Low-Cost Task Trainer for In Utero Fetal Stent Placement.

INTRODUCTION: Some fetal procedures such as intrauterine fetal stent placement remain rare, and simulation is needed to help learners and specialists in attaining and maintaining technical competence. We sought to design and assess a low-cost, easily assembled yet clinically relevant task trainer for fetal stent placement. METHOD: The simulator was constructed using 2 quart-sized freezer bags filled with ultrasound gel and sealed with clear packing tape. The bags were stacked vertically in a transparent plastic container with ultrasound gel applied between the bags when ultrasound was used. This task trainer was used to deploy in utero stents with or without the use of ultrasound. It has been used at the annual meeting of the Society for Maternal-Fetal Medicine since 2015, the annual meeting of the International Society of Ultrasound in Obstetrics and Gynecology in 2015 and 2016, and at regional Maternal-Fetal Medicine Fellow simulation workshops since 2016. Participants were asked to complete a 5-point Likert scale survey regarding the model's realism and usefulness in training. RESULTS: One hundred thirty-three course participants evaluated the task trainer. The median rating for realism of the ultrasound images, haptic feel of stent deployment, and usefulness in training was 5 (interquartile range, 4-5). Seven physicians participated in the timed assessment of model assembly, stent deployment, and model reassembly. The average times required for the freezer bag task trainer were 2.3 minutes (2.20-2.35), 1.0 minutes (0.70-1.93), and 0.1 minutes (0.08-0.10), respectively. For the porcine tissue-based model tested in parallel, the average times were 6.0 minutes (5.00-7.06), 3.7 minutes (3.63-3.75), and 3.3 minutes (3.00-3.70), respectively. CONCLUSIONS: This low-cost simulator was rated highly when used to practice in utero stent deployment and allows for numerous repetitions in each training session. It could be a valuable tool in training novice providers and allow more experienced providers to maintain competence in this low-volume procedure.

The effects of heparin, aspirin, and maternal clinical factors on the rate of nonreportable cell-free DNA results: a retrospective cohort study.

BACKGROUND: Technological advances in the analysis of cell-free DNA in maternal serum have allowed expanded prenatal screening possibilities for fetal aneuploidies. The sensitivity and positive predictive value of the assay are partly dependent on the amount of cell-free DNA present in maternal circulation. Thus, it is important to know what fetal and maternal factors influence the level of cell-free DNA in maternal circulation. Maternal heparin use has been associated with an increase in nonreportable cell-free DNA results because of a low fetal fraction in some, but not all, previous studies. In addition, there are likely additional factors that affect cell-free DNA that remain uncharacterized. OBJECTIVE: This study aimed to determine whether heparins, low-dose aspirin, and maternal clinical factors affect the rate of nonreportable cell-free DNA testing results. STUDY DESIGN: A retrospective cohort study was conducted using pregnant people receiving cell-free fetal DNA testing from January 1, 2014, to June 30, 2018. Data were collected on patient demographics, medical comorbidities, medication use, and cell-free DNA test results. Univariate and multivariate analyses were performed to determine which factors were independently associated with the rate of nonreportable results. RESULTS: From an original sample of 1117 pregnant people, 743 met the inclusion criteria. Maternal weight (odds ratio, 1.02), heparin use (odds ratio, 12.06), aspirin use (odds ratio, 4.70), chronic hypertension (odds ratio, 5.26), pregestational diabetes mellitus (odds ratio, 2.46), and autoimmune disease (odds ratio, 3.59) were significantly associated with an increased rate of nonreportable results in the univariate analysis. Moreover, the association was present for maternal weight (odds ratio, 1.02), heparin use (odds ratio, 21.87),and aspirin use (odds ratio, 2.85) in the multivariate analysis. CONCLUSION: The previously seen association between maternal heparin use and an increase in nonreportable cell-free DNA results was confirmed. Furthermore, there seems to be an increase in nonreportable results in pregnant people taking low-dose aspirin. Providers should consider the effect of these medications when counseling patients on prenatal genetic screening options.

Hands-on Simulation Workshop for Obstetric Ultrasound-Guided Invasive Procedures.

Introduction: Due to the introduction of cell-free DNA genetic testing options, the number of clinical ultrasound procedures has greatly diminished in recent years. With fewer real-life ultrasound-guided procedures being performed, it is difficult for OB/GYN and maternal-fetal medicine (MFM) trainees to achieve competency in doing them. Simulation can be utilized to address this issue and supplement a learner's real-life training. Methods: We developed a simulation workshop incorporating previously described ultrasound guidance task trainers and simulators of amniocentesis and chorionic villus sampling. The workshop had three parts: needle guidance basics, targeting task performance, and procedure-specific simulation. A form of this workshop has been held at the annual meeting of the Society for Maternal-Fetal Medicine since 2015 and as a regional course for MFM fellows since 2017. During the 2019 and 2020 courses, participants completed Likert-scale surveys evaluating the course. Results: Since the workshops began in 2015, approximately 300 people have participated. In 2019-2020, 41 MFM attending physicians, 136 MFM fellows, and three OB/GYN residents took our course and completed a postcourse survey. Participants rated the course highly and thought it was highly effective. Discussion: We created an introductory simulation workshop for obstetric ultrasound-guided invasive procedures that participants rated highly and thought was very effective. Objective clinical assessment of skill improvement after completion of this course is needed to verify its true impact. Repeated exposure to this introductory simulation and creation of more challenging workshops are needed to achieve a sustained high level of procedural skill.

Integrating the experience: Principles for digital transformation across the patient journey.

As medical science advances and the population ages, the prevalence of chronic conditions has also grown. The traditional model of care, with its focus on acute and episodic issues within the office visit, is not designed to meaningfully address long-term patient needs. With COVID-19 has come unprecedented digital adoption, bringing health care delivery to a critical juncture. While digital tools and technologies present vast opportunities for democratizing and decentralizing care experiences, their piecemeal application to the existing "sick care" model and its information technology infrastructure will not only limit their value, but will inevitably add cost, inefficiency, and burden to care teams. In order to build upon this momentum and reap the full benefits of practice digitization, care model transformation must occur. This entails holistically reexamining how every component of the health care experience, from the digital tools to visit interactions, synchronizes to address the full continuum of patient needs throughout the journey. By doing this, care shifts away from one-size-fits-all, fragmented strings of visits, toward seamless experiences that adapt to patients' needs in real-time while integrating within their daily lives. Rather than acting as a substitute for care, technology instead is vital to promoting and amplifying the impact of all those involved. To achieve this, this paper outlines 10 principles for restructuring care to incorporate digital health capabilities. Each describes how all care model components work as a system that aligns with patient needs. By doing this, technology is now an integral in supporting relationships across the full continuum of care.

Differential Expression of CB1 Cannabinoid Receptor and Cannabinoid Receptor Interacting Protein 1a in Labor.

Background: The endocannabinoid system is present in multiple organ systems and is involved in smooth muscle regulation, immune function, neuroendocrine modulation, and metabolism of tissues. Limited data are available regarding the presence and role of this system in reproductive tissues. Components of the endocannabinoid system have been identified in myometrial and placental tissues. However, no study has investigated differential expression of the endocannabinoid system in labor. Objectives: The purpose of this study was to identify and quantify two components of the endocannabinoid system, the CB1 cannabinoid receptor and cannabinoid receptor interacting protein 1a (CRIP1a) in uterine and placental tissues, and to determine if there is differential expression in tissues exposed to labor. We hypothesized that CB1 cannabinoid receptor concentration would be altered in uterine and placental tissue exposed to labor compared with tissues not exposed to labor. Study Design: Uterine and placental tissue samples were collected in nine laboring and 11 nonlaboring women undergoing cesarean delivery. CB1 cannabinoid receptor and CRIP1a presence and quantification were evaluated using western blot, immunohistochemistry, and real-time quantitative polymerase chain reaction. Statistical comparisons of laboring and nonlaboring subjects were made for uterine and placental tissue using a Mann-Whitney test. Results: Immunohistochemistry demonstrated positive staining for CB1 cannabinoid receptors and CRIP1a in uterine tissue. The protein abundance of CB1 cannabinoid receptor in uterine tissue was significantly lower in tissues exposed to labor (p=0.01). The protein abundance of CRIP1a was lower in uterine tissue exposed to labor but did not reach statistical significance (p=0.06). mRNA expression of CB1 cannabinoid receptor (p=0.20) and CRIP1a (p=0.63) did not differ in labored compared with nonlabored uterine tissues. Conclusions: Our findings of diminished protein density of CB1 cannabinoid receptor in uterine tissue exposed to labor support the hypothesis that the endocannabinoid system plays a role in parturition. Our data add to the growing body of evidence indicating the endocannabinoid system is of importance for successful reproduction and support the need for additional research investigating this complex system as it pertains to labor. ClinicalTrials.gov ID: NCT03752021.

Continued Validation of Ultrasound Guidance Targeting Tasks: Relationship with Procedure Performance.

RATIONALE AND OBJECTIVES: To determine if deliberative practice with novel ultrasound guidance targeting tasks improves simulated procedural skill. MATERIALS AND METHODS: In a nonrandomized interventional trial first year medical students practiced the previous described dowel and straw targeting tasks 1 hour a week for 4 weeks (training group) or had no training (controls). Afterward, they each performed a simulated amniocentesis (AMN) and chorionic villus sampling (CVS) procedure. Procedures were scored using a global rating scale (GRS) and compared between groups with Mann-Whitney U tests. Two-way random effects intraclass correlation coefficients for the inter- and intra-rater variability were calculated for each item in both GRS's. RESULTS: The training group (n = 22) had higher scores on several aspects and overall performance of AMN compared to controls (n = 15). There were no differences between groups for CVS. The inter-rater and intra-rater reliability of the GRS's for both AMN and CVS ranged from 0.16 to 0.89 with most values demonstrating good to excellent agreement. CONCLUSION: This study demonstrates validity evidence in the content and internal structure domains for the AMN and CVS simulators and their accompanying GRS's. Repetitive practice of the targeting tasks improved student performance in simulated AMN, but modifications are needed for it to be relevant to other procedures such as CVS.

Evaluation of the Patterns of Learning in the Labor Cervical Examination.

OBJECTIVE: The aim of the study was to evaluate patterns of skill acquisition in the labor cervical examination in novice providers, such as the change in accuracy and overestimation and underestimation over time and the impact of dilation and effacement on accuracy. METHODS: In this descriptive longitudinal study, medical students each performed 120 simulated cervical examinations. Accuracy and how often students overestimated and underestimated dilation and effacement during was determined for each set of 10 repetitions. Accuracy data were grouped and compared by dilation (1-3, 4-6, and 7-10 cm) and effacement (90%, 75%, 50%, and 25%). RESULTS: Student accuracy in dilation significantly improved throughout the course of the study (P < 0.001). At the beginning of the study, students more often overestimated dilation, but this decreased over time (P < 0.001). In addition, the accuracy of the students' estimations was 84%, 62%, and 52% for dilations of 1-3, 4-6, and 7-10 cm, respectively (P < 0.001). Student accuracy in effacement significantly improved throughout the course of the study (P < 0.001). At the beginning of the study, students more often overestimated effacement, but as training progressed, more students tended to overestimate and underestimate equally often (P < 0.001). In addition, accuracy of the students' estimations was 93%, 88%, 81%, and 35% for effacements of 90%, 75%, 50%, and 25%, respectively (P < 0.001). CONCLUSIONS: Knowing that students tend to overestimate cervical dilation and effacement early in training and that cervices of high dilation and low effacement are more difficult to assess will be helpful in designing more efficient cervical examination training regimens.

Using Simulation to Define the Learning Curve for the Digital Cervical Examination.

INTRODUCTION: To assess how skill in the digital cervical examination is acquired in medical students. METHODS: In a longitudinal study, medical students completed 200 simulated cervical examinations. We performed regressions of each student's cumulative accuracy using the linear, power, and sigmoidal models to determine best fit. We also constructed multilevel models to determine the influence of dilation and effacement on accuracy and to determine whether the starting level and rate of learning varied between individuals. To assess skill decay, we assessed accuracy at 1, 2, and 5 months after training. We defined the amount of sustained accuracy needed to achieve competence using cumulative summation analyses and determined the amount of practice needed to reach this level of skill. RESULTS: Twenty-five medical students participated. The median (interquartile range) of cumulative accuracy at the end of the study was 69% (65-78) for dilation and 80% (76-91) for effacement. The sigmoidal model had the best fit. All students achieved competence during the study. The multilevel models showed that accuracy decreased with higher dilation and lower effacement and found that starting level and rate of learning varied between individuals. Maximal accuracy in both dilation and effacement was seen after 150 repetitions. Accuracy of the medical students persisted for 1 month for dilation and 2 months for effacement. The average±SD number of repetitions needed to achieve competence was 89±46 (range 35-195) for dilation and 48±38 (range 11-174) for effacement. DISCUSSION: Based on the variability in skill between individuals and the rate of skill acquisition and decay, we feel that a competence-based rather than time-based approach is most appropriate, that trainee performance should be monitored both during and after training, and that 150 repetitions, or more, should be included in any digital cervical examination simulation regimen.

Migratory strategies of juvenile northern fur seals (Callorhinus ursinus): bridging the gap between pups and adults.

In species exhibiting differential migration by sex and age, understanding what differences exist, and the adaptive reasons for these differences is critical for determining how demographic groups will respond to environmental variability and anthropogenic perturbations. We used satellite-telemetered movement and diving data to investigate differential migration and its ontogeny in a highly migratory North Pacific Ocean predator, the northern fur seal (Callorhinus ursinus; NFS), with a focus on understudied juvenile (1- to 2-year-old) animals. We instrumented 71 juvenile NFS in two years (2006-07 and 2007-08) at three major North American breeding sites and compared their migratory strategies with pups and adults. Although sexual dimorphism is strong in adult NFS, only weak differences in body mass between sexes were found in juveniles, which had similar body mass to pups (~3-4 months). However, unlike widely-dispersed pups, juvenile male and female NFS dispersed in different directions, and used different habitats characterized by distinct hydrography and prey assemblages during migration, similar to breeding adults. Juvenile diving behavior differed only modestly among habitats and between sexes, consistent with weak differences in body mass. Evidence of habitat sexual segregation by juvenile NFS contradicts previous hypotheses that physiological differences predominantly drive the ontogeny of differential migration.

Clinical Impact of a Restrictive Labor Induction Approval Process.

BACKGROUND/AIMS: The aim of this study was to evaluate the impact of a restrictive labor induction approval process on induction and primary cesarean delivery rates. METHODS: A retrospective cohort study was conducted at a tertiary care academic center from 2006 through 2012. The cohort of deliveries before (pre-intervention) and after (post-intervention) the process included term, singleton pregnancies with no contraindication to vaginal delivery. The primary outcome was induction of labor rates, subgrouped on the basis of whether it was medically or nonmedically indicated. Secondary outcomes included the primary cesarean rate and other maternal and neonatal outcomes. RESULTS: Of 13,753 deliveries, 6,746 met study inclusion criteria. There was a significant decrease in induction rates comparing the pre- and post-intervention periods (21.0 vs. 18.5%, p = 0.01). Nonmedically indicated induction rates also decreased significantly (2.9 vs. 0.6%, p < 0.001). No difference was observed in medically indicated induction (18.1 vs. 17.9%, p = 0.84), the primary cesarean rate (14.4 vs. 15.8%, p = 0.12), or any of the measured neonatal outcomes (p > 0.05). CONCLUSIONS: Implementation of a labor induction approval process was associated with a significant reduction in overall and non-indicated induction rates but did not affect the primary cesarean rate or neonatal outcomes.

Novel Approach to Reduction of an Incarcerated Uterus.

BACKGROUND: Incarceration of the pregnant uterus is a rare condition and can lead to bladder obstruction, renal failure, or uterine rupture. We present a novel, noninvasive technique to reduce an incarcerated uterus. METHOD: With conscious sedation, the patient was placed in all-fours position. The physician's hands were placed on the patient's abdomen and pressure applied until the uterine fundus was palpated. Gentle, steady fundal pressure on both sides was directed toward the maternal chest (bilateral mediocephalad pressure) elevating the uterus out of the pelvis. This approach successfully reduced the gravid incarcerated uterus and was well tolerated by the patient and fetus. EXPERIENCE: The author's experience with this method is limited to this case. Prior experience with reduction of the incarcerated uterus has been with methods previously described in the literature. CONCLUSION: In conjunction with conscious sedation and all-fours positioning, transabdominal manipulation of the uterine fundus with bilateral mediocephalad pressure may facilitate reduction of an incarcerated uterus. This method may obviate the need for more invasive procedures.

Body fat index: A novel alternative to body mass index for prediction of gestational diabetes and hypertensive disorders in pregnancy.

OBJECTIVES: To evaluate the association of ultrasound measurement of maternal abdominal subcutaneous and pre-peritoneal fat thickness in relation to the subsequent diagnosis of gestational diabetes (GDM), and to assess the association of body fat index (BFI), compared to conventional body mass index (BMI), with respect to the development of some obstetric related complications. STUDY DESIGN: A prospective study included non-diabetic pregnant women who were scheduled for fetal anatomic survey. Women underwent fat measurements and BFI (pre-peritoneal fat x subcutaneous fat/height) was calculated. They underwent routine glucose screening and diagnostic tests for GDM. Obstetric complications, mode of delivery, and delivery related events were reported. Multivariable logistic regression was used to test potential predictors for development of obesity-related complications. Primary outcome was development of GDM. Secondary outcomes included development of hypertensive disorders during pregnancy and need for cesarean delivery due to labor dystocia. The optimal cut-off points for continuous variables were obtained using a receiver operating characteristic (ROC) curve analyses. RESULTS: 389 women met study criteria. Median gestational age at time of ultrasound evaluation was 19.1 weeks. Positive family history of diabetes (adjusted odds ratio "OR" 2.30, 95% CI 1.35-3.92), history of GDM (adjusted OR 6.87, 95% CI 3.03-15.61), subcutaneous fat≥13 mm (adjusted OR 4.63, 95% CI 1.60-13.38) and pre-peritoneal fat≥12 mm (adjusted OR 3.32, 95% CI 1.06-10.42) were significant predictors for development of GDM. ROC analysis demonstrated that a BFI > 0.5 was statistically superior to a BMI > 25 or 30 as a predictor of gestational diabetes (adjusted OR 6.24, 95% CI 1.86-20.96). A Similar ROC analysis demonstrated that a BFI > 0.8 was associated with a higher risk for the development of hypertensive disorders of pregnancy (adjusted OR 2.70 [95% CI 1.60-4.55]), and need for cesarean delivery (adjusted OR 2.01[95% CI 1.23-3.28]) than a BMI > 25 or 30. CONCLUSION: Values obtained by ultrasound measurement of subcutaneous and pre-peritoneal fat are associated with development of GDM and hypertensive disorders in pregnancy. Our data suggest that BFI was a better predictor than BMI for development of GDM and hypertensive disorders in pregnancy and should be studied further.

OB Nest: Reimagining Low-Risk Prenatal Care.

Using a human-centered design method, our team sought to envision a new model of care for women experiencing low-risk pregnancy. This model, called OB Nest, aimed to demedicalize the experience of pregnancy by providing a supportive and empowering experience that fits within patients' daily lives. To explore this topic, we invited women to use self-monitoring tools, a text-based smartphone application to communicate with their care team, and moderated online communities to connect with other pregnant women. Through observations of tool use and patient- and care team-provided feedback, we found that self-measurement and access to a fetal heart monitor provided women with confidence and joy in the progress of their pregnancies while shifting their position to being an active participant in their care. The smartphone application gave women direct access to their care team, provided continuity, and removed hurdles in establishing communication. The online community platform was a space where women in the same obstetric clinic could share nonmedical questions and advice with one another. This created a sense of community, leveraged the knowledge of women, and provided a venue beyond the clinic visit for information exchange. These findings were integrated into the design of the Mayo Clinic OB Nest model. This model redistributes care based on the individual needs of patients by providing self-measurement tools and continuous flexible access to their care team. By enabling women to meaningfully participate in their care, there is potential for cost savings and improved patient satisfaction.

A model-based solution for observational errors in laboratory studies.

Molecular techniques for detecting microorganisms, macroorganisms and infectious agents are susceptible to false-negative and false-positive errors. If left unaddressed, these observational errors may yield misleading inference concerning occurrence, prevalence, sensitivity, specificity and covariate relationships. Occupancy models are widely used to account for false-negative errors and more recently have even been used to address false-positive errors, too. Current modelling options assume false-positive errors only occur in truly negative samples, an assumption that yields biased inference concerning detection because a positive sample could be classified as such not because the target agent was successfully detected, but rather due to a false-positive test result. We present an extension to the occupancy modelling framework that allows false-positive errors in both negative and positive samples, thereby providing unbiased inference concerning occurrence and detection, as well as reliable conclusions about the efficacy of sampling designs, handling protocols and diagnostic tests. We apply the model to simulated data, showing that it recovers known parameters and outperforms other approaches that are commonly used when confronted with observation errors. We then apply the model to an experimental data set on Batrachochytrium dendrobatidis, a pathogenic fungus that is implicated in the global decline or extinction of hundreds of amphibian species. The model-based approach we present is not only useful for obtaining reliable inference when data are contaminated with observational errors, but also eliminates the need for establishing arbitrary thresholds or decision rules that have hidden and unintended consequences.

Optimizing the amount of simulation training used to teach vaginal delivery skills to medical students.

OBJECTIVE: To determine the amount of simulation training required for students to attain minimal competence and mastery of a vaginal delivery. METHODS: An observational study was conducted at a US medical school between May 11, 2015, and May 8, 2016. Using a modified Angoff method, 10 members of the Obstetrics and Gynecology faculty evaluated a vaginal delivery procedural checklist and established cutoff scores for minimal competence and mastery. During a 5-week period, all third-year students received between two and five 45-minute vaginal delivery simulation sessions; performance was assessed during week 6. Performance according to the checklist was compared. RESULTS: The cutoff score was 20 and 26 out of 30 for minimal competence and mastery, respectively. Among 115 students, mean checklist scores in final assessment rose with increasing number of simulations: 23.6, 25.1, 27.5, and 27.6 points for two, three, four, and five training sessions, respectively (P<0.001). The proportion of patients achieving mastery also increased with number of simulations: 34%, 59%, 73%, and 93% for two, three, four, and five training sessions, respectively (P<0.001). Two or three training sessions were sufficient to attain minimal competence in most students; however, no significant between-group difference was found. CONCLUSION: Simulation training exerts an increasing effect on performance with each additional session that students receive.

Assessment of Chronic Wasting Disease Prion Shedding in Deer Saliva with Occupancy Modeling.

The detection of prions is difficult due to the peculiarity of the pathogen, which is a misfolded form of a normal protein. The specificity and sensitivity of detection methods are imperfect in complex samples, including in excreta. Here, we combined optimized prion amplification procedures with a statistical method that accounts for false-positive and false-negative errors to test deer saliva for chronic wasting disease (CWD) prions. This approach enabled us to discriminate the shedding of prions in saliva and the detection of prions in saliva-a distinction crucial to understanding the role of prion shedding in disease transmission and for diagnosis. We found that assay sensitivity and specificity were indeed imperfect, and we were able to draw several conclusions pertinent to CWD biology from our analyses: (i) the shedding of prions in saliva increases with time postinoculation, but is common throughout the preclinical phase of disease; (ii) the shedding propensity is influenced neither by sex nor by prion protein genotype at codon 96; and (iii) the source of prion-containing inoculum used to infect deer affects the likelihood of prion shedding in saliva; oral inoculation of deer with CWD-positive saliva resulted in 2.77 times the likelihood of prion shedding in saliva compared to that from inoculation with CWD-positive brain. These results are pertinent to horizontal CWD transmission in wild cervids. Moreover, the approach described is applicable to other diagnostic assays with imperfect detection.

Validation of Ultrasound Guidance Targeting Tasks: Relationship of Performance and Clinical Experience.

OBJECTIVE: To assess whether health care provider performance on a novel task trainer and a set of newly created ultrasound guidance targeting tasks relates with their level of clinical experience. METHODS: In a prospective cohort study, two assessment sessions were carried out in which inexperienced (n=21 and n=15) and experienced (n=14 and n=10) health care providers completed five previously described ultrasound guidance targeting tasks. Raw completion time, number of targeting errors, and error-adjusted completion time for each task were compared between groups with a t test for independent measures. Receiver operating characteristic analyses were performed to estimate whether error-adjusted completion time or number of errors could accurately differentiate between groups. RESULTS: Raw completion time was similar between groups. The number of errors and error-adjusted completion time were significantly lower in the experienced health care providers in all but the out-of-plane dowel task. The receiver operating characteristic analyses of number of errors demonstrated very high areas under the curve (0.93-0.98), sensitivities (100%), specificities (76-86%), positive likelihood ratios (4.2-7.0), and negative likelihood ratios (<0.001) indicating excellent differentiation between experienced and inexperienced health care providers. These values were notably lower in the receiver operating characteristic analyses of error-adjusted completion times. CONCLUSION: Task performance related well with a health care provider's level of clinical experience providing evidence of construct validity. For each task, we were able to determine a cutoff for number of errors that categorized experienced and inexperienced health care providers with very favorable sensitivity, specificity, positive likelihood ratios, and negative likelihood ratios. Our findings suggest it may be possible to use these cutoffs to objectively classify trainees as competent or not competent.

Effectiveness of a Labor Cervical Exam Model in Family Medicine and OB-GYN Residents.

BACKGROUND AND OBJECTIVES: Labor cervical exam accuracy is an essential skill for family medicine and OB-GYN residents to master. To determine the effectiveness of simulation on labor cervical exam training, family medicine and OB-GYN residents were trained using a self-constructed PVC pipe-based cervical exam model during a short and intensive simulation workshop or "boot camp." METHODS: A task trainer was constructed that allows for the blind examination of cervical dilation and effacement. This model was used in the training of first-year family medicine and OB-GYN residents during an 8 day simulation course. A longitudinal comparison of pre- and post-training accuracy was performed. Using a cohort design, the post-training accuracy of first-year family medicine and OB-GYN residents (interns) was also compared to second-fourth year OB-GYN residents. RESULTS: Use of the model by interns (n=25) resulted in significant improvements in the accuracy of their assessments of cervical dilation, but not effacement, and decreased intra-rater variability. When compared to the second-fourth year residents (n=25) who received traditional training, but not simulation training, interns were significantly more accurate and showed less intra-rater variability in their assessments of both dilation and effacement immediately after training compared to their senior colleagues. CONCLUSIONS: Training with the cervical exam model improved interns' accuracy and precision immediately after an 8-day simulation course. Use of this model in resident education may aid in the early stages of training and benefit more experienced trainees by augmenting traditional clinical training.

Functional benefits and patient satisfaction with upper blepharoplasty - evaluated by objective and subjective outcome measures.

PURPOSE: To investigate the functional benefits and patient satisfaction with upper blepharoplasty in patients meeting the Danish visitation guidelines for upper blepharoplasty from the Danish Health and Medicines Authority (Sundhedsstyrelsen). METHODS: Before and 3 months after upper blepharoplasty, the following investigations were made: (i) a standard eye examination, (ii) photographic documentation with a normal camera and the infrared camera of a Spectralis Optical Coherence Tomograph and (iii) measurements of the upper visual fields using the blepharoptosis test of Octopus 900. Along with the pre- and postoperative examinations, the patients completed a questionnaire concerning the functional and psychosocial impact of their eyelids. RESULTS: Ninety eyelids of 45 patients were studied, 34 females and 11 males. The mean age was 56.9 years (SD: 12.8). The mean change in the distance between the upper eyelid skin fold and the visual axis or the marginal reflex distance (MRD), depending on which was lowest, was 1.6 mm (SD: 0.8 mm) for the right eyelids and 1.2 (SD: 0.9 mm) for the left eyelids. The mean improvement in the upper visual field was 31.3% points for the right eyelids (SD: 21.4% points) and 28.3% points for the left eyelids (SD: 24.9% points). A statistically significant correlation between the preoperative distance from skin fold to visual axis/MRD and the pre- and postoperative visual field was found. The patients reported an improvement in their symptoms postoperatively. All subjects were satisfied with the postoperative result and would undergo the surgery again if they had to make the choice again. CONCLUSION: Patients meeting the Danish visitation guidelines for upper blepharoplasty experience a measurable improvement in function and alleviation of symptoms after blepharoplasty.