To err is human; to provide safe, quality, and cost-effective hysterectomy is divine!

Approximately 500,000 hysterectomies are performed each year in the United States despite the existence of numerous nondefinitive alternatives. Gaining an understanding of the relationship between quality, safety, and cost is critical to gynecologists performing this procedure. Analysis of quality measures includes important process measures such as time-out procedures, the Surgical Care Improvement Project, Peer Review, and Credentialing. Databases, such as the National Surgical Quality Improvement Program, are also available for review of quality. Safety is evaluated by analyzing outcomes including complications, route of procedure, and patient satisfaction. The cost of hysterectomy is impacted by continuous quality and safety improvements.

Lipomatous angiomyofibroblastoma: a case report of a unique vulvar mass.

BACKGROUND: Vulvar masses are commonly biopsied in the outpatient setting. They may present as clinically benign masses, but the pathological evaluation and diagnosis is important in establishing the correct management. CASE: A 41-year-old El Salvadoran woman presented with a nontender vulvar mass of over 12 years' duration that had enlarged rapidly over the past 8 months. After surgical excision, the pathologic diagnosis was a rare lipomatous variant of angiomyofibroblastoma. CONCLUSION: The lipomatous form of angiomyofibroblastoma is a very rare vulvar tumor, and to our knowledge 8 have been identified and we present the ninth. Although it is benign, there is an aggressive variant of angiomyofibroblastoma that is locally invasive and requires wide local excision to prevent recurrence.

Sexual Health.

Women's sexual health is a frequently ignored area of geriatric medicine. There are clearly defined criteria for sexual dysfunction that are organized by phase of sexual function, including desire, arousal, orgasm, and pain. The menopause transition and comorbid medical conditions (as well as their treatments) can contribute to alterations in sexual function. The partner must be included and involved in the evaluation and management to achieve a better intimate relationship in an established couple. A variety of effective and evidence-based treatments are available to women for sexual concerns in the geriatric population.

A Mobile Prenatal Care App to Reduce In-Person Visits: Prospective Controlled Trial.

BACKGROUND: Risk-appropriate prenatal care has been asserted as a way for the cost-effective delivery of prenatal care. A virtual care model for prenatal care has the potential to provide patient-tailored, risk-appropriate prenatal educational content and may facilitate vital sign and weight monitoring between visits. Previous studies have demonstrated a safe reduction in the frequency of in-person prenatal care visits among low-risk patients but have noted a reduction in patient satisfaction. OBJECTIVE: The primary objective of this study was to test the effectiveness of a mobile prenatal care app to facilitate a reduced in-person visit schedule for low-risk pregnancies while maintaining patient and provider satisfaction. METHODS: This controlled trial compared a control group receiving usual care with an experimental group receiving usual prenatal care and using a mobile prenatal care app. The experimental group had a planned reduction in the frequency of in-person office visits, whereas the control group had the usual number of visits. The trial was conducted at 2 diverse outpatient obstetric (OB) practices that are part of a single academic center in Washington, DC, United States. Women were eligible for enrollment if they presented to care in the first trimester, were aged between 18 and 40 years, had a confirmed desired pregnancy, were not considered high-risk, and had an iOS or Android smartphone that they used regularly. We measured the effectiveness of a virtual care platform for prenatal care via the following measured outcomes: the number of in-person OB visits during pregnancy and patient satisfaction with prenatal care. RESULTS: A total of 88 patients were enrolled in the study, 47 in the experimental group and 41 in the control group. For patients in the experimental group, the average number of in-person OB visits during pregnancy was 7.8 and the average number in the control group was 10.2 (P=.01). There was no statistical difference in patient satisfaction (P>.05) or provider satisfaction (P>.05) in either group. CONCLUSIONS: The use of a mobile prenatal care app was associated with reduced in-person visits, and there was no reduction in patient or provider satisfaction. TRIAL REGISTRATION: ClinicalTrials.gov NCT02914301; https://clinicaltrials.gov/ct2/show/NCT02914301 (Archived by WebCite at http://www.webcitation.org/76S55M517).

Improving teaching skills in obstetrics and gynecology residents: evaluation of a residents-as-teachers program.

OBJECTIVE: The purpose of this study was to determine if a residents-as-teachers program improves residents' teaching skills. STUDY DESIGN: Twenty-four residents (13 intervention, 11 controls) participated in a controlled trial of a residents-as-teachers program. The intervention group attended a 10.5-hour workshop-based program. Afterwards, both groups were tested with a 6-station Objective Structured Teaching Examination (OSTE), conducted by standardized students. Both groups also completed teaching skills self-assessment questionnaires. In addition, the intervention group completed evaluations of each workshop. RESULTS: On the OSTE, the intervention group outscored the control group overall (mean: 74 vs 63, P =.001, 95% CI: 6-7 points) and on 4 out of 6 stations. Intervention residents increased their teaching self-assessment mean ratings from 3.5 to 4.0; residents gave the 6 workshops a mean rating of 4.49 (1-5 scale, 5 = best). CONCLUSION: The residents-as-teachers program improved the teaching skills of residents. Their self-assessment of their teaching skills also improved. They rated the workshops highly.

Testing the Feasibility of Remote Patient Monitoring in Prenatal Care Using a Mobile App and Connected Devices: A Prospective Observational Trial.

BACKGROUND: Excessive weight gain and elevated blood pressure are significant risk factors for adverse pregnancy outcomes such as gestational diabetes, premature birth, and preeclampsia. More effective strategies to facilitate adherence to gestational weight gain goals and monitor blood pressure may have a positive health benefit for pregnant women and their babies. The impact of utilizing a remote patient monitoring system to monitor blood pressure and weight gain as a component of prenatal care has not been previously assessed. OBJECTIVE: The objective of this study is to determine the feasibility of monitoring patients remotely in prenatal care using a mobile phone app and connected digital devices. METHODS: In this prospective observational study, 8 women with low risk pregnancy in the first trimester were recruited at an urban academic medical center. Participants received a mobile phone app with a connected digital weight scale and blood pressure cuff for at-home data collection for the duration of pregnancy. At-home data was assessed for abnormal values of blood pressure or weight to generate clinical alerts to the patient and provider. As measures of the feasibility of the system, participants were studied for engagement with the app, accuracy of remote data, efficacy of alert system, and patient satisfaction. RESULTS: Patient engagement with the mobile app averaged 5.5 times per week over the 6-month study period. Weight data collection and blood pressure data collection averaged 1.5 times and 1.1 times per week, respectively. At-home measurements of weight and blood pressure were highly accurate compared to in-office measurements. Automatic clinical alerts identified two episodes of abnormal weight gain with no false triggers. Patients demonstrated high satisfaction with the system. CONCLUSIONS: In this pilot study, we demonstrated that a system using a mobile phone app coupled to remote monitoring devices is feasible for prenatal care.

Implementation and evaluation of a genetics curriculum to improve obstetrician-gynecologist residents' knowledge and skills in genetic diagnosis and counseling.

OBJECTIVE: This study was undertaken to develop, implement, and evaluate a genetics curriculum for obstetrician-gynecologist residents. STUDY DESIGN: We prospectively evaluated the effect of a genetics curriculum on obstetrician-gynecologist residents' knowledge and skills. Residents completed a needs assessment and pretest. Educational intervention included 2 3-hour didactic sessions with 1 hour of lecture followed by case discussion and 1 3-hour session of experiential learning using standardized patients who evaluated residents' knowledge and skills in taking family history, drawing genetic pedigrees, and counseling patients. Posttest scores were compared with pretest scores. RESULTS: Needs assessment was completed by all 40 obstetrics and gynecology residents and identified limited and variable genetics education in medical school. Twenty-eight of 40 residents attended the entire educational intervention and completed the pretest and posttest, and 25 of 28 showed improved test scores. Residents stated that they were more confident in their ability to take a family history, record a 3-generation pedigree, and counsel patients about genetic conditions after completion of the genetics curriculum. CONCLUSION: This multifaceted genetics curriculum improved residents' knowledge of genetics as well as their confidence in applying genetic concepts as assessed by the pretest and posttest and by their comments in the debrief session.

Marginal Iodine Status and High Rate of Subclinical Hypothyroidism in Washington DC Women Planning Conception.

INTRODUCTION: Subclinical hypothyroidism during pregnancy has been associated with adverse maternal and fetal outcomes. A subset of pregnant women in the United States have been shown to have mild iodine deficiency. No study has evaluated the thyroid and iodine status of women who are planning to become pregnant in the near future. METHODS: Thyroid function tests, thyroid antibodies, and urine iodine levels were evaluated in women presenting for preconception screening and counseling. A thyrotropin (TSH) level above 3.0 mIU/L was considered abnormal. RESULTS: One hundred and forty one women enrolled in the study. The median TSH level was 1.70 mIU/L (range 0.43-5.3 mIU/L). Sixteen women (11%) had a TSH above the upper limit of normal (>3.0 mIU/L). Eleven women (8%) were positive for TPO-Ab and 21 women (15%) for TgAb. Twenty-three women (16%) were positive for at least one thyroid antibody (TPOAb and/or TgAb). Median serum TSH concentrations were higher in women with detectable antithyroid antibodies than in women who were antibody negative (2.2 mIU/L vs. 1.7 mIU/L; p=0.005). The median urinary iodine concentration was 100.5 µg (range 19-843 µg/L). DISCUSSION: The present cohort exhibited the lowest median urinary iodine concentration levels to date reported in the United States for women in their childbearing years. One out of every nine women (11%) had thyroid function tests consistent with subclinical hypothyroidism.

Using a commercially available web-based evaluation system to enhance residents' teaching.

BACKGROUND: Residents-as-teachers (RATs) programs have been shown to improve trainees' teaching skills, yet these decline over time. INTERVENTION: We adapted a commercial Web-based system to maintain resident teaching skills through reflection and deliberate practice and assessed the system's ability to (1) prevent deterioration of resident teaching skills and (2) provide information to improve residents' teaching skills and teaching program quality. METHODS: Ten first-year obstetrics-gynecology (Ob-Gyn) residents participated in a RATs program. Following the program, they used a commercial evaluation system to complete self-assessments of their teaching encounters with medical students. Students also evaluated the residents. To assess the system's effectiveness, we compared these residents to historical controls with an Objective Structured Teaching Examination (OSTE) and analyzed the ratings and the free text comments of residents and students to explore teaching challenges and improve the RATs program. RESULTS: The intervention group outscored the control group on the OSTE (mean score ± SD  =  81 ± 8 versus 74 ± 7; P  =  .05, using a 2-tailed Student t-test). Rating scale analysis showed resident self-assessments were consistently lower than student evaluations, with the difference reaching statistical significance in 3 of 6 skills (P < .05). Comments revealed that residents most valued using innovative teaching techniques, while students most valued a positive educational climate and interpersonal connections with residents. Recommended targets for RATs program improvement included teaching feedback, time-limited teaching, and modeling professionalism behaviors. CONCLUSIONS: Our novel electronic Web-based reinforcement system shows promise in preventing deterioration of resident teaching skills learned during an Ob-Gyn RATs program. The system also was effective in gaining resident and student insights to improve RATs programs. Because our intervention was built upon a commercially available program, our approach could prove useful to the large population of current subscribers.