Investigating racial/ethnic differences in procedure experience in obstetrics & gynecology trainees at a single academic institution: a retrospective cohort study.

BACKGROUND: Discrimination is common in medical education. Resident physicians of races and ethnicities underrepresented in medicine experience daily discrimination which has been proven to negatively impact training. There is limited data on the impact of resident race/ethnicity on OB/GYN surgical training. The objective of this study was to investigate the impact of race/ethnicity on procedural experience in OB/GYN training. METHODS: A retrospective analysis of graduated OB/GYN resident case logs from 2009 to 2019 was performed at a single urban academic institution. Self-reported race/ethnicity data was collected. Association between URM and non-URM were analyzed using t-tests. Trainees were categorized by self-reported race/ethnicity into underrepresented in medicine (URM) (Black, Hispanic, Native American) and non-URM (White, Asian). RESULTS: The cohort consisted of 84 residents: 19% URM (N = 16) and 79% non-URM (n = 66). Difference between URM and non-URM status and average case volume was analyzed using t-tests. There was no difference between non-URM and URM trainees and reported mean number of Total GYN (349 vs. 334, p = 0.31) and Total OB (624 vs. 597, P = 0.11) case logs. However, compared with non-URM, on average URM performed fewer Total procedures (1562 vs. 1469, P = 0.04). Analyzing individual procedures showed a difference in average number of abortions performed between URM and non-URM (76 vs. 53, P = 0.02). There were no other statistically significant differences between the two groups. CONCLUSIONS: This single institution study highlights potential differences in trainee experience by race/ethnicity. Larger national studies are warranted to further explore these differences to identify bias and discrimination, and to ensure equitable experience for all trainees.

Longitudinal impact of a residency-based postplacental levonorgestrel intrauterine device insertion program: Expulsion rates in years 1, 2, and 3.

OBJECTIVE: To evaluate expulsion rates in the first 3 years of an academic postplacental levonorgestrel intrauterine device (LNG-IUD) insertion program. STUDY DESIGN: Retrospective case series, January 2016 to December 2018. We measured LNG-IUD expulsion rates by 12 weeks postpartum. RESULTS: Of 235 LNG-IUD insertions, in years 1, 2, and 3, expulsion rates were 11/39 (28%), 9/94 (10%), and 15/102 (15%) (p = 0.03). After vaginal delivery, manual insertion was associated with a higher expulsion rate than ring-forceps (10/28 [36%] vs 17/105 [16%], p = 0.04). CONCLUSIONS: LNG-IUD expulsion rates decreased after program year 1, suggesting program maturity may be associated with a lower expulsion risk.

ACR Appropriateness Criteria® Transgender Breast Cancer Screening.

Breast cancer screening recommendations for transgender and gender nonconforming individuals are based on the sex assigned at birth, risk factors, and use of exogenous hormones. Insufficient evidence exists to determine whether transgender people undergoing hormone therapy have an overall lower, average, or higher risk of developing breast cancer compared to birth-sex controls. Furthermore, there are no longitudinal studies evaluating the efficacy of breast cancer screening in the transgender population. In the absence of definitive data, current evidence is based on data extrapolated from cisgender studies and a limited number of cohort studies and case reports published on the transgender community. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Sensation of Pain Using Buffered Lidocaine for Infiltration Before Vulvar Biopsy: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effects of buffered lidocaine on pain scores during vulvar biopsy. METHODS: We conducted a double-blind, randomized controlled trial, using prefilled, sequentially numbered, randomized syringes to infiltrate either 3 mL of buffered or nonbuffered lidocaine before vulvar biopsy. The primary outcome was a pain score marked on a 100-mm visual analog scale during infiltration. Secondary outcomes included pain scores after the procedure and change from baseline to infiltration. Participants were recruited to detect a clinically meaningful 15-mm difference in pain scores between groups. Sample size was calculated based on the null hypothesis that the mean pain score would be the same in women treated with buffered lidocaine as in those treated with nonbuffered placebo based on prior studies. Categorical data were compared by Fisher exact test, and continuous data were compared between groups by t-test or Wilcoxon rank sum test. RESULTS: From July 2015 to April 2018, 129 participants were randomized to one of two groups: nonbuffered lidocaine or buffered lidocaine. One hundred twenty-five were analyzed (nonbuffered n=62, buffered n=63). Four patients were excluded. The majority of participants were non-Hispanic white women with a mean age of 59 years. There was no difference in the primary outcome of pain during infiltration with a mean pain score of 35.8 mm in the buffered lidocaine group compared with 42.2 in the nonbuffered lidocaine group (mean difference -6.4; 95% CI -18.4 to 5.6; P=.3 by Wilcoxon rank sum test). There was also no difference in secondary outcomes of pain over the entire procedure (mean difference -0.3, 95% CI -9.7 to 9.2; P=.7) or change in pain from baseline to infiltration (mean difference -6.9, 95% CI -18.4 to 4.7; P=.2). CONCLUSION: There was no difference in pain scores during vulvar biopsy infiltration between the buffered and nonbuffered lidocaine groups. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02698527.

Anal and Cervical High-Risk Human Papillomavirus Genotyping in Women With and Without Genital Neoplasia.

OBJECTIVE: The aim of the study was to compare the prevalence, genotypes, and rates of concomitant anal and cervical high-risk human papillomavirus (HR-HPV) in women with and without a history of HPV-related genital neoplasia. MATERIALS AND METHODS: This was a prospective cohort study conducted from December 2012 to February 2014. Women with a history of neoplasia were considered the high-risk group. Women without a history of neoplasia were considered the low-risk group. Cervical and anal cytology and HPV genotyping were performed. All women with abnormal anal cytology were referred for anoscopy. RESULTS: One hundred eighty-four women met inclusion criteria. High-risk HPV was detected in the anal canal of 17.4% of the high-risk group and 1.5% of the low-risk group (p = .003). High-risk HPV was detected in the cervix of 30.5% of the high-risk group and 7.6% of the low-risk group (p < .001). Concomitant anal and cervical high-risk HPV was detected in 4.4% of the high-risk group and was not detected in the low-risk group (p = .2). Among women with anal intraepithelial neoplasia 2 or greater (n = 5), 60% had HR-HPV detected in the anal canal while none had HR-HPV detected in the cervix. CONCLUSIONS: Women with a history of genital neoplasia are more likely to be positive for anal and cervical HR-HPV compared with women without a history of genital neoplasia. Although there was no significant difference in rates of concomitant HR-HPV between low- and high-risk groups, HR-HPV can be found concomitantly in the anus and the cervix and may be associated with anal intraepithelial neoplasia or carcinoma.

Understanding Women's Sexual Behaviors That May Put Them at Risk for Human Papillomavirus-Related Neoplasias: What Should We Ask?

OBJECTIVES: Human papillomavirus is a multifocal infection that can involve the cervix, vagina, vulva, anus, and oropharynx. Our study aimed to determine whether standard sexual history questions regarding anal intercourse identify women participating in anal-related sexual practices. MATERIALS AND METHODS: A cross-sectional survey was conducted at the dysplasia clinic of a large academic medical center. Women presenting with human papillomavirus-related cervical, vulvar, or vaginal abnormalities were eligible. Participants completed a self-administered sexual history questionnaire that included standard sexual history questions and more detailed questions about sexual practices. Additional demographic information was obtained from chart review. RESULTS: A total of 149 eligible women were approached, 125 (84%) consented and enrolled (ages = 21-65 years). Forty-seven (44%) reported participating in some type of anal-related sexual practice: anal fingering, oral-anal penetration, or anal intercourse. Of those participating in anal-related practices, 5 (11%) reported only anal fingering or oral-anal penetration. Thus, adding the new anal questions detected an additional 5% of women with high-risk anal behaviors that may have been missed by the standard question (p = .06). Seventy-nine women (63%) reported receiving oral penetration of the vagina, and 102 (82%) reported receiving vaginal fingering. Fifty-nine women (47%) used sex toys: 58 (98%) used sex toys vaginally, with 5 (8.5%) using them also anally. CONCLUSIONS: Women are willing to report their participation in a range of sexual practices. Of those who participated in anal practices, 11% did not have anal intercourse. Adding additional sexual health questions to clinical intake forms may enable clinicians to better counsel their patients on risky sexual behaviors.

Evaluation of anal cytology and dysplasia in women with a history of lower genital tract dysplasia and malignancy.

OBJECTIVE: To compare the prevalence of abnormal anal cytology, high-risk anal HPV and biopsy proven anal dysplasia among women with a history of lower genital tract malignancy compared to those with dysplasia. METHODS: A prospective cohort study was performed from December 2012 to February 2014 at outpatient clinics at an academic medical center. Women with a history of high-grade cervical, vulvar, or vaginal dysplasia, or malignancy were recruited. Anal cytology and HPV genotyping were performed. All women with abnormal anal cytology were referred for high-resolution anoscopy and biopsy. RESULTS: Sixty-seven women had a lower genital tract malignancy and 123 had a history of genital dysplasia. Average age in the malignancy group was 52.6years (range 27-86) versus 43.5years (range 21-81) in the dysplasia group (p<0.0002). Similar rates of anal dysplasia were seen in both groups, 12.99% (10 cases) in the malignancy group, versus 12.20% (15) in the dysplasia group (p=1.0). Six women in the malignancy group had anal intraepithelial neoplasia (AIN2+) compared to 2 in the dysplasia group (p=0.03). CONCLUSIONS: We found high rates of abnormal anal cytology and HPV in women with lower genital tract dysplasia and malignancy. We also found high rates of anal dysplasia in both groups with a trend towards increased rate in those women with history of genital malignancy. Since precancerous anal lesions are detectable and treatable, anal cancer screening may be potentially useful in both of these higher risk groups.

Anal Cytology and Human Papillomavirus Genotyping in Women With a History of Lower Genital Tract Neoplasia Compared With Low-Risk Women.

OBJECTIVE: To compare the prevalence of abnormal anal cytology and high-risk human papillomavirus (HPV) among women with a history of HPV-related genital neoplasia with women without a history of HPV-related genital neoplasia. METHODS: A cross-sectional cohort study was performed from December 2012 to February 2014. Women were recruited from outpatient clinics at an academic medical center. Women with a history of high-grade cervical, vulvar, or vaginal cytology, dysplasia, or cancer were considered the high-risk group. Women with no history of high-grade anogenital dysplasia or cancer were considered the low-risk group. Human immunodeficiency virus-positive women were excluded. Anal cytology and HPV genotyping were performed. Women with abnormal anal cytology were referred for high-resolution anoscopy. RESULTS: There were 190 women in the high-risk group and 83 in the low-risk group. The high-risk group was slightly older: 57 years compared with 47 years (P=.045); 21.7% of low-risk women had abnormal anal cytology compared with 41.2% of high-risk women (P=.006). High-risk HPV was detected in the anal canal of 1.2% of the low-risk group compared with 20.8% of the high-risk group (P<.001). Among women who underwent anoscopy, no anal dysplasia was detected in the low-risk group, whereas 13.4% in the high-risk group had anal dysplasia with 4.2% having anal intraepithelial neoplasia 2 or greater (P<.001). CONCLUSION: Human immunodeficiency virus-negative women with a history of lower genital tract neoplasia are more likely to have positive anal cytology, anal high-risk HPV, and anal intraepithelial neoplasia. Anal cancer screening should be considered for these high-risk women. LEVEL OF EVIDENCE: II.

Myomectomy after a vaginal delivery to treat postpartum hemorrhage resulting from an intracavitary leiomyoma.

BACKGROUND: Postpartum myomectomy is typically discouraged as a result of the risk of hemorrhage and longer operative times. However, myomectomy at the time of cesarean delivery or after a vaginal delivery is feasible and is sometimes necessary. CASE: A 38-year-old multiparous woman with a 9-cm pedunculated submucosal leiomyoma presented in labor and underwent a vacuum-assisted vaginal delivery with manual extraction of the placenta. In the immediate postpartum period she had bleeding and hemodynamic instability requiring blood transfusion. Examination under anesthesia demonstrated uterine atony and placental fragments adherent to the pedunculated leiomyoma. An abdominal myomectomy was performed, and the patient recovered normally. CONCLUSION: Although it should not be recommended routinely, postpartum myomectomy is feasible and can be life-saving, even after a vaginal delivery.

The effects of age on treatment and outcomes in women with stages IB1-IIB cervical cancer.

OBJECTIVE: Age may affect the treatment choice and subsequent outcome in elderly patients with cervical cancer. Given the potential for cure with either surgery or chemoradiation in early stage disease, we aimed to determine whether a patient's age influenced treatment received and the ensuing outcome. MATERIALS AND METHODS: We identified 303 patients with stages IB1-IIB cervical carcinoma treated at our institution between 2000 and 2010, who were divided into two groups based on age at time of diagnosis: < 65 and ≥ 65 years. Adjusted odd ratios were calculated to determine variables associated with treatment received. Single and multivariate Cox proportional hazards modeling were used to estimate hazard ratios (HRs) for variables associated with disease-specific survival. RESULTS: Patients were more commonly <65 years at diagnosis (83% versus 17% ≥ 65 years). There was no difference between the two groups in terms of tumor histology, stage at presentation, and grade. Women ≥ 65 years of age were less likely to receive primary surgical management (p=0.03). Age did not influence disease-specific or all-cause mortality. However, women over 65 years who underwent primary surgery were at significantly increased risk of all-cause mortality compared to younger women (HR 6.53, 95% CI: 2.57-16.6). CONCLUSIONS: Age appears to influence treatment received by patients with stages IB1-IIB cervical cancer. Although there was no difference in cancer-specific mortality stratified by type of treatment received, surgery was associated with a 6.5-fold increased risk of all-cause mortality among women 65 years or over.

Vaginal cuff dehiscence: risk factors and management.

Vaginal cuff dehiscence and evisceration are rare but serious complications of pelvic surgery, specifically hysterectomy. The data on risks of vaginal cuff dehiscence are variable, and there is no consensus on how to manage this complication. In our review, we present a summary of the risk factors, with symptoms, precipitating events, and treatment options for patients with vaginal cuff dehiscence after pelvic surgery. In addition, we provide a review of the current literature on this important surgical outcome and suggestions for future research on the incidence and prevention of vaginal cuff dehiscence.

Discussion: 'Treatment of symptomatic uterine fibroids' by van der Kooij et al.

In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed: van der Kooij SM, Hehenkamp WJK, Volkers NA, et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-years outcome from the randomized EMMY trial. Am J Obstet Gynecol 2010;203:105.e1-13.

Attitudes toward physician-assisted suicide among physicians in Vermont.

BACKGROUND: Legislation on physician-assisted suicide (PAS) is being considered in a number of states since the passage of the Oregon Death With Dignity Act in 1994. Opinion assessment surveys have historically assessed particular subsets of physicians. OBJECTIVE: To determine variables predictive of physicians' opinions on PAS in a rural state, Vermont, USA. DESIGN: Cross-sectional mailing survey. PARTICIPANTS: 1052 (48% response rate) physicians licensed by the state of Vermont. RESULTS: Of the respondents, 38.2% believed PAS should be legalised, 16.0% believed it should be prohibited and 26.0% believed it should not be legislated. 15.7% were undecided. Males were more likely than females to favour legalisation (42% vs 34%). Physicians who did not care for patients through the end of life were significantly more likely to favour legalisation of PAS than physicians who do care for patients with terminal illness (48% vs 33%). 30% of the respondents had experienced a request for assistance with suicide. CONCLUSIONS: Vermont physicians' opinions on the legalisation of PAS is sharply polarised. Patient autonomy was a factor strongly associated with opinions in favour of legalisation, whereas the sanctity of the doctor-patient relationship was strongly associated with opinions in favour of not legislating PAS. Those in favour of making PAS illegal overwhelmingly cited moral and ethical beliefs as factors in their opinion. Although opinions on legalisation appear to be based on firmly held beliefs, approximately half of Vermont physicians who responded to the survey agree that there is a need for more education in palliative care and pain management.

Effect of environmental intervention on mouse allergen levels in homes of inner-city Boston children with asthma.

BACKGROUND: Recent studies have suggested that mouse allergen exposure and sensitization are common in urban children with asthma. The effectiveness of environmental intervention in reducing mouse allergen exposure has not been established. OBJECTIVE: To evaluate whether environmental intervention of mouse extermination and cleaning results in a reduction in mouse allergen levels. METHODS: Eighteen homes of children with positive mouse allergen skin test results and at least mild persistent asthma in urban Boston, MA, with evidence of mouse infestation or exposure were randomized in a 2:1 ratio (12 intervention and 6 control homes). The intervention homes received an integrated pest management intervention, which consisted of filling holes with copper mesh, vacuuming and cleaning, and using low-toxicity pesticides and traps. Dust samples were collected and analyzed for major mouse allergen (Mus m 1) and cockroach allergen (Bla g 1) at baseline and 1, 3, and 5 months after the intervention was started and compared with control homes. RESULTS: Mouse allergen levels were significantly decreased compared with control homes by the end of the intervention period at month 5 in the kitchen and bedroom (kitchen intervention, 78.8% reduction; control, 319% increase; P = .02; bedroom intervention, 77.3% reduction; control, 358% increase; P < .01; and living room intervention, 67.6% reduction; control, 32% reduction; P = .07). CONCLUSIONS: Mouse allergen levels were significantly reduced during a 5-month period using an integrated pest management intervention.

Antibiotic desensitization for the allergic patient: 5 years of experience and practice.

BACKGROUND: Antibiotic desensitization is an option for patients with suspected IgE-mediated antibiotic allergy when no other alternative exists for treating life-threatening bacterial infections. However, there are limited data describing the outcomes of this procedure with newer, commonly used antibiotics. OBJECTIVE: To evaluate the safety and utility of antibiotic desensitization. METHODS: We retrospectively reviewed the medical records of all patients undergoing antibiotic desensitization in our institution between November 1996 and November 2001. RESULTS: There were a total of 57 desensitizations performed in 21 patients. The mean age of the patients was 22.8 years (range, 1.9-44.5 years) and 15 (71%) were female. Nineteen (90%) of the 21 patients had been diagnosed as having cystic fibrosis. In 33 (100%) of 33 desensitizations to unique antibiotics that occurred during the study period, the indication for desensitization was a history suggestive of an IgE-mediated reaction to the antibiotic and/or a positive skin test result to the antibiotic or a known cross-reactive antibiotic. Desensitizations were performed to 12 different antibiotics. Successful outcomes were achieved in 43 desensitizations (75%). Of the 11 cases (19%) that were terminated due to an allergic reaction, there were no fatalities, intubations, or other aggressive interventions besides the use of epinephrine, antihistamines, and corticosteroids. In 7 of 11 unsuccessful desensitizations, a non-IgE mechanism appeared to be responsible for the allergic reaction. CONCLUSIONS: Antibiotic desensitization is a useful option when treating patients with life-threatening infections who must receive antibiotics to which they have an IgE-mediated allergy. These data indicate that in most cases, patients with presumed IgE-mediated antibiotic allergy may safely receive antibiotics after desensitization.

Montelukast improves asthma control in asthmatic children maintained on inhaled corticosteroids.

BACKGROUND: Because of potential toxicities of inhaled corticosteroid (ICS) use in pediatric asthma, alternative or steroid-sparing therapy is desirable. There are no previous studies evaluating montelukast's steroid-sparing effects in children with asthma. OBJECTIVE: To evaluate whether (1) montelukast as add-on therapy improves asthma symptom control and (2) montelukast provides steroid-sparing effects in children with asthma treated with low to moderate doses of ICS therapy. METHODS: In a double-blind, placebo-controlled trial, 36 children ages 6 to 14 years with symptomatic asthma maintained on a stable low to moderate dose of ICSs were randomly assigned to receive montelukast or matching placebo for 24 weeks after a run-in period of 2 weeks (period I). During the trial, subjects kept daily asthma diary cards and monthly spirometry was performed. After a 4 week add-on period (period II), the subjects completed a 20-week (period III) ICS tapering period based on a predetermined protocol. RESULTS: In period II, the difference in the number of rescue-free days was significantly higher in the montelukast group (P = 0.0001), and the number of rescue-free days per week was also significantly higher in montelukast-treated subjects compared with placebo subjects (P = 0.002). In period III, the percentage reduction in ICS dose was not significant between montelukast and placebo (P = 0.10), but the montelukast group experienced an average 17% decrease in ICS dose and the control group experienced an average 64% increase in ICS dose. CONCLUSIONS: Montelukast treatment significantly increased the number of rescue-free days in symptomatic children with asthma.