Preventing Obesity in Midlife Women: A Recommendation From the Women's Preventive Services Initiative.

DESCRIPTION: The Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient advocacy representatives, developed a recommendation for counseling midlife women aged 40 to 60 years with normal or overweight body mass index (BMI; 18.5 to 29.9 kg/m2) to maintain weight or limit weight gain to prevent obesity with the long-term goals of optimizing health, function, and well-being. This recommendation is intended to guide clinical practice and coverage of clinical preventive health services for the Health Resources and Services Administration and other stakeholders. Clinicians providing preventive health care to women in primary care settings are the target audience for this recommendation. METHODS: The WPSI developed this recommendation after evaluating results of a systematic review of the effectiveness and harms of interventions to prevent weight gain and obesity in women aged 40 to 60 years without obesity. Seven randomized clinical trials including 51 638 participants and using various counseling and behavioral interventions were included. Trials indicated favorable weight changes with interventions that were statistically significantly different from control groups in 4 of 5 trials of counseling, but not in 2 trials of exercise. Few harms were reported. RECOMMENDATION: The WPSI recommends counseling midlife women aged 40 to 60 years with normal or overweight BMI (18.5 to 29.9 kg/m2) to maintain weight or limit weight gain to prevent obesity. Counseling may include individualized discussion of healthy eating and physical activity.

Screening for Anxiety in Adolescent and Adult Women: A Recommendation From the Women's Preventive Services Initiative.

DESCRIPTION: The Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient representatives, developed a recommendation on screening for anxiety in adolescent and adult women to improve detection; achieve earlier diagnosis and treatment; and improve health, function, and well-being. The WPSI's recommendations are intended to guide clinical practice and coverage of services for the Health Resources and Services Administration and other stakeholders. The target audience for this recommendation includes all clinicians providing preventive health care to women, particularly in primary care settings. This recommendation applies to women and adolescent girls aged 13 years or older who are not currently diagnosed with anxiety disorders, including pregnant and postpartum women. METHODS: The WPSI developed this recommendation after evaluating results of a systematic review of the effectiveness of screening, accuracy of screening instruments, and benefits and harms of treatments in adolescent girls and adult women. No studies directly evaluated the overall effectiveness or harms of screening for anxiety. Twenty-seven screening instruments and their variations were moderately to highly accurate in identifying anxiety (33 individual studies and 2 systematic reviews; 171 studies total). Symptoms improved and relapse rates decreased with psychological therapies (246 randomized controlled trials [RCTs] in 5 systematic reviews) and with selective serotonin reuptake inhibitors or selective serotonin and norepinephrine reuptake inhibitors (126 RCTs in 3 systematic reviews). The WPSI also considered the effect of screening on symptom progression and identification of associated and underlying conditions, as well as implementation factors. RECOMMENDATION: The WPSI recommends screening for anxiety in women and adolescent girls aged 13 years or older who are not currently diagnosed with anxiety disorders, including pregnant and postpartum women. Optimal screening intervals are unknown, and clinical judgment should be used to determine frequency. When screening suggests the presence of anxiety, further evaluation is necessary to establish the diagnosis and determine appropriate treatment and follow-up.

Obstetric Care Consensus #9: Levels of Maternal Care: (Replaces Obstetric Care Consensus Number 2, February 2015).

Maternal mortality and severe maternal morbidity, particularly among women of color, have increased in the United States. The leading medical causes of maternal mortality include cardiovascular disease, infection, and common obstetric complications such as hemorrhage and vary by timing relative to the end of pregnancy. Although specific modifications in the clinical management of some of these conditions have been instituted, more can be done to improve the system of care for high-risk women at facility and population levels. The goal of levels of maternal care is to reduce maternal morbidity and mortality, including existing disparities, by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs. To standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, this classification system establishes levels of maternal care that pertain to basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The determination of the appropriate level of care to be provided by a given facility should be guided by regional and state health care entities, national accreditation and professional organization guidelines, identified regional perinatal health care service needs, and regional resources. State and regional authorities should work together with the multiple institutions within a region, and with the input from their obstetric care providers, to determine the appropriate coordinated system of care and to implement policies that promote and support a regionalized system of care. These relationships enhance the ability of women to give birth safely in their communities while providing support for circumstances when higher level resources are needed. This document is a revision of the original 2015 Levels of Maternal Care Obstetric Care Consensus, which has been revised primarily to clarify terminology and to include more recent data based on published literature and feedback from levels of maternal care implementation.

Screening for Urinary Incontinence in Women: A Recommendation From the Women's Preventive Services Initiative.

Description: Recommendation on screening for urinary incontinence in women by the Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient representatives. The WPSI's recommendations are intended to guide clinical practice and coverage of services for the Health Resources and Services Administration and other stakeholders. The target audience for this recommendation includes all clinicians providing preventive health care for women, particularly in primary care settings. This recommendation applies to women of all ages, as well as adolescents. Methods: The WPSI developed this recommendation after evaluating evidence regarding the benefits and harms of screening for urinary incontinence in women. The evaluation included a systematic review of the accuracy of screening instruments and the benefits and harms of treatments. Indirect evidence was used to link screening and health outcomes in the chain of evidence that might support screening in the absence of direct evidence. The WPSI also considered the effect of screening on symptom progression and avoidance of costly and complex treatments, as well as implementation factors. Recommendation: The WPSI recommends screening women for urinary incontinence annually. Screening ideally should assess whether women experience urinary incontinence and whether it affects their activities and quality of life. The WPSI recommends referring women for further evaluation and treatment if indicated.

Race-specific molecular alterations correlate with differential outcomes for black and white endometrioid endometrial cancer patients.

BACKGROUND: The objective of this study was to identify molecular alterations associated with disease outcomes for white and black patients with endometrioid endometrial cancer (EEC). METHODS: EEC samples from black (n = 17) and white patients (n = 13) were analyzed by proteomics (liquid chromatography-tandem mass spectrometry) and transcriptomics (RNA-seq). Coordinate alterations were validated with RNA-seq data from black (n = 49) and white patients (n = 216). Concordantly altered candidates were further tested for associations with race-specific progression-free survival (PFS) in black (n = 64) or white patients (n = 267) via univariate and multivariate Cox regression modeling and log-rank testing. RESULTS: Discovery analyses revealed significantly altered candidate proteins and transcripts between black and white patients, suggesting modulation of tumor cell viability in black patients and cell death signaling in black and white patients. Eighty-nine candidates were validated as altered between these patient cohorts, and a subset significantly correlated with differential PFS. White-specific PFS candidates included serpin family A member 4 (SERPINA4; hazard ratio [HR], 0.89; Wald P value = .02), integrin subunit α3 (ITGA3; HR, 0.76; P = .03), and Bet1 Golgi vesicular membrane trafficking protein like (BET1L; HR, 0.48; P = .04). Black-specific PFS candidates included family with sequence similarity 228 member B (FAM228B; HR, 0.13; P = .001) and HEAT repeat containing 6 (HEATR6; HR, 4.94; P = .047). Several candidates were also associated with overall survival (SERPINA4 and ITGA3) as well as PFS independent of disease stage, grade and myometrial invasion (SERPINA4, BET1L and FAM228B). CONCLUSIONS: This study has identified and validated molecular alterations in tumors from black and white EEC patients, including candidates significantly associated with altered disease outcomes within these patient cohorts. Cancer 2017;123:4004-12. © 2017 American Cancer Society.

The Associations Between Clerkship Objective Structured Clinical Examination (OSCE) Grades and Subsequent Performance.

Construct: We investigated the extent of the associations between medical students' clinical competency measured by performance in Objective Structured Clinical Examinations (OSCE) during Obstetrics/Gynecology and Family Medicine clerkships and later performance in both undergraduate and graduate medical education. BACKGROUND: There is a relative dearth of studies on the correlations between undergraduate OSCE scores and future exam performance within either undergraduate or graduate medical education and almost none on linking these simulated encounters to eventual patient care. Of the research studies that do correlate clerkship OSCE scores with future performance, these often have a small sample size and/or include only 1 clerkship. APPROACH: Students in USU graduating classes of 2007 through 2011 participated in the study. We investigated correlations between clerkship OSCE grades with United States Medical Licensing Examination Step 2 Clinical Knowledge, Clinical Skills, and Step 3 Exams scores as well as Postgraduate Year 1 program director's evaluation scores on Medical Expertise and Professionalism. We also conducted contingency table analysis to examine the associations between poor performance on clerkship OSCEs with failing Step 3 and receiving poor program director ratings. RESULTS: The correlation coefficients were weak between the clerkship OSCE grades and the outcomes. The strongest correlations existed between the clerkship OSCE grades and the Step 2 CS Integrated Clinical Encounter component score, Step 2 Clinical Skills, and Step 3 scores. Contingency table associations between poor performances on both clerkships OSCEs and poor Postgraduate Year 1 Program Director ratings were significant. CONCLUSIONS: The results of this study provide additional but limited validity evidence for the use of OSCEs during clinical clerkships given their associations with subsequent performance measures.

Nestin: A biomarker of aggressive uterine cancers.

OBJECTIVE: Evidence of potential prognostic and predictive value for nestin was investigated in well-annotated uterine cancers (UCs). METHODS: Nestin expression and previously-published biomarkers were evaluated by immunohistochemistry (IHC) in UC tissue microarrays. Biomarkers were categorized as low vs. high, and nestin was cut at 10% positive staining. Relationship between nestin and clinicopathologic factors, biomarkers and outcome were evaluated using exact/log-rank testing or logistic/Cox modeling. RESULTS: There were 323 eligible cases, 34% had advanced stage disease, 37% had type II disease, and 5% were carcinosarcomas. High nestin, observed in 19% of cases, was more common in advanced vs. early stage disease, type II cancers or uterine carcinosarcoma vs. type I cancers, grade 3 disease, positive lymphovascular space invasion (LVSI) and tumors >6cm (p<0.05). Nestin was inversely correlated with ER, PR and TFF3, and correlated with p53 and IMP3. Women with high vs. low nestin had worse progression-free survival (PFS) and cancer-specific survival overall, and worse PFS in the subset who received no adjuvant therapy or radiation, or had early stage, type I disease or tumors with both low and high ER, PR, TFF3, PTEN, p53 or IMP3. The relationship between nestin and PFS was independent of stage, LVSI and risk categorization but not type of UC. CONCLUSIONS: High nestin was more common in UCs with aggressive features and poor outcome. Nestin may represent a predictive biomarker for treatment selection for patients previously considered to be lower risk and a candidate for no or radiation-based adjuvant therapy, and compliment ER/PR testing.

Proteomics of the human endometrial glandular epithelium and stroma from the proliferative and secretory phases of the menstrual cycle.

Despite its importance in reproductive biology and women's health, a detailed molecular-level understanding of the human endometrium is lacking. Indeed, no comprehensive studies have been undertaken to elucidate the important protein expression differences between the endometrial glandular epithelium and surrounding stroma during the proliferative and midsecretory phases of the menstrual cycle. We utilized laser microdissection to harvest epithelial cells and stromal compartments from proliferative and secretory premenopausal endometrial tissue and performed a global, quantitative mass spectrometry-based proteomics analysis. This analysis identified 1224 total proteins from epithelial cells, among which 318 were differentially abundant between the proliferative and secretory phases (q < 0.05), and 1005 proteins from the stromal compartments, 19 of which were differentially abundant between the phases (q < 0.05). Several proteins were chosen for validation by immunohistochemistry in an independent set of uterine tissues, including carboxypeptidase M, tenascin C, neprilysin, and ectonucleotide pyrophosphatase/phosphodiesterase family member 3 (ENPP3). ENPP3, which was elevated in epithelial glandular cells in the secretory phase, was confirmed to be elevated in midsecretory-phase baboon uterine lavage samples and also observed to have an N-linked glycosylated form that was not observed in the proliferative phase. This study provides a detailed view into the global proteomic alterations of the epithelial cells and stromal compartments of the cycling premenopausal endometrium. These proteomic alterations during endometrial remodeling provide a basis for numerous follow-up investigations on the function of these differentially regulated proteins and their role in reproductive biology and endometrial pathologies.

Frequency of Prenatal Care Visits: A Core Outcome Set for Prenatal Care Schedules.

Objective: The aim of this study is to develop a core outcome set for the frequency and modality of prenatal care visits. Material and Methods: A consensus development study was conducted in the United States with participants, including 31 health care professionals, 12 public policy members or public health payers, and 18 public members, representing 24 states. A modified Delphi method and modified nominal group technique were utilized. Results: Twenty-one potential core outcomes were developed by combining the outcomes reported in three systematic reviews that evaluated the frequency of prenatal care visits or modality of prenatal visit type (e.g., in person, telemedicine, or hybrids of both). Eighteen consensus outcomes were identified from the Delphi process, following which 10 maternal and 4 neonatal outcomes were agreed at the consensus development meeting. Maternal core outcomes include maternal quality of life; maternal mental health outcomes; the experience of maternity care; lost time; attendance of recommended visits; unplanned care utilization; completion of the American College of Obstetricians and Gynecologists-recommended services; diagnosis of obstetric complications-proportion and timing; disparities in care outcomes; and severe maternal morbidity or mortality. Neonatal core outcomes include gestational age at birth, birth weight, stillbirth or perinatal death, and neonatal intensive care unit admissions. Conclusions: The core outcome set for the frequency and modality of prenatal visits should be utilized in forthcoming randomized controlled trials and systematic reviews. Such application will warrant that in future research, consistent reporting will enrich care and improve outcomes. Clinical Trial Registration number: 2021.

Routine Prenatal Care.

The one-size-fits-all model of prenatal care has remained largely unchanged since 1930. New models of prenatal care delivery can improve its efficacy, equity, and experience through tailoring prenatal care to meet pregnant people's medical and social needs. Key aspects of recently developed prenatal care models include visit schedules based on needed services, telemedicine, home measurement of routine pregnancy parameters, and interventions that address social and structural drivers of health. Several barriers that affect the individual, provider, health system, and policy levels must be addressed to facilitate implementation of new prenatal care delivery models.

Impact of Obstetrics and Gynecology Clerkship Order on NBME Exam Scores After a Curriculum Change.

OBJECTIVE: Our Institution instituted curriculum reform in 2013. We sought to examine the impact of rotation order on the end of clerkship National Board of Medical Examiners (NBME) Obstetrics and Gynecology (Ob/Gyn) Subject Exam scores after curriculum restructuring. DESIGN: This is a retrospective analysis of Ob/Gyn NBME scores over 2 years after curriculum reform. At our university, a 15-week block is divided into 5-week intervals of General Surgery, Ob/Gyn, and surgical subspecialties, in any order. During the 16 weeks, students take the NBME Subject Examinations for Ob/Gyn and Surgery. We defined rotation groups by proximity to the shelf exam. Group 1 completed Ob/Gyn first, furthest away from the exam, Group 2 completed Ob/Gyn second, and Group 3 completed Ob/Gyn last, closest to the test. We compared average shelf exam scores between Groups. SETTING: Uniformed Services University of Health Sciences during the clerkship year. PARTICIPANTS: Medical students at the Uniformed Services University. RESULTS: We obtained data from 331 students (118 students in Group 1, 106 in Group 2, and 107 in Group 3). Scores ranged from 55 to 99 (mean 72.5, SD 7.3). Mean (SD) NBME score was 71.9 (6.9) in Group 1, 73.2 (7.2) in Group 2, and 72.6 (7.7) in Group 3 (p = 0.415). CONCLUSION: Rotation order does not affect NBME Ob/Gyn Subject exam scores in a fifteen-week integrated clerkship block.

Frequency of Prenatal Care Visits: Protocol to Develop a Core Outcome Set for Prenatal Care Schedules.

BACKGROUND: Prenatal care, one of the most common preventive care services in the United States, endeavors to improve pregnancy outcomes through evidence-based screenings and interventions. Despite the prevalence of prenatal care and its importance to maternal and infant health, there are several debates about the best methods of prenatal care delivery, including the most appropriate schedule frequency and content of prenatal visits. Current US national guidelines recommend that low-risk individuals receive a standard schedule of 12 to 14 in-office visits, a care delivery model that has remained unchanged for almost a century. OBJECTIVE: In early 2020, to mitigate individuals' exposure to the SARS-CoV-2 virus, prenatal care providers implemented new paradigms that altered the schedule frequency, interval, and modality (eg, telemedicine) of how prenatal care services were offered. In this paper, we describe the development of a core outcome set (COS) that can be used to evaluate the effect of the frequency of prenatal care schedules on maternal and infant outcomes. METHODS: We will systematically review the literature to identify previously reported outcomes important to individuals who receive prenatal care and the people who care for them. Stakeholders with expertise in prenatal care delivery (ie, patients or family members, health care providers, and public health professionals and policy makers) will rate the importance of identified outcomes in a web-based survey using a 3-round Delphi process. A digital consensus meeting will be held for a group of stakeholder representatives to discuss and vote on the outcomes to include in the final COS. RESULTS: The Delphi survey was initiated in July 2022 with invited 71 stakeholders. A digital consensus conference was conducted on October 11, 2022. Data are currently under analysis with plans to submit them in a subsequent manuscript. CONCLUSIONS: More research about the optimal schedule frequency and modality for prenatal care delivery is needed. Standardizing outcomes that are measured and reported in evaluations of the recommended prenatal care schedules will assist evidence synthesis and results reported in systematic reviews and meta-analyses. Overall, this COS will expand the consistency and patient-centeredness of reported outcomes for various prenatal care delivery schedules and modalities, hopefully improving the overall efficacy of recommended care delivery for pregnant people and their families. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/43962.

The association between specialty match and third-year clerkship performance.

PURPOSE: The United States is experiencing an accelerating physician shortage, especially within primary care. Medical educators are actively seeking ways to predict student specialty match and workforce requirements. Previous studies investigating specialty match have focused on factors known at the time of matriculation. This study examined whether third-year clerkship performance could be used to predict specialty match later in medical school. METHOD: The authors evaluated the clerkship performance of 802 students graduating from the Uniformed Services University between 2007 and 2011. They examined the relationship of students' clerkship grades and National Board of Medical Examiners' clinical subject examination scores to specialty match. In addition, the authors combined student performance in family medicine, internal medicine, and pediatrics to create composite variables and assessed their associations with the match. RESULTS: Among 802 students, 339 (42.4%) students matched to primary care specialties. There was a positive association between higher family medicine (Odds ratio [OR] 1.65, 95% confidence interval [CI] 1.05, 2.59), general surgery (OR 1.91, 95% CI 1.22, 2.99), internal medicine (OR 2.17, 95% CI 1.35, 3.49), and pediatrics (OR 2.59, 95% CI 1.52, 4.43) clerkship grades and students matching into family medicine, general surgery, internal medicine, and pediatrics, respectively. Only family medicine showed a weak correlation between higher National Board of Medical Examiners' scores and specialty match. CONCLUSIONS: Higher clerkship performance in four of six Uniformed Services University third-year clerkships is associated with matching into the corresponding specialty. Clerkship performance provides a potential tool for educators in counseling students and predicting future specialty match.

Michigan Plan for Appropriate Tailored Healthcare in Pregnancy Prenatal Care Recommendations: A Practical Guide for Maternity Care Clinicians.

Prenatal care is an important preventive service designed to improve the health of pregnant patients and their infants. Prenatal care delivery recommendations have remained unchanged since 1930, when the 12-14 in-person visit schedule was first established to detect preeclampsia. In 2020, the American College of Obstetricians and Gynecologists, in collaboration with the University of Michigan, convened a panel of maternity care experts to determine new prenatal care delivery recommendations. The panel recognized the need to include emerging evidence and experience, including significant changes in prenatal care delivery during the COVID-19 pandemic, pre-existing knowledge of the importance of individualized care plans, the promise of telemedicine, and the significant influence of social and structural determinants of health (SSDoH) on pregnancy outcomes. Recommendations were derived using the RAND-UCLA appropriateness method, a rigorous e-Delphi method, and are designed to extend beyond the acute public health crisis. The resulting Michigan Plan for Appropriate Tailored Healthcare in pregnancy (MiPATH) includes recommendations for key aspects of prenatal care delivery: (1) the recommended number of prenatal visits, (2) the frequency of prenatal visits, (3) the role of monitoring routine pregnancy parameters (blood pressure, fetal heart tones, weight, and fundal height), (4) integration of telemedicine into routine care, and (5) inclusion of (SSDoH). Resulting recommendations demonstrate a new approach to prenatal care delivery that incorporates medical, SSDoH, and patient preferences, to develop individualized prenatal care delivery plans. The purpose of this document is to outline the new MiPATH recommendations and to provide practical guidance on implementing them in routine practice.

Laparoscopic hysterectomy using various energy sources in swine: a histopathologic assessment.

OBJECTIVE: Analyze energy-induced damage to the swine vagina during laparoscopic hysterectomy. STUDY DESIGN: Laparoscopic colpotomy was performed in swine using ultrasonic, monopolar, and bipolar energy. Specimens (n = 22) from 13 swine were stained with hematoxylin and eosin and Masson's trichrome for energy-related damage. The distal scalpel-cut margin was used as reference. Energy induced damage was assessed by gynecologic and veterinary pathologists blinded to energy source. RESULTS: Injury was most apparent on Masson's trichrome, demonstrating clear injury demarcation, allowing consistent, quantitative damage measurements. Mean injury was 0 ± 0 µM (scalpel, n = 22), 782 ± 359 µM (ultrasonic, n = 7), 2016 ± 1423 µM (monopolar, n = 8), and 3011 ± 1239 µM (bipolar, n = 7). Using scalpel as the reference, all were significant (P < .001). CONCLUSION: All energy sources demonstrated tissue damage, with ultrasonic showing the least and bipolar the greatest. Further study of tissue damage relative to cuff closure at laparoscopic hysterectomy is warranted.

Evaluation of the impact of resident work hour restrictions on resident outpatient clinical experience.

OBJECTIVE: To estimate the effect of work hour restrictions on resident outpatient clinical experience. STUDY DESIGN: Schedule templates from academic years 1998-1999 (before work hour restrictions), 2002-2003 (when night float rotation was added in anticipation of work hour restrictions), and 2008-2009 (during work hour restrictions) were compared for outpatient clinic experience before and after work hour restrictions were implemented. Actual clinics on specific rotations and estimated patient encounters per scheduled clinic were considered. RESULTS: Between academic year (AY) 1998-1999 and AY 2008-2009 there was a generalized downward trend in average outpatient encounters for postgraduate year (PGY)-2, PGY-3 and PGY-4 residents (45%, 34% and 36%, respectively). For obstetrics, gynecology and ambulatory rotations, there was a downward trend in average outpatient encounters for each rotation type (61%, 14% and 63%, respectively). The average number of scheduled clinics per week was slightly decreased when comparing AY 1998-1999 to either AY 2002-2003 or AY 2008-2009. CONCLUSION: Rotation schedules before and after work hour restrictions demonstrated a downward trend in the number of scheduled outpatient encounters. These findings indicate a potential negative impact on preparation for clinical practice.

The Michigan Plan for Appropriate Tailored Healthcare in Pregnancy Prenatal Care Recommendations.

OBJECTIVE: To describe MiPATH (the Michigan Plan for Appropriate Tailored Healthcare in pregnancy) panel process and key recommendations for prenatal care delivery. METHODS: We conducted an appropriateness study using the RAND Corporation and University of California Los Angeles Appropriateness Method, a modified e-Delphi process, to develop MiPATH recommendations using sequential steps: 1) definition and scope of key terms, 2) literature review and data synthesis, 3) case scenario development, 4) panel selection and scenario revisions, and 5) two rounds of panel appropriateness ratings with deliberation. Recommendations were developed for average-risk pregnant individuals (eg, individuals not requiring care by maternal-fetal medicine specialists). Because prenatal services (eg, laboratory tests, vaccinations) have robust evidence, panelists considered only how services are delivered (eg, visit frequency, telemedicine). RESULTS: The appropriateness of key aspects of prenatal care delivery across individuals with and without common medical and pregnancy complications, as well as social and structural determinants of health, was determined by the panel. Panelists agreed that a risk assessment for medical, social, and structural determinants of health should be completed as soon as individuals present for care. Additionally, the panel provided recommendations for: 1) prenatal visit schedules (care initiation, visit timing and frequency, routine pregnancy assessments), 2) integration of telemedicine (virtual visits and home devices), and 3) care individualization. Panelists recognized significant gaps in existing evidence and the need for policy changes to support equitable care with changing practices. CONCLUSION: The MiPATH recommendations offer more flexible prenatal care delivery for average-risk individuals.

The effect of the night float rotation on annual in-training examination performance.

OBJECTIVE: To assess whether night-float rotation affected resident performance on the Council on Resident Education in Obstetrics and Gynecology (CREOG) in-service examination. STUDY DESIGN: Review of annual CREOG in-service examination scores standardized for postgraduate year level (2001-2009) compared scores for residents on night float rotation at time of examination to those on non-night float rotation. Data were analyzed by linear mixed effects model. RESULTS: Data were obtained for 72 residents, 20 of whom were on night float at time of at least one examination. One to four test scores were available for each resident (total 225 test scores). Average test score was 213 (SD = 20). The mean score for residents on night float was 214 (95% CI 207-221); the mean score for those on non-night float rotations was 212 (95% CI 208-216, p = 0.53). Sample size was sufficient to detect a difference of 12 points with 80% power. CONCLUSION: Although night float rotations necessitate a complete reversal in sleep schedules, we found that night float service did not significantly affect scores On the annual in-service examination. To our knowledge, no studies have evaluated the impact of this schedule on test-taking ability.

Diffuse laminar endocervical glandular hyperplasia: a case report.

BACKGROUND: Diffuse laminar endocervical glandular hyperplasia is extremely rare with only 14 cases reported in the literature. Diffuse laminar endocervical glandular hyperplasia is a benign lesion that is easily confused with malignancy. CASE REPORT: We present a 22-year-old woman referred to our gynecologic oncology service with a 2.0 x 4.0-cm exophytic cervical mass. Colposcopic-directed cervical biopsies were diagnosed as adenocarcinoma, suggestive of minimal deviation adenocarcinoma. Computed tomographic scans of the abdomen and the pelvis failed to reveal any metastatic foci. A radical abdominal hysterectomy with pelvic and para-aortic lymph node sampling was performed without complications. Final pathology revealed diffuse laminar endocervical glandular hyperplasia. CONCLUSIONS: Diffuse laminar endocervical glandular hyperplasia is an uncommon histological type of pseudoneoplastic glandular lesions that may be found in the cervix, and this entity should be considered in the differential diagnosis of a potentially malignant endocervical glandular lesion.