Decision regret after failed autologous in vitro fertilization in women ≥42 years of age.

OBJECTIVE: To quantify the level of decision regret in women ≥42 years of age after autologous in vitro fertilization (IVF) and identify factors associated with moderate-to-severe regret. DESIGN: Cross-sectional survey. SETTING: Academic center. PATIENT(S): Ninety-four women ≥42 years of age who underwent autologous IVF between 2012 and 2018. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Decision regret score, with >25 as threshold for moderate-to-severe regret. RESULT(S): The overall response rate was 22%. Respondents had a median age of 43 years at the time of IVF. The median and mean decision regret scores were 10 and 17.1 (range, 0-75), respectively. Seventy-three percent (n = 69) had absent-to-mild regret (score, 0-25), and 27% (n = 25) had moderate-to-severe regret (score, >25) after IVF. Having no live births was associated with increased regret (odds ratio [OR], 22 [95% confidence interval {CI}, 2.82-171.82]). Among those who were unsuccessful, 40% (n = 24) had moderate-to-severe regret. Predictors for moderate-to-severe regret in this group included the lack of insurance coverage (OR, 0.33 [95% CI, 0.12-0.99]). Conversely, the perceived adequacy of information/counseling (OR, 0.44 [95% CI, 0.2-0.77]) and the perceived adequacy of emotional support (OR, 0.29 [95% CI, 0.15-0.55]) were protective factors inversely correlated with regret. CONCLUSION(S): Autologous IVF carries a low success rate and a considerable risk of decision regret in women ≥42 years of age. In those who were unsuccessful, the perceived adequacy of information and that of emotional support were protective factors against increased regret. Although concluding from a small, selected pool, our results strongly suggest that ample counseling and psychological support should be particularly emphasized within this patient population.

Rethinking How to Introduce the Learning Sciences: a Near-Peer Approach.

To address the problem of students cramming for examinations using short-term memorization, we developed an interactive session for first-year medical students in which a near-peer discussed evidence-based learning strategies and how to apply them to specific curricular activities to promote long-term retention and deep understanding. Immediate and delayed post-survey data suggested this new session promoted adoption of evidence-based learning strategies and was well-received by students.

Assessment to Optimize Learning Strategies: A Qualitative Study of Student and Faculty Perceptions.

Phenomenon: The format of medical knowledge assessment can promote students' use of effective learning strategies from the learning sciences literature, such as elaboration, interleaving, retrieval practice, and distributed learning. Assessment format can also influence faculty teaching. Accordingly, our institution implemented a new assessment strategy in which pre-clerkship medical students answered weekly formative quizzes with constructed response questions (also referred to as open-ended questions) and multiple-choice questions in preparation for summative open-ended question examinations, to support students' use of recommended learning strategies. Our qualitative study explored medical student and faculty perceptions of this assessment strategy on learning and teaching. Approach: We conducted semi-structured interviews with 16 second-year medical students to explore their preparation for quizzes and summative examinations. We also interviewed 10 faculty responsible for writing and grading these assessments in the pre-clerkship foundational sciences curriculum regarding their approach to writing assessments and rubrics, and their perceptions of how their teaching may have changed with this assessment strategy. We analyzed interview transcripts using thematic analysis with a priori sensitizing concepts from the learning sciences literature. Findings: We identified four major themes characterizing student and faculty perceptions of weekly formative quizzes and summative OEQ examinations. Participants found that this assessment strategy helped (1) prioritize conceptual understanding, (2) simulate clinical problem solving, and (3) engage students and faculty in continuous improvement in their approach to learning or teaching. Faculty and students also recognized challenges and potential tradeoffs associated with these assessment formats. Participants identified (4) facilitators and barriers when implementing this assessment strategy. Insights: Our findings suggested that assessment of medical knowledge through weekly formative quizzes and summative open-ended question examinations can facilitate students' use of effective learning strategies. Faculty also recognized improvements in their teaching and in quality of assessment. This format of assessment also presented some challenges and potential tradeoffs and significant institutional resources were required for implementation.

Third party assessment of resection margin status in head and neck cancer.

BACKGROUND: Definitive assessment of primary site margin status following resection of head and neck cancer is necessary for prognostication, treatment determination and qualification for clinical trials. This retrospective analysis determined how often an independent reviewer can assess primary tumor margin status of head and neck cancer resections based on review of the pathology report, surgical operative report, and first follow-up note alone. METHODS: We extracted from the electronic medical record pathology reports, operative reports, and follow-up notes from head and neck cancer resections performed at Stanford Hospital. We classified margin status as definitive or not. We labeled any pathology report clearly indicating a positive, negative, or close (<5mm) margin as definitive. For each non-definitive pathology report, we reviewed the operative report and then the first follow-up note in an attempt to clarify margin status. We also looked for associations between non-definitive status and surgeon, year, and primary site. RESULTS: 743 unique cases of head and neck cancer resection were extracted. We discarded 255 as non-head and neck cancer cases, or cases that did not involve a definitive resection of a primary tumor site. We could not definitively establish margin status in 20% of resections by independent review of the medical record. There was no correlation between margin determination and surgeon, site, or year of surgery. CONCLUSION: A substantial fraction (20%) of primary site surgical margins could not be definitively determined via independent EMR review. This could have implications for subsequent patient care decisions and clinical trial options.

Multiple sclerosis normal-appearing white matter: pathology-imaging correlations.

OBJECTIVE: The study was undertaken to determine the pathologic basis of subtle abnormalities in magnetization transfer ratio (MTR) and diffusion tensor imaging (DTI) parameters observed in normal-appearing white matter (NAWM) in multiple sclerosis brains. METHODS: Brain tissues were obtained through a rapid postmortem protocol that included in situ magnetic resonance imaging (MRI). Four types of MRI-defined regions of interest (ROIs) were analyzed: (1) regions that were abnormal on all images (T2T1MTR lesions); (2) NAWM regions with slightly abnormal MTR located close to white matter lesions (sa-WM Close); (3) NAWM regions with slightly abnormal MTR located far from lesions (sa-WM Far); and (4) NAWM regions with normal MTR (NAWM). Immunohistochemical analysis for each ROI comprised immunostaining for myelin, axonal markers, activated microglia/macrophages, astrocytes, plasma proteins, and blood vessels. RESULTS: Forty-eight ROIs from 4 secondary progressive MS brains were analyzed. sa-WM Close ROIs were associated with significantly more axonal swellings. There were more enlarged major histocompatibility complex II(+) microglia and macrophages detected in sa-WM Far, sa-WM Close, and T2T1MTR lesions than in NAWM. Across all ROIs, MTR and DTI measures were moderately correlated with myelin density, axonal area, and axonal counts. Excluding T2T1MTR lesions from analysis revealed that MTR and DTI measures in nonlesional white matter (WM) were correlated with activated microglia, but not with axonal or myelin integrity. INTERPRETATION: The pathologic substrates for MRI abnormalities in NAWM vary based on distance from focal WM lesions. Close to WM lesions, axonal pathology and microglial activation may explain subtle MRI changes. Distant from lesions, microglial activation associated with proximity to cortical lesions might underlie MRI abnormalities.