Emily K. Kobernik

Food insecurity and dietary intake among US youth, 2007–2010

There is limited research describing associations between food insecurity and dietary intake.

Interactions among pelvic organ protrusion, levator ani descent, and hiatal enlargement in women with and without prolapse

BACKGROUND: Pelvic organ prolapse has 2 components: (1) protrusion of the pelvic organs beyond the hymen; and (2) descent of the levator ani. The Pelvic Organ Prolapse Quantification system measures the first component, however, there remains no standard measurement protocol for the second mechanism. OBJECTIVE: We sought to test the hypotheses that: (1) difference in the protrusion area is greater than the area created by levator descent in prolapse patients compared with controls; and (2) prolapse is more strongly associated with levator hiatus compared to urogenital hiatus. STUDY DESIGN: Midsagittal magnetic resonance imaging scans from 30 controls, 30 anterior predominant, and 30 posterior predominant prolapse patients were assessed. Levator area was defined as the area above the levator ani and below the sacrococcygeal inferior pubic point line. Protrusion area was defined as the protruding vaginal walls below the levator area. The levator hiatus and urogenital hiatus were measured. Bivariate analysis and multiple comparisons were performed. Bivariate logistic regression was performed to assess prolapse as a function of levator hiatus, urogenital hiatus, levator area, and protrusion. Pearson correlation coefficients were calculated. RESULTS: The levator area for the anterior (34.0 ± 6.5 cm2) and posterior (35.7 ± 8.0 cm2) prolapse groups were larger during Valsalva compared to controls (20.9 ± 7.8 cm2, P < .0001 for both); similarly, protrusion areas for the anterior (14.3 ± 6.2 cm2) and posterior (14.4 ± 5.7 cm2) prolapse groups were both larger compared to controls (5.0 ± 1.8 cm2, P < .0001 for both). The levator hiatus length for the anterior (7.2 ± 1 cm) and posterior (6.9 ± 1 cm) prolapse groups were longer during Valsalva compared to controls (5.2 ± 1.5 cm, P < .0001 for both); similarly, urogenital hiatus lengths for the anterior (5.7 ± 1 cm) and posterior (6.3 ± 1.1 cm) prolapse groups were both longer than controls (3.8 ± 0.8 cm, P < .0001 for both). The difference in levator area in prolapse patients compared with controls was greater than the difference in protrusion area (14.0 ± 7.2 cm2 vs 9.4 ± 5.9 cm2, P < .0002). The urogenital hiatus was more strongly associated with prolapse than the levator hiatus (odds ratio, 12.9; 95% confidence interval, 4.1–39.2, and odds ratio, 4.3; 95% confidence interval, 2.3–7.5). Levator hiatus and urogenital hiatus are both correlated with levator and protrusion areas, and all were associated with maximum prolapse size (P ≤ .001, for all comparisons). CONCLUSION: In prolapse, the levator area increases more than the protrusion area and both the urogenital hiatus and levator hiatus are larger. The odds of prolapse for an increase in the urogenital hiatus are 3 times larger than for the levator hiatus, which leads us to reject both the original hypotheses.

The Decision to Incision Curriculum: Teaching Preoperative Skills and Achieving Level 1 Milestones

OBJECTIVE To evaluate the effectiveness of a preoperative skills curriculum, and to assess and document competence in associated Obstetrics and Gynecology Level 1 Milestones. DESIGN The Decision to Incision curriculum was developed by a team of medical educators with the goal of teaching and evaluating 5 skills pertinent to Milestone 1: Preoperative consent, patient positioning, Foley catheter placement, surgical scrub, and preoperative time-out. Competence, overall skill performance, and knowledge were assessed by evaluator rating using checklists before and after the educational intervention. Differences between preintervention and postintervention skills performance and competence were assessed using Wilcoxon rank test and Fisher exact test, respectively. SETTING Clinical Simulation Center at an academic medical center. PARTICIPANTS Overall, 29 fourth year medical students matriculating into Obstetrics and Gynecology residencies. RESULTS The proportion of participants meeting Milestone competence significantly increased in all 5 skills, with competence achieved in 95.6% (95% CI: 92.1-99.0) of posttest skills assessments. Median overall performance also significantly improved for all 5 skills, with 83.6% (95% CI: 77.3-89.9) earning scores of 4 out of 5 or greater on the posttest. For knowledge testing, the proportion of correct responses significantly increased for both topics evaluated, from 45.2% to 99.7% (p < 0.0001) for positioning and from 32.8% to 83.1% (p < 0.0001) for time-out. CONCLUSIONS The decision to incision curriculum significantly improved preoperative skills, including skills that may be required on day 1 of residency. This curriculum also facilitated achievement and documentation of competence in multiple Milestones.

The Use of Opportunistic Salpingectomy at the Time of Benign Hysterectomy

STUDY OBJECTIVE To delineate the use of opportunistic salpingectomy over the study period, to examine factors associated with its use, and to evaluate whether salpingectomy was associated with perioperative complications. DESIGN A retrospective cross-sectional study (Canadian Task Force classification II-2). SETTING The Michigan Surgical Quality Collaborative. PATIENTS Women undergoing ovarian-conserving hysterectomy for benign indications from January 2013 through April 2015. INTERVENTIONS The primary outcome was the performance of opportunistic salpingectomy with ovarian preservation during benign hysterectomy. The change in the rate of salpingectomy was examined at 4-month intervals to assess a period effect over the study period. Multivariate logistic regression was performed to evaluate independent effects of patient, operative, and period factors. Perioperative outcomes were compared using propensity score matching. MEASUREMENTS AND MAIN RESULTS There were 10 676 (55.9%) ovarian-conserving hysterectomies among 19 090 benign hysterectomies in the Michigan Surgical Quality Collaborative in the study period. The rate of opportunistic salpingectomy was 45.8% (n = 4890). Rates of opportunistic salpingectomy increased over the study period from 27.5% to 61.6% (p < .001), demonstrating a strong period effect in the consecutive 4-month period analysis. Salpingectomy was more likely with the laparoscopic approach (odds ratio = 3.48; 95% confidence interval, 3.15-3.85) and among women younger than 60 years of age (odds ratio = 1.60; 95% CI, 1.34-1.92). There was substantial variation in salpingectomy across hospital sites, ranging from 3.6% to 79.9%. Salpingectomy was associated with a 12-minute increase in operative time (p < .001), but there were no differences in the estimated blood loss or perioperative complications. CONCLUSION The rates of salpingectomy increased significantly over the study period. The laparoscopic approach and younger age are associated with an increased probability of salpingectomy. Salpingectomy is not associated with increased blood loss or perioperative complications.

Healthcare provider attitudes regarding the provision of assisted reproductive services for HIV‐affected couples in Addis Ababa, Ethiopia

To evaluate the acceptability and feasibility of providing assisted reproductive services as part of routine HIV care and treatment in Ethiopia.

Levator ani defect severity and its association with enlarged hiatus size, levator bowl depth, and prolapse size

limited by the observational design and low rate of events precluding adjustment for other risk factors that may have affected AKI risk, such as diabetes. Given the strong association between AKI and postoperative mortality, the adverse consequences of expanded antimicrobial therapy should be seriously considered. Although combination regimens appear to be beneficial in the healthy peripartum population undergoing cesarean deliveries with inherently high rates of SSI, the risks of adverse events such as AKI coupled with a lower expected rate of SSI after hysterectomy may tip the scale against expanded antibiotic regimens in this population, particularly combinations including vancomycin. These data underscore the importance of carefully considering adverse drug events and unintended consequences in future studies of combination prophylaxis and other interventions designed to reduce preventable patient harm. -

The impact of cost sharing on women’s use of annual examinations and effective contraception

BACKGROUND: We sought to describe the relationship between the elimination of out‐of‐pocket costs and womens use of preventive care office visits and long‐acting reversible contraception after accounting for baseline levels of cost sharing. OBJECTIVES: The objective of this analysis was to describe the relationship between the elimination of out‐of‐pocket costs and utilization of preventive care visits and long‐acting reversible contraception insertion while taking baseline cost sharing levels under consideration. STUDY DESIGN: In 2017, we used administrative health plan data to examine changes in out‐of‐pocket costs and service utilization among 2,172,065 women enrolled in 15,118 employer‐based health plans between 2008 and 2015. We used generalized estimating equations to examine utilization patterns. RESULTS: Women in this sample generally had low costs at baseline (

Nationwide trends in the utilization of and payments for hysterectomy in the United States among commercially insured women

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71: Predictors of urinary tract infection and need for sling revision due to obstructive symptoms after sub urethral sling procedures

29 for preventive care visits and long‐acting reversible contraception insertion, respectively). The elimination of baseline out‐of‐pocket costs were related to changes in the utilization of both services but more consistently for contraceptive device placement. Women whose low/moderate out‐of‐pocket costs were eliminated were more likely to use a preventive care office visit than women with persistent low/moderate costs (odds ratio, 1.05; 95% confidence interval, 1.04–1.05), but women with high out‐of‐pocket costs had lower utilization rates, even after their costs were eliminated. In contrast, the odds of having a contraceptive device placed was higher among all groups of women when out‐of‐pocket costs were zero, as compared with women with low/moderate costs. For instance, when compared with women with low/moderate costs, women were less likely to have a contraceptive device inserted (odds ratio, 0.92; 95% confidence interval, 0.86–0.97) when they had high costs but more likely after their costs were eliminated (odds ratio, 1.15; 95% confidence interval, 1.09–1.20). CONCLUSION: Out‐of‐pocket costs were low prior to the Affordable Care Act. Eliminating costs was associated with increases in preventive service use among those with high levels of cost, but effect sizes were low, suggesting that cost is only 1 barrier. Failing to recognize that cost sharing was already low could cause us to falsely conclude that the elimination of cost sharing was ineffective.

Utility of Ultrasound and Magnetic Resonance Imaging in Patients with Disorders of Sex Development Who Undergo Prophylactic Gonadectomy.

BACKGROUND: Laparotomy followed by inpatient hospitalization has traditionally been the most common surgical care for hysterectomy. The financial implications of the increased use of laparoscopy and outpatient hysterectomy are unknown. OBJECTIVES: The objective of the study was to quantify the increasing use of laparoscopy and outpatient hysterectomy and to describe the financial implications among women with commercially based insurance in the United States. STUDY DESIGN: Hysterectomies between 2010 and 2013 were identified in the Health Care Cost Institute, a national data set with inpatient and outpatient private insurance claims for more than 25 million women. Surgical approach was categorized with procedure codes as abdominal, laparoscopic, laparoscopic assisted vaginal, or vaginal. Payments were adjusted to 2013 US dollars to account for change because of inflation. RESULTS: Between 2010 and 2013, there were 386,226 women who underwent hysterectomy. The rate of utilization decreased 12.4%, from 39.9 to 35.0 hysterectomies per 10,000 women. The largest absolute decreases were observed among women younger than 55 years and among those with uterine fibroids, abnormal uterine bleeding, and endometriosis. The proportion of laparoscopic hysterectomies increased from 26.1% to 43.4%, with concomitant decreases in abdominal (38.6% to 28.3%), laparoscopic assisted vaginal (20.2 to 16.7%), and vaginal (15.1% to 11.5%) hysterectomies. There was also a shift from inpatient to outpatient surgery. In 2010, the inpatient and outpatient rates of hysterectomy were 26.6 and 13.3 per 10,000 women, respectively. By 2013, the rates were 15.4 and 19.6 per 10,000 women. In each year of analysis, the average reimbursement for outpatient procedures was 44‐46% less than for similar inpatient procedures. Offsetting the lower utilization of hysterectomy and lower reimbursement for outpatient surgery were increases in average inpatient and outpatient hysterectomy reimbursement of 19.4% and 19.8%, respectively. Total payments for hysterectomy decreased 6.3%, from