought to assess the additional burdens experienced by women whose nearest clinic closed.     

The Time-to-Integrate-to-Nest Test as an Indicator of Wellbeing in Laboratory Mice

Minimizing and alleviating pain and distress in laboratory mice without compromising the methodologic integrity of research is a crucial goal. However, current methods for welfare assessment in mice are not well suited to cageside checks. In the present study, we developed a simple assessment tool—the time-to-integrate-to-nest test (TINT)—and evaluated its ability to identify mice with compromised welfare. To conduct the TINT, a nominal amount of nesting material is added to a mouse cage, and the nesting behaviors that occur immediately thereafter are observed. The TINT yields a positive result when a mouse integrates the new nesting material into the main nest site within 10 min; failure to interact with the nesting material is defined as a negative TINT. Our first experiment examined whether genetic background and sex are associated with differences in the likelihood of a positive TINT in unmanipulated mice. A significant effect related to mouse strain was found: C3H/HeNCrl had the lowest positive TINT rate among the 10 strains evaluated. A second experiment assessed whether results of the TINT would be altered after a painful surgical procedure, such as carotid artery injury. Despite all mice having received buprenorphine as analgesia at the time of surgery, significantly more mice had a negative TINT for 2 d after surgery than before surgery. Based on the results of the current study, additional work is needed to specifically validate the TINT in injured and noninjured subjects.Abbreviations: CAI, carotid artery injury; TINT, time-to-integrate-to-nest testEvaluation of pain in laboratory animals typically incorporates the measurement of physiologic and behavioral indicators. To date, the assessment of pain in laboratory mice has involved the evaluation of one of more of the following: locomotor activity, food and water consumption, body weight gain or loss, fur quality, threshold or latency to stimulus testing, posture evaluation, presence of vocalization, temperament changes, biochemical changes, level of self-administration of analgesics, and other behavioral measures.^{7,12,15,21,29} Each of these methods has limitations. Many of them require handling, sample analysis, or concurrent controls and therefore are not useful for clinical evaluation. In addition, single physiologic parameters are not specific to pain and do not fully characterize the experience in the way that behavioral observation does.^14,22 Effects of pain on locomotor activity have been studied, but locomotion deficits can either be a side effect of anesthesia and analgesia or a sign of pain.²⁹ Furthermore, rodents have been suggested to display few, if any, overt behaviors indicative of ongoing pain.¹⁹ These and other hurdles have made effective pain assessment and management in laboratory mice onerous.An objective, simple, and valid diagnostic screening tool for pain or distress in laboratory mice is needed. Observation of activity levels, general appearance, temperament, changes in feeding and surgical site evaluation may all play a role in determining whether mice are experiencing pain.²⁹ For example, the Mouse Grimace Scale is a useful and increasingly validated technique for the scientific study of pain that focuses on capturing facial grimaces by using video footage for subsequent scoring and assessment.^15,19 Using the Mouse Grimace Scale in mice may provide a specific and sensitive detection method for significant acute pain, but it currently appears to require investments of equipment and time to train and score individual animals.¹⁶ To provide a practical, straightforward assessment tool for mice, we can examine mouse behavioral time budgets by focusing on the behaviors that this species is most motivated to perform. If a mouse is unable to perform motivated behaviors or acquire commodities that are most directly related to fitness and survival, then one can surmise that its welfare is affected.⁶The nests of mice have been described as “the central location for a mouse''s activities”.¹⁷ The functions of a nest for mice are many: thermoregulation, rearing and maternal activity, avoidance of predators, cover from harsh lighting conditions, and protection from other external environmental variations.^3,17,25,31 Mice that have nests have improved conversion of calories because of their ability to regulate their body temperature and maintain homeostatic control.^9,25 Differences in nesting behavior between strains largely revolve around the ability to construct more or less sophisticated nests rather than in the basic ability or motivation to nest.^4,8 In fact, all mice are highly motivated to construct and use nests.^11,25,30,33 Through both preference assessment and operant conditioning methods, mice have been shown to work very hard to gain access to nesting material.³¹Therefore, reasonable evidence supports the conclusion that nest construction is a species-specific behavior that is a direct behavioral strategy to improve fitness and survival. Normal, noninjured healthy mice should be intensely motivated to rapidly perform nesting behavior when presented with a small amount of fresh nesting material. Our novel assessment tool—the time-to-integrate-to-nest test (TINT)—produces a binary outcome. A mouse that integrates the new nesting material into the main nest site within 10 min is considered to have a positive TINT. Failure to retrieve the nesting material in 10 min is scored as a negative TINT. To make use of this tool across a variety of laboratory conditions, using various strains of laboratory mice, we must verify that normal, noninjured healthy mice routinely exhibit this nesting behavior. We hypothesize that genetic background and sex will not affect the TINT in healthy laboratory mice. We also hypothesize that the TINT will be altered when a laboratory mouse undergoes a painful surgical procedure.     

Detection and Characterization of Mycoplasma pneumoniae during an Outbreak of Respiratory Illness at a University

An outbreak at a university in Georgia was identified after 83 cases of probable pneumonia were reported among students. Respiratory specimens were obtained from 21 students for the outbreak investigation. The TaqMan array card (TAC), a quantitative PCR (qPCR)-based multipathogen detection technology, was used to initially identify Mycoplasma pneumoniae as the causative agent in this outbreak. TAC demonstrated 100% diagnostic specificity and sensitivity compared to those of the multiplex qPCR assay for this agent. All M. pneumoniae specimens (n = 12) and isolates (n = 10) were found through genetic analysis to be susceptible to macrolide antibiotics. The strain diversity of M. pneumoniae associated with this outbreak setting was identified using a variety of molecular typing procedures, resulting in two P1 genotypes (types 1 [60%] and 2 [40%]) and seven different multilocus variable-number tandem-repeat analysis (MLVA) profiles. Continued molecular typing of this organism, particularly during outbreaks, may enhance the current understanding of the epidemiology of M. pneumoniae and may ultimately lead to a more effective public health response.     

Correlates of SARS-CoV-2 anti-RBD IgG antibody titers among persons experiencing homelessness in Los Angeles

Objectives

People experiencing homelessness (PEH) have been especially impacted by the COVID-19 pandemic, likely due to increased vulnerabilities stemming from chronic diseases, substance use, and mental health conditions.

Design

A case–control study to assess the presence of antibodies against SARS-CoV-2 among PEH and associations with key variables.

Sample

A convenience sample of 97 PEH in Skid Row, Los Angeles.

Measurements

A structured questionnaire assessing socio-demographic, mental health, drug and alcohol use, health care access, pandemic stress, and other COVID-19-specific questions.

Results

We found high anti-receptor binding domain (RBD) IgG titers among five of 15 PEH who reported no prior COVID-19 diagnosis or being vaccinated, suggesting undiagnosed and/or asymptomatic COVID-19. While anti-RBD IgG titers across vaccination categories were not statistically significant (p = .069), participants vaccinated with Janssen had the lowest mean anti-RBD IgG titers. In multivariable analysis, we found negative associations between level of SARS-CoV-2 antibody titers with the Janssen vaccine and depression; thus, a need for integrated care for PEH with depression and COVID-19.

Conclusions

Further research is warranted to confirm the immune response, initial and over time, to SARS-CoV-2 infection and to COVID-19 vaccinations, particularly among PEH whose immune systems may be impacted by multiple health conditions.     

Collection of hematopoietic stem cells and immune effector cells in small children

Apheresis procedures are standard of care for a wide range of indications in children, collection of hematopoietic stem cells being the most frequent one. With increasing numbers of hematopoietic stem cell transplants, advances in graft manipulation techniques and the development of innovative therapies using immune effector cells and gene therapy, apheresis within the pediatric population is growing in demand. While young children have higher circulating white blood cell counts and robustly mobilize hematopoietic stem cells, apheresis machines were designed for use within the adult population and apheresis procedures in children, particularly small children, can be more challenging as vascular access, collection techniques and impact of extracorporeal volumes increase the rate of adverse events. In this article we review topics of particular relevance to hematopoietic stem cell and immune effector cell collections in small children.     

Endoscopic balloon dilation for management of stricturing Crohn's disease in children

BACKGROUND Crohn's disease(CD) has a multitude of complications including intestinal strictures from fibrostenotic disease. Fibrostenotic disease has been reported in 10%-17% of children at presentation and leads to surgery in 20%-50% of cases within ten years of diagnosis. When symptoms develop from these strictures, the treatment in children has primarily been surgical resection. Endoscopic balloon dilation(EBD) has been shown to be a safe and efficacious alternative to surgery in adults, but evidence is poor in the literature regarding its safety and efficacy in children.AIM To evaluate the outcomes of children with fibrostenosing CD who underwent EBD vs surgery as a treatment.METHODS In a single-center retrospective study, we looked at pediatric patients(ages 0-18) who carry the diagnosis of CD, who were diagnosed after opening a dedicated Inflammatory Bowel Disease clinic on July 1, 2012 through May 1, 2019. We used diagnostic codes through our electronic medical record to identify patients with CD with a stricturing phenotype. The type of intervention for patients' strictures was then identified through procedural and surgical billing codes. We evaluated their demographics, clinical variables, whether they underwent EBD vs surgery or both, and their clinical outcomes.RESULTS Of the 139 patients with CD, 25(18%) developed strictures. The initial intervention for a stricture was surgical resection in 12 patients(48%) and EBD in 13 patients(52%). However, 4(33%) patients whom initially had surgical resection required follow up EBD, and thus 17 total patients(68%) underwent EBD at some point in their treatment process. For those 8 patients who underwent successful surgical resection alone, 4 of these patients(50%) had a fistula present near the stricture site and 4(50%) had strictures greater than 5 cm in length. All patients who underwent EBD had no procedural complications, such as a perforation. Twenty-two(88%) of the treated strictures were successfully managed by EBD and did not require any further surgical intervention during our follow up period.CONCLUSION EBD is safe and efficacious as an alternative to surgery for palliative management of strictures in selected pediatric patients with CD.     

Exceptional Mortality Prediction by Risk Scores from Common Laboratory Tests

Background

Some components of the complete blood count and basic metabolic profile are commonly used risk predictors. Many of their components are not commonly used, but they might contain independent risk information. This study tested the ability of a risk score combining all components to predict all-cause mortality.

Methods

Patients with baseline complete blood count and basic metabolic profile measurements were randomly assigned (60%/40%) to independent training (N = 71,921) and test (N = 47,458) populations. A third population (N = 16,372) from the Third National Health and Nutrition Examination Survey and a fourth population of patients who underwent coronary angiography (N = 2558) were used as additional validation groups. Risk scores were computed in the training population for 30-day, 1-year, and 5-year mortality using age- and sex-adjusted weights from multivariable modeling of all complete blood count and basic metabolic profile components.

Results

Area under the curve c-statistics were exceptional in the training population for death at 30 days (c = 0.90 for women, 0.87 for men), 1 year (c = 0.87, 0.83), and 5-years (c = 0.90, 0.85) and in the test population for death at 30 days (c = 0.88 for women, 0.85 for men), 1 year (c = 0.86, 0.82), and 5 years (c = 0.89, 0.83). In the test, the Third National Health and Nutrition Examination Survey, and the angiography populations, risk scores were highly associated with death (P <.001), and thresholds of risk significantly stratified all 3 populations.

Conclusion

In large patient and general populations, risk scores combining complete blood count and basic metabolic profile components were highly predictive of death. Easily computed in a clinical laboratory at negligible incremental cost, these risk scores aggregate baseline risk information from both the popular and the underused components of ubiquitous laboratory tests.