Colposcopy Standards: Guidelines for Endocervical Curettage at Colposcopy.

OBJECTIVE: The most recent guidelines for colposcopy practice in the United States, the 2017 Colposcopy Standards Consensus Guidelines, did not include recommendations for endocervical curettage (ECC). This document provides updated guidelines for use of ECC among patients referred for colposcopy. METHODS: Consensus guidelines for the use of ECC were developed in 2012. To update these guidelines in concordance with the 2017 Colposcopy Standards process, an expert workgroup was convened in 2021. Literature had been previously reviewed through 2011, before the 2012 guideline. Literature from the years 2012-2021 and data from the NCI Biopsy study were reviewed, focusing on the additional yield of ECC. RESULTS: Endocervical curettage is recommended for patients with high-grade cytology, human papillomavirus 16/18 infection, positive results on dual staining for p16/Ki67, for those previously treated for known or suspected cervical precancer or considering observation of cervical intraepithelial neoplasia grade 2, and when the squamocolumnar junction is not fully visualized at colposcopy. Endocervical curettage is preferred for all patients aged older than 40 years. Endocervical curettage is acceptable for all nonpregnant patients undergoing colposcopy but may be omitted when a subsequent excisional procedure is planned, the endocervical canal does not admit a sampling device, or in nulliparous patients aged younger than 30 years, with cytology reported as atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion regardless of whether the squamocolumnar junction is fully visualized. Endocervical curettage is unacceptable in pregnancy. CONCLUSIONS: These guidelines for ECC add to the 2017 consensus recommendations for colposcopy practice in the United States.

Please Scream Inside Your Heart: Compounded Loss and Coping during the COVID-19 Pandemic.

Individuals are experiencing unprecedented personal challenges as a result of the novel COVID-19 virus. Stay at home orders and social distancing guidelines were in place, which has had a direct effect on American lives: forcing the cancellation of events, ending in-person school or childcare, forcing remote work environments, and leading to drastic changes to recreational activities. All these life changes can be experienced as losses that lead to real grief. However, grieving in the time of COVID-19 is fraught with unique challenges. This study recruited 257 participants from across North America to participate in an online survey investigating the types of losses experienced due to COVID-19, feelings of guilt and delegitimization, communal coping, and general coping behaviors. Results indicate that people experienced various losses during the COVID-19 pandemic, many of which were compounded and varying in degrees of intensity (e.g., loss of a loved one, loss of a job, loss of physical activity routine). Because of these differences in intensity, people felt guilty for grieving over their losses, and subsequently were less likely to appraise the losses as communal and more likely to utilize avoidant coping mechanisms on their own. The theoretical and public health implications of the study are discussed.

Disbudding and dehorning practices for preweaned dairy calves by farmers in Wisconsin, USA.

Many dairy farmers in North America disbud or dehorn their cattle to improve human and animal safety. The Farmers Assuring Responsible Management (FARM v. 4.0) program requires that disbudding be performed before 8 wk of age with pain-control medication. The objective of this observational cross-sectional study was to quantify disbudding and dehorning practices of Wisconsin dairy producers to target future extension programming. Responses from 217 Wisconsin dairy producers and calf raisers were collected via digital surveys distributed at extension events and through industry contacts. Of the 217 respondents, 188 performed on-farm disbudding themselves. Most respondents (61%) used caustic paste as their primary method, which was most commonly applied on the day the calf was born (53%). Hot iron was used by 32% of respondents, and surgical methods (gouge, scoop, or wire saw) were used by 6% of respondents. Hot-iron disbudding was most commonly performed at 4 to 8 wk of age (41%) and 1 to 4 wk of age (33%), whereas surgical methods were most commonly performed at 8 wk or older (73%). Pain-control medication was used by 43% of respondents. Specifically, 35% used an anti-inflammatory, and 21% used a local nerve block. Veterinary involvement in creating the disbudding protocol was associated with increased odds of using pain control. Respondents with a target weaning age of ≥10 wk had greater odds of complying with FARM disbudding requirements and were also more likely to use polled genetics. Respondents aged 18 to 34 and respondents with >60 calves were more likely to have made changes to their disbudding or dehorning protocol in the last decade. Although use of pain control was higher than in previous US studies, full adoption of pain management requires further extension efforts. Veterinarians appeared influential on adoption of pain control, and their involvement may encourage adoption of pain management. Further research should investigate how the implementation of new FARM v. 4.0 standards will change the disbudding and dehorning practices of American dairy producers.

Interactive Learning Modules With Visual Feedback Improve Resident Learning in Colposcopy.

OBJECTIVE: The Accreditation Council for Graduate Medical Education and the Council on Resident Education in Obstetrics and Gynecology have milestones and/or competencies relating to colposcopy; however, the optimal way to reach these objectives is not proscribed and left to individual programs. Here, we aim to assess resident skill, confidence levels, perceived level of knowledge, and satisfaction with colposcopic training before and after implementation of a new interactive learning module with visual feedback. MATERIALS AND METHODS: A new online educational intervention was developed by the author (E.L.N.) based on adult learning theory and introduced into our obstetrics and gynecology resident colposcopy curriculum in July 2014. We assessed performance on an objective competency examination administered at baseline and repeated after 6 months of our 24 residents.In addition, we assessed resident confidence levels, perceived level of knowledge, and satisfaction with training before and 6 months after intervention. RESULTS: Scores on a national online examination improved after the intervention (p = .014). Significant improvements on the examination were seen in the sections of medical knowledge (p = .031) and management (p = .011). Residents' perceived knowledge increased significantly after the intervention (p = .030). CONCLUSIONS: Learning outcomes improved after introduction of a novel teaching intervention.

A Systematic Review of Tests for Postcolposcopy and Posttreatment Surveillance.

OBJECTIVE: For the 2019 ASCCP Risk-Based Management Consensus Guidelines, we conducted a systematic review of diagnostic assays for postcolposcopy and posttreatment management. MATERIALS AND METHODS: A literature search was conducted to identify articles reporting on tests/assays for cervical cancer screening, triage, postcolposcopy surveillance, and posttreatment surveillance published between 2012 and 2019 in PubMed and Embase. Titles and abstracts were evaluated by co-authors for inclusion. Included articles underwent full-text review, data abstraction, and quality assessment. Pooled absolute pretest and posttest risk estimates were calculated for studies evaluating management of patients after treatment. RESULTS: A total of 2,862 articles were identified through the search. Of 50 articles on postcolposcopy, 5 were included for data abstraction. Of 66 articles on posttreatment, 23 were included for data abstraction and were summarized in the meta-analysis. The pooled posttreatment risk of cervical intraepithelial neoplasia (CIN) 2+ in all studies was 4.8% (95% CI = 3.4%-6.8%), ranging from 0.4%-19.5% (τ = 0.57) in individual studies. Among individuals testing negative for human papillomavirus (HPV) posttreatment, the risk of CIN 2+ was 0.69% (95% CI = 0.3%-1.5%); among individuals testing positive for HPV posttreatment, the risk of CIN 2+ was 18.3% (95% CI = 12.1%-26.6%) in all studies. All risk estimates were substantially higher for liquid-based cytology. The HPV-cytology co-testing provided slightly better reassurance compared with HPV alone at the cost of much higher positivity. CONCLUSIONS: Despite a large number of published studies on postcolposcopy and posttreatment surveillance, only few met criteria for abstraction and were included in the meta-analysis. More high-quality studies are needed to evaluate assays and approaches that can improve management of patients with abnormal screening.

Reporting and Assessing the Quality of Diagnostic Accuracy Studies for Cervical Cancer Screening and Management.

OBJECTIVE: We adapted the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool for studies of cervical cancer screening and management and used the adapted tool to evaluate the quality of studies included in a systematic review supporting the 2019 Risk-Based Management Consensus Guidelines. METHODS: We evaluated the quality of all studies included in our systematic review for postcolposcopy (n = 5) and posttreatment (n = 23) surveillance using QUADAS-2 criteria. Subsequently, we adapted signaling questions to indications of cervical cancer screening and management. An iterative process was carried out to evaluate interrater agreement between 2 study authors (M.A.C. and N.W.). Discrepant ratings were discussed, and criteria were adapted accordingly. We also evaluated the influence of study quality on risk estimates and between study variation using stratified subgroup meta-analyses. RESULTS: Twelve signaling questions for bias assessment that were adapted to or newly developed for cervical cancer screening and management are described here. Interrater agreement on bias assessment increased from 70% to 83% during the adaptation process. Detailed assessment of bias and applicability showed that all studies on postcolposcopy management and 90% of studies on posttreatment management had high risk of bias in at least 1 domain. Most commonly, high risk of bias was observed for the patient selection domain, indicating the heterogeneity of study designs and clinical practice in reported studies. CONCLUSIONS: The adapted QUADAS-2 will have broad application for researchers, evidence evaluators, and journals who are interested in designing, conducting, evaluating, and publishing studies for cervical cancer screening and management.

High-Fiber Diet and Acetate Supplementation Change the Gut Microbiota and Prevent the Development of Hypertension and Heart Failure in Hypertensive Mice.

BACKGROUND: Dietary intake of fruit and vegetables is associated with lower incidence of hypertension, but the mechanisms involved have not been elucidated. Here, we evaluated the effect of a high-fiber diet and supplementation with the short-chain fatty acid acetate on the gut microbiota and the prevention of cardiovascular disease. METHODS: Gut microbiome, cardiorenal structure/function, and blood pressure were examined in sham and mineralocorticoid excess-treated mice with a control diet, high-fiber diet, or acetate supplementation. We also determined the renal and cardiac transcriptome of mice treated with the different diets. RESULTS: We found that high consumption of fiber modified the gut microbiota populations and increased the abundance of acetate-producing bacteria independently of mineralocorticoid excess. Both fiber and acetate decreased gut dysbiosis, measured by the ratio of Firmicutes to Bacteroidetes, and increased the prevalence of Bacteroides acidifaciens. Compared with mineralocorticoid-excess mice fed a control diet, both high-fiber diet and acetate supplementation significantly reduced systolic and diastolic blood pressures, cardiac fibrosis, and left ventricular hypertrophy. Acetate had similar effects and markedly reduced renal fibrosis. Transcriptome analyses showed that the protective effects of high fiber and acetate were accompanied by the downregulation of cardiac and renal Egr1, a master cardiovascular regulator involved in cardiac hypertrophy, cardiorenal fibrosis, and inflammation. We also observed the upregulation of a network of genes involved in circadian rhythm in both tissues and downregulation of the renin-angiotensin system in the kidney and mitogen-activated protein kinase signaling in the heart. CONCLUSIONS: A diet high in fiber led to changes in the gut microbiota that played a protective role in the development of cardiovascular disease. The favorable effects of fiber may be explained by the generation and distribution of one of the main metabolites of the gut microbiota, the short-chain fatty acid acetate. Acetate effected several molecular changes associated with improved cardiovascular health and function.

The Luminescent Oligothiophene p-FTAA Converts Toxic Aß1-42 Species into Nontoxic Amyloid Fibers with Altered Properties.

Aggregation of the amyloid-ß peptide (Aß) in the brain leads to the formation of extracellular amyloid plaques, which is one of the pathological hallmarks of Alzheimer disease (AD). It is a general hypothesis that soluble prefibrillar assemblies of the Aß peptide, rather than mature amyloid fibrils, cause neuronal dysfunction and memory impairment in AD. Thus, reducing the level of these prefibrillar species by using molecules that can interfere with the Aß fibrillation pathway may be a valid approach to reduce Aß cytotoxicity. Luminescent-conjugated oligothiophenes (LCOs) have amyloid binding properties and spectral properties that differ when they bind to protein aggregates with different morphologies and can therefore be used to visualize protein aggregates. In this study, cell toxicity experiments and biophysical studies demonstrated that the LCO p-FTAA was able to reduce the pool of soluble toxic Aß species in favor of the formation of larger insoluble nontoxic amyloid fibrils, there by counteracting Aß-mediated cytotoxicity. Moreover, p-FTAA bound to early formed Aß species and induced a rapid formation of ß-sheet structures. These p-FTAA generated amyloid fibrils were less hydrophobic and more resistant to proteolysis by proteinase K. In summary, our data show that p-FTAA promoted the formation of insoluble and stable Aß species that were nontoxic which indicates that p-FTAA might have therapeutic potential.

Cyberframing Cancer: An Exploratory Investigation of Valenced Cybercoping on Cancer Blogs.

Although scholarship on coping with cancer implies many ways that coping is communicative, the discursive features of coping have been understudied. The purpose of the present investigation was to theorize the content of cancer blogs, a form of cybercoping, by examining valenced coping-relevant frames that bloggers use to describe their experiences with cancer. This research is both theoretically and methodologically innovative. Theoretically, we advance the concept of cyberframing by connecting the rather disconnected literatures on coping and framing and by studying this topic from a communication perspective. Methodologically, this is one of the few studies of coping with cancer that has used naturally occurring communication data to its advantage. A content analysis of cancer blog entries (N = 194) indicated that more than 90% of cancer blog posts were embedded in a valenced frame. The frames were either negative, positive, or balanced; balanced frames varied in the intensity of the valence. The most common frames were positive and balanced with low affect.

Vulvar Intraepithelial Neoplasia (VIN) and Condylomata.

Human papillomavirus (HPV) infection of the lower genital tract is common and its effects are variable. The majority of infections are transient and the related pathology is self-resolving. Condyloma accuminatum is caused predominantly by HPV 6, 11 and can be managed with medical or surgical therapy. Vulvar intraepithelial neoplasia is a treatable precursor to vulvar cancer with 2 main forms: one related to HPV and the other to chronic vulvar inflammatory conditions. It may be treated medically, surgically, or potentially via the use of therapeutic HPV vaccines. Preventive utilization of a quadrivalent HPV vaccine has the potential to decrease HPV-related lower genital disease burden substantially.

Tracking a complete voltage-sensor cycle with metal-ion bridges.

Voltage-gated ion channels open and close in response to changes in membrane potential, thereby enabling electrical signaling in excitable cells. The voltage sensitivity is conferred through four voltage-sensor domains (VSDs) where positively charged residues in the fourth transmembrane segment (S4) sense the potential. While an open state is known from the Kv1.2/2.1 X-ray structure, the conformational changes underlying voltage sensing have not been resolved. We present 20 additional interactions in one open and four different closed conformations based on metal-ion bridges between all four segments of the VSD in the voltage-gated Shaker K channel. A subset of the experimental constraints was used to generate Rosetta models of the conformations that were subjected to molecular simulation and tested against the remaining constraints. This achieves a detailed model of intermediate conformations during VSD gating. The results provide molecular insight into the transition, suggesting that S4 slides at least 12 Å along its axis to open the channel with a 3(10) helix region present that moves in sequence in S4 in order to occupy the same position in space opposite F290 from open through the three first closed states.

Effect of shift-based scheduling on student learning, satisfaction and capacity in obstetrics and gynecology rotations.

Objectives: Determine how a shift- based schedule to accommodate more students affects learning, performance, and satisfaction with the Obstetrics and Gynecology (OBG) rotation. Methods: The study was conducted among third year OBG medical students with a triangular convergent cross-sectional approach. A new shift-based schedule was implemented. After each rotation, an online survey was conducted using a convenience sampling. Student scores on the National Board of Medical Examiner (NBME) OBG subject exam were analyzed using paired t test. Survey data was analyzed using two sample t test. The relationship between survey responses and exam score findings were described. Data from shift-schedule students was compared to traditional schedule students from the prior academic year. Results: A statistically significant improvement was seen for average NBME score for shift-schedule students during the beginning portion (groups 1-3) of the academic year (M=80, SD=6.9) compared to traditional (M=75.7, SD=7.3) [t (145) =3.69, p =.001]. A similar pattern was not seen in subsequent groups (groups 4-6). Shift-schedule students also showed a statistically significant improvement in their perception of learning (t (183) =-2.54, p =.012). Parallel results were seen for belonging, manageable workload, time to study, and engaging meaningfully. Using this model, we increased rotation capacity from 24 to 30 students per group (20%). Conclusions: Shift based scheduling allows 20% increase in capacity. Exam scores and student learning outcomes were similar or better than traditional schedule controls.

Transforming food systems: a gendered perspective on local agricultural innovation in Cuba.

Compared to many countries, Cuba has made significant progress in advancing women's rights and gender equity; however, disparities remain. In the country's rural communities and agricultural sector, women continue to face barriers to equal participation and recognition for the value of their work. This case study shares the story of gender equity efforts that have been conducted within the framework of a broader development project-the Project to Strengthen a System of Innovation in Local Agricultural Development (PIAL, for its initials in Spanish). PIAL began in 2001 as a participatory plant-breeding initiative aimed at increasing the genetic diversity of key crops such as maize and beans. Over the course of two decades, the project's goals expanded to include an emphasis on increasing women's participation. In the beginning, those efforts focused on including women in the participatory plant-breeding activities, which enabled them to prioritize traits they cared about such as grain texture, cooking speed, and taste in the selection process. Over time, the participatory nature of the PIAL methodology empowered women to identify and pursue capacity-building in other areas of local agricultural innovation. While PPB remained central to PIAL, women also chose to pursue opportunities in seed bank management, leadership training, and small-scale farm-based entrepreneurship. The results of the PIAL work on gender have included not just more inclusive plant breeding, but also important economic improvements for rural women as they have been able to diversify their livelihoods, and social change as they have gained confidence and recognition as leaders in their households, communities, and beyond.

Spontaneous vulvar hematoma during pregnancy: a case report.

BACKGROUND: Vulvar hematoma is a relatively uncommon occurrence. Most have been described resulting from traumatic injury in nonpregnant women or as an uncommon complication of childbirth. We describe a case of a spontaneous 6-cm vulvar hematoma that presented as unexplained vulvar edema in a 35-weeks-pregnant woman. CASE: A pregnant woman presented to the obstetrics triage unit with rapid onset unilateral vulvar swelling and no preceding traumatic event. A detailed physical examination and radiologic evaluation revealed a spontaneous vulvar hematoma as the cause. After incision and drainage of the hematoma, her edema resolved and the patient went on to have an uneventful vaginal delivery 4 weeks later. CONCLUSION: Spontaneous vulvar hematoma is a rare event. Rapid recognition and treatment in this case allowed for complete recovery and enabled this pregnant woman to continue a normal pregnancy with uncomplicated spontaneous vaginal delivery.

Ontario Dairy Producers' Perceived Barriers and Motivations to the Use of Pain Control for Disbudding and Dehorning Calves: A Qualitative Study.

Canadian dairy farmers are required to use a local anesthetic and analgesic prior to all disbudding and dehorning procedures. This study was done to investigate the opinions of Ontario dairy farmers on the use of pain control for disbudding and dehorning calves and their perspectives on the current requirements of the quality assurance program. Interviews were conducted with 29 dairy farmers across Ontario. All participants used a cautery iron to disbud or dehorn their calves and some form of pain control (i.e., NSAID and/or local anesthetic). Of the 29 producers that were interviewed, 22 (76%) were in compliance with the proAction requirements for pain control. Many participants felt positive about the use of pain control for these practices. Education from veterinarians was one of the most commonly listed resources to reduce barriers to pain control use by producers. A farmer's attitude was highly referenced as an influence on producer behaviour. Although participants had positive views of pain control use, full compliance with national quality assurance requirements for disbudding and dehorning was not met by all. Producer education through veterinarians is a potential avenue to encourage the adoption of pain control use for disbudding and dehorning practices.

A taxonomy of risk-associated alternative health practices: A Delphi study.

Defining alternative health care and the recording of associated adverse events and harm remains problematic. This Canadian study aimed to establish and classify risk-associated alternative health practices in a Delphi study undertaken with an interdisciplinary panel of 17 health experts in 2020. It provides a new functional definition of alternative health care and an initial taxonomy of risk-associated alternative health care practices. A number of risk-associated practices were identified and categorized into general practices that conflict with biomedical care or largely untested therapies, alternative beliefs systems, physical manipulative alternative therapies, and herbal and nutritional supplements. Some risk significant harms including major physical injuries or even death. The lack of systematic methods for recording adverse events in alternative health care makes establishing the frequency of such events challenging. However, it is important that people engaging with alternative health care understand they are not necessarily risk-free endeavours, and what those risks are.

Commentary: Some Questions about No-Fault Reform of the Medical Liability System.

No-fault reform has been highlighted as a solution to a pressing problem in the context of Canadian medical malpractice claims: less than 1% of those harmed in the course of medical care receive any compensation for their injuries. Lee et al. (2021) suggest that a shift to a no-fault system is the answer for Canada's malpractice system. No-fault reform would certainly improve access to compensation but compensation is not the only reason to pursue a malpractice claim. Accountability and safety are important considerations that are not addressed by a move to a no-fault system.

Baseline Clinical Skill of Medical Students Entering the Obstetrics and Gynecology Core Clinical Clerkship.

PURPOSE: Determine baseline clinical skills of medical students entering the Obstetrics and Gynecology (OB/GYN) clerkship with prior clinical curricular exposure. BACKGROUND: Students are introduced to clinical correlates sooner in the preclinical curriculum to facilitate adult learning. There are few studies determining clerkship-specific clinical skills readiness in OB/GYN, a specialty with historically limited previous exposure. METHODS: An anonymous 15-question clinical readiness survey (1-5 Likert scale) was administered to medical students during their OB/GYN Orientation at the University of Texas Health Science Center San Antonio over four academic years, 2014-2018, to determine baseline OB/GYN clinical skill knowledge and confidence. Statistical analysis included Spearman rank correlation and Kruskal-Wallis tests, with significance defined as p < 0.05. RESULTS: The survey was completed by 346 students (77% participation). Overall, students felt most confident in knot tying skills (17%) and closed gloving technique (7%) and least confident in knowledge of labor curve (86%), Leopold's maneuvers (88%), and Montevideo units (MVU) (90%). Confidence in performing closed gloving (4% vs. 11%, p < 0.01) and tying knots (8% vs. 27%, p < 0.01) was significantly higher during rotations later in the academic year. Students who expressed a higher level of interest felt more prepared for the clerkship (rs = 0.21, p < 0.01). DISCUSSION: Results indicate that confidence in obstetric-specific clinical skills is relatively low throughout the academic year; however, baseline surgical skills show improvement. It is important for teaching faculty to know baseline clinical skills of the medical student with earlier clinical exposure to enhance adult learning and optimize clinical competency. In medical students receiving earlier clinical exposure, confidence in baseline obstetric-specific clinical skill is relatively low throughout the academic year. Confidence in general surgical skills demonstrates improvement over the academic year.

Perspectives of Stakeholders About an Early Result Acceptance Program to Complement the Residency Match in Obstetrics and Gynecology.

Importance: The residency application process is flawed, costly, and distracts from the preparation for residency. Disruptive change is needed to improve the inefficiencies in current selection processes. Objective: To determine interest in an early result acceptance program (ERAP) among stakeholders in obstetrics and gynecology (OBGYN), and to estimate its outcome in future application cycles. Design, Setting, and Participants: Surveys of stakeholders in March 2021 queried interest in ERAP across the US. Respondents included OBGYN residency applicants, members of the Association of American Medical Colleges Group on Student Affairs, OBGYN clerkship directors, and residency program directors. Statistical analysis was performed from March to April 2021. Exposures: Respondents completed surveys sent by email from the Association of American Medical Colleges (to OBGYN applicants and members of the Group on Student Affairs), the Association of Professors of Gynecology and Obstetrics (to clerkship directors), and the Council on Resident Education in Obstetrics and Gynecology (to program directors). Main Outcomes and Measures: Applicants and program directors indicated their interest in participating in ERAP, and clerkship directors and members of the Group on Student Affairs indicated their likelihood of recommending ERAP using a 5-point Likert scale. Results: Respondents included 879 (34.0%) of 2579 applicants to OBGYN, 143 (50.3%) of 284 residency program directors, 94 (41.8%) of 225 clerkship directors, and 51 (32.9%) of 155 student affairs deans. The majority of respondents reported being either somewhat or extremely likely to participate in ERAP, including 622 applicants (70.7%) and 87 program directors (60.8%). Interest in ERAP was independent of an applicant's reported board scores, medical school type, race, number of applications submitted, or number of interviews completed. Among program directors, those at university programs were more likely to participate. Stakeholders supported a limit of 3 applications for ERAP, to fill 25% to 50% of residency positions. Estimating the outcome of ERAP using these data suggests 26 280 to 52 560 fewer applications could be submitted in the regular match cycle. Conclusions and Relevance: Stakeholders in the OBGYN application process expressed broad support for the concept of ERAP. The majority of applicants and programs indicated that they would participate, with potentially substantial positive impact on the application process. Careful pilot testing and research regarding implementation are essential to avoid worsening an already dysfunctional application process.