Christopher N. Herndon

Simulation Study of Rested Versus Sleep-deprived Anesthesiologists

Background Sleep deprivation causes physiologic and subjective sleepiness. Studies of fatigue effects on anesthesiologist performance have given equivocal results. The authors used a realistic simulation environment to study the effects of sleep deprivation on psychomotor and clinical performance, subjective and objective sleepiness, and mood. Methods Twelve anesthesia residents performed a 4-h anesthetic on a simulated patient the morning after two conditions of prior sleep: sleep-extended (EXT), in which subjects were allowed to arrive at work at 10:00 am for 4 consecutive days, thus allowing an increase in nocturnal sleep time, and total sleep deprivation (DEP), in which subjects were awake at least 25 h. Psychomotor testing was performed at specified periods throughout the night in the DEP condition and at matched times during the simulation session in both conditions. Three types of vigilance probes were presented to subjects at random intervals as well as two clinical events. Task analysis and scoring of alertness were performed retrospectively from videotape. Results In the EXT condition, subjects increased their sleep by more than 2 h from baseline (P = 0.0001). Psychomotor tests revealed progressive impairment of alertness, mood, and performance in the DEP condition over the course of the night and when compared with EXT during the experimental day. DEP subjects showed longer response latency to vigilance probes, although this was statistically significant for only one probe type. Task analysis showed no difference between conditions except that subjects “slept” more in the DEP condition. There was no significant difference in the cases’ clinical management between sleep conditions. Subjects in the DEP condition had lower alertness scores (P = 0.02), and subjects in the EXT condition showed little video evidence of sleepiness. Conclusions Psychomotor performance and mood were impaired while subjective sleepiness and sleepy behaviors increased during simulated patient care in the DEP condition. Clinical performance between conditions was similar.

Unique Transcriptome, Pathways, and Networks in the Human Endometrial Fibroblast Response to Progesterone in Endometriosis

Eutopic endometrium in endometriosis has molecular evidence of resistance to progesterone (P4) and activation of the PKA pathway in the stromal compartment. To investigate global and temporal responses of eutopic endometrium to P4, we compared early (6-h), intermediate (48-h), and late (14-Day) transcriptomes, signaling pathways, and networks of human endometrial stromal fibroblasts (hESF) from women with endometriosis (hESFendo) with hESF from women without endometriosis (hESFnonendo). Endometrial biopsy samples were obtained from subjects with and without mild peritoneal endometriosis (n = 4 per group), and hESF were isolated and treated with P4 (1 μM) plus estradiol (E2) (10 nM), E2 alone (10 nM), or vehicle for up to 14 days. Total RNA was subjected to microarray analysis using a Gene 1.0 ST (Affymetrix) platform and analyzed by using bioinformatic algorithms, and data were validated by quantitative real-time PCR and ELISA. Results revealed unique kinetic expression of specific genes and unique pathways, distinct biological and molecular processes, and signaling pathways and networks during the early, intermediate, and late responses to P4 in both hESFnonendo and hESFendo, although a blunted response to P4 was observed in the latter. The normal response of hESF to P4 involves a tightly regulated kinetic cascade involving key components in the P4 receptor and MAPK signaling pathways that results in inhibition of E2-mediated proliferation and eventual differentiation to the decidual phenotype, but this was not established in the hESFendo early response to P4. The abnormal response of this cell type to P4 may contribute to compromised embryonic implantation and infertility in women with endometriosis.

Disease concepts and treatment by tribal healers of an Amazonian forest culture

BackgroundThe extensive medicinal plant knowledge of Amazonian tribal peoples is widely recognized in the scientific literature and celebrated in popular lore. Despite this broad interest, the ethnomedical systems and knowledge of disease which guide indigenous utilization of botanical diversity for healing remain poorly characterized and understood. No study, to our knowledge, has attempted to directly examine patterns of actual disease recognition and treatment by healers of an Amazonian indigenous culture.MethodsThe establishment of traditional medicine clinics, operated and directed by elder tribal shamans in two remote Trio villages of the Suriname rainforest, presented a unique investigational opportunity. Quantitative analysis of clinic records from both villages permitted examination of diseases treated over a continuous period of four years. Cross-cultural comparative translations were articulated of recorded disease conditions through ethnographic interviews of elder Trio shamans and a comprehensive atlas of indigenous anatomical nomenclature was developed.Results20,337 patient visits within the period 2000 to 2004 were analyzed. 75 disease conditions and 127 anatomical terms are presented. Trio concepts of disease and medical practices are broadly examined within the present and historical state of their culture.ConclusionThe findings of this investigation support the presence of a comprehensive and highly formalized ethnomedical institution within Trio culture with attendant health policy and conservation implications.

Global Transcriptome Abnormalities of the Eutopic Endometrium From Women With Adenomyosis

Objective: Adenomyosis is a clinical disorder defined by the presence of endometrial glands and stroma within the myometrium, the pathogenesis of which is poorly understood. We postulate that dysregulation of genes and pathways in eutopic endometrium may predispose to ectopic implantation. No study, to our knowledge, has examined the global transcriptome of isolated eutopic endometrium from women with clinically significant adenomyosis. Design: Laboratory-based study with full institutional review board approval and consents. Material and Methods: Endometrial sampling was performed on hysterectomy specimens (proliferative phase) from symptomatic women with pathologically confirmed diffuse adenomyosis (n = 3). Controls (n = 5) were normo-ovulatory patients without adenomyosis. All patients were free from leiomyoma, endometriosis, and hormonal exposures. Isolated purified total RNA was subjected to microarray analysis using the Gene 1.0 ST Affymetrix platform. Data were analyzed with GeneSpring and Ingenuity Pathway analysis. Validation of several genes was undertaken by quantitative real-time reverse transcriptase polymerase chain reaction. Results: Comparison of transcriptomes of proliferative endometrium from women with and without adenomyosis revealed 140 upregulated and 884 downregulated genes in samples from women with adenomyosis compared to controls. Highly differentially expressed genes include those involved in regulation of apoptosis, steroid hormone responsiveness, and proteins involved in extracellular matrix remodeling as well as microRNAs of unknown significance. Affected canonical pathways included eukaryotic initiation factor 2 signaling, oxidative phosphorylation, mitochondrial dysfunction, estrogen receptor signaling, and mammalian target of rapamycin signaling. Conclusion: The eutopic endometrium in patients with adenomyosis has fundamental abnormalities that may predispose to invasion and survival beyond the myometrial interface.

Uterine didelphys associated with obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome

Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome is a rare complex of structural abnormalities of the female urogenital tract. A 17-year-old girl with uterine didelphys associated with OHVIRA syndrome presented with progressive development of cyclic lower abdominal discomfort and a large abdominopelvic mass. We describe the findings from ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI), the first case report of this syndrome to examine all three different imaging modalities in a single patient. We also review the literature on OHVIRA syndrome and discuss important considerations relevant to radiologists and other clinicians.

The arcuate uterine anomaly: a critical appraisal of its diagnostic and clinical relevance.

The diagnostic criteria and clinical relevance of the arcuate uterine anomaly have long been debated. Our review critically examines the contemporary and past literature regarding the definition, prevalence, and clinical impact of the arcuate uterine anomaly on reproductive outcomes. To bring a novel perspective to the debate, we examined studies evaluating the clinical significance of the presence of a residual septal stump following surgical resection, which has morphology comparable to that of the arcuate anomaly. The balance of the existing literature does not support an association of the arcuate anomaly to adverse reproductive outcomes. Hysteroscopic resection of arcuate anomaly does not appear to be universally indicated. Treatment decisions should be individualized at clinician discretion for symptomatic patients without otherwise identifiable etiology. Target Audience: General Obstetricians & gynecologists, Reproductive Endocrinology & Infertility Specialists and Radiologists. Learning Objectives: After completion of this article, the reader should be able to distinguish the arcuate uterine anomaly and its diagnosis, demonstrate its clinical significance, and what impact, if any, it may have on reproductive potential. Furthermore, the reader should be able to assess which patient population, if any, might benefit from surgical management of the arcuate anomaly.

Obstetrics and Gynecology Residency and Fertility Needs National Survey Results

Infertility is a common reproductive disease, with a prevalence of 9% to 18% of the general population. To date, no studies have attempted to examine the prevalence and experience of infertility among resident physicians in the United States. In female obstetrics and gynecology (Ob/Gyn) residents of age where infertility becomes more prevalent, ability to seek fertility may be influenced by rigorous professional demands and low remuneration. We seek to understand the prevalence of infertility, as well as experience and utilization of infertility services among Ob/Gyn residents. Cross-sectional descriptive survey was distributed among US Accreditation Council for Graduate Medical Education-accredited Ob/Gyn programs. Demographics, intentions to conceive during residency, fertility problems, fertility treatment, affordability of care, and perceptions of support were surveyed. A total of 241 responses were received in an equal distribution between junior (n = 120) and senior (n = 121) residents. The majority of respondents were female (91%), 25 to 35 years old (94%), and married (54%). Eighty-five percent (195 of 230) did not actively pursue fertility during residency. Twenty-nine percent (68 of 235) considered fertility preservation, but only 2% sought consultation. Twenty-nine percent of those interested in fertility (22 of 75) experienced infertility of some degree. Sixty-three percent felt low or no support from the program. Thirty-five percent reported stigma associated with their infertility. In conclusion, infertility is a prevalent reproductive health impairment among Ob/Gyn residents. The majority of residents defer childbearing during residency despite advancing reproductive age. A majority felt little or no support from training programs in addressing their fertility care. Further studies are indicated to understand the barriers and impact among resident trainees.

Out-of-Pocket Costs for Men Undergoing Infertility Care and Associated Financial Strain

Introduction: We determined the out‐of‐pocket expenses, measures taken to finance these expenses and associated financial strain for men seeking fertility care. Methods: In this retrospective cohort the patients completed questionnaires recording the total amount of money spent on infertility care and on what aspect of care the money was spent. Participants also recorded measures taken to finance these costs, the amount of financial strain experienced, and how this strain impacted decisions to seek and continue care. Multivariable logistic regression was performed to assess the relationships of fertility characteristics to financial costs and financial strain. Results: A total of 111 participants completed the full survey. During the course of care 16% of patients spent more than

Infiltrative neurosarcoidosis presenting as secondary amenorrhea: case report and review of the literature.

50,000 dollars. 16% spent between

Birth of a healthy child after preimplantation genetic screening of embryos from sperm of a man with non-mosaic Down syndrome

30,000 and