bluuebunny/crossref_metadata_2025 huggingface dataset:
ISO 9002 in the Microscopy Laboratory
Authors: Terry AJ
Published: March 2018

Many laboratories today wish to assure their clients of the implementation of a sound quality system. The International Standards Organization (ISO) has the 9000 series of quality systems which is recognized globally. This article specifically addresses issues to be considered for a good quality system in a modern service oriented microscopy laboratory.

The quality system is devised to attain certain objectives which are consistent throughout the company, whether they be research and development, marketing and sales, supply of a service, procurement, shipping, etc. Each company devises a quality system specific to their business and that serves their own and their client's needs. Some of these objectives may be the following: assurance of cost effective operations; prevention of errors in all aspects of the operation; assurance to the client that the objectives, deliverables and time frame are understood, prevention of delays; increase of productivity, a commitment to meeting the client's quality assurance requirements.
Scanning Acoustical Microscopy
Authors: Gailet Jacqueline
Published: March 2018

One of Olympus' not well known product in the American market is the UH3 Scanning Acoustic Microscope (SAM). This state of the art, highly versatile microscope has many applications from non-destructive imaging to biomedical analysis, to pharmaceutical applications to name a few areas of current industrial interest.

The principle behind SAM is quite simple, and uses the basic physical laws of reflection. High frequency sound waves are mechanically produced by a piezoelectric crystal. A high voltage impulse spike starts the crystal vibrating at its preset resonant frequency emitting acoustical plane waves through a medium with a relatively high sound velocity such as sapphire. The waves are made to converge by a half-spherical lens at the bottom of the sapphire rod. The diameter of the lens is less than one millimeter and depends on the operating frequency. The lower the frequency, the larger is the diameter of the lens.
Biomedical Applications: Pitfalls in the Practice
Authors: Shelbourne JD , Ingram Peter , Roggli Victor L , LeFurgey Ann
Published: March 2018

At present most medical microprobe analysis is conducted on insoluble particulates such as asbestos fibers in lung tissue. Cryotechniques are not necessary for this type of specimen. Insoluble particulates can be processed conventionally Nevertheless, it is important to emphasize that conventional processing is unacceptable for specimens in which electrolyte distributions in tissues are sought. It is necessary to flash-freeze in order to preserve the integrity of electrolyte distributions at the subcellular and cellular level. Ideally, biopsies should be flash-frozen in the operating room rather than being frozen several minutes later in a histology laboratory. Electrolytes will move during such a long delay. While flammable cryogens such as propane obviously cannot be used in an operating room, liquid nitrogen-cooled slam-freezing devices or guns may be permitted, and are the best way to achieve an artifact-free, accurate tissue sample which truly reflects the in vivo state. Unfortunately, the importance of cryofixation is often not understood.
See Atoms in Motion!
Authors: Carmichael Stephen W
Published: March 2018

It is impressive enough that individual atoms can be resolved with the atomic force microscope (AFM), but who would have thought that atomic motion would be detected so soon? Atomic resolution with the AFM was only recently achieved. As reported in this column, Franz Giessibl was able to demonstrate local resolution of adatoms of the Si(111) 7×7 reconstructed surface. Now, Yasuhiro Sugawara. Masahiro Ohta, Hitoshi Ueyama, and Seizo Morita of Hiroshima University have demonstrated atomic resolution of the surface of InP(110). Not only that, but images taken about one minute apart show that some of the atoms had moved! Sugawara et al, used a very compact AFM under ultrahigh vacuum (4 X 10-8 Pa) to accomplish this impressive feat. A stiff (spring constant of 34 N/m) silicon cantilever was used. This stiffness, along with a mechanical resonant frequency of 151 kHz, was used to keep the cantilever from jumping onto the sample and crushing the initially sharp tip.
Through a Cracked Lens: Alternate Views of Light Microscopy Part 3: Illuminating Illumination
Authors: Lund Mark W
Published: March 2018

Did I ever tell you about my first optical enginsering project? It was a video projector which used many innovative ideas, including one of the first liquid crystal video displays. It was dssigned to be the brightest projector ever made and was used in a helmet mounted display prototype. My first job out of college was to gather the parts, put it together, and measure its characteristics. To make a long story short, I had to turn the room lights out to see the image! What made a 20,000-footlambert design into a 20- footlambert display? Illumination! I learned a lot about illumination in those few short weeks, and everything I learned is directly applicable to microscopes. In fact the whole science of illumination was developed by microscapists. Electron microscopes deal with exactly the same concepts.
Evolution and Comparison of Electron Sources
Authors: Rathkey Doug
Published: March 2018

Over the years, we've seen major developments in electron source technologies in response to the demands for better performance. This article presents a brief overview of the cathode technologies in use today.

Two types of electron sources are used in commercially available scanning electron microscopes (SEMs), transmission electron microscopes (TEMs), scanning Auger microprobes, and electron beam lithography systems: thermionic and field emission electron cathodes. Thermionic cathodes reiease electrons from the cathode material when they are heated while field emission cathodes rely on a high electric field to draw electrons from the cathode material.
Enlightenment - Cathodoluminescence: The Bright Technique, Part I
Authors: Wright Paul
Published: March 2018

This is the first in a series of articles that serve to identify what scanning Cathodoluminescence can offer the materials technologist. Whilst begining with Electronic Materials. Geological,Ceramic and Diamond applications will be covered over the next installments concluding with a reveiw of instrumentation needed to perform the studies covered in the final chapter.

Cathodoluminescence (CL) is the most important optical phenomenon used by all electron microscopists. It is the process by which electrons are converted into light in the Everhart Thornley secondary electron detector and also in the screens and cameras of TEMs.
Embedding Brains In Egg Yolk For Cryosectioning
Authors: Ayyad Karen
Published: March 2018

Fifteen years ago, I learned from a neurologist how to embed perfused, glutaraldehyde-fixed rat brain in egg yolk (from store-bought, separated chicken eggs). The original technical note by Adoff (reference below) for whole dog brain tissue was used, and we adapted the procedure for rat brain.

1) Fix the whole brain, minus the meningas, in 10% formalin or glutaraldehydesucrose (1 % glutaraldehyde + 30% sucrose), then place in a specimen container of 30% sucrose, 10% formalin and 0.9% NaCl, The brain is left in this solution until it sinks (less than a week). This step prevents formation of ice crystals when freezing (The meninges must be removed, or the brain will not adhere to the egg yolk.).
Particle Analysis
Authors: McCrone Walter C
Published: March 2018

If you can recognize a robin or a banana by sight, you should be able to recognize single particles of coal, cement or gypsum when the microscope magnifies them to an equivalent size. This is the thesis of those who identify small particles by microscopy. No other microanalytical method identifies such small samples of such diverse substances so quickly.

Single particles of almost any substance - animal, vegetable, mineral, industrial byproduct, raw material, corrosion product, flyash - can be identified in a few seconds to a few minutes by a microscopist trained in particle identification. The particle must be at least 2 to 3 microns in diameter and 10 picograms or 10-11 gram in weight for identification by light microscopy.
Liquid Nitrogen Safety
Authors: Butterick Charles J
Published: March 2018

Recent Internet postings on the Microscopy listserver indicate paradoxical views on the personal protective equipment (PPE) necessary to handle liquid nitrogen (LN2) safely. Those views range from full protective gear to, somewhat facetiously, complete nudity. The crux of the paradox is that both extremes have points of validity.

The gist of preventing frostbite or cold injury to the skin is to prevent continuous contact with LN2. The physics of the Leidenfrost effect (LE) protects the skin from momentary contact or splashes of LN2. A layer of gas between the LM2 and the skin prevents significant heat transfer from the skin, stopping damage. The LE does not apply to inadvertent splashes of LN2 to the cornea. Alternatively, using protective equipment insulates the skin and prevents trapping of the cryogen by allowing the LN2 to run off.
Instrument Demos: A Dreaded Necessity
Authors: Hessler Robert J
Published: March 2018

I've been selling high tech products for about 20 years and I've never quite gotten over the fear of the phrase: “I'd like to go to the plant for a demo.”

As many of us have said in the past, there's no such thing as a good demo, only one which didn't disintegrate beyond all recognition. Every salesperson I know has his or her favorite stories of incredible happenings when the “Proximity Effect” takes over. (For the unknowing, the Proximity Effect states that the more closely the customer approaches a demo instrument, the more likely it is to self-destruct.)

My most memorable demo occurred when I was working with a French company selling semiconductor manufacturing equipment, I arrived with customers from the States and the first morning we were standing outside the demo lab passing the time until we were given the all clear from the instrument technician. As we conversed, an acrid odor permeated the lobby and the lights in the demo lab seemed to dim a bit. The odor became overpowering.
Resolution Considerations for Photomacrography and Photomicroscopy
Authors: Clarke Theodore M
Published: March 2018

My Inter/Micro-84 presentation and subsequent article in The Microscope dealt with optimizing diffraction limited depth of field in photomacrography and is referenced by Brian Bracegirdle in his “Scientific Photomacrography. My analysis was based upon the classical solution for the diffraction pattern image of a point light source, using the Rayleigh criterion of resolution. H. Lou Gibson's method of treating combined diffraction and geometric blurring away from the object focal plane was used. The calculations and the experimental results indicated that a final print resolution, for the object focal plane, of 7 lines/mm (.29 mm Airy disk) gives an optimum balance of depth of field and resolution. The 7 lines/mm criterion is equivalent to an Abbe criterion of total magnification equal to 440 times the numerical aperture. The 500 times numerical aperture Abbe criterion recommended for microscopists with very acute vision corresponds to a maximum resolution of 6 lines/mm in the final image.
Homo Videns
Authors: Levy Gabor B
Published: March 2018

After the trauma of birth, a baby is suddenly in a strange new world. The first order of the day is to make sense out of the jumbie of signals in order to form an image of what is out there. This image building proceeds with increased accuracy throughout adolescence. For those who labor in science the process never stops. They continue to try to refine their mental image of nature throughout their professional lives. In this effort, vision is the most valuable natural sense. In a happy blend of poetry and science, Diane Ackerman in her book, A Natural History of Senses, calls eyes “the great monopolist of our senses.” It is, in fact, hard to imagine experimental science without the power of vision. By the same token, any enhancement of visual acuity will promote the precision of our image of nature - the very essence of science.
Detecting Bacteria in Wood using a Fluorescent Lipid Probe
Authors: Xiao Ying , Singh Adya P , Wakeling Robin N
Published: March 2018

Wood cells have strong autofluorescence in a wide wavelength band due to lignin in the cell walls. The detection of microorganisms in wood is very difficult when using fluorescent microscopy because of interferences. We have recently developed fluorescent staining techniques to differentiate fungal hyphae from wood cell walls (Singh, et al., 1997; Xiao, et al., 1997). This study was aimed at developing fluorescent techniques to visualize bacteria in wood using confocal laser scanning microscopy (CLSM). Nitrobenzoxadiazole glycerophosphoethanolamine (NBD-PE, Molecular Probes), a widely used membrane probe which accords strong fluorescence upon lipids, was compared with glutaraldehyde which had proved useful in our initial attempts to visualize fungal hyphae in wood because of the cell auto fluorescence it causes (Singh et al., 1997).
Modern Microscopy on the Light Side Analyzing Chemical States and Phases
Authors: Rhodes Kent
Published: March 2018

As an industrial consulting laboratory specializing in small particle, thin film, and surface analysis, instrumental techniques to solve problems involving contamination, failure analysis, processing control, and materials research are used on a daily basis. In many cases, elemental analysis for samples is sufficient to pinpoint problems and suggest solutions. However, some cases require a more detailed understanding of chemical states and phases in small particles and films than that typically obtained from light and electron microscopy and x-ray microanalysis.

The chemical states and phases in crystalline particles and thick films can be analyzed with several techniques found in many laboratories, including polarized light microscopy, x-ray diffraction, and electron diffraction. In combination with elemental analysis, these techniques oftentimes provide a very detailed understanding of the chemistry of particles and films.
Near Contact Mode AFM: Overcoming Surface Fluid Layer In Air And Achieve Ultra-High Resolution
Authors: Ho Huddee J
Published: March 2018

A major goal of Atomic Force Microscopy (AFM) is to achieve nanometer resolution on surface topography, Vibrating cantilever mode (VCM) is an important configuration of an AFU instrument, It was proposed in the first AFM paper.

VCM in ultra-high vacuum (UHV) results in true AFM atomic resolution, which reveals atomic scale surface defects such as a single missing atom in a lattice. However, the VCM operation in air has many difficulties due to the surface contamination on the sample and the AFM tip. The most popular operation modes of the VCM are the non-contact mode and the Tapping mode. Both of these have limited lateral resolution in air.
A Simple Stage Heater / Cooler For Light Microscopy
Authors: Moss Anthony G
Published: March 2018

Microscopists frequently find that they need to regulate temperature during the course of their experiments. This is especially true for cell biologists working with living cells, Excellent commercial equipment does exist to control the stage temperature of light microscopes, and regulation by such devices is tightly controlled; ± 0.1°C is routinely reported. However, such equipment is often quite expensive and may not provide the investigator with the certainty that the experiment is being performed at exactly the temperature reported by the readout of the thermoelectric control, since the temperature sensor is often at a distance from the actual site of observation. The temperature also varies considerably from the stage heater/cooler to the critical, observed portion of the slide.
Six-Axis SEM Stage
Authors: Murosako Ross
Published: March 2018

The primary function of an SEM specimen stage is to optimize the orientation of the specimen to the signal detectors. The ease and precision with which the stage executes this function determine its utility to the microscopist. While the majority of scanning electron microscopes are equipped with general purpose five-axis specimen stages, a six-axis stage can significantly enhance specimen orientation. Specimen manipulation can be further simplified by incorporation of a six-axis hand controller that enables the microscopist to move the specimen intuitively as if the specimen were held directly in the hand.

SEM manufacturers typically install general purpose five-axis specimen stages in their scanning electron microscopes. In addition to translation along the X and Y axes, these stages are capable of tilt (T), elevation (Z motion), and rotation (R). Tilt directs the specimen surface toward the secondary electron detector to optimize signal collection. Elevation adjusts the working distance while rotation orients specific image features within the picture frame.
The Function of a Water Logd in A Laboratory Microwave
Authors: Slap Steven E
Published: March 2018

There are three ways that objects can react to microwave energy within a microwave cavity:

1. They can absorb microwave enengy. This is the case with all polar molecules (substances with positive and negative ionic poles). Examples include water, alcohols and biological specimens. Objects which absorb microwave energy will get hot as a result. The total amount of microwave absorbing material within the miaowave cavity is called the “load.” 2. They can reflect microwaves. This is the case with metals. The function of the medal walls which make up a microwave cavity is to keep the microwave energy within the cavity. The metal walls themselves will not get hot. 3. They can be “microwave-transparent.” This is the case with many non-polar molecules, such as paraffin and many plastics. Objects which ane microwave transpanent will heet very poorly in a microwave.
Good Posture Is Essential To Good Microscopy
Authors: Shaffer Stephen A
Published: March 2018

Let's face it. Looking through a microscope is not what our bodies were built for, and looking through a microscope for an extended period of time requires an unnatural rigidity of the body. You're not moving around, even a bit, as you normally would. The result can be cramped muscles, especially in the neck and shoulders, and a whole body fatigue Hi at can make 10:00 AM feel like 5:03 PM. The solution is correct posture and a proper arrangement of microscope, chair, and body.
Stability Testing, Shelf Life and Product Expiration Dating
Authors: Takes Peter A
Published: March 2018

Reagents available for laboratory, research, and clinical use are often acquired with a specified expiration date. Yet, many are not, depending on the manufacturer and reagent type. What a manufacturer does is frequency determined by how they label the product.

The U.S. Ricd and Drug Administration [FDA] has defined categories by which reagents can he labeled based on their “intended use”. individual reagents (e.g., antibodies) intended for clinical diagnostic laboratory use will be labeled as an in Vitro Diagnostic [IVD] or Analyte Specific Reagent [ASR]. Under these categories, specified expiration dates must be supported by stability testing which establishes the product shelf life.
The Use of SEM and Other Complimentary Techniques for the Determination of Properties of Cementitious Materials
Authors: Draper Eric A , Skalny Jan
Published: March 2018

The need for continued rehabilitation of our concrete infrastructure has lead to the adaptation of modern “state-of-the-art” analytical methods for the characterization of concrete and other cementitious materials. Some of these techniques have not, until relatively recently, been commonly associated with the evaluation of concrete but are very useful both as tools for quality assurance and in the determination of the extent of existing damage. The technique of interest here is the coordinated electron-optical microscopic evaluation of concrete.

Concrete is the most widely used building material in the world. Contrary to popular belief, concrete is not inert but chemically very complex and dynamic. While it is true that, pound far pound, concrete and its raw materials (cement, aggregate and water) are the most inexpensive building materials available for construction, it is also true that it responds to its environment in numerous and sometimes very subtle ways. These responses may sometimes result in a loss of durability and tremendous amounts of time and money being expended while searching far the cause(s) of the problem and providing a cost-effect solution. A quick survey of any large metropolitan area and the on-going construction repairs to highways and bridge decks there will quickly confirm this.
Modern Microscopy On the Light Side
Authors: Paienik Skip
Published: March 2018

Developments in microscopy in the last twenty years or so have been dramatic and impressive. Not only can individual atoms be seen with relatively inexpensive instruments, but is even possible to manipulate them, fulfilling the prophecies made by Richard Feyrman in his “Room at the Bottom” address given in 1959. Why, one might reasonably ask. when it is possible to observe, manipulate, and identify single atoms, would someone want to waste their time with an instrument so “old fashioned” as a light microscope?
Widespread Mantle Upwelling Beneath Oceanic Transform Faults
Authors: Cook Terri
Published: March 2018

A global characterization of mantle flow patterns beneath active oceanic transforms suggests pervasive upwelling stabilizes divergent plate boundaries by warming and weakening these enigmatic features.
Observing multiple populations in globular clusters with the ESO archive: NGC 6388 reloaded
Authors: Carretta Eugenio , Bragaglia Angela
Published: March 2018

The metal-rich and old bulge globular cluster (GC) NGC 6388 is one of the most massive Galactic GCs (M ~ 106 M⊙). However, the spectroscopic properties of its multiple stellar populations rested only on 32 red giants (only 7 of which observed with UVES, the others with GIRAFFE), given the difficulties in observing a rather distant cluster, heavily contaminated by bulge and disc field stars. We bypassed the problem using the resources of the largest telescope facility ever: the European Southern Observatory (ESO) archive. By selecting member stars identified by other programmes, we derive atmospheric parameters and the full set of abundances for 15 species from high-resolution UVES spectra of another 17 red giant branch stars in NGC 6388. We confirm that no metallicity dispersion is detectable in this GC. About 30% of the stars show the primordial composition of first-generation stars, about 20% present an extremely modified second-generation composition, and 50% have an intermediate composition. The stars are clearly distributed in the Al–O and Na–O planes in three discrete groups. We find substantial hints that more than a single class of polluters is required to reproduce the composition of the intermediate component in NGC 6388. In the heavily polluted component the sum Mg+Al increases as Al increases. The sum Mg+Al+Si is constant, and is the fossil record of hot H-burning at temperatures higher than about 70 MK in the first-generation polluters that contributed to form multiple populations in this cluster.
Finite element simulation of laser cutting process of steel sheet
Authors: Meško Jozef , Zrak Andrej , Nigrovič Rastislav , Žmindák Milan
Published: March 2018

Lasers are widely used in industry as cutting tools due to ultra flexibility of the cutting conditions, obtaining high quality end product, quick set up, non-mechanical contact between the workpiece and the tool, and small size of the heat affected zone. In the present study, laser gas assisted cutting process is examined. The laser cutting sheet solution is practically always very convenient compared to conventional technologies and brings the greatest cost savings in the manufacturing process.
Analysis of the porous bone-implant fixation – experimental verification of numerical model
Authors: Berdychowski Maciej , Mielniczuk Janusz
Published: March 2018

In this paper a new type of endoprothesis THRA with needle-palisade fixation system has been described. A numerical model of such fixation has been created. The developed model was subjected to experimental verification. During the test, the prototype of the needle palisade structure was inserted into the cancellous bone. The test results were compared with numerical simulation.
Balints Gedanken in einer zeitgemäßen Form
Authors: Davidsen Annette
Published: March 2018

In der Primärversorgung ist das Zusammenspiel zwischen Körper und Seele besonders wichtig. Im Gegensatz zu der Sekundärversorgung, wo Fachärzte sich um eine spezielle Symptomatik des Patienten kümmern, ist die Primärversorgung des Hausarztes dafür zuständig, sich zu dem komplexen Zusammenhang von körperlichen und seelischen Symptomen des Patienten zu verhalten, und ihn in einer gesamtheitlichen Perspektive zu verstehen. Balint interessierte sich für die Arzt-Patienten-Beziehung in der Primärversorgung und für die Behandlung der ganzen Person. Gemeinsam mit Enid Balint trainierte er Allgemeinärzte in einem ganzheitlichen Verständnisprozess, wo Körper und Seele in einer dynamischen Wechselwirkung stehen. Balints Gedanken waren jedoch nicht sehr deutlich beschrieben und haben in der Primärversorgung nicht Fuß fassen können. Heute wird die Primärversorgung in ihrer bestehenden Form für bedroht gehalten. Um dem entgegenzuwirken, benötigt sie einen theoretischen Zugang, der Körper und Seele als eine Einheit betrachtet. In diesem Artikel beschreibe ich verschiedene Begriffe, die für eine solche Theorie die Grundlage bilden könnten. Ich zeige, dass Balints Auslegung des Verständnisprozesses in der Arzt-Patient-Beziehung mit der Definition des intersubjektiven Verstehens der Mentalisierungstheorie übereinstimmt und darüber hinaus auch mit der phänomenologischen Einstellung, die eben die Unterscheidung von Körper und Seele ablehnt. Allgemeinärzte wie z. B. McWhinney und Rudebeck haben ein solches ganzheitliches Denken formuliert. In England überlebte die Primärversorgung in den fünfziger Jahren nur dank Balints Überzeugungen. Wenn die Primärversorgung heutzutage wieder bedroht ist, könnte dies mit dem erneuten Verschwinden des psychodynamischen Zuganges in Zusammenhang stehen. Die Mentalisierungstheorie ist grundlegend psychodynamisch. Sie stimmt mit den Haltungen Balints und der Allgemeinärzte, die sowohl von Balint als auch von der Phänomenologie inspiriert waren, überein. Allgemeinärzte können das Mentalisieren trainieren. Dabei würden sie den psychodynamischen Zugang und die Fähigkeit, sich in die gesamte Situation des Patienten hineinversetzen zu können, bewahren.
Recommendations to Sustain the Academic Mission Ecosystem at U.S. Medical Schools
Authors: Kerschner Joseph E. , Hedges Jerris R. , Antman Karen , Abraham Edward , Colón Negrón Edgar , Jameson J. Larry
Published: March 2018

Academic medical center (AMC) faculty, administrators, and leaders have the critical tasks of teaching and training the next generation of health care providers and biomedical researchers, as well as generating new knowledge that improves the health of all. In the United States, medical schools and their affiliated hospitals train remarkably high-quality physicians and scientists, and the research conducted at these institutions results in advances in health. To that end, AMCs have become essential engines for driving better health in the United States and the rest of the world; they also have become essential engines driving the economies of their respective communities and regions. The education and research missions, however, require subsidization because tuition and extramural grant funding do not cover the costs of these endeavors. This subsidization largely has come from revenues generated by AMCs’ clinical endeavors. The viability of this cross-subsidization, however, is increasingly threatened in the current clinical environment. The authors of this Perspective discuss these issues in depth and provide some concrete recommendations to address these challenges. They hope to stimulate discussion and, ultimately, ensure the financial viability of U.S. AMCs—a national resource of utmost importance. Recommendations to sustain research include creating strategic biomedical research plans, developing a defined and sustained model to support National Institutes of Health funding that keeps pace with inflation, and evolving funding mechanisms. Recommendations to sustain medical education include limiting student debt, creating more cost-effective curricula, and ensuring that clinical training opportunities that meet national standards are available to students.
Harm Reduction for Abortion in the United States
Authors: Tasset Julia , Harris Lisa H.
Published: March 2018

Access to abortion in the United States has eroded significantly. Accordingly, there is a growing movement to empower women to self-induce abortion. To date, physicians' roles and responsibilities in this changing environment have not been defined. Here, we consider a harm reduction approach to first-trimester abortion as a way for physicians to honor clinical and moral obligations to care for women, negotiate ever-increasing abortion restrictions, and support women who consider abortion self-induction. Harm reduction approaches to abortion have been successfully implemented in a range of countries around the world and typically take the form of teaching women how to use misoprostol. When women self-administer misoprostol, rather than resort to other means such as self-instrumentation or abdominal trauma, to end a pregnancy, maternal mortality falls. There are clinical and ethical benefits as well as limitations to a harm reduction approach to abortion in U.S. settings. Its legal implications for patients and physicians are unclear. Ultimately, we suggest that despite its limitations, a harm reduction approach may help both physicians and patients.
Clitoral Reconstruction Using a Vaginal Graft After Female Genital Mutilation
Authors: Mañero Ivan , Labanca Trinidad
Published: March 2018

BACKGROUND:

Clitoral reconstruction after genital mutilation is a feasible and effective strategy to reduce clitoral pain, improve sexual pleasure, and restore vulvar appearance.

TECHNIQUE:

We describe a novel surgical technique for clitorolabial reconstruction using a vaginal graft.

EXPERIENCE:

We present a series of 32 consecutive women who underwent this procedure at Iván Mañero Clinic, Barcelona, Spain, and were prospectively followed. The total Female Sexual Function Index changed favorably from 16 before surgery to 29 after surgery (P<.05). Likewise, the Female Self-Image Genital Scale changed favorably from 11 to 23 (P<.05).

CONCLUSION:

Clitoral reconstruction after genital mutilation was associated with improved sexual function and genital aesthetic perception.
Statewide Quality Improvement Initiative to Reduce Early Elective Deliveries and Improve Birth Registry Accuracy
Authors: Kaplan Heather C. , King Eileen , White Beth E. , Ford Susan E. , Fuller Sandra , Krew Michael A. , Marcotte Michael P. , Iams Jay D. , Bailit Jennifer L. , Bouchard Jo M. , Friar Kelly , Lannon Carole M.
Published: March 2018

OBJECTIVE:

To evaluate the success of a quality improvement initiative to reduce early elective deliveries at less than 39 weeks of gestation and improve birth registry data accuracy rapidly and at scale in Ohio.

METHODS:

Between February 2013 and March 2014, participating hospitals were involved in a quality improvement initiative to reduce early elective deliveries at less than 39 weeks of gestation and improve birth registry data. This initiative was designed as a learning collaborative model (group webinars and a single face-to-face meeting) and included individual quality improvement coaching. It was implemented using a stepped wedge design with hospitals divided into three balanced groups (waves) participating in the initiative sequentially. Birth registry data were used to assess hospital rates of nonmedically indicated inductions at less than 39 weeks of gestation. Comparisons were made between groups participating and those not participating in the initiative at two time points. To measure birth registry accuracy, hospitals conducted monthly audits comparing birth registry data with the medical record. Associations were assessed using generalized linear repeated measures models accounting for time effects.

RESULTS:

Seventy of 72 (97%) eligible hospitals participated. Based on birth registry data, nonmedically indicated inductions at less than 39 weeks of gestation declined in all groups with implementation (wave 1: 6.2–3.2%, P<.001; wave 2: 4.2–2.5%, P=.04; wave 3: 6.8–3.7%, P=.002). When waves 1 and 2 were participating in the initiative, they saw significant decreases in rates of early elective deliveries as compared with wave 3 (control; P=.018). All waves had significant improvement in birth registry accuracy (wave 1: 80–90%, P=.017; wave 2: 80–100%, P=.002; wave 3: 75–100%, P<.001).

CONCLUSIONS:

A quality improvement initiative enabled statewide spread of change strategies to decrease early elective deliveries and improve birth registry accuracy over 14 months and could be used for rapid dissemination of other evidence-based obstetric care practices across states or hospital systems.
Dos and Don'ts in Pregnancy
Authors: Fox Nathan S.
Published: March 2018

Pregnancy is a time of excitement and anxiety. The reality for pregnant women is that their actions could affect their pregnancies and their fetuses. As such, they need to know what they should and should not do to minimize risk and optimize outcomes. Whereas this advice used to come from doctors, a few books, and some family and friends, in the age of the internet, women are now bombarded with information and recommendations, which are often confusing at best and conflicting at worst. The objective of this review is to present current, evidence-based recommendations for some of the things that pregnant women should and should not routinely do during pregnancy.
Abnormal Vaginal Bleeding in Women Desiring Contraception Who Are Taking Anticoagulation Therapy
Authors: Bonnington Adam , Autry Amy M.
Published: March 2018

A 30-year-old nulligravid woman is referred to you for heavy menstrual cycles. Although her menstrual cycles were previously light, she was recently diagnosed with an unprovoked lower extremity venous thromboembolism and is taking anticoagulation therapy after a negative thrombophilia workup. She wants help with her vaginal bleeding and desires contraception.
Anaphylactic Shock After Intravenous Fluorescein Administration for Intraoperative Cystoscopy
Authors: Lee Toy , Sanderson Derrick , Doyle Paula , Buchsbaum Gunhilde
Published: March 2018

BACKGROUND:

Rates of administration of intravenous sodium fluorescein during cystoscopy have increased since indigotindisulfonate sodium was removed from the market in 2014. Although sodium fluorescein has been extensively evaluated and found to be safe, side effects including anaphylaxis have been observed, with an incidence between 0.05% and 1.0%.

CASE:

We present a case of anaphylactic shock after administration of intravenous sodium fluorescein for the assessment of ureteral efflux in a patient with a history of frequent severe allergic reactions undergoing urethral lysis and cystoscopy for urinary retention. Cardiopulmonary structure and function were evaluated and found to be normal. An elevated serum tryptase level was identified, indicating an anaphylactoid reaction. Timely recognition of symptoms associated with a severe allergic reaction in the setting of hemodynamic instability with prompt supportive and pharmacologic therapy was vital in the patient's recovery.

CONCLUSION:

Health care providers must be aware of this potential complication, especially in patients with a history of severe allergic reactions.
Family Planning and Counseling Desires of Women Who Have Experienced Miscarriage
Authors: Flink-Bochacki Rachel , Hamm Megan E. , Borrero Sonya , Chen Beatrice A. , Achilles Sharon L. , Chang Judy C.
Published: March 2018

OBJECTIVE:

To explore initial pregnancy intentions and postmiscarriage family planning needs and counseling preferences of women experiencing spontaneous abortion.

METHODS:

We conducted semistructured qualitative interviews with women who recently experienced spontaneous abortion to explore their feelings about conception, pregnancy, and miscarriage; their future family planning goals; and contraceptive counseling preferences. Two trained coders utilized an inductive, iterative approach to code transcripts and identify themes using Atlas.ti software to organize the analysis.

RESULTS:

We interviewed 26 women reporting varied intentions in their recent pregnancies: 54% were trying to conceive, 27% were not trying but not preventing, and 19% were attempting to avoid pregnancy. Participants reported a range of feelings about the pregnancy diagnoses and eventual miscarriages with some relatively unemotional (“a little disappointed…suffering for two months for nothing”) and others feeling devastated by their pregnancy losses (“in shock,” “for it to be taken away was crushing”). Varying character and intensity of emotional reactions were seen across the range of initial pregnancy intentions. Some participants had consistent childbearing plans before and after miscarriage, whereas others experienced their pregnancies and losses as clarifying events leading to changed goals moving forward (“it was a wake-up call”). Although family planning needs were inconsistently addressed after spontaneous abortion, women were generally receptive to the idea of contraceptive counseling, though they had different preferences regarding timing, ranging from immediately to weeks later.

CONCLUSION:

Women's reproductive goals after spontaneous abortion cannot be inferred based on initial pregnancy intention or emotional reactions to pregnancy loss. Health care providers should offer family planning counseling to all women after spontaneous abortion, remaining responsive to individual patient needs.
Occult Gynecologic Cancer in Women Undergoing Hysterectomy or Myomectomy for Benign Indications
Authors: Desai Vrunda B. , Wright Jason D. , Schwartz Peter E. , Jorgensen Elisa M. , Fan Linda , Litkouhi Babak , Lin Haiqun , Gross Cary P. , Xu Xiao
Published: March 2018

OBJECTIVE:

To estimate the prevalence of corpus uteri, cervix uteri, and ovarian malignancy in women undergoing hysterectomy or myomectomy for presumed benign indications.

METHODS:

We conducted a secondary analysis of data from the 2014–2015 American College of Surgeons National Surgical Quality Improvement Program. Adult women undergoing hysterectomies and myomectomies without evidence for known or suspected cancer at the beginning of surgery were identified from the database. Our primary outcome measure was pathology-confirmed malignancy in the corpus uteri, cervix uteri, and ovary. We performed adjusted logistic regression analysis to examine the association of patient characteristics with the risk for malignancy.

RESULTS:

Our sample included 24,076 women undergoing hysterectomy and 2,368 women undergoing myomectomy. Malignancy of the corpus uteri was found in 1.44% (95% CI 1.29–1.59%) of the women undergoing hysterectomy. The prevalence varied considerably across surgical routes with the rate being 0.23% (95% CI 0.06–0.58%) in laparoscopic supracervical hysterectomy and 1.89% (95% CI 1.65–2.14%) in total laparoscopic or laparoscopic-assisted vaginal hysterectomy. Older women were significantly more likely to have preoperatively undetected malignancy of the corpus uteri (adjusted odds ratio 6.46, 95% CI 4.96–8.41 for age 55 years or older vs age 40–54 years). Additionally, 0.60% (95% CI 0.50–0.70%) and 0.19% (95% CI 0.14–0.25%) of the women undergoing hysterectomy were found to have malignancy of the cervix uteri and the ovary, respectively. Among patients undergoing myomectomy, 0.21% (95% CI 0.03–0.40%) were found to have malignancy of the corpus uteri with no occult cervical or ovarian cancer identified.

CONCLUSION:

Prevalence of occult corpus uteri, cervical, and ovarian malignancy was 1.44%, 0.60%, and 0.19%, respectively, among women undergoing hysterectomy and it varied by patient age and surgical route.
Manual Compared With Electric Vacuum Aspiration for Treatment of Molar Pregnancy
Authors: Padrón Lilian , Rezende Filho Jorge , Amim Junior Joffre , Sun Sue Yazaki , Charry Rafael Cortés , Maestá Izildinha , Elias Kevin M. , Horowitz Neil , Braga Antonio , Berkowitz Ross S.
Published: March 2018

OBJECTIVE:

To evaluate uterine evacuation of patients with molar pregnancy, comparing manual with electric vacuum aspiration.

METHODS:

This is a retrospective cohort study of patients with molar pregnancy followed at the Rio de Janeiro Trophoblastic Disease Center from January 2007 to December 2016. The individual primary study outcomes were incomplete uterine evacuation, uterine perforation, development of uterine synechia, and development of postmolar gestational trophoblastic neoplasia. Secondary endpoints were other features of the perioperative outcomes (operative time, rate of transfusion, hemoglobin change, length of stay) and the clinical course of neoplasia (Prognostic Risk Score, presence of metastases, time to remission, and need for multiagent chemotherapy).

RESULTS:

Among 1,727 patients with molar pregnancy, 1,206 underwent electric vacuum aspiration and 521 underwent manual vacuum aspiration. After human chorionic gonadotropin normalization, patients with benign molar pregnancy were followed for 6 months and patients treated for gestational trophoblastic neoplasia were followed for 12 months. Baseline risk factors for gestational trophoblastic neoplasia and demographic features were similar between the treatment groups. Uterine synechia developed less frequently after manual vacuum aspiration than after electric vacuum aspiration, 6 of 521 vs 63 of 1,206 (adjusted odds ratio [OR] 0.21, 95% CI 0.09–0.49), despite no differences in the occurrence of incomplete uterine evacuation, 65 of 521 vs 161 of 1,206 (adjusted OR 0.93, 95% CI 0.69–1.27), development of postmolar gestational trophoblastic neoplasia, 90 of 521 vs 171 of 1,206 (adjusted OR 1.26, 95% CI 0.96–1.67), or the need for multiagent chemotherapy, 22 of 521 vs 41 of 1,206 (adjusted OR 0.81, 95% CI 0.73–1.28).

CONCLUSION:

Manual vacuum aspiration appears to be similar to electric vacuum aspiration for treatment of molar pregnancy and may be associated with less development of uterine synechia.
Quality Improvement to Demonstrate the Lack of Reliability of the Human Papillomavirus mRNA Assay to Identify Women With Latent Human Papillomavirus Infections
Authors: Cotton Sarah , Brown Robert E. , Nugent Elizabeth K. , Robazetti Sonia C. , Berens Pamela D. , Smith Judith A.
Published: March 2018

OBJECTIVE:

To assess the consistency between human papillomavirus (HPV) mRNA testing in women with a history of previous HPV infections diagnosed by HPV DNA assay and the potential effects on follow-up HPV screening.

METHODS:

This was a quality improvement study that used data from a pathology laboratory software database reviewed from November 2014 to June 2016 to identify female patients aged 30 years or older with greater than one HPV-positive result, including one or more HPV mRNA assay results and one or more documented HPV DNA assay results for comparison. Previous correlative cytology and colposcopic histopathology were also documented. American College of Obstetricians and Gynecologists' cervical cancer screening guidelines were used to compare potential differences in follow-up recommendations.

RESULTS:

Four hundred twenty-five charts for female patients 30 years of age or older were identified with one or more prior high-risk HPV infections by DNA assay. There was a 69.3% difference in HPV mRNA results compared with previous HPV DNA–positive results. There was a potential change in follow-up for 71.7% of patients with one prior high-risk-HPV-positive result and 60.0% of patients with two or more prior high-risk HPV-positive results. There were 231 colposcopy reports evaluated in this study. Of these, 62 (26.8%) were abnormal colposcopy reports, including 45 low-grade squamous intraepithelial lesions, 15 high-grade squamous intraepithelial lesions, and two cancers. Twenty-five (40.3%) abnormal colposcopy findings were in patients with a history of at least than two prior HPV DNA–positive results and a report of currently being HPV-negative with the mRNA assay.

CONCLUSION:

The HPV mRNA assays are less sensitive for detection of latent HPV infections compared with HPV DNA assays. Based on these data and the potential change in follow-up care, the HPV mRNA assay should not be used for a primary screening tool for cervical cancer. Many pathology laboratories have shifted to using the HPV mRNA assay without clear discussion with gynecologists about the effects on patient follow-up. The type of HPV assay being used should be documented and any HPV mRNA result confirmed by HPV DNA assay.
A Unique Institutional Response to the Zika Virus Epidemic
Authors: Dran Jenna
Published: March 2018

In 2015, Zika virus rapidly emerged as a concern for obstetric patients and health care providers as the disease spread geographically and it was discovered that Zika virus infection had the potential to cause devastating birth defects. Essentially overnight, obstetric care providers were faced with an influx of rapidly evolving information and an increased workload. New systems, workflows, and personnel were needed to effectively address the new patient care needs fueled by the burgeoning Zika virus epidemic. The University of California, San Francisco responded by filling a Zika Response Nurse Coordinator position to take on tasks necessary to design a systematic approach for Zika virus management. The Zika Response Coordinator at the University of California, San Francisco serves as a subject matter expert who counsels patients and health care providers, arranges testing and follow-up care after potential Zika virus exposure, and helps design the screening tools, protocols, and educational material needed to manage the evolving Zika virus response. The position has enabled a Zika virus response that has been tightly coordinated, consistent, and thorough without overburdening health care providers. The Zika Response Nurse Coordinator Role serves as a template for how institutions can model coordinated Zika virus care and prepare for future threats that will necessitate a focused and rapid response. Timely institutional financial support is critical for an appropriate response to emerging diseases for not only Zika virus but future epidemics as well.