What are essential laparoscopic skills these days? Results of the SAGES Fundamentals of Laparoscopic Surgery (FLS) Committee technical skills survey.

INTRODUCTION: The Fundamentals of Laparoscopic Surgery (FLS) program tests basic knowledge and skills required to perform laparoscopic surgery. Educational experiences in laparoscopic training and development of associated competencies have evolved since FLS inception, making it important to review the definition of fundamental laparoscopic skills. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) assigned an FLS Technical Skills Working Group to characterize technical skills used in basic laparoscopic surgery in current practice contexts and their possible application to future FLS tests. METHODS: A group of subject matter experts defined an inventory of 65 laparoscopic skills using a Nominal Group Technique. From these, a survey was developed rating these items for importance, frequency of use, and priority for testing for FLS certification. This survey was distributed to SAGES members, recent recipients of FLS certification, and members of the Association of Program Directors in Surgery (APDS). Results were collected using a secure web-based survey platform. RESULTS: Complete data were available for 1742 surveys. Of these, 1143 comprised results for post-residency participants who performed advanced procedures. Seventeen competencies were identified for FLS testing prioritization by determining the proportion of respondents who identified them of highest priority, at median (50th percentile) of the maximum survey scale rating. These included basic peritoneal access, laparoscope and instrument use, tissue manipulation, and specific problem management skills. Sixteen could be used to show appropriateness of the domain construct by confirmatory factor analysis. Of these 8 could be characterized as manipulative tasks. Of these 5 mapped to current FLS tasks. CONCLUSIONS: This survey-identified competencies, some of which are currently assessed in FLS, with a high level of priority for testing. Further work is needed to determine if this should prompt consideration of changes or additions to the FLS technical skills test component.

Lateral decubitus position to facilitate pelvic examination of the patient with severe obesity.

BACKGROUND: Patients with elevated BMI pose a number of challenges for the gynecologist. Pelvic examination may be more difficult due to adiposity in the perineum and labia, increasing the distance between the vulva and cervix. The objective of the current work was to describe use of the lateral decubitus position to improve visualization of the cervix in women with severe obesity. METHODS: A case series was collected. From 7/1/2010 until 1/31/2020, all records of patients with obesity and unsuccessful cervical visualization during pelvic exam in the dorsal lithotomy position in the author's clinical practice were reviewed after obtaining Mayo Clinic Institutional Review Board approval. For the lateral decubitus position, the patient was asked to lie on her side on the exam table, facing away from the examiner with knees bent. An assistant elevated the upper bent leg 45 degrees from horizontal, exposing the perineum. A vaginal speculum was then placed in the vagina with the posterior blade toward the anus. The speculum was opened gently as would be done with examination in dorsal lithotomy position until the cervix was visualized. RESULTS: Eleven patients with severe obesity in the gynecologic practice of the author with prior unsuccessful cervical visualization in dorsal lithotomy position were examined in the lateral decubitus position. In all but one case the cervix was successfully visualized in the lateral decubitus position and all intended intrauterine procedures were successfully performed. CONCLUSIONS: In this case series, the use of the lateral decubitus position appears to improve visualization of the cervix in the outpatient setting among women with severe obesity. Consideration should be given to use of the lateral decubitus position when the cervix cannot be visualized in the dorsal lithotomy position.

The nucleic acid binding protein YB-1-controlled expression of CXCL-1 modulates kidney damage in liver fibrosis.

Acute kidney injury is a common complication of advanced liver disease and increased mortality of these patients. Here, we analyzed the role of Y-box protein-1 (YB-1), a nucleic acid binding protein, in the bile duct ligation model of liver fibrosis and monitored liver and subsequent kidney damage. Following bile duct ligation, both serum levels of liver enzymes and expression of hepatic extracellular matrix components such as type I collagen were significantly reduced in mice with half-maximal YB-1 expression (Yb1+/-) as compared to their wild-type littermates. By contrast, expression of the chemokine CXCL1 was significantly augmented in these Yb1+/- mice. YB-1 was identified as a potent transcriptional repressor of the Cxcl1 gene. Precision-cut kidney slices from Yb1+/- mice revealed higher expression of the CXCL1 receptor CXCR2 as well as enhanced responsivity to CXCL1 compared to those from wild-type mice. Increased CXCL1 content in Yb1+/- mice led to pronounced bile duct ligation-induced damage of the kidneys monitored as parameters of tubular epithelial injury and immune cell infiltration. Pharmacological blockade of CXCR2 as well as application of an inhibitory anti-CXCL1 antibody significantly mitigated early systemic effects on the kidneys following bile duct ligation whereas it had only a modest impact on hepatic inflammation and function. Thus, our analyses provide direct evidence that YB-1 crucially contributes to hepatic fibrosis and modulates liver-kidney crosstalk by maintaining tight control over chemokine CXCL1 expression.

The YB-1:Notch-3 axis modulates immune cell responses and organ damage in systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is an autoimmune disease and lupus nephritis is a major risk factor for morbidity and mortality. Notch-3 signaling induced by membrane-bound or soluble ligands such as YB-1 constitutes an evolutionarily conserved pathway that determines major decisions in cell fate. Mass spectrometry of extracellular YB-1 in sera from patients with SLE and lupus-prone mice revealed specific post-translational guanidinylation of two lysine residues within the highly conserved cold-shock domain of YB-1 (YB-1-G). These modifications highly correlated with SLE disease activity, especially in patients with lupus nephritis and resulted in enhanced activation of Notch-3 signaling in T lymphocytes. The importance of YB-1:Notch-3 interaction in T cells was further evidenced by increased interleukin (Il)10 expression following YB-1-G stimulation and detection of both, YB-1-G and Notch-3, in kidneys of MRL.lpr mice by mass spectrometry imaging. Notch-3 expression and activation was significantly up-regulated in kidneys of 20-week-old MRL.lpr mice. Notably, lupus-prone mice with constitutional Notch-3 depletion (B6.Faslpr/lprNotch3-/-) exhibited an aggravated lupus phenotype with significantly increased mortality, enlarged lymphoid organs and aggravated nephritis. Additionally, these mice displayed fewer regulatory T cells and reduced amounts of anti-inflammatory IL-10. Thus, our results indicate that the YB-1:Notch-3 axis exerts protective effects in SLE and that Notch-3 deficiency exacerbates the SLE phenotype.

YB-1 orchestrates onset and resolution of renal inflammation via IL10 gene regulation.

The Y-box-binding protein (YB)-1 plays a non-redundant role in both systemic and local inflammatory response. We analysed YB-1-mediated expression of the immune regulatory cytokine IL-10 in both LPS and sterile inflammation induced by unilateral renal ischaemia-reperfusion (I/R) and found an important role of YB-1 not only in the onset but also in the resolution of inflammation in kidneys. Within a decisive cis-regulatory region of the IL10 gene locus, the fourth intron, we identified and characterized an operative YB-1 binding site via gel shift experiments and reporter assays in immune and different renal cells. In vivo, YB-1 phosphorylated at serine 102 localized to the fourth intron, which was paralleled by enhanced IL-10 mRNA expression in mice following LPS challenge and in I/R. Mice with half-maximal expression of YB-1 (Yb1+/- ) had diminished IL-10 expression upon LPS challenge. In I/R, Yb1+/- mice exhibited ameliorated kidney injury/inflammation in the early-phase (days 1 and 5), however showed aggravated long-term damage (day 21) with increased expression of IL-10 and other known mediators of renal injury and inflammation. In conclusion, these data support the notion that there are context-specific decisions concerning YB-1 function and that a fine-tuning of YB-1, for example, via a post-translational modification regulates its activity and/or localization that is crucial for systemic processes such as inflammation.

Clinical Manifestations and Outcomes in Surgically Managed Gartner Duct Cysts.

STUDY OBJECTIVE: Gartner duct cysts (GDCs) are rare embryological remnants of the mesonephric duct with the majority of cases discovered incidentally in asymptomatic patients. The largest prior published series evaluating the surgical management of GDCs included 4 patients. The present study aimed to determine the manifestations and outcomes of surgically managed patients with GDCs with important implications for surveillance, monitoring, and management. DESIGN: A retrospective chart review (Canadian Task Force classification III). SETTING: A tertiary care center. PATIENTS: All women diagnosed with GDCs from January 1994 to April 2014 at our institution were identified. Patients were included if they underwent surgical management and had GDCs confirmed by pathology. One hundred twenty-four charts were manually reviewed, and 29 patients were included in the analysis. INTERVENTIONS: All patients underwent surgical management, which included vaginal excision or marsupialization. MEASUREMENTS AND MAIN RESULTS: A total of 29 patients met the inclusion criteria for this study. The median age of the patients included in the analysis was 36 years old. Eleven patients were asymptomatic at the time of diagnosis (37.9%). The reason for surgical intervention was not available in 9 of these patients. Surgical intervention was performed in 2 of the 11 asymptomatic patients because of an increasing size of the lesion during observation. Presenting symptoms included dyspareunia or pain with tampon placement (37.9%), pelvic pain or pressure (24.1%), pelvic mass or bulge (17.2%), and urinary incontinence (6.9%). Preoperative imaging studies were obtained in 62% of patients; ultrasound was used in 44.4%, computed tomographic scanning in 22.2%, magnetic resonance imaging in 16.7%, and multiple modalities in 16.7%. Approximately 10% were found to have other genitourinary anomalies, including a bladder cyst, urethral diverticulum, and a solitary right kidney with uterine didelphis and septate vagina. The average cyst size was 3.5 cm (±1.8 cm). Surgical excision of GDCs was performed in all except for 3 cases of marsupialization. No intraoperative complications occurred. The median follow-up was 82 months (range, 0-246 months). One patient had possible recurrence with dyspareunia and protruding tissue diagnosed 14 months postoperatively. There were no other postoperative complications in the follow-up period. CONCLUSION: GDCs are rare pelvic masses that are often asymptomatic but may present with dyspareunia, pelvic pain or pressure, pelvic mass or bulge, or urinary symptoms. Excision or marsupialization is successful in the majority of cases without significant morbidity.

Intraoperative Predictors of Long-term Outcomes After Radiofrequency Endometrial Ablation.

STUDY OBJECTIVE: To identify intraoperative predictors of radiofrequency ablation (RFA) failure after adjusting for clinical risk factors. DESIGN: A cohort study (Canadian Task Force II-2). SETTING: An academic institution in the Upper Midwest. PATIENTS: Data were retrospectively collected from medical records of women who underwent RFA and who had a postprocedure gynecologic assessment between April 1998 and December 2011. INTERVENTIONS: RFA. MEASUREMENTS AND MAIN RESULTS: The primary outcome was RFA failure, which was defined as hysterectomy, repeat ablation, synechiolysis, or treatment with gonadotropin-releasing hormone analogue for postablation pain or bleeding. Cox proportional hazards regression was used to test the predictability of intraoperative variables on RFA failure with adjustment for baseline predictors. We created an RFA index to capture the procedure duration divided by the uterine surface area. One thousand one hundred seventy-eight women were eligible. The median age at ablation was 44 years (interquartile range, 40-48 years), and the median parity was 2 (interquartile range, 2-3). Dysmenorrhea and prior tubal ligation were reported in 37.1% and 37.2% of women, respectively. After adjustment for baseline characteristics, intraoperative predictors of failure were uterine sounding length >10.5 cm (adjusted hazard ratio [HR] = 2.58; 95% confidence interval [CI], 1.31-5.05), uterine cavity length >6 cm (adjusted HR = 2.06; 95% CI, 1.30-3.27), uterine width >4.5 cm (adjusted HR = 2.06; 95% CI, 1.29-3.28), surface area >25 cm(2) (adjusted HR = 2.02; 95% CI, 1.26-3.23), procedure time <93 seconds (adjusted HR = 2.61; 95% CI, 1.25-5.47), and RFA index <3.6 (adjusted HR = 3.14; 95% CI, 1.70-5.77). CONCLUSION: Intraoperative parameters are predictive of long-term adverse outcomes of RFA independent of patient clinical characteristics. Uterine length, procedure duration, and RFA index are associated with unfavorable outcomes and thus could be used to optimize postprocedure patient counseling.

Hysteroscopic Morcellation Versus Resection for the Treatment of Uterine Cavitary Lesions: A Systematic Review and Meta-analysis.

This systematic review and meta-analysis compares hysteroscopic morcellation with electrosurgical resection to treat uterine cavitary lesions. A search of Ovid MEDLINE, Ovid Embase, Scopus, and Web of Science was conducted through August 18, 2015, for randomized controlled trials (RCTs) and prospective and retrospective studies, regardless of surgical indication and study language or sample size. Seven studies were eventually included (4 RCTs and 3 retrospective observational studies), enrolling 650 women. The meta-analysis showed that the total procedure time was significantly shorter for morcellation than for resection (weighted mean difference = 9.36 minutes; 95% confidence interval [CI], -15.08 to -3.64). When reviewing RCTs only, intrauterine morcellation was associated with a smaller fluid deficit and lower odds of incomplete lesion removal. This difference was not statistically significant in observational studies. There was no significant difference in the odds of surgical complications (odds ratio = 0.72; 95% CI, 0.20-2.57) or the number of insertions (weighted mean difference = -3.04; 95% CI, -7.86-1.78). In conclusion, compared with hysteroscopic resection, hysteroscopic morcellation is associated with a shorter operative time and possibly lower odds of incomplete lesion removal. The certainty in evidence was limited by heterogeneity and the small sample size.

Combined Endometrial Ablation and Levonorgestrel Intrauterine System Use in Women With Dysmenorrhea and Heavy Menstrual Bleeding: Novel Approach for Challenging Cases.

STUDY OBJECTIVE: To evaluate the feasibility and impact of levonorgestrel intrauterine system (LNG-IUS) on treatment failure after endometrial ablation (EA) in women with heavy menstrual bleeding (HMB) and dysmenorrhea at 4 years. DESIGN: Cohort study (Canadian Task Force II-2). SETTING: An academic institution in the upper Midwest. PATIENTS: All women with HMB and dysmenorrhea who underwent EA with combined placement of LNG-IUS (EA/LNG-IUS cohort, 23 women) after 2005 and an historic reference group from women who had EA alone (EA cohort, 65 women) from 1998 through the end of 2005. INTERVENTION: Radiofrequency EA, thermal balloon ablation, and LNG-IUS. MEASUREMENTS AND MAIN RESULTS: The primary outcome was treatment failure defined as persistent pain, bleeding, and hysterectomy after EA at 4 years. The combined treatment failure outcome was documented in 2 patients (8.7%) in the EA/LNG-IUS group and 19 patients (29.2%) in the EA group with an unadjusted OR of .23 (95% CI, .05-1.08). After adjusting for known risk factors of failure, the adjusted OR was .19 (95% CI, .26-.88). None of the women who underwent EA/LNG-IUS had hysterectomy for treatment failure compared with 16 (24%) in the EA group (p = .009); postablation pelvic pain was documented in 1 woman (4.3%) in the EA/LNG-IUS group compared with 8 women (12.3%) in the EA group (p = .24). One woman in the EA/LNG-IUS group (4.3%) presented with persistent bleeding compared with 15 (23.1%) in the EA group (p = .059). Office removal of the intrauterine device was performed in 4 women with no complications. CONCLUSION: LNG-IUS insertion at the time of EA is feasible and can provide added benefit after EA in women with dysmenorrhea and HMB.

Asymptomatic thickened endometrium in postmenopausal women: malignancy risk.

STUDY OBJECTIVE: To assess the diagnostic findings and determine the frequency of malignancy in postmenopausal women evaluated by office hysteroscopy for a thickened endometrium without bleeding. DESIGN: Retrospective cohort (Canadian Task Force classification II-B). SETTING: Academic medical center in the Midwestern United States. PATIENTS: Over 3600 women underwent an office hysteroscopy between January 1, 2007, and October 20, 2011, for abnormal uterine bleeding or an abnormal ultrasound. Of these, 154 postmenopausal women had a thickened endometrium (>4 mm) and no bleeding. INTERVENTIONS: Flexible office hysteroscopy using a 3.1-mm scope with saline as the distending media was performed for clinical reasons, and results were captured within a research database. MEASUREMENTS AND MAIN RESULTS: For the 154 women, the range of endometrial measurements was 4.2 to 28 mm (mean = 10.0 mm). Hysteroscopy diagnoses included 93 patients with polyps, 19 with myomas or uterine synechiae, and 34 with benign-appearing endometrium. Nine hysteroscopies were inadequate because of poor visualization (n = 1), cervical stenosis (n = 6), or patient discomfort (n = 2). Endometrial biopsies (EMBs) were performed in 109 patients, and none were found to have cancer or an atypical endometrium. Six had simple hyperplasia without atypia, and their endometrial measurements were within the range of the patients in our study who had a benign endometrium (5-15 mm, mean = 10.3). Of the women with a polyp, 73 (78.4%) subsequently underwent polypectomy. On final pathology, 1 had cancer (endometrial measurement = 24 mm), and 1 had complex hyperplasia with atypia (endometrial measurement = 17 mm). EMBs performed in the office for these 2 patients showed an insufficient endometrium and inactive endometrium, respectively. CONCLUSION: Cancer and atypia can occur in asymptomatic women. Endometrial thickness was 17 mm or greater in 2 cases, and EMBs performed in the office were inconsistent with the final diagnosis. Hysteroscopy is important when ultrasound and EMB do not agree. Polypectomy may be indicated even in asymptomatic women, but further studies regarding an endometrial measurement threshold or polyp size are warranted.

Perceived risk of cervical cancer among low-income women.

BACKGROUND: Risk perception is an important predictor of cancer prevention behaviors. We examined the perceived risk of cervical cancer among an ethnically diverse population of women of lower socioeconomic status. MATERIALS AND METHODS: Females attending a women's health clinic were recruited for a study addressing cervical cancer prevention. Survey questions evaluated lifetime perceived risk of cervical cancer (0%-100%), beliefs about the accuracy of the Pap test, and estimated incidence of abnormal Pap test results. Risk estimates for oneself were followed with an item seeking a brief, qualitative explanation of the risk estimate. RESULTS: Surveys were completed by 338 women. The mean (SD) age of respondents was 29.9 (8.6) years. Women self-identified as Hispanic/Latina (32%, n=107), White (34%, n=116), and African American (34%, n=115). Estimated perceived lifetime risk of getting cervical cancer ranged from 0% to 100% (59.2 [29.5]). Risk estimates were associated with perceived prevalence of abnormal results (r=0.24, p<.001) and perceptions regarding the accuracy of the Pap test (r=0.13, p<.05). On average, women estimated that nearly half of all women have ever had an abnormal result (49.2 [26.9]; n=335; range, 0%-100%), with African American women estimating a higher percentage compared to Hispanic/Latina and White women. Women who themselves experienced an abnormal Pap test result reported higher proportions of other women experiencing an abnormal result (t333=-3.67, p<.01). CONCLUSIONS: This study advances our understanding of misperception of risk and how women qualitatively view their risk of cervical cancer. The findings underscore areas for practitioners to enhance patient education efforts.

Direct aspiration endometrial biopsy via flexible hysteroscopy.

STUDY OBJECTIVE: To determine feasibility and efficacy of direct aspiration endometrial biopsy via the fluid channel of a flexible diagnostic hysteroscope. DESIGN: Retrospective review (Canadian Task Force classification II-3). SETTING: Abnormal uterine bleeding clinic in a tertiary care center. PATIENTS: All women who underwent direct aspiration endometrial biopsy from January 2007 through August 2011 via a flexible diagnostic hysteroscope because traditional office-based endometrial biopsy using a suction piston device was not technically possible. INTERVENTIONS: Diagnostic hysteroscopy followed by direct aspiration endometrial biopsy, accomplished by applying suction to the fluid channel of a 3.1-mm flexible diagnostic hysteroscope via a 10-mL syringe. The hysteroscope tip was agitated within the uterine cavity to obtain a tissue sample. MEASUREMENTS AND MAIN RESULTS: The median age of the 32 identified patients was 50 years; 18 women (56%) were nulliparous, and 10 (31%) were postmenopausal. Thirty-one patients underwent hysteroscopy/direct aspiration biopsy because of abnormal uterine bleeding or postmenopausal bleeding. The vaginoscopic approach was used in 19 patients (59%). Indications for direct aspiration endometrial biopsy included cervical stenosis, inability to pass the endometrial biopsy instrument into the uterine cavity, and patient intolerance of endometrial biopsy. Adequate endometrial samples were obtained in 28 patients (87.5%). In 3 of 4 patients in whom direct aspiration endometrial biopsy did not provide sufficient tissue, hysteroscopy revealed an atrophic-appearing endometrium. The direct aspiration endometrial biopsy diagnosis was confirmed in 5 of 7 patients who subsequently underwent dilation and curettage or hysterectomy. CONCLUSION: Direct aspiration endometrial biopsy is a simple and effective endometrial sampling method when traditional office-based endometrial biopsy is not feasible. Further prospective studies including larger populations are needed to confirm these results.

Use of High-Fidelity Simulation to Enhance Interdisciplinary Collaboration and Reduce Patient Falls.

OBJECTIVES: This pilot study aimed to determine the effect of nurse/physician interdisciplinary team training on patient falls. Specifically, we evaluated team training in a simulation center as a method for targeting and minimizing breakdowns in perceptions of respect, collaboration, communication, and role misunderstanding behaviors between care disciplines. METHODS: Registered nurses (RNs) were randomly assigned to participate. Residents were divided into groups and assigned based on their availability and clinical responsibility. All participants completed a demographic form, the Professional Practice Environment Assessment Scale (PPEAS), and the Mayo High Performance Teamwork Scale (MHPTS) after consenting and before participation in simulation training. The PPEAS and the MHPTS were readministered at 2 and 6 months after the simulation experience. Differences in MHPTS and PPEAS scores between the baseline and 2- and 6-month assessments were analyzed; fall rates over time were evaluated using Cochran-Armitage trend tests. RESULTS: After the team training exercises, teamwork as measured by the MHPTS improved significantly at both 2 and 6 months (P = 0.01; P < 0.001) compared with baseline measurement. Practice environment subscores, with the exception of positive organizational characteristics, also increased when measured 6 months after training. The primary outcome, reduction in anticipated patient falls, improved significantly (P = 0.02) over the course of the study. CONCLUSIONS: Results of this pilot study show that team training exercises result in improvement in both patient safety (anticipated patient falls) and team member perception of their work environment. If validated by other studies, improvement in this patient safety metric would represent an important benefit of simulation and team training.

Improving patient access through office hysteroscopy clinic redesign.

BACKGROUND AND OBJECTIVE: Patients with abnormal uterine bleeding (AUB) often require hysteroscopy as part of the diagnostic workup. The purpose of this study was to improve efficiency by shortening the time to patient appointment for office hysteroscopy. INTERVENTIONS: Preintervention, nurse practitioners (NPs) and gynecologists saw patients with abnormal uterine bleeding (AUB) separately. This created inefficiency for the patients, frequently requiring second visits for hysteroscopy. A new hysteroscopy clinic was designed to increase practice efficiency. A collaborative team model was created including consecutive visits with NPs and gynecologists. Each patient with AUB was first evaluated by an NP, followed immediately by a shorter visit with a gynecologist for office hysteroscopy as indicated. NPs managed other diagnostic evaluation and bleeding treatment if hysteroscopy was not warranted. Collaborative clinic staffing consisted of two NPs seeing patients with AUB paired with one gynecologist for procedural support. MEASUREMENTS AND RESULTS: Electronic records of 393 patients scheduled for AUB visits from January to June 2015 were evaluated for preintervention data. Postintervention, 647 patient records were reviewed from January to June of 2016. During the preintervention period, 30% of patients had a hysteroscopy appointment scheduled within 0-13 days from the initial visit for AUB. Postintervention, the wait time for appointments decreased, with 63% of patients scheduled within 0-13 days. Clinic redesign also resulted in an increase of 57.5% in appointment slots. No-show rates and appointment fill rates were not adversely affected. CONCLUSIONS: A collaborative team-based care model using NPs and gynecologists improved efficiency and access to office hysteroscopy services.

What makes a chronic pelvic pain patient satisfied?

Purpose: Caring for women with chronic pelvic pain (CPP) is challenging. There have been few studies on what factors patients consider to be important when being treated for their pelvic pain. This study sought to identify the key factors of the health care visit that contribute to patient's overall satisfaction with their care in a CPP clinic. Materials and methods: Between January 2015 and December 2016, new patients visiting a tertiary care CPP clinic were recruited to complete a patient satisfaction survey. Inductive thematic analysis was performed on response data regarding important factors that impact patient satisfaction with their visit/care. Results: Five themes of patient satisfaction identified included: providers with a compassionate and caring attitude, being listened to, clear communication with collaboration when needed, quality time spent with patient, and having a plan of care with recommendations. The theme regarding provider's compassion and listening skills was the most frequently identified. Pain relief was seldom mentioned as a source of patient satisfaction. Conclusions: The data suggest that a focus on empathic communication may make a meaningful difference in meeting the needs of women with CPP as well as strengthening the provider/patient relationship.

Use of Asynchronous Video Interviews for Selecting Obstetrics and Gynecology Residents.

OBJECTIVE: To assess the effect of using of asynchronous video interviewing as a screening tool for obstetrics and gynecology residency selection. METHODS: This project was part of a quality-improvement effort to enhance the resident application process. Applications to a single obstetrics and gynecology residency program were scored using standardized criteria. In the 2018 Match, top-scored applicants were invited to in-person interviews, and second-tier applicants were asked to complete a three-question asynchronous video interview. Video interviews were scored and used to invite the remaining applicants for in-person interviews. In the 2019 Match, video interviewing was expanded to all applicants with top application scores, and the video score was used to determine in-person interview invitations. Applicants for 2019 were surveyed on their views regarding video interviewing. RESULTS: Half of the candidates interviewed in person in the 2018 season were screened by the video interview process compared with 82% in the 2019 season. The mean in-person interview score increased from 59.0 in 2017, before screening with asynchronous video interviews, to 62.2 in 2018 (effect size 0.50; 95% CI 0.09-0.90) In 2018, a nonsignificant correlation was seen between the video interview score and rank list percentile (r=0.22, P=.15, n=27) and in-person interview score (r=0.18, P=.12, n=46). United States Medical Licensing Examination step 1 and 2 scores were not correlated with video interview scores in either season. Most (58%) candidates indicated that the asynchronous video interview was an effective way to tell their story; however, only 42% were comfortable with the interview process. CONCLUSION: Video interviewing may have promise as a tool for program directors to use to select candidates from a competitive applicant pool by measuring important noncognitive skills. Acceptance by obstetrics and gynecology applicants was mixed.

Microbicides: information, beliefs, and preferences for insertion.

OBJECTIVES: Microbicides are products in development to prevent sexually transmitted infection and HIV acquisition; they are not yet available to the public. We evaluated (1) where women would expect to seek information about microbicides, (2) factors that women think might affect microbicide effectiveness, and (3) women's anticipated preferences for timing and place of insertion and partner involvement. METHODS: A cross-sectional face-to-face interview was administered to women aged 18-35 years (n=126) recruited from a gynecology clinic in Galveston, Texas. Women were shown a microbicide surrogate and asked to complete a series of closed-ended questions focusing on demographics, expected sources of information on microbicides, perceived factors related to effectiveness, and preferences for timing and place of insertion and level of partner involvement. Univariate descriptive analyses were used to calculate means, medians, and frequencies. RESULTS: Women's most cited anticipated sources of information for microbicides were physicians (89%), the package insert/box (86%), and pharmacists (70%). Approximately two thirds of the women believed that menstruation or taking other medicines and approximately one third believed that taking a bath/shower before intercourse or after intercourse or using birth control medication could limit effectiveness. Women anticipated preferring to insert the microbicide before intercourse (90%) and while in the bathroom (73%). Most (95%) anticipated telling their partners they planned to use a microbicide, and 38% anticipated having their partner insert the product for them. CONCLUSIONS: Women's beliefs about those factors that could limit effectiveness of microbicides should be addressed as part of anticipatory guidance or in the package inserts. Partners likely will be involved in the use of microbicides; thus, education/marketing efforts should also incorporate partner beliefs and preferences.

Medical therapy versus radiofrequency endometrial ablation in the initial treatment of heavy menstrual bleeding (iTOM Trial): A clinical and economic analysis.

BACKGROUND: Radiofrequency endometrial ablation (REA) is currently a second line treatment in women with heavy menstrual bleeding (MHB) if medical therapy (MTP) is contraindicated or unsatisfactory. Our objective is to compare the effectiveness and cost burden of MTP and REA in the initial treatment of HMB. METHODS: We performed a randomized trial at Mayo Clinic Rochester, Minnesota. The planned sample size was 60 patients per arm. A total of 67 women with HMB were randomly allocated to receive oral contraceptive pills (Nordette ®) or Naproxen (Naprosyn®) (n = 33) or REA (n = 34). Primary 12-month outcome measures included menstrual blood loss using pictorial blood loss assessment chart (PBLAC), patients' satisfaction, and Menorrhagia Multi-Attribute Scale (MMAS). Secondary outcomes were total costs including direct medical and indirect costs associated with healthcare use, patient out-of-pocket costs, and lost work days and activity limitations over 12 months. RESULTS: Compared to MTP arm, women who received REA had a significantly lower PBLAC score (median [Interquartile range, IQR]: 0 [0-4] vs. 15 [0-131], p = 0.003), higher satisfaction rates (96.8%vs.63.2%, p = 0.003) and higher MMAS (median [IQR]: 100 [100-100] vs. 100 [87-100], p = 0.12) at 12 months. Direct medical costs were higher for REA ($5,331vs.$2,901, 95% confidence interval (CI) of mean difference:$727,$4,852), however, when indirect costs are included, the difference did not reach statistical significance ($5,469 vs. $3,869, 95% CI of mean difference:-$339, $4,089). CONCLUSION: For women with heavy menstrual bleeding, initial radiofrequency endometrial ablation compared to medical therapy offered superior reduction in menstrual blood loss and improvement in quality of life without significant differences in total costs of care. CLINICAL TRIAL REGISTRATION: NCT01165307.