Usability of ENTRUST as an Assessment Tool for Entrustable Professional Activities (EPAs): A Mixed Methods Analysis.

OBJECTIVE: As the American Board of Surgery transitions to a competency-based model of surgical education centered upon entrustable professional activities (EPAs), there is a growing need for objective tools to determine readiness for entrustment. This study evaluates the usability of ENTRUST, an innovative virtual patient simulation platform to assess surgical trainees' decision-making skills in preoperative, intra-operative, and post-operative settings. DESIGN: This is a mixed-methods analysis of the usability of the ENTRUST platform. Quantitative data was collected using the system usability scale (SUS) and Likert responses. Analysis was performed with descriptive statistics, bivariate analysis, and multivariable linear regression. Qualitative analysis of open-ended responses was performed using the Nielsen-Shneiderman Heuristics framework. SETTING: This study was conducted at an academic institution in a proctored exam setting. PARTICIPANTS: The analysis includes n = 47 (PGY 1-5) surgical residents who completed an online usability survey following the ENTRUST Inguinal Hernia EPA Assessment. RESULTS: The ENTRUST platform had a median SUS score of 82.5. On bivariate and multivariate analyses, there were no significant differences between usability based on demographic characteristics (all p > 0.05), and SUS score was independent of ENTRUST performance (r = 0.198, p = 0.18). Most participants agreed that the clinical workup of the patient was engaging (91.5%) and felt realistic (85.1%). The most frequent heuristics represented in the qualitative analysis included feedback, visibility, match, and control. Additional themes of educational value, enjoyment, and ease-of-use highlighted participants' perspectives on the usability of ENTRUST. CONCLUSIONS: ENTRUST demonstrates high usability in this population. Usability was independent of ENTRUST score performance and there were no differences in usability identified in this analysis based on demographic subgroups. Qualitative analysis highlighted the acceptability of ENTRUST and will inform ongoing development of the platform. The ENTRUST platform holds potential as a tool for the assessment of EPAs in surgical residency programs.

ENTRUST: A Serious Game-Based Virtual Patient Platform to Assess Entrustable Professional Activities in Graduate Medical Education.

Background: As entrustable professional activities (EPAs) are implemented in graduate medical education, there is a great need for tools to efficiently and objectively evaluate clinical competence. Readiness for entrustment in surgery requires not only assessment of technical ability, but also the critical skill of clinical decision-making. Objective: We report the development of ENTRUST, a serious game-based, virtual patient case creation and simulation platform to assess trainees' decision-making competence. A case scenario and corresponding scoring algorithm for the Inguinal Hernia EPA was iteratively developed and aligned with the description and essential functions outlined by the American Board of Surgery. In this study we report preliminary feasibility data and validity evidence. Methods: In January 2021, the case scenario was deployed and piloted on ENTRUST with 19 participants of varying surgical expertise levels to demonstrate proof of concept and initial validity evidence. Total score, preoperative sub-score, and intraoperative sub-score were analyzed by training level and years of medical experience using Spearman rank correlations. Participants completed a Likert scale user acceptance survey (1=strongly agree to 7=strongly disagree). Results: Median total score and intraoperative mode sub-score were higher with each progressive level of training (rho=0.79, P<.001 and rho=0.69, P=.001, respectively). There were significant correlations between performance and years of medical experience for total score (rho=0.82, P<.001) and intraoperative sub-scores (rho=0.70, P<.001). Participants reported high levels of platform engagement (mean 2.06) and ease of use (mean 1.88). Conclusions: Our study demonstrates feasibility and early validity evidence for ENTRUST as an assessment platform for clinical decision-making.

Correlation of Performance on ENTRUST and Traditional Oral Objective Structured Clinical Examination for High-Stakes Assessment in the College of Surgeons of East, Central, and Southern Africa.

BACKGROUND: To address the global need for accessible evidence-based tools for competency-based education, we developed ENTRUST, an innovative online virtual patient simulation platform to author and securely deploy case scenarios to assess surgical decision-making competence. STUDY DESIGN: In partnership with the College of Surgeons of East, Central, and Southern Africa, ENTRUST was piloted during the Membership of the College of Surgeons (MCS) 2021 examination. Examinees (n = 110) completed the traditional 11-station oral objective structured clinical examinations (OSCEs), followed by 3 ENTRUST cases, authored to query similar clinical content of 3 corresponding OSCE cases. ENTRUST scores were analyzed for associations with MCS Examination outcome using independent sample t tests. Correlation of ENTRUST scores to MCS Examination Percentage and OSCE station scores was calculated with Pearson correlations. Bivariate and multivariate analyses were performed to evaluate predictors of performance. RESULTS: ENTRUST performance was significantly higher in examinees who passed the MCS examination compared with those who failed (p < 0.001). The ENTRUST score was positively correlated with MCS Examination Percentage (p < 0.001) and combined OSCE station scores (p < 0.001). On multivariate analysis, there was a strong association between MCS Examination Percentage and ENTRUST Grand Total Score (p < 0.001), Simulation Total Score (p = 0.018), and Question Total Score (p < 0.001). Age was a negative predictor for ENTRUST Grand Total and Simulation Total Score, but not for Question Total Score. Sex, native language status, and intended specialty were not associated with performance on ENTRUST. CONCLUSIONS: This study demonstrates feasibility and initial validity evidence for the use of ENTRUST in a high-stakes examination context for assessment of surgical decision-making. ENTRUST holds potential as an accessible learning and assessment platform for surgical trainees worldwide.

Using AI and computer vision to analyze technical proficiency in robotic surgery.

BACKGROUND: Intraoperative skills assessment is time-consuming and subjective; an efficient and objective computer vision-based approach for feedback is desired. In this work, we aim to design and validate an interpretable automated method to evaluate technical proficiency using colorectal robotic surgery videos with artificial intelligence. METHODS: 92 curated clips of peritoneal closure were characterized by both board-certified surgeons and a computer vision AI algorithm to compare the measures of surgical skill. For human ratings, six surgeons graded clips according to the GEARS assessment tool; for AI assessment, deep learning computer vision algorithms for surgical tool detection and tracking were developed and implemented. RESULTS: For the GEARS category of efficiency, we observe a positive correlation between human expert ratings of technical efficiency and AI-determined total tool movement (r = - 0.72). Additionally, we show that more proficient surgeons perform closure with significantly less tool movement compared to less proficient surgeons (p < 0.001). For the GEARS category of bimanual dexterity, a positive correlation between expert ratings of bimanual dexterity and the AI model's calculated measure of bimanual movement based on simultaneous tool movement (r = 0.48) was also observed. On average, we also find that higher skill clips have significantly more simultaneous movement in both hands compared to lower skill clips (p < 0.001). CONCLUSIONS: In this study, measurements of technical proficiency extracted from AI algorithms are shown to correlate with those given by expert surgeons. Although we target measurements of efficiency and bimanual dexterity, this work suggests that artificial intelligence through computer vision holds promise for efficiently standardizing grading of surgical technique, which may help in surgical skills training.

Preventive Health Screening in Veterans Undergoing Bariatric Surgery.

INTRODUCTION: Individuals with obesity are vulnerable to low rates of preventive health screening. Veterans with obesity seeking bariatric surgery are also hypothesized to have gaps in preventive health screening. Evaluation in a multidisciplinary bariatric surgery clinic is a point of interaction with the healthcare system that could facilitate improvements in screening. METHODS: This is a retrospective cohort study of 381 consecutive patients undergoing bariatric surgery at a Veterans Affairs Hospital from January 2010 to October 2021. Age- and sex-appropriate health screening rates were determined at initial referral to a multidisciplinary bariatric surgery clinic and at the time of surgery. Rates of guideline concordance at both time points were compared using McNemar's test. Univariate and multivariate analyses were performed to identify the risk factors for nonconcordance. RESULTS: Concordance with all recommended screening was low at initial referral and significantly improved by time of surgery (39.1%‒63.8%; p<0.001). Screening rates significantly improved for HIV (p<0.001), cervical cancer (p=0.03), and colon cancer (p<0.001). Increases in BMI (p=0.005) and the number of indicated screening tests (p=0.029) were associated with reduced odds of concordance at initial referral. Smoking history (p=0.012) and increasing distance to the nearest Veterans Affairs Medical Center (p=0.039) were associated with reduced odds of change from nonconcordance at initial referral to concordance at the time of surgery. CONCLUSIONS: Rates of preventive health screening in Veterans with obesity are low. A multidisciplinary bariatric surgery clinic is an opportunity to improve preventive health screening in Veterans referred for bariatric surgery.

Validity Evidence for ENTRUST as an Assessment of Surgical Decision-Making for the Inguinal Hernia Entrustable Professional Activity (EPA).

OBJECTIVE: As the American Board of Surgery (ABS) moves toward implementation of Entrustable Professional Activities (EPAs), there is a growing need for objective evaluation of readiness for entrustment of residents. This requires not only assessment of technical skills and knowledge, but also surgical decision-making in preoperative, intraoperative, and postoperative settings. We developed and piloted an Inguinal Hernia EPA Assessment on ENTRUST, a serious game-based online virtual patient simulation platform to assess trainees' decision-making competence. DESIGN: This is a prospective analysis of resident performance on the ENTRUST Inguinal Hernia EPA Assessment using bivariate analyses. SETTING: This study was conducted at an academic institution in a proctored exam setting. PARTICIPANTS: Forty-three surgical residents completed the ENTRUST Inguinal Hernia EPA Assessment. RESULTS: Four case scenarios for the Inguinal Hernia EPA and corresponding scoring algorithms were iteratively developed by expert consensus aligned with ABS EPA descriptions and functions. ENTRUST Inguinal Hernia Grand Total Score was positively correlated with PGY-level (p < 0.0001). Preoperative, Intraoperative, and Postoperative Total Scores were also positively correlated with PGY-level (p = 0.001, p = 0.006, and p = 0.038, respectively). Total Case Scores were positively correlated with PGY-level for cases representing elective unilateral inguinal hernia (p = 0.0004), strangulated inguinal hernia (p < 0.0001), and elective bilateral inguinal hernia (p = 0.0003). Preoperative Sub-Scores were positively correlated with PGY-level for all cases (p < 0.01). Intraoperative Sub-Scores were positively correlated with PGY-level for strangulated inguinal hernia and bilateral inguinal hernia (p = 0.0007 and p = 0.0002, respectively). Grand Total Score and Intraoperative Sub-Score were correlated with prior operative experience (p < 0.0001). Prior video game experience did not correlate with performance on ENTRUST (p = 0.56). CONCLUSIONS: Performance on the ENTRUST Inguinal Hernia EPA Assessment was positively correlated to PGY-level and prior inguinal hernia operative performance, providing initial validity evidence for its use as an objective assessment for surgical decision-making. The ENTRUST platform holds potential as tool for assessment of ABS EPAs in surgical residency programs.

Social Belonging as a Predictor of Surgical Resident Well-being and Attrition.

OBJECTIVE: In light of the predicted shortage of surgeons, attrition from surgical residency is a significant problem. Prior data have shown that those who are happier are more productive, and those who are less well have higher rates of absenteeism. This study sought to identify the role of social belonging and its relationship to well-being and risk of attrition. DESIGN: Surgical residents were invited to participate in an online survey containing measures of social belonging (a 10-item scale adapted from previous studies), well-being (the Dupuy Psychological General Well-Being Scale, Beck Depression Inventory Short Form, and Maslach Burnout Inventory), and risk of attrition (indicated by frequency of thoughts of leaving the program). SETTING: We surveyed residents at 2 tertiary care centers, Stanford Health Care (2010, 2011, and 2015) and Washington University in St. Louis (2017). PARTICIPANTS: Categorical general surgery residents, designated preliminary residents going into 7 surgical subspecialties, and nondesignated preliminary residents were included. RESULTS: One hundred sixty-nine residents responded to the survey for a response rate of 66%. Belonging was positively correlated with general psychological well-being (r = 0.56, p < 0.0001) and negatively correlated with depression (r = -0.57, p < 0.0001), emotional exhaustion (r = -0.58, p < 0.0001), and depersonalization (r = -0.36, p < 0.0001). Further, belonging was negatively correlated with frequency of thoughts of leaving residency (r = -0.45, p < 0.0001). In regression analysis controlling for demographic variables, belonging was a significant positive predictor of psychological well-being (B = 0.95, t = 8.18, p < 0.0001) and a significant negative predictor of thoughts of leaving (B = -1.04, t = -5.44, p < 0.0001). CONCLUSIONS: Social belonging has a significant positive correlation with well-being and negative correlation with thoughts of leaving surgical training. Lack of social belonging appears to be a significant predictor of risk of attrition in surgical residency. Efforts to enhance social belonging may protect against resident attrition.

Perceived Value of a Program to Promote Surgical Resident Well-being.

OBJECTIVE: The demands of surgical residency are intense and threaten not only trainees' physical wellness, but also risk depression, burnout, and suicide. Our residency program implemented a multifaceted Balance in Life program that is designed to improve residents' well-being. The purpose of this study was to evaluate the program utilization and perceived value by residents. DESIGN, SETTING, PARTICIPANTS: Residents (n = 56, 76% response rate) were invited to participate in a voluntary survey from December 2013 to February 2014 regarding utilization, barriers to use, and perceived value of 6 program components (refrigerator, After Hours Guide, psychological counseling sessions, Resident Mentorship Program, Class Representative System, and social events). They were also asked questions about psychological well-being, burnout, grit, and sleep and exercise habits before and after implementation of the program. RESULTS: The most valued components of the program were the refrigerator (mean = 4.61) and the psychological counseling sessions (mean = 3.58), followed by social events (mean = 3.48), the Resident Mentorship Program (mean = 2.79), the Class Representative System (mean = 2.62), and the After Hours Guide (mean = 2.10). When residents were asked how they would allocate $100 among the different programs, the majority was allocated to the refrigerator ($54.31), social events ($26.43), and counseling sessions ($24.06). There was no change in psychological well-being or burnout after the program. Residents had higher levels of grit (ß = 0.26, p < 0.01) and exercised (ß = 1.02, p < 0.001) and slept (ß = 1.17, p < 0.0001) more after the program was implemented. CONCLUSIONS: This study demonstrated that a multifaceted program to improve the well-being of trainees is feasible, highly valued, and positively perceived by the residents. Further research is needed to quantify the effectiveness and longitudinal impact such a program has on resident depression, burnout, and other psychological factors.

A Mixed-Methods Analysis of a Novel Mistreatment Program for the Surgery Core Clerkship.

PURPOSE: To review mistreatment reports from before and after implementation of a mistreatment program, and student ratings of and qualitative responses to the program to evaluate the short-term impact on students. METHOD: In January 2014, a video- and discussion-based mistreatment program was implemented for the surgery clerkship at the Stanford University School of Medicine. The program aims to help students establish expectations for the learning environment; create a shared and personal definition of mistreatment; and promote advocacy and empower ment to address mistreatment. Counts and types of mistreatment were compared from a year before (January-December 2013) and two years after (January 2014-December 2015) implementation. Students' end-of-clerkship ratings and responses to open-ended questions were analyzed. RESULTS: From March 2014-December 2015, 141/164 (86%) students completed ratings, and all 47 (100%) students enrolled from January-August 2014 provided qualitative program evaluations. Most students rated the initial (108/141 [77%]) and final (120/141 [85%]) sessions as excellent or outstanding. In the qualitative analysis, students valued that the program helped establish expectations; allowed for sharing experiences; provided formal resources; and provided a supportive environment. Students felt the learning environment and culture were improved and reported increased interest in surgery. There were 14 mistreatment reports the year before the program, 9 in the program's first year, and 4 in the second year. CONCLUSIONS: The authors found a rotation-specific mistreatment program, focused on creating shared understanding about mistreatment, was well received among surgery clerkship students, and the number of mistreatment reports decreased each year following implementation.

Prevalence and predictors of depression among general surgery residents.

BACKGROUND: Recent resident suicides have highlighted the need to address depression among medical trainees. This study sought to identify the prevalence and predictors of depression among surgical residents. METHODS: Surgical residents at a single institution were surveyed. Depression and personal traits were assessed using validated measures; participant demographics were also obtained. RESULTS: 73 residents completed the survey (response rate 63%). 36% met criteria for at least mild depression, of which 20% met criteria for moderate to severe depression. In multivariate linear regression analyses controlling for demographic factors, trait emotional intelligence alone was a significant inverse predictor of depression (ß = -0.60, p < 0.001). CONCLUSIONS: Depression is prevalent among general surgery residents. Identifying protective factors and at-risk populations may allow for effective initiatives to be developed to address depression, and optimize the mental health of trainees.

A Narrative Review and Novel Framework for Application of Team-Based Learning in Graduate Medical Education.

BACKGROUND: Team-based learning (TBL) promotes problem solving and teamwork, and has been applied as an instructional method in undergraduate medical education with purported benefits. Although TBL curricula have been implemented for residents, no published systematic reviews or guidelines exist for the development and use of TBL in graduate medical education (GME). OBJECTIVE: To review TBL curricula in GME, identify gaps in the literature, and synthesize a framework to guide the development of TBL curricula at the GME level. METHODS: We searched PubMed, MEDLINE, and ERIC databases from 1990 to 2014 for relevant articles. References were reviewed to identify additional studies. The inclusion criteria were peer-reviewed publications in English that described TBL curriculum implementation in GME. Data were systematically abstracted and reviewed for consensus. Based on included publications, a 4-element framework-system, residents, significance, and scaffolding-was developed to serve as a step-wise guide to planning a TBL curriculum in GME. RESULTS: Nine publications describing 7 unique TBL curricula in residency met inclusion criteria. Outcomes included feasibility, satisfaction, clinical behavior, teamwork, and knowledge application. CONCLUSIONS: TBL appears feasible in the GME environment, with learner reactions ranging from positive to neutral. Gaps in the literature occur within each of the 4 elements of the suggested framework, including: system, faculty preparation time and minimum length of effective TBL sessions; residents, impact of team heterogeneity and inconsistent attendance; significance, comparison to other instructional methods and outcomes measuring knowledge retention, knowledge application, and skill development; and scaffolding, factors that influence the completion of preparatory work.

Student perceptions of a simulation-based flipped classroom for the surgery clerkship: A mixed-methods study.

BACKGROUND: The flipped classroom, a blended learning paradigm that uses pre-session online videos reinforced with interactive sessions, has been proposed as an alternative to traditional lectures. This article investigates medical students' perceptions of a simulation-based, flipped classroom for the surgery clerkship and suggests best practices for implementation in this setting. METHODS: A prospective cohort of students (n = 89), who were enrolled in the surgery clerkship during a 1-year period, was taught via a simulation-based, flipped classroom approach. Students completed an anonymous, end-of-clerkship survey regarding their perceptions of the curriculum. Quantitative analysis of Likert responses and qualitative analysis of narrative responses were performed. RESULTS: Students' perceptions of the curriculum were positive, with 90% rating it excellent or outstanding. The majority reported the curriculum should be continued (95%) and applied to other clerkships (84%). The component received most favorably by the students was the simulation-based skill sessions. Students rated the effectiveness of the Khan Academy-style videos the highest compared with other video formats (P < .001). Qualitative analysis identified 21 subthemes in 4 domains: general positive feedback, educational content, learning environment, and specific benefits to medical students. The students reported that the learning environment fostered accountability and self-directed learning. Specific perceived benefits included preparation for the clinical rotation and the National Board of Medical Examiners shelf exam, decreased class time, socialization with peers, and faculty interaction. CONCLUSION: Medical students' perceptions of a simulation-based, flipped classroom in the surgery clerkship were overwhelmingly positive. The flipped classroom approach can be applied successfully in a surgery clerkship setting and may offer additional benefits compared with traditional lecture-based curricula.

Emotional Intelligence as a Predictor of Resident Well-Being.

BACKGROUND: There is increasing recognition that physician wellness is critical; it not only benefits the provider, but also influences quality and patient care outcomes. Despite this, resident physicians suffer from a high rate of burnout and personal distress. Individuals with higher emotional intelligence (EI) are thought to perceive, process, and regulate emotions more effectively, which can lead to enhanced well-being and less emotional disturbance. This study sought to understand the relationship between EI and wellness among surgical residents. STUDY DESIGN: Residents in a single general surgery residency program were surveyed on a voluntary basis. Emotional intelligence was measured using the Trait Emotional Intelligence Questionnaire-Short Form. Resident wellness was assessed with the Dupuy Psychological General Well-Being Index, Maslach Burnout Inventory, and Beck Depression Inventory-Short Form. Emotional intelligence and wellness parameters were correlated using Pearson coefficients. Multivariate analysis was performed to identify factors predictive of well-being. RESULTS: Seventy-three residents participated in the survey (response rate 63%). Emotional intelligence scores correlated positively with psychological well-being (r = 0.74; p < 0.001) and inversely with depression (r = -0.69, p < 0.001) and 2 burnout parameters, emotional exhaustion (r = -0.69; p < 0.001) and depersonalization (r = -0.59; p < 0.001). In regression analyses controlling for demographic factors such as sex, age, and relationship status, EI was strongly predictive of well-being (ß = 0.76; p < 0.001), emotional exhaustion (ß = -0.63; p < 0.001), depersonalization (ß = -0.48; p = 0.002), and depression (ß = -0.60; p < 0.001). CONCLUSIONS: Emotional intelligence is a strong predictor of resident well-being. Prospectively measuring EI can identify those who are most likely to thrive in surgical residency. Interventions to increase EI can be effective at optimizing the wellness of residents.

Novel Use of Google Glass for Procedural Wireless Vital Sign Monitoring.

Purpose This study investigates the feasibility and potential utility of head-mounted displays for real-time wireless vital sign monitoring during surgical procedures. Methods In this randomized controlled pilot study, surgery residents (n = 14) performed simulated bedside procedures with traditional vital sign monitors and were randomized to addition of vital sign streaming to Google Glass. Time to recognition of preprogrammed vital sign deterioration and frequency of traditional monitor use was recorded. User feedback was collected by electronic survey. Results The experimental group spent 90% less time looking away from the procedural field to view traditional monitors during bronchoscopy (P = .003), and recognized critical desaturation 8.8 seconds earlier; the experimental group spent 71% (P = .01) less time looking away from the procedural field during thoracostomy, and recognized hypotension 10.5 seconds earlier. Trends toward earlier recognition of deterioration did not reach statistical significance. The majority of participants agreed that Google Glass increases situational awareness (64%), is helpful in monitoring vitals (86%), is easy to use (93%), and has potential to improve patient safety (85%). Conclusion In this early feasibility study, use of streaming to Google Glass significantly decreased time looking away from procedural fields and resulted in a nonsignificant trend toward earlier recognition of vital sign deterioration. Vital sign streaming with Google Glass or similar platforms is feasible and may enhance procedural situational awareness.

Effectiveness of the Surgery Core Clerkship Flipped Classroom: a prospective cohort trial.

BACKGROUND: The flipped classroom has been proposed as an alternative curricular approach to traditional didactic lectures but has not been previously applied to a surgery clerkship. METHODS: A 1-year prospective cohort of students (n = 89) enrolled in the surgery clerkship was taught using a flipped classroom approach. A historical cohort of students (n = 92) taught with a traditional lecture curriculum was used for comparison. Pretest and post-test performance, end-of-clerkship surveys, and National Board of Medical Examiners (NBME) scores were analyzed to assess effectiveness. RESULTS: Mean pretest and post-test scores increased across all modules (P < .001). There was no difference between mean NBME examination score in the prospective and historical cohorts (74.75 vs 75.74, P = .28). Mean ratings of career interest in surgery increased after curriculum completion (4.75 to 6.50, P < .001), with 90% reporting that the flipped classroom contributed to this increase. CONCLUSIONS: Implementation of a flipped classroom in the surgery clerkship is feasible and results in high learner satisfaction, effective knowledge acquisition, and increased career interest in surgery with noninferior NBME performance.

Validity evidence for Surgical Improvement of Clinical Knowledge Ops: a novel gaming platform to assess surgical decision making.

BACKGROUND: Current surgical education curricula focus mainly on the acquisition of technical skill rather than clinical and operative judgment. SICKO (Surgical Improvement of Clinical Knowledge Ops) is a novel gaming platform developed to address this critical need. A pilot study was performed to collect validity evidence for SICKO as an assessment for surgical decision making. METHODS: Forty-nine subjects stratified into 4 levels of expertise were recruited to play SICKO. Later, players were surveyed regarding the realism of the gaming platform as well as the clinical competencies required of them while playing SICKO. RESULTS: Each group of increasing expertise outperformed the less experienced groups. Mean total game scores for the novice, junior resident, senior resident, and expert groups were 5,461, 8,519, 11,404, and 13,913, respectively (P = .001). Survey results revealed high scores for realism and content. CONCLUSIONS: SICKO holds the potential to be not only an engaging and immersive educational tool, but also a valid assessment in the armamentarium of surgical educators.

Conjugated bisphenol A in maternal serum in relation to miscarriage risk.

OBJECTIVE: To examine the relationship between the maternal serum bisphenol A (BPA) concentration at the time of the missed menstrual cycle and miscarriage risk. DESIGN: Retrospective cohort of prospectively collected serum samples. SETTING: Academic fertility center. PATIENT(S): Women presenting for early pregnancy monitoring with singleton pregnancies. INTERVENTION(S): Stored serum samples from 4 to 5 weeks' gestation analyzed for conjugated serum BPA concentrations. MAIN OUTCOME MEASURE(S): Live birth, miscarriage, and chromosome content of miscarriage. RESULT(S): With the 115 women included in the study, there were 47 live births and 68 clinical miscarriages (46 aneuploid and 22 euploid). Median conjugated BPA concentrations were higher in the women who had miscarriages than in those who had live births (0.101 vs. 0.075 ng/mL). Women with the highest quartile of conjugated BPA had an increased relative risk of miscarriage (1.83; 95% CI, 1.14-2.96) compared with the women in the lowest quartile. We found a similar increase risk for both euploid and aneuploid miscarriages. CONCLUSION(S): Maternal conjugated BPA was associated with a higher risk of aneuploid and euploid miscarriage in this cohort. The impact of reducing individual exposure on future pregnancy outcomes deserves further study.

Somatization and psychological distress among women with vulvar vestibulitis syndrome.

OBJECTIVE: To investigate the distribution of psychological characteristics and pain reporting among women with vulvar vestibulitis syndrome (VVS). METHODS: In this exploratory study, 109 women with VVS completed a battery of questionnaires to assess pain with intercourse and psychological characteristics (e.g. somatization, anxiety, distress). The distribution of these characteristics was compared, first with a conventional binary classification schema (primary and secondary) and subsequently with a 3-category schema (primary, latent primary, secondary). RESULTS: Severity of pain with intercourse did not differ among the subgroups using either classification schema. Women with primary VVS consistently showed higher levels of somatization, anxiety, and distress compared with those with secondary VVS. Using a 3-tiered classification system, we found no difference between latent primary diagnosis and the other 2 groups (primary and secondary). CONCLUSION: This study highlights the critical need for research on subtype definition and the role of psychological factors in VVS.