Amy M. Autry

Nationwide Use of Laparoscopic Hysterectomy Compared With Abdominal and Vaginal Approaches

OBJECTIVE: To examine factors associated with undergoing laparoscopic hysterectomy compared with abdominal hysterectomy or vaginal hysterectomy. METHODS: This is a cross-sectional analysis of the 2005 Nationwide Inpatient Sample. All women aged 18 years or older who underwent hysterectomy for a benign condition were included. Multivariable analyses were used to examine demographic, clinical, and health-system factors associated with each hysterectomy route. RESULTS: Among 518,828 hysterectomies, 14% were laparoscopic, 64% abdominal, and 22% vaginal. Women older than 35 years had lower rates of laparoscopic than abdominal (odds ratio [OR] 0.85, 95% confidence interval [CI] 0.77–0.94 for age 45–49 years) or vaginal hysterectomy (OR 0.61, 95% CI 0.540.69 for age 45–49 years). The odds of laparoscopic compared with abdominal hysterectomy were higher in the West than in the Northeast (OR 1.77, 95% CI 1.2–2.62). African-American, Latina, and Asian women had 40–50% lower odds of laparoscopic compared with abdominal hysterectomy (P<.001). Women with low income, Medicare, Medicaid, or no health insurance were less likely to undergo laparoscopic than either vaginal or abdominal hysterectomy (P<.001). Women with leiomyomas (P<.001) and pelvic infections (P<.001) were less likely to undergo laparoscopic than abdominal hysterectomy. Women with leiomyomas (P<.001), endometriosis (P<.001), or pelvic infections (P<.001) were more likely to have laparoscopic than vaginal hysterectomy. Laparoscopic hysterectomy had the highest mean hospital charges (

Reliability and validity of reflection exercises for obstetrics and gynecology residents

18,821, P<.001) and shortest length of stay (1.65 days, P<.001). CONCLUSION: In addition to age and clinical diagnosis, nonclinical factors such as race/ethnicity, insurance status, income, and region appear to affect use of laparoscopic hysterectomy compared with abdominal hysterectomy and vaginal hysterectomy. LEVEL OF EVIDENCE: III

Teaching surgical skills using video internet communication in a resource-limited setting.

OBJECTIVE Self-evaluation is an essential skill throughout a physicians career, and reflection is thought to be a necessary mechanism for effective self-evaluation. The aim of our study was to establish the reliability and validity of structured assessments of critical self-reflection. STUDY DESIGN Thirty-two residents completed 6 exercises that were scored from 0 (no description of event) to 6 (deep reflection). We calculated interrater and internal consistency reliability for the exercises and compared scores by postgraduate year and with other competency assessments. RESULTS Residents completed 183 reflections. Interrater reliability was 0.89. Surgical skill reflections scored highest (score, 3.2 +/- 0.91 [SD]). Five exercises had adequate internal consistency reliability (0.62). Senior residents received higher reflection scores than junior residents; the magnitude of difference was similar for other competency measures and not statistically significant. Reflection scores were correlated with professionalism and communication skill assessments (score, 0.36-0.37; P < .01) but not with medical knowledge. CONCLUSION Self-reflection can be assessed reliably with scored exercises that demonstrate concurrent validity with other assessments. We encourage further research that should include multiple training programs to further evaluate our approach for the assessment of reflection in postgraduate education.

County Jail as a Novel Site for Obstetrics and Gynecology Resident Education

OBJECTIVE: To study the feasibility and acceptability of using video Internet communication to teach and evaluate surgical skills in a low-resource setting. METHODS: This case-controlled study used video Internet communication for surgical skills teaching and evaluation. We randomized intern physicians rotating in the Obstetrics and Gynecology Department at Mulago Hospital at Makerere University in Kampala, Uganda, to the control arm (usual practice) or intervention arm (three video teaching sessions with University of California, San Francisco faculty). We made preintervention and postintervention videos of all interns tying knots using a small video camera and uploaded the files to a file hosting service that offers cloud storage. A blinded faculty member graded all of the videos. Both groups completed a survey at the end of the study. RESULTS: We randomized 18 interns with complete data for eight in the intervention group and seven in the control group. We found score improvement of 50% or more in six of eight (75%) interns in the intervention group compared with one of seven (14%) in the control group (P=.04). Scores declined in five of the seven (71%) controls but in none in the intervention group. Both intervention and control groups used attendings, colleagues, and the Internet as sources for learning about knot-tying. The control group was less likely to practice knot-tying than the intervention group. The trainees and the instructors felt this method of training was enjoyable and helpful. CONCLUSION: Remote teaching in low-resource settings, where faculty time is limited and access to visiting faculty is sporadic, is feasible, effective, and well-accepted by both learner and teacher. LEVEL OF EVIDENCE: II

Medical treatment of ectopic pregnancy: is there something new?

INTRODUCTION Obstetrics and gynecology residents benefit from providing care to diverse patient populations and increasing their awareness of the social determinants of health. OBJECTIVES To describe and evaluate an outpatient rotation for obstetrics and gynecology residents at a county jail. METHODS A comprehensive curriculum incorporating Accreditation Council for Graduate Medical Education (ACGME) core competencies was designed for all first-year residents to rotate weekly at the local county jail during their 6-week ambulatory care block. Residents completed an anonymous online evaluation and wrote a reflective essay at the end of the rotation. Data for patient visits were tabulated. RESULTS All 9 first-year residents completed the rotation and the evaluation. Seventy-eight percent of patient visits were for gynecologic services, predominantly family planning. Residents reported that the rotation overall was a positive experience, emphasizing the unique intersection between psychosocial issues and health care in the jail setting. Rotation objectives that satisfied the 6 ACGME competencies were met. DISCUSSION Providing care to incarcerated women through a structured curriculum is a novel way to encourage obstetrics and gynecology residents to consider the social determinants of health and for residents to cultivate their counseling skills. The rotation also included a wide breadth and depth of clinical diagnoses and procedures. Obstetrics and gynecology residency programs should consider a curriculum in reproductive health for incarcerated women.

Impact of mode of delivery on pregnancy outcomes in women with premature rupture of membranes after 28 weeks of gestation in a low-resource setting: A prospective cohort study

Ectopic pregnancy occurs in 1.5–2.0% of all pregnancies. 1 It is perhaps one of the few disease states that, although it has increased in incidence, has decreased in mortality, primarily owing to earlier diagnosis and treatment before rupture. Worldwide, ectopic pregnancy is the leading cause of maternal death in the first trimester. Treatment in the developed world has progressed from primarily surgical by laparotomy to either minimally invasive surgery or medical management with methotrexate. The management of ectopic pregnancy with methotrexate, an antimetabolite that binds to the catalytic site of dihydrofolate reductase, began in the early 1980s. The success of methotrexate as a treatment modality can be predicted by b-hCG levels, with approximately 30% of patients meeting strict treatment criteria. Cost-effectiveness analyses have shown that medical management has benefits over surgical management when the b-hCG level is greater than 1,500 milli-international units/mL. Tubal patency rates and ectopic recurrence rates are similar between methotrexate treatment and conservative surgical treatment. In this issue of Obstetrics & Gynecology (see pages 737 and 745), the authors of two complementary articles look at the addition of gefitinib, an orally administered tyrosine kinase inhibitor used in the treatment of non–small-cell lung cancer and breast cancer, to methotrexate for the treatment of ectopic pregnancy. For the clinician, they have presented an interesting translational story. They began with the knowledge that gefitinib selectively inhibits the tyrosine kinase domain of epidermal growth factor (EGF) receptor and that the placenta has the highest expression of EGF of all nonmalignant tissues in the body. They hypothesized that gefitinib would be an effective treatment for ectopic pregnancy and developed a series of sequential experiments to substantiate this hypothesis. Initially, they demonstrated that ectopic syncitiotrophoblasts strongly expressed EGF receptors. Next, they found gefitinib and methotrexate to be additive and more effective than either agent alone in inhibiting cell growth of three placental cell lines (two choriocarcinoma and a purified first-trimester trophoblast sample), blocking EGF receptor phosphorylation, and inducing apoptosis. Armed with these findings, they developed a xenograft model of ectopic pregnancy in immunocompromised mice and again demonstrated additive effects of gefitinib and methotrexate on reduction of transplanted placental volume. In their last laboratory experiment, they demonstrated that both drugs doubled the rate of intrauterine fetal resorption in pregnant immunocompetent mice compared with either agent alone. In the second article, the group presented their results from a small phase 1 trial looking at safety and tolerability of the addition of gefitinib to methotrexate in 12 women who met the criteria for traditional singledose methotrexate at their institutions (stable, b-hCG between 1,000 and 3,000 milli-international units/mL). They compared the study group with a historical group of 71 women who had been treated successfully with See related articles on pages 737 and 745.

Advising and Interview Patterns of Medical Students Pursuing Obstetrics and Gynecology Residency

Background Despite the high prevalence of premature rupture of membranes (PROM) in low-resource settings, the preferred mode of delivery remains unclear. We compared the perinatal mortality in a prospective cohort of women with PROM after 28 weeks following vaginal or caesarean delivery at Mulago Hospital with the aim of adopting evidence based practice and improving patient care. Methods Between November 2015 and May 2016, 1455 women with PROM after 28 weeks of gestation and their newborns were prospectively followed from admission to discharge at Mulago Hospital. The primary outcome was perinatal mortality. Secondary neonatal outcomes included sepsis and admission to the Special Care Unit. Maternal outcomes included maternal deaths and complications. Outcomes were compared between women who had vaginal vs. caesarean delivery using multivariable logistic regression. All statistical tests were 2-sided with the level of statistical significance set at p < 0.05. Results The incidence of PROM was 12.1%. The perinatal mortality following PROM was 65 per 1000 live births. Of the 1425 women with PROM, 991 (69.5%) had vaginal delivery and 434 (30.5%) underwent Caesarean section. There was no statistical difference in perinatal mortality by the mode of delivery (vaginal vs. caesarean) in PROM (p = 0.12). The risk factors for perinatal mortality included chorioamnionitis, failure to administer corticosteroids in preterm PROM, gestational age (28–33 weeks), duration of drainage of liquor (24–48 hours), and presence of maternal complications. Caesarean delivery was associated with increased maternal postpartum infections, admission to the Special Care Unit and maternal death. Conclusion In low resource settings, vaginal delivery is the preferred mode of delivery for PROM after 28 weeks gestation. It is associated with lesser maternal and perinatal morbidity when compared to caesarean delivery.

A comparison of medical induction and dilation and evacuation for second-trimester abortion

OBJECTIVE: To describe the advising practices at medical schools and interview patterns among medical students pursuing obstetrics and gynecology residency training. METHODS: A voluntary, anonymous survey was distributed to all applicants interviewing for obstetrics and gynecology residency during the 2014–2015 cycle at the University of Colorado, University of Washington, University of California, San Francisco, and Loyola University. Demographic data were obtained. The survey explored student advising in the residency application process including number of applications and interviews recommended by advisors. Data are reported as percentage for each survey item and compared by select demographics using an exact &khgr;2. RESULTS: Among 315 unique possible applicants, 73% (n=230) responded. Students were most commonly advised by the obstetrics and gynecology clerkship director (33%) with recommendations to apply to 21–30 programs (48%). Thirty-four percent of students applied to 21–30 programs, 32% to 31–40 programs, and 30% to greater than 40 programs. Students were advised (70%) and planned (55%) to interview at 10–14 programs. Concern over competitiveness of the applicant pool was the most important factor (31%) in determining the number of applications. The number of programs advised to or plan to interview at was greater for those in the couples match (P<.001). CONCLUSION: Medical students pursuing obstetrics and gynecology are most likely to be advised by obstetrics and gynecology clerkship directors and concern over the competitiveness of the applicant pool results in students applying to large numbers of programs. This practice may adversely affect the obstetrics and gynecology match process for both programs and applicants through the requirements of managing additional applications and potentially needing to complete a greater number of interviews.