bluuebunny/crossref_metadata_2025 huggingface dataset:
Match Preparation: Optimizing Success and Satisfaction
Authors: Duncan Karen M. , Winkel Abigail Ford
Published: September 2018

Local Mentor:

Abigail Ford Winkel

APGO Advisor:

Hope Ricciotti, MD

PROBLEM:

There is a lack of structured advising for 4th year medical students applying for Ob/Gyn residency. Given the increasing need for Ob/Gyns, it is critical to support top applicants and ensure success. This advising program offers standardized guidance to improve student satisfaction with the match process and outcome.

INTERVENTION:

A specialty-specific program was designed for structured advising and preparation to optimize match results, preparedness for residency interviews, and satisfaction with the match process and outcome. The program consists of 3 group advising meetings for Fourth Year Schedule Planning, Application Strategy and Preparation, and Interview Preparation. Students are assigned to faculty advisors to further assist with applications and participated in mock interviews. Outcomes measured include unmatched rate relative to national rate, percentage of students matching at their top 3 programs, percentage of students participating in the advising program, and satisfaction with the advising process and match outcome measured by survey.

CONTEXT:

This program was implemented during students' third year of medical school and extended through residency match.

OUTCOME/LESSONS LEARNED:

All students applying for Ob/Gyn residency participated in the advising program. All students felt at least somewhat prepared for interviews. Most students felt well prepared. Some students reported the timing of one group advising session was not optimal for the focus topic. All 12 students who participated in the advising program matched into categorical Ob/Gyn residencies, compared to 70% for US graduates. Of the respondents, 72.7% matched into one of their top 3 programs. The majority of students were satisfied with the match process and match results.
Using Motion Tracking to Analyze Forceps Paths During Standardized Simulated Operative Vaginal Deliveries
Authors: Holbert Michael , Altman Alan , Bramblet Rachel
Published: September 2018

Local Mentor:

Steven Johnson, MD

APGO Advisor:

Jody Steinauer, MD

OBJECTIVE:

The purpose of this study is to evaluate the ability of motion tracking to discern variation in forceps paths during standardized simulated operative vaginal deliveries among experienced and inexperienced obstetric providers.

METHODS:

This is a pilot study involving 24 Obstetrics and Gynecology residents and six faculty at a single institution. Each participant was filmed performing standardized simulated forceps assisted vaginal deliveries on a high-fidelity model. Motion tracking software was used to track the path of the forceps blade and this data was analyzed for total path length, total x plane displacement, total y plane displacement, and final forceps angle. One-way ANOVA was used to evaluate for statistically significant differences between groups based upon education year, with Tukey's HSD post-hoc test to identify interactions.

RESULTS:

There were statistically significant differences noted between groups in the total path length (F=7.57, P<.001) and total y plane displacement (F=5.79, P<.001). In the post-hoc analysis, this included faculty-PGY1 (P<.001) and faculty-PGY2 (P=.004) for total path length and faculty-PGY1 (P=.001) and faculty-PGY2 (P=.022) for total y plane displacement. There were no statistically significant differences noted between groups for total x plane displacement (F=0.89, P=.475) and final forceps angle (F=2.45, P=.052).

CONCLUSION:

Motion tracking of standardized simulated operative vaginal deliveries identifies statistically significant differences between experienced and inexperienced obstetric providers. This suggest that motion tracking can be used to design an educational intervention to improve forceps technique among Obstetrics and Gynecology residents.
Improving Clerkship Feedback With a New Evaluation form, a Retrospective Comparison
Authors: Lackritz Katie , Wolf Abigail , Braverman Andrea , Mercier Rebecca
Published: September 2018

Local Mentor:

Abigail Wolf, MD

APGO Advisor:

Lee Learman, MD, PhD

OBJECTIVE:

To determine if a new evaluation process resulted in longer student evaluations by faculty.

METHODS:

After receiving IRB exemption a retrospective review of completed evaluations from third year obstetrics and gynecology clerkship students was completed. All students at a single institution were included from two academic years for 526 total evaluations. The control group was evaluated with a standard institutional form. The intervention group received a supplemental evaluation that the students distributed electronically to individual faculty they worked with. Student t-test and Chi squared analysis compared the word counts, the clinical grades, and the word count by location of the rotation. Grade distribution between the two years was also analyzed.

RESULTS:

The length of the comments increased by 49% (144 words to 216), two-tailed P-value <.01. Analyzing clinical grades showed: “good” comments decreased by 17% (162 to 134), “excellent” comments increased by 69% (110 to 186), “honors” comments increased by 61% (165 to 267). Nine of the ten sites showed word count increases ranging from 20-198%. Grade distribution showed no change in the clinical grade of “good”, the clinical grade of “excellent” decreased from 66% to 59% of the class and “honors” increased from 29% to 36%. No students received a marginal or failing grade.

CONCLUSION:

Changing the evaluation process yielded longer comments from the obstetrics and gynecology clerkship. Students with higher clinical grades had the longest comments; students with the lowest clinical grade had the shortest comments. This may reflect that it is easier to give positive than negative feedback. With the intervention, a higher proportion of students received the clinical grade of honors.
Outcomes of Performance Based Assessments With Varied Sexual History Communication Curricula
Authors: Shaffer Sarah , Gnade Colette , Kreiter Clarence , Stockdale Colleen K.
Published: September 2018

Local Mentor:

Colleen K. Stockdale, MD, MS

APGO Advisor:

Hope Ricciotti, MD

OBJECTIVE:

Evaluate the effect of differing sexual history communication curricula as assessed by a standardized performance examination administered at the end of the Obstetrics and Gynecology clerkship. Differences in specific types of communication skills were considered based on varied training in sexual history-taking as experienced by medical students.

METHODS:

This retrospective cohort study examined “naturally occurring” comparison groups of medical students resulting from curricular changes in sexual history communication training over time. The curricular changes were hypothesized to positively affect practice based assessment (PBA) scores. Other variables considered were medical student sex and year. Outcome measures included items regarding clinical history, physical exam, communication skills and final diagnosis related to sexual history communication curriculum experienced. Group means and paired t-tests were performed for individual variables as well as several composite variables.

RESULTS:

Nine hundred and nine (n = 909) PBA scores were analyzed. Post-hoc power analysis defined minimum group size to be 45, which was exceeded. There was no relationship, positive or negative, between sexual history communication curricula with any outcome measure. Females performed significantly better on the PBA overall (P<.0001) and on several individual communication measures on the PBA checklist (range P 0.0003–0.02). Students who received “double” sexual history communication training compared to those who received “single” or no training showed no difference on any outcome measure (P 0.06).

CONCLUSION:

There appears to be minimal correlation of differing sexual history communication curricula with individual or composite communication skill scores as evaluated with a standardized performance examination administered at the end of the Obstetrics and Gynecology clerkship.
Use of a Mobile Diary App to Influence Narrative Feedback on Medical Student Evaluations
Authors: Todd Rebecca , Martin Jacob , McQuerry Kristen
Published: September 2018

Local Mentor:

Wendy Hansen, MD and Brady Reynolds, PhD

APGO Advisor:

Jody Steinauer, MD

OBJECTIVE:

To evaluate the impact of using a mobile diary app on the quantity and quality of narrative feedback written on medical student evaluations during medicine, surgery, and ob/gyn rotations at rural and university hospitals.

METHODS:

Narrative feedback written by 46 faculty members was obtained for 6 months during a cohort study (baseline 1-3, comparison 4-6). The intervention (month 3) instructed participants to keep daily notes on student performance using a diary app on their mobile device. Quantity was determined by a simple word count, compared before and after the intervention. Quality was evaluated by 4 blinded raters using The Quality Improvement Instrument (QI) and the Completed Clinical Evaluation Report Rating (CCERR). The study had 80% power to detect a 30% increase in word count. Scores were compared using a T-test.

RESULTS:

Baseline evaluations (n=43) contained an average word count of 43 (range 2 to 216). The baseline mean CCERR score was 16.6 and the Quality Improvement score was 2.8. Preliminary results from the post-intervention evaluations (n=45) included an average word count of 45 (range 5 to 169). The mean CCERR and QI scores were 21.4 and 3.4, respectively. No differences were statistically significant at a P<.5.

CONCLUSION:

Use of a mobile diary app to record daily student performance did not statistically improve the quantity or rated quality of narrative feedback in medical student education. Effort should be focused elsewhere to improve written comments by faculty.
Social Mission Content in U.S. OB/GYN Residency Websites
Authors: Whetstone Sara , Steinauer Jody , Autry Meg
Published: September 2018

Local Mentor:

Meg Autry, MD

APGO Advisor:

Hope Ricciotti, MD

OBJECTIVE:

A well-trained provider workforce is thought to be essential in caring for underserved US patient populations. We conducted a pilot study to explore how US-based OB/GYN residencies describe their commitment to and training of residents to provide high-quality care in these communities.

METHODS OF STUDY SELECTION:

A convenience sample of 20 US OB/GYN residency programs was chosen based on input of OB/GYN GME leaders and association of programs with public and/or safety net hospitals.

DATA SOURCES:

One author conducted a content analysis of the residency programs’ web-based descriptions, specifically searching for the following terms: diversity/minority, underserved or vulnerable, community health or community based, health disparities, social justice, primary care, and shortage areas.

RESULTS:

Half (10) of the programs described a commitment to training residents to provide care for underserved or diverse patient populations. Seven programs had an explicit statement of valuing care for underserved populations on the residency's home page, often featuring the program director's statement. Several included residents’ comments which served to emphasize the value placed on caring for underserved women and/or addressing health disparities. Programs highlighted their diverse patient populations, clinical sites, and experiences that provided opportunities to care for vulnerable populations locally. Only rarely did programs discuss diversity among trainees/faculty and placement of graduates in health provider shortage areas.

CONCLUSION:

Only half of identified OB/GYN residency programs explicitly highlight training providers to care for underserved populations on their websites. More research is needed to explore whether this reflects a lack of training focus.
Surgical Management of Postpartum Hemorrhage—Building a Standardized, Validated Task Trainer
Authors: Chuang Meleen , Smith Heather , Koai Esther , Kaplan Julie , Lerner Veronica , Banks Erika
Published: September 2018

Faculty Advisor:

Erika Banks, MD

PURPOSE:

To develop a validated, reproducible, cost-effective task-trainer used to teach surgical management of postpartum hemorrhage.

BACKGROUND:

Postpartum hemorrhage is the third leading cause of preventable maternal death. While the use of compression and ligation sutures is infrequent, simulation teaching of skills is important.

METHODS:

Study participants (N=77) consisted of junior residents (35), senior residents (17) and faculty attending physicians (25) at a large, urban academic hospital. Pre and post- test were collected assessing prior experience, comfort, and perception regarding the model. Participants were de-identified and individually filmed performing bilateral O’Leary Stitch and B-Lynch. Two evaluators independently reviewed recordings and completed the task-specific evaluation tools, both the new untested and objective skill-assessment tool (OSAT) and previously validated Global Rating Scale (GRS). Intra-rater and inter-rater reliability were assessed, and validity was tested by comparing OSAT scores stratified by different characteristics to GRS scores.

RESULTS:

Intrarater reliability was demonstrated for both raters across each simulation and scoring tool (P<.0001). Interrater reliability for OSAT showed high agreement (Kappa 0.97 B-Lynch, 0.90 O’Leary). Construct validity was demonstrated for B-Lynch; attendings and seniors scoring higher than juniors on OSATS (17 vs. 16.7 vs. 3, P<.0001) and GRS (5 vs. 23 vs. 25, P<.0001), as well as for O’Leary simulation for both OSATS (15.5 vs. 15.0 vs. 11.0, P<.0001) and GRS (25 vs. 24 vs. 12, P<.0001).

DISCUSSION:

We have shown validation of a simple task-specific trainer that can be used to teach B-Lynch and O’Leary. The respective OSATs are reliable to assess performance.
Managing Hemorrhage After Second-Trimester D&E: Individual Simulation Training for Ob/Gyn Residents
Authors: Deans Elizabeth , Broach Amy , Boardman Amy
Published: September 2018

Faculty Advisor:

Amy Boardman, MD

PURPOSE:

To evaluate the efficacy of case-based simulation on resident knowledge and retention for management of a rare clinical event.

BACKGROUND:

Abortion is a safe procedure with the risks of complications increasing as gestational age increases. Although rare, hemorrhage is a common cause of mortality with second-trimester abortion. Teaching how to anticipate and manage any rare, potentially catastrophic clinical event is a challenge in medical education.

METHODS:

In our university program of 31 residents, a needs assessment identified management of hemorrhage after D&E as a desired simulation topic. Two different case-based scenarios were developed in which each resident managed the patient encounter alone. After each post-simulation debrief, residents reviewed a management algorithm and topic handout. Pre- and post-tests were completed with both simulations. The interval between the simulations and a retention post-test was approximately 2.4 months.

RESULTS:

Twenty-five residents (81%) completed the first simulation, and 18 residents (58%) completed both simulations. Median baseline pre-test score for PGY1/2 residents was statistically different than PGY3/4s (P=.002). Overall, post-test scores were greater than pre-test scores with both simulation sessions (P<.0001). Pre-test scores of second simulation decreased slightly compared to the first post-test, but not to baseline. The retention score was unchanged from the 2nd simulation post-test (P=.26). Ninety-six percent of evaluations agreed that simulation was an effective, and desirable way to learn management of rare clinical events.

DISCUSSION:

Simulation provides opportunity for resident education of rare clinical events. This low-fidelity, case-based simulation demonstrates improved baseline resident knowledge for management of post-D&E hemorrhage.
Development of a Proficiency-Based Simulation Training Model for Laparoscopic Vaginal Cuff Closure
Authors: Khalilian Sepideh , Robinson James , Hardesty Jessica , Arumala Ruth , Huelsmann Erica , Rezvani Sepideh
Published: September 2018

Faculty Advisor:

Amy Boardman, MD

PURPOSE:

To evaluate if a low fidelity simulation model and training video will improve resident surgical performance of laparoscopic vaginal cuff closure.

BACKGROUND:

Laparoscopic surgical complexity and resident work-hour restrictions have increased the need for surgical simulation in OBGYN residencies. Evidence of transfer of acquired surgical skills from simulation to the operating room (OR) is limited.

METHODS:

This prospective, randomized study compares resident surgical skills acquisition after low-fidelity simulation training of vaginal cuff closure versus no intervention. Study phases include development of a vaginal cuff closure training video; video documentation of resident lab performance; and video assessment of resident surgical skill by blinded surgical experts using I – GOALS, II – error events, and III – surgical checklist.

RESULTS:

OBGYN residents (N=18) from MedStar Georgetown and Washington Hospital Center were randomized to control group (N=7) or intervention group (N=11). Intervention group reviewed the training video on laparoscopic vaginal cuff closure. All residents then used the low-fidelity cuff closure model and recorded baseline videos. Three surgeons scored the videos with an inter-rater reliability of 0.585, 0.531, and 0.825 for tests I, II, and III. Wilcoxon Rank Sum test was used to evaluate differences between groups by averaging all raters’ scores. There was significant difference between the control and intervention groups for Test II (P=.01) but no difference between the control and intervention groups for tests I and III.

DISCUSSION:

Simulation training of laparoscopic vaginal cuff closure reduces error events after immediate exposure. Continued research will evaluate if acquired skills transfer to OR performance.
The Hysterectomy Teaching Program: How Can We Improve Quality and Consistency of Teaching in the Operating Room?
Authors: Pradhan Tana , Simpson Desiree
Published: September 2018

Faculty Advisor:

Arthur Ollendorff, MD

BACKGROUND:

Since the numbers of hysterectomies performed is declining nationally, there is an increased need to maximize the effectiveness of real-time surgical teaching.

ASSESSMENT OF PROBLEMS:

Faculty members have increased pressures of maintaining clinical volume, performing excellent patient care and being responsible for surgical teaching. Therefore, a hysterectomy teaching program was implemented with: 1) a novel, universal teaching checklist which was to be utilized for all modes of hysterectomy, 2) prompting to use the checklist by emails and texting, 3) faculty development sessions. The teaching checklist was reviewed by 3 expert surgeons and was available on the MyTipsReport evaluation tool.

RESULTS OF ASSESSMENT/MEASUREMENT:

After IRB exemption, 172 scheduled elective hysterectomy cases and four faculty development sessions were included over 9 months. When compared to a cohort in the past 6 months prior to implementation, there was no statistically significant change in patient ASA class, total OR time or relevant milestone data. Of PGY III/IV who were surveyed—75% (6 of 8) found the checklist “helpful” and 1 found it “more helpful than they thought.” Of residents, 50% (4/8) found the checklist most useful for facilitating feedback at the end of the case followed by 37.5% (3/8) found it helpful in learning the steps. Resident perceived improvement in surgical confidence and real-time feedback was not statistically significant (n=12). Faculty physicians found the checklist most helpful in setting surgical goals for the case (6/8, 75%) followed by facilitating feedback (4/8, 50%).

STRATEGIES FOR QUALITY IMPROVEMENT/CHANGE:

The hysterectomy teaching program is feasible. Additional longitudinal data and validation in a multi-site initiative would be necessary. Finally, from attending surveys, a needs assessment for robotic teaching is necessary as the checklist was least helpful for complex robotic cases.

LESSONS AND MESSAGES:

A simple universal teaching tool with prompting may increase consistent teaching by faculty.
Diagnostic Role of Digital Breast Tomosynthesis
Authors: Lee Su-Ju , Chen Xiaopei , Mahoney Mary C.
Published: September 2018

Since its introduction in 2011, digital breast tomosynthesis has been adopted rapidly worldwide for screening mammography. Digital breast tomosynthesis is a new technology that acquires a series of low-dose images of the compressed breast from different angles while the x-ray tube moves along an overhead arc.1 This projection image dataset is then used to reconstruct 1-mm thin-section images in standard mammographic views. Displaying the breast tissue in 1-mm-thin slices results in decreased tissue overlap, improved lesion visibility, better delineation of lesion margins, and more accurate characterization of lesion architecture.1 Numerous studies have established that digital breast tomosynthesis increases the sensitivity and specificity of screening mammography. With the addition of digital breast tomosynthesis to conventional digital mammography, Skaane et al2 documented a 27% increase in the detection rate for in situ and invasive cancers combined, and a 40% increase in the detection rate for invasive cancers. Haas et al3 reported a significant reduction in screening recall rates from 12.0% to 8.4% with combined digital breast tomosynthesis and digital mammography, especially in women younger than age 50 years and those with dense breasts.
Abdominal point tenderness and an impending aneurysmal rupture
Authors: Smith David A. , Kaplan Lewis J.
Published: September 2018

Although isolated iliac artery aneurysms are rare and occur in only 2% of patients, isolated internal iliac artery aneurysms are even more uncommon. Patients with these aneurysms require urgent vascular surgery consultation and evaluation; untreated aneurysms have a high propensity to increase in size and rupture. Providers should be aware of this critical incidental finding on CT scan and MRI and know when to initiate an emergency workup and therapy.
A call to action on prediabetes
Authors: Dugan Joy , Cantillep Alegria , Newberry Kathryn , Shubrook Jay
Published: September 2018

Diabetes and prediabetes have become an epidemic in the United States. The keys to battling this public health challenge are effective screening and evidence-based interventions. Studies show that intensive lifestyle interventions, medications, and weight loss surgery can reduce or delay new-onset type 2 diabetes. This article reviews the steps clinicians can take to help patients stay ahead of this disease.
Opioid use disorder
Authors: Alexander Lisa Mustone , Keahey David , Dixon Katelyn
Published: September 2018

The treatment of patients with acute and chronic pain not attributed to cancer or end-of-life conditions is a challenge for many clinicians. Although CDC guidelines that focus on the primary care setting have provided critical recommendations, evidence-based guidance is lacking on optimal duration of opioid treatment for postoperative and acute care in specialty settings. Over the last 2 decades, the liberal use of opioids has resulted in many unintended consequences, including dependence and abuse, illicit distribution of legally and illegally prescribed opioid medication, progression to IV heroin and an epidemic of overdoses, and most recently an increase in the incidence of HIV among patients sharing syringes, frequently in communities with historically low HIV rates. This article analyzes these complex issues and proposes strategies to help clinicians improve patient care through education and responsible prescribing.
What are the new vaccination recommendations for herpes zoster?
Authors: Mospan Cortney M. , Colvin Natasha
Published: September 2018

A new vaccine to prevent herpes zoster (shingles) has been included in the 2018 Advisory Committee on Immunization Practices' adult immunization schedule as the preferred herpes zoster vaccination for all immunocompetent adults age 50 years and older. This article discusses new vaccination recommendations for herpes zoster.
Preclinical Pharmacology in the Rhesus Monkey of CW 1759-50, a New Ultra-short Acting Nondepolarizing Neuromuscular Blocking Agent, Degraded and Antagonized by L-Cysteine
Authors: Savarese John J. , Sunaga Hiroshi , McGilvra Jeff D. , Belmont Matthew R. , Murrell Matthew T. , Jeannotte Erin , Cooke Farrell E. , Wastila William B. , Heerdt Paul M.
Published: September 2018

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Structure–activity studies were performed to identify a new neuromuscular blocking agent retaining the ultra-short acting characteristics of gantacurium, including degradation and reversal by l-cysteine, but lacking its histaminoid properties in man. CW 1759-50 has emerged from this program.

Methods

Adduction of CW 1759-50 with l-cysteine was studied by high-performance liquid chromatography and mass spectrometry. Institutional Animal Care and Use Committee–approved comparisons of CW 1759-50 to gantacurium were performed in rhesus monkeys. ED95 for neuromuscular blockade was established. Spontaneous recovery was compared to reversal by l-cysteine in paired studies of boluses or infusions. In addition, changes in mean arterial pressure and heart rate after very large doses of 15 to 60 × ED95 were compared.

Results

The half-time of adduction of l-cysteine to CW 1759-50 in vitro was 2.3 min. The ED95 of CW 1759-50 was 0.069 ± 0.02 mg/kg; ED95 of gantacurium was 0.081 ± 0.05 mg/kg (P = 0.006). Duration of action (recovery to 95% twitch height after 98 to 99% blockade) was as follows: CW 1759-50, 8.2 ± 1.5 min; and gantacurium, 7.4 ± 1.9 min; (n = 8 and 9, P = 0.355). Administration of l-cysteine (30 mg/kg) shortened recovery (i.e., induced reversal) from CW 1759-50 after boluses or infusions (P always less than 0.0001). Recovery intervals (5 to 95% twitch) ranged from 6.1 to 6.7 min (and did not differ significantly) after boluses of 0.10 to 0.50 mg/kg, as well as control infusions (P = 0.426 by analysis of variance). Dose ratios comparing changes of 30% in mean arterial pressure or heart rate to ED95 for neuromuscular blockade (ED 30% Δ [mean arterial pressure or heart rate]/ED95) were higher for CW 1759-50 than for gantacurium.

Conclusions

CW 1759-50, similar to gantacurium, is an ultra-short acting neuromuscular blocking agent, antagonized by l-cysteine, in the monkey. The circulatory effects, however, are much reduced in comparison with gantacurium, suggesting a trial in humans.
Succinylcholine and Intracranial Pressure
Authors: Cottrell James E.
Published: September 2018

Intracranial and Hemodynamic Changes after Succinylcholine Administration in Cats. By Cottrell JE, Hartung J, Giffin JP, and Shwiry B. Anesthesia & Analgesia 1983; 62:1006–9. Reprinted with permission.

Bolus injections of succinylcholine (1.5 mg/kg) significantly increased intracranial pressure (ICP) in cats under normal conditions from control levels of 8 +/- 1 mmHg to 16 +/- 3 mmHg (+/- SEM, P less than 0.01), and in the presence of artificially increased ICP from control levels of 27 +/- 1 mmHg to 47 +/- 4 mmHg (P less than 0.01). These approximately 100% increases in ICP were accompanied by a transitory decrease in mean arterial pressure (approximately 10 s), followed by a 15 to 20% increase (P less than 0.05). Pulmonary arterial pressure increased 20 to 30% (P less than 0.05). These results, when considered in conjunction with results previously obtained in humans, suggest that succinylcholine may be contraindicated in neurosurgical patients.
Intrauterine Device Expulsion After Postpartum Placement
Authors: Jatlaoui Tara C. , Whiteman Maura K. , Jeng Gary , Tepper Naomi K. , Berry-Bibee Erin , Jamieson Denise J. , Marchbanks Polly A. , Curtis Kathryn M.
Published: September 2018

OBJECTIVE:

To estimate expulsion rates among women with postpartum intrauterine device (IUD) placement by timing of insertion, IUD type, and delivery method.

DATA SOURCES:

We searched PubMed, Cochrane Library, and ClinicalTrials.gov from 1974 to May 2018.

METHODS OF STUDY SELECTION:

We searched databases for any published studies that examined postpartum placement of a copper IUD or levonorgestrel intrauterine system and reported counts of expulsions. We assessed study quality using the U.S. Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of IUD expulsion and estimated adjusted relative risks (RRs) for timing of postpartum placement, delivery method, and IUD type using log-binomial multivariable regression model.

TABULATION, INTEGRATION, AND RESULTS:

We identified 48 level I to II-3 studies of poor to good quality. Pooled rates of expulsion varied by timing of IUD placement, ranging from 1.9% with interval placements (4 weeks postpartum or greater), 10.0% for immediate placements (10 minutes or less after placental delivery), and 29.7% for early placements (greater than 10 minutes to less than 4 weeks postpartum). Immediate and early postpartum placements were associated with increased risk of expulsion compared with interval placement (adjusted RR 7.63, 95% CI 4.31–13.51; adjusted RR 6.17, 95% CI 3.19–11.93, respectively). Postpartum placement less than 4 weeks after vaginal delivery was associated with an increased risk of expulsion compared with cesarean delivery (adjusted RR 5.19, 95% CI 3.85–6.99). Analysis of expulsion rates at less than 4 weeks postpartum also indicated that the levonorgestrel intrauterine system was associated with a higher risk of expulsion (adjusted RR 1.91, 95% CI 1.50–2.43) compared with CuT380A.

CONCLUSION:

Postpartum IUD expulsion rates vary by timing of placement, delivery method, and IUD type. These results can aid in counseling women to make an informed choice about when to initiate their IUD and to help institutions implement postpartum contraception programs.
Trends and Outcomes Associated With Using Long-Acting Opioids During Delivery Hospitalizations
Authors: Duffy Cassandra R. , Wright Jason D. , Landau Ruth , Mourad Mirella J. , Siddiq Zainab , Kern-Goldberger Adina R. , D’Alton Mary E. , Friedman Alexander M.
Published: September 2018

OBJECTIVE:

To assess trends in use of long-acting opioids during delivery hospitalizations.

METHODS:

The Perspective database, an administrative inpatient database that includes medication receipt, was analyzed to evaluate patterns of long-acting opioid use during delivery hospitalizations from January 2006 through March 2015. Medications evaluated included methadone, formulations including buprenorphine and extended-release formulations of oxycodone, morphine, fentanyl, and other opioids. Temporal trends in use of these medications were determined. Unadjusted and adjusted models evaluating the role of demographic and hospital factors were created evaluating both use of these medications and risk for severe morbidity. Risk for severe morbidity was determined based on Centers for Disease Control and Prevention criteria.

RESULTS:

Our analysis included 2,994,630 delivery hospitalizations meeting study criteria. Over the entire study period, use of long-acting opioids increased significantly from 457 to 844 per 100,000 deliveries. Although buprenorphine and methadone use increased, use of other long-acting opioids decreased. In 2006, methadone and buprenorphine accounted for less than one third of all long-acting opioids used during delivery hospitalizations. By 2015, buprenorphine and methadone represented 73.5% of long-acting opioids used. In adjusted and unadjusted models, risk for severe morbidity was significantly lower with buprenorphine or methadone compared with other long-acting opioids. Restricting the cohort to only women with drug abuse or dependence, risk for severe morbidity was lower with methadone and buprenorphine than without any long-acting opioids.

CONCLUSION:

Increased use of methadone and buprenorphine in this study supports the feasibility of use of these medications during pregnancy and uptake of clinical recommendations for women with opioid use disorder. Use of methadone and buprenorphine is associated with decreased maternal morbidity, although causation cannot be presumed from this study model.
Choice of Prophylactic Antibiotics and Surgical Site Infections After Cesarean Delivery
Authors: Kawakita Tetsuya , Huang Chun-Chih , Landy Helain J.
Published: September 2018

OBJECTIVE:

To examine the rate of surgical site infection according to the choice of antibiotics in women undergoing cesarean delivery.

METHODS:

We conducted a retrospective cohort study of women undergoing cesarean delivery (labored, unlabored, and scheduled) from 2012 to 2017. Women with chorioamnionitis and those who did not receive any antibiotics were excluded. Our primary outcome was defined a priori as a composite of cellulitis, endometritis, deep wound infection, abdominopelvic abscess, and sepsis. Outcomes were examined according to the choice of antibiotics: cefazolin, a standard alternative (both clindamycin and gentamicin), and inappropriate alternatives (such as clindamycin only). A multivariable logistic regression model was used to calculate the propensity score for each observation, which was the probability of receiving a particular antibiotic regimen. The propensity score-adjusted logistic regression models were conducted to calculate adjusted odds ratios (ORs) and 95% CIs. Firth's penalized likelihood approach was applied to address issues of rare events.

RESULTS:

Among 6,584 selected women, 6,163 (93.6%), 274 (4.2%), and 147 (2.2%) received cefazolin, a standard alternative, and inappropriate alternatives, respectively. Use of standard alternative antibiotics compared with cefazolin was not associated with increased odds of the primary outcome (crude OR 1.50 [0.92–2.46]; adjusted OR 1.63 [0.97–2.60]) but was associated with increased odds of cellulitis (crude OR 2.07 [1.16–3.70]; adjusted OR 1.93 [1.03–3.31]). Use of inappropriate alternative antibiotics compared with cefazolin was associated with increased odds of the primary outcome (crude OR 4.37 [2.80–6.83]; adjusted OR 4.13 [2.59–6.36]) as well as some components of the composite outcome such as endometritis before discharge (crude OR 6.85 [3.94–11.90]; adjusted OR 6.68 [3.69–11.44]) and cellulitis (crude OR 3.36 [1.78–6.34]; adjusted OR 3.23 [1.63–5.81]).

CONCLUSION:

Both standard alternative and inappropriate alternatives were associated with increased odds of surgical site infections compared with cefazolin.
Use of Kratom, an Opioid-like Traditional Herb, in Pregnancy
Authors: Smid Marcela C. , Charles Jasmin E. , Gordon Adam J. , Wright Tricia E.
Published: September 2018

BACKGROUND:

Kratom (Mitragyna speciosa) is an herbal preparation with opioid-like effects made from a tree native to Southeast Asia and the Pacific Islands. Increasingly, kratom is used for self-treatment of opioid use disorder and recently has been associated with a multistate outbreak of salmonellosis. Few data are available on the clinical outcomes of kratom use in pregnancy.

CASES:

We present two cases of pregnant women presenting with kratom dependence. Both women presented with symptoms consistent with opioid withdrawal. Both women were initiated on opioid replacement, with successful treatment of symptoms.

CONCLUSIONS:

Kratom is an emerging self-treatment for opioid use disorder in the obstetric population. Obstetric care providers should be aware of kratom and consider opioid replacement for pregnant women with kratom dependence.
Gynecologic Health and Disease Research at the Eunice Kennedy Shriver National Institute of Child Health and Human Development
Authors: Tingen Candace M. , Mazloomdoost Donna , Halvorson Lisa M.
Published: September 2018

In May 2016, the newly formed Gynecologic Health and Disease Branch in the Eunice Kennedy Shriver National Institute of Child Health and Human Development invited experts to a 2-day meeting aimed at identification of emerging opportunities in gynecologic investigation. Four primary disorders were chosen for emphasis because they represent the majority of the current Gynecologic Health and Disease Branch portfolio: uterine leiomyomas, endometriosis, pelvic floor disorders, and gynecologic pain conditions. Discussions generated a set of seven cross-cutting themes, which encompass both gaps in our current knowledge and potential directions for further research. These themes formed a continuum for understanding these disorders beginning with the need for classification systems, improved understanding of the natural history and etiology of these disorders, development of novel diagnostics, identification of opportunities for prevention, and the generation of new treatments using cutting-edge approaches. Along with these themes, three broad strategies were proposed to facilitate future research. First, investigators should improve utilization of existing research resources and focus on developing new resources to include databases, biospecimen repositories, animal models, and patient cohorts. Second, multidisciplinary scientific partnerships should be strengthened to bring new insights and approaches to gynecologic research. Third, patient and health care provider education must be promoted to ensure timely and accurate diagnosis and optimize treatment of gynecologic disorders. This article provides a summary of the workshop themes and suggestions, several of which have already been implemented through the development of program priorities and funding opportunity announcements aimed at improving women's reproductive health.
Intrawound Vancomycin Powder Reduces Bacterial Load in Contaminated Open Fracture Model
Authors: Caroom Cyrus , Moore Dustin , Mudaliar Nithya , Winkler Craig , Murphree Jefferson , Ratheal Ian , Fry Michael , Jenkins Mark , Tullar Jessica , Hamood Abdul
Published: September 2018

Objectives:

To compare the effectiveness of both vancomycin powder and antibiotic bead placement to irrigation and debridement alone in prevention of infection in a contaminated open fracture model in rats.

Methods:

In a previously described model of contaminated open fractures, 45 rats had simulated open fractures created, stabilized, and contaminated with Staphylococcus aureus. They were then treated 6 hours later with 3 interventions: irrigation and debridement alone (control group) or in combination with placement of polymethyl methacrylate beads containing vancomycin and tobramycin powders (antibiotic bead group) or placement of 10 mg of intrawound vancomycin powder (powder group). Rats were allowed to recover and then killed 14 days later for harvest of femurs and plates. Femurs and plates were both incubated overnight, and bacterial colonies were counted in each group for comparison.

Results:

Quantitative counts of bacteria in bone showed significantly reduced growth in both bead and powder groups when compared with control group (P < 0.0001). Quantitative counts of bacteria in plates showed significantly reduced growth in both bead and powder groups when compared with control group (P < 0.0003; 0.029). No significant differences were seen in bacterial growth between bead and powder groups for either bones (P = 0.13) or plates (P = 0.065).

Conclusions:

When compared with irrigation and debridement alone, placement of intrawound vancomycin powder significantly decreased bacterial load in a contaminated open fracture model in rats similar to placing antibiotic beads. This may provide an additional adjuvant treatment that does not require a secondary surgery for bead removal.
Validation of Neck-Shaft Angle Correction After Cephalomedullary Nail Fixation
Authors: Parry Joshua A. , Barrett Ian , Schoch Bradley , Cross William , Yuan Brandon
Published: September 2018

Objectives:

To validate a neck-shaft angle (NSA) correction formula using the known angle between the medullary nail and lag screw of an indwelling cephalomedullary nail (CMN).

Methods:

Pertrochanteric femur fractures were created in 7 synthetic femurs and reconstructed with a CMN. Anteroposterior x-rays were taken with the proximal femur in 0, 15, 30, and 45 degrees of internal/external rotation and 10 and 20 degrees of flexion with neutral rotation. The femoral NSA and the nail angle were measured on anteroposterior x-rays. The corrected NSA was obtained by multiplying the known nail angle by the quotient of the measured NSA over the measured nail angle.

Results:

With increasing degrees of internal or external rotation, the difference between the actual and the measured NSA increased. After correction using the known angle of the nail, the measured NSA was reduced to within 3 degrees of the actual NSA over all degrees of rotation. At neutral rotation, 15 degrees of external rotation, and 10 and 20 degrees of hip flexion, there was minimal difference between the actual NSA and the measured NSA, negating the effect of the correction formula.

Conclusions:

The measured NSA after CMN of intertrochanteric fractures is altered by hip rotation. This study validates the correction formula, which determines this difference by using the known angle between the lag screw and the nail.
Clinical Research Course for International Orthopaedic Surgeons: 2-Year Outcomes
Authors: Wu Hao-Hua , Ibrahim John , Conway Devin , Liu Max , Morshed Saam , Miclau Theodore , Coughlin Ralph Richard , Shearer David W.
Published: September 2018

Background:

Although orthopaedic trauma occurs at higher rates in low- and middle-income countries (LMICs), most research on this topic is conducted in high-resource settings. Few initiatives exist to promote local research in LMICs. Investigators created the Institute for Global Orthopaedics and Traumatology (IGOT) International Research Symposium to promote local research initiatives by surgeons practicing in low-resource environments. The purpose of this study is to determine the efficacy of this symposium in teaching orthopaedic surgeons practicing in LMICs how to conduct clinical research.

Methods:

In this prospective observational study, orthopaedic surgeons from LMICs with no formal research training were recruited to attend the 1-day IGOT International Research Symposium in San Francisco. A survey was administered immediately before and after the symposium to inquire about the participants' confidence in different aspects related to research using a 1–5 Likert scale. A second survey, conducted 2 years later, recorded the attendees' research productivity after the workshop.

Results:

Forty-three participants representing 10 different LMICs from Africa and Asia attended the 2013 course. At 2 year postcourse, participants reported starting 25 research projects, authored 7 “accepted or published manuscripts” (vs. 1 before the course; P < 0.01), and were selected for 12 podium or poster presentations (vs. 3 before the course; P < 0.01). Two research symposium attendees received “Top International Forum Paper” at the 2015 Orthopaedic Trauma Association Annual Meeting.

Discussion:

A 1-day research course resulted in increased participant confidence in conducting research. This was associated with greater research productivity by participants 2 years later. These results suggest that the IGOT International Research Symposium can improve the number of initiated research projects by surgeons in LMICs.
Orthopaedic Trauma in the Developing World: Where Are the Gaps in Research and What Can Be Done?
Authors: Challa Sravya , Wu Hao-Hua , Cunningham Brian P. , Liu Max , Patel Kushal , Shearer David W. , Morshed Saam , Miclau Theodore
Published: September 2018

Purpose:

There are an estimated 1.2 million deaths from road traffic injuries annually, disproportionately affecting patients in low-resource settings. The purpose of this scoping review is to identify knowledge gaps in global orthopaedic trauma in an effort to help prioritize future research.

Methods:

Using the 6-stage Arksey and O'Malley framework for conducting a scoping review, orthopaedic trauma literature was reviewed over a ten-year period from 2004 to 2014. Studies from low-resource settings were included and categorized by geographic location, anatomic region, study type, and level of evidence.

Results:

Of 548 included studies, 51.4% were from low- and middle-income countries in South Asia and 33.7% were from sub-Saharan Africa. Therapeutic (53.3%), epidemiologic (26.4%), and qualitative (8.9%) studies were most common. Only 10.2% of the studies were considered high level of evidence, whereas the vast majority (89.8%) was level 3 or below. Overall, lower extremity injuries were much more frequently represented in the literature compared with upper extremity injuries (233 vs. 78). Pelvic and acetabular fractures were the least studied anatomic region of the lower extremity (3.4%).

Conclusions:

Our study identified a lack of cost-effectiveness analyses pertaining to injury and intervention, paucity of high-quality research, and under-representation of pelvic, acetabular, and upper extremity injuries. Improved and prioritized research in low- and middle-income countries may help optimize care and inform policy makers of how to reduce the global burden of musculoskeletal trauma.
Buttress plating for volar Barton fractures in children: Salter–Harris II distal radius fractures in sagittal plane
Authors: Cha Soo Min , Shin Hyun Dae
Published: September 2018

We observed an unusual type of volar Barton fracture in the pediatric age and performed open reduction and internal fixation of the fragment, using the buttress plate in consecutive children. We report the radiological and clinical outcomes after follow-up for at least 3 years. From March 2008 to September 2014, nine consecutive children were treated by buttress plating. Their mean age at the time of injury was 13.1 years. All of the fractures were metaphyseal fractures in the coronal plane and typical Salter–Harris II fractures in the sagittal plane. After accurate reduction of the fragment, a cortical screw was inserted in the proximal area until the maximum compressive force against the fragment was obtained. Then, one or two locking screws were added adjacent to the initial cortical screw. No screw was fixed in the distal fragment. All evaluations were done at least 3 years postoperatively with a mean follow-up of 48.8 months. At final follow-up, the radial inclinations, volar tiltings, and ulnar variances were 23.2°±1.78° (98.7% of contralateral side), 9.4°±2.12° (98.4% of contralateral side), and –1.56±0.88 mm (93% of contralateral side), respectively. All radiological parameters of the distal radius were not significantly different from the contralateral values. The flexion–extension arc was 140.56°±5.27°, and the pronation–supination arc was 165.00°±8.29°. The grip strength was 26.67±5.56 kg. All clinical outcomes except the flexion–extension arc were similar to those of the normal side, with statistical significance. A volar Barton type injury can occur in the pediatric age involving the physis, and the buttress plating that is used in adults is also a useful treatment method. However, there is little information on this injury, and it was difficult to compare treatment outcomes with other methods. Because of the rarity of the injury, a larger, multicenter prospective comparative study is required to further explore appropriate treatment options, long-term outcomes, and complications. Level of Evidence: Therapeutic, Level IV.