The Effect of Anesthesia on Passive Ankle Dorsiflexion.

BACKGROUND: Equinus contractures can commonly be due to contractures of gastrocnemius muscle or combined contractures of the gastrocnemius-soleus Achilles tendon complex. The decision to release part or all of the gastrocnemius-soleus Achilles tendon complex is often assessed intraoperatively while the patient is under anesthesia. It remains unknown whether the administration of general anesthesia affects the measurement of passive ankle dorsiflexion. METHODS: The unaffected, nonoperative limb on 46 foot and ankle patients underwent a Silfverskiold test measuring passive ankle dorsiflexion preoperatively and intraoperatively after administration of general anesthesia using an instrumented force-angular displacement goniometer. To determine clinical significance, we surveyed experienced surgeons to estimate the perceived minimally detectable clinical accuracy for measuring passive ankle dorsiflexion. RESULTS: Forty-six subjects were included with mean age of 42 ± 14.8 years, mean body mass index of 26.2 ± 4.9, and 52% female. The mean change in dorsiflexion values from before anesthesia to after the administration of general anesthesia was 1.9 degrees with 10 lb of pressure with knee extended (E10), 2.3 degrees with 20 lb of pressure with knee extended (E20), 2.8 degrees with 10 lb of pressure with knee flexed (F10), and 2.3 degrees with 20 lb of pressure with knee flexed (F20) (all P < .001). Thirty-three of 45 (73%) surgeons responded to the survey; all thought their minimally detectable clinical accuracy was 5 degrees or greater. CONCLUSION: After the administration of general anesthesia, a small but likely not clinically detectable increase in passive ankle dorsiflexion occurs. The common clinical practice of making intraoperative treatment decisions regarding the presence of a gastrocnemius-soleus driven equinus contractures after general anesthesia without use of paralytic agents appears reasonable given the magnitude of the changes identified in this study. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Differences in Pelvic Floor Symptoms During Pregnancy Between Hispanic and Non-Hispanic White Women.

OBJECTIVES: This study aimed to describe and compare pelvic floor symptoms and symptom burden between nulliparous Hispanic and non-Hispanic white women in the third trimester of pregnancy and to determine, in women with stress urinary incontinence (SUI), whether bother differs between groups, adjusted for UI severity. METHODS: In this cross-sectional analysis, participants completed the Epidemiology of Prolapse and Incontinence and Incontinence Severity Index questionnaires. We compared differences in symptom domains between groups using logistic regression and tested the effect of ethnicity on bother in women with SUI using linear regression. RESULTS: The sample comprised 418 non-Hispanic white and 154 Hispanic women. Prevalence rates of symptom domains ranged from 5.0% and 7.1% for pelvic organ prolapse to 95.2% and 94.2% for overactive bladder in non-Hispanic white and Hispanic women, respectively. After adjusting age, height, weight, education, physical activity, and gestational age, non-Hispanic whites had 2.37-fold increased odds (95% confidence interval, 1.44-3.92) for defecatory dysfunction and had nonsignificant increases in other symptom domains. Non-Hispanic whites were more likely to endorse symptoms in 3 or more domains than Hispanic women (58.9% vs 40.3%, respectively; P = 0.0001). Given the same UI severity (Incontinence Severity Index), Hispanic women with SUI reported 7.5 points greater bother (Epidemiology of Prolapse and Incontinence) than non-Hispanic white women (P = 0.07). CONCLUSIONS: After adjustment, we found few differences in the prevalence of pelvic floor symptom domains between Hispanic and non-Hispanic white women, apart from defecatory dysfunction. If differences by ethnicity in other pelvic floor symptoms exist, they do not seem to originate during the first pregnancy.

A Student-Led National Conference on Leadership: Broadening the Medical Student Role.

This article was migrated. The article was marked as recommended. Students have traditionally held a singular role in medical education - the learner. This narrow view neglects students unique perspective and ability to shape the future of medical education. In recognizing the need for deliberate leadership skill development and networking opportunities for medical student leaders, the American Medical Association (AMA) supported the first AMA Accelerating Change in Medical Education Student-Led Conference on Leadership in Medical Education. A planning committee of 19 students from seven medical schools collaborated to develop this conference, which took place on August 4-5, 2017 at the University of Michigan, Ann Arbor. The primary goal of the conference was for students to learn about leadership skills, connect with other student leaders, feel empowered to lead change, and continue to lead from their roles as students. Attendees participated in a variety of workshops and presentations focused on developing practical leadership skills. In addition, students formed multi-institutional teams to participate on in the MedEd Impact Challenge, attempting to address issues in medical education such as leadership curriculum development, wellness, and culture change. Post-conference surveys showed an overwhelming majority of students connected with other student leaders, shared ideas, developed collaborations, and felt empowered to enact change. Looking forward, we believe that similar student-led conferences focused on broadening the medical student role would provide avenues for positive change in medical education.

Unprotected intercourse in the 2 weeks prior to requesting emergency intrauterine contraception.

BACKGROUND: Previous emergency contraception studies have excluded women who report >1 episode of unprotected or underprotected intercourse. Thus, clinical recommendations are based on exposure to a single episode of underprotected intercourse. OBJECTIVE: We sought to assess the prevalence and timing of underprotected intercourse episodes among women requesting emergency contraception and to examine the probability of pregnancy following an emergency contraception regimen including placement of either a copper intrauterine device or a levonorgestrel intrauterine device with simultaneous administration of an oral levonorgestrel pill in women reporting multiple underprotected intercourse episodes, including episodes beyond the Food and Drug Administration-approved emergency contraception time frame (6-14 days). STUDY DESIGN: Women seeking emergency contraception who had a negative pregnancy test and desired either a copper intrauterine device or levonorgestrel emergency contraception regimen enrolled in this prospective observational study. At enrollment, participants reported the number and timing of underprotected intercourse episodes in the previous 14 days. Two weeks later, participants reported the results of a self-administered home pregnancy test. RESULTS: Of the 176 women who presented for emergency contraception and received a same-day intrauterine device, 43% (n = 76) reported multiple underprotected intercourse episodes in the 14 days prior to presenting for emergency contraception. Women with multiple underprotected intercourse episodes reported a median of 3 events (range 2-20). Two-week pregnancy data were available for 172 (98%) participants. Only 1 participant had a positive pregnancy test. Pregnancy occurred in 0 of 97 (0%; 95% confidence interval, 0-3.7%) women with a single underprotected intercourse episode and 1 of 75 (1.3%; 95% confidence interval, 0-7.2%) women reporting multiple underprotected intercourse episodes; this includes 1 of 40 (2.5%; 95% confidence interval, 0-13.2%) women reporting underprotected intercourse 6-14 days prior to intrauterine device insertion. CONCLUSION: Women seeking emergency contraception from clinics commonly reported multiple recent underprotected intercourse episodes, including episodes occurring beyond the Food and Drug Administration-approved emergency contraception time frame. However, the probability of pregnancy was low following same-day intrauterine device placement.

Choice of Emergency Contraceptive and Decision Making Regarding Subsequent Unintended Pregnancy.

OBJECTIVES: To prospectively evaluate (1) pregnancy desirability, (2) stated intentions should pregnancy occur among emergency contraception (EC) users, and (3) explore differences between women selecting the copper T380 intrauterine device (Cu IUD) or oral levonorgestrel (LNG) regarding hypothetical pregnancy plans and actual pregnancy actions during subsequent unintended pregnancies. STUDY DESIGN: In this prospective observational trial, women received the Cu IUD or oral LNG for EC without cost barriers. At baseline, participants completed a visual analogue scale measuring pregnancy desirability (anchors: 0, "trying hard not to get pregnant"; 10, "trying hard to get pregnant") and self-reported plans (abortion, adoption, parenting, and unsure) if the pregnancy test were to come back positive. Pregnancies were tracked for 12 months, and actions regarding unintended pregnancies were compared between EC method groups. RESULTS: Of 548 enrolled women, 218 chose the Cu IUD and 330 the oral LNG for EC. Pregnancy desirability at baseline was low, with no difference between EC groups (IUD group: 0.51, SD ± 1.60; LNG group: 0.68, SD ± 1.74). Fifty-four (10%) women experienced unintended pregnancies. Pregnancy plans from baseline changed for 27 (50%) women when they became pregnant. EC groups did not differ in hypothetical pregnancy intention (p = 0.15) or in agreement of hypothetical pregnancy intention with actual pregnancy action (p = 0.80). CONCLUSIONS: Women presenting for EC state high desire to prevent pregnancy regardless of method selected. When considering a hypothetical pregnancy, half of women had a plan for how they would respond to that situation, but when confronting an actual unintended pregnancy, half altered their plan. CLINICAL TRIAL REGISTRATION NUMBER: Clinicaltrials.gov identifier NCT00966771.

Sexual Behavior, Satisfaction, and Contraceptive Use Among Postpartum Women.

INTRODUCTION: This study aimed to 1) describe the behaviors and timing of the first sexual activity postpartum, 2) compare characteristics of women who return to vaginal intercourse by 6 weeks postpartum to those who initiate intercourse after 6 weeks, 3) evaluate contraceptive use of postpartum women, and 4) describe the physical and emotional satisfaction with the first sexual activity postpartum. METHODS: This prospective study recruited participants during prenatal visits or postpartum prior to hospital discharge. Women completed an initial survey regarding pregnancy intendedness, contraceptive history, breastfeeding plans, sexual activity, satisfaction, and initiation. Postpartum surveys were conducted every 2 weeks starting 6 weeks after birth until 12 weeks or return to vaginal sexual intercourse. RESULTS: A total of 370 participants were recruited; 304 (82%) were followed to first intercourse. By life table analysis at 6 weeks (42 days) postpartum, 132 (43%) of women had resumed sexual intercourse, but only 65 (49%) of those women reported using contraception. There were no significant demographic or obstetric differences by timing of resumption of intercourse. However, when controlling for these characteristics, women who reported using contraception at 6 weeks postpartum were 1.8 times (95% confidence interval [CI], 1.2-3.2; P = .015) more likely to have had vaginal intercourse by 6 weeks postpartum compared to women who were not using contraception then. By 12 weeks postpartum, 341 (92%) of women had resumed vaginal intercourse. Psychological and physical satisfaction during sex was lower both during pregnancy and after giving birth, relative to satisfaction before pregnancy (P < .001). DISCUSSION: By 6 weeks postpartum, 4 in 10 women had resumed vaginal intercourse, with only half using contraception. Counseling regarding postpartum contraception should meet normative behavior. Thus, contraceptive plans need to be established during prenatal care, and the postpartum visit should occur earlier than the current standard time of 6 weeks.

Evaluation of an intervention designed to improve the management of difficult IUD insertions by advanced practice clinicians.

OBJECTIVES: To assess whether clinical skills training in cervical dilation and paracervical anesthesia, as well as the introduction of a clinical protocol for difficult insertions, increased intrauterine device (IUD) insertion success rates among advanced practice clinicians (APCs) including women's health and family practice nurse practitioners, physician assistants and certified nurse midwives. STUDY DESIGN: This prospective study assessed an intervention to improve IUD insertions among APCs at six family planning clinics in Utah. We collected data on IUD insertions performed by participating clinicians during two observation phases: preintervention (Phase 1) and postintervention (Phase 2). Using electronic medical records, we tracked patient characteristics, IUD insertion success, difficulties and failures. We constructed a mixed-effects logistic regression model to control for provider and patient demographics influencing insertion success rates. RESULTS: Nine clinicians participated in both preintervention and postintervention phases. The analysis included 428 IUD insertion procedures (242 preintervention and 186 postintervention). During Phase 1, 31/242 (12.8%) insertions failed. Insertion rates in Phase 2 improved with only 8/186 (4.3%) failures. Using mixed-effects logistic regression, the odds of a successful insertion postintervention was 4.8 times greater than preintervention (aOR=4.8.95% CI 1.8-12.7) when controlling for provider and patient characteristics. Increased risk of insertion failure was associated with nulliparity and younger age during Phase 1, but not during Phase 2. CONCLUSIONS: A brief training for APCs and the use of a clinical protocol for difficult insertions may be able to improve IUD insertion rates. IMPLICATIONS: Clinics with high rates of IUD insertion failure can improve care with a simple intervention, which may yield significant benefits in IUD service delivery.

Adult consequences of spina bifida: a cohort study.

BACKGROUND: Patients with spina bifida potentially experience social isolation with limited employment opportunities and restriction of independent living, neurologic and intellectual impairment, and orthopaedic and urologic consequences of their condition. However, the degree of disability as these individuals age into adulthood has not been completely delineated. QUESTIONS/PURPOSE: In adults with spina bifida we determined the cause of death for those who had died, IQ, level of education, work history, independent living status, physical disabilities, and urologic status; we then identified surgical procedures that led to better adult function. METHODS: We retrospectively reviewed 84 individuals with myelomeningocele, examining social, cognitive, and physical disabilities. The minimum age at followup was 20 years (mean, 31 years; range, 20-64 years). RESULTS: Forty-two percent had normal IQs. Seventy percent never needed a neurosurgical shunt and those without shunts had higher IQs. Forty-four percent had regular education and 8% achieved college degrees. Fifty-six percent were unemployed. Thirty percent lived independently. Twenty-three percent were either married or divorced with nine normal offspring. Eighty-five percent dressed themselves, 65% shopped independently, 54% drove. Thirty-one percent were at the thoracic neurologic level (all used wheelchairs), 12% were at L1-L3 (all used a wheelchair except one), 33% were at L4-L5 (78% used a wheelchair at least part-time), and 24% were at S1 and below (all walked). Fifty-four percent experienced decubiti and as a consequence, four required major extremity amputations. Spinal fusions protected sitting balance, but hip surgery did not produce congruent hips and occasionally resulted in debilitating stiffness. Pressure sores resulted in partial foot amputations despite plantigrade feet. CONCLUSIONS: Our observations confirm the consequences associated with the physical and cognitive disabilities of patients with spina bifida. Many of these consequences can likely be mitigated by modern multidisciplinary care and special education to increase independence.