Perspectives of gynecologic oncology fellowship training and preparedness for practice.

We aimed to examine the preparedness of recent gynecologic oncology fellowship graduates for independent practice.We conducted a web-based survey study using REDCap targeting Society of Gynecologic Oncology (SGO) members who graduated gynecologic oncology fellowship within the last six years. The survey included 52 items assessing fellowship training experiences, level of comfort in performing core gynecologic oncology surgical procedures and administering cancer-directed therapies. Questions also addressed factors driving participants' selection of fellowship programs, educational experience, research and preparedness for independent practice. A total of 296 participants were invited to complete the survey. Response rate was 42% with n = 124 completed surveys included for analysis. The highest ranked factor for fellowship selection was fit with program 36% (n = 45). Upon completing fellowship, most were uncomfortable performing ureteral conduit formation 84% (n = 103), ureteroneocystostomy 77% (n = 94), exenteration 68% (n = 83), splenectomy 67% (n = 83) and lower anterior resection 41% (n = 51). Most were comfortable managing intraoperative complications 85% (n = 104) and standard cancer staging procedures (range: 61%-99%). Majority were comfortable providing cancer directed therapies with chemotherapy 99% (n = 123), immunotherapy 84% (n = 104), and poly ADP-ribose polymerase (PARP) inhibitors 97% (n = 120). Upon completing fellowship, 77% (n = 95) report having mentorship that met their expectations during fellowship and 94% (n = 116) felt they were ready for independent practice. Majority of fellowship graduates were prepared for independent practice and felt comfortable performing routine surgical procedures and cancer directed treatment. However, most are not comfortable with ultra-radical gynecologic oncology procedures. Maximizing surgical opportunities during fellowship training and acquiring early career mentorship may help.

Two is better than one: the double diffusion technique in classifying heart failure.

Background: Heart failure (HF) is a chronic condition in which the heart does not pump enough blood to meet the body's demands. Diffusing capacity of the lung for nitric oxide (DLNO) and carbon monoxide (DLCO) may be used to classify patients with HF, as DLNO and DLCO are lung function measurements that reflect pulmonary gas exchange. Our objectives were to determine 1) if DLNO added to DLCO testing predicts HF better than DLCO alone and 2) whether the binary classification of HF is better when DLNO z-scores are combined with DLCO z-scores than using DLCO z-scores alone. Methods: This was a retrospective secondary data analysis in 140 New York Heart Association Class II HF patients (ejection fraction <40%) and 50 patients without HF. z-scores for DLNO, DLCO and DLNO+DLCO were created from reference equations from three articles. The model with the lowest Bayesian Information Criterion was the best predictive model. Binary HF classification was evaluated with the Matthews Correlation Coefficient (MCC). Results: The top two of 12 models were combined z-score models. The highest MCC (0.51) was from combined z-score models. At most, only 32% of the variance in the odds of having HF was explained by combined z-scores. Conclusions: Combined z-scores explained 32% of the variation in the likelihood of an individual having HF, which was higher than models using DLNO or DLCO z-scores alone. Combined z-score models had a moderate ability to classify patients with HF. We recommend using the NO-CO double diffusion technique to assess gas exchange impairment in those suspected of HF.

The Precision Between Transcutaneous Carbon Dioxide Versus PaCO2 in Infants Undergoing Therapeutic Hypothermia.

BACKGROUND: Infants with hypoxic-ischemic encephalopathy are often treated with therapeutic hypothermia and high-frequency ventilation. Fluctuations in PaCO2 during therapeutic hypothermia are associated with poor neurodevelopmental outcomes. Transcutaneous CO2 monitors offer a noninvasive estimate of PaCO2 represented by transcutaneously measured partial pressure of carbon dioxide (PtcCO2 ). We aimed to assess the precision between PtcCO2 and PaCO2 values in neonates undergoing therapeutic hypothermia. METHODS: This was a retrospective chart review of 10 neonates who underwent therapeutic hypothermia requiring respiratory support over 2 y. A range of 2-27 simultaneous PtcCO2 and PaCO2 pairs of measurements per neonate were analyzed via linear mixed models and a Bland-Altman plot for multiple observations per neonate. RESULTS: A linear mixed-effect model demonstrated that PtcCO2 and PaCO2 (controlling for sex) were similar. The 95% CI of the mean difference ranged from -2.3 to 5.7 mm Hg (P = .41). However, precision was poor as the PtcCO2 ranged from > 18 mm Hg to < 13 mm Hg than PaCO2 values for 95% of observations. CONCLUSIONS: The neonates' PtcCO2 was as much as 18 mm Hg higher to 13 mm Hg lower than the PaCO2 95% of the time. Transcutaneous CO2 monitoring may not be a good trending tool, nor is it appropriate for estimating PaCO2 in patients undergoing therapeutic hypothermia.

The stability of blood gases and CO-oximetry under slushed ice and room temperature conditions.

OBJECTIVES: Human blood gas stability data is limited to small sample sizes and questionable statistical techniques. We sought to determine the stability of blood gases under room temperature and slushed iced conditions in patients using survival analyses. METHODS: Whole blood samples from ∼200 patients were stored in plastic syringes and kept at room temperature (22-24 °C) or in slushed ice (0.1-0.2 °C) before analysis. Arterial and venous pO2 (15-150 mmHg), pCO2 (16-72 mmHg), pH (6.73-7.52), and the CO-oximetry panel [total hemoglobin (5.4-19.3 g/dL), percentages of oxyhemoglobin (O2Hb%, 20-99%), carboxyhemoglobin (COHb, 0.1-5.4%) and methemoglobin (MetHb, 0.2-4.6%)], were measured over 5-time points. The Royal College of Pathologists of Australasia's (RCPA's) criteria determined analyte instability. Survival analyses identified storage times at which 5% of the samples for various analytes became unstable. RESULTS: COHb and MetHb were stable up to 3 h in slushed ice and at room temperature; pCO2, pH was stable at room temperature for about 60 min and 3 h in slushed ice. Slushed ice shortened the storage time before pO2 became unstable (from 40 to 20 min), and the instability increased when baseline pO2 was ≥60 mmHg. The storage time for pO2, pCO2, pH, and CO-oximetry, when measured together, were limited by the pO2. CONCLUSIONS: When assessing pO2 in plastic syringes, samples kept in slushed ice harm their stability. For simplicity's sake, the data support storage times for blood gas and CO-oximetry panels of up to 40 min at room temperature if following RCPA guidelines.

The influence of sexual activity on athletic performance: a systematic review and meta-analyses.

Several anecdotal reports suggest that sex before competition can affect performance. Our objective was to perform a systematic review and meta-analysis to determine whether athletic performance or some physical fitness measure is affected by prior sexual activity. Web of Science (all databases) and Google Scholar were used to identify studies from which adult healthy subjects were included. As all studies were crossover trials, an inverse variance statistical method with random effects was used to minimize the uncertainty of the pooled effect estimate. Bias was assessed via the revised Cochrane Risk of Bias tool (RoB 2) with a "per protocol" analysis. Nine crossover studies (133 subjects, 99% male) were used in this meta-analysis. All those studies did not examine athletic performance per se, but all studies assessed one or more physical fitness parameters. The RoB 2 suggested that overall, there were some concerns with bias. As there was moderate heterogeneity amongst the different outcomes (Tau2 = 0.02, Chi-square = 17.2, df = 8, p = 0.03, I2 = 54%), a random-effects model was used. The results neither favored abstinence nor sexual activity before a physical fitness test [standardized mean difference = 0.03 (- 0.10 to 0.16), Z = 0.47, p = 0.64, where a negative standardized mean difference favors abstinence, and a positive standardized mean difference favors sexual activity]. The results demonstrate that sexual activity within 30 min to 24 h before exercise does not appear to affect aerobic fitness, musculoskeletal endurance, or strength/power.

Stability of Whole Blood Electrolyte Specimens at Room Temperature vs. Slushed Ice Conditions.

BACKGROUND: Data on the stability of whole blood electrolytes is limited to small sample sizes. We sought to determine the stability of whole blood electrolytes under room temperature and slushed iced conditions in human patients at a major hospital center. METHODS: Whole blood samples were obtained from 203 patients hospitalized for various pathophysiological conditions. Electrolyte concentrations of sodium, potassium [K+], ionized calcium, and chloride were measured at 5 different timepoints spanning 3 h. Samples were stored at room temperature (22-24 °C) or under slushed ice conditions (0.1-0.2 °C) before analysis. RESULTS: Under both conditions, sodium, ionized calcium, and chloride did not show a measurable change up to 109 min compared to baseline; however, the mean increase in [K+] over 138 min of storage in slushed ice was 0.0032 (0.0021 [5th percentile] to 0.0047 [95th percentile]) mmol/L/min (adjusted R2 = 0.62, P < 0.001). Five percent of the specimens demonstrated a ≥0.3 mmol/L change in [K+] from baseline after 67 min of storage in slushed ice. In contrast, 1% of the specimens stored at room temperature showed the same change at the same timepoint. CONCLUSIONS: Whole blood sodium, [K+], ionized calcium, and chloride concentrations remain stable for at least 109 min at room temperature. However, whole blood specimens stored in slushed ice for not more than 67 min exhibit a 5% probability that the [K+] concentration will increase by at least 0.3 mmol/L compared to baseline. The other analytes do not destabilize for up to 178 min of slushed ice storage.

Week to week variability of pulmonary capillary blood volume and alveolar membrane diffusing capacity in patients with heart failure.

BACKGROUND: Alveolar-capillary membrane diffusing capacity for carbon monoxide (DMCO) and pulmonary capillary volume (Vcap) can be estimated by the multi-step Roughton and Foster (RF, original method from 1957) or the single-step NO-CO double diffusion technique (developed in the 1980s). The latter method implies inherent assumptions. We sought to determine which combination of the alveolar membrane diffusing capacity for nitric oxide (DMNO) to DMCO ratio, an specific conductance of the blood for NO (θNO) and CO (θCO) gave the lowest week-to-week variability in patients with heart failure. METHODS: 44 heart failure patients underwent DMCO and Vcap measurements on three occasions over a ten-week period using both RF and double dilution NO-CO techniques. RESULTS: When using the double diffusing method and applying θNO = infinity, the smallest week-to-week coefficient of variation for DMCO was 10 %. Conversely, the RF method derived DMCO had a much greater week-to-week variability (2x higher coefficient of variation) than the DMCO derived via the NO-CO double dilution technique. The DMCO derived from the double diffusion technique most closely matched the DMCO from the RF method when θNO = infinity and DMCO = DLNO/2.42. The Vcap measured week-to-week was unreliable regardless of the method or constants used. CONCLUSIONS: In heart failure patients, the week-to-week DMCO variability was lowest when using the single-step NO-CO technique. DMCO obtained from double diffusion most closely matched the RF DMCO when DMCO/2.42 and θNO = infinity. Vcap estimation was unreliable with either method.

Stability of Whole Blood Lactate Specimens at Room Temperature Versus Slushed Ice Conditions.

BACKGROUND: There are limited data on lactate stability in whole blood. The purpose of this study was to determine whole blood lactate stability at room temperature and in slushed ice conditions. METHODS: An equal number of arterial and venous samples were obtained from 202 subjects hospitalized for various pathophysiological conditions. Whole blood lactate concentration was measured over 5 different times spanning 80-90 min in a blood gas lab at a major hospital center. Samples were stored at room temperature (22-24°C) or in slushed ice conditions (0.1-0.2°C) before analysis. RESULTS: The mean increase in lactate concentration was 0.001 mmol/L/min in samples on slushed ice over 90 min. However, at room temperature conditions, the mean increase in lactate concentration was 0.008 mmol/L/min regardless of whether the sample was arterial or venous. An increase in whole blood lactate concentration of ≥ 0.4 mmol/L occured after 45 min at room temperature, with 5% of all whole blood specimens demonstrating a meaningful change at ≤ 20 min. The ≥ 0.4 mmol/L change in whole blood lactate is considered significant based on the College of American Pathologists instrument peer-group standards. CONCLUSIONS: Considering that a change in whole blood lactate concentration of ≥ 0.4 mmol/L is unacceptable instrument peer-group variation as defined by the College of American Pathologists, ice is no longer needed to stabilize whole blood lactate specimens when the draw time to analyze time is < 45 min. Samples remain stable even at 90 min when left on ice.

Correction: The Effect of Protandim® Supplementation on Athletic Performance and Oxidative Blood Markers in Runners.

[This corrects the article DOI: 10.1371/journal.pone.0160559.].

Variability in pulmonary diffusing capacity in heart failure.

BACKGROUND: As pulmonary diffusing capacity is related to mortality risk and prognosis in patients with heart failure (HF), it is measured frequently. As such, it would be essential to know the week-to-week variability (reproducibility) of pulmonary diffusing capacity for carbon monoxide (DLCO) and nitric oxide (DLNO). This variability would let clinicians understand what a clinically measurable change in DLCO and DLNO would be in these patients. METHODS: On three different days spanning over ten weeks, 40 H F patients underwent testing for DLCO and DLNO. DLCO was determined after a 4 s and 10 s breath-hold maneuver, while DLNO was determined after a 4 s breath-hold maneuver. RESULTS: Forty heart failure patients (66 ± 10 years; BMI = 28.4 ± 4.6 kg∙m-2; 28 males), that were referred to our clinic were able to complete the protocol. DLCO (4 s breath-hold) and DLNO (4 s breath-hold) were 79 ± 19 % and 59 ± 14 % predicted, respectively. Fifty percent of patients (n = 20) were below the lower limit of normal (LLN, below the 5th percentile) for predicted DLCO (4 s), while 78 % of patients (n = 31) were below the LLN for predicted DLNO. All 16 patients that were below the LLN for DLCO were also below the LLN for DLNO. Over a ten week period, the reproducibility of DLNO (4 s) DLCO (4 s) and DLCO (10 s) was 18.9, 8.2, and 5.9 mL min mmHg-1, respectively. CONCLUSIONS: The week-to-week fluctuation in DLNO (4 s), as a percentage, is less than DLCO (4 s) in patients with HF. The reproducibility of DLNO in patients with HF is like that of healthy subjects.

Sexual Activity the Night Before Exercise Does Not Affect Various Measures of Physical Exercise Performance.

INTRODUCTION: The idea that sexual activity can affect athletic performance has been a matter of conjecture for the past several decades. AIM: To provide preliminary data on whether sexual activity the evening before several physical exercise performance tests affects performance the next day. METHODS: Eight participants (mean age, 28 ± 5 years) underwent several physical exercise performance tests on 3 different mornings, under 3 conditions: (i) no sexual intercourse the night before the tests (control), (ii) sexual intercourse the night before the tests, and (iii) yoga the night before the tests (randomized, single-blinded). MAIN OUTCOME MEASURES: Physical work capacity, lower body muscular power (standing vertical jump), upper body strength (handgrip strength), reaction time, and upper body musculoskeletal endurance (number of push-ups completed). RESULTS: All participants experienced orgasm through intercourse. The more pleasurable the orgasm, the lower the systolic blood pressure (SBP) on the day after intercourse (Spearman's rho = -0.86; P = .007). For every 2% increase in the total orgasm score, SBP decreased by 1 mmHg. Intercourse lasted 13 minutes; mean heart rate (HR) and caloric expenditure ranged from 88 to 145 beats/minute and from 53 to 190 kcal, respectively. There were no significant differences in the physical working capacity that elicited an HR of 170 beats/minute, number of push-ups completed, vertical jump height, grip strength, or reaction time across the 3 conditions. CONCLUSION: Orgasm through sexual activity on the night before physical exercise may reduce SBP; however, we were unable to demonstrate a statistically significant difference in physical exercise performance in any of the 3 conditions. Zavorsky GS, Vouyoukas E, Pfaus JG. Sexual Activity the Night Before Exercise Does Not Affect Various Measures of Physical Exercise Performance. Sex Med 2019;7:235-240.

Acute Reduction in Spirometry Values After Prolonged Exercise Among Recreational Runners.

BACKGROUND: Prolonged endurance running may acutely reduce spirometric lung values. This study examined changes in spirometry before and immediately after prolonged endurance exercise (running and/or walking). Specifically, we examined potential factors that predict the presence of at least a 10% postexercise reduction in FEV1. METHODS: After institutional review board approval, recruitment occurred at a pre-race exposition, where informed consent was obtained. Pre-and post-race spirometry measurements were taken from 79 study subjects who competed in a half-marathon (n = 66) or a marathon (n = 13). Spirometry was performed 1-2 days before the marathon or half-marathon and 25 min after finish the race. RESULTS: We identified a subgroup of 23 subjects with a postexercise decrease in FEV1 of ≥10%. In this subgroup, the mean post-race values for FEV1, FVC, and peak expiratory flow were 19-24% lower than the pre-race values. In the 56 subjects with a change in FEV1 of <10%, the mean post-race changes in spirometry values were not >6%. There was no difference between the 2 groups in sex distribution or between subjects who completed the half-marathon or the full marathon. For every 1-y increase in age, the likelihood of developing a postexercise reduction in FEV1 of at least 10% decreased by nearly 10% (R2 = 0.15, P = .003). CONCLUSIONS: Exercise-induced bronchoconstriction (EIB) is the most probable explanation for the reduction in post-race FEV1. Prolonged endurance exercise reduced spirometric lung function by ∼20% in those with EIB. Age was the only predictor for EIB, and EIB did not affect the finish times among recreational runners and/or walkers.

Effects of sexual activity on several measures of physical performance in young adult males.

BACKGROUND: There has been considerable debate as to whether sexual activity prior to an athletic event can affect physical performance. The goal of the study was to determine if sexual activity the evening before several physical performance tests affected the results compared to the same performance tests after five days of abstinence. METHODS: Ten, monogamous, married young men (28±7 years old, body mass index = 25.5±2.7 kg/m2) underwent a six-physical performance/balance/agility tests (forearm grip strength, balance, lateral movement, reaction time, anaerobic power, and maximal oxygen uptake) on three different days. The first day was a familiarization session, where the subjects familiarized themselves with the performance tests. Then, two randomized, single-blind mornings sessions occurred there was either no sexual intercourse on the five days prior to the tests (control condition) or sexual intercourse on the night before the tests (experimental condition) in a randomized counterbalanced, fashion. The six performance tests were performed in the same order for each of the three sessions. A paired-t-test was used to compare each fitness test between conditions. RESULTS: The results showed that sexual activity had no effect on any of the six physical performance tests. CONCLUSIONS: This suggests that physical performance is unaffected by sexual activity within 24 hours prior to competition in young men.

Waterpipe Smoking in Health-Care Students: Prevalence, Knowledge, Attitudes, and Motives.

BACKGROUND: Waterpipe (hookah) smoking is a form of tobacco smoking that is noticeably increasing worldwide, particularly among young adults. A growing body of literature indicates that college students may not be as knowledgeable as they should be in making decisions about waterpipe smoking. PURPOSE: This study evaluated the prevalence, knowledge, and attitudes regarding waterpipe smoking use among college-based health-care students. METHODS: Two instruments were found to be appropriate to the study, and permission was obtained to modify usage in this specific study. Three hundred nineteen college-based health-care students were asked to participate and complete a questionnaire. Data were analyzed by using statistical software. RESULTS: Respondents used or tried waterpipe smoking before (n = 156 [49%]). Many respondents were able to identify health hazards that might result from waterpipe smoking, but 58% (n = 187) believed that cigarette smoking was more harmful than waterpipe smoking. Chi-square tests revealed significant differences between age groups (P = .029) and program of study (P = .01) but no differences among sex (P = .76), ethnicity (P = .19), or educational status (P = .65). CONCLUSIONS: This study showed that waterpipe smoking was common but not widespread among this group of health-care students. Their knowledge of the risks and health-related attitudes toward waterpipe smoking was lacking. Many had misinformation and misconceptions when comparing waterpipe smoking versus cigarette smoking. Further studies are needed to fully understand the reasons for waterpipe smoking among health-care students. Also, there is a need to offer educational campaigns that increase students' knowledge and awareness as well as to correct misinformation that can lead to misguided beliefs and attitudes.

Team Logo Predicts Concussion Risk: Lessons in Protecting a Vulnerable Sports Community from Misconceived, but Highly Publicized Epidemiologic Research.

BACKGROUND: Observational research has linked altitude to concussion risk, but the physiologic and epidemiologic bases for this association remain questionable. METHODS: We performed a retrospective cohort study by analyzing four seasons of National Football League data from a widely used database (Concussion Watch) to determine if previous claims that altitude ≥196 m reduced concussion risk were replicable and whether an arbitrary predictor variable (animal vs. non-animal team logo) was related to concussion risk. Relative risk (RR) and 95% confidence intervals (95% CIs) were computed. RESULTS: The previous association with altitude was reproduced for earlier seasons, but not replicable for recent seasons (RR = 0.92 [95% CI = 0.70, 1.22]). Across four combined seasons, "higher altitude" (RR = 0.78 [0.64, 0.96]) and animal logo (RR = 0.75 [0.63, 0.89]) were similarly associated with reduced concussion risk. CONCLUSIONS: Inconsistent epidemiologic effects, combined with weak physiologic rationale, suggest links between altitude and concussion are coincidental. Interdisciplinary critique of concussion research is necessary to ensure that marketing claims and clinical recommendations are scientifically justified.See video abstract at, http://links.lww.com/EDE/B234.