Erika Banks

Three-Year Outcome of the Halt Trial: A Prospective Analysis of Radiofrequency Volumetric Thermal Ablation of Myomas

STUDY OBJECTIVE To analyze the clinical success of radiofrequency volumetric thermal ablation (RFVTA) at 3-year follow-up in terms of subject responses to validated questionnaires and surgical repeat intervention to treat myomas. DESIGN Prospective follow-up of patients for 36 months after treatment in a multicenter international trial of outpatient, laparoscopic ultrasound-guided RFVTA of symptomatic uterine myomas (Canadian Task Force classification II-1). SETTING University hospitals and private surgical centers. PATIENTS One hundred thirty-five premenopausal women (mean [SD] age, 42.5 [4.6] years; body mass index, 30.5 [6.1]) with symptomatic uterine myomas and objectively confirmed heavy menstrual bleeding (≥ 160 to ≤ 500 mL). INTERVENTIONS Laparoscopic ultrasound-guided RFVTA. MEASUREMENTS AND MAIN RESULTS One hundred four participants were followed prospectively for 36 months after treatment of myomas via RFVTA. For 104 evaluable participants with 36-month data, change in mean (SD) symptom severity from baseline (60.2 [18.8]) to 36 months was -32.6 (95% confidence interval, -37.5 to -27.8; p < .001). Health-related quality of life also was improved, from the baseline value of 39.2 (19.2) to 38.6 (95% confidence interval, 33.3 to 43.9; p < .001) at 36 months. Patient-reported Uterine Fibroid Symptom and Health-Related Quality of Life questionnaire subscores demonstrated statistically significant improvement from baseline to 36 months in all categories (Concern, Activities, Energy/Mood, Control, Self-consciousness, and Sexual Function) (p < .001). For the 104 participants with 36-month data, mean state of health scores (EuroQOL-5D Health State Index) improved from a baseline value of 71.0 (19.3) to 86.2 (11.7) at 36 months. The cumulative repeat intervention rate of 11% (14 of 135 participants) at 36 months was well below the possible 25% maximum expected at the beginning of the trial. CONCLUSION RFVTA of uterine myomas resulted in sustained relief from myoma symptoms and continued improvement in health-related quality of life through 36 months after ablation. The low repeat intervention data through 36 months is a positive outcome for patient well-being.

Efficacy of a novel educational curriculum using a simulation laboratory on resident performance of hysteroscopic sterilization.

OBJECTIVE To assess whether a novel educational curriculum using a simulation teaching laboratory improves resident knowledge, comfort with, and surgical performance of hysteroscopic sterilization. DESIGN An educational prospective, pretest/posttest study. SETTING The Montefiore Institute of Minimally Invasive Surgery Laboratory. PATIENT(S)/SUBJECT(S): Thirty-four OB/GYN residents in an academic medical center. INTERVENTION(S) Hysteroscopic sterilization simulation laboratory and a brief didactic lecture. MAIN OUTCOME MEASURE(S) Differences in scores on validated skill assessment tools: Task specific checklist, Global Rating Scale (GRS), pass fail assessment, and a multiple-choice examination to evaluate knowledge and attitude. RESULT(S) In the entire cohort improvements were observed on all evaluation tools after the simulation laboratory, with 31% points (SD+/-11.5, 95% confidence interval [CI] 27.3-35.3) higher score on the written evaluation; 63% points (SD+/-15.7, 95% CI 57.8-68.8) higher score on the task specific checklist; and 54% points (SD+/-13.6, 95% CI 48.8-58.3) higher score on the GRS. Higher PGY status was correlated with better pretest performance, but was not statistically significant in posttest scores. Residents reported an improvement in comfort performing the procedure after the laboratory. CONCLUSION(S) Simulation laboratory teaching significantly improved resident knowledge, comfort level, and technical skill performance of hysteroscopic sterilization.

Comparison of 3‐dimensional with 2‐dimensional saline infusion sonohysterograms for the evaluation of intrauterine abnormalities

To compare 3‐dimensional saline infusion sonohysterography (3DSIS) with 2‐dimensional sonohysterography (2DSIS) using hysteroscopy and histologic diagnosis as the gold standard.

Buccal misoprostol for treatment of fetal death at 14–28 weeks of pregnancy: a double-blind randomized controlled trial

OBJECTIVE To assess whether buccal misoprostol is effective for the treatment of intrauterine fetal death. STUDY DESIGN This double-blind randomized trial was conducted at five tertiary-level hospitals in the United States and Vietnam. One hundred fifty-three women with an intrauterine fetal death at 14-28 weeks of pregnancy received either 100 mcg buccal misoprostol or 200 mcg buccal misoprostol every 6 h for a maximum of 8 doses. The main outcome measure was the fetal-placental delivery rate within 48 hours of prostaglandin commencement without any additional intervention. RESULTS Most of the women (140/153) were recruited at the study site in Vietnam. Expulsion of both fetus and placenta within 48 hours of prostaglandin commencement without any additional interventions occurred in 61.8% (47/76) of women receiving misoprostol 100 mcg and 77.9% (60/77) of women receiving misoprostol 200 mcg. The 200 mcg dose was significantly more effective than the 100 mcg dose at expelling the fetus and placenta within 48 h [RR 0.68 (95% CI: 0.50-0.92; p=.03)]. The mean time to expulsion was significantly shorter using the 200 mcg dose (18.5±11.9 h) than the 100 mcg dose (23.9±12.5 h) (p=.02). Most women in both groups found the procedure satisfactory or very satisfactory (100 mcg: 76.7% (56/73); 200 mcg: 89.5% (68/76) [RR 0.86 (95% CI: 0.74-1.00)]. CONCLUSION Buccal misoprostol is an effective method for medical induction of labor after intrauterine fetal demise. A 200 mcg dose is significantly more effective than 100 mcg for evacuating the uterus within 48h. The treatment is highly acceptable to women. IMPLICATIONS Administration of 200 mcg buccal misoprostol every six hours is an effective and acceptable method to effect the delivery of a demised fetus at 14-28 weeks that can be feasibly implemented in a wide variety of settings.

Global health training in US obstetrics and gynaecology residency programmes: perspectives of students, residents and programme directors

Background Benefits of exposure to global health training during medical education are well documented and residents’ demand for this training is increasing. Despite this, it is offered by few US obstetrics and gynaecology (OBGYN) residency training programmes. Objectives To evaluate interest, perceived importance, predictors of global health interest and barriers to offering global health training among prospective OBGYN residents, current OBGYN residents and US OGBYN residency directors. Methods We designed two questionnaires using Likert scale questions to assess perceived importance of global health training. The first was distributed to current and prospective OBGYN residents interviewing at a US residency programme during 2012–2013. The second questionnaire distributed to US OBGYN programme directors assessed for existing global health programmes and global health training barriers. A composite Global Health Interest/Importance score was tabulated from the Likert scores. Multivariable linear regression was performed to assess for predictors of Global Health Interest/Importance. Results A total of 159 trainees (77%; 129 prospective OBGYN residents and 30 residents) and 69 (28%) programme directors completed the questionnaires. Median Global Health Interest/Importance score was 7 (IQR 4–9). Prior volunteer experience was predictive of a 5-point increase in Global Health Interest/Importance score (95% CI −0.19 to 9.85; p=0.02). The most commonly cited barriers were cost and time. Conclusion Interest and perceived importance of global health training in US OBGYN residency programmes is evident among trainees and programme directors; however, significant financial and time barriers prevent many programmes from offering opportunities to their trainees. Prior volunteer experience predicts global health interest.

A 5-day educational program for teaching cervical cancer screening using visual inspection with acetic acid in low-resource settings

To assess the effectiveness of an educational program in visual inspection with acetic acid (VIA) for cervical cancer screening among healthcare providers in 2 low‐resource countries.

Quantification of nucleolar channel systems: uniform presence throughout the upper endometrial cavity

OBJECTIVE To determine the prevalence of nucleolar channel systems (NCSs) by uterine region, applying continuous quantification. DESIGN Prospective clinical study. SETTING Tertiary care academic medical center. PATIENT(S) Forty-two naturally cycling women who underwent hysterectomy for benign indications. INTERVENTION(S) NCS presence was quantified by a novel method in six uterine regions-fundus, left cornu, right cornu, anterior body, posterior body, and lower uterine segment (LUS)-with the use of indirect immunofluorescence. MAIN OUTCOME MEASURE(S) Percentage of endometrial epithelial cells (EECs) with NCSs per uterine region. RESULT(S) NCS quantification was observer independent (intraclass correlation coefficient 0.96) and its intrasample variability low (coefficient of variation 0.06). Eleven of 42 hysterectomy specimens were midluteal, ten of which were analyzable with nine containing >5% EECs with NCSs in at least one region. The percentage of EECs with NCSs varied significantly between the LUS (6.1%; interquartile range [IQR] 3.0-9.9) and the upper five regions (16.9%; IQR 12.7-23.4), with fewer NCSs in the basal layer of the endometrium (17 ± 6%) versus the middle (46 ± 9%) and luminal layers (38 ± 9%) of all six regions. CONCLUSION(S) NCS quantification during the midluteal phase demonstrates uniform presence throughout the endometrial cavity, excluding the LUS, with a preference for the functional luminal layers. Our quantitative NCS evaluation provides a benchmark for future studies and further supports NCS presence as a potential marker for the window of implantation.

Providing Global Health Training in an Obstetrics and Gynecology Residency Program [125]

INTRODUCTION: Very few obstetrics and gynecology residency programs offer global health training for their residents. Participants of a structured global health program were surveyed to assess the perceived benefits of the training. METHODS: Albert Einstein College of Medicines Department of Obstetrics and Gynecology created a global womens health program in 2010. This comprehensive program includes a seminar series, simulation training, journal club, specialty clinics, and three types of international experience: research, clinical rotations, and public health initiatives. It has three arms: medical student program, residency track, and clinical and research program for fellows. Anonymous surveys assessing the global health program and perceptions of the benefits of the program on overall training were sent electronically to all past participants. Descriptive statistics were used to analyze the data. RESULTS: Twelve of the 14 participants (86%) completed the survey. Rwanda, Uganda, Benin, Ethiopia, and Uganda were the reported sites for international field experience. Sixty-seven percent of respondents used vacation time to complete these electives. The majority of respondents (67%) participated in clinical rotations, research implementation, and public health initiatives during their field experience. The most commonly cited benefit of global health training was an increased commitment to work with medically underserved populations (33%). After completing the global health training program, 58% reported they were more surgically skilled, 75% reported they were more clinically skilled, and 92% reported they were more culturally sensitive. CONCLUSION: There are many diverse benefits of global health training in residency programs.

An editorial dedication to bicoastal mentorship.

The Department of Obstetrics and Gynecology and Womens Health at the Albert Einstein College of Medicine and Montefiore Medical Center was honored to co-sponsor the 100th meeting of the Population Councils International Committee for Contraception Research (ICCR). It was particularly meaningful and appropriate that we were able to help dedicate the content of the meeting to Daniel R. Mishell, Jr., M.D., one of the founding members of ICCR, and a pioneer in the field of contraception. Dr. Mishell has long served as a mentor and role model to many members of our department. Irwin R. Merkatz, M.D., the University Chair, first provided a summary of Dans role as his mentor and friend over the more than 50 years they have been colleagues. He cited a few of Professor Mishells accomplishments within the academic world. He went on to enumerate that Dan was founder of Contraception and the Journals Editor-in-Chief for more than 42 years. He had served as President of the American Board of Obstetrics and Gynecology and served a key role in the initiation of the Susan Buffett Foundation Fellowships in Family Planning. He served as Chairman of the Department of Obstetrics and Gynecology at the University of Southern California for 27 years. In 2007, he received the Lifetime Achievement Award from The Society of Family Planning for his tremendous contribution to the field. Dan has authored more than 293 peer-reviewed scientific papers and written more than 170 textbook chapters mainly on topics relating to contraception

Factors influencing long-term pessary use: reply by the authors

Dear Editor, The publication in April 2010 by Matsubara et al. [1] showed a case series of patients who had complete uterine prolapse and were fitted with ring pessaries. The prolapse in these patients remained resolved even after the pessary removal. Our publication from January 2010 was cited in a subsequent letter to the editor by Matsubara et al. showing the importance of long-term follow-up and identifying factors contributing to successful pessary usage for over 1 year. We studied 150 women with pelvic organ prolapse using a pessary for over 1 year [2]. Of these 150 women, 115 (77%) continued using pessaries after 1 year and the remaining 35 (23%) discontinued usage. The reason for discontinuation was surgery in 25 women and pessary removal without further treatment in the other 10 women. Matsubara et al. wondered whether these 10 patients with pessary removal continued to have prolapse or whether the pessary management was discontinued because the prolapse disappeared or improved. These 10 women discontinued their pessary usage for various reasons: because of ulcerations, discomfort, or annoyance with their pessaries. Though some did show improvement of their prolapse symptoms after removal, we were unable to quantify this. The 12 gynecologists who had managed these 150 women did not all report complete POPQ examinations upon discontinuation of pessary usage. Our team agrees that a prospective longitudinal study should be performed to determine whether pessary usage can improve prolapse even after discontinuation. Our retrospective chart review did not have an adequate sample size to support or negate Matsubara et al.’s assertion that pessary use may be not only symptomatic relief but also, in some patients, a therapeutic option for uterine prolapse.