bluuebunny/crossref_metadata_2025 huggingface dataset:
What Are We Learning? An Update on Abortion Education in Medical Schools [29G]
Authors: Heger Julie , Roth Joeli , Kenya Sonjiya
Published: April 2020

INTRODUCTION:

Nearly one in four U.S. women will have an abortion by age 40, making abortion one of the most common medical procedures women undergo in the United States. Despite its prevalence, abortion education has been historically limited in United States (US) medical schools’ curricula. The last assessment of medical schools' reproductive health curricula was done in 2005. This research aims to reexamine the status of abortion education.

METHODS:

We emailed a three-question survey to the Obstetrics & Gynecology clerkship directors at 143 US allopathic medical schools. The survey assessed the availability and type of reproductive health exposure students have during their pre-clinical and clinical years. Participants were invited to complete the survey in April, and reminder emails with the survey link were sent in July and September.

RESULTS:

Thus far, 79 clerkship directors have responded to the survey, for a response rate of 56%. Ten percent of clerkship directors reported no formal abortion education in preclinical or clinical years. This is compared to 2005, with 17% of clerkship directors indicating no formal abortion education. In the clinical years, 47% of respondents indicated abortion education was integrated into the experience, while 28% reported students had to arrange participation on their own.

CONCLUSION:

While there has been some increase in the availability of abortion education in U.S. medical schools, this improvement pales in comparison to the national demand for the procedure. As a fundamental aspect of reproductive health, abortion education deserves a place in the curricula at every medical school.
ZIP Codes Affected by Hurricane Harvey in Proximity to Superfund Sites and Impacts to Maternal and Neonatal Morbidity [30G]
Authors: Hanson Frances K. , Aagaard Kjersti , Suter Melissa
Published: April 2020

INTRODUCTION:

A time series (TS) analysis before and after Hurricane Harvey to understand the impact of flooding and proximity to Texas Superfund sites on composite maternal (CMM) and neonatal morbidity (CNM) in affected region.

METHODS:

A population-based cohort was used to select gravidae delivering within a fixed two-year time interval before and after Harvey, and analyzed by proximity to 11 Superfund sites in the region. CMM included: hypertensive disorder of pregnancy, chorioamnionitis, endometritis, blood transfusion, peripartum hysterectomy, maternal ICU admission, pulmonary edema or maternal death. CNM included: 5-minute Apgar score ≤ 3, respiratory distress syndrome, use of ventilatory/CPAP, suspected newborn sepsis, seizure, stillbirth, or neonatal death. CMM and CNM were aggregated across ZIP codes and mapped alongside regional Superfund sites using GIS. A TS assessment of the spatial relationship between ZIP codes and their proximity to the Superfund sites before and after Harvey was performed.

RESULTS:

Affected ZIP codes saw an increased hotspot CMM by 16% before and 4% after Harvey when compared to all regional ZIP codes. The affected ZIP codes saw an increased hotspot CNM by 12% before and a decrease of 6.67% after Harvey when compared to regional ZIP codes. The TS assessment showed a decrease in hotspot CMM by 17.2% in affected ZIP codes. The hotspot CNM among affected ZIP codes decreased by 66.67%.

CONCLUSION:

The decrease in hotspot morbidity for both CMM and CNM after Harvey unveils the substantial impact of three significant flooding events that occurred within the region in the two years inclusive of Harvey.
Can We Harness the Business Paradigm of Value Creation to Support Quality Improvement Projects? [31G]
Authors: Paek Bettina , Walker Martin
Published: April 2020

INTRODUCTION:

Quality improvement projects are generally not reimbursed by payers and often rely on engaged staff and physician volunteers. Physicians typically receive no training in business strategy. We hypothesized that adopting a paradigm of value creation has the potential to support QI projects and thereby enhance patient outcomes in a financially sustainable way.

METHODS:

Childbirth is the most common indication for hospital admission in the US. We identified pain points for insurance companies and hospitals that coincided with existing quality improvement initiatives. A decrease in the cesarean rate was chosen as a potentially modifiable target that would create a compelling value proposition for payers. A labor support app was then designed with content curated to support a QI initiative to decrease the NTSV cesarean rate. A business plan was built around the app and tested for viability in the investor community, with hospital administrators, insurance- and employer representatives.

RESULTS:

We partnered with Penny Simkin, to provide labor support content. Labor support has been shown to decrease cesarean birth. The app format allows for easy access by patients and their care team. Every cesarean avoided results in cost savings for payers, favoring payment of the app. This was highly acceptable to hospitals administrators, insurance and employer representatives. The business plan won first place in the business plan competition, indicating a high level of support of the local business community.

CONCLUSION:

Approaching clinical problems with a perspective of value creation to payers has the potential to create financially viable solutions and improve care for our patients.
Determining the Impact of Journal Abstract Structure and Word Limit on the Completeness of Study Reporting [32G]
Authors: Freedman Lesle , D'Souza Rohan D. , Nica Alex , Huszti Ella
Published: April 2020

INTRODUCTION:

It is vital that journal abstracts, which summarize clinical research, contain sufficient information on the study, for readers to draw appropriate conclusions. Our study examined the influence of variations in abstract structure and maximum word limit among obstetrics and gynecology (OBGYN) journals on the completeness of study reporting.

METHODS:

We conducted a retrospective study examining 163 abstracts from 50 OBGYN journals using a modified, 32-item, version of a previously-published checklist for abstract assessment. Abstracts were classified into three groups based on abstract structure – unstructured, structured-with-headings and structured-without-headings, and three based on word count – less-than-250, 250- and greater-than-250 words. Based on preliminary assessment of abstracts, which scored 37-78% on the checklist, we determined that we needed 140 abstracts to determine differences between groups, with 80% power. Primary outcome was abstract quality score. ANOVA and linear regression analysis were used to determine whether abstract structures and word limits were associated with journal abstract quality.

RESULTS:

A significant difference in mean abstract scores were found for word limit (P=.012) but not abstract structure (P>.05). Mean score of the greater-than-250-word and 250-word category were significantly higher than those of the less-than-250-word category (68.25 vs 59.69, P=.003 and 65.20 vs 59.69, P=.046 respectively).

CONCLUSION:

Although abstract structure does not seem to influence quality, OBGYN journal abstracts with less-than-250-words might exclude important study information. Research on other factors influencing abstract quality could help journals improve the appropriate condensation of study information into abstracts, which are most widely read and often used to guide busy clinicians.
Parvovirus in the Second Trimester: A Case of Unremitting Fetal Anemia [34G]
Authors: Roser Brittany , O'Hara Shaelyn , Stone Joanne L.
Published: April 2020

INTRODUCTION:

Parvovirus B19 has been associated with spontaneous abortion, hydrops fetalis, and stillbirth when acquired in pregnancy.[1] When fetal anemia is diagnosed prenatally, fetuses usually respond to a single transfusion. In surviving neonates, the post-natal course and timeframe for bone marrow recovery is not established.

METHODS:

A 27 year-old primigravida at 26 weeks gestation presented to her community hospital with decreased fetal movement. Work-up revealed nonimmune hydrops fetalis secondary to Parvovirus B19 infection with +IgM seroconversion, for which she transferred to our center for percutaneous umbilical blood sampling (PUBS) and transfusion. She underwent three PUBS procedures due to persistently elevated MCA Dopplers and Category II tracing prior to presenting in preterm labor at 29 weeks. Upon delivery, the neonate weighed 1490 g, Apgar scores were 4 and 7 at 1 and 5 minutes, and a venous umbilical cord gas pH was 7.45. The neonate was admitted to the NICU for prematurity and required transfusions on day of life (DOL) 0, 18, 32, and 46 for persistent Parvovirus-induced erythroblastopenia. A repeat Parvovirus B19 PCR was greater than 10,000,000 copies at DOL 43 prompting IVIG therapy. Blood counts stabilized thereafter. On DOL 73 the neonate was 3100 g and breathing on room air, discharged home without other complications. On DOL 154, the Parvovirus B19 PCR was 70,350 copies and the infant was doing well at home.

CONCLUSION:

We present a case of parvovirus infection acquired in the second trimester requiring multiple transfusions, with an unusual post-natal course that has yet to be described.
Pregnancy Outcomes in Women With Acute Porphyria: A Systematic Literature Review [35G]
Authors: Kanninen Tomi T. , Stroobant Emily , Pierce-Williams Rebecca , Berger Seth , Al-Kouatly Huda B.
Published: April 2020

INTRODUCTION:

The porphyrias are a group of rare disorders caused by deficiencies in enzymes of heme biosynthesis. Our objective is to determine the rate of acute attacks in pregnant patients with acute porphyria and risk of preterm birth.

METHODS:

PubMed, EMBASE and ScienceDirect were screened from the inception of the databases to May 2019 resulting in 872 articles. Our primary outcome was rate of acute attacks during pregnancy and postpartum period manifesting with severe abdominal pain, neurological dysfunction and psychiatric disturbances in women with acute porphyria. Secondary outcome was the rate of preterm delivery. The Meta-analysis of Observational Studies in Epidemiology guidelines was used (MOOSE).

RESULTS:

We identified 49 case reports with a total of 59 patients. Mean maternal age was 26.7 (±5.6) years. Mean gestational age at presentation was 19 weeks. Positive urine porphobilinogen was used to diagnose 84.8% (39/46) of women. During pregnancy 71.2% of women (42/59) suffered an acute attack. The clinical spectrum of attacks were: neurologic 52% (26/59), abdominal pain 49.2% (29/59), and psychiatric 22% (13/59). Preterm delivery occurred in 29% (9/31) of women (range 30-36 weeks). The mean gestational age at delivery was 35 weeks 6 days (±32 days) with a mean birth weight of 2705.9 (±721.5) grams. Cesarean section occurred in 45.5% of women (20/44). Hematin (or Hemin) was used in only nine patients (15.3%) without complication.

CONCLUSION:

The results of our systematic review demonstrate the increased rate of acute attacks in patients with porphyria in pregnancy with nearly one third having preterm delivery.
Changing the Landscape of Obstetric Resident Education in LMIC Using Simulation Based Training [37G]
Authors: Meza Pamela K. , Bianco Katherine , Herrarte Edgar , Daniels Kay
Published: April 2020

INTRODUCTION:

Maternal mortality continues to be one of the largest health burdens in reproductive-aged women in low- and middle-income countries (LMIC). Simulation-based training (SBT) has been previously piloted demonstrating that SBT was an accepted method of teaching skills for managing high-risk labor in LMIC.

METHODS:

An in-country simulation based education course on the management of post-partum hemorrhage (PPH), shoulder dystocia (SD), and maternal cardiac arrest (MCA) were provided to three major governmental teaching hospitals in Guatemala City, Guatemala. Participants were 46 OB/GYN residents. A paired Student t-test was conducted to compare clinical knowledge regarding these obstetric emergencies at three timepoints: before SBT, one week, and six months after SBT.

RESULTS:

There was significant increase in scores in clinical knowledge of SD and MCA one week (M=7.83, SD=1.1) following SBT compared to baseline (M=5.96, SD=1.75); P≤.05. However, for PPH there was no increase in scores one-week (M=2.91, SD=0.94) following SBT compared to baseline (M=2.73, SD 0.65); P>.05. Additionally, the difference in scores was maintained at six months following SBT for SD and MCA (M=7.52, SD=1.09) compared to baseline (M=5.96, SD=1.75); P≤.05. PPH scores at six-months (M=3.36, SD 0.65) showed a significant increase compared to baseline (M=2.73, SD=0.65); P≤.05.

CONCLUSION:

Simulation-based training was found to be an effective method to increase cognitive clinical knowledge in LMIC for rarely seen events of MCA and SD but not with the more common event of PPH. This knowledge increase was maintained six-months after participation in the training.
Simulation to Teach Cesarean Section and Hemorrhage Management: Evaluation of a Novel High-Fidelity Simulator [38G]
Authors: Foglia Lisa M. , Eubanks Allison , Peterson Logan , Hickey Kimberly , Jackson Amanda , Deering Shad
Published: April 2020

INTRODUCTION:

The cesarean delivery the most common surgical procedure performed within the military health system (MHS). The gold standard for training physicians to perform a cesarean section is didactics and then practicing on actual patients. The objective of this study is to evaluate the efficacy of a novel high-fidelity simulator to train physicians with limited surgical obstetric experience to perform cesarean sections and manage operative hemorrhage.

METHODS:

Gynecology, family medicine, and surgery residents were recruited for the IRB approved study. All participants received the same didactic training on performing a cesarean section and managing postpartum hemorrhage. The intervention group received additional training on a simulator to perform the procedure and management of hemorrhage. All participants were then evaluated on their ability to perform a cesarean section with operative complications using the simulator.

RESULTS:

From July 2017 to January 2019 a total of 33 participants were recruited and randomized. The intervention group had higher scores on the cesarean delivery (p-values 0.013 and 0.017), hemorrhage management (p-value .0002), and overall skill (p-value .008). There was no difference in preoperative management, postoperative management, counseling, technical skills, and teamwork.

CONCLUSION:

Participants who received training using a high-fidelity simulator performed significantly better on all procedural aspects of a cesarean section and hemorrhage management. Simulation allows trainees to gain procedural experience while eliminating patient risk. Cesarean section simulators may be useful to train and reinforce surgical skills for residents, military physicians about to deploy, ancillary providers in low-resource settings, and physicians at low-volume medical centers.
A Prospective Evaluation of Opioid Utilization After Benign Gynecological Surgery [01H]
Authors: Wright Danielle , Soper David , Korte Jeffrey
Published: April 2020

INTRODUCTION:

Opioids provide an effective means to controlling postoperative pain. However, this medicine is overprescribed and the lack of prescribing guidelines contribute to this issue. As-Sanie et al (2007) reported gynecologists prescribed twice the amount of opioids than the average patient used after hysterectomy. Our goal, for this study, was to define the pattern of opioid utilization after benign gynecologic surgery.

METHODS:

This is a prospective cohort study. Women were deemed eligible for enrollment if they underwent hysteroscopy, laparoscopy, and hysterectomy. Patients were excluded from the study if there was suspicion for malignancy. Following discharge, a 17-question phone survey was completed 14 days post op to assess opioid consumption.

RESULTS:

A total of 109 women participated in the survey. Over all procedures, the median proportion of opioids used was 40% (IQR 13-100%) with the difference between the median MME (morphine milligram equivalent) prescribed and used being statistically significant for all procedures.

CONCLUSION:

This study highlights the practice of overprescribing, which should be a target area for improvement for benign gynecologists. We recommend using each procedure’s IQR for prescribing guidance. Adjustments in quantity can be made based on patient history and collaborative decision making.
Demonstrating Lack of Child Care as a Barrier to Health Care for Women in Parkland Health & Hospital System [04H]
Authors: Gaur Priyanka , Kuo Madyson , Kho Kimberly A.
Published: April 2020

INTRODUCTION:

Women face significant barriers to care related to their roles as caretakers; in a prior survey, up to 20% report foregoing care because of difficulties with child care. We describe how lack of child care impacts access to health care and determine patient interest in a hospital-based day care center.

METHODS:

This is a non-regulated cross-sectional survey of 300 women of reproductive age attending Parkland Health & Hospital System (PHHS) clinics. Outpatient clinics sampled included: Primary Care, Obstetrics & Gynecology, Oncology.

RESULTS:

Response rate was 96.7% with 52.7% reporting foregoing health care for lack of child care in the past 12 months. On average, women delayed 3.7 ± 2.7 appointments/year. 38.2% delayed care for 1 to 6 months and 30.9% for 1 week to 1 month. 86.8% missed checkups, and 31.8% missed problem visits. Lack of child care (52.7%) was the most frequently cited reason for missing care followed by lack of transportation (32.8%) and insurance (25.2%). There was an association between race/ethnicity and whether women delayed care in the past 12 months with 68.8% white, 55.0% black, and 34.3% Hispanic (P=.001). 87.9% felt a hospital-based day care would help them attend visits.

CONCLUSION:

Our study demonstrates that child care is the most significant barrier to accessing health care, affecting women of all races/ethnicities in our county-supported safety net system. A hospital-based day care center may help alleviate this barrier, and our goal is to study outcomes after the introduction of such a center at PHHS in 2020.
Does the ACS NSQIP Surgical Risk Calculator Accurately Predict Surgical Outcomes for Benign Hysterectomy? [06H]
Authors: Thigpen Brooke , Eppes Carey , Schaumberg Jordan , Johnson Emily , Sangi-Haghpeykar Haleh , Swaim Laurie S.
Published: April 2020

INTRODUCTION:

Hysterectomy complications result in morbidity and financial burden. The American College of Surgeons NSQIP Surgical Risk Calculator (ACS NSQIP SRC) estimates the chances of postoperative complications using the National Surgical Quality Improvement Program (NSQIP) database. Our objective was to evaluate the ACS NSQIP SRC predictive ability for postoperative complications after total abdominal hysterectomy (TAH) and total laparoscopic hysterectomy (TLH) for benign disease.

METHODS:

Preoperative and postoperative data were extracted from the records of all patients after a TAH or TLH at a single academic hospital from January 2012 to December 2015. Surgical risk scores calculated using the ACS NSQIP SRC tool and postoperative complications were correlated using logistic regression. A c-statistic and Brier score were used to assess the ability of the calculator to accurately predict complications. During the time period reviewed, an infection prevention bundle was implemented. Results were analyzed during the entire period, as well as before and after bundle implementation.

RESULTS:

Of the 700 patients reviewed, 99.7% were less than 65 years-old, 94.2% ASA class 2 or greater, and 60% obese. Most underwent TAH (61%). In all patients, the calculator performed best for predicting venous thromboembolism (VTE) (c statistic=0.96 brier 0.003). It performed well predicting surgical site infection (SSI) after bundle implementation (c statistic=0.71 brier 0.04), but not before bundle implementation. The calculator was a poor predictor of other complications, including urinary tract infection, reoperation, and readmission.

CONCLUSION:

The ACS NSQIP SRC adequately predicts VTE and SSI. The calculator did not accurately predict other complications.
Endosalpingiosis: Clinical Presentation and Coexisting Pathology [07H]
Authors: Sajnani Jocelyn , Swan Kimberly
Published: April 2020

INTRODUCTION:

Describe the clinical presentation and coexisting pathology of women with endosalpingiosis (ES), the presence of ectopic fallopian tube-like epithelium.

METHODS:

Retrospective analysis of pathology reports containing the keyword “endosalpingiosis” for procedures performed at the University of Kansas Medical Center between 2007-2017 Demographic information, clinical characteristics, and relevant pathology were collected for patients (N=98) with pathologically confirmed ES.

RESULTS:

Patient Characteristics: the cohort had a mean age of 51 at diagnosis, 52% were post-menopausal, 52% were never smokers, their mean BMI was 32, and 59% had prior abdominal or pelvic surgery. Clinical Presentation: 43% complained of pelvic pain, 31% of the post-menopausal subgroup presented with bleeding, and 26% experienced abdominal pain or bloating. Abdominal or pelvic mass was the most frequent indication for surgery (35%), followed by evaluation of a known gynecologic malignancy (31%) of which 60% were endometrial adenocarcinoma. Pathology Findings: 79% of patients had a single ES lesion on biopsy most likely to be found in an abdominal or pelvic lymph node (38%), ovary (21%), and perimetrium (14%). All 98 women in the cohort had other pathology in addition to ES. A new gynecologic malignancy was diagnosed after surgery in 29% of which 62% were ovarian. The majority also presented with concomitant benign disease (cyst, leiomyoma, etc) and 19% had concurrent endometriosis.

CONCLUSION:

Women with ES commonly complain of pelvic pain and the majority have a concurrent gynecologic cancer. It appears ES rarely occurs in isolation and further research is necessary to determine its role in the pathogenesis of gynecologic disease.
Patient-Reported Use of Medical Cannabis for Management of Chronic Pelvic Pain [12H]
Authors: Carrubba Aakriti R. , Spaulding Aaron C. , Ebbert Jon O. , DeStephano Christopher C.
Published: April 2020

INTRODUCTION:

Chronic pelvic pain (CPP) affects up to 15% of women in the United States. The endocannabinoid system can be a pharmacological target for endometriosis-related pelvic pain, as cannabis receptors are highly expressed in the uterus and other non-reproductive tissues. We hypothesize that many patients with CPP use cannabis and report improvement in symptoms.

METHODS:

An anonymous, confidential, electronic survey was performed from March through August 2019. Patients aged 18 through 89 were included if they had a diagnosis of pelvic/perineal pain, dyspareunia, or endometriosis. Subjects were approached during outpatient appointments. Study approval was obtained from the Institutional Review Board.

RESULTS:

A total of 122 of 240 (50.8%) patients responded. Of these, 113 self-reported a diagnosis of CPP (92.6%). Twenty-six patients reported cannabis use (23%). Six (24%) used Cannabidiol (CBD), 3 (12%) used tetrahydrocannabinol (THC), and 15 (60%) used a combination of CBD and THC. Frequency of use varied, with the majority using at least once per week (n=18, 69.2%). Only 5 (19.2%) utilized a State Medical Cannabis Program to obtain a certification. Of users, 24 (92.3%) reported improvement in symptoms, including pain, cramping, muscle spasms, anxiety, depression, sleep disturbances, libido, and irritability. However, 21 (80.7%) reported side effects; the most common were dry mouth, sleepiness, and feeling “high.”

CONCLUSION:

Up to 23% of patients with CPP report use of cannabis as an adjunct to their prescribed therapy, and they use a variety of formulations and doses. Most report daily or weekly use. Although side effects are common, most users report improvement in symptoms.
Reducing Opioid Prescriptions Through Patient Education and Standardized Protocols [14H]
Authors: DePaula-Cox Rose , Nair Pallavi , Provost Holly
Published: April 2020

INTRODUCTION:

Deaths due to opioid overdose continue to rise in the US. Initial exposure to opioids is largely due to surgical procedures. Our project hopes to reduce opioid needs and prescriptions after an outpatient laparoscopic procedure with a multi-disciplinary bundle pain management provided preoperatively.

METHODS:

Thirty narcotic-naïve patients undergoing laparoscopy underwent education of pain expectations, diet, bowel hygiene and exercise, and our 3 day treatment plan. Instruction was given at preoperative visit, anesthesia visit, day of procedure, and discharge. Patient inquiries about pain were made PODs #1 and after #4. Requests for opioid refills were monitored. Preop use of acetaminophen 1000 mg and gabapentin 1200 mg orally and lidocaine injected at trocar sites. Ketorolac 30 mg IV given at the end of the case. Only 6 oxycodone 5 mg tablets were prescribed for PRN needs. Three days of scheduled medication (acetaminophen, naproxen) given at discharge. IRB approval was waived.

RESULTS:

Three patients requested opioids but none were prescribed with pain management education. Six cases had endometriosis with only 2 of those patients requesting more opioids. The third patient had significant lysis of adhesions.

CONCLUSION:

This study emphasized the importance of repetitive pain management expectation discussions with patients. It also showed that having a more extensive surgery or source of preoperative pain does not require additional narcotics. 2/3 of patients with endometriosis did not request additional narcotics. This project will be expanded to all procedures while creating a standardized regimen for opioids and non-opioids postoperatively.
Robotic-Assisted Vaginal Cuff Closure Technique and Vaginal Cuff Dehiscence Rates [16H]
Authors: Tisser Danielle , Burdeaux Shayna , Guta Paulina , Staudenmaier Emily K. , Wadhwa Ruchi K. , Vullo John
Published: April 2020

INTRODUCTION:

While the implementation of robotic surgery has improved many postoperative outcomes, an increased rate of vaginal cuff dehiscence (VCD) has been observed in colpotomy closures performed robotically compared to transvaginal or laparoscopic closures. No consensus exists for suture interval or depth of tissue in intracorporal vaginal cuff closure. A study published by O’Hanlan et al. (Minimally Invasive Surgery, 2016) proposes a suture interval and depth of 5 mm. Our study aims to assess if there is any advantage for decreasing postoperative complications with an alternative closure technique.

METHODS:

This is a descriptive study of post-operative outcomes at our institution that was conducted via a retrospective chart review. Instances of complications including infection, reoperation and VCD rates were recorded for robotic-assisted laparoscopic hysterectomies and trachelectomies performed between 2016-2017. Robotic vaginal cuff closure was performed using V-Loc 90 suture with suture interval and depth of 10 mm. These outcome rates were compared to the complication rates published by O’Hanlan et al. IRB approval was obtained.

RESULTS:

160 patients were included in Group 1. An overall complication rate of 11.9% was noted in our study which included infection, VCD, bleeding and re-operation rates. A 2.5% VCD rate was observed with 1.25% of patient’s requiring re-operation. Postoperative infection rate in Group 1 was 3.1%.

CONCLUSION:

No significant benefit was demonstrated in patients who underwent robotic-assisted vaginal cuff closure with a suture interval and depth of 10 mm compared to previously published data by O’Hanlan et al using a closure interval and depth of 5 mm.
The Independent Contribution of Endocervical Curettage in Detecting High Grade Dysplasia at the Time of Colposcopy [17H]
Authors: Rojas Christine , Samardzic Kristen , Zammarrelli William A. , Jackson Amanda
Published: April 2020

INTRODUCTION:

As of October 2017, consensus recommendations identified the need for re-evaluation of the indications for and performance of endocervical sampling (ECC). The primary objective of this study was to evaluate the independent contribution of ECC in detecting high grade cervical intraepithelial neoplasia at the time of colposcopy.

METHODS:

This was a retrospective review of laboratory records provided to us by LabCorp. We examined the colposcopy results of women in a large multispecialty clinic in Las Vegas, Nevada whose specimen dates were between 9/1/2017 and 5/31/2018. The outcome of interest was any scenario where the ECC was CIN2 or greater and all of the ectocervical biopsies concurrently performed were CIN 1 or less.

RESULTS:

We examined 232 ECC records. Among the 19 ECCs in women 21 to 25 years old, one was CIN 2 or greater (5.3%) compared to 3/42 (7.1%) among women 25 to 29 and 19/171 (11.1%) among women 30 and older. Among women less than 25, in 14/19 cases (73.7%), two or more ectocervical biopsies were performed with the ECC as compared to 15/42 (35.7%) and 74/171 (32.8%) cases among women 25 to 29 and 30 years and older, respectively (P=.01). When only an ECC was performed, ECC was CIN 2 or greater in 1/51 cases (2%). When one ectocervical biopsy was performed with ECC, the outcome of interest occurred in 8/96 cases (8.3%) as compared to 1/85 cases (1.2%) in which two or more ectocervical biopsies were concurrently performed (P=.01).

CONCLUSION:

Our results suggest that ECC is most clinically influential when only one ectocervical biopsy is concurrently performed.
Association of Insurance Status and Cervical Cancer Tumor Size in the United States [22H]
Authors: Erfani Hadi , Rezaei Atefeh , Shamshirsaz Alireza
Published: April 2020

INTRODUCTION:

Health disparity based on insurance status has been of great attention recently. We sought to study the association of insurance status with cervical cancer tumor size at the time of diagnosis.

METHODS:

The US Surveillance, Epidemiology and End Results (SEER) database was accessed (1973-2016). Since the variable “Tumor Size Summary” was available only for the year of 2016, data for cervical cancer in 2016 in the United States were extracted using the case-listing procedure. Mann-Whitney U test, Chi-Square/Fisher’s exact test, and regression analyses were performed as appropriate. Statistical analyses were done using SEER*Stat 8.3.5 and R 3.6.1.

RESULTS:

Total of 3276 subjects with cervical cancer was included in this study; 155 subjects (4.7%) were uninsured. The rate for Non-Hispanic black (20.6% vs. 12.3%) and Hispanic (51.6% vs. 24.5%) race/ethnicity, Unmarried status (61.3% versus 54.8%) were higher in uninsured group (P<.05 for all). Before and after appropriate adjustments (for age, race/ethnicity, marital status and Medicaid-eligibility based on age >65) tumor sizes at the time of diagnosis [50 mm (28, 69) vs. 38 mm (15, 60); P=.04] was found to be larger in the uninsured group.

CONCLUSION:

Being uninsured is associated with having a larger tumor at the time of diagnosis of cervical cancer. An increase in insurance coverage and access to cancer screening for all women is essential.
Effects of E2/P4 Oral Capsules on Bone Turnover in Women With Vasomotor Symptoms [06F]
Authors: Kagan Risa , McClung Michael R. , Graham Shelli , Bernick Brian , Mirkin Sebastian , Constantine Ginger
Published: April 2020

INTRODUCTION:

Menopausal hormone therapy slows bone turnover and reduces the risk of osteoporotic fractures. The objective of this post hoc analysis was to evaluate bone turnover markers (BTM) in the phase 3 REPLENISH trial, which evaluated vasomotor symptoms (VMS) with an oral estradiol/progesterone (E2/P4) in postmenopausal women with a uterus.

METHODS:

Eligible women for this analysis had ≥50 moderate to severe VMS/week, <5 years since last menstrual period, and BTM measurements at baseline, and months 6 and 12. Percent changes for 3 BTM (bone specific alkaline phosphatase [BSAP], C-terminal telopeptide of type I collagen [CTX-1], and N-terminal propeptide of type I procollagen [PINP]) assessed by immunoassay methods were evaluated from baseline to months 6 and 12 for the 1/100, 0.5/100 and placebo groups.

RESULTS:

A total of 157 women (40-61 years, 69% white) were analyzed (56 for each 1/100 and 0.5/100; 45 for placebo). Mean baseline values ranged from 14.0-14.3 U/L for BSAP, 0.34-0.39 ng/mL for CTX-1, and 76.9-79.3 ng/mL for PINP. Mean differences in percent change from baseline versus placebo significantly decreased with both E2/P4 doses for all 3 BTM at months 6 and 12. Mean differences from placebo for E2/P4 at months 6/12 ranged from -8.1% to -17.8% for BSAP (all, P≤0.02), -30% to -41% for CTX-1 (all, P≤0.001), and -14% to -29% for PINP (all, P≤0.007).

CONCLUSION:

REPLENISH data provide support for a potential skeletal benefit of E2/P4 when used for the treatment of moderate to severe VMS.
Anxiety and Pain in Patients Undergoing Pipelle Endometrial Biopsy: A Prospective Study [11F]
Authors: Adambekov Shalkar , Lopa Samia , Edwards Robert P. , Bovbjerg Dana H. , Linkov Faina , Donnellan Nicole
Published: April 2020

INTRODUCTION:

Pipelle biopsy is a minimally invasive endometrial sampling procedure, important for early diagnosis of endometrial pathology and treatment planning. While generally well tolerated, some women experience considerable pain. The prospective study reported here provides a first critical test of the hypothesis that heightened anxiety may contribute to the risk of severe pain in women undergoing Pipelle biopsy.

METHODS:

Pain and anxiety levels immediately prior to, during, and after the Pipelle biopsy were assessed (0-10 numeric rating) in a sample (n=113) of consecutively recruited women undergoing outpatient Pipelle biopsies in a tertiary care facility. Personal and clinical data were extracted from medical records and from surveys administered to providers. Multivariable logistic regression models and generalized estimating equations examined associations between severe (≥7) pain and anxiety prior to, during, and after the biopsy.

RESULTS:

Severe pain was reported by 9%, 43%, and 13% of participants prior to, during and after the procedure (respectively), while severe anxiety was reported by 30%, 38% and 12%. Pain was significantly associated with anxiety levels at all times assessed. Adjusting for covariates (e.g., age, BMI, biopsy indication), the odds of severe pain prior to, during, and after biopsy were 5.9, 2.3, and 11.0 times higher (respectively) for patients with severe anxiety prior to the procedure.

CONCLUSION:

The strong relationships between anxiety prior to Pipelle biopsy and patients’ experiences of severe pain associated with the procedure suggest that interventions aimed at reducing anxiety might substantially improve the patient experience of this widely-used procedure for endometrial biopsy.
High-Risk Pregnancies and Health Conditions in Medicaid-Insured Participants in a Federal Healthy Start Program [13F]
Authors: Roman Lee Anne , Strutz Kelly , Luo Zhehui , Johnson Melinda , Meulen Peggy Vander , Meghea Cristian
Published: April 2020

INTRODUCTION:

Decreasing disparities in maternal morbidity and mortality and addressing maternal chronic health conditions in Medicaid-insured pregnant women are important national goals. Federal Healthy Start (HS) programs provide care for underserved and racial/ethnic minority women, many with self-reported medical conditions, and address social determinants; an opportunity for strategic partnerships with clinical providers. The study objective was to use administrative data and describe health conditions and compare risks in a cohort of HS participants with a statewide population of Medicaid-insured women.

METHODS:

Medicaid-insured HS participants (N=389) were compared with Michigan beneficiaries (N=80,547). Linked Medicaid claims and vital record data were used to identify health conditions and high-risk pregnancy; AHRQ’s Clinical Classification Software diagnoses were used to identify behavioral health conditions and assess multiple health conditions during pre-pregnancy and pregnancy periods. IRB determined the study did not involve human subjects.

RESULTS:

HS participants were significantly more likely to have high-risk pregnancy claims (67.4% vs 30.2%), mental health conditions (31.9% vs. 20.2%), multiple health conditions (61% vs. 49%), prior preterm birth (6.7% vs. 3.7%), less than 12 grade education/health literacy (41.6% vs. 16.9%) and be African American (54% vs. 29%). There was a trend for chronic hypertension (5.7% vs. 4%), but no group differences for chronic diabetes (5.7% vs. 5.8%).

CONCLUSION:

Findings support that HS, equipped to address cultural and social determinants, serves many Medicaid-insured women with multiple, complex health problems, high-risk pregnancies, and mental health issues. Standard processes for program referral and coordination within practices who provide prenatal care could optimize services for high-risk women.
If You Didn’t Document It, It Didn’t Happen: Improving Documentation of Annual Visits at Resident Clinic [14F]
Authors: Mishra Supriya
Published: April 2020

INTRODUCTION:

Improve documentation of annual exams based on ACOG’s Women’s Preventative Service Initiative. By increasing consistency in documentation, improve provided patient care.

METHODS:

Study broken into cycles: (1) A needs assessment (2) first intervention (3) post intervention analysis, (4) 2nd intervention, (5) 2nd post intervention analysis. Epic EMR between 10/2018-05/2019 used to review note documentation by examining presence/absence of the following key elements: gynecologic history section, age appropriate screening offered, HPV vaccination status, Flu vaccination status, menstrual flow, inter-menstrual bleed, healthy living tips, sexual partners, sexual dysfunction, STD testing, fertility desire, family history specific to gynecologic cancer, BMI, Smoker status, history of domestic violence, history of mental health issues. Descriptive analysis was performed using Pivot Table function in Microsoft. Chi square and Fisher exact tests were performed to look for statistical significance.

RESULTS:

One hundred and seven (n=107) notes were evaluated in needs assessment study, documentation scores varied between 1 to 15 out of 18 total. A new note template was introduced to EMR. 68 charts were analyzed and scores varied from 3-18 out of total score of 18. 2nd intervention was implemented with one-on-one feedback to providers. 21 charts were reviewed, scores varied 8-18, out of 18. Overall Median scores improved from 8 to 15 to 18 after each intervention. 15 components were noted to have a statistically significant improvement in documentation.

CONCLUSION:

Study findings support planned use of the Institute of Healthcare Improvement’s model of Plan-Do-Study-Act (PDSA) cycles to modify the EMR note template. These efforts enhance physician documentation of patient well-being.
Mifepristone Combination Therapy Versus Misoprostol Monotherapy for Early Pregnancy Loss: A Cost Analysis [17F]
Authors: Berkley Holly , Wittenberger Michael
Published: April 2020

INTRODUCTION:

For years, mifepristone combined with misoprostol was considered standard treatment for first-trimester abortions. In 2018, ACOG finally updated its recommendations to include mifepristone for management of early pregnancy loss (EPL). Adoption of this has met resistance. One perceived barrier to the provision of mifepristone is cost. Our aim is to determine if mifepristone pretreatment adversely affects cost of medical management of EPL.

METHODS:

Decision tree analyses were constructed comparing costs of combination therapy versus monotherapy in multiple scenarios weighing provider practice, patient income, and surgical evacuation modalities for failed medical management. Rates of completed medical evacuation for each were obtained from recent randomized controlled trials.

RESULTS:

In nearly every scenario, combination therapy was favored over monotherapy. When surgical costs were higher, combined therapy was highly favored ($254.90 vs $391.60 per patient, 54% greater for monotherapy). Only when office manual vacuum aspiration was exclusively used and the patient population received minimum Federal wages was monotherapy minimally favored ($149.91 vs $152.54 per patient, 2% less for monotherapy). For equality of cost to occur in the various scenarios, the difference in completion rates between combination therapy and monotherapy needed to be between 5.6% and 15.2% - levels significantly less than that found in the literature (14.7% to 30.9%).

CONCLUSION:

Mifepristone combined with misoprostol is overall more cost effective than monotherapy and therefore cost should not be a deterrent to its adoption.
Patient Perception Regarding Education and Emotional Support Related to Early Pregnancy Complications and Loss [19F]
Authors: Metwally Hadeer , Roussos-Ross Kay , Bright Melissa
Published: April 2020

INTRODUCTION:

Although about 15% of pregnancies end in early loss, to the individual woman, this loss is significant. Physicians are trained to identify abnormal pregnancies but are not formally trained in providing emotional care for patients following this diagnosis. The purpose of this study was to determine whether patients feel they received adequate support after an early miscarriage.

METHODS:

An anonymous survey utilizing Likert scale type questions was offered to all patients in the pregnancy loss clinic at UF Health between October 2018 and September 2019. After IRB approval, all patients had a pregnancy loss or threatened loss within the first trimester. Survey items measured perceptions of care and support following this diagnosis.

RESULTS:

A sample of 100 women participated. Nearly all women (90% and higher) reported agreeing to the following statements: I feel I spent enough time with my doctor; I feel my doctor answered all my questions; I feel my doctor did a good job explaining my diagnosis to me; My doctor gave me emotional support today. Forty-two (42%) of women reported feeling that it would be good for them to talk with someone about their feelings (counselor, therapist). Additionally, 54% reported that they would want to see a counselor within the clinic.

CONCLUSION:

Our findings suggest that women had positive perceptions of their care within this institution. However, it appears that they felt they would benefit from psychosocial support. In particular, it may be most beneficial to co-locate therapy services with clinics focused on pregnancy loss.
A Multidisciplinary Resident-Led Training on Medication-Assisted Treatment for Opioid Use Disorder [24F]
Authors: Trinh Elyse , Liu Chi-Mei , Murphy Sara
Published: April 2020

INTRODUCTION:

This was a performance improvement project led by a first-year OB/Gyn resident with two goals: to improve resident knowledge on opioid use disorder (OUD) and medication-assisted treatment (MAT), and to increase the number of buprenorphine and methadone prescribers in Santa Clara County.

METHODS:

A four-hour, American Academy of Addiction Psychiatry-approved training was held in March 2019, attended by 25 residents from 6 institutions and 6 specialties: IM, OB/Gyn, Anesthesia, EM, Neurology, and FM. After, attendees completed an online session to become MAT prescribers. Attendees completed a pre- and post- survey assessing knowledge of MAT and OUD, and attitudes toward substance use disorders.

RESULTS:

Attendees demonstrated improvement in knowledge of OUD and MAT. 16 of the 25 attendees went on to complete the online training and earn waivers to prescribe MAT. This represents a 7.6% increase in the number of eligible prescribers in Santa Clara County.

CONCLUSION:

The opioid epidemic is a public health crisis; patients in MAT have lower mortality rates than those who are not. However, there are inadequate MAT providers. This training effectively increases resident knowledge of OUD and MAT and increases the number of MAT prescribers. It also demonstrates motivation among residents of multiple specialties to be part of the solution. The strong and diverse attendance demonstrates that resident education must be a site of intervention to curb the opioid epidemic. More must be done to create opportunities for residents to put this learning into practice.
Associations Between Chinese Immigrant Women’s Social Network Use and Cancer Screening Behavior [25F]
Authors: Guo Xiaoyue M. , Tom Laura S. , Leung Ivy S. , Simon Melissa
Published: April 2020

INTRODUCTION:

Increasing use of social media has changed how patients obtain healthcare information, with over 90% of residents in China interacting with healthcare information online. These social media preferences likely persist in the Chinese-American population, who have amongst the lowest cancer screening prevalence among ethnic minorities in the United States. We hypothesize that health-seeking behaviors and use of social media will predict up-to-date breast and cervical cancer screening in a cohort of Chinese immigrant women. Findings may guide future outreach efforts.

METHODS:

Survey data was collected for 732 Chinese women living in Chicago’s Chinatown area from 2013 to 2018 who participated in a patient navigation program. Questions included sociodemographic information, self-reported healthcare utilization and health information-seeking behaviors.

RESULTS:

Most respondents (60%) were aged 50 or older, had less than a college education (92%), and an annual income <$20,000 (55%). Nearly all (94%) spoke Chinese, and over 80% had public or no insurance. 44% have sought out health information, with the majority using the Internet. Of participants who responded to social network questions, 71% reported using social media, 55% of whom reported looking to contacts for health opinions and information. Seeking health information was associated with receiving appropriate Papanicolaou (within 5 years) and mammogram screening (within 2 years; all P<.05), whereas using social media trended towards receiving appropriate mammogram screening (P=.08).

CONCLUSION:

As healthcare-seeking behavior and use of social media are associated with improved cervical and breast cancer screening, leveraging use of social media networks may help increase cancer screening behaviors in the Chinese-American population.
Differences in Knowledge of Colorectal Cancer Screening and Its Contribution to Screening Practices by Ob/Gyns [27F]
Authors: Clare Camille , Liu Clive
Published: April 2020

INTRODUCTION:

Colorectal cancer is the second most commonly diagnosed cancer in women. Surveys show that physicians have an influence in the rates of colorectal screening. This study investigates whether a lack of colorectal screening knowledge prevents Ob/Gyns of different academic levels and practice types from effectively screening colorectal cancer.

METHODS:

An IRB approved, validated survey eliciting colorectal screening guidelines, practices, and potential barriers to screening was circulated online, at the National Medical Association national conference, ACOG District II conference, and the New York City Health + Hospitals/Metropolitan Dept of Ob/Gyn between October 2018 to January 2019.

RESULTS:

A total of 142 respondents answered the survey. Only one out of 142 respondents (0.7%) answered correctly the question which identified all of the risk factors for colorectal cancer. A significant difference was noted in correctly identifying risk factors when comparing attendings (36.6%) and residents (75%) P=.004. Most respondents were able to correctly identify age to start screening (93.6%), but fewer were able to correctly identify age to stop screening (23.2%). For screening intervals, 76.8% correctly answered for colonoscopy, 66.9% correctly answered for flexible sigmoidoscopy. A significant difference was noted after stratifying for age (ages 20-40 vs 50-70s P=.003), gender (women vs men P=.01), and academic level (resident vs attending P=.03): younger, resident, and female physicians provided more correct answers.

CONCLUSION:

Difference in colorectal cancer screening knowledge between residents and attendings contributes to less than effective screening. Education on colorectal cancer should focus on attendings through maintenance of certification and continued integration in residency education.