Identifying Gaps in Pelvic Pain Education: A Scoping Review and Structured Analysis of Obstetrics and Gynecology Training Milestones.

OBJECTIVE: Several clinical practice guidelines on the evaluation and management (EM) of chronic pelvic pain (CPP) have been published; however, it is not known whether obstetrics and gynecology (OBGYN) educational milestones are aligned with current practice recommendations. Therefore, this scoping review and structured analysis aims to identify gaps between clinical guidelines for the EM of CPP and OBGYN training milestones published by educational authorities like the Accreditation Council for Graduate Medical Education (ACGME) and the AAGL. DATA SOURCES: The literature search was performed in MEDLINE, PubMed Central, and Bookshelf on the PubMed interface from January 2018 to September 2022. Peer-reviewed publications were included if they were a systematic review of recent practice guidelines and focused on female CPP. Publications that focused on a single pelvic pain condition or focused on a specific treatment were excluded. METHODS OF STUDY SELECTION: Two reviewers extracted the data and appraised the study quality following the Critical Appraisal Skills Programme Checklist for systematic reviews. Four articles met inclusion criteria for thematic analysis. A reflexive thematic analysis via the inductive approach was performed to develop clinical themes common to all review articles and presumed important in the EM of CPP. Pelvic pain experts and Delphi methodology was used to assess validity and relevance of each theme in OBGYN training. Validated themes were used in a strengths weaknesses opportunities threats (SWOT) analysis of the ACGME and the AAGL Milestones used for training OBGYN residents and fellows. A SWOT analysis is an organizational tool used to analyze processes in terms of strengths, weaknesses, opportunities for improvement, and threats to implementing a potential change. TABULATION, INTEGRATION, AND RESULTS: Twelve clinical themes were conceptualized and achieved ≥ 90% consensus as being important in the EM of CPP. Clinical themes pertained to pathophysiology, biopsychosocial approach, trauma-informed care, history and physical examination, diagnostic testing, multimodal/multidisciplinary management, pain education, and medical and surgical management. SWOT analysis showed that the ACGME Milestones lacked milestones specific to CPP, while the AAGL Milestones had 6 CPP-focused competencies with multiple milestones. Milestones on trauma-informed care and application of biopsychosocial assessment were notably absent. CONCLUSION: OBGYN educational milestones published by the ACGME and the AAGL are not yet aligned with current clinical guidelines for the EM of CPP.

Validation of a Simulation Model for Robotic Myomectomy.

STUDY OBJECTIVE: Several simulation models have been evaluated for gynecologic procedures such as hysterectomy, but there are limited published data for myomectomy. This study aimed to assess the validity of a low-cost robotic myomectomy model for surgical simulation training. DESIGN: Prospective cohort simulation study. SETTING: Surgical simulation laboratory. PARTICIPANTS: Twelve obstetrics and gynecology residents and 4 fellowship-trained minimally invasive gynecologic surgeons were recruited for a 3:1 novice-to-expert ratio. INTERVENTIONS: A robotic myomectomy simulation model was constructed using <$5 worth of materials: a foam cylinder, felt, a stress ball, bandage wrap, and multipurpose sealing wrap. Participants performed a simulation task involving 2 steps: fibroid enucleation and hysterotomy repair. Video-recorded performances were timed and scored by 2 blinded reviewers using the validated Global Evaluative Assessment of Robotic Skills (GEARS) scale (5-25 points) and a modified GEARS scale (5-40 points), which adds 3 novel domains specific to robotic myomectomy. Performance was also scored using predefined task errors. Participants completed a post-task questionnaire assessing the model's realism and utility. MEASUREMENTS AND MAIN RESULTS: Median task completion time was shorter for experts than novices (9.7 vs 24.6 min, p = .001). Experts scored higher than novices on both the GEARS scale (median 23 vs 12, p = .004) and modified GEARS scale (36 vs 20, p = .004). Experts made fewer task errors than novices (median 15.5 vs 37.5, p = .034). For interrater reliability of scoring, the intraclass correlation coefficient was calculated to be 0.91 for the GEARS assessment, 0.93 for the modified GEARS assessment, and 0.60 for task errors. Using the contrasting groups method, the passing mark for the simulation task was set to a minimum modified GEARS score of 28 and a maximum of 28 errors. Most participants agreed that the model was realistic (62.5%) and useful for training (93.8%). CONCLUSION: We have demonstrated evidence supporting the validity of a low-cost robotic myomectomy model. This simulation model and the performance assessments developed in this study provide further educational tools for robotic myomectomy training.

Interactive video module and simulated model for uterine manipulation during laparoscopic hysterectomy.

BACKGROUND: Hysterectomy is one of the most common gynecologic surgeries, with an increasing proportion of hysterectomies performed by a laparoscopic approach. Uterine manipulation is critical for patient safety and surgical efficiency; however, the most junior member of the surgical team assumes the responsibility of uterine manipulation, commonly without preparation. The objective of our study was to determine whether kinesthetic learning using a low-cost simulated pelvic model while learning the uterine manipulation maneuvers of a laparoscopic hysterectomy improves learning efficacy and application efficiency compared to an interactive video module alone. METHODS: Our randomized control trial at an academic medical center included forty first-year and second-year medical students. Participants were randomized to the intervention group that used a low-cost simulated pelvic model for kinesthetic learning during the video module or the control group who only had the interactive video module to learn the uterine manipulation maneuvers of a laparoscopic hysterectomy. RESULTS: Participants in the intervention group were less likely to make unnecessary movements with demonstration of both pelvic side walls (right wall: control 78.9%, intervention 42.9%, p < 0.027; left wall: control 94.7%, intervention 66.7%, p < 0.046), and this was more pronounced in novice first-year participants (p < 0.009). Additionally, participants in the intervention group reported higher perceived preparedness (100% versus 71.4% in control group, p < 0.037). However, there was no difference in verbal or physical cues required, time per task, or force used between the groups. CONCLUSION: Kinesthetic practice may not be required for learning the uterine manipulation maneuvers of a laparoscopic hysterectomy, but it may be beneficial for more novice learners and to increase learners' perceived preparedness. Our novel interactive video module alone may be sufficient to prepare learners to perform uterine manipulation maneuvers prior to the operating room.

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.

A systematic review on the use of artificial intelligence in gynecologic imaging - Background, state of the art, and future directions.

OBJECTIVE: Machine learning, deep learning, and artificial intelligence (AI) are terms that have made their way into nearly all areas of medicine. In the case of medical imaging, these methods have become the state of the art in nearly all areas from image reconstruction to image processing and automated analysis. In contrast to other areas, such as brain and breast imaging, the impacts of AI have not been as strongly felt in gynecologic imaging. In this review article, we: (i) provide a background of clinically relevant AI concepts, (ii) describe methods and approaches in computer vision, and (iii) highlight prior work related to image classification tasks utilizing AI approaches in gynecologic imaging. DATA SOURCES: A comprehensive search of several databases from each database's inception to March 18th, 2021, English language, was conducted. The databases included Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Ovid Cochrane Database of Systematic Reviews and ClinicalTrials.gov. METHODS OF STUDY SELECTION: We performed an extensive literature review with 61 articles curated by three reviewers and subsequent sorting by specialists using specific inclusion and exclusion criteria. TABULATION, INTEGRATION, AND RESULTS: We summarize the literature grouped by each of the three most common gynecologic malignancies: endometrial, cervical, and ovarian. For each, a brief introduction encapsulating the AI methods, imaging modalities, and clinical parameters in the selected articles is presented. We conclude with a discussion of current developments, trends and limitations, and suggest directions for future study. CONCLUSION: This review article should prove useful for collaborative teams performing research studies targeted at the incorporation of radiological imaging and AI methods into gynecological clinical practice.

Development and validation of a simulation model for laparoscopic myomectomy.

BACKGROUND: Simulation is an important adjunct to traditional surgical training, allowing for repetitive practice of new skills without compromising patient safety. Although several simulation models have been described and evaluated for gynecologic procedures, there is a lack of such models for laparoscopic myomectomy. OBJECTIVE: This study aimed to design a low-cost, low-fidelity laparoscopic myomectomy simulation model and to assess the model's validity as a training tool. STUDY DESIGN: The model was constructed using a "cup turner" foam cylinder, felt, a 2-inch stress ball, self-adhesive bandage wrap, multipurpose sealing wrap, red marker, and hook-and-loop fastener. Participants were recruited at a quaternary care academic center and at the Society for Gynecologic Surgeons Annual Scientific Meeting. The simulation task involved the following 2 steps: fibroid enucleation and hysterotomy repair. Validity evidence was collected by comparing expert and novice simulation task performances. Video recordings were scored by 2 blinded reviewers using the Global Operative Assessment of Laparoscopic Skills scale (5-20 points) and a modified Global Operative Assessment of Laparoscopic Skills scale (5-35 points), incorporating 3 novel domains specific to laparoscopic myomectomy. The Mann-Whitney U test was used to compare the task completion times and performance scores. Interrater reliability of scoring was assessed using the interclass correlation coefficient. Validity was also assessed with a post-task survey regarding the model's realism, utility, and educational effect. RESULTS: The total cost to construct each model was under $5. A 3:1 ratio was used to recruit 15 novices and 5 experts. The median time to task completion was shorter for experts than for novices (11.8 vs 20.1 minutes; P=.004). The experts scored higher than the novices on both the Global Operative Assessment of Laparoscopic Skills scale (median 19 [range 13-20] vs 10 [6-17.5]; P=.007) and the modified Global Operative Assessment of Laparoscopic Skills scale (31.5 [21.5-33.5] vs 18.5 [13.5-32]; P=.009). The interclass correlation coefficient was 0.95 for the Global Operative Assessment of Laparoscopic Skills scores and 0.96 for the modified Global Operative Assessment of Laparoscopic Skills scores. Most of the participants agreed that the model closely approximated the feel of fibroid enucleation (70% [14/20]) and suturing the uterus (80% [16/20]). All the participants agreed that the model was useful for learning or teaching laparoscopic myomectomy. CONCLUSION: This study demonstrates evidence supporting the validity of a novel, low-cost laparoscopic myomectomy model and a novel assessment scale for laparoscopic myomectomy training. This simulation model provides a targeted training tool that allows learners to focus on the key aspects of laparoscopic myomectomy and may improve readiness for the operating room.

Endometriosis biomarkers of the disease: an update.

PURPOSE OF REVIEW: Endometriosis is a complex benign gynaecologic condition with heterogenous presentations and a large impact on the global healthcare system and on the quality of life for millions of women. Currently, the gold standard for diagnosis involves direct visualization of lesions during surgery confirmed by histopathological diagnosis, resulting in an average delay in its initial diagnosis of 8-10 years. Therefore, the search for noninvasive diagnostic testing options has been subject to a large body of research. RECENT FINDINGS: Multiple potential biomarkers have been explored for noninvasive testing for endometriosis, including glycoproteins, inflammatory cytokines, immunological molecules, angiogenesis markers, hormones, micro RNAs (miRNAs), proteomics, metabolomics, genomics and the microbiome. SUMMARY: Although there are challenges to consider, areas for real promise and advancement in the noninvasive diagnosis of endometriosis are currently being explored with real promise in the area of miRNAs, proteomics, metabolomics, genomics and the microbiome.

Surgical Science-Simbionix Robotic Hysterectomy Simulator: Validating a New Tool.

STUDY OBJECTIVE: To gather validity evidence for and determine acceptability of Surgical Science-Simbionix Hysterectomy Modules for the DaVinci Xi console simulation system (software; 3D Systems by Simbionix [now Surgical Science-Simbionix], Littleton, CO, and hardware; Intuitive Surgical, Inc., Sunnyvale, CA) and evaluate performance benchmarks between novice and experienced or expert surgeons. DESIGN: Prospective education study (Messick validity framework). SETTING: Multicenter, academic medical institutions. PARTICIPANTS: Residents, fellows, and faculty in obstetrics and gynecology were invited to participate at 3 institutions. Participants were categorized by experience level: fewer than 10 hysterectomies (novice), 10 to 50 hysterectomies (experienced), and more than 50 hysterectomies (expert). A total of 10 novice, 10 experienced, and 14 expert surgeons were included. INTERVENTIONS: Participants completed 4 simulator modules (ureter identification, bladder flap development, colpotomy, complete hysterectomy) and a qualitative survey. Simulator recordings were reviewed in duplicate by educators in minimally invasive gynecologic surgery using the Modified Global Evaluative Assessment of Robotic Skills (GEARS) rating scale. MEASUREMENTS AND MAIN RESULTS: Most participants felt that the simulator realistically simulated robotic hysterectomy (64.7%) and that feedback provided by the simulator was as or more helpful than feedback from previous simulators (88.2%) but less helpful than feedback provided in the operating room (73.5%). Participants felt that this simulator would be helpful for teaching junior residents. Simulator-generated metrics correlated with GEARS performance for the bladder flap and ureter identification modules in multiple domains including total movements and total time for completion. GEARS performance for the bladder flap module correlated with experience level (novice vs experienced/expert) in the domains of interest and total score but did not consistently correlate for the other procedural modules. Performance benchmarks were evaluated for the bladder flap module for each GEARS domain and total score. CONCLUSION: The modules were well received by participants of all experience levels. Individual simulation modules appear to better discriminate between novice and experienced/expert users than overall simulator performance. Based on these data and participant feedback, the use of individual modules in early residency education may be helpful for providing feedback and may ultimately serve as 1 component of determining readiness to perform robotic hysterectomy.

Persistent Pelvic Pain in Patients With Endometriosis.

As our understanding of chronic pain conditions, including endometriosis-related pain and chronic pelvic pain evolves, the evaluation and management of patients should reflect our increasing appreciation of the role of central sensitization, comorbid conditions and biopsychosocial factors on the pain experience and treatment outcomes. This review provides a systematic approach to persistent pain in patients with endometriosis. Expanding the evaluation and treatment of endometriosis-related pain by all health care providers could limit unnecessary surgical interventions and best meet our patient's needs.

Robotic Surgery: The Impact of Simulation and Other Innovative Platforms on Performance and Training.

OBJECTIVE: To review the current status of robotic training and the impact of various training platforms on the performance of robotic surgical trainees. DATA SOURCES: Literature review of Google Scholar and PubMed. The search terms included a combination of the following: "robotic training," "simulation," "robotic curriculum," "obgyn residency robotic training," "virtual reality robotic training," "DaVinci training," "surgical simulation," "gyn surgical training." The sources considered for inclusion included peer-reviewed articles, literature reviews, textbook chapters, and statements from various institutions involved in resident training. METHODS OF STUDY SELECTION: A literature search of Google Scholar and PubMed using terms related to robotic surgery and robotics training, as mentioned in the "Data Sources" section. RESULTS: Multiple novel platforms that use machine learning and real-time video feedback to teach and evaluate robotic surgical skills have been developed over recent years. Various training curricula, virtual reality simulators, and other robotic training tools have been shown to enhance robotic surgical education and improve surgical skills. The integration of didactic learning, simulation, and intraoperative teaching into more comprehensive training curricula shows positive effects on robotic skills proficiency. Few robotic surgery training curricula have been validated through peer-reviewed study, and there is more work to be completed in this area. In addition, there is a lack of information about how the skills obtained through robotics curricula and simulation translate into operating room performance and patient outcomes. CONCLUSION: Data collected to date show promising advances in the training of robotic surgeons. A diverse array of curricula for training robotic surgeons continue to emerge, and existing teaching modalities are evolving to keep up with the rapidly growing demand for proficient robotic surgeons. Futures areas of growth include establishing competency benchmarks for existing training tools, validating existing curricula, and determining how to translate the acquired skills in simulation into performance in the operating room and patient outcomes. Many surgical training platforms are beginning to expand beyond discrete robotic skills training to procedure-specific and team training. There is still a wealth of research to be done to understand how to create an effective training experience for gynecologic surgical trainees and robotics teams.

Vaginal Diazepam for Nonrelaxing Pelvic Floor Dysfunction: The Pharmacokinetic Profile.

BACKGROUND: Vaginal diazepam is frequently used to treat pelvic floor tension myalgia and pelvic pain despite limited knowledge of systemic absorption. AIM: To determine the pharmacokinetic and adverse event profile of diazepam vaginal suppositories. METHODS: We used a prospective pharmacokinetic design with repeated assessments of diazepam levels. Eight healthy volunteers were administered a 10-mg compounded vaginal diazepam suppository in the outpatient gynecologic clinic. Serum samples were collected at 0, 45, 90, 120, and 180 minutes; 8, 24, and 72 hours; and 1 week following administration of a 10-mg vaginal suppository. The occurrence of adverse events was assessed using the alternate step and tandem walk tests, the Brief Confusion Assessment Method, and numerical ratings. Plasma concentrations of diazepam and active long-acting metabolites were measured. Pharmacokinetic parameters were calculated by standard noncompartmental methods. RESULTS: The mean peak diazepam concentration (Cmax) of 31.0 ng/mL was detected at a mean time (Tmax) of 3.1 hours after suppository placement. The bioavailability was found to be 70.5%, and the mean terminal elimination half-life was 82 hours. The plasma levels of temazepam and nordiazepam peaked at 0.8 ng/mL at 29 hours and 6.4 ng/mL at 132 hours, respectively. Fatigue was reported by 3 of 8 participants. CLINICAL IMPLICATIONS: Serum plasma concentrations of vaginally administered diazepam are low; however the half-life is prolonged. STRENGTHS & LIMITATIONS: Strengths include use of inclusion and exclusion criteria aimed at mitigating clinical factors that could adversely impact diazepam absorption and metabolism, and the use of an ultrasensitive LC-MS/MS assay. Limitations included the lack of addressing the efficacy of vaginal diazepam in lieu of performing a pure pharmacokinetic study with healthy participants. CONCLUSION: Vaginal administration of diazepam results in lower peak serum plasma concentration, longer time to peak concentration, and lower bioavailability than standard oral use. Providers should be aware that with diazepam's long half-life, accumulating levels would occur with chronic daily doses, and steady-state levels would not be reached for up to 1 week. This profile would favor intermittent use to allow participation in physical therapy and intimacy. Larish AM, Dickson RR, Kudgus RA, et al. Vaginal Diazepam for Nonrelaxing Pelvic Floor Dysfunction: The Pharmacokinetic Profile. J Sex Med 2019;16;763-766.

Teaching learners to raise the roof: a vaginal surgery simulator for apical suspension.

INTRODUCTION AND HYPOTHESIS: The objective was to discuss the importance of apical suspension following vaginal hysterectomy and demonstrate a surgical model to aide in educating learners on a variety of apical suspension procedures. METHODS: Rates of pelvic organ prolapse are not insignificant following hysterectomy. Re-support of the vaginal apex should be performed at the time of hysterectomy in those with or without a diagnosis of prolapse. Exposure to vaginal apical support procedures may be limited owing to declining rates of vaginal hysterectomy and limited trainee work hours. Surgical models are increasingly being used to supplement operating room experience. The model we present was originally developed for hysterectomy, although its design allows for teaching a variety of apical support procedures that incorporate the uterosacral ligament (USL) for support. We demonstrate performing a USL suspension, internal McCall suture, and modified McCall suture using the model. RESULTS: The model is constructed from readily available supplies, is multi-use, and inexpensive. It allows learners to identify relevant anatomy, understand/visualize surgical steps, and practice suturing technique. CONCLUSION: Pelvic organ prolapse is common in women, although opportunities to teach apical suspension procedures may be limited. The proposed vaginal surgery simulator can be used to supplement the experience of gynecological surgery trainees with apical suspension procedures.

Visuospatial Aptitude Testing Differentially Predicts Simulated Surgical Skill.

OBJECTIVE: To determine whether visuospatial perception (VSP) testing is correlated to simulated or intraoperative surgical performance as rated by the American College of Graduate Medical Education (ACGME) milestones. DESIGN: (Canadian Task Force classification II-2). SETTING: Two academic training institutions. PARTICIPANTS: Forty-one residents, including 19 from Brigham and Women's Hospital and 22 from the Mayo Clinic, from 3 different specialties: obstetrics and gynecology, general surgery, and urology. INTERVENTION: Participants underwent 3 different tests: visuospatial perception testing (VSP), Fundamentals of Laparoscopic Surgery (FLS) peg transfer, and da Vinci robotic simulation peg transfer. Surgical grading from the ACGME milestones tool was obtained for each participant. Demographic and background information was also collected, including specialty, year of training, previous experience with simulated skills, and surgical interest. Standard statistical analyses were performed using Student's t test, and correlations were determined using adjusted linear regression models. MEASUREMENTS AND MAIN RESULTS: In univariate analysis, Brigham and Women's Hospital and Mayo Clinic training programs differed in times and overall scores for both the FLS peg transfer and da Vinci robotic simulation peg transfer tests (p < .05 for all). In addition, type of residency training affected time and overall score on the robotic peg transfer test. Familiarity with tasks correlated with higher score and faster task completion (p = .05 for all except VSP score). There were no differences in VSP scores by program, specialty, or year of training. In adjusted linear regression modeling, VSP testing was correlated only to robotic peg transfer skills (average time, p = .006; overall score, p = .001). Milestones did not correlate to either VSP or surgical simulation testing. CONCLUSION: VSP score was correlated with robotic simulation skills, but not with FLS skills or ACGME milestones. This suggests that the ability of VSP score to predict competence differs between tasks. Therefore, further investigation of aptitude testing is needed, especially before its integration as an entry examination into a surgical subspecialty.

Choosing a women's health career.

BACKGROUND: In 2005, in response to a decline in residency applications in obstetrics and gynecology (OB GYN), the American College of Obstetrics and Gynecology Presidential Task Force outlined strategies for attracting medical students to OB GYN. Application rates have increased since then, but little is known about which interventions are effective. We aimed to identify modifiable and nonmodifiable variables that may contribute to students choosing OB GYN for their careers; this information could be used to inform curriculum design, faculty development, and innovative exposures to women's health. METHODS: This qualitative study received institutional review board approval. Eligible participants were students who applied or recently matched into OB GYN residency programs from the class of 2014-2016 at our institution. Students were interviewed with open-ended questions and a Likert-type survey. Thematic analysis was performed. RESULTS: Ten qualitative interviews were completed and analyzed. Intrinsic themes such as the potential for a meaningful job in women's health, advocacy for women, or empowerment of women were identified as factors contributing to participant career choice. Extrinsic themes such as positive impressions during the clinical clerkship and welcoming teams were also identified. Most students indicated that the clerkship was the most influential experience. CONCLUSIONS: Participants identified important events, including some that even preceded medical school that guided them toward OB GYN. The data guide us to consider the importance of emphasizing the unique combination of characteristics in OB GYN and improving the learning environment in the clerkship as a way to encourage student recruitment.

Changes over time in the health and functioning of older people moving into care homes: analysis of data from the English Longitudinal Study of Ageing.

Background: the number of people requiring care home support is projected to rise in future years, but little information is available on the needs of new care home residents. Objective: to measure the health and functioning of people moving into care homes and how they have changed between 2002 and 2015. Setting: English Longitudinal Study of Ageing. Participants: two hundred fifty-four of the 313 (1.99%) individuals who moved from the community into a care home, and were interviewed in the survey wave prior to entry. Main outcome measures: changes over time for number of health conditions and functional deficits (deficits in activities of daily living (ADL), and instrumental ADLs (IADLs)), assessed in the survey wave prior to admission. Results: over time there were significant increases in the total number of health conditions and functional deficits amongst soon to be care home entrants (P = 0.0011), the proportion with high blood pressure (OR 1.37, 95% CI: 1.17-1.62, P < 0.0001), memory problems (OR 1.33, 95% CI: 1.11-1.61, P = 0.0021) or total number of IADL deficits (P = 0.008). Non-significant increases were observed in the proportion of care home entrants with cancer (OR 1.23, 95% CI: 0.93-1.65, P = 0.15), lung disease (OR 1.21, 95% CI: 0.85-1.75), heart disease (OR 1.12, 95% CI: 0.95-1.30) and arthritis (OR 1.11, 95% CI: 0.95-1.30). Stroke and ADL deficits did not increase. No differential ageing effect was observed. Conclusions: the support needs of care home entrants in England appear to be increasing over time. This has important implications for the provision and funding of care home places and community services.

Establishing Benchmarks For Minimum Competence With Dry Lab Robotic Surgery Drills.

The Robotic Objective Structured Assessment of Technical Skills (R-OSATS) is a previously validated assessment tool that is used to assess 5 standardized inanimate robotic surgery drills. R-OSATS is used to evaluate performance on surgical drills, with scores of 0 to 20 for each drill. Our objective was to establish the minimum threshold score that denotes competence on these drills. Thus, we performed a standard setting study using data from surgeons and trainees in 8 academic medical centers. Cutoff scores for the minimal level of competence using R-OSATS were established using 2 techniques: the modified Angoff and the contrasting groups methods. For the modified Angoff method, 8 content experts met and, in an iterative process, derived the scores that a minimally competent trainee should receive. After 2 iterative rounds of scoring and discussion with the modified Angoff method, we established a minimum competence score per drill with high agreement (rWG range, 0.92-0.98). There was unanimous consensus that a trainee needs to achieve competence on each independent drill. A second method, the contrasting groups method, was used to verify our results. In this method, we compared R-OSATS scores from "inexperienced" (34 postgraduate year 1 and 2 trainees) with "experienced" (22 faculty and fellow) robotic surgeons. The distributions of scores from both groups were plotted, and a cutoff score for each drill was determined from the intersection of the 2 curves. Using this method, the minimum score for competence would be 14 per drill, which is slightly more stringent but confirms the results obtained from the modified Angoff approach. In conclusion, using 2 well-described standard setting techniques, we have established minimum benchmarks designating trainee competence for 5 dry lab robotic surgery drills.

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.

Insights into catalytic oxidation at the Au/TiO(2) dual perimeter sites.

Gold (Au) nanoparticles supported on reducible oxides such as TiO2 demonstrate exceptional catalytic activity for a wide range of gas phase oxidation reactions such as CO oxidation, olefin epoxidation, and water gas shift catalysis. Scientists have recently shifted their hypotheses on the origin of the reactivity of these materials from the unique electronic properties and under-coordinated Au sites on nanometer-sized particles to bifunctional sites at the Au-support interface. In this Account, we summarize our recent experimental and theoretical results to provide insights into the active sites and pathways that control oxidation over Au/TiO2 catalysts. We provide transmission IR spectroscopic data that show the direct involvement of the Au-Ti(4+) dual perimeter sites, and density functional theory results that connect the electronic properties at these sites to their reactivity and to plausible reaction mechanisms. We also show the importance of interfacial Au-Ti(4+) sites in adsorbing and activating O2 as a result of charge transfer from the Au into antibonding states on O2 causing di-σ interactions with interfacial Au-Ti(4+) sites. This results in apparent activation energies for O2 activation of 0.16-0.60 eV thus allowing these materials to operate over a wide range of temperatures (110-420 K) and offering the ability also to control H-H, C-H, and C-O bond scission. At low temperatures (100-130 K), adsorbed O2 directly reacts with co-adsorbed CO or H2. In addition, we observe the specific consumption of CO adsorbed on TiO2. The more strongly held CO/Au species do not react at ∼120 K due to high diffusion barriers that prevent them from reaching active interfacial sites. At higher temperatures, O2 directly dissociates to form active oxygen adatoms (O*) on Au and TiO2. These readily react with bound hydrocarbon intermediates via base-catalyzed nucleophilic attack on unsaturated C═O and C═C bonds or via activation of weakly acidic C-H or O-H bonds. We demonstrate that when the active Au-Ti(4+) sites are pre-occupied by O*, the low temperature CO oxidation rate is reduced by a factor 22. We observe similar site blocking for H2 oxidation by O2, where the reaction at 210 K is quenched by ice formation. At higher temperatures (400-420 K), the O* generated at the perimeter sites is able to diffuse onto the Au particles, which then activate weakly acidic C-H bonds and assist in C-O bond scission. These sites allow for active conversion of adsorbed acetate intermediates on TiO2 (CH3COO/TiO2) to a gold ketenylidene species (Au2═C═C═O). The consecutive C-H bond scission steps appear to proceed by the reaction with basic O* or OH* on the Au sites and C-O bond activation occurs at the Au-Ti(4+) dual perimeter sites. There is a bound-intermediate transfer from the TiO2 support to the Au sites during the course of reaction as the reactant (CH3COO/TiO2) and the product (Au2═C═C═O) are bound to different sites. We demonstrate that IR spectroscopy is a powerful tool to follow surface catalytic reactions and provide kinetic information, while theory provides atomic scale insights into the mechanisms and the active sites that control catalytic oxidation.

Incorporating resident/fellow training into a robotic surgery program.

With the rapid uptake of the robotic approach in gynecologic surgery, a thorough understanding of the technology, including its uses and limitations, is critical to maximize patient outcomes and safety. This review discusses the role of training modalities and development of curricula for robotic surgery. Furthermore, methods for incorporating the entire surgical team and the process of credentialing/maintaining privileges are described.

Surgical site infections after hysterectomy among HIV-infected women in the HAART era: a single institution's experience from 1999-2012.

OBJECTIVE: We sought to determine risk factors associated with surgical site infection (SSI) among a cohort of human immunodeficiency virus (HIV)-infected women undergoing hysterectomy during the era of highly active antiretroviral therapy. STUDY DESIGN: This is a retrospective study of HIV-infected women who underwent a hysterectomy for benign indications at a tertiary care center. Electronic medical records were reviewed from January 1999 through December 2012. SSI was defined using Centers for Disease Control and Prevention criteria. RESULTS: There were 77 HIV-infected women who underwent a hysterectomy: 47 (61%) were abdominal; 16 (21%) were laparoscopic or robot-assisted; and 14 (18%) were vaginal. Acquired immune deficiency syndrome was diagnosed in 58% of patients, and 75% of patients self-reported use of highly active antiretroviral therapy at the time of surgery. There were 17 (22%) SSIs; 5 (29%) superficial incisional wound infections, 3 (18%) vaginal cuff cellulitis, and 9 (53%) pelvic abscesses were diagnosed. After multivariable logistic regression, preoperative albumin level (adjusted odds ratio [aOR], 0.14; 95% confidence interval [CI], 0.02-0.86) and minimally invasive hysterectomy (aOR, 0.16; 95% CI, 0.03-0.84) were associated with decreased SSI. Preoperative absolute CD4 count was not associated with SSI (aOR, 0.99; 95% CI, 0.99-1). CONCLUSION: Low preoperative serum albumin levels and abdominal hysterectomy are associated with increased risk of SSIs in HIV-infected women.