Jaden R. Kohn

Student-derived solutions to address barriers hindering reports of unprofessional behaviour

Barriers hinder medical students from reporting breaches in professional behaviour, which can adversely impact institutional culture. No studies have reported student perspectives on how to address these barriers successfully. Our study (i) evaluated the likelihood of reporting based on violation severity, (ii) assessed barriers to reporting and (iii) elicited students’ proposed solutions.

Placenta Percreta and Incomplete Uterine Rupture after Endometrial Ablation and Tubal Occlusion

Endometrial ablation offers symptomatic relief for menorrhagia. Pregnancy after ablation is rare but is often complicated due to pregnancy loss, growth restriction, preterm premature rupture of membranes, preterm delivery, and morbidly adherent placentation, a dangerous complication that can result in hemorrhage, intensive care unit admission, and cesarean hysterectomy. We report a case of pregnancy conceived contemporaneously with endometrial ablation and tubal occlusion. Diagnosis of pregnancy was delayed due to low suspicion. Complications included cervical implantation and placenta percreta, necessitating hysterectomy with the fetus in situ. Intraoperatively, incomplete uterine rupture was noted. Abnormal neovascularization, fibrous adhesions, and anatomical distortion necessitated a complex surgical approach. Women undergoing endometrial ablation must be thoroughly counseled about the serious risks of postablation pregnancy, the need for contraception, and the risk of sterilization failure. Pregnancy should remain in the differential diagnosis for women of reproductive age, regardless of tubal occlusion. Cases of placenta percreta should be referred early to centers of excellence with multidisciplinary teams.

Shock index and delta-shock index are superior to existing maternal early warning criteria to identify postpartum hemorrhage and need for intervention

Abstract Objective: To determine whether shock index (SI) is superior to traditional vital signs in predicting postpartum hemorrhage and need for intervention. Methods: Retrospective case-control study in an academic tertiary-care county hospital. Forty-one consecutive postpartum hemorrhage (PPH) cases and 41 controls were frequency-matched by mode of delivery and maternal weight. We measured four criteria: heart rate, systolic blood pressure (SBP), SI (HR/SBP), and delta-SI (peak SI – baseline SI). Using received operating characteristic curves, we compared the discrimination performance of each criterion to predict PPH, transfusion, and surgical intervention, and identified thresholds with the strongest classification. Results: SI ≤1.1 can be normal in peripartum. Peak SI and delta-SI were generally superior to heart rate (HR) and SBP in predicting PPH, transfusion, and surgical intervention. SI ≥1.143 and SI ≥1.412 were strong initial and “critical” thresholds. Delta-SI was the strongest classifier overall; both SI and delta-SI remain sensitive and specific when adjusted for potential confounders. Conclusions: SI and delta-SI appear to be superior to HR and SBP in predicting PPH and need for intervention. Utility of delta-SI should be prospectively explored.

Teachers as Learners: Developing Professionalism Feedback Skills via Observed Structured Teaching Encounters

ABSTRACT This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Southern Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of 4 experts who shared their thoughts stimulated by the study. These thoughts explore the value of the Observed Structured Teaching Encounter in providing structured opportunities for medical students to engage with the complexities of providing peer feedback on professionalism.

Genetic counseling for men with recurrent pregnancy loss or recurrent implantation failure due to abnormal sperm chromosomal aneuploidy

PurposeThe purpose of this study is to review recurrent pregnancy loss (RPL) due to sperm chromosomal abnormalities and discuss the genetic counseling that is required for men with sperm chromosomal abnormalities.MethodThe literature was reviewed, and a genetic counselor lends her expertise as to how couples with RPL and sperm chromosomal abnormalities ought to be counseled. The review of the literature was performed using MEDLINE.ResultsSperm fluorescence in situ hybridization (FISH) can be used to determine if disomy or unbalanced chromosomal translocations are present. In men with aneuploidy in sperm or who carry a chromosomal translocation, pre-implantation genetic screening (PGS) combined with in vitro fertilization (IVF) and intra-cytoplasmic sperm injection (ICSI) can increase chances of live birth. In men with abnormal sperm FISH results, the degree of increased risk of abnormal pregnancy remains unclear. Genetic counselors can provide information to couples about the risk for potential trisomies and sex chromosome aneuploidies and discuss their reproductive and testing options such as PGS, use of donor sperm, and adoption. The provision of genetic counseling also allows a couple to be educated about recommended prenatal testing since pregnancies conceived with a partner who has had abnormal sperm FISH are considered to be at increased risk for aneuploidy.ConclusionWe review the literature and discuss genetic counseling for couples with RPL or recurrent implantation failure due to increased sperm aneuploidy.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery Sacrocolpopexy: Tips and Tricks

STUDY OBJECTIVE To demonstrate helpful tips and tricks for the successful use of transvaginal natural orifice transluminal endoscopic surgery (NOTES) for performing sacrocolpopexy and salpingo-oophorectomy surgery. Minimally invasive approaches for treating pelvic organ prolapse via sacrocolpopexy have traditionally included laparoscopy either with or without robotic assistance. Transvaginal NOTES is a novel minimally invasive approach that both avoids abdominal incisions and provides improved visualization; however, it can be technically challenging. DESIGN Stepwise demonstration with narrated video footage (Canadian Task Force classification III). SETTING An academic tertiary care hospital in Guangdong, China. PATIENT A 61-year-old gravida 3, para 3 woman with 3 spontaneous vaginal deliveries and stage III uterine prolapse, stage III cystocele, and stage III rectocele. The preoperative vaginal length was 6 cm. INTERVENTION After performing vaginal hysterectomy, we show the usefulness of NOTES for salpingo-oophorectomy. We also demonstrate useful techniques for transvaginal NOTES sacrocolpopexy including hydrodissection, division of the Y mesh, anchoring of the anterior mesh before reducing prolapse, retroperitoneal tunneling, and hand suturing of the mesh and vaginal cuff. MEASUREMENTS AND MAIN RESULTS The procedure was successfully performed in approximately 190 minutes. The postoperative vaginal length was 5 cm. Postoperative pelvic organ prolapse quantification was stage 0. CONCLUSION The transvaginal NOTES approach is feasible and efficient for sacrocolpopexy and salpingo-oophorectomy; additionally, it is a reasonable option for patients who desire a minimally invasive approach with excellent cosmetic results. Surgical techniques that aid in effectively performing transvaginal NOTES sacrocolpopexy include the use of hydrodissection, Y mesh division, anterior mesh anchoring before reducing prolapse, retroperitoneal tunneling, and hand suturing. Using the techniques presented here, we were able to insert the port only 1 time, which improves the efficiency and safety of this surgery.

Pregnancy after endometrial ablation: a systematic review

Pregnancies have been reported after endometrial ablation but there is little data regarding subsequent pregnancy outcomes.

PD13-08 SHIFT WORK IS ASSOCIATED WITH ALTERED SEMEN PARAMETERS IN INFERTILE MEN

to model the costs of screening and treatment of infertile men at risk for TC. RESULTS: Using incidence, prevalence and census data, the number of infertile men in the U.S. was calculated to be 2,350,000. Using co-prevalence data, 375 new cases of TC per year were estimated in the infertile male population. Screening using testicular selfexamination (TSE) resulted in no cost burden. Prior to treatment, confirmation of the diagnosis of TC in men with testicular masses included tumor markers and scrotal ultrasound; these costs are folded into treatment costs. Early treatment was defined as radical orchiectomy followed by low-dose chemotherapy. Late TC treatment was defined as radical orchiectomy followed by chemotherapy and retroperitoneal lymph node dissection (RPLND), as well as salvage chemotherapy. The total cost associated with early treatment of infertile men diagnosed with TC using TSE was

Pregnancy Success via Intrauterine Insemination and Effect of Sperm Morphology: Systematic Review & Meta-Analysis [10E]

7,035,394, in contrast with a total cost of

Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Sacrocolpopexy: A Pilot Study of 26 Cases

19,350,096 for late treatment of this population. Thus, the cost savings resulting from early detection of TC in infertile men using TSE is approximately