Perioperative Venous Thromboembolism Risk in Patients Undergoing Hysterectomy for Fibroids: A US Retrospective Cohort Study.

OBJECTIVES: Venous thromboembolism (VTE) occurs in 0.4%-0.7% of benign hysterectomies. Pelvic vascular compression secondary to fibroids may elevate VTE risk. We aimed to evaluate the incidence and timing of VTE among individuals undergoing hysterectomy for fibroids and other benign indications. METHODS: Retrospective cohort study of patients who underwent a hysterectomy for fibroid and non-fibroid indications from January 2015 to December 2021. Main outcome measure was VTE consisting of pulmonary embolism or deep venous thrombosis diagnosed during 3 periods: (1) preoperative (1 year before surgery until day before surgery), (2) early postoperative (surgery date through 6 weeks after surgery), and (3) late postoperative (6 weeks to 1 year after surgery). Demographics, comorbidities, surgical characteristics, and VTE rates were compared by indication. RESULTS: A total of 263 844 individuals with fibroids and 203 183 without were identified. In total, 1.1% experienced VTE. On multivariable regression (adjusted demographic confounders and route of surgery), the presence of fibroids was associated with increased odds of preoperative (adjusted odds ratio [aOR] 1.12; 95% CI 1.03-1.22, P = 0.011) and reduced odds of late postoperative VTE (aOR 0.81; 95% CI 0.73-0.91, P < 0.001). For individuals with fibroids, uterine weight ≥250 g and undergoing laparotomy were independently associated with preoperative (aOR 1.29; 95% CI 1.09-1.52, P = 0.003 and aOR 2.32; 95% CI 2.10-2.56, P < 0.001) and early postoperative VTE (aOR 1.32; 95% CI 1.08-1.62, P = 0.006 and aOR 1.72; 95% CI 1.50-1.96, P < 0.001). CONCLUSIONS: Patients with fibroids were at increased odds of having VTE 1 year before hysterectomy. For those with fibroids, elevated uterine weight and laparotomy were associated with greater risk of preoperative and early postoperative VTEs.

Patient-Reported Outcome Measures Used in Randomized Controlled Trials Following Surgical Intervention for Endometriosis: A Structured Review from the AAGL Practice Guidelines Group.

OBJECTIVE: No consensus currently exists regarding patient-reported outcome measure (PROM) instruments. This structured review was conducted to identify the PROMs used by randomized controlled trials (RCTs) that evaluated surgical treatment in patients with endometriosis. DATA SOURCES: Two parallel searches were conducted by a medical librarian using Ovid MEDLINE, Ovid Embase, and Cochrane Library for RCTs published from 2000 to July 2022. One search focused on studies reporting quality of life (QoL), and the second search focused on studies reporting pain and sexual, bowel, and bladder function. METHOD OF STUDY SELECTION: During the title and abstract screening and reference check, 600 results were identified on PROMs relating to QoL and 465 studies on PROMs relating to pain and sexual, bowel, and/or bladder function and an evaluation of 17 and 12 studies conducted, respectively. The inclusion criteria involved selecting RCTs that focused on surgical intervention and assessing QoL, pain, and sexual, bowel, and/or bladder function using PROMs. TABULATION, INTEGRATION, AND RESULTS: Covidence software was used to organize and identify duplicate articles through screening. We developed a data extraction form to collect key information about each included study, as well as the pertinent PROMs used in the study. Assessment of the risk of bias of each study was also performed. A total of 19 studies were identified involving 2089 participants and a total of 16 PROMs used across the studies; 9 of 19 studies (47%) were rated as having a low risk of bias. There were no high-risk studies identified in this review. CONCLUSION: This study identified a large number of RCTs in surgical treatment of endometriosis that used various PROMs to assess QoL, pain, and bladder, bowel, and sexual function. The PROMs used by high-quality RCTs for QoL include Endometriosis Health Profile-30, Endometriosis Health Profile-5, Short-Form 36, Short-Form 12, and EQ-5D; for bowel-related symptoms Knowles-Eccersley-Scott-Symptom Questionnaire, Gastrointestinal Quality of Life Index, and Cleveland Clinic Fecal Incontinence Severity Scoring System/Wexner; for bladder-related function Bristol Female Lower Urinary Tract Symptoms, International Prostate Symptom Score, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, and Urinary Symptom Profile; and finally for sexual function Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire and Sexual Activity Questionnaire. Unlike other domains, only one tool (visual analog scale) was the dominant PROM used for the assessment of pain. In addition, the use of more than one PROM in each study to assess different aspects of patient's health and pain symptoms did not become prevalent until after 2015.

Bilateral Cornual Resection for Uterine-sparing Removal of Tubal Sterilization Devices.

STUDY OBJECTIVE: To describe a uterine-sparing minimally invasive surgical technique for laparoscopic resection of tubal occlusion devices using bilateral cornuectomy. DESIGN: This video reviews the background of the tubal occlusion device known as Essure and the indications and methods for surgical removal with a stepwise demonstration of a minimally invasive technique with narrated video footage. SETTING: The most cited reason for patients' desire for removal of the Essure device is pelvic pain. Both hysteroscopic and laparoscopic methods have been used for removal of these devices. Laparoscopy is indicated if it has been >3 months since insertion, if a coil is noted to be malpositioned, or if the patient desires continued permanent sterilization. Techniques for removal include salpingostomy, salpingectomy, and cornuectomy. Removal of the entire device is essential, given that any remaining coil or polyethylene terephthalate fibers may continue to cause symptoms. The coils of the device can easily be fractured; therefore, in our practice we perform a bilateral cornuectomy when uterine retention is desired Supplemental Videos 1 and 2, because fracture rates are higher with salpingectomy than cornuectomy. We demonstrate the steps of this method and highlight the critical aspects for surgeons to consider during the procedure. INTERVENTIONS: Laparoscopic bilateral cornuectomy approach to a uterine-sparing excision of Essure tubal occlusion devices to reduce the risk of coil retention and fracture: 1) Injection of dilute vasopressin at the uterine cornua for vasoconstriction and hemostasis 2) Circumferential dissection of the uterine cornua using monopolar energy 3) Confirmation of endometrial cavity entry using methylene blue 4) Excision of fallopian tube along mesosalpinx to include the fimbriated end 5) Closure of the myometrial layers using a unidirectional barbed suture in a running fashion CONCLUSION: In patients who desire uterine preservation, we recommend a minimally invasive technique of bilateral cornual resection for removal of tubal sterilization devices to avoid device fracture and inadvertent retention of coils.

Multidisciplinary approach to the surgical management of interstitial ectopic pregnancy.

OBJECTIVE: To present a multidisciplinary approach to localize and resect suspected interstitial ectopic pregnancies. Interstitial ectopic pregnancies are distinct from eccentric intracavitary pregnancies and are defined by ultrasound-based criteria, including an empty uterine cavity, gestational sac located >1 cm from the cavity, thin overlying myometrium <5 mm, and the interstitial line sign. DESIGN: Case report. SETTING: Academic medical center. PATIENT(S): Here, we present the case of a 28-year-old patient at 6 weeks of gestation by last menstrual period who presented to the emergency department with spotting. Initial pelvic ultrasound findings demonstrated a gestational sac and yolk sac that were believed to be located eccentrically within the uterine cavity. Follow-up imaging was performed 2 weeks later that revealed the pregnancy was located at the uterotubal junction and distinct from the endometrial cavity, consistent with an interstitial ectopic. The patient had ongoing light spotting with mild cramping, a benign clinical exam, and normal laboratory findings. Accurate assessment of pregnancy location is critical given that the mortality rate from interstitial pregnancies is twice that of other ectopics. In contrast, live birth rates for eccentric intracavitary pregnancies may be up to 69%, and some clinicians consider expectant management of asymptomatic patients in the first trimester. INTERVENTION: The patient was recommended for inpatient admission with expedited surgical management of interstitial ectopic pregnancy. On laparoscopic entry, the pregnancy was not well-visualized because it did not deform the uterine serosa. MAIN OUTCOME MEASURES: We present a surgical approach to suspected interstitial ectopic pregnancy that is not well-visualized at the time of laparoscopy. RESULTS: The following principles are explored: the use of multiple minimally invasive modalities (laparoscopy and hysteroscopy) to perform a thorough evaluation of the pregnancy location; incorporation of intraoperative ultrasound; temporary vessel ligation and injection of intramyometrial vasopressin; complete enucleation of the products of conception; and closure of the myometrial defect. CONCLUSION: We emphasize the benefits of a multidisciplinary approach for the localization and resection of interstitial ectopic pregnancy. This patient was discharged home in good condition with no complications.

Implementation of Office Hysteroscopy for the Evaluation and Treatment of Intrauterine Pathology.

Hysteroscopy provides a minimally invasive strategy to evaluate intrauterine pathology and manage conditions such as abnormal uterine bleeding, infertility, intrauterine adhesions, müllerian anomalies, and intrauterine foreign bodies. Increasing access to hysteroscopy procedures in the office has the potential to improve patient care by minimizing financial and logistical barriers, aiding in streamlined diagnosis and treatment planning, and potentially averting unnecessary operative procedures and anesthesia. Office hysteroscopy refers to procedures performed in outpatient settings where pain management involves no medications, oral nonsedating medications, local anesthetic agents, or oral or inhaled conscious sedation. We present best practices for the implementation of hysteroscopy in an office setting. These include appropriate patient selection, optimal procedural timing, cervical preparation for patients at highest risk of cervical stenosis or pain with dilation, individualized pain-management strategies, use of distension media, and video monitoring to engage patients in the procedure. We describe miniaturized equipment for use in the office setting and "no-touch" vaginoscopic approaches to limit patient discomfort. With appropriate training and experience, office hysteroscopy presents a simple and cost-effective modality for optimizing gynecologic care for our patients.

Surgical techniques for excision of juvenile cystic adenomyoma.

OBJECTIVE: To review causes of pelvic pain among adolescents and discuss surgical techniques for safe and effective resection of juvenile cystic adenomyomas. DESIGN: Case report. SETTING: Academic medical center. PATIENTS: We present a 16-year-old patient with chronic pelvic pain and ultrasound evidence of a 2.4 cm adenomyoma. The lesion was thought specifically to represent a juvenile cystic adenomyoma, defined as a cystic lesion >1 cm occurring in women younger than 30 years with severe dysmenorrhea that is distinct from the uterine cavity and surrounded by hypertrophic myometrium. INTERVENTION: Given minimal relief from medical therapy and high suspicion for coexistent endometriosis, our patient elected to undergo laparoscopic resection of adenomyoma and excision of pelvic lesions. MAIN OUTCOME MEASURES: Preoperative considerations discussed in this video include imaging to identify the location of the lesion and adjacent structures, such as the uterine vessels, discontinuation of gonadotropin-releasing hormone agonist for adequate intraoperative visualization, and the high likelihood of encountering endometriosis at operation. RESULTS: We review the following surgical techniques: maximize visualization with the use of a uterine manipulator and temporary oophoropexy, optimize hemostasis via temporary uterine artery ligation and control of collateral blood vessels, complete ureterolysis, meticulous enucleation of adenomyoma, and excision of coexistent endometriotic lesions. Surgical findings demonstrated a 2 cm lesion along the left lower uterine segment and red-brown lesions along bilateral ovarian fossa, pathologically confirmed as adenomyoma and superficial endometriosis, respectively. CONCLUSION: This video presents strategies for safe and effective adenomyoma resection and treatment of refractory chronic pelvic pain in an adolescent.

Salpingo-oophorectomy or surveillance for ovarian endometrioma in asymptomatic premenopausal women: a cost-effectiveness analysis.

BACKGROUND: The lifetime risk of ovarian cancer is 1.9% among women with endometriosis compared with 1.3% among the general population. When an asymptomatic endometrioma is incidentally discovered on imaging, gynecologists must weigh the procedural complications and the potential for subsequent surgical menopause against future ovarian pathology or cancer. OBJECTIVE: We aimed to determine if performing unilateral salpingo-oophorectomy is a more cost-effective strategy for the prevention of death than surveillance for asymptomatic endometriomas. STUDY DESIGN: We created a cost-effectiveness model using TreeAge Pro (TreeAge Software Inc; Williamstown, MA) with a lifetime horizon. Our hypothetical cohort included premenopausal patients with 2 ovaries who did not desire fertility. Those diagnosed with asymptomatic endometrioma underwent either unilateral salpingo-oophorectomy or surveillance (ultrasound 6-12 weeks after diagnosis, then annually). Our primary effectiveness outcome was mortality, including death from ovarian cancer or surgery and all-cause mortality related to surgical menopause (± hormone replacement therapy) if the contralateral ovary is removed. We modeled the probabilities of surgical complications, occult malignancy, development of contralateral adnexal pathology, surgical menopause, use of hormone replacement therapy, and development of ovarian cancer. The costs included surgical procedures, complications, ultrasound surveillance, hormone therapy, and treatment of ovarian cancer, with information gathered from Medicare reimbursement data and published literature. Cost-effectiveness was determined using the incremental cost-effectiveness ratio of Δ costs / Δ deaths with a willingness-to-pay threshold of $11.6 million as the value of a statistical life. Multiple 1-way sensitivity analyses were performed to evaluate model robustness. RESULTS: Our model demonstrated that unilateral salpingo-oophorectomy is associated with improved outcomes compared with surveillance, with fewer deaths (0.28% vs 1.50%) and fewer cases of ovarian cancer (0.42% vs 2.96%). However, it costs more than sonographic surveillance at $6403.43 vs $5381.39 per case of incidental endometrioma. The incremental cost-effectiveness ratio showed that unilateral salpingo-oophorectomy costs $83,773.77 per death prevented and $40,237.80 per case of ovarian cancer prevented. As both values were well below the willingness-to-pay threshold, unilateral salpingo-oophorectomy is cost-effective and is the preferred strategy. If unilateral salpingo-oophorectomy were chosen over surveillance for premenopausal patients with incidental endometriomas, 1 diagnosis of ovarian cancer would be prevented in every 40 patients and 1 death averted in every 82 patients. We performed 1-way sensitivity analyses for all input variables and determined that there were no reasonable inputs that would alter our conclusions. CONCLUSION: Unilateral salpingo-oophorectomy is cost-effective and is the preferred strategy compared with surveillance for the management of incidental endometrioma in a premenopausal patient not desiring fertility. It incurs fewer deaths and fewer cases of ovarian cancer with costs below the national willingness-to-pay thresholds.

Racial and ethnic disparities in surgical care for endometriosis across the United States.

BACKGROUND: Despite an estimated 10% prevalence of endometriosis among reproductive-age women, surgical population-based data are limited. OBJECTIVE: We sought to investigate racial and ethnic disparities in surgical interventions and complications among patients undergoing endometriosis surgery across the United States. STUDY DESIGN: We performed a retrospective cohort study of American College of Surgeons National Surgical Quality Improvement Program data from 2010 to 2018 identifying International Classification of Diseases, Ninth/Tenth Revision codes for endometriosis We compared procedures, surgical routes (laparoscopy vs laparotomy), and 30-day postoperative complications by race and ethnicity. RESULTS: We identified 11,936 patients who underwent surgery for endometriosis (65% White, 8.2% Hispanic, 7.3% Black or African American, 6.2% Asian, 1.0% Native Hawaiian or Pacific Islander, 0.6% American Indian or Alaska Native, and 11.5% of unknown race). Perioperative complications occurred in 9.6% of cases. After adjusting for confounders, being Hispanic (adjusted odds ratio, 1.31; 95% confidence interval, 1.06-1.64), Black or African American (adjusted odds ratio, 1.71; confidence interval, 1.39-2.10), Native Hawaiian or Pacific Islander (adjusted odds ratio, 2.08; confidence interval, 1.28-3.37), or American Indian or Alaska Native (adjusted odds ratio, 2.34; confidence interval, 1.32-4.17) was associated with surgical complications. Hysterectomies among Hispanic (adjusted odds ratio, 1.68; confidence interval, 1.38-2.06), Black or African American (adjusted odds ratio, 1.77; confidence interval, 1.43-2.18), Asian (adjusted odds ratio, 1.87; confidence interval, 1.43-2.46), Native Hawaiian or Pacific Islander (adjusted odds ratio, 4.16; confidence interval, 2.14-8.10), and patients of unknown race or ethnicity (adjusted odds ratio, 2.07; confidence interval, 1.75-2.47) were more likely to be open. Being Hispanic (adjusted odds ratio, 1.64; confidence interval, 1.16-2.30) or Black or African American (adjusted odds ratio, 2.64; confidence interval, 1.95-3.58) was also associated with receipt of laparotomy for nonhysterectomy procedures. The likelihood of undergoing oophorectomy was increased for Hispanic and Black women (adjusted odds ratio, 2.57; confidence interval, 1.96-3.37 and adjusted odds ratio, 2.06; confidence interval, 1.51-2.80, respectively), especially at younger ages. CONCLUSION: Race and ethnicity were independently associated with surgical care for endometriosis, with elevated complication rates experienced by Hispanic, Black or African American, Native Hawaiian or Pacific Islander, and American Indian or Alaska Native patients.

Surgical coaching in obstetrics and gynecology: an evidence-based strategy to elevate surgical education and promote lifelong learning.

The American Board of Medical Specialties, of which the American Board of Obstetrics and Gynecology is a member, released recommendations in 2019 reimagining specialty certification and highlighting the importance of individualized feedback and data-driven advances in clinical practice throughout the physicians' careers. In this article, we presented surgical coaching as an evidence-based strategy for achieving lifelong learning and practice improvement that can help to fulfill the vision of the American Board of Medical Specialties. Surgical coaching involves the development of a partnership between 2 surgeons in which 1 surgeon (the coach) guides the other (the participant) in identifying goals, providing feedback, and facilitating action planning. Previous literature has demonstrated that surgical coaching is viewed as valuable by both coaches and participants. In particular, video-based coaching involves reviewing recorded surgical cases and can be integrated into the physicians' busy schedules as a means of acquiring and advancing both technical and nontechnical skills. Establishing surgical coaching as an option for continuous learning and improvement in practice has the potential to elevate surgical performance and patient care.

Perioperative outcomes in a nationwide sample of patients undergoing surgical treatment of ovarian endometriomas.

OBJECTIVE: To evaluate the perioperative outcomes of premenopausal women undergoing cystectomy or oophorectomy for ovarian endometriomas (OMAs) and other benign neoplasms. DESIGN: Retrospective cohort study. SETTING: Clinical database containing information from 580 US hospitals. PATIENT(S): Women 18 to 50 years old who underwent ovarian cystectomy or oophorectomy for benign indications between 2010 and 2020. INTERVENTION(S): We compared procedure route, length of hospital stay, and complication rates by surgical indication (OMA vs. other benign neoplasms) and surgical procedure (cystectomy vs. oophorectomy). MAIN OUTCOME MEASURE(S): Thirty-day perioperative adverse events following adnexal surgery, including conversion to laparotomy, blood transfusion, ileus, urinary tract injury, bowel injury, readmission, and death. RESULT(S): We identified 120,208 ovarian cystectomies (28,182 OMAs and 92,026 other indications) and 53,476 oophorectomies (8,622 OMAs and 44,854 other indications). During cystectomy, patients with OMAs more commonly experienced conversion to laparotomy (5.1% vs. 3.1%) and readmission (8.5% vs. 7.1%). For oophorectomies, patients with OMAs less frequently had minimally invasive surgery (55.8% vs. 64.8%) or outpatient procedures (33.8% vs. 41.8%). Urinary tract and bowel injuries were rare. Multivariable logistic regression demonstrated that the presence of OMA predicted composite complications during cystectomy (adjusted odds ratio [aOR] 1.23, 95% confidence interval [CI] 1.18-1.28) but not during oophorectomy (aOR 1.05, 95% CI 0.99-1.12). Patients with OMAs had 1.37 times the odds of a composite complication during oophorectomy than during cystectomy (95% CI 1.28-1.47). CONCLUSION(S): Patients undergoing ovarian cystectomy for OMAs had higher rates of perioperative adverse events than patients undergoing ovarian cystectomy for other benign neoplasms. Laparotomies were performed more often during oophorectomies for OMAs than for other benign indications.

Chronic Pelvic Pain Educational Experience Among Minimally Invasive Gynecologic Surgery Fellows and Recent Graduates: A Needs Assessment.

STUDY OBJECTIVE: Learning to evaluate and treat chronic pelvic pain (CPP) is an established curriculum objective within the Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS). Our aim was to investigate current educational experiences related to the evaluation and management of CPP and the impacts of those experiences on FMIGS fellows and recent fellowship graduates, including satisfaction, confidence in management, and clinical interest in CPP. DESIGN: The AAGL-Elevating Gynecologic Surgery Special Interest Group for pelvic pain developed a 33-item survey tool to investigate the following topics: (1) current educational experiences with the assessment and management of patients with CPP, (2) satisfaction with fellowship training in CPP, (3) perceived preparedness to treat patients with CPP, (4) plans to incorporate management of CPP into clinical practice, and (5) perceived desires to expand CPP exposure. Composite scores were created to examine experiences related to diseases associated with CPP and pharmaceutical and procedural treatment options. SETTING: Electronic survey. PATIENTS: Not applicable. INTERVENTIONS: The survey was distributed via AAGL email lists and offered on FMIGS social media sites from August 2017 to November 2017 to all active FMIGS fellows and individuals who graduated the fellowship during the preceding 5 years. MEASUREMENTS AND MAIN RESULTS: Fifty-three of 82 (65%) current FMIGS fellows and 104 of 169 (62%) recent fellowship graduates completed the survey. Only 66% of current fellows endorsed working with a fellowship faculty member whose clinical work focused on CPP. Most current fellows reported having a "good amount" of experience or "extensive" experience with superficial endometriosis (39/53, 74%) and deeply infiltrative endometriosis (34/53, 64%), whereas the majority reported having "no" or "little" experience with frequently comorbid conditions like irritable bowel syndrome (68%), pelvic floor tension myalgia (55%), and interstitial cystitis/painful bladder syndrome (51%). For both current fellows and recent graduates, increased CPP Disease Experience composite scores were associated with satisfaction with CPP training (current fellows odds ratio [OR] 1.9, p =.002; recent graduates OR 1.5, p < .001), perceived preparedness to treat patients with CPP (current fellows OR 2.0, p = .0021; recent graduates OR 1.5, p <.001), and the desire to incorporate the treatment of CPP into future clinical practice (current fellows OR 1.8, p = .0099; recent graduates OR 1.3, p = .0178). More than 80% (43/53) of current fellows indicated that they believed an expanded pelvic pain curriculum should be part of the FMIGS fellowship. CONCLUSION: This needs assessment of FMIGS fellows and recent graduates suggests that there are gaps between FMIGS curriculum objectives and current educational experiences, and that fellows desire increased CPP exposure. Expansion and standardization of the CPP educational experience is needed and could lead to increased focus on this disease process among subspecialty benign gynecologic surgeons.

Homelessness, housing instability, and abortion outcomes at an urban abortion clinic in the United States.

BACKGROUND: Adverse reproductive health outcomes are well documented among people experiencing homelessness or housing instability. Little is known about abortion outcomes among this population. OBJECTIVE: This study aimed to investigate the relationship between housing status and abortion outcomes and whether gestational age mediates this relationship. STUDY DESIGN: Our sample comprised 1903 individuals who had abortions at an urban clinic in San Francisco, CA, from 2015 to 2017. We defined homelessness or housing instability as a binary exposure, which included staying outside, with friends and/or family, or in a tent, vehicle, shelter, transitional program, or hotel. We evaluated gestational duration of ≥20 weeks as a mediator variable. Our primary outcome was any abortion complication. Logistic regression models were adjusted for age, race, substance use, mental health diagnoses, and previous vaginal and cesarean deliveries. RESULTS: Approximately 19% (n=356) of abortions were among people experiencing homelessness or housing instability. Compared with those with stable housing, people experiencing homelessness or housing instability presented later in pregnancy (mean gestational duration, 13.3 vs 9.5 weeks; P<.001) and had more frequent complications (6.5% vs 2.8%; P<.001; odds ratio, 2.2; 95% confidence interval, 1.2-3.9). Adjusting for race, substance use, mental health diagnoses, and previous cesarean deliveries, individuals experiencing homelessness or housing instability were more likely to have abortion complications (odds ratio, 2.3; 95% confidence interval, 1.3-4.0). However, the relationship was attenuated after adjusting for gestational duration (odds ratio, 1.4; 95% confidence interval, 0.7-2.6), suggesting that gestational duration mediates the relationship between housing status and abortion complications. CONCLUSION: Patients experiencing homelessness or housing instability presented later in gestation, which seems to contribute to the increased frequency of abortion complications.

Retention of laparoscopic and robotic skills among medical students: a randomized controlled trial.

BACKGROUND: Although simulation training beneficially contributes to traditional surgical training, there are less objective data on simulation skills retention. OBJECTIVE: To investigate the retention of laparoscopic and robotic skills after simulation training. METHODS: We present the second stage of a randomized single-blinded controlled trial in which 40 simulation-naïve medical students were randomly assigned to practice peg transfer tasks on either laparoscopic (N = 20, Fundamentals of Laparoscopic Surgery, Venture Technologies Inc., Waltham, MA) or robotic (N = 20, dV-Trainer, Mimic, Seattle, WA) platforms. In the first stage, two expert surgeons evaluated participants on both tasks before (Stage 1: Baseline) and immediately after training (Stage 1: Post-training) using a modified validated global rating scale of laparoscopic and robotic operative performance. In Stage 2, participants were evaluated on both tasks 11-20 weeks after training. RESULTS: Of the 40 students who participated in Stage 1, 23 (11 laparoscopic and 12 robotic) underwent repeat evaluation. During Stage 2, there were no significant differences between groups in objective or subjective measures for the laparoscopic task. Laparoscopic-trained participants' performances on the laparoscopic task were improved during Stage 2 compared to baseline measured by time to task completion, but not by the modified global rating scale. During the robotic task, the robotic-trained group demonstrated superior economy of motion (p = .017), Tissue Handling (p = .020), and fewer errors (p = .018) compared to the laparoscopic-trained group. Robotic skills acquisition from baseline with no significant deterioration as measured by modified global rating scale scores was observed among robotic-trained participants during Stage 2. CONCLUSION: Robotic skills acquired through simulation appear to be better maintained than laparoscopic simulation skills. CLINICAL TRIAL: This study is registered on ClinicalTrials.gov (NCT02370407).

Medical students' perceptions of the patient-centredness of the learning environment.

BACKGROUND: Patient-centred care is an important aspect of quality health care. The learning environment may impact medical students' adoption of patient-centred behaviours. METHODS: All medical students at a single institution received an anonymous, modified version of the Communication, Curriculum, and Culture instrument that measures patient-centredness in the training environment along three domains: role modelling, students' experience, and support for patient-centred behaviours. We compared domain scores and individual items by class year and gender, and qualitatively analyzed responses to two additional items that asked students to describe experiences that demonstrated varying degrees of patient-centredness. RESULTS: Year 1 and 2 students reported greater patient-centredness than year 3 and 4 students in each domain: role modelling (p = 0.03), students' experience (p = <0.001), and support for patient-centred behaviours (p < 0.001). Female students reported less support for patient-centred behaviours compared with male students (p = 0.03). Qualitative analysis revealed that explicit patient-centred curricula and positive role modelling fostered patient-centredness. Themes relating to low degrees of patient-centredness included negative role modelling and students being discouraged from being patient-centred. CONCLUSIONS: Students' perceptions of the patient-centredness of the learning environment decreased as students progressed through medical school, despite increasing exposure to patients. Qualitative analysis found that explicit patient-centred curricula cultivated patient-centred attitudes. Role modelling impacted student perceptions of patient-centredness within the learning environment.

Preoperative Duplex Scanning is a Helpful Diagnostic Tool in Neurogenic Thoracic Outlet Syndrome.

OBJECTIVE: To evaluate the diagnostic role of venous and arterial duplex scanning in neurogenic thoracic outlet syndrome (NTOS). METHODS: Retrospective review of patients who underwent duplex ultrasonography prior to first rib resection and scalenectomy (FRRS) for NTOS from 2005 to 2013. Abnormal scans included ipsilateral compression (IC) with abduction of the symptomatic extremity (>50% change in subclavian vessel flow), contralateral (asymptomatic side) compression (CC) or bilateral compression (BC). RESULTS: A total of 143 patients (76% female, average age 34, range 13-59) underwent bilateral preoperative duplex scanning. Ipsilateral compression was seen in 44 (31%), CC in 12 (8%), and BC in 14 (10%). Seventy-three (51%) patients demonstrated no compression. Patients with IC more often experienced intraoperative pneumothoraces (49% vs. 25%, P < .05) and had positive Adson tests (86% vs. 61%, P < .02). CONCLUSION: Compression of the subclavian vein or artery on duplex ultrasonography can assist in NTOS diagnosis. Ipsilateral compression on abduction often correlates with Adson testing.

"Everything I Needed from Her Was Everything She Gave Back to Me:" An Evaluation of Preconception Counseling for U.S. HIV-serodiscordant Couples Desiring Pregnancy.

OBJECTIVES: We sought to evaluate preconception counseling (PCC) through a qualitative examination of the experiences of couples with serodiscordant human immunodeficiency virus (HIV) status desiring pregnancy. METHODS: Patients involved in HIV-serodiscordant relationships who received PCC between January 2013 and January 2015 were recruited to participate in 40-minute semistructured telephone interviews. Participants were asked about their experiences with PCC and the impact of counseling on their knowledge of safer conception strategies and reproductive decisions. Two researchers independently coded interview transcripts, and delineated common ideas to generate emerging themes from participants' responses. RESULTS: Eleven respondents completed the interviews, including nine women and two men. Six respondents were HIV positive. Our thematic analysis revealed that patients gained knowledge and confidence through PCC that conception was both possible and safe. They had varied reactions to assisted reproductive technologies that correlated with income level, and explored complicated weighing of personal risk of HIV transmission. Patients reported major challenges including poor access to PCC, difficulty identifying peak fertility periods, and lack of long-term conception follow-up. DISCUSSION: PCC is a valuable resource for patients involved in HIV-serodiscordant relationships. We recommend the following opportunities for improvement: developing practical safer conception clinical and counseling guidelines for HIV-affected couples, increasing patient access to and awareness of PCC services, distributing more helpful resources to identify peak fertility, and providing long-term support for patients.

Public Health Information Delivery in the Emergency Department: Analysis of a Kiosk-Based Program.

BACKGROUND: Because more than one-third of the U.S. population visits an emergency department (ED) any given year, public health interventions in the ED can have major population-level impacts. OBJECTIVES: We determined ED patients' interest in receiving information via kiosk on common, chronic conditions for which education and preventive screening could offer public health benefit and to assess what topical information patients are interested in receiving. METHODS: This is a secondary analysis of survey data from an ED pilot program December 2011 to April 2012. Main outcome measures were patients' interests in receiving information on health topics via kiosk module. RESULTS: More than half of the 4351 patients indicated interest in receiving information on at least one health topic, including high blood pressure (30%), depression (21%), diabetes (18%), sexually transmitted diseases (11%), drug abuse (6%), and physical abuse (3%). African-American patients were more likely to be interested in receiving information on high blood pressure (odds ratio [OR] 2.7, 95% confidence interval [95% CI] 2.2-3.2]), depression (OR 1.3, 95% CI 1.1-1.6), diabetes/sugar (OR 2.2, 95% CI 1.8-2.8), drug abuse (OR 1.4, 95% CI 1.0-1.9), and sexually transmitted diseases (OR 2.6, 95% CI 1.9-3.7). Participants >55 years of age were more likely to desire information on high blood pressure and diabetes (age 55-64 years: OR 4.0, 95% CI 3.1-5.1; age >64 years: OR 4.4, 95% CI 3.2-6.2). Patients who were interested in receiving public health information were more likely to be older, African American, and male (p < 0.05). CONCLUSIONS: Interest in obtaining kiosk-delivered education on hypertension predominated. Kiosks are versatile tools that could be used in ED settings to provide health education services.