United States

Background
Periprosthetic infection (PI) remains a feared complication of implant-based reconstruction (IBR), with reported rates of 10-20% despite multiple prevention techniques​​. PI leads to patient morbidity and healthcare costs, requiring systemic antibiotics and potentially implant removal. Antibiotic-impregnated bone discs (ABC) have been utilized to prevent infection in orthopedic procedures, but evidence for ABC in IBR is scarce and limited primarily to implant salvage​. 

Methods
Patients underwent two stage IBR with tissue expander (TE) and ABC disc placement after mastectomy. ABC was prepared by adding antibiotics to polymethacrylate bone cement to a total concentration of 2.4 g tobramycin and 3 g vancomycin and forming the compound into discs. These discs were implanted underneath the TE and inserted in the prepectoral plane with complete acellular dermal matrix coverage. Discs were removed at exchange of TE to implant. We evaluated wound complications and need for explantation postoperatively. 

Results
Sixty-six patients (one hundred and thirteen breasts) were included in the study. Twenty-one (30.3%) patients had unilateral reconstruction, and forty-six (69.7%) had bilateral. Complications included seromas, which were aspirated in 3 patients (2.7%), hematoma in one breast (0.9%), superficial skin or partial flap necrosis treated conservatively in five patients (4.4%), and mastectomy flap necrosis requiring debridement and replacement of TE in three patients (2.7%). Two (1.8%) TE explants of seven (6.2%) were due to infection of the TE.

Conclusion
We found a low postoperative complication rate and only two periprosthetic infections with the use of ABC discs in IBR. This technique is a promising modality for reducing morbidity associated with implant-associated infection.

AMA Research Challenge 2025 

Using Antibiotic-Impregnated Discs for Infection Control in Implant-Based Breast Reconstruction

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Background
Cancer can recur when a subset of tumor cells, termed persister cells, survive therapy and re-enter the cell cycle. The cellular origins that give rise to persister cells and the mechanisms that confer the persister state remain poorly understood. We hypothesize that an epigenetic signature underlies the drug-tolerant persister state, characterized by transcriptional and chromatin accessibility changes that promote survival of residual cancer following chemotherapy.

Methods
To identify clinically relevant features of persister cells in untreated tumors and residual disease, we performed single-cell multiomic profiling (scRNA+scATAC) on a cohort of treatment-naïve and neoadjuvant chemotherapy (NACT)-treated high-grade serous ovarian cancer (HGSOC) samples. Additionally, we sought to validate the features that give rise to a persister state experimentally by performing single-cell multiomic profiling on HGSOC patient-derived xenograft (PDX) models before and after platinum-based chemotherapy.



Results
We identified differences in gene expression and DNA binding factor - transcription factors (TF) and chromatin regulators - enrichment between naïve and residual patient tumors following chemotherapy. Notably, the changes in chromatin accessibility present in residual NACT tumors were also found in treatment-naive samples from patients who later developed resistance. This suggests that a pre-existing epigenetic signature may be driving the chemotherapy-tolerant state in persister cells. This epigenetic signature independently predicted chemotherapy response in PDX models of HGSOC and in a separate patient cohort of metastatic HGSOC. Cells enriched in the persister state arose from multiple tumor lineages and displayed activation of oncogenic pathways, including altered stress responses, epithelial to mesenchymal transition, and changes to the cell cycle promoting quiescence. Additionally, we identified a subset of genes that are epigenetically primed for expression before treatment and are upregulated after treatment. These genes stay dormant or lowly expressed before chemotherapy but are significantly upregulated after treatment, which could explain the mechanism by which persister cells gain resistance to chemotherapy.

Conclusion
Our study reveals an intrinsic epigenetic program that primes tumor cells towards chemotherapy tolerance and identifies new vulnerabilities that could be exploited to delay or prevent cancer recurrence. The ability of the epigenetic signature to stratify treatment-naïve patient tumors into chemotherapy-sensitive and -resistant groups suggests that epigenetic profiling could be used as a predictive biomarker to guide therapeutic decisions and reduce cancer recurrence.



Single-cell multiomic analysis of HGSOC reveals an epigenetic program driving chemotherapy tolerance

Background
Accurate detection and classification of intracranial hemorrhages (ICH) from computed tomography (CT) images are critical for timely clinical intervention. Large language models (LLMs) like GPT have shown potential in medical imaging tasks, yet their effectiveness in complex classification scenarios remains unclear. This study assesses GPT-4o's capability to identify hemorrhage presence and categorize hemorrhage subtypes using publicly available CT imaging data.

Methods
CT scans from the PhysioNet Intracranial Hemorrhage CT Dataset were preprocessed into axial slices, normalized to 8-bit grayscale, and combined into composite images to comply with GPT-4o’s token constraints. The evaluation consisted of two tasks:
Binary classification (hemorrhage presence vs. absence) involving 75 scans (36 positive, 39 negative).
Multi-class classification of hemorrhage subtypes (intraventricular, intraparenchymal, subarachnoid, epidural, subdural) among the 36 positive cases.
Model outputs were assessed using accuracy, precision, recall, F1-score, exact match accuracy, and Hamming scores.

Results
In the binary classification task, GPT-4o achieved an overall accuracy of 0.52, with precision of 0.50, recall of 0.14, and F1-score of 0.22 for detecting hemorrhages. Non-hemorrhagic cases were identified with higher recall (0.87) but similar precision (0.52), yielding an F1-score of 0.65.

For subtype classification, precision was highest for epidural hemorrhages (1.0) but accompanied by low recall (0.14) and an F1-score of 0.25. Intraparenchymal hemorrhage showed balanced precision (0.46) and recall (0.75), achieving an F1-score of 0.57. Exact match accuracy was low (0.06), indicating GPT-4o rarely identified all subtypes correctly in a single prediction. The average Hamming score was moderate at 0.54, highlighting partial accuracy across subtypes.

Conclusion
GPT-4o demonstrated modest performance in hemorrhage detection, particularly limited by low recall in positive cases. While specificity was comparatively better, the overall diagnostic capability remained suboptimal. Subtype classification posed additional challenges, reflected by poor exact match accuracy despite acceptable partial label accuracy. These findings suggest the necessity of refined training approaches, targeted model tuning, and potential integration with hybrid analytical methods to improve clinical reliability.


Evaluating GPT-4o Performance for Hemorrhage Detection and Subtype Classification in Head CT Scans


Background:
Male breast cancer is a rare malignancy, accounting for less than 1% of all breast cancer cases, typically affecting men around age 65, though younger cases occur. In 2025, about 2,800 new cases and 510 deaths are expected in the U.S. African American men experience worse outcomes despite a lower incidence. The lifetime risk is roughly 1 in 726, influenced by genetic and environmental factors including BRCA2 mutations, radiation exposure, hormonal imbalances, liver disease, and obesity. Germline mutations, especially BRCA2, contribute significantly, with up to 10% of cases linked to this gene. BRCA1 mutations are less common but relevant. Other hereditary genes implicated include CHEK2 (notably the 1100delC variant), PALB2, and ATM. PALB2 mutations occur in about 1–2% of cases and confer a 4- to 6.6-fold increased risk. Invasive ductal carcinoma is the predominant histologic subtype, accounting for 65–95% of male cases, while lobular carcinoma is rare. Identifying hereditary syndromes is crucial for risk stratification and screening.

Case presentation:
We report a 59-year-old African American man with a history of Hodgkin’s lymphoma treated with radiation. In September 2024, he presented with a right subareolar lump without itching, tenderness, or skin changes. Given a strong family history of breast cancer (sister, uncle, mother) and stomach cancer (father), germline testing revealed a PALB2 mutation; BRCA1/2 mutations were negative. Ultrasound showed a right retroareolar solid mass; biopsy confirmed a well-differentiated invasive ductal carcinoma (IDC) measuring 1.2 cm. PET-CT excluded metastasis. On October 24, 2024, he underwent a right mastectomy with sentinel lymph node biopsy. Pathology revealed a 2.2 x 1.5 x 1.5 cm Grade 2 IDC (T2N0M0, Stage IIA) with rare vascular invasion, deep dermal extension, and in situ ductal carcinoma with comedo necrosis. Immunohistochemistry was ER/PR positive and HER2 negative, supporting hormonal therapy. Oncotype DX score was 18, indicating low recurrence risk, so chemotherapy was not recommended. Given prior radiation and surgery, no further radiation was advised, and Tamoxifen 20 mg daily was started.

Discussion:
This case highlights the multifactorial nature of male breast cancer, showing the interplay between environmental exposure and genetic predisposition. Prior chest irradiation was the principal carcinogenic factor, while the PALB2 mutation likely increased susceptibility. Though BRCA mutations are most common, this case underscores the importance of other predisposition genes like PALB2 and the need for long-term surveillance in male cancer survivors with genetic risk and radiation history.

Radiation-Induced Male Breast Cancer in the Setting of a PALB2 Germline Mutation

Background:

Granulomatosis with polyangiitis (GPA), formerly known as Wegener’s granulomatosis, is a rare necrotizing vasculitis affecting small to medium-sized vessels, commonly involving the respiratory tract and kidneys. The disease has a strong association with anti-neutrophil cytoplasmic antibodies (ANCA), particularly c-ANCA directed against proteinase-3. Early diagnosis is challenging due to overlapping symptoms with infections and other inflammatory conditions.

Case Presentation:

A 52-year-old non-diabetic, non-hypertensive female presented with a one-month history of fever with chills, a single episode of haemoptysis, and a recent onset of weight loss, anorexia, and productive cough. On examination, she was pale, tachycardic, and required supplemental oxygen. Auscultation revealed bilateral basal crepitations. Laboratory findings included leukocytosis, elevated CRP (239), and a positive c-ANCA test. Chest X-ray and HRCT thorax revealed multiple cavitary lesions with surrounding consolidation and ground-glass opacities. Despite empirical anti-tubercular and antibiotic therapy, the patient worsened with persistent fever and desaturation. A CT-guided lung biopsy showed granulomatous inflammation with Langhans giant cells and dense lymphoplasmacytic infiltrates, confirming the diagnosis of GPA. She was treated with pulse steroids (IV methylprednisolone 1 g for 3 days), followed by oral corticosteroids, co-trimoxazole, and cyclophosphamide infusions per standard protocol.

Discussion:

The diagnosis was initially confounded by a presumptive diagnosis of pulmonary tuberculosis. However, the absence of microbiological evidence, c-ANCA positivity, constitutional symptoms, and progressive respiratory involvement shifted the suspicion towards GPA with diffuse alveolar hemorrhage. The case highlights the importance of high clinical suspicion, ANCA testing, and timely histopathological confirmation in atypical pulmonary presentations.

Conclusion:

GPA is a life-threatening, multi-system autoimmune vasculitis. Prompt diagnosis and early immunosuppressive therapy with corticosteroids and cyclophosphamide are critical for improving outcomes, especially in cases presenting with diffuse alveolar
hemorrhage. Clinicians must maintain a differential diagnosis of GPA in patients with cavitating lung lesions and systemic symptoms unresponsive to standard antimicrobial therapy.

Granulomatosis with Polyangiitis Presenting as Diffuse Alveolar Hemorrhage: A Case Report

Background 
Pituitary adenomas (PA) are common, typically benign tumors with a prevalence of approximately 22%. Endoscopic transsphenoidal (TSS) resection of PAs is the standard of care for large or symptomatic tumors presenting with visual disturbances or endocrinopathies. Postoperative complications include cerebrospinal fluid (CSF) leak, hormonal and visual disturbances, and hematomas leading to acute visual decline. Delayed cyst formation is well-documented and consists largely of arachnoid cysts. Rapid postoperative suprasellar cyst development leading to acute visual deterioration is exceedingly rare, with only 1 case reported in the literature. A cyst composed of normal pituitary gland has not been previously reported. We present the rapid formation of a nonneoplastic pituitary cyst following TSS resection of a large PA. The management and functional outcome are reviewed and the underlying pathogenesis is explored.

Case Presentation
A 63-year-old female presented with a large PA causing significant compression of the optic apparatus. Preoperative evaluation demonstrated normal visual acuity and fields. Gross total resection was achieved via the endoscopic approach and cytological analysis revealed a pituitary gonadotroph, subtype positive for follicle-stimulating hormone. The patient remained neurologically intact and immediate postoperative computed tomography (CT) confirmed complete resection and decompression of the optic apparatus. On postoperative day 6, the patient developed a sudden bitemporal hemianopsia. CT revealed a new suprasellar cystic lesion compressing the optic chiasm. The patient underwent emergent craniotomy and a cyst clearly emanating from the pituitary stalk was identified and resected. The attachment was sharply transected and the stalk was left both anatomically and functionally intact. Pathology demonstrated non-neoplastic anterior pituitary gland. Visual acuity and fields returned to the preoperative baseline. Six months post-resection the patient has normal pituitary function and vision and magnetic resonance imaging demonstrates no evidence of residual or recurrent disease.

Discussion
We present a rare case of a rapidly growing cyst of pituitary origin after TSS resection of a PA. A literature review into postoperative cyst formation after TSS for sellar masses yielded 469 articles, with 6 describing cyst growth within a year of TSS. The fastest developing lesion was a suprasellar arachnoid cyst that presented with acute visual impairment 1 day after surgery. There are no reports of postoperative cysts of pituitary origin. Emergent cyst resection resulted in preservation of vision and pituitary function, supporting surgical management. The pathogenesis of this lesion remains unknown. Future surgical and pathology reports will help identify variables contributing to postoperative cyst formation after PA resection.


Rapid Pituitary Cyst Development After Endoscopic Transsphenoidal Resection of Pituitary Adenoma

Background:
Spinal dural arteriovenous fistulas (SDAVFs) are rare vascular malformations involving an abnormal connection between a dural artery and a medullary vein, leading to venous hypertension and progressive myelopathy. Literature estimates an annual incidence of 5 cases per million, with a strong male predominance between 50-70 years old (~80%), with women accounting for only 20% of cases. This case presents a patient with a proposed novel mechanism for acquired SDAVF through equestrian activity.
Case Presentation:
An 81-year-old woman with hypertension and hypothyroidism presented with bilateral leg paresthesias progressing over three weeks to flaccid lower extremity paralysis, urinary retention, and constipation. She denied back or neuropathic pain. At baseline, she was fully independent and had recently taken up horseback riding.
Lumbar spine MRI revealed multilevel degenerative disc disease and foraminal narrowing. She was discharged to a skilled nursing facility with presumed lumbar radiculopathy. Two weeks later, she re-presented with worsening symptoms: 0/5 strength in the lower extremities, areflexia, T12-L1 sensory level, mute plantar responses, and sphincter dysfunction.
Thoracic spine MRI showed long-segment T2 hyperintensity, cord expansion, and serpentine flow voids. Digital subtraction angiography confirmed an SDAVF at the right T12 intercostal artery. She underwent Onyx-18 embolization with minimal improvement, followed by T11–L1 laminoplasty and direct ligation with nBCA embolization of a residual extradural component.
Postoperatively, she regained movement in hips, knees, and feet but remained Foley- dependent. She is undergoing rehabilitation with gradual improvement.
Discussion:
SDAVFs are acquired lesions often associated with dural sinus thrombosis, trauma, or prior surgery. This patient had none of these risk factors and her only recent change was picking up horseback riding as a new hobby in the last year, which introduced repetitive axial spinal stress. However, with her history of hypertension weakening the arterial walls and the introduction of horseback riding, this could have contributed to the formation of the abnormal connection between arteries and veins that characterizes a SDAVF. This may have triggered angiogenic pathways, particularly vascular endothelial growth factor (VEGF), leading to abnormal arteriovenous shunt formation. Additional mediators such as FGF and IL-6 could have contributed to endothelial injury and neovascularization. No prior literature has linked equestrian activity with SDAVF, making this a novel etiologic consideration. The delay in diagnosis reflects the overlap of symptoms with more common conditions like lumbar stenosis. Clinicians should consider SDAVF in elderly patients with progressive myelopathy and sphincter dysfunction even if the etiology does not follow medical norms for SDAVF’s.

Saddled With A Fistula; A Rare Case of Spinal Dural AVF In An 81 Year Old Equestrian

Background
Chronic abdominal pain (CAP), defined as constant or recurrent pain lasting more than three months, is a common yet diagnostically and therapeutically challenging condition, particularly in patients with overlapping gastrointestinal (GI), musculoskeletal, and connective tissue disorders. Given its multifactorial pathophysiology, CAP often necessitates a multimodal treatment strategy. Osteopathic manipulative treatment (OMT) offers a hands-on, non-pharmacologic approach to address somatic and viscerosomatic dysfunction, but remains underutilized in managing complex CAP.

Case Presentation
This clinical vignette evaluates the effectiveness of OMT, including both somatic and visceral techniques, in managing chronic idiopathic right lower quadrant (RLQ) pain in a patient with complex comorbidities and inconclusive prior workup. The objective is to assess OMT’s therapeutic value and provide clinical insight into a structured, reproducible OMT protocol that may inform future educational and research efforts.

A 25-year-old white woman presented with a two-year history of constant, sharp RLQ pain rated 1- 7/10 in severity. Prior evaluation included a negative abdominal computed tomography (CT) scan in 2023 and an unremarkable transabdominal and ovarian ultrasound during the study period. Her medical history was notable for Ehlers-Danlos syndrome, Celiac disease, irritable bowel syndrome-mixed (IBS-M), reactive hypoglycemia, and post-treatment Lyme disease syndrome. Over nine weeks, she underwent weekly, 20-60 minute OMT sessions. Treatments progressed from somatic-focused techniques (weeks 1–4) to combined somatic-visceral techniques (weeks 5–8) and visceral-focused treatment (week 9). Techniques included muscle energy, counterstrain, and visceral techniques targeting structures such as GI sphincters, fascia of Toldt, and the ileocecal valve. Pre- and post-treatment assessments included positional pain ratings (standing, supine, etc.), somatic dysfunctions (innominate rotation, sacral torsions), and Chapman’s and counterstrain points. 

Initial somatic-focused sessions yielded short-term pain relief (18-48 hours). However, addition of visceral OMT extended symptom relief up to three days. Notable improvements were observed in counterstrain and Chapman’s point tenderness, particularly those corresponding to the pancreas and ileocecal valve. 
By the end of treatment, average pain scores had decreased by 68% (right lateral) and 58% (left lateral), with all positional scores exceeding the common 30% threshold for clinically meaningful improvement.

Discussion
This case illustrates a diagnostic and therapeutic gap frequently encountered in outpatient care to manage chronic abdominal pain despite unremarkable imaging. The structured application of OMT, particularly with visceral integration, revealed clinically relevant dysfunctions not apparent through conventional diagnostics and provided meaningful, though transient, symptom relief. These findings support further exploration of OMT’s role in managing chronic abdominal pain in outpatient settings.

Integrating Somatic & Visceral Osteopathic Techniques to Manage Chronic Abdominal Pain in a Patient with Ehlers-Danlos Syndrome: A Case Study

Background: Computerized Provider Order Entry (CPOE) systems are designed to improve patient safety by allowing providers to electronically enter medication, diagnostic, and treatment orders. Despite widespread recognition of their potential benefits, adoption of CPOE systems across U.S. hospitals remains inconsistent due to complex implementation challenges. Prior studies highlight both the transformative effects of CPOE and the substantial barriers to its integration into clinical workflows. This review aimed to synthesize recent evidence on the benefits and barriers of CPOE implementation in the U.S. hospital setting to inform future systems-level improvements and strategies.

Methods: A hybrid, systematized review was conducted using the MEDLINE Ovid database. MeSH terms including "Medical Records System, Computerized," "Medical Order Entry Systems," and "Medication Errors" were combined with non-MeSH keywords such as "computerized provider order entry," "implementation," "benefits," and "barriers" using Boolean operators. Inclusion criteria required that articles assess either benefits or barriers of CPOE implementation in U.S. hospitals. Studies were excluded if they were not in English, focused on international settings, non-hospital environments, or were non-original research. Of 50 articles screened, 16 met criteria for final inclusion.

Results: The MEDLINE Ovid search yielded n=34,432 articles. Keyword searches for “computerized provider order entry,” “implementation,” “benefits,” “barriers,” and “CPOE” returned n=1,311, n=323,456, n=572,332, and n=1,183 results. After Boolean filtering, 50 articles were screened; 16 met inclusion. Reported benefits included improved test/medication ordering and reduced medication errors (12), fewer adverse drug events (8), shorter stays (6), cost savings (5), and better data access (3). Barriers included provider resistance (9), high costs (8), workflow disruption (6), and usability issues. Studies emphasized leadership engagement, vendor selection, and training as key to overcoming resistance and optimizing CPOE integration.

Conclusion: CPOE systems have demonstrated clear potential to enhance patient safety and hospital efficiency. However, significant implementation barriers persist, particularly related to cost, user adoption, and workflow disruption. Hospitals should prioritize structured implementation strategies that include early stakeholder engagement, targeted training, and efforts to minimize clinical disruption. Future research should focus on department-specific implementations and sustainable models for CPOE integration in resource-variable settings. Addressing these barriers is essential to maximizing the clinical and operational benefits of CPOE technology.

Benefits and Barriers of Computerized Provider Order Entry (CPOE) Implementation in U.S. Hospitals: A Systematized Review

Background 

During the COVID-19 pandemic, health-promoting institutions emphasized the threat of severe COVID-19 symptoms and the increased risk of infection for individuals with pre-existing health conditions. Therefore, public health messaging focused on positive framing of the COVID-19 vaccine to promote vaccine uptake in individuals with chronic health conditions. Using a nationally representative sample of American individuals, this study explores the interplay between chronic illness experience, institutional medical mistrust, and COVID-19 vaccine uptake to better understand perceptions of health promotion messaging. 

Methods
Study participants consisted of a nationally representative sample of 1,151 survey respondents who were enrolled in a parent study that validated the Institutional Medical Mistrust Scale (IMMS). The IMMS measures participants’ perceptions of three types of institutions: 1) health care organizations, 2) local and state government, and 3) federal government. Participants also answered a survey on physical and mental conditions, perceived COVID-19 threat, COVID-19 vaccine behavior, and demographics. Thirteen of the physical conditions and five of the mental conditions that the Centers for Disease Control and Prevention categorized as conclusively carrying a higher risk for severe COVID-19 illness were used in the analysis. 

Results
The average IMMS score was significantly lower for those who received the COVID-19 vaccine compared to those who did not. Age and perceived COVID-19 threat were significantly associated with an increased likelihood of vaccine uptake. Compared to those who felt “not at all” threatened, individuals who felt “very much” or “extremely” threatened were more likely to receive the vaccine. Chronic physical and mental conditions were found not to have significant relationships with vaccine uptake. 

Conclusion
Given that a lower level of institutional medical mistrust and a higher level of perceived COVID-19 threat was found to be associated with greater vaccine uptake, our study highlights the importance of recognizing institutional medical mistrust and perceived health threat as significant motivators for health behaviors. Future investigation to better understand facilitating factors of institutional medical mistrust and perceived health threat will be valuable for improving public health messaging appeal and consequent health-behavior adoption. Our findings provide evidence for health-promoting institutions to tailor their messaging to address these predictive factors when providing health education and messaging.



Navigating COVID-19 Vaccination: The Nuanced Roles of Chronic Illness Experience, Institutional Medical Mistrust and Perceived Health Threat 


TITLE: Impact of Area Deprivation and Pregnancy Intention on Maternal Stress and Anxiety Levels during Early Pregnancy in the Mountain Mama and Baby Cohort
AUTHORS: Emma V Reger, Amna Umer, Elly Marshall, Bethany Barone Gibbs
INTRODUCTION: Young adults living in high deprivation areas experience more stress and anxiety, and higher rates of unintended pregnancy. Though unintended pregnancy may contribute to peripartum stress and anxiety, the extent to which it explains differences in mental health with higher area deprivation is unknown. 
PURPOSE: Determine the relationship between area deprivation, pregnancy intention, and peripartum stress and anxiety. 
METHODS: Participants [n=372, age 27.57 ± 5.55 years (M±SD)] were enrolled in the Mountain Mama and Baby Cohort during their first prenatal visit with WVU Medicine. Participants completed the Perceived Stress Scale (PSS) and Generalized Anxiety Disorder-7 (GAD-7) questionnaires. State deprivation index (SDI) was determined using the participant’s home address (scored 1-10;10 indicating highest deprivation). Pregnancy intention was abstracted from the electronic medical record. Linear regression evaluated relationships between SDI and pregnancy intention with PSS/GAD-7. Logistic regression was used to calculate odds of unintended pregnancy based on SDI. Results were adjusted for pregnancy intention to determine effect on PSS and GAD-7 using percent mediation. 
RESULTS: Higher SDI was associated with greater stress score (+0.26 points, 95% CI [0.023, 0.51]), p=0.028) though anxiety score was not significantly associated (+0.01 points, 95% CI [ -0.05 0.28], p=0.156). Higher SDI was strongly associated with increased odds of unplanned pregnancy by 14.5% (OR=1.15, 95% CI [1.07 1.23], p<0.001). Unplanned pregnancy was associated with greater stress scores (+3.57 points, 95% CI [2.22, 4.94], p<0.001) and anxiety scores (+2.40 points, 95% CI [1.47,3.32], p<0.001). Adjusting for unplanned pregnancy explained 39% of the association between SDI and stress score. 
CONCLUSION: SDI was associated with greater stress during pregnancy; this association was partly explained by unintended pregnancy. Greater peripartum stress associated with unintended pregnancies suggests it is vital to reassess accessibility of contraceptives and quality of sex education to promote mental health, especially in high deprivation areas.

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