Provider attitudes and current practice regarding the prescription of opioid-containing pain medication for vaginal delivery.

BACKGROUND: The epidemic of opioid misuse and abuse is rampant in the United States. A large percentage of patients who go on to misuse or abuse opioids were initially legally prescribed an opioid medication by their physician. One of the most common reasons patients of reproductive age seek medical care is for pregnancy and delivery. These patients are frequently prescribed opioids. Greater than one in 10 Medicaid-enrolled women fill an opioid prescription after vaginal delivery. OBJECTIVE: To assess the opioid prescribing patterns of obstetric providers following vaginal deliveries. STUDY DESIGN: Obstetric physicians and certified nurse midwives (CNMs) from different practice backgrounds were administered a questionnaire regarding opioid prescribing practices for patients who undergo vaginal delivery. Providers were contacted via email and completed survey via REDCap. RESULTS: Ninety-nine providers completed the survey between October 2018 and January 2019. Eight percent of all providers reported prescribing opioids at discharge after vaginal deliveries. There was a statistically significant difference in the proportion of physicians who provided opioid prescriptions at discharge compared to CNMs (16.7 percent vs 1.8 percent, respectively, p < .05). Common reasons for prescribing opioids at discharge included post-partum tubal ligation (56.4 percent), third- and fourth-degree lacerations (59.6 and 73.4 percent, respectively), and operative deliveries (26.6 percent). Physicians were significantly more likely to prescribe an opioid after a second-degree laceration than CNMs (19.1 percent vs 5.3 percent, p < 0.05). CONCLUSIONS: Practice patterns for opioid prescription vary by provider type as well as by delivery characteristics. Further study is necessary to delineate the optimal care while minimizing unnecessary opioid prescriptions.

Evaluating Shared Decision-Making in Postpartum Contraceptive Counseling Using Objective Structured Clinical Examinations.

Background: Shared decision-making (SDM) may support widespread uptake of progestin-containing long-acting reversible contraceptives in the immediate postpartum period. We piloted an Objective Structured Clinical Examination (OSCE) to evaluate first-year obstetrics and gynecology resident physicians' use of SDM in postpartum contraception counseling. Methods: As part of their 2015 and 2016 OSCEs, first-year OB/GYN residents were instructed to provide contraceptive counseling to a Standardized Patient (SP) portraying a 29-year-old postpartum patient seen during rounds on the morning following her delivery. Three investigators independently scored each resident encounter using a 10-item rubric adapted from a 9-item SDM measure and assigned scores of 0 (absent), 1 (partial), or 2 (complete). Each encounter was video and audio recorded, then transcribed for qualitative analysis. Descriptive statistics was produced using SPSS version 24. Results: Eighteen residents participated. The majority (78%) discussed contraceptive options and timing of initiation. Nearly 33% elicited factors most important to the SP in influencing her preference. Only 6% discussed the benefits of exclusive breastfeeding, and few addressed the uncertainty of progesterone on milk supply and production. Conclusion: Although residents conveyed ample clinical information, the vast majority did not discuss elements of SDM, such as her preferences, values, and goals for future fertility and breastfeeding. Our work revealed that critical elements of SDM are often not explored and deliberated by resident physicians. Trainings (e.g., OSCEs) are needed to equip residents with effective communication skills to facilitate more SDM in postpartum contraceptive care.

Evaluating Shared Decision Making in Trial of Labor After Cesarean Counseling Using Objective Structured Clinical Examinations.

Introduction: Although shared decision making (SDM) is optimal for trial of labor after cesarean (TOLAC) counseling, resources to assess residents' clinical competency and communication skills are lacking. We addressed this gap by developing and testing an objective structured clinical examination (OSCE) to evaluate whether learners were able to use SDM in TOLAC counseling. Methods: We created three simulation scenarios with increasing complexity to assess the skills of residents in their first, second, or third postgraduate year in using SDM in TOLAC counseling. All cases involved a standardized patient requesting a TOLAC consultation. Residents were provided with a medical history and instructed to counsel and develop a care plan. A 10-item scoring rubric was used, and each item was rated 0 (absent), 1 (partial), or 2 (complete). Three coders independently rated the encounters; discrepancies were resolved by consensus. Results: Over 3 years, 39 residents participated in 60 OSCE encounters. The majority provided complete discussions of the clinical issue (93%), chances of success (72%), and maternal and fetal risks (100% and 85%, respectively) but obtained partial assessments of understanding (78%). Discussions of benefits were typically absent, with the exception of the maternal benefits (47%). More than 40% of residents did not discuss the patient's goals, 53% lacked discussion of uncertainties related to TOLAC, and half failed to explore the patient's preference, with most deferring a decision to a future encounter. Discussion: Residents consistently discussed diagnosis, prognosis, and maternal risks yet infrequently addressed goals and preferences-two critical elements of SDM.

Evaluating shared decision-making in periviable counseling using objective structured clinical examinations.

OBJECTIVE: To develop and test an Objective Structured Clinical Examination to evaluate the use of shared decision-making (SDM) in periviable counseling among fourth-year OB/GYN residents. METHODS: Residents counseled a standardized patient presenting with preterm premature rupture of membranes at 23 weeks' gestation. Braddock's 9-item measure of SDM was adapted to a 10-item scoring rubric; rating each: 0 (absent), 1 (partial), or 2 (complete). RESULTS: Twenty-six residents participated. All provided "complete" discussions of the clinical issue and "complete" or 'partial' ratings for informing the woman of her prognosis (62 and 38%, respectively) and addressing her role in decision-making (42 and 50%). Discussions of her goals and preferences were often absent (69 and 62%). Only 42% discussed uncertainties. CONCLUSION: Critical elements of SDM related to a woman's values, goals and preferences were not explored when counseling about periviable delivery. Training in SDM is needed to advance communication skills for complex clinical decision-making.

Circumcision bleeding complications: neonatal intensive care infants compared to those in the normal newborn nursery.

PURPOSE: To determine if a significant difference exists in the bleeding complications following circumcision in neonates admitted to neonatal intensive care unit (NICU) versus the normal newborn nursery (NNN). MATERIALS AND METHODS: Observational cohort study of 260 infants undergoing circumcision with Gomco clamp. Vitamin K was given to neonates at delivery. Demographic data, procedural characteristics, bleeding complications, and interventions were recorded. The bleeding rates of the two groups were compared using chi square. RESULTS: NICU neonates experienced increased bleeding complications versus NNN neonates (22% vs. 9.6%, p = .029). No differences were found regarding gestational age at delivery, age at circumcision, and birth weight. Neonates with circumcision performed at ≥5 days of life experienced increased rates of bleeding complications versus those performed at ≤4 days (28% vs. 10.3%, p = .023). All neonates with circumcision performed ≥5 days of life were initially admitted to the NICU. CONCLUSION: NICU neonates had increased rate of bleeding complications following circumcision when compared to the NNN neonates. There was an increased rate of bleeding complications in neonates who undergo circumcision at ≥5 days of life. Further research may help to determine if redosing of vitamin K or variations in the circumcision procedure are necessary for circumcision at >4 days of life.

Preference elicitation tool for abnormal uterine bleeding treatment: a randomized controlled trial.

BACKGROUND: It is estimated that one-third of women will experience abnormal menstrual bleeding. The majority of these cases are not due to cancer or pregnancy complications and, as a result, women are faced with a variety of treatment alternatives, the selection of which is largely dependent on personal preferences for care rather than clinical outcomes. OBJECTIVE: This randomized trial was designed to evaluate a preference elicitation tool to promote physician-patient collaborative decision making for treatment of abnormal uterine bleeding (AUB). METHODS: Adaptive conjoint analysis (ACA) was used to create a preference elicitation tool in English and in Spanish. Women with AUB were enrolled to the study and randomly assigned to ACA or usual counseling at the initial clinic visit at four clinics (three in Indianapolis, IN, USA, and one in Southern Pines, NC, USA). The ACA tool elicited preferences across eight attributes: treatment efficacy; sexual function; medical care; cost; fertility; frequency of medication use; permanence; and recovery time. t tests were used to compare differences in the primary outcomes of decision regret and treatment satisfaction at the follow-up visit. The study was designed to have 80 % power to detect significant differences between groups for the primary outcomes of regret and satisfaction. RESULTS: Women were enrolled in the study between September 2009 and March 2012. 183 participants were randomized to ACA and 191 to usual counseling. Overall, mean (standard deviation) treatment satisfaction was high at 35.71 (9.72) (scale of 0-44), and decision regret was low at 25.9 (21.0) (scale of 0-100), creating ceiling effects for the selected outcome variables; there were no significant differences between the ACA and control groups at the follow-up assessment. There was a strong inverse relationship between age and decision regret (p = 0.007). Exploratory subgroup analysis in the youngest quartile comprising 64 women aged 19-35 years showed a statistically non-significant difference in mean regret scores for the ACA group versus usual counseling (24.6 vs. 34.6, respectively; p = 0.08). CONCLUSIONS: A preference elicitation tool at the initial consultation visit did not reduce decision regret or improve treatment satisfaction among patients with AUB; however, there is a need for additional research to further understand this tool's potential role in promoting collaborative decision making, which may be particularly important among younger women.

Vitamin E succinate decreases lung cancer tumor growth in mice.

BACKGROUND: In vitro studies have shown that Vitamin E succinate (VES) arrests lung cancer proliferation; however, in vivo studies have not been performed. This study examined in vivo effects of VES on lung cancer. METHODS: An in vitro dose-response curve of human A549 lung cancer tumors to VES was established. A549 tumors were established in the right submammary fat pads of athymic nude mice (C57/BL/6J-Hfh11nu). Seven days after injection, mice were separated into VES and control groups. VES mice (n = 12) underwent daily intraperitoneal (IP) injection of VES (150 mg/kg in 7% dimethyl sulfoxide, 93% polyethylene glycol); control mice (n = 11) were injected with vehicle only. At 27 days, harvested tumors were measured and weighed. Lungs were stained for metastases using hematoxylin-eosin. Tumor volume and weights were compared using a two-sample t test. Tumor growth curves were compared using a mixed model analysis of variance. RESULTS: In vitro studies demonstrated dose-dependent manner inhibition of A549 cell proliferation by VES (IC(50) 18 mug/mL). Tumor volumes and weights differed significantly between VES and control mice with volumes of 192.6 +/- 20.4 mm(3)versus 292.9 +/- 31.4 mm(3) (P = 0.01) and weights of 168.6 +/- 20.0 mg versus 255.7 +/- 37.0 mg, respectively (P = 0.05). Tumor growth differed significantly (P < 0.001). Both groups of mice showed pulmonary metastases. CONCLUSIONS: Lung cancer cells appear to respond to VES, albeit incompletely. Because tumor cell response is seen, lung cancer patients may derive some benefit from VES and should be considered in eventual clinical studies using this vitamin E derivative.