An undergraduate medical curriculum framework for providing care to transgender and gender diverse patients: A modified Delphi study.

INTRODUCTION: The lack of attention to transgender and gender diverse (TGD) people in undergraduate medical education (UME) is a point of concern, particularly among medical students. A project was undertaken to develop a UME curriculum framework for teaching the healthcare needs of TGD people. METHODS: Using a modified Delphi methodology, four rounds of surveys were presented to an expert stakeholder group that included content experts, generalist physicians, UME teaching faculty, and medical students. Questions covered what content should be taught, who should teach the content, and how much time should be dedicated for this teaching. Once the Delphi process was complete, feedback on the provisional framework was sought from members of the TGD community to ensure it represented their needs and perspectives. RESULTS: 71 panel members and 56 community members participated in the study. Core values included the scope of the framework, and topics such as inclusivity, and safety in practice and in teaching. The framework included terminology, epidemiology, medical and surgical treatment, mental health, sexual and reproductive health, and routine primary care. There was also guidance on who should teach, time to be allocated, and the learning environment. DISCUSSION: There is a clear need to train tomorrow's doctors to provide competent and respectful healthcare services to and for TGD patients. Although local factors will likely shape the way in which this framework will be implemented in different contexts, this paper outlines a core UME-level curriculum framework for Canada and, potentially, for use in other parts of the world.

Measures to Reduce Perioperative and Intraoperative Blood Loss at Myomectomy: A Survey of Obstetrician-Gynaecologists.

OBJECTIVE: This study sought to determine current techniques used by Canadian obstetrician-gynaecologists (OB/GYNs) to medically optimize patients undergoing myomectomy during the perioperative and intraoperative periods and to identify gaps in knowledge or barriers to access of blood conservation methods. METHODS: From September to December 2016, a self-administered electronic questionnaire was distributed to 120 Canadian OB/GYNs who perform myomectomies and who practise in either academic, community, or community academic-affiliated hospitals. RESULTS: A total of 68 of 120 (57%) completed responses were analyzed. Most respondents were general OB/GYNs (72.1%; n = 49) who worked in the community (70.6%; n = 48) and had practised >10 years (67.7%; n = 46); 79.4% (n = 54) delayed surgery to correct anemia. The most common preoperative medical agents used included tranexamic acid (94.1%), ulipristal acetate (92.6%), gonadotropin-releasing hormone agonist (79.4%), and combined hormonal contraception (58.8%). The majority had access to hematology (83.8%; n = 57) and intravenous iron (82.4%; n = 56). However, respondents had variable knowledge of oral and intravenous iron dosing and administration. The most common intraoperative agents used included vasopressin (94.1%; n = 64 [subserosal, 59.4% vs. intramyometrial, 40.6%]), vasopressin with epinephrine (26.6%; n = 17 [subserosal, 58.8% vs. intramyometrial, 41.2%]), intravenous tranexamic acid (73.5%; n = 50), mechanical tourniquet (66.2%; n = 45), misoprostol (33.8%; n = 23), uterine artery ligation (22.1%; n = 15), topical sealant (17.6%; n = 12), and intraoperative blood salvage (11.8%; n = 8). CONCLUSION: Most OB/GYNs delay surgery to correct anemia, but they are uncertain of personal and institutional transfusion rates, iron dosing and administration, and optimal multimodal approaches to minimize intraoperative blood loss during myomectomy. Education and creation of a clinical pathway to address blood conservation may decrease perioperative morbidity for patients undergoing myomectomy.

Reproductive Health Considerations in Sexual and/or Gender Minority Adolescents.

Disparities exist in the area of reproductive health for lesbian, gay, bisexual (LGB), and transgender and gender nonconforming (TGNC) adolescents compared with cisgender, heterosexual adolescents, particularly related to pregnancy and pregnancy risk factors. Review of the literature indicates an estimated increased risk of adolescent pregnancy involvement between 2 and 10 times higher for LGB youth compared with heterosexual youth. This might be explained by a broad spectrum of sexual health risks experienced, including an earlier age of sexual debut, exposure to sexual abuse, and a higher number of sexual partners. TGNC youth face conflict with their gender identity and potentially their sexual orientation. It is likely that their experience is similar to cisgender LGB adolescents as it pertains to reproductive health considerations. TGNC adolescents additionally confront the added challenge of fertility preservation. Health care providers play an important role in identifying and addressing these risk factors to improve the health of LGB and TGNC adolescents. Unfortunately, whether implicit or explicit, bias among health care providers exists and affects patient care. We believe it is the responsibility of health care providers to be informed about the increased needs of these patients and to provide appropriate risk-reducing management while using inclusive and sensitive history-taking and language.

Implementation and validation of a retroperitoneal dissection curriculum.

BACKGROUND: Competency-based education requires educators to use simulation training for the purposes of education and assessment of resident trainees. Research demonstrates that improvement in surgical skills acquired in a simulated environment is transferrable to the operative environment. Laparoscopic retroperitoneal dissection, opening the retroperitoneal space and identifying the ureter, is a fundamental skill for gynecologists. Integrating simulation models into a formal and comprehensive curriculum for teaching ureterolysis could translate to increased surgical competency. OBJECTIVE: Our goal was to validate a comprehensive curriculum for laparoscopic retroperitoneal dissection for the purpose of identification of the ureter by evaluating intraoperative performance. STUDY DESIGN: A comprehensive curriculum, encompassing didactic and technical skills components and using a previously developed pelvic model, was designed to teach laparoscopic ureterolysis. Novice surgeons (postgraduate years 3-5) were recruited. Participants completed precurriculum and postcurriculum multiple-choice questionnaires to evaluate a didactic component. Preperformance and postperformance on the model was video-recorded. As part of the technical component, participants received constructive feedback from expert surgeons on how to perform laparoscopic retroperitoneal dissection using the simulation model. Participants were then video-recorded performing laparoscopic retroperitoneal dissection in the operating room within 3 months of the curriculum. All videos were blindly assessed by an expert using the Objective Structured Assessment of Technical Skills tool. At the conclusion of the study, participants completed a course evaluation. RESULTS: Thirty novice gynecologic surgeons were recruited. High baseline knowledge of ureteric anatomy and injury (multiple-choice question score median and interquartile range) still significantly increased from 7 (5-7.25) precurriculum to 8 (7-9) postcurriculum (P < .001). The median (interquartile range) technical Objective Structured Assessment of Technical Skills score increased significantly from 24.5 (23-28.25) precurriculum to 30 (29.75-32) postcurriculum (P < .001). Video-recordings were completed for 23 participants performing laparoscopic retroperitoneal dissection in the operating room. Intraoperative Objective Structured Assessment of Technical Skills scores (median of 29 [interquartile range 27-32]) correlated with postcurriculum Objective Structured Assessment of Technical Skills scores on the model (r = 0.53, P = .01). The ureter was identified intraoperatively by 91% (n = 21/23) of participants. The majority of residents (81%, n = 21/26) were more comfortable completing a supervised retroperitoneal dissection as a result of participating in the curriculum. Residents believed that this model would be useful to enhance skills acquisition prior to performing the skill in the operating room (65%, n = 17/26). CONCLUSION: A comprehensive retroperitoneal dissection curriculum showed improvement in cognitive knowledge and technical skills, which also translated to competent performance in the operating room. In addition to the objective measures, residents believed that their skills acquisition was improved following course completion.

Spontaneous uterine rupture and surgical repair at 21 weeks gestation with progression to live birth: a case report.

BACKGROUND: Uterine rupture in the non-laboring uterus is a rare occurrence, which can lead to significant morbidity and mortality for the mother and fetus. Management of this presentation is complex at pre-viable gestations. CASE PRESENTATION: A 35 year old primigravid woman with multiple previous myomectomies presented with spontaneous complete thickness uterine rupture at 21 weeks gestation. A 10 cm myometrial defect and iatrogenic amniotomy were surgically corrected with fetal preservation. This led to pregnancy continuation to 32 weeks gestation when elective cesarean delivery resulted in excellent neonatal outcome. CONCLUSIONS: Early surgical diagnosis, multidisciplinary team approach, iatrogenic amniotomy and continuous two-layer myometrial closure were factors that contributed to pregnancy prolongation in this large myometrial rupture.

The development of a retroperitoneal dissection model.

Knowledge of ureteric anatomy is essential for ureteric injury prevention in laparoscopic gynecologic surgery. Rates of injury increase with limited surgical experience and reduced surgical volume. Currently, there are no low-fidelity or high-fidelity simulation models for teaching and practicing ureteric dissection. Our goal was to design a laparoscopic simulation model for retroperitoneal anatomy with high face validity that is low-cost and easily reproducible. A low-fidelity 3-dimensional simulation model was developed that represents key anatomic structures encountered during retroperitoneal dissection and ureteric identification. Materials, construction steps, and costs were determined. The models were trialed by expert laparoscopic surgeons. Demographic information that included age, gender, surgical experience, and complex laparoscopic case volumes was collected. Face validity was assessed with a 5-item Likert-scale. The total cost of 1 model ranged from $65 to $75. The majority of the materials that were used were reusable, except for 2 components that cost <$1 per use. Seven expert surgeons participated in the study, all of whom were fellowship-trained minimally invasive gynecologic surgeons or currently enrolled in this type of fellowship program. Participants agreed or strongly agreed that the model resembled the texture of the ureter, vessels, and peritoneal layer (n=6; 86%), approximated the correct anatomic course of the ureter (n=7; 100%), and closely approximated live surgery (n=5; 71%). They also agreed or strongly agreed that the model would be useful for teaching laparoscopic retroperitoneal dissection (n=7; 100%), for assessing a learner's ability before performing in the operating room (n=6; 86%), was low-cost (n=7; 100%), and was easily reproducible (n=6; 86%). This unique model fills a gap in laparoscopic simulation training. No other low- or high-fidelity models for laparoscopic retroperitoneal ureteric dissection have been identified in the literature. This simulation model is low-cost, easily reproducible, closely resembles retroperitoneal dissection during laparoscopic gynecologic surgery, and can be used for education and assessment.

Comparing two Uterine Manipulators During Total Laparoscopic Hysterectomy: A Randomized Controlled Trial.

STUDY OBJECTIVE: To compare 2 different types of uterine manipulators (i.e., tight fitting vs loose fitting) used for total laparoscopic hysterectomy (TLH). DESIGN: A randomized controlled trial. The primary end points were time for colpotomy, time from skin incision to detachment of the uterus, and histologic assessment of thermal damage to the vagina (Canadian Task Force classification I). SETTING: A university teaching hospital. PATIENTS: All consecutive women scheduled for TLH from May 2014 to December 2015. Patients were excluded if pregnancy or malignancy was suspected or uterine size exceeded 20 weeks' gestation. INTERVENTIONS: Patients were randomized to undergo TLH with 1 of the following uterine manipulators: (1) Colpo-Probe Vaginal Fornix Delineator (Cooper Surgical, Inc, Trumbull, CT) or (2) Hohl manipulator (KARL STORZ AG, Tuttlingen, Germany). MEASUREMENTS AND MAIN RESULTS: A total of 91 patients, 49 in the Hohl manipulator group and 42 in the Colpo-Probe group, were included in the final analysis. There was no difference in patient characteristics, uterine weight, or estimated blood loss. The median time for insertion of the manipulator (2 minutes [interquartile range (IQR), 2-5 minutes] vs 6 minutes [IQR, 5-7], p < .001), the median time from skin incision to detachment of the uterus (55 minutes [IQR, 41-70] vs 65 minutes [IQR, 58-79], p = .004), and the median time for colpotomy (7 minutes [IQR, 5-10] vs 12 [IQR, 8-17], p < .001) were shorter with the Hohl manipulator. Thermal damage to the vagina varied greatly and ranged from 32 µm to 5232 µm but was not significantly different between groups (median maximum thermal damage = 1043 µm [IQR, 682-1934] vs 1522 µm [IQR, 884-2144], p = .211). CONCLUSION: Use of the Hohl manipulator results in a shorter operative time from skin incision to detachment of the uterus during TLH. Although the colpotomy time is shorter using the Hohl manipulator, this did not translate to less thermal damage to the vaginal cuff. Further studies comparing uterine manipulators are warranted to find the optimal instrument for ease of surgery and decreased thermal spread.

Urinary retention and uterine leiomyomas: a case series and systematic review of the literature.

Uterine leiomyomas are underrecognized as a cause of acute urinary retention (AUR) in women. The objective of this study was to present a case series and systematic review of the literature, to elucidate the pathogenesis of leiomyoma-related AUR, and to suggest management strategies. We included patients presenting with AUR and uterine leiomyomas at our institution between January 2011 and December 2013. Further, we systematically searched the Cochrane Library (from 1898 to June 2014), EMBASE (from 1947 to June 2014), and MEDLINE (from 1946 to June 2014) databases according to the PRISMA guidelines. A total of six patients with AUR and leiomyomas presented to our institution. Through the systematic review, another 31 cases of AUR were identified. Combined patient ages ranged from 25 to 75 years. Uterine size ranged from 10 to 22 weeks on physical examination and from 5.5 to 26 cm on imaging. The dominant leiomyoma size ranged from 5.7 to 22.4 cm. Significant risk factors were posterior or fundal leiomyoma position and the presence of a retroverted uterus. Proposed mechanisms for leiomyoma-related AUR include proximal urethra or bladder-neck compression, premenstrual pelvic congestion, vascular steal effect, and compression of pudendal or sacral nerves. Patients were treated with hysterectomy, myomectomy, uterine fibroid embolization, hormones, or by conservative management alone. In the absence of neurologic disorders or other risk factors, neither urodynamic studies nor neuromuscular testing seem to contribute to diagnosis or guide management in women with uterine leiomyomas and AUR. Patients presenting to gynecologists seem to experience shorter times to diagnosis and treatment compared with other specialties. It is essential to recognize leiomyomas as a potential cause of AUR in order to reduce unnecessary testing and delays in diagnosis and management.

Access to fertility services for lesbian women in Canada.

OBJECTIVE: To determine reproductive services offered to lesbian patients by Canadian fertility clinics, policies of practice, ease of access to these services, and sensitivity of clinics to this population of patients. DESIGN: Survey sent to assisted reproductive technology (ART) clinic directors. SETTING: Academic medical center, university-based ethics institute. PATIENT(S): None. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The percentage of Canadian fertility clinics that will provide reproductive services to lesbian patients; services offered; the presence of clinic policies on lesbian care; and the presence on web sites of heteronormative material. RESULT(S): Completed surveys were received from 71% (24/34) of clinics. All clinics surveyed provided reproductive services to lesbian patients, with the exception of one clinic. Five of 24 (21%) clinics have a written policy on care for lesbian patients; 29% (7/24) will provide services to lesbian patients without prior investigations. All clinics will offer IUI and cycle monitoring to lesbian patients. Twenty-three of 24 clinics (96%) will offer IVF services when required. Fourteen of 32 clinic web sites (44%) make mention of lesbian patients and 27% (8/30) have heteronormative information only. CONCLUSION(S): Lesbians encounter several barriers to accessing reproductive services in Canada. Addressing these issues could improve experiences of lesbian women and couples seeking care at fertility clinics.

Reactive oxygen species, PKC-beta1, and PKC-zeta mediate high-glucose-induced vascular endothelial growth factor expression in mesangial cells.

Vascular endothelial growth factor (VEGF) is implicated in the development of proteinuria in diabetic nephropathy. High ambient glucose present in diabetes stimulates VEGF expression in several cell types, but the molecular mechanisms are incompletely understood. Here primary cultured rat mesangial cells served as a model to investigate the signal transduction pathways involved in high-glucose-induced VEGF expression. Exposure to high glucose (25 mM) significantly increased VEGF mRNA evaluated by real-time PCR by 3 h, VEGF cellular protein content assessed by immunoblotting or immunofluorescence within 24 h, and VEGF secretion by 24 h. High-glucose-induced VEGF expression was blocked by an antioxidant, Tempol, and antisense oligonucleotides directed against p22(phox), a NADPH oxidase subunit. Inhibition of protein kinase C (PKC)-beta(1) with the specific pharmacological inhibitor LY-333531 or inhibition of PKC-zeta with a cell permeable specific pseudosubstrate peptide also prevented enhanced VEGF expression in high glucose. Enhanced VEGF secretion in high glucose was prevented by Tempol, PKC-beta(1), or PKC-zeta inhibition. In normal glucose (5.6 mM), overexpression of p22(phox) or constitutively active PKC-zeta enhanced VEGF expression. Hypoxia inducible factor-1alpha protein was significantly increased in high glucose only by 24 h, suggesting a possible contribution to high-glucose-stimulated VEGF expression at later time points. Thus reactive oxygen species generated by NADPH oxidase, and both PKC-beta(1) and -zeta, play important roles in high-glucose-stimulated VEGF expression and secretion by mesangial cells.

Mesangial cell-reduced Ca2+ signaling in high glucose is due to inactivation of phospholipase C-beta3 by protein kinase C.

In high glucose, glomerular mesangial cells (MCs) demonstrate impaired Ca(2+) signaling in response to seven-transmembrane receptor stimulation. To identify the mechanism, we first postulated decreased release from intracellular stores. Intracellular Ca(2+) was measured in fluo-3-loaded primary cultured rat MCs using confocal fluorescence microscopy. In high glucose (HG) 30 mM for 48 h, the 25 nM ionomycin-stimulated intracellular Ca(2+) response was reduced to 82% of that observed in normal glucose (NG). In NG 5.6 mM, Ca(2+) responses to endothelin (ET)-1 and platelet-derived growth factor (PDGF) were unchanged in cells cultured in 50 nM Ca(2+) vs. 1.8 mM Ca(2+). Depletion of intracellular Ca(2+) stores with thapsigargin eliminated ET-1-stimulated Ca(2+) responses. Incubation in 30 mM glucose (HG) for 48 h or stimulation with phorbol myristate acetate (PMA) for 10 min eliminated the Ca(2+) response to ET-1 but had no effect on the PDGF response. Downregulation of protein kinase C (PKC) with 24-h PMA or inhibition with Gö6976 in HG normalized the Ca(2+) response to ET-1. Because ET-1 and PDGF stimulate Ca(2+) signaling through different phospholipase C pathways, we hypothesized that, in HG, PKC selectively phosphorylates and inhibits PLC-beta(3). Using confocal immunofluorescence imaging, in NG, a 1.6- to 1.7-fold increase in PLC-beta(3) Ser(1105) phosphorylation was observed following PMA or ET-1 stimulation for 10 min. In HG, immunofluorescent imaging and immunoblotting showed increased PLC-beta(3) phosphorylation, without change in total PLC-beta(3), which was reversed with 24-h PMA or Gö6976. We conclude that reduced Ca(2+) signaling in HG cannot be explained by reduced Ca(2+) stores but is due to conventional PKC-dependent phosphorylation and inactivation of PLC-beta(3).