Perioperative Management of the Gynecologic Patient on Long-term Anticoagulation.

The perioperative management of patients taking antithrombotic or antiplatelet medications is based on an assessment of the individual patient's risk for thrombosis or bleeding, the specific medication involved, and the nature of the planned procedure. This article describes specific strategies for whether and how these medications should be interrupted before gynecologic procedures, when they can be restarted following the procedure, and whether bridging therapy should be considered.

Experiences and Perceptions of Maternal Autonomy and Racism Among BIPOC Veterans Receiving Cesarean Sections.

BACKGROUND: Previous studies of pregnant veterans enrolled in Department of Veterans Affairs (VA) care reveal high rates of cesarean sections among racial/ethnic minoritized groups, particularly in southern states. The purpose of this study was to better understand contributors to and veteran perceptions of maternal autonomy and racism among veterans receiving cesarean sections. METHODS: We conducted semi-structured interviews to understand perceptions of maternal autonomy and racism among 27 Black, Indigenous, People of Color (BIPOC) veterans who gave birth via cesarean section using VA maternity care benefits. RESULTS: Our study found that a substantial proportion (67%) of veterans had previous cesarean sections, ultimately placing them at risk for subsequent cesarean sections. More than 60% of veterans with a previous cesarean section requested a labor after cesarean (LAC) but were either refused by their provider or experienced complications that led to another cesarean section. Qualitative findings revealed the following: (1) differences in treatment by veterans' race/ethnicity may reduce maternal agency, (2) many veterans felt unheard and uninformed regarding birthing decisions, (3) access to VA-paid doula care may improve maternal agency for BIPOC veterans during labor and birth, and (4) BIPOC veterans face substantial challenges related to social determinants of health. CONCLUSION: Further research should examine veterans' perceptions of racism in obstetrical care, and the possibility of VA-financed doula care to provide additional labor support to BIPOC veterans.

Novel Spaced Repetition Flashcard System for the In-training Examination for Obstetrics and Gynecology.

INTRODUCTION: Electronic flashcards allow repeated information exposure over time along with active recall. It is increasingly used for self-study by medical students but remains poorly implemented for graduate medical education. The primary goal of this study was to determine whether a flashcard system enhances preparation for the in-training examination in obstetrics and gynecology (ob-gyn) conducted by the Council on Resident Education in Obstetrics and Gynecology (CREOG). METHODS: Ob-gyn residents at Duke University were included in this study. A total of 883 electronic flashcards were created and distributed. CREOG scores and flashcard usage statistics, generated internally by interacting with the electronic flashcard system, were collected after the 2019 exam. The primary outcome was study aid usage and satisfaction. The secondary outcome was the impact of flashcard usage on CREOG exam scores. RESULTS: Of the 32 residents, 31 (97%) participated in this study. Eighteen (58%) residents used the study's flashcards with a median of 276 flashcards studied over a median of 3.7 h. All of the flashcard users found the study aid helpful, and all would recommend them to another ob-gyn resident. Using the flashcards to study for the 2019 CREOG exam appeared to correlate with improvement in scores from 2018 to 2019, but did not achieve statistical significance after adjusting for post-graduate year (beta coefficient = 10.5; 95% confidence interval = - 0.60,21.7; p = 0.06). DISCUSSION: This flashcard resource was well received by ob-gyn residents for in-training examination preparation, though it was not significantly correlated with improvement in CREOG scores after adjusting for post-graduate year.

Correction to: Novel Spaced Repetition Flashcard System for the In-training Examination for Obstetrics and Gynecology.

[This corrects the article DOI: 10.1007/s40670-021-01320-z.].

Rules of Engagement: Implementing Student-Centered Learning in Breast Imaging.

In response to changing learner needs, our institution launched a new translational curriculum wherein basic sciences and clinical skills were integrated, longitudinal patient care experiences provided, and earlier opportunities in specialty fields introduced to better inform residency program decisions. Medical students taking the breast imaging elective were enrolled in a breast imaging immersive experience designed to meet the School of Medicine's core competencies. In focusing the elective on a narrow range of specialized topics and skills, we labeled this experience the Breast Imaging Boot Camp. Outcome data from March 6, 2017, to April 26, 2019, have been analyzed for this report. The modifications made to the elective include: e-mailing a detailed orientation document to students prior to the start of the rotation; assigning students to diagnostic, procedural, and screening roles; the attendance of students at introductory radiology symposia; students' weekly attendance at institutional multidisciplinary and divisional breast radiologic-pathologic correlation conferences; student self-study assignments using faculty-vetted resources; student participation in breast biopsy simulation and small parts ultrasound laboratories; the development of a student-centric radiology educational website; and student-directed publishing of digital case files. Medical student feedback and course analytics indicated superior course evaluation scores reinforced by narrative feedback. In website domain utilization data, the breast file domain is the most viewed subspecialty domain. The Breast Imaging Boot Camp is a successful curriculum. Its novelty lies in both its integrated approach to medical student core competencies and its clinician educators' use of today's student-favored teaching tools.

A Survey of Family Planning Training, Knowledge, and Practices Among Health Care Providers Within the Military Health System at Joint Base Lewis-McChord.

INTRODUCTION: Within the active duty U.S. military population, the age-adjusted unintended pregnancy rate is higher than the national average. Unplanned pregnancy within the military impacts individual and unit medical readiness. Contraceptive education and availability are means to reduce unintended pregnancy rates; health care providers are key facilitators in provision of contraception. Understanding provider knowledge and practices related to contraceptive provision may identify strengths and gaps in order to provide focal points for sustainment or improvement in family planning practices. The purpose of this study was to assess family planning knowledge, training, and practices among health care providers serving military and dependent beneficiaries within the military health care system at Fort Lewis, Washington. MATERIAL AND METHODS: This was a cross-sectional survey of health care providers on Joint Base Lewis-McChord in Tacoma, Washington who deliver health care services to U.S. uniformed service members and their dependents in varied settings, including outpatient clinics and a tertiary care center. The survey included questions regarding prior contraceptive training, and current contraceptive knowledge and practices. Survey results were evaluated using descriptive and bivariate analyses. The study was approved by both Institutional Review Boards at Emory University and at Madigan Army Medical Center. RESULTS: Overall, 79 eligible health care providers completed the survey. Eighty-six percent of women's health providers consistently ("always or most of the time") provided family planning services to female service members, compared with 38% of primary care providers. Women's health providers were more likely to counsel by method effectiveness and adapt their counseling to consider patients' reproductive life plans. There were no differences between provider type in considering service members' deployment status during contraceptive counseling. Overall, providers identified the correct effectiveness of long-acting contraceptive methods, but tended to overestimate the effectiveness of short-acting methods. CONCLUSIONS: Family planning services available to service members may be improved through enhanced provider education, targeting efficacy-based counseling and identification of barriers to access and provision of long-acting reversible contraceptive methods.

Factors associated with low-lying intrauterine devices: a cross-sectional ultrasound study in a cohort of African-American women.

OBJECTIVE: The object of this study is to examine factors and symptoms associated with low-lying IUDs as defined by ultrasound. STUDY DESIGN: This is a cross-sectional sub-study of participants in the Study of Environment, Life-style, and Fibroids (SELF). SELF participants had screening ultrasounds for fibroids at study enrollment; those with an IUD in place are included in this sub-study. Low-lying IUDs were identified and localized. Logistic regression was used to identify factors and symptoms associated with low-lying IUDs. RESULTS: Among 168 women with IUDs at ultrasound, 28 (17%) had a low-lying IUD. Having a low-lying IUD was associated with low education level (≤high school: aOR 3.1 95% CI 1.14-8.55) and with increased BMI (p=.002). Women with a low-lying IUD were more likely to report a "big problem" with dysmenorrhea (the highest option of the Likert scale) as compared to women with a normally-positioned IUD (OR 3.2 95% CI 1.07-9.54). CONCLUSION: Our study found that women with a low-lying IUD are more likely to be of lower education and higher BMI, and to report more dysmenorrhea. IMPLICATIONS: Women who are obese may benefit from additional counseling and closer follow-up after IUD placement. Future research is warranted to investigate IUD placement and possible IUD migration among women who are obese.

Biosynthesis of oleic, arachidonic and docosahexaenoic acids from their C18 precursors in the yolk sac membrane of the avian embryo.

The yolk sac membrane (YSM) of the chicken embryo is known to express delta-9 and delta-6 desaturase activities, suggesting that biosynthesis of the unsaturated fatty acids 18:1n-9, 20:4n-6 and 22:6n-3 might occur during the transfer of yolk lipids across the YSM. If so, this biosynthesis could help to satisfy the demands of the embryonic tissues for these unsaturates. To assess the ability of the YSM to perform these conversions, pieces of the tissue were incubated in vitro with the precursor fatty acids, 14C-18:0, 14C-18:2n-6 or 14C-18:3n-3, and the recovery of radioactivity in the respective products, 18:1n-9, 20:4n-6 and 22:6n-3, was determined. After 4 h of continuous incubation, radioactivity from these precursors was incorporated primarily into triacylglycerol and phospholipid of the tissue pieces. Only small proportions (0.3-4.7%) of this incorporated radioactivity were, however, recovered as 18:1n-9, 20:4n-6 or 22:6n-3. The majority of the incorporated label was retained in the form of the precursor fatty acids. After a 1-h pulse incubation with the 14C precursors, followed by a 3-h chase incubation in the absence of exogenous label, the conversion of incorporated radioactivity to the end product unsaturates was again relatively low (0.5-8.1%). Thus, although conversions of the precursors to the end product fatty acids were detectable in this system, the biosynthesis of these unsaturates is apparently a quantitatively minor pathway in the YSM. Nevertheless, since the amount of 18:2n-6 in the yolk lipids far exceeds that of 20:4n-6, the conversion of even a small proportion of the former to the latter fatty acid could significantly increase the supply of 20:4n-6 to the embryonic tissues.

Differential incorporation of docosahexaenoic and arachidonic acids by the yolk sac membrane of the avian embryo.

During avian development, lipoproteins derived from yolk lipid are assembled in the yolk sac membrane (YSM) for secretion into the embryonic circulation. To investigate how yolk polyunsaturated fatty acids, essential for the development of certain tissues, are distributed among the lipid classes of the lipoproteins, pieces of YSM were incubated in vitro with [14C]arachidonic and [14C]docosahexaenoic acids (DHA). There was a marked difference in the partitioning of these two precursors among the lipid classes of the tissue. Of the radioactivity incorporated into total lipid from [14C]-arachidonic acid during 1 h of incubation, 67.3% was esterified as phospholipid and 29.5% as triacylglycerol. In contrast, only 14.6% of the label incorporated from [14C]-DHA was esterified as phospholipid, whereas 73.2% was recovered in triacylglycerol. This pattern of differential partitioning was observed at all time points and across a 20-fold range of fatty acid concentrations. There was no evidence for conversion of the radioactive arachidonic and DHAs to other fatty acids prior to incorporation into tissue lipids. It is suggested that the selective incorporation of yolk-derived DHA into the triacylglycerol of secreted lipoproteins represents part of a mechanism for directing this polyunsaturate to particular embryonic tissues.

Intrauterine devices for adolescents: a systematic review.

BACKGROUND: The appropriateness of IUDs for adolescents remains unsettled, as does the definition of the term adolescent. Unplanned pregnancy among teenagers remains epidemic, and long-acting methods, such as IUDs, offer the promise of top-tier effectiveness. STUDY DESIGN: We conducted a systematic review of the literature concerning IUD use in adolescents using MEDLINE, Popline, EMBASE and CINAHL databases. RESULTS: Six cohort studies and seven case-series reports met our inclusion criteria; none included IUDs in current use in the United States. Overall, continuation rates were high and cumulative pregnancy rates low, ranging from 2% at 6 months to 11% at 48 months. Compared with combined oral contraceptives, IUDs had similar or better continuation rates; pregnancy rates were similar at 2 years. IUD expulsion rates may be inversely related to age. CONCLUSIONS: The literature on IUD use among adolescents is scanty and obsolete. Nevertheless, published reports were generally reassuring. Randomized controlled trials and cohort studies comparing contemporary IUDs with other methods are urgently needed.