A Three-Year Analysis of the Impact of a Student-Run Gynecology Clinic on Access to Reproductive Health Care for Uninsured Women in East Harlem.

The East Harlem Health Outreach Partnership (EHHOP) is a medical student-run and attending-supervised clinic that provides primary care to predominantly Spanish-speaking, uninsured patients living in East Harlem, New York. In 2010, the clinic launched a Women's Health Clinic (WHC), to offer comprehensive gynecologic and reproductive healthcare under the guidance of faculty gynecologists. In this cross-sectional study, we analyzed WHC data from January 2018 to March 2021. Over this period, 59 individual patients were seen over 39 clinical sessions through a total of 164 clinical encounters staffed by 43 medical students and 19 faculty preceptors from the Department of Obstetrics and Gynecology at Mount Sinai. The most common reasons for referral to the EHHOP WHC were abnormal uterine bleeding, contraception counseling, and management of abnormal Pap smears; the most common procedures performed were Pap smears, long-acting reversible contraception placements and removals, and colposcopies. We discuss the critical role that student-run, physician-supervised reproductive health clinics play in reducing disparities in gynecologic care for uninsured women.

A Subconscious Interaction between Fixation and Anticipatory Pursuit.

Ocular smooth pursuit and fixation are typically viewed as separate systems, yet there is evidence that the brainstem fixation system inhibits pursuit. Here we present behavioral evidence that the fixation system modulates pursuit behavior outside of conscious awareness. Human observers (male and female) either pursued a small spot that translated across a screen, or fixated it as it remained stationary. As shown previously, pursuit trials potentiated the oculomotor system, producing anticipatory eye velocity on the next trial before the target moved that mimicked the stimulus-driven velocity. Randomly interleaving fixation trials reduced anticipatory pursuit, suggesting that a potentiated fixation system interacted with pursuit to suppress eye velocity in upcoming pursuit trials. The reduction was not due to passive decay of the potentiated pursuit signal because interleaving "blank" trials in which no target appeared did not reduce anticipatory pursuit. Interspersed short fixation trials reduced anticipation on long pursuit trials, suggesting that fixation potentiation was stronger than pursuit potentiation. Furthermore, adding more pursuit trials to a block did not restore anticipatory pursuit, suggesting that fixation potentiation was not overridden by certainty of an imminent pursuit trial but rather was immune to conscious intervention. To directly test whether cognition can override fixation suppression, we alternated pursuit and fixation trials to perfectly specify trial identity. Still, anticipatory pursuit did not rise above that observed with an equal number of random fixation trials. The results suggest that potentiated fixation circuitry interacts with pursuit circuitry at a subconscious level to inhibit pursuit.SIGNIFICANCE STATEMENT When an object moves, we view it with smooth pursuit eye movements. When an object is stationary, we view it with fixational eye movements. Pursuit and fixation are historically regarded as controlled by different neural circuitry, and alternating between invoking them is thought to be guided by a conscious decision. However, our results show that pursuit is actively suppressed by prior fixation of a stationary object. This suppression is involuntary, and cannot be avoided even if observers are certain that the object will move. The results suggest that the neural fixation circuitry is potentiated by engaging stationary objects, and interacts with pursuit outside of conscious awareness.

Pregnancy-Associated Onset of Adult-Onset Still's Disease.

Objective This study aims to elucidate the clinical manifestations, diagnostic challenges, and management strategies of adult-onset Still's disease (AOSD) during pregnancy, leveraging a case series overview and a detailed case report from our center. Study Design A comprehensive review of 21 published case reports on AOSD diagnosed during pregnancy was conducted, alongside a detailed case report of a patient diagnosed and managed at our center. This study emphasizes the importance of recognizing AOSD in pregnant patients, outlines the therapeutic challenges encountered, and discusses the potential complications arising from the disease and its treatment. Results The onset of AOSD during pregnancy predominantly occurs in the first or second trimester, with a polycyclic disease course observed in most cases. Management primarily involves corticosteroids and immunosuppressive medications, balancing the disease control with potential pregnancy complications. The case report highlights the complex interplay between AOSD, hemophagocytic lymphohistiocytosis, and pregnancy, illustrating a multidisciplinary approach to management that ensured favorable maternal and fetal outcomes despite the significant challenges. Conclusion AOSD presents unique diagnostic and therapeutic challenges during pregnancy, requiring careful consideration of maternal and fetal health. Early diagnosis, a multidisciplinary approach to care, and judicious use of immunosuppressive therapy are critical for managing AOSD flares and associated complications. Further research is necessary to optimize care for this rare condition in the context of pregnancy.

Uterine Fibroid-Induced Compressive Neuropathy of Lumbar Plexus and Obturator Nerve.

Introduction: Uterine fibroids are the most common gynecologic tumors in reproductive-aged women with a prevalence of up to 80%. Symptoms can range from heavy vaginal bleeding and bulk symptoms to, less frequently, deep vein thrombosis and bowel obstruction. Case Description: A 32-year-old female patient presented with acute-onset of right groin and knee pain, and difficulty ambulating. A large posterior uterine fibroid was found to be compressing branches of the lumbar plexus, including the obturator nerve. The patient underwent gynecologic evaluation and an urgent laparoscopic myomectomy. Postoperatively, she had significant improvement in neurologic symptoms. She continued physical therapy for residual mild paresthesia and pain with prolonged ambulation. Discussion: Large pelvic masses such as uterine fibroids should be considered on the differential diagnosis for acute-onset non-gynecologic symptoms such as compressive neuropathy, which require urgent evaluation and possible surgical management.

Loss of independence after emergency inguinal hernia repair in elderly patients: How aggressive should we be?

BACKGROUND: Loss of independence (LOI) assesses patient quality of life after surgery and is associated with increased readmission and death. This paper compares LOI among the elderly who received elective versus emergent inguinal hernia repair. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files from 2015 to 2017 were reviewed for inguinal hernia repairs in patients 70-years-old or older. Chi-square analysis, Student t-test, and backwards multivariate logistic analysis were performed appropriately. RESULTS: Patients undergoing elective open or laparoscopic repair were less likely to experience LOI (OR 0.061, CI 0.035-0.106) and (OR 0.052 CI 0.024-0.113), respectively, and they were less likely to experience mortality (OR 0.07, CI 0.026-0.185) and (OR 0.059, CI 0.015-0.229), respectively. CONCLUSIONS: Significant debility occurs following emergency inguinal hernia repair in elderly patients. Elective surgery may be indicated more often in order to reduce emergencies and LOI in elderly patients.

Gender as a Deterministic Factor in Procedure Selection and Outcomes in Bariatric Surgery.

BACKGROUND AND OBJECTIVES: With obesity rates rising in the United States, bariatric surgery has become a well-established and effective treatment for morbid obesity and its comorbid conditions. Laparoscopic Roux-en-Y gastric bypass and laparoscopic Sleeve Gastrectomy are two of the more common bariatric procedures. This study analyzes whether gender differences play a role in procedure selection and outcomes following either procedure. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database for years 2015 to 2017, we assessed demographics, postoperative complications, and readmission rates. Chi-square analysis, student t-test, and propensity analyses were performed appropriately. RESULTS: Data review found that men presenting for bariatric surgery had a higher incidence of comorbidities and higher body mass index than women. More men than women underwent Sleeve Gastrectomy (68.5% vs 63.0%, P <0.0001), while more women than men underwent Laparoscopic Roux-en-Y gastric bypass (37.0% vs 31.5%, P < 0.0001). In the Laparoscopic Roux-en-Y group, men experienced more postoperative complications, including cardiac arrest (0.2% vs 0.1%, P = 0.02) and unplanned intubation (0.4% vs 0.2%, P = 0.02). In the Sleeve Gastrectomy group, men experienced more postoperative complications, including myocardial infarction (0.2% vs 0.1%, P = 0.006). In both groups, women experienced higher rates of unplanned readmissions (3.5% vs 2.8%, P = 0.0012). CONCLUSIONS: This study found that men are more likely to undergo Sleeve Gastrectomy than Laparoscopic Roux-en-Y gastric bypass, despite higher complication rates for both. Women have higher rates of unplanned readmission rates regardless of procedure, despite lower postoperative morbidity.

A Pilot Study of Motive Control to Reduce Vengeance Cravings.

Violence is a serious public health problem in the United States, and a common risk factor for many forms of violence is the perpetrator's motivation to achieve personal justice for past wrongs and injustices. Using a fictional transgression scenario to stimulate revenge feelings, we studied the preliminary efficacy of an intervention designed to mitigate revenge desires among victims of perceived injustice. The intervention consisted of a guided role-play of key figures in the justice system (e.g., victim, prosecutor, defendant, judge, etc.) in an imaginary mock trial of the offender. Study participants' revenge desires toward the perpetrator decreased significantly immediately after the intervention and at a 2-week follow-up interview. Benevolence toward the offender increased immediately postintervention and at a 2-week follow-up interview. These results suggest that the intervention has promise to decrease revenge desires in people who have been victimized, and it potentially opens the door to behavioral health motive control approaches to violence prevention. Findings on the roles of vengeance and the desire for retaliation in relation to violent acts, as well as neuroscience research that suggests a connection between retaliatory aggression and the neural circuitry of anticipated reward and cravings, are discussed. Limitations of this pilot study are also discussed, and recommendations for future research are provided.