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An executive summary of the trends and patterns among adults and seniors, 1987-1998, unintentional injuries in British Columbia
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Objectives To assess associations between pre-pregnancy BMI and severe maternal morbidity (SMM), perinatal death and neonatal morbidity in twin pregnancies. Design Retrospective cohort study. Setting British Columbia, Canada (2000-2017).... more
Objectives To assess associations between pre-pregnancy BMI and severe maternal morbidity (SMM), perinatal death and neonatal morbidity in twin pregnancies. Design Retrospective cohort study. Setting British Columbia, Canada (2000-2017). Population All twin births at ≥20 weeks’ gestation. Methods We examined associations between pre-pregnancy BMI, categorized as underweight (BMI <18.5m/kg2), normal BMI (18.5m/kg2 BMI <25m/kg2), overweight (25m/kg2 BMI <30m/kg2) and obese (BMI ≥30m/kg2) and adverse maternal and perinatal outcomes, using targeted maximum-likelihood estimation, adjusted for demographics and obstetric history. Outcomes SMM, perinatal death, severe perinatal morbidity. Results Overall, 7770 (368 underweight, 1704 overweight and 1016 obese) women with twin pregnancy were included. The rates of SMM (per 10,000 pregnancies) were: 271.1, 320.4, 270.0 and 225.9 in underweight, normal BMI, overweight and obese women, respectively. Underweight women had higher rates ...
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Sensitivity analysis of the final model among singleton and multiple pregnancies. (DOCX 13Â kb)
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Corrected calibration curve of the final model after internal validation. (DOCX 27Â kb)
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Pregnancy outcomes among women who presented at 24â 34Â weeks. (DOCX 15Â kb)
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Kaplan-Meier curve showing the proportion of women who remained pregnant from the time that they were admitted to hospital and identified as being at risk of delivery within 7Â days. (DOCX 26Â kb)
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A list of all members of the collaborative group in CPN. (DOCX 13Â kb)
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Pregnancy-associated cancer—that is diagnosed in pregnancy or within 365 days after delivery—is increasingly common as cancer therapy evolves and survivorship increases. This study assessed the incidence and temporal trends of... more
Pregnancy-associated cancer—that is diagnosed in pregnancy or within 365 days after delivery—is increasingly common as cancer therapy evolves and survivorship increases. This study assessed the incidence and temporal trends of pregnancy-associated cancer in Alberta and Ontario—together accounting for 50% of Canada’s entire population. Linked data from the two provincial cancer registries and health administrative data were used to ascertain new diagnoses of cancer, livebirths, stillbirths and induced abortions among women aged 18–50 years, from 2003 to 2015. The annual crude incidence rate (IR) was calculated as the number of women with a pregnancy-associated cancer per 100,000 deliveries. A nonparametric test for trend assessed for any temporal trends. In Alberta, the crude IR of pregnancy-associated cancer was 156.2 per 100,000 deliveries (95% CI 145.8–166.7), and in Ontario, the IR was 149.4 per 100,000 deliveries (95% CI 143.3–155.4). While no statistically significant temporal ...
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Atonic postpartum hemorrhage rates have increased in many industrialized countries in recent years. We examined the blood loss, risk factors, and management of the third stage of labour associated with atonic postpartum hemorrhage. We... more
Atonic postpartum hemorrhage rates have increased in many industrialized countries in recent years. We examined the blood loss, risk factors, and management of the third stage of labour associated with atonic postpartum hemorrhage. We carried out a case-control study of patients in eight tertiary care hospitals in Canada between January 2011 and December 2013. Cases were defined as women with a diagnosis of atonic postpartum hemorrhage, and controls (without postpartum hemorrhage) were matched with cases by hospital and date of delivery. Estimated blood loss, risk factors, and management of the third stage labour were compared between cases and controls. Conditional logistic regression was used to adjust for confounding. The study included 383 cases and 383 controls. Cases had significantly higher mean estimated blood loss than controls. However, 16.7% of cases who delivered vaginally and 34.1% of cases who delivered by Caesarean section (CS) had a blood loss of < 500 mL and <...
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Few studies have examined fetal, infant and maternal mortality and morbidity among pregnant women at very early gestation with an open cervix and prolapsed membranes. We carried out a study describing the outcomes of women hospitalized... more
Few studies have examined fetal, infant and maternal mortality and morbidity among pregnant women at very early gestation with an open cervix and prolapsed membranes. We carried out a study describing the outcomes of women hospitalized with prolapsed membranes at 22-28 weeks' gestation. We prospectively recruited women with singleton pregnancies admitted at 22-28 weeks' gestation to tertiary hospitals of the Canadian Perinatal Network between 2005 and 2009. Time-to-delivery, perinatal death, neonatal intensive care unit (NICU) admission, severe neonatal morbidity and severe maternal morbidity were compared between women admitted at 22-25 vs. 26-28 weeks gestation. Logistic regression was used to estimate adjusted odds ratios (AOR) and 95% confidence intervals. 129 women at 22-25 weeks gestation and 65 women at 26-28 weeks gestation were admitted to hospital and the median time-to-delivery was 4 days in both groups. Stillbirth rates were 12.4% vs 4.6% among women admitted at ...
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Microbial invasion of the amniotic cavity (MIAC) can affect outcomes following rescue cerclage. We carried out a study to compare the diagnostic performance of the Gram stain and glucose tests for detecting subclinical MIAC. We used... more
Microbial invasion of the amniotic cavity (MIAC) can affect outcomes following rescue cerclage. We carried out a study to compare the diagnostic performance of the Gram stain and glucose tests for detecting subclinical MIAC. We used individual-level data from published studies on Gram stain, glucose, and amniotic fluid culture among women with preterm labour. We calculated the sensitivity, specificity, area under the curve (AUC) and other indices, with amniotic fluid culture results used as the gold standard. The probability of infection using both tests as predictors was also estimated using logistic regression. The rate of culture-confirmed MIAC was 11.8% (34 of 288 women). The Gram stain test yielded a sensitivity of 65% (95% CI 46% to 78%) and a specificity of 99% (95% CI 98% to 100%). A positive Gram stain or glucose test had a sensitivity of 88% (95% CI 72% to 96%) and a specificity of 87% (95% CI 82% to 90%), while a positive Gram stain and a positive glucose test had a sensi...
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Increased use of operative vaginal delivery (i.e., forceps or vacuum application), of which 20% occurs at midpelvic station, has been advocated to reduce the rate of cesarean delivery. We aimed to quantify severe perinatal and maternal... more
Increased use of operative vaginal delivery (i.e., forceps or vacuum application), of which 20% occurs at midpelvic station, has been advocated to reduce the rate of cesarean delivery. We aimed to quantify severe perinatal and maternal morbidity and mortality associated with attempted midpelvic operative vaginal delivery. We studied all term singleton deliveries in Canada between 2003 and 2013, by attempted midpelvic operative vaginal or cesarean delivery with labour (with and without prolonged second stage). The primary outcomes were composite severe perinatal morbidity and mortality (e.g., convulsions, assisted ventilation, severe birth trauma and perinatal death), and composite severe maternal morbidity and mortality (e.g., severe postpartum hemorrhage, shock, sepsis, cardiac complications, acute renal failure and death). The study population included 187 234 deliveries. Among women with dystocia and prolonged second stage of labour, midpelvic operative vaginal delivery was assoc...
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This thesis examines the association between maternal age and adverse birth outcomes in the province of British Columbia (Canada). It explores the differential effect of plurality and parity on this association; and describes differences... more
This thesis examines the association between maternal age and adverse birth outcomes in the province of British Columbia (Canada). It explores the differential effect of plurality and parity on this association; and describes differences in obstetric interventions and birth outcomes between older mothers living in rural versus urban areas. Data were obtained from the BC Perinatal Health Program’s Database Registry, 1999-2003. The database includes all births in BC and contains information about maternal demographic characteristics, behavioural and life-style factors, and obstetric history. Among older mothers with singleton pregnancies, we observed a higher rate of stillbirths, preterm births, small-for-gestational-age babies, and admissions to a neonatal intensive care. The risk of preterm birth and small-for-gestational-age was modified by parity. The relative risk of preterm birth associated with maternal age was higher among primiparae, compared to multiparae. Older primiparae w...
Research article Psychological health of family caregivers of children admitted at birth to a NICU and healthy children: a population-based cross-sectional survey
We assessed the incidence, risk factors and adverse birth outcomes associated with elevated liver enzymes and low platelets (HELLP) syndrome.
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OBJECTIVE Clinician-initiated deliveries at 34 to 36 weeks gestation have increased in Canada since 2006, but the impacts of clinician-initiated deliveries on the overall preterm birth (PTB) rate and concomitant changes in neonatal... more
OBJECTIVE Clinician-initiated deliveries at 34 to 36 weeks gestation have increased in Canada since 2006, but the impacts of clinician-initiated deliveries on the overall preterm birth (PTB) rate and concomitant changes in neonatal outcomes are unknown. This study examined gestational age-specific trends in spontaneous and clinician-initiated PTB and associated neonatal mortality and morbidity. METHODS This population-based study included 1 880 444 singleton live births in Canada (excluding Québec) in 2009-2016, using hospitalization data from the Canadian Institute for Health Information. The primary outcomes were neonatal mortality and a composite outcome mortality and/or severe neonatal morbidity identified by International Statistical Classification of Diseases and Related Health Problems, 10th revision, Canada codes. Outcomes were stratified by spontaneous and clinician-initiated deliveries and gestational age categories. Logistic regression yielded adjusted odds ratios (aORs) per 1-year change and 95% confidence intervals (CIs) (Canadian Task Force Classification II-2). RESULTS The PTB rate remained stable (6.2%) and the proportion of clinician-initiated PTBs increased from 31.0% to 37.9% (P < 0.001). Although overall neonatal mortality remained stable (1.1%), mortality declined among infants born spontaneously at 28 to 33 weeks gestation (aOR 0.92; 95%CI 0.87-0.97). The composite mortality and/or severe morbidity declined from 12.7% to 12.2% (aOR 0.98; 95%CI 0.97-0.99). Declines were observed in the rates of sepsis (aOR 0.96; 95%CI 0.95-0.98) and respiratory distress syndrome requiring ventilation (aOR 0.97; 95%CI 0.96-0.98), whereas rates of intraventricular hemorrhage increased (aOR 1.03; 95%CI 1.01-1.05). CONCLUSION With the increase in clinician-initiated deliveries, the stable rates of PTB and neonatal mortality and the decline in composite mortality and/or severe morbidity are encouraging findings. This study adds to clinical understanding of carefully timed and medically justified early interventions.
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Objectives To determine the incidence and severe maternal morbidity associated with assisted reproduction technology (ART). Methods We carried out a population based retrospective cohort study of all hospital live births at 20 weeks or... more
Objectives To determine the incidence and severe maternal morbidity associated with assisted reproduction technology (ART). Methods We carried out a population based retrospective cohort study of all hospital live births at 20 weeks or beyond gestation between 2009 and 2012. We used data from the Discharge Abstract Database of the Canadian Institute for Health Information. The Discharge Abstract Database contains information on all separations from hospitals in Canada (except Quebec). Maternal characteristics, disease frequency, case fatality, and length of hospitalization of severe maternal morbidity associated with assisted reproduction were quantified. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were estimated using logistic regression adjusting for maternal age, Pularity, and parity. Results Among the 1,993,946 women who delivered between 2009 and 2012, there were 46,029 pregnancies achieved by ART. The rate of severe maternal morbidity among assisted reproduction mothers was 29.8 (95% CI 28.3-31.4) per 1000 deliveries Vs 10.4 (95% CI 10.3-10.6) per 1000 in non- assisted reproduction group. The rate ratio is 2.86 (95% CI 2.71-3.02). The median length of hospital stay for women with and without assisted reproduction was 4days versus 3days, while the frequency of prolonged hospital stay (? 7 days) was 6.41% versus 1.51%, respectively (rate ratio 4.24; 95% CI 4.07 to 4.40). Assisted reproduction was associated with high rates of severe maternal morbidity such as Severe preeclampsia or HELLP syndrome, Placenta previa with hemorrhage and red cell transfusion, Intrapartum hemorrhage with red cell transfusion, severe postpartum hemorrhage, Hysterectomy, Disseminated intravascular coagulation, Cerebral edema or coma, and Acute fatty liver. (AOR 60.6, 95% CI 45.4-79.4). The mortality rate in ART group were estimated as 5.43 per 100,000 comparing with non-ART pregnancies 3.03 per 100,000. Case fatality rate was 1.79 (95% CI 0.51-6.36) per 100,000. Conclusions Disease frequency, case fatality, and severe maternal morbidity and mortality patterns among pregnancies achieved by ART suggest that they are at increased risk of severe maternal morbidity and mortality events compare to pregnancies achieved without ART thus warrant proper counselling and vigilant care for women contemplating ART to get pregnant.
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STUDY OBJECTIVE To investigate ethnic differences for moderate-to-severe endometriosis. DESIGN Analysis of a prospective registry (Canadian Task Force classification II-2). SETTING Tertiary referral center. PATIENTS A total of 1594 women... more
STUDY OBJECTIVE To investigate ethnic differences for moderate-to-severe endometriosis. DESIGN Analysis of a prospective registry (Canadian Task Force classification II-2). SETTING Tertiary referral center. PATIENTS A total of 1594 women with pelvic pain and/or endometriosis. INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS: On logistic regression, adjusting for potential confounders, East/South East Asians were 8.3 times more likely than whites to have a previous diagnosis of stage III/IV endometriosis before referral (adjusted odds ratio [aOR], 8.33; 95% confidence interval [CI], 3.74-18.57), 2.7 times more likely to have a palpable nodule (aOR, 2.66; 95% CI, 1.57-4.52), 4.1 times more likely to have an endometrioma on ultrasound (aOR, 4.10; 95% CI, 2.68-6.26), and 10.9 times more likely to have stage III/IV endometriosis at the time of surgery at our center (aOR, 10.87; 95% CI, 4.34-27.21). CONCLUSION Moderate-to-severe endometriosis was more common in women with East or South East Asian ethnicity in our tertiary referral center. This could be explained by East/South East Asians with minimal to mild disease being less likely to seek care or genetic/environmental differences that increase the risk of more severe disease among East/South East Asians. (ClinicalTrials.gov, NCT02911090.).
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This study sought to quantify perinatal and maternal morbidity and mortality associated with forceps and vacuum delivery compared with Caesarean delivery in the second stage of labour and to estimate whether these associations differed by... more
This study sought to quantify perinatal and maternal morbidity and mortality associated with forceps and vacuum delivery compared with Caesarean delivery in the second stage of labour and to estimate whether these associations differed by pelvic station. The investigators conducted a population-based, retrospective cohort study of term singleton deliveries by operative delivery with prolonged second stage of labour in Canada (2003-2013) using national hospitalization data. The primary study outcomes were severe perinatal morbidity and mortality (i.e., seizures, assisted ventilation, severe birth trauma, and perinatal death) and severe maternal morbidity and mortality (i.e., severe postpartum hemorrhage, cardiac complication, and maternal death). Logistic regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) after stratifying by indication (dystocia or fetal distress). The Breslow-Day chi-square test for heterogeneity in ORs was used to test eff...
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Increased use of operative vaginal delivery (use of forceps, vacuum or other device) has been recommended to address high rates of cesarean delivery. We sought to determine the association between rates of operative vaginal delivery and... more
Increased use of operative vaginal delivery (use of forceps, vacuum or other device) has been recommended to address high rates of cesarean delivery. We sought to determine the association between rates of operative vaginal delivery and obstetric trauma and severe birth trauma. We carried out an ecological analysis of term, singleton deliveries in 4 Canadian provinces (2004-2014) using data from the Canadian Institute for Health Information. The primary exposure was mode of delivery. The primary outcomes were obstetric trauma and severe birth trauma. Data on 1 938 913 deliveries were analyzed. The rate of obstetric trauma was 7.2% in nulliparous women, and 2.2% and 2.7% among parous women without and with a previous cesarean delivery, respectively, and rates of severe birth trauma were 2.1, 1.7 and 0.7 per 1000, respectively. Each 1% absolute increase in rates of operative vaginal delivery was associated with a higher frequency of obstetric trauma among nulliparous women (adjusted r...
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Cannabis is the most commonly used illicit drug among general and pregnant populations. Despite recommendations to abstain from cannabis use, its use is increasing during the perinatal period. In this integrative review, we aim to... more
Cannabis is the most commonly used illicit drug among general and pregnant populations. Despite recommendations to abstain from cannabis use, its use is increasing during the perinatal period. In this integrative review, we aim to understand women's perspectives about the health aspects of perinatal cannabis use. The following databases were searched: MEDLINE, PsycInfo, EMBASE, and CINAHL. We included quantitative and qualitative studies with a primary focus on perinatal cannabis use. The methodological quality of the included studies was appraised using appropriate checklists. Extracted data were integrated into a single data matrix and iteratively compared across studies to summarize and synthesize the data. Full text of 33 citations was retrieved and reviewed of which 6 studies met the inclusion criteria. Women who continued to use cannabis during pregnancy often perceived no general or pregnancy-specific risk compared to nonusers. The uncertainty regarding adverse perinatal consequences, its perceived therapeutic effects, and lower costs of cannabis compared to that of cigarettes contributed to cannabis use. A lack of communication with health care providers regarding the health aspects of cannabis was evident. Women perceived this lack of counseling as an indication that adverse outcomes associated with cannabis use are not significant. Women's perceptions of health risks associated with cannabis use are important factors in the decision-making process regarding use or cessation, particularly as legal concerns are fading away. A discussion about health concerns surrounding cannabis use may influence women's perceptions of risk and help them to make informed choices.
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Chronic pelvic pain affects ∼15% of women, and presents a challenging problem for gynecologists due to its complex etiology involving multiple comorbidities. Thus, an interdisciplinary approach has been proposed for chronic pelvic pain,... more
Chronic pelvic pain affects ∼15% of women, and presents a challenging problem for gynecologists due to its complex etiology involving multiple comorbidities. Thus, an interdisciplinary approach has been proposed for chronic pelvic pain, where these multifactorial comorbidities can be addressed by different interventions at a single integrated center. Moreover, while cross-sectional studies can provide some insight into the association between these comorbidities and chronic pelvic pain severity, prospective longitudinal cohorts can identify comorbidities associated with changes in chronic pelvic pain severity over time. We sought to describe trends and factors associated with chronic pelvic pain severity over a 1-year prospective cohort at an interdisciplinary center, with a focus on the role of comorbidities and controlling for baseline pain, demographic factors, and treatment effects. This was a prospective 1-year cohort study at an interdisciplinary tertiary referral center for pelvic pain and endometriosis, which provides minimally invasive surgery, medical management, pain education, physiotherapy, and psychological therapies. Exclusion criteria included menopause or age &gt;50 years. Sample size was 296 (57% response rate at 1 year; 296/525). Primary outcome was chronic pelvic pain severity at 1 year on an 11-point numeric rating scale (0-10), which was categorized for ordinal regression (none-mild 0-3, moderate 4-6, severe 7-10). Secondary outcomes included functional quality of life and health utilization. Baseline comorbidities were endometriosis, irritable bowel syndrome, painful bladder syndrome, abdominal wall pain, pelvic floor myalgia, and validated questionnaires for depression, anxiety, and catastrophizing. Multivariable ordinal regression was used to identify baseline comorbidities associated with the primary outcome at 1 year. Chronic pelvic pain severity decreased by a median 2 points from baseline to 1 year (6/10-4/10, P &lt; .001). There was also an improvement in functional quality of life (42-29% on the pain subscale of the Endometriosis Health Profile-30, P &lt; .001), and a reduction in subjects requiring a physician visit (73-36%, P &lt; .001) or emergency visit (24-11%, P &lt; .001) in the last 3 months. On multivariable ordinal regression for the primary outcome, chronic pelvic pain severity at 1 year was independently associated with a higher score on the Pain Catastrophizing Scale at baseline (odds ratio, 1.10; 95% confidence interval, 1.00-1.21, P = .04), controlling for baseline pain, treatment effects (surgery), age, and referral status. Improvements in chronic pelvic pain severity, quality of life, and health care utilization were observed in a 1-year cohort in an interdisciplinary setting. Higher pain catastrophizing at baseline was associated with greater chronic pelvic pain severity at 1 year. Consideration should be given to stratifying pelvic pain patients by catastrophizing level (rumination, magnification, helplessness) in research studies and in clinical practice.
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Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in reproductive age women, yet its clinical presentation shares similarities with several other endocrine disorders such as thyroid disease. Hence, the objective of this... more
Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in reproductive age women, yet its clinical presentation shares similarities with several other endocrine disorders such as thyroid disease. Hence, the objective of this study was to further evaluate this association by investigating the clinical, hormonal, and metabolic parameters between subclinical hypothyroidism (SCH) and PCOS. This is a cross-sectional study conducted in a tertiary care clinic at Cleveland, Ohio, USA. A total of 137 women diagnosed with PCOS by Rotterdam criteria were examined. SCH was defined as thyroid-stimulating hormone >2.5 mIU/L in the absence of symptoms of overt hypothyroidism. The mean age, body mass index (BMI), fasting plasma glucose (FPG), glucose tolerance test, hemoglobin A1c, fasting insulin, a 2 hours insulin level after 75 g glucose load, cholesterol, LDL, HDL, and homeostatic model assessment (HOMA) were compared between women with and without SCH. Logistic regression was us...
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Biomarkers, Medicine, Insulin Resistance, Lipids, Humans, and 14 moreBlood Glucose, Insulin, Female, Body Mass Index, Risk factors, Hypothyroidism, Ohio, Polycystic Ovary Syndrome, Adult, Risk Factors, Glucose Tolerance Test, Cross Sectional Studies, Glycated hemoglobin A, and Medical and Health Sciences
Our objective was to evaluate the appropriateness of antibiotic prescriptions in the neonatal intensive care unit (NICU) using standardised criteria and determine the effects of an antimicrobial stewardship programme (ASP) on patterns of... more
Our objective was to evaluate the appropriateness of antibiotic prescriptions in the neonatal intensive care unit (NICU) using standardised criteria and determine the effects of an antimicrobial stewardship programme (ASP) on patterns of antibiotic usage. A retrospective audit of antibiotic use from July 2010-June 2013 was conducted, focusing on prescriptions of vancomycin, cefotaxime, meropenem and linezolid for >3 calendar days. We evaluated the appropriateness of each course of antibiotic treatment based on the Centers for Disease Control and Prevention (CDC) 12-Step Guidelines to Prevent Antimicrobial Resistance (Steps 4, 6 and 9). An ASP was introduced in August 2014, and the same audit criteria were applied to review antimicrobial use in the subsequent 12 months. In the pre-ASP era, 26.3%, 12.1%, 11.4% and 0% of meropenem, cefotaxime, vancomycin and linezolid courses, respectively, were inappropriate. The most common instance of inappropriate utilisation included failure to...
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To assess the impact of variations in the definition of severe neurodevelopmental impairment (NDI) on the incidence of severe NDI and the association with risk factors using the Canadian Neonatal Follow-Up Network cohort. Literature... more
To assess the impact of variations in the definition of severe neurodevelopmental impairment (NDI) on the incidence of severe NDI and the association with risk factors using the Canadian Neonatal Follow-Up Network cohort. Literature review of severe NDI definitions and application of these definitions were performed in this database cohort study. Infants born at 23-28 completed weeks of gestation between 2009 and 2011 (n = 2187) admitted to a Canadian Neonatal Network neonatal intensive care unit and assessed at 21 months' corrected age were included. The incidence of severe NDI, aORs, and 95% CIs were calculated to express the relationship between risk factors and severe NDI using the definitions with the highest and the lowest incidence rates of severe NDI. The incidence of severe NDI ranged from 3.5% to 14.9% (highest vs lowest rate ratio 4.29; 95% CI 3.37-5.47). The associations between risk factors and severe NDI varied depending on the definition used. Maternal ethnicity, ...
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Endometriosis is a common disease characterized by the presence of ectopic endometrial tissue. Although the pathogenesis of endometriosis remains unclear, several factors have been implicated, including the dysregulation of homeobox (... more
Endometriosis is a common disease characterized by the presence of ectopic endometrial tissue. Although the pathogenesis of endometriosis remains unclear, several factors have been implicated, including the dysregulation of homeobox ( HOX) genes. Our objective was to investigate the localization and immunoreactivity of HOXB4 in endometrial tissues from women with or without endometriosis. We studied samples of eutopic endometrium (EE), endometriomas (Eoma), superficial endometriosis (SE), and deep infiltrating endometriosis (DIE) from 34 women with endometriosis, as well as eutopic endometrium from 38 women without endometriosis (EC). HOXB4 localization and immunoreactivity was assessed using immunohistochemistry and histoscore analysis. Data were analyzed with and without stratification by menstrual cycle phase. HOXB4 protein was present in the nuclei of endometrial glandular epithelial cells but not in stromal cells. HOXB4 immunoreactivity was reduced in DIE samples compared to al...