United States

Introduction: Breast cancer is the most common non-skin cancer in women in the United States. Minority groups such as Hispanics and Blacks generally have worse outcomes compared to the general population even after accounting for potential confounders. We hypothesize that stage at diagnosis modifies the magnitude of the disparities in survival seen in different racial/ethnic groups. 

Objective: To assess if breast cancer survival is associated with race/ethnicity defined as Non-Hispanic Whites (NHW), Non-Hispanic Blacks (NHB), Hispanic Whites (HW), and Hispanic Blacks (HB), and whether this association is modified by stage at diagnosis.

Methods: A historical cohort, including breast cancer cases in Hispanic and non-Hispanic black and white women was assembled using the Surveillance, Epidemiology, and End Results (SEER) Database 2000-2019. Kaplan-Meier survival functions for each race/ethnicity were compared using the log rank test. Using multivariable Cox regression analysis, hazard ratios for cancer mortality for each race/ethnicity group were estimated while testing for the interaction between race/ethnicity and stage at diagnosis (localized, regional, and distant) and controlling for potential confounders.

Results: The study included 820,748 women 20 years or older with primary breast cancer. The 95-percentile survival time was 27, 25, 19 and 14 months for NHW, HW, HB and NHB respectively. As compared to NHW, HR (95%CI) in localized tumors were: NHB 1.57(1.50-1.65); HB 1.43(1.02-2.01); HW 1.05(0.99-1.11); In regional tumors NHB 1.50(1.45-1.54); HB 1.39(1.12-1.71); HW 1.11(1.07-1.15) and in distant tumors NHB 1.36(1.31-1.42); HB 1.16(0.89-1.50); HW 1.36(1.31-1.42). 

Discussion/Conclusions: The study found that the association between race/ethnicity and breast cancer survival is indeed modified by stage at diagnosis. Compared to NHW, both HB and NHB have worse survival, and such differences in survival decrease as the stage at diagnosis is more advanced. Disparities in survival between HW and NHW are only evident in non-local tumors. Further research should clarify the role of biological vs. social factors in these disparities.

AMA Research Challenge 2024 

The Effect of Stage at Diagnosis on the Association Between Race/Ethnicity and Survival in Patients with Primary Breast Cancer

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Background
The CDC recommends that all children follow the primary immunization series vaccination schedule to prevent vaccine-preventable diseases. The treatment for acute lymphoblastic leukemia (ALL) targets lymphocytes, which are cells that play a role in memory retention for vaccine immunity. The purpose of this experiment is to determine whether there is loss of vaccine immunity in children treated for ALL and whether there is a difference between the high- risk ALL protocols and standard-risk ALL protocols. Understanding loss of immunity in children treated for ALL can help to establish reimmunization guidelines in order to protect survivors from vaccine-preventable diseases.

Methods 
This retrospective study consisted of chart reviews of 45 pediatric patients who are ALL survivors at Children's Hospital of Richmond. The results of hepatitis B, varicella, MMR, and Dtap titers drawn from these patients were compared to the general population using a one- proportion z-test. The ALL group was then divided into high-risk protocol and standard-risk protocol groups. Titers and lymphocyte enumeration panels were then compared between the two groups using a two-proportion z-test.

Results
The results of this study showed that there was a significantly higher percentage of negative hepatitis B, varicella, MMR, and Dtap titers for the ALL group than in the general pediatric population (p<.01). However, there was no significant difference between children treated with high-risk protocols and standard-risk protocols (p = .42). The standard-risk group had 44% negative titers while the high-risk group had 53%. Additionally, the standard-risk group had 78% abnormal lymphocyte enumeration panel while the high-risk group had 86%.

Conclusion
This study showed that children treated with chemotherapy for ALL lose immunity against vaccine preventable diseases and require reimmunization to protect them from future infection. Additionally, there is no significant statistical difference in immunity between the children treated with high-risk protocols vs standard-risk protocols. However, the percentage of negative titers and abnormal lymphocyte enumeration panels in the high-risk group was greater than the standard-risk group, so there may be some clinical significance. Therefore, routine revaccinations should be implemented after chemotherapy and children treated with high-risk protocols may require more follow-ups and precautions. Limitations of this study include small sample size and possible revaccinations at outside hospital systems. Future studies will look at the rate of lymphocyte recovery in standard vs high-risk protocol groups to further assess impacts of chemotherapy protocols on immunity.

Vaccine Immunity after Acute Lymphoblastic Leukemia Treatment


Title: Incidence of human rabies following bite or exposure to laboratory confirmed rabid animals
Kanwarpreet Singh Sandhu 1, Pahul Kaur Bawa 2 and Bhupinder Singh Sandhu 3
1 Non PG resident ,DMCH , Ludhiana, Punjab-India
2 MBBS Scholar, Sri Guru Ramdas University of Health Sciences, Sri Amritsar, India
3. In charge, Rabies Diagnostic Laboratory, Professor cum Head Department of Veterinary Pathology, Guru Angad Dev Veterinary and Animal Sciences University, Ludhiana, Punjab, India

Background: Rabies is one of the important endemic fatal zoonotic viral disease afflicting humans and animals in Punjab, India. The present study investigated the incidence of rabies in humans bitten/exposed to laboratory confirmed rabid animals, as well as incidence after use of vaccine or RIG and clinico-epidemiological studies.
Methods: A study was conducted during August, 2021 to September, 2022 on forty (40) rabies suspected animals presented to diagnose rabies by dFAT at Rabies Diagnostic Laboratory (RDL), GADVASU, Punjab, India. A detailed questionnaire was prepared for obtaining information about exposure/bite of humans by rabid animals, death of humans, demographic and epidemiological information of victims. 
Results: Out of total forty (40) suspected rabies cases, 30(75%) were found positive for rabies by dFAT. Laboratory confirmed rabies (LCR) incidence was 60.80% and 21.73% in stray and pet dogs, respectively. All pet dogs were vaccinated but no stray dog was vaccinated. The LCR incidence in buffaloes and cattle was 77.77% and100%, respectively. Further in humans exposed to rabid animals (59), males were at more risk than females. The human rabies incidence was 3.38% (2/59). Highest incidence of dog bites in adult males on lower limb was observed from urban stray dogs (60.80%) followed by children. Post exposure vaccination was given to 98.3% humans exposed to rabid animals. Human’s rabies in two cases was due to no vaccination or RIG.
Conclusions: Vaccination is an important step in controlling rabies in India. There is a need for integrated and comprehensive management of street dogs and bite management. 
Key Words: Epidemiology, Dog bite, dFAT, Incidence, India, Rabies.


Incidence of human rabies following bite or exposure to laboratory confirmed rabid animals


Topic: Barriers to Goals of Care Discussion and Advance Care Planning

Background:
Goals of care (GOC) discussions are critical conversations between healthcare providers and patients that ensure medical treatments align with patients' values and preferences. Despite their importance in improving patient satisfaction and outcomes, numerous barriers hinder these discussions.

Introduction:
The Goals of Care (GOC) discussions are structured conversations between healthcare providers and patients (or their families) aimed at understanding the patient’s preferences, values, and desired outcomes for their medical treatment and care. These discussions are crucial in establishing a clear, shared understanding of what the patient hopes to achieve with their healthcare, whether it involves curative treatments, palliative care, or a combination. Advance Care Planning (ACP) is a proactive process that allows individuals to make decisions about their future healthcare preferences in case they become unable to communicate those decisions. There are multiples barriers related to Patient, Family, and Physician which we need to know to have better GOC and advance care planning with our patients. The aim of this Study was to Identify the barriers towards to Goal of Care Discussion and Advance Care Planning in our Setting from the Perspective of Medical Residents and Attendings.
Methodology:
The methodology of this study employs a cross-sectional and qualitative approach. Data collection was conducted using Google Forms, which were distributed through Outlook Email and Microsoft Teams. The study was carried out at CCMC from January 2024 to May 2024. Participants included internal medicine residents from all three years, transitional year residents, and Crozer attendings. Data analysis was performed using SPSS v29.

Results:
The results of the study revealed several key insights regarding the awareness and practices related to advance directives and goals of care (GOC) discussions among the participants. Only 40.6% of the study population were unaware of the advance directive tab in EMR. Only 7.8% of participants documented GOC and advance planning in the dedicated EMR tab for advance care planning, with the majority opting to include this information in HPI/progress notes instead. Challenges in having GOC discussions were reported, with 56.3% sometimes and 12.5% always experiencing difficulties. Only 23.4% of respondents consistently discussed GOC with patients aged 65 and older with comorbidities such as COPD, CHF, and dementia. Additionally, only 37.5% regularly reviewed charts to find prior documentation on advance directives and living wills. 
Discussion and Conclusion:
The barriers to the goals of care discussions and advance care planning identified in this study were like those reported in surveys conducted at other hospitals and institutions. We can overcome some of barriers by having GOC early with our Patients and using a Standardized Template for Advance care Planning in EMR. 


Barriers to Goal of Care Discussion and Advance Care Planning

Background:
Social media platforms like Twitter (now X) play an increasingly significant role in education and advocacy within the medical community, including neurology. This study seeks to analyze the top 100 neurology-focused influencers on X and investigate the relationship between their social media presence and academic impact.

Methods:
Using Right Relevance software, we identified 100 influential X accounts in the field of neurology based on follower engagement and activity. We gathered data on each influencer's follower count, h-index, and academic contributions, such as the number of publications. Statistical analyses, including Pearson's correlation, were conducted to assess the relationship between social media influence and academic metrics.

Results:
Our analysis showed a positive correlation between X follower count and h-index - when accounting for outliers - suggesting that a larger social media presence may enhance academic visibility and citation rates. Despite the correlation, the relationship remained weak, indicating room for improvement in using social media for academic purposes.

Conclusion:
The field of neurology has yet to fully capitalize on social media for public education and knowledge dissemination compared to other specialties. This study highlights the need for neurologists to engage strategically on platforms like X to promote accurate information and counter misinformation. Further research is recommended to explore the broader impacts of social media on medical education and patient care.

Correlation between social media influence and academic impact among top 100 neurology X (Twitter) users

Background
The widespread production and disposal of plastics have led to an alarming accumulation of microplastics in the environment, with significant implications for human health. By 2050, 12 billion metric tons of microplastics are expected to be in the environment, a trend exacerbated by the COVID-19 crisis through the increased use of single use plastic gloves and masks. Microplastics have infiltrated various ecosystems worldwide and consequently accumulated in human bodies, posing severe health risks, including the onset and acceleration of neurodegenerative diseases such as Parkinson’s, Alzheimer’s, and multiple sclerosis through mechanisms of neuroinflammation.

Methods
This study utilizes a narrative review approach to explore the impact of microplastics on neurodegenerative diseases and the underlying molecular mechanisms. A comprehensive search of relevant literature was conducted using various electronic databases including PubMed, Web of Science, and Google Scholar. The search strategy involved the use of keywords such as "microplastics," "neurodegenerative diseases," "neuroinflammation," "blood-brain barrier," "glial cells," and "Parkinson’s disease," "Alzheimer’s disease," and "multiple sclerosis." 

Results
The findings indicate that microplastics can infiltrate the CNS through inhalation and direct penetration of the BBB. Detection methods employing engineered nanostructures and gold nanoparticles have been effective in identifying microplastic presence. Moreover, studies using in vitro cultures of glial cells exposed to microplastics showed significant increases in the production of pro-inflammatory cytokines, indicating glial overactivation. In vivo studies in animal models further confirmed these findings, demonstrating that microplastic exposure led to glial cell activation, neuroinflammation, and the acceleration of neurodegenerative disease processes.

Conclusion
The findings emphasize the impact of microplastics on CNS health, particularly through the overactivation of glial cells and the resultant neuroinflammation. This study highlights the need for further research into the mechanisms of microplastic-induced neurotoxicity and the development of advanced detection methods and treatments. There is a gap in research regarding the long-term effects of chronic microplastic exposure on the brain and the potential cumulative impact over an individual’s lifespan. Additionally, the study calls for environmental policy changes to reduce microplastic pollution and mitigate its health effects. Given the current trends in plastic production and waste, microplastics are likely to become an even larger issue in the future without swift action.

The Impact of Microplastics on Neurodegenerative Diseases and Underlying Molecular Mechanisms

Background and Introduction: Menstrual irregularities, encompassing a range of issues such as missed periods, irregular cycle lengths, and abnormal bleeding patterns, are a common concern for many individuals. While several factors can contribute to these irregularities, stress has been identified as a significant influencing factor. Stress, a physiological and psychological response to external pressures, can impact the body's hormonal balance, which is crucial for the regular functioning of the menstrual cycle. The hypothalamus, a part of the brain that regulates hormone production, is particularly sensitive to stress, potentially disrupting the release of gonadotropin-releasing hormone (GnRH). This disruption can alter the menstrual cycle, manifesting as irregular periods.
Objective: This study aims to investigate the association between stress levels and menstrual irregularities in women, focusing on physical and psychological impacts.
Materials and Methods: A cross-sectional study was conducted involving 259 women from different counties surveyed for stress levels and menstrual health. Data were collected using a standardized questionnaire assessing stress scores (Perceived Stress Scale), physical symptoms during stress, painful periods, and menstrual irregularities. Statistical analyses, including t-tests and logistic regression, were performed to determine the relationships between stress and menstrual health outcomes.
Results: The t-test results indicated that women experiencing physical symptoms and painful periods during stress had significantly higher stress scores compared to those who did not report these symptoms. Logistic regression analysis showed a statistically significant positive association between stress and menstrual irregularities, with an adjusted odds ratio (aOR) of 2.7 (95% CI: 1.14-6.53) for women experiencing physical symptoms during stress and still having menstrual irregularities. Additionally, women who perceived stress as a major contributor to their menstrual irregularities reported higher stress scores.
Conclusions: The findings suggest that stress has a significant physical and psychological impact on menstrual health. Managing stress should be considered an integral part of treatment and intervention strategies for menstrual irregularities. Addressing the physical and psychological aspects of stress can improve menstrual health outcomes.
Keywords: Perceived Stress Scale, Menstrual Irregularities, Physical Symptoms, Psychological Impact, Women's Health

Associating the Relationship Between Stress Levels and Menstrual Irregularities: A Cross-Sectional Study

INTRODUCTION: Receiving over $250 million in state government support since 2022, crisis pregnancy centers (CPCs) have expanded following the Supreme Court’s overturn of Roe v. Wade, particularly in states with policies limiting abortion services. As a result, patients may have an increasingly difficult time distinguishing between CPCs and legitimate abortion providers, which may represent a significant barrier to care especially for patients looking for out-of-state abortion services. The National Abortion Federation (NAF) offers membership for providers whose abortion services meet their standardized requirements. However, it is unclear whether these providers sufficiently guarantee their services for patients unfamiliar with the NAF or if these providers clearly list their NAF membership on their website.The purpose of this study was to perform a website content analysis on NAF member facility websites to evaluate how each facility demonstrates the legitimacy of its services. 

METHODS: First, a list of 438 NAF member names and websites was compiled from the NAF’s “Find a Provider” page. Hospitals and Planned Parenthoods were excluded from this study, in addition to facilities that were closed, did not have a website, or did not offer abortion services. The 290 remaining NAF member websites were independently reviewed by two coders, with a third coder to resolve any discrepancies. All websites were evaluated for the following variables: mentions of the right to choose, inclusions of the NAF logo or certification, warnings about CPCs and misinformation, and where each member advertised their abortion services on their website (homepage or subpage). Websites were also assessed for explicit statements guaranteeing the clinic’s legitimacy. State abortion policies were categorized as being protective, neutral, restrictive, and most-restrictive (banned) based on classifications by the Guttmacher Institute. Protective and restrictive states that have a shared border with at least one most-restrictive state were labeled Protective-Bordering-Most-Restrictive (PBMR) and Restrictive-Bordering-Most-Restrictive (RBMR) respectively. Finally, a series of logistic regression analyses were performed to compare the aforementioned variables between different state classifications. 

RESULTS: Through our analysis, we found that 91% of providers mentioned the right to choose, although only 62% had it on their homepage. 96% of clinics that offer procedural abortions advertised it on their homepage, compared to 81% for medical abortions and 84% for abortion pills by mail. 63% of clinics in protective states advertised their NAF membership compared to 79% of clinics in restrictive states (OR = 0.5, p < 0.01). Meanwhile, clinics in protective states were more likely than those in restrictive states to warn about CPCs (OR = 2.7, p < 0.01). This same disparity in CPC warnings was also observed when comparing clinics in PBMR and RBMR states (OR = 3.1, p < 0.01). While no significant differences were found nationally, clinics in PBMR states were considerably more likely to provide legitimacy statements than clinics in RBMR states (OR = 3.3, p < 0.05). 

DISCUSSION: In conclusion, our study suggests that most NAF members clearly advertise their abortion services, especially for procedural abortions. Most NAF members also clearly mention the right-to-choose and their NAF membership. However, relatively few facilities provide guarantees of their legitimacy or warnings about CPCs, especially in RBMR states. Overall, our study suggests patients in restrictive states that are unfamiliar with the NAF may have a harder time identifying legitimate clinics than patients in protective states. Furthermore, patients in restrictive states may also be less informed about CPCs. Because of our results, moving forward we will be interested in assessing how abortion providers without NAF affiliations are able to demonstrate the legitimacy of their services.

Demonstrating Legitimacy: Assessing how Abortion Providers Guarantee Their Services

Black maternal mortality rates in the United States continue to present a dire public health crisis, marked by stark disparities between Black and non-Black birthing outcomes. In this paper, we will investigate the persistent disparities in maternal health outcomes among Black women in the United States, with a specific focus on California, particularly within Los Angeles County. Drawing upon data obtained from the California Department of Public Health, we will highlight the challenges faced by Black mothers in accessing timely and adequate prenatal care, leading to a disproportionately high maternal mortality rate compared to their White counterparts. Through an analysis and critique of two key policies aimed at addressing maternal health disparities in California - the California Momnibus Act (SB 65) and the Perinatal Equity Initiative (PEI), we will identify the strengths and limitations inherent in these legislative efforts. Finally, the paper will propose policy recommendations aimed at enhancing access to quality prenatal care, addressing socioeconomic barriers, fostering provider cultural competency, and strengthening community outreach and diversity initiatives. By advocating for a holistic approach that tackles systemic racism and promotes patient-centered care, we seek to contribute to the ongoing conversations and efforts to address the Black maternal mortality crisis in California and the larger United States and improve prenatal health equity for Black families.

Ensuring Prenatal Health Equity: Policy Review and Recommendations for Black Families in California

Group Yoga Sessions for Improving Breastfeeding: A Scoping Review 
Nyoko Brown, Denise Willoughby, Shahrzad Bazargan-Hejazi, PhD, Bita Amani, Ph.D., M.H.S, 
Miranda Lam
Charles R. Drew University of Medicine and Science – College of Medicine
Telephone: (661) 427-3679
Email: nyokobrown@cdrewu.edu
Abstract Title: Group Yoga Sessions for Improving Breastfeeding: A Scoping Review
Introduction: Breastmilk is crucial to the growth and development of healthy children. 
Investigating interventions that may improve lactation is important for the overall improvement 
of maternal and infant health outcomes. This scoping review aims to show how relaxation and 
physical health benefits from yoga can support breastfeeding efforts.
Background: Prenatal yoga may be used as an effective approach for increased lactation due to 
preliminary studies that have found beneficial effects on mental health such as depression and 
anxiety. 
Methods: An electronic search in PubMed was performed using the keywords: “breastfeeding 
AND stress factors”, “breastfeeding”, “yoga AND lactation”, “benefits of yoga”, “lactation”, 
“breastfeeding interventions.” Two investigators independently evaluated the titles and abstracts 
in the first stage and the full text in a second stage review. Articles not published between 2019 
and 2024, articles that did not examine relationships between yoga and breastfeeding and/or 
breastfeeding and mood disorders were excluded. 11 studies were selected and included. Data 
was independently extracted.
Results: Increased stress showed an association with a decrease in exclusive breastfeeding. 
Participants who exclusively breastfed, as opposed to supplementing with formula, showed 
lower risk of postpartum PTSD. Higher anxiety and depression scores were associated with 
lower maternal oxytocin levels during breastfeeding. Mindfulness, a large facet of yoga, was 
significantly and negatively associated with the discontinuation of breastfeeding. When looking 
at the effect of counseling with stress management on postpartum anxiety and distress, the 
intervention group showed significantly lower mean score of state anxiety. Participants who 
received the intervention also showed a significantly higher mean score of breastfeeding selfefficacy and milk output and volume. The most effective interventions were community-based 
interventions. 
Conclusions: Significant associations between breastfeeding practices and maternal distress 
suggest that a consistent mindfulness practice, such as yoga, may improve breastfeeding 
adequacy. Pre-natal yoga was found to lower stress, depression, and anxiety. Postpartum yoga 
was found to result in higher oxytocin and prolactin levels in primipara women. Group yoga
sessions also have a propensity towards creating community amongst participants, and 
community-based interventions were found to be the most successful in increasing early 
initiation breastfeeding.
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x 
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Dhaurali, S., Dugat, V., Whittler, T., Shrestha, S., Kiani, M., Ruiz, M. G., Ali, I., Enge, C., & 
Amutah-Onukagha, N. (2023). Investigating Maternal Stress, Depression, and 
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(2023). Stress, social support, and racial differences: Dominant drivers of exclusive 
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Kinder und Mutter.) 
Lin, I. H., Huang, C. Y., Chou, S. H., & Shih, C. L. (2022). Efficacy of Prenatal Yoga in the 
Treatment of Depression and Anxiety during Pregnancy: A Systematic Review and MetaAnalysis. Int J Environ Res Public Health, 19(9). https://doi.org/10.3390/ijerph19095368 
Nagel, E. M., Howland, M. A., Pando, C., Stang, J., Mason, S. M., Fields, D. A., & Demerath, E. 
W. (2022). Maternal Psychological Distress and Lactation and Breastfeeding Outcomes: 
a Narrative Review. Clin Ther, 44(2), 215-227. 
https://doi.org/10.1016/j.clinthera.2021.11.007 
Noushad, S., Ahmed, S., Ansari, B., Mustafa, U. H., Saleem, Y., & Hazrat, H. (2021). 
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(Qassim), 15(5), 46-59. https://www.ncbi.nlm.nih.gov/pubmed/34548863 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8434839/pdf/IJHS-15-46.pdf 
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Group Yoga Sessions for Improving Breastfeeding: A Scoping Review

Introduction: 
The Dobbs decision (June 24, 2022), which overturned Roe v. Wade, introduced significant changes to abortion laws across the United States. It remains unclear how this policy shift has impacted reproductive health care among different racial groups. This study aims to evaluate these effects, hypothesizing that the Dobbs decision would lead to increased preventive measures and decreased abortion procedures due to heightened awareness and potential legal restrictions.
Methods: 
Utilizing data from the TriNetX global health research network, which aggregates electronic health records (EHR) from over 120 clinical sites, patient cohorts were categorized based on ICD, CPT, or medication codes, focusing on periods before and after the Dobbs decision (June 30, 2020, to January 1, 2022, and December 31, 2022, to June 30, 2024, with a 6-month washout period). The groupings included prevention (contraceptive medication, emergency contraceptives, encounters for general counseling and advice on contraception, and insertion of IUD), screening (PAP tests), complications (preterm labor, spontaneous abortion, pregnancy with abortive outcome), and overall abortion procedures. Statistical analyses, including propensity matching for demographic features and access to healthcare services, were performed to identify significant trends and disparities within TriNetX.
Results: 
TriNetX identified 9,124,941 patients after propensity matching 35 ± 13.1 age of which 60.1% white, 16.8% black, 13.1% Hispanic, and 4.3% Asian. Adverse pregnancy outcomes slightly increased post-Dobbs (OR: 1.05, 95% CI: 1.04-1.06, p-value < 0.01). There was an increase in abortion procedures post-Dobbs (OR: 1.05, 95% CI: 1.03-1.08, p-value < 0.01), but disaggregated data into individual racial groups found unique reproductive health behavioral patterns. Abortions were non-significant for the white and Asian populations (p = .24, and .80, respectively). The only racial group to have increased preventive measures post-Dobbs were Asians (OR: 1.1, 95% CI: 1.07-1.12, p-value < 0.01). Screenings statistically significantly decreased for all racial groups (OR: 0.78, 95% CI: 1.77-1.78, p-value < 0.01) post-Dobbs.
Conclusion:
Adverse pregnancy outcomes rose for all racial groups except African Americans, and Asians were the only group with a significant increase in preventive measures. Odds ratio for these findings are slightly above 1.0, which indicates that the observed changes may not be clinically significant. This analysis underscores the importance of continuing research and dialogue on the potential impacts of the Dobbs decision on women's health and racial disparities.

Impact of the Dobbs Decision on Abortion Rates, Preventive Measures, and Pregnancy Outcomes Across Racial Groups: A Large Public Health Database Analysis

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