Reducing physical restraints in pediatrics: A quality improvement mixed-methods analysis of implementing a clinical debriefing process after behavioural health emergencies in a Children's Hospital.

INTRODUCTION: An increasing number of pediatric patients with mental and behavioral health (MBH) conditions present to Emergency Department (ED) and inpatient settings with behavioral events that require physical restraint (PR). PR usage is associated with adverse outcomes. Clinical debriefing (CD) programs have been associated with improved performance but have not been studied in this population. After implementing an MBH-CD program in our Children's Hospital, we aimed to decrease the baseline (7/2018-3/2021) rate of a second PR episode (2PR) by 50 % in the ED and inpatient settings over two years. METHODS: A multidisciplinary team implemented an MBH-CD process in April 2021 for hospital teams to use immediately after behavioral events. We included patients ≤18 years old, with an ED or inpatient discharge MBH diagnosis, between July 2018 and June 2023. Pre- and post-implementation secondary outcomes included the ED median duration of PR and the ED PR time per 1000 h of ED care. ED and inpatient mean length of stay (LOS) and mean monthly visits (MMV) in pre- and post-implementation were also compared. Qualitative analysis identified major themes. RESULTS: Post-implementation, the ED significantly decreased 2PR rate by 67 %; in inpatients, no significant change was demonstrated. Median duration of ED PR decreased from 112 to 71 min (p = 0.006) and ED PR time significantly decreased by 82 % (14.8 to 2.7 h per 1000 h). In the post-implementation period, mean LOS (ED and inpatient) and MMV (ED only) were significantly higher. Fifty-one percent of 494 behavioral alerts were debriefed. Median debriefing duration was 6 min (IQR 4,10). Common themes included cooperation and coordination (23 %) and clinical standards (14 %). DISCUSSION: Clinical debriefing implementation was associated with significant improvement in ED patient outcomes. Inpatient outcomes were unchanged, but debriefings in both settings should enable frontline teams to continuously identify opportunities to improve future outcomes.

Creating affiliations, learning, and mindfulness for in vitro fertilization patients (CALM IVF): a clinical trial.

Objective: Determine if group psychoeducational support can improve in vitro fertilization (IVF) patients' quality of life (QoL). Design: Randomized controlled trial (NCT04048772). Setting: University-affiliated IVF clinic. Patients: Women (n = 76) and male partners undergoing initial autologous IVF cycle from August 2019, to December 2020. Interventions: Couples were assigned to groups based on projected oocyte retrieval date. Groups were randomly assigned to the control or intervention arm. Clinic closures because of the COVID-19 pandemic delayed treatment for a portion of participants. Groups were conducted in person before and virtually during the pandemic. Main Outcome Measures: The primary outcome was a change in fertility quality of life (FertiQoL) from baseline to 3 days after retrieval. Secondary outcomes were changes in depression (Patient Health Questionnaire 9), anxiety (Generalized Anxiety Disorder 7), resilience (Connor-Davidson Resilience scale), IVF knowledge scores, and the likelihood of return to treatment. Results: Knowledge scores among women in Creating Affiliations, Learning, and Mindfulness (CALM) for IVF groups significantly increased compared with control (mean difference 13.19 [3.53 - 22.84]) before the pandemic. During the pandemic, women in CALM IVF had significant improvement in the social FertiQoL score compared with controls (10.42 [1.79 - 19.04]). Compared with controls, male CALM IVF participants had significantly greater improvement in total FertiQoL (mean difference 6.68 [0.39 - 12.98]), treatment FertiQoL (8.26 [0.69 - 15.82]), and resilience (Connor-Davidson 1.13 [0.54 - 1.72]). Immediate return to care did not significantly differ between arms. Conclusions: For women undergoing IVF, group psychoeducational programs can improve IVF knowledge and social QoL during a pandemic. Participation in a group psychoeducational program can improve QoL and resilience in IVF dyad male partners. Clinical Trial Registration Number: Trial registration NCT04048772.

Cumulative live birth rate in women aged ≤37 years after in vitro fertilization with or without preimplantation genetic testing for aneuploidy: a Society for Assisted Reproductive Technology Clinic Outcome Reporting System retrospective analysis.

Objective: To investigate cumulative live birth rates (CLBRs) in cycles with and without preimplantation genetic testing for aneuploidy (PGT-A) among patients aged <35 and 35-37 years. Design: Retrospective cohort study. Setting: Society for Assisted Reproductive Technology reporting clinics. Patients: A total of 31,900 patients aged ≤ 37 years with initial oocyte retrievals between January 2014 and December 2015 followed through December 2016. Interventions: None. Main outcome measures: The primary outcome was CLBR among patients aged <35 and 35-37 years. The secondary outcomes included multifetal births, miscarriage, preterm birth, perinatal mortality, and the time to pregnancy resulting in a live birth. Adjusted odds ratios (aORs) adjusting for age, body mass index, total 2 pronuclei embryos, embryos transferred, and follow-up timeframe. Results: Among patients aged <35 years, PGT-A was associated with reduced CLBRs (70.6% vs. 71.1%; aOR, 0.82; 95% CI [confidence interval], 0.72-0.93). No association was found between PGT-A and CLBRs among patients aged 35-37 years (66.6% vs. 62.5%; aOR, 0.92; 95% CI, 0.83-1.01). Overall, there was no significant difference in the miscarriage rate (aOR, 0.97; 95% CI, 0.82-1.14). Multifetal birth rates were lower with PGT-A (9.5% vs. 23.1%); however, PGT-A was not an independent predictor of multifetal birth (aOR, 1.11; 95% CI, 0.91-1.36). The average time to pregnancy resulting in a live birth was 2.37 months (SD 3.20) for untested transfers vs. 4.58 months (SD 3.53) for PGT-A transfers. Conclusions: In women aged <35, the CLBR was lower with PGT-A than with the transfer of untested embryos. In women aged 35-37 years, PGT-A did not improve CLBRs.

Low oocyte maturity ratio is associated with a reduced in vitro fertilization and intracytoplasmic sperm injection live birth rate.

OBJECTIVE: To determine whether a low oocyte maturity ratio in a cohort of oocytes from an in vitro fertilization cycle predicts outcomes and to examine clinical factors associated with oocyte maturity. DESIGN: A retrospective cohort study. SETTING: An academic medical center. INTERVENTION(S): Determination of oocyte maturity immediately after the retrieval and 6 hours later if intracytoplasmic sperm injection was performed. MAIN OUTCOME MEASURE(S): The primary outcome was live birth rate after the first embryo transfer. Secondary outcomes included clinical pregnancy, miscarriage, and fertilization rates. RESULT(S): After adjusting for age, preimplantation genetic testing, and number of embryos transferred, we found that a low oocyte maturity ratio was associated with a decreased live birth rate (adjusted odds ratio [AOR], 0.41; 95% confidence interval [CI], 0.22-0.77) and clinical pregnancy rate (AOR, 0.32; 95% CI, 0.17-0.61). We did not find a relationship between oocyte maturity and miscarriage rate (AOR, 0.25; 95% CI, 0.03-1.91) or fertilization rate (Welch test). The number of 2 pronuclei embryos per retrieved oocyte was found to be associated with the maturity ratio at retrieval. Patients with anovulation had slightly reduced oocyte maturity compared with other diagnostic groups. CONCLUSION(S): Low oocyte maturity ratio is an important factor related to poor in vitro fertilization outcomes, including decreased pregnancy and live birth rates.

Use of Lean Healthcare to Improve Hospital Throughput and Reduce LOS.

Improving the discharge process is an area of focus throughout healthcare organizations. Capacity constraints, efficiency improvement, patient safety, and quality care are driving forces for many discharge process workgroups. METHODS: Following the Pareto principle, we focused on improving the discharge process on the medical-surgical units that received the most patients admitted from the emergency department. Increased demand for medical-surgical beds, renovations, and diminished bed capacity made it imperative to improve efficiency using quality improvement techniques. A core team of frontline staff decreased the time between computer entry of discharge orders and patient's departure from the unit to less than 60 minutes, with 80% compliance. The team developed a daily dashboard that detailed the process and outcome measures to create situational awareness and daily visual management. Additional observations of staff workflow uncovered excessive walking for printer use. Printers were placed at the point of use to reduce transport times. Next, using survey results provided by patients on discharge quality, a Treasure Map that aided with teach-back and Team Discharge were implemented to level the staff's workload. Finally, physicians discharged patients earlier in the day. They standardized their discharge criteria to remove subjectivity from the discharge process and enable better team involvement. RESULTS: After implementing 4 interventions, the average time between computer entry of discharge orders and patient's departure from the unit decreased (94.26 versus 65.98 minutes; P < 0.001), simultaneously reducing our average length of stay from 5.62 to 4.81 days (P < 0.001). CONCLUSIONS: In conclusion, hardwiring proven interventions and complementing them with daily visual management led to significant, sustained results.

Dual trigger protocol is an effective in vitro fertilization strategy in both normal and high responders without compromising pregnancy outcomes in fresh cycles.

OBJECTIVE: To study the birth rates of normal vs. high responders after dual trigger of final oocyte maturation with gonadotropin-releasing hormone (GnRH) agonist and human chorionic gonadotropin in fresh in vitro fertilization (IVF) cycles in which ovarian stimulation was achieved by a flexible GnRH antagonist protocol. DESIGN: Retrospective cohort study. SETTING: University hospital. PATIENTS: In women <35 years of age, 290 fresh IVF cycles using the dual trigger protocol with day 5 embryo transfers from January 2013 to July 2018 were included. Cycles excluded were those with preimplantation genetic testing, gestational carriers, donor oocytes, and fertility preservation. INTERVENTIONS: IVF with dual trigger. MAIN OUTCOME MEASURES: Clinical pregnancy rate, live birth rate. RESULTS: Comparing normal responders, defined as <30 oocytes retrieved, and high responders, defined as ≥30 oocytes retrieved, the clinical pregnancy rates (67.0% vs. 69.3%, respectively) and live birth rates (60.5% vs. 60.0%, respectively) were not significantly different. No cases of ovarian hyperstimulation syndrome were reported in either group. CONCLUSIONS: Ovarian stimulation by a flexible GnRH antagonist protocol followed by dual trigger yields comparable outcomes between normal and high responders in fresh IVF cycles.

Elective transfer of one embryo is associated with a higher cumulative live birth rate and improved perinatal outcomes compared to the transfer of two embryos with in vitro fertilization.

OBJECTIVE: To compare the effects of initial elective single embryo transfer (ieSET) and initial double embryo transfer (iDET) strategies on the cumulative live birth rate (CLBR) and perinatal outcomes after IVF. DESIGN: Retrospective cohort study. SETTING: Society for Assisted Reproductive Technology (SART) reporting clinics. PATIENTS: 49,333 patients with initial oocyte retrievals between January 2014 and December 2015. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The primary outcome was CLBR, defined as up to 1 live birth resulting from a retrieval cycle and linked transfer cycles. Secondary outcomes included cycles to pregnancy, multifetal delivery rate, infant birthweight, and perinatal mortality rate. RESULTS: Compared to iDET, ieSET was associated with increased CLBR (74% vs. 57%; adjusted odds ratio [AOR], 1.32; 95% CI, 1.26-1.38). When stratified by age, the same trend was seen in all age categories, with statistical significance for those <38 years of age. ieSET was associated with reduced multifetal delivery (8% vs. 34%; AOR, 0.13; 95% CI, 0.12-0.14), increased birthweight (mean difference, 406 grams; 95% CI, 387-425), reduced preterm births (1.2% vs. 2.8%), and reduced perinatal mortality (0.5% vs. 1.2%). Compared with iDET, ieSET was associated with slightly more embryo transfer cycles (1.7 vs. 1.4 cycles; AOR, 1.19; 95% CI, 1.16-1.21) to achieve a pregnancy resulting in live birth. CONCLUSIONS: The association of ieSET with a higher CLBR and markedly improved perinatal outcomes outweigh the relatively minor increase in time to pregnancy, reinforcing the guidance for eSET in initial transfer cycles, particularly in younger patients with a good prognosis.

The effect of weight and body mass index on serum progesterone values and live birth rate in cryopreserved in vitro fertilization cycles.

OBJECTIVE: To determine if weight or body mass index (BMI) affects the serum progesterone level at the time of the pregnancy test in cryopreserved blastocyst transfer cycles and to determine if those serum progesterone levels affect live births. DESIGN: Retrospective cohort study. SETTING: US academic medical center. PATIENTS: Six hundred thirty-three patients undergoing their first cryopreserved embryo transfer cycle. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The primary outcome was the serum progesterone level on the day of the pregnancy test by patient weight and BMI. Our secondary analysis assessed the serum progesterone effect on live birth rate (LBR) in a clinic where progesterone supplementation was increased if the progesterone level was <15 ng/mL on the day of the pregnancy test. RESULTSS: There was a strong negative correlation between serum progesterone level and both BMI and weight, with BMI accounting for 27% and weight accounting for 29% of the variance in progesterone level. Serum progesterone level on the day of the pregnancy test was <15 ng/mL in 3% of women weighing <68 kg compared with 29% of women weighing ≥90.7 kg. Among women weighing ≥90.7 kg, live birth occurred in 47% whose serum progesterone level was <15 ng/mL on the day of the pregnancy test compared with 49% in those with serum progesterone level of 15-19 ng/mL and 44% in those with serum progesterone level of ≥20 ng/mL. CONCLUSIONS: Body weight was a significant factor in serum progesterone level at the time of the pregnancy test, with nearly 30% of patients weighing ≥90.7 kg having serum progesterone level of <15 ng/mL, a value associated with lower LBRs in prior studies. However, we found no effect of low progesterone levels on LBR after cryopreserved embryo transfer cycles in a clinic where progesterone dosing was increased if serum progesterone levels were <15 ng/mL.

Effect of body mass index on intrauterine insemination cycle success.

OBJECTIVE: To determine whether body mass index (BMI) affects intrauterine insemination treatment success. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PATIENT(S): A total of 3,217 intrauterine insemination treatment cycles in 1,306 patients. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Primary outcome was live birth rate stratified by BMI. Secondary outcomes included rates of clinical pregnancy (defined as an intrauterine pregnancy with a heartbeat present on ultrasound), multiple gestation, biochemical pregnancy, missed abortion, ectopic, and spontaneous abortion. RESULT(S): Women with BMI 25 to 29.99 kg/m2 or ≥30 kg/m2 were equally likely to have a live birth as women of normal BMI. Women with BMI ≥30 kg/m2 did have a higher likelihood of biochemical pregnancy than women with normal BMI. CONCLUSION(S): A BMI between 25 and 29.99 kg/m2 or ≥30 kg/m2 does not appear to have a negative effect on live birth after intrauterine insemination. Obesity may be associated with a higher risk of biochemical pregnancy after intrauterine insemination.

Laparoscopic resection of functional, noncommunicating uterine horn in close approximation to functional hemiuterus.

OBJECTIVE: To review the presentation of unicornuate uterus with a functional noncommunicating rudimentary uterine horn and a laparoscopic method of management, highlighting laparoscopic surgical techniques. DESIGN: A video review of unicornuate uterus with a functional noncommunicating rudimentary uterine horn and a laparoscopic approach to treatment in a 13-year-old pubertal female with severe menstrual pain. SETTING: Tertiary care facility. PATIENT(S): A 13-year-old G0 was referred to the clinic for severe cyclic right lower quadrant pain during menses. Transvaginal ultrasonography revealed a left unicornuate uterus with a right-sided noncommunicating rudimentary horn measuring 4.8 × 4.7 × 4.6 cm, containing blood consistent with hematometra. Her kidneys were bilaterally present and normal by ultrasonography. INTERVENTION(S): Because of the patient's worsening pain and the presence of hematometra, we proceeded with diagnostic laparoscopy and removal of the rudimentary uterine horn. The entire procedure was performed laparoscopically, with an estimated total blood loss of 20 mL. Included are tips for laparoscopic resection and suturing. MAIN OUTCOME MEASURE(S): Pathologic features and postoperative course. RESULTS: The patient's pathologic features were benign, and her severe menstrual pain was resolved. She had no complications or readmissions. CONCLUSION(S): In patients with severe menstrual pain from outflow obstruction from a noncommunicating rudimentary uterine horn with functional endometrium, laparoscopic resection can be a safe and effective method of treatment.

Confidence and readiness to discuss, plan and implement postpartum contraception during prenatal care versus after delivery.

No studies exist to determine the optimal timing to counsel women regarding postpartum contraception which means opportunities for immediate postpartum contraception are often missed. Women between the gestational ages of 250/7 and 356/7 weeks, meeting inclusion criteria and attending an outpatient clinic were offered to participate in the study. Subjects completed surveys querying readiness, capability and confidence in discussing and committing to a postpartum contraceptive plan. Two hundred and forty-three patients were enrolled in the study. Sixty-three percent of patients responded they considered that the best time for contraception discussion was the second or third trimester. More women reported a contraception plan was important or very important postpartum than prenatally (78% vs. 56%; p<.0001). More women reported feeling ready or very ready to discuss (82% vs. 66%; p<.0001), and ready or very ready to choose (84% vs. 64%; p<.007), capable or highly capable of choosing (90% vs. 79%; p=.0009) postpartum than prenatally. Postpartum, more women felt confident or very confident (98% vs. 90%; p=.0006) in their ability to use effective contraception after delivery. Women reported higher levels of readiness and capability to choose and discuss contraception postpartum than prenatally. Most women felt ready and capable to choose a contraceptive option prior to postpartum discharge. IMPACT STATEMENT What is already known on this subject? Short interpregnancy interval is associated with increased maternal and neonatal morbidity and mortality. Effective postpartum contraception can be decided upon and administered, thereby increasing the interval between subsequent pregnancies. What do the results of this study add? The results of this study demonstrate that women report high levels of readiness and capability to choose and discuss contraception before postpartum discharge. What are the implications of these findings for clinical practice and/or further research? These findings imply that further research is needed to determine how to use motivational interviewing to encourage pregnant women to make a postpartum contraception decision prior to the postpartum period to facilitate uptake of their contraceptive choice.

A randomized controlled trial of combination letrozole and clomiphene citrate or letrozole alone for ovulation induction in women with polycystic ovary syndrome.

OBJECTIVE: To evaluate whether a combination of letrozole and clomiphene citrate (CC) results in higher ovulation rates than letrozole alone in infertile women with polycystic ovary syndrome (PCOS). DESIGN: Open-label randomized controlled trial. SETTING: Academic medical center using two clinic sites. PATIENT(S): Women 18-40 years of age with a diagnosis of infertility and PCOS as defined by the Rotterdam criteria and no other known cause of infertility. INTERVENTIONS(S): Participants were randomized in a 1:1 ratio, stratified by age and body mass index, to either 2.5 mg letrozole alone or the combination of 2.5 mg letrozole and 50 mg CC daily on cycle days 3-7 for one treatment cycle. MAIN OUTCOME MEASURE(S): Ovulation defined as mid-luteal serum progesterone concentration ≥3 ng/mL. RESULT(S): Seventy patients were randomized: 35 to letrozole alone and 35 to letrozole and CC. Results were analyzed according to the intention-to-treat principle. Women who received the combination of letrozole and CC had a statistically higher ovulation rate compared with those who received letrozole alone (27 of 35 women [77%] vs. 15 of 35 women [43%]). There were no serious adverse events or multiple-gestation pregnancies in either group. The side-effects profile was similar in the two treatment groups. CONCLUSION(S): The combination of letrozole and CC was associated with a higher ovulation rate compared with letrozole alone in women with infertility and PCOS. Further studies are needed to evaluate the effect on live birth rate. CLINICAL TRIAL REGISTRATION NUMBER: NCT02802865.

Effect of body weight on early hormone levels in singleton pregnancies resulting in delivery after in vitro fertilization.

OBJECTIVE: To evaluate which clinical characteristics influence early maternal ß-human chorionic gonadotropin (hCG) and progesterone levels in in vitro fertilization (IVF) pregnancies. DESIGN: Retrospective cohort analysis. SETTING: Academic medical center. PATIENT(S): Women with a live birth after single-blastocyst embryo transfer in either a fresh or frozen cycle between 2004 and 2017, comprising 1,282 pregnancies in 1,057 patients. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The initial human chorionic gonadotropin concentration (ß-hCG1) measured a mean of 10 days (range: 9-12 days) after embryo transfer, the rate of increase in ß-hCG concentrations, and progesterone concentration, with all analyses controlled for number of days between the embryo transfer and the ß-hCG1 measurement. RESULT(S): The clinical factor that positively influenced the ß-hCG1 level in the fresh cycle was the stimulation type (antagonist cycle higher than long agonist cycle). The clinical factors that negatively influenced both fresh and frozen cycle ß-hCG1 were lower embryo quality and increasing body weight. Increasing weight negatively impacted progesterone levels in both fresh and frozen cycles. A 100 lb (45.4 kg) difference in weight was associated with a 34.8% reduction in ß-hCG1 for both fresh and frozen cycle pregnancies. The rate of increase in ß-hCG was unaffected by body weight. A 100 lb (45.4 kg) difference in weight was associated with a 53.3% and a 32.8% reduction in progesterone in fresh and frozen cycles, respectively. CONCLUSION(S): Increasing body weight is associated with significantly lower ß-hCG and progesterone concentrations in early pregnancy after blastocyst single-embryo transfer in both fresh and frozen cycles. Clinicians should consider this when evaluating these hormone levels for prognostic and diagnostic purposes.

A Comprehensive Survey of Institutional Patient/Family Educational Practices for Newly Diagnosed Pediatric Oncology Patients.

Patient/family education is an important component of nursing practice and is essential to the care of children newly diagnosed with cancer. Practices regarding patient/family education in Children's Oncology Group (COG) treatment centers have not been well described. We used an Internet-based survey to determine current patient/family educational practices at COG institutions; participation rate was 90.5% (201/222). Patient/family education was delivered primarily by an individual (rather than a team) at 43% of institutions. Advanced practice nurses had primary responsibility for providing education at 32% of institutions. "Fever" was the most frequently reported topic considered mandatory for inclusion in education for newly diagnosed patients. More than half of institutions reported using checklists and/or end-of-shift reports to facilitate health care team communication regarding patient/family education, and 77% reported using the "teach-back" method of assessing readiness for discharge. Thirty-seven percent of institutions reported delays in hospital discharge secondary to the need for additional teaching. An understanding of current practices related to patient/family education is the first step in establishing effective interventions to improve and standardize educational practices in pediatric oncology.

Gq/11-Dependent Changes in the Murine Ovarian Transcriptome at the End of Gestation.

Parturition in rodents is highly dependent on the engagement of the luteal prostaglandin F2 alpha receptor, which, through activation of the Gq/11 family of G proteins, increases the expression of Akr1c18, leading to an increase in progesterone catabolism. To further understand the involvement of Gq/11 on luteolysis and parturition, we used microarray analysis to compare the ovarian transcriptome of mice with a granulosa/luteal cell-specific deletion of Galphaq/11 with their control littermates on Day 18 of pregnancy, when mice from both genotypes are pregnant, and on Day 22, when mice with a granulosa/luteal cell-specific deletion of Galphaq/11 are still pregnant but their control littermates are 1-2 days postpartum. Ovarian genes up-regulated at the end of gestation in a Galphaq/11 -dependent fashion include genes involved in focal adhesion and extracellular matrix interactions. Genes down-regulated at the end of gestation in a Galphaq/11-dependent manner include Serpina6 (which encodes corticosteroid-binding globulin); Enpp2 (which encodes autotaxin, the enzyme responsible for the synthesis of lysophosphatidic acid); genes involved in protein processing and export; reproductive genes, such as Lhcgr; the three genes needed to convert progesterone to estradiol (Cyp17a1, Hsd17b7, and Cyp19a1); and Inha. Activation of ovarian Gq/11 by engagement of the prostaglandin F2 alpha receptor on Day 18 of pregnancy recapitulated the regulation of many but not all of these genes. Thus, although the ovarian transcriptome at the end of gestation is highly dependent on the activation of Gq/11, not all of these changes are dependent on the actions of prostaglandin F2 alpha.

Ethical issues identified by obstetrics and gynecology learners through a novel ethics curriculum.

OBJECTIVE: Obstetrics and gynecology (ob/gyn) is fraught with bioethical issues, the professional significance of which may vary based on clinical experience. Our objective was to utilize our novel ethics curriculum to identify ethics and professionalism issues highlighted by ob/gyn learners and to compare responses between learner levels to further inform curricular development. STUDY DESIGN: We introduced an integrated and dynamic ob/gyn ethics and professionalism curriculum and mixed methods analysis of 181 resulting written reflections (case observation and assessments) from third-year medical students and from first- to fourth-year ob/gyn residents. Content was compared by learner level using basic thematic analysis and summary statistics. RESULTS: Within the 7 major ethics and professionalism domains, learners wrote most frequently about miscellaneous ob/gyn issues such as periviability and abortion (22% of students, 20% of residents) and problematic treatment decisions (20% of students, 19% of residents) rather than professional duty, communication, justice, student-/resident-specific issues, or quality of care. The most commonly discussed ob/gyn area by both learner groups was obstetrics rather than gynecology, gynecologic oncology, or reproductive endocrinology and infertility, although residents were more likely to discuss obstetrics-related concerns than students (65% vs 48%; P = .04) and students wrote about gynecologic oncology-related concerns more frequently than residents (25% vs 6%; P = .002). In their reflections, sources of ethical value (eg, the 4 classic ethics principles, professional guidelines, and consequentialism) were cited more frequently and in greater number by students than by residents (82% of students cited at least 1 source of ethical value vs 65% of residents; P = .01). Residents disagreed more frequently with the ethical propriety of clinical management than did students (67% vs 43%; P = .005). CONCLUSION: Our study introduces an innovative and dynamic approach to an ob/gyn ethics and professionalism curriculum that highlights important learner-identified ethics and professionalism issues both specific to ob/gyn and common to clinical medicine. Findings will help ob/gyn educators best utilize and refine this flexible curriculum such that it is appropriately focused on topics relevant to each learner level.

Activation of Gq/11 in the mouse corpus luteum is required for parturition.

Mice with a deletion of Gα(q/11) in granulosa cells were previously shown to be subfertile. They also have a reduced ovulatory response due to a deficiency in the ability of the activated LH receptor to fully induce the granulosa cell progesterone receptor. Because this conditional deletion of Gα(q/11) will interfere with the actions of any G protein-coupled receptor that activates G(q/11) in granulosa or luteal cells, we sought to determine whether the actions of other hormones that contribute to fertility were also impaired. We focused our attention on prostaglandin F2 (PGF2)α, because this hormone is known to activate phospholipase C (a prominent Gα(q/11) effector) in luteal cells and because the action of PGF2α on luteal cells is the first step in the murine parturition pathway. Our data show that the conditional deletion of Gα(q/11) from granulosa cells prevents the ability of PGF2α to induce Akr1c18 in luteal cells. Akr1c18 codes for 20α-hydroxysteroid dehydrogenase, an enzyme that inactivates progesterone. The PGF2α-mediated induction of this enzyme towards the end of pregnancy increases the inactivation of progesterone and precipitates parturition in mice. Thus, the conditional deletion of Gαq/11 from granulosa/luteal cells prevents the progesterone withdrawal that occurs at the end of pregnancy and impairs parturition. This novel molecular defect contributes to the subfertile phenotype of the mice with a deletion of Gα(q/11) from granulosa cells.