The double-edged sword of abortion regulations: Decreasing training opportunities while increasing knowledge requirements.

PURPOSE: The authors explore how abortion regulations in Ohio, an abortion-restrictive state in the USA, impact obstetrician-gynecologists' (OB/GYNs) training in reproductive healthcare and describe what OB/GYNs believe to be the broader impact of Ohio's regulations on skill-building, skills maintenance, and professional retention of reproductive healthcare providers in the state. Authors discuss how their findings foreshadow abortion training limitations in Ohio and other abortion-restrictive states now that abortion regulations have returned to the states. METHODS: The authors conducted four semi-structured focus groups and five in-depth interviews between April 2019 and March 2020. Participants included OB/GYNs practicing obstetrics and gynecology in Ohio between 2010 and 2020. Thematic analysis was conducted using Atlas.ti. RESULTS: Twenty attending physicians and 15 fellows and residents participated in the study. Participants discussed the impact of Ohio's written transfer agreement, gestational-limit, and abortion method and facility bans on training and skill-building opportunities. Participants felt that Ohio's strict abortion regulations 1) limit opportunities to observe and perform abortion procedures during training; 2) require learning the ever-changing legality of abortion provision; 3) limit the number of abortions OB/GYNs can provide, leading to the atrophy of their skills over time; and 4) may prevent prospective medical students and residents from choosing to study in Ohio and may lead to physician attrition from the state. CONCLUSION: Prior to the reversal of federal protections for abortion in 2022, OB/GYNs in Ohio and other abortion-hostile states experienced barriers to training in abortion care. In returning abortion regulation to the states, access to training is likely to be increasingly restricted. This research demonstrates how abortion-restrictions hamper physicians' skills needed to care for patients, particularly in emergent situations. This puts patients at risk and places physicians in precarious ethical positions. Expanding protections and reducing restrictions on abortion will ensure OB/GYNs and trainees have the skills necessary to care for patients presenting for reproductive healthcare.

Counseling, contraception, and conception rates in patients undergoing bariatric surgery: A retrospective review.

OBJECTIVES: To determine conception rates, contraceptive use patterns, and frequency of counseling regarding pregnancy recommendations in patients undergoing bariatric surgery. STUDY DESIGN: Using a database of bariatric surgery patients at our institution, we identified female patients aged 18 to 45 who underwent surgery from 2013 to 2018. Patient charts were reviewed for demographic information, documentation of counseling regarding pregnancy recommendations, conception during the postoperative period, and pre and postoperative contraception use. We examined rates of contraception use and used standard statistical tests to compare conception rates between groups. RESULTS: Of the 460 patients that met inclusion criteria and did not have a history of permanent contraception, 54% (95% CI 49-58) had documented postoperative contraception use, most commonly the levonorgestrel-releasing intrauterine device followed by combination oral contraceptive pills. In the 18 months following bariatric surgery, 6% of patients (95% CI 4-8) had a documented pregnancy. Over 50% (95% CI 35-71) of pregnancies occurred in patients without documented postoperative contraception. CONCLUSIONS: For bariatric surgery patients at risk of pregnancy, postoperative contraception use patterns and conception rates are not consistent with the recommendation to refrain from pregnancy for 18 months. IMPLICATIONS: Individualized contraceptive counseling that includes a discussion of fertility and weight loss goals, planned bariatric procedure type, and patient preference should be implemented as part of standard preoperative care for patients at risk of pregnancy undergoing bariatric surgery.

Fragile X Mental Retardation Protein Bidirectionally Controls Dendritic Ih in a Cell Type-Specific Manner between Mouse Hippocampus and Prefrontal Cortex.

Channelopathies are implicated in Fragile X syndrome (FXS), yet the dysfunction of a particular ion channel varies with cell type. We previously showed that HCN channel function is elevated in CA1 dendrites of the fmr1-/y mouse model of FXS, but reduced in L5 PFC dendrites. Using male mice, we tested whether Fragile X Mental Retardation Protein (FMRPO), the protein whose absence causes FXS, differentially modulates HCN channels in CA1 versus L5 PFC dendrites. Using a combination of viral tools, intracellular peptide, and dendritic electrophysiology, we found that FMRP regulates HCN channels via a cell-autonomous protein-protein interaction. Virally expressed FMRP restored WT HCN channel-related dendritic properties in both CA1 and L5 neurons. Rapid intracellular perfusion of the non-mRNA binding N-terminal fragment, FMRP1-298, similarly restored dendritic function. In support of a protein-protein interaction, we found that FMRP associated with HCN-TRIP8b complexes in both hippocampus and PFC. Finally, voltage-clamp recordings showed that FMRP modulated Ih by regulating the number of functional dendritic HCN channels rather than individual channel properties. Together, these represent three novel findings as to the nature of the changes in dendritic function in CA1 and PFC neurons based on the presence or absence of FMRP. Moreover, our findings provide evidence that FMRP can regulate its targets in opposite directions depending upon the cellular milieu.SIGNIFICANCE STATEMENT Changes in dendritic function, and voltage-gated ion channels in particular, are increasingly the focus of neurological disorders. We, and others, previously identified cell type-specific channelopathies in a mouse of model of Fragile X syndrome. The present study shows that replacing Fragile X Mental Retardation Protein, which is absent in Fragile X syndrome, in adult CA1 and L5 PFC neurons regulates the number of functional dendritic HCN channels in a cell type-specific manner. These results suggest that Fragile X Mental Retardation Protein regulates dendritic HCN channels via a cell-autonomous protein--protein mechanism.

Improving end-of-rotation transitions of care among ICU patients.

BACKGROUND: Hospitalised patients whose inpatient teams rotate off service experience increased mortality related to end-of-rotation care transitions, yet standardised handoff practices are lacking. OBJECTIVE: Develop and implement a multidisciplinary patient-centred handoff intervention to improve outcomes for patients who are critically ill during end-of-rotation transitions. DESIGN, SETTING AND PARTICIPANTS: Single-centre, controlled pilot study of medical intensive care unit (ICU) patients whose resident team was undergoing end-of-rotation transition at a university hospital from June 2017 to February 2018. INTERVENTION: A 4-item intervention was implemented over two study periods. Intervention 1 included: (1) in-person bedside handoff between teams rotating off and on service, (2) handoff checklist, (3) nursing involvement in handoff, and (4) 30 min education session. Intervention 2 included the additional option to conduct bedside handoff via videoconferencing. MAIN OUTCOME MEASURES: Implementation was measured by repeated clinician surveys and direct observation. Patient outcomes included length of stay (LOS; ICU and hospital) and mortality (ICU, hospital and 30 days). Clinician perceptions were modelled over time using per cent positive responses in logistic regression. Patient outcomes were compared with matched control 'transition' patients from 1 year prior to implementation of the intervention. RESULTS: Among 270 transition patients, 46.3% were female with a mean age of 55.9 years. Mechanical ventilation (64.1%) and in-hospital death (27.6%) rates were prevalent. Despite high implementation rates-handoff participation (93.8%), checklist utilisation (75.0%), videoconferencing (62.5%), nursing involvement (75.0%)-the intervention did not significantly improve LOS or mortality. Multidisciplinary survey data revealed significant improvement in acceptability by nursing staff, while satisfaction significantly declined for resident physicians. CONCLUSIONS: In this controlled pilot study, a structured ICU end-of-rotation care transition strategy was feasible to implement with high fidelity. While mortality and LOS were not affected in a pilot study with limited power, the pragmatic strategy of this intervention holds promise for future trials.