Does Participation in Obstetrics and Gynecology Subspecialties Improve Clerkship Outcomes?

OBJECTIVE

The primary objective is to determine if participation in subspecialty rotations during Ob/Gyn core clerkships improves student performance as measured by National Board of Medical Examiners (NBME) Ob/Gyn clinical science subject exam scores, clinical evaluations, and final clerkship summative grades when compared to students without focused subspecialty time.

METHODS

This is a retrospective study of third-year Alpert Medical School of Brown University (AMS) Ob/Gyn core clerkship students at a single institution (Women and Infants Hospital in Providence, RI) from 2012 to 2017. Participation in Maternal Fetal Medicine (MFM) and/or Gynecologic oncology (Gyn Onc) subspecialty track (a one-week focused experience), NBME Ob/Gyn clinical science subject exam raw score, clinical evaluation score, final clerkship summative grade, and decision to pursue Ob/Gyn as a career were analyzed.

RESULTS

There was no significant difference in NBME scores or final clerkship summative grade when comparing general track students to the subspecialty track. There was a significant difference in the clinical evaluation scores between general track and sub-specialty track students (p < 0.002). Of the students who pursued an Ob/Gyn residency, 75% participated in a subspecialty track.

CONCLUSION

Exposure to subspecialty fields is not uniform during core clerkships. Our study indicates that using core clerkship time for early subspecialty exposure does not negatively impact student outcomes, and potentially improves clinical evaluations.

Feasibility of a Regional Approach to an Obstetrics and Gynecology Transition to Residency Course

OBJECTIVE

To demonstrate the feasibility of a regional Obstetrics and Gynecology (Ob/Gyn) Transition to Residency Course (TRC) through compliance, satisfaction, and sustainability.

METHODS

We implemented a two-week, multi-institutional regional TRC (RTRC) for fourth-year medical students matched in Ob/Gyn or Family Medicine from four New England medical schools. Curriculum was developed to meet Ob/Gyn Milestone One (M1) and Core Entrustable Professional Activity (CEPA) objectives. Compliance, satisfaction, and sustainability were identified as feasibility outcomes.

RESULTS

From 2015-2018, a total of 63 fourth-year students have participated. The number of students remained stable each year. All students attended 100% of sessions. There was an average of >9/10 in all satisfaction metrics all four years. The number of faculty members from each institution remained stable over the four years.

CONCLUSION

A RTRC is feasible as measured through compliance, satisfaction and sustainability.

Urinary fistula and incontinence

It is estimated that as many as 3.5 million women worldwide suffer from obstetric urinary fistula. This public health tragedy is a result of obstructed labor and inadequate access to health care, and its eradication lies in prevention and treatment. Efforts at prevention should be made through targeted education and public intervention for improved nutrition, access to health care, and women's social status. Diagnosis and treatment in limited resource settings can occur, and there are specific recommendations regarding nonsurgical and surgical approaches to care. Treatment success may be complicated by social, psychological, and clinical factors, with reintegration a primary concern for this group of women.

Implementation and evaluation of a novel operating room curriculum for the obstetrics and gynecology clerkship

OBJECTIVE

Primary objective is to estimate the effect of an operating room (OR) curriculum on obstetrics and gynecology (Ob/Gyn) students' clinical knowledge related to the OR. Secondary objective is to estimate the effect of the curriculum on student confidence and satisfaction related to the OR experience.

STUDY DESIGN

Prospective cohort study of 6 Ob/Gyn clerkship groups from September 2011 to June 2012. Three control groups received usual teaching and 3 intervention groups received the OR curriculum plus usual teaching. The primary outcome was the measurement of student knowledge using preclerkship and postclerkship questionnaires. Student confidence and satisfaction related to the OR experience were also measured using questionnaires. Standard clerkship evaluations were reviewed to rate the quality of faculty teaching. Between-group scores were compared using Student t test. A total of 26 students per group were needed to detect a 20% difference in between-group change in clinical knowledge (α = 0.05, 80% power).

SETTING

Women and Infants' Hospital, Providence, Rhode Island, a tertiary care teaching hospital for the Warren Alpert Medical School of Brown University.

PARTICIPANTS

Ob/Gyn clerkship students.

RESULTS

Overall, 70 students were enrolled-68 completed evaluation measures immediately after clerkship and 27 at 6 months after clerkship. More intervention subjects were fourth-year students (p = 0.03) and had completed surgery clerkships (p = 0.003). At baseline, groups demonstrated similar clinical knowledge and confidence (p > 0.05). Although there was no difference between groups in knowledge scores immediately after clerkship, at 6 months, the intervention group had greater retention in clinical knowledge scores (1.2 ± 2.6 vs 3.5 ± 1.8; p = 0.02). At clerkship completion, intervention group was more satisfied with student-faculty interaction (mean sum score = 14.7 ± 3.5 vs 16.9 ± 3.0; p = 0.01). On review of standard clerkship evaluations, intervention subjects gave significantly higher scores for quality of faculty teaching (3.82 ± 1.18 vs 4.39 ± 0.67; p = 0.01).

CONCLUSIONS

Our OR curriculum improved knowledge retention, increased student satisfaction with student-faculty interactions in the OR, and improved faculty teaching evaluation.

Perceptions of operating room learning experiences during the obstetrics and gynecology clerkship

BACKGROUND

There is little published describing curriculum development for the medical student in the operating room (OR).

PURPOSE

Explore student and faculty perceptions of learning experiences in the OR during the Obstetrics and Gynecology (Ob/Gyn) clerkship as a prelude to defining OR-specific learning objectives and curriculum.

METHODS

Fourth year students and Obstetrics and Gynecology faculty participated in structured, audiotaped focus groups aimed at defining OR educational objectives and curriculum content. Review of audiotapes identified emergent themes used to categorize perceived learning experiences.

RESULTS

Two focus groups including 13 students and 1 focus group including 5 faculty were conducted. Four dominant categories of OR learning were identified: (1) development of a foundation of clinical knowledge; (2) surgical technique and skill acquisition; (3) personal insight into career choice; and (4) surgical culture and OR functioning.

CONCLUSIONS

Students and faculty were aligned regarding general categories of key OR learning experiences, building an experiential framework for developing OR-specific learning objectives and curricular components.

Improving medical student knowledge of female pelvic floor dysfunction and anatomy: a randomized trial

OBJECTIVE

The objective of the study was to estimate the effect of an interactive computer trainer on improving medical student knowledge and attitudes regarding female pelvic anatomy (PA) and pelvic floor dysfunction (PFD).

STUDY DESIGN

Forty-three students were randomized to the trainer and usual teaching vs usual teaching alone. Pre- and postintervention knowledge and attitude questionnaires were completed. Between-group pre- and postintervention scores were analyzed. Multiple linear regression was used to estimate trainer effect on scores, adjusting for confounders.

RESULTS

There was no difference in baseline scores between groups (P > .05). The trainer group had significantly higher postintervention knowledge (mean score, 15.6 +/- 1.9 vs 12.6 +/- 2.5; P = .007) and attitude (mean score, 19.2 +/- 2.8 vs 15.8 +/- 3.2; P = .001) scores compared with the usual teaching group. On multiple linear regression, the trainer group had significantly higher postintervention knowledge and attitude scores, after adjusting for year of medical education and prior clerkships.

CONCLUSION

An interactive computer trainer to teach female PA and PFD improves medical student knowledge and attitudes.

Pelvic organ prolapse

Pelvic organ prolapse can encompass a range of disorders, from asymptomatic, altered anatomy to complete eversion of the vagina and may present with associated urinary, defecatory, and sexual dysfunction. Patient symptoms are important to elicit, because many patients with prolapse are asymptomatic. Ascertaining patient treatment goals is necessary when discussing options for management, and patients can choose from conservative, noninvasive treatment and prevention to surgical reconstruction. As comparable data for prolapse operations are poor, surgical route is determined based on the type and severity of prolapse, surgeon preference, and desired outcome.

Long-term follow-up of a transvaginal Burch urethropexy for stress urinary incontinence

OBJECTIVE

The objective of the study was to describe long-term objective and subjective success rates and complications following transvaginal Burch urethropexy for stress urinary incontinence.

STUDY DESIGN

A case series of 66 women who underwent vaginal Burch urethropexy for urodynamic stress urinary incontinence with urethral hypermobility using a suture carrier device is presented. Concurrent prolapse repairs were performed as indicated.

RESULTS

Sixty-six women (mean age 49.4 +/- 12.1 years) underwent vaginal Burch urethropexy. Mean follow-up time was 20.9 +/- 18.9 months. Objective failure was observed in 16 patients (24.2%). Subjective failure was reported by 21.2% of patients, with 50% and 28.8% reporting success and improvement, respectively. Six patients (9%) experienced febrile illness, 4 (6%) experienced intraoperative hemorrhage, 1 (1.5%) received transfusion, and 1 (1.5%) experienced pelvic abscess. Twelve patients (18.2%) experienced suture erosion; half required surgical revision or excision.

CONCLUSION

Vaginal Burch urethropexy is generally well tolerated but is associated with poor long-term success and high suture erosion rates.

Vesicouterine fistula presenting with urinary incontinence after primary cesarean section: a case report

BACKGROUND

Vesicouterine fistula is a rare complication most commonly associated with cesarean section. Though conservative management has been reported, surgical intervention is usually required to treat the condition.

CASE

A 32-year-old woman presented with urinary incontinence following a primary cesarean section; it was initially thought to be a vesicovaginal fistula. Careful evaluation and a high index of suspicion resulted in the correct diagnosis of a vesicouterine fistula. The patient was successfully treated with uterus-sparing surgery.

CONCLUSION

This case illustrates the importance of a comprehensive evaluation of all patients suspected of having a urogenital fistula. A thorough workup led to the correct diagnosis of vesicouterine fistula and allowed the surgeons to plan the appropriate operative strategy in managing the patient.

Pyometra necessitating hysterectomy after colpocleisis in an extremely elderly patient

As the number of women more than the age 65 increases, so will the need for treatment of pelvic organ prolapse and the comorbidities that come with surgical treatment of an aging population gain significance. Colpocleisis is an option for women failing or refusing conservative prolapse management and not desiring sexual function. The advantages of colpocleisis are decreased operative time, low complication rate, and ability to use local or regional anesthesia. We report a case of a 95-year-old woman whose procidentia was treated with colpocleisis. Endometrial evaluation with dilation and curettage was performed at the time of colpocleisis. Postoperative course was complicated by pyometra necessitating total abdominal hysterectomy and bilateral salpingoopherectomy, leading to further complications including deep vein thrombosis, anemia, atrial fibrillation, and pleural effusions. Preoperative versus intraoperative endometrial evaluation may decrease the risk of developing pyometra after colpocleisis and, therefore, diminish the possibility of multiple complications.

Pelvic arterial embolization in the setting of acute hemorrhage as a result of the anterior Prolift® procedure

Acute hemorrhage following pelvic reconstructive surgery is a complication requiring immediate evaluation and treatment. Therapeutic options include fluid resuscitation, tamponade techniques, exploratory surgical intervention, and, more recently, pelvic vessel embolization. New approaches to pelvic organ prolapse have been evolving rapidly with little reported on safety and efficacy. We present a 77-year-old female who had a life-threatening acute pelvic hemorrhage from an anterior Prolift procedure successfully treated with pelvic artery embolization.

Shigellosis complicating preterm premature rupture of membranes resulting in congenital infection and preterm delivery

BACKGROUND

The association of chorioamnionitis with preterm birth is well established. Intra-amniotic infection complicates 13-60% of preterm premature rupture of membranes (PROM) with enteric gram-negative pathogens accounting for 20-40% of recoverable organisms. However, the source of enteric pathogens leading to premature birth has been poorly characterized.

CASE

A 36-year-old multiparous woman presented at 2567 weeks with preterm PROM. She reported a 5-day history of bloody, mucous diarrhea. A fourth cesarean delivery was performed secondary to the onset of labor. Fetal blood, placental membrane, and vaginal pool cultures revealed the presence of Shigella sonnei. With appropriate antibiotic therapy, the patient was discharged home on postoperative day 5. Neonatal stool cultures revealed evidence of in utero fetal transmission.

CONCLUSION

It is prudent to treat pregnant patients with clinical symptoms suggestive of shigellosis because this pathogen can result in preterm PROM and preterm delivery. Neonatal testing is indicated if maternal disease is suspected before delivery.

Factors useful in predicting the success of oocyte donation: a 3-year retrospective analysis

OBJECTIVE

To establish prognostic relevance of parameters assessed in oocyte donation cycles.

DESIGN

Retrospective analysis.

SETTING

Large university-based donor oocyte program.

PATIENT(S)

All oocyte recipient cycles achieving embryo transfer from September 1995 to October 1998.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Pregnancy.

RESULT(S)

Recipient age and reproductive status, day 9 and 12 serum estradiol (E(2)) levels and a progesterone (P) level obtained 2 days after initiation of hormonal therapy did not correlate with pregnancy. Endometrial thickness, but not endometrial pattern, was useful in predicting pregnancy outcome. The clinical pregnancy and live-birth rate in cycles where the endometrial thickness was less than 8 mm was significantly lower when compared to cycles with an endometrial thickness > or =9 mm. Cycles where optimal quality embryos were transferred had the highest implantation (36%), clinical pregnancy (63%) and live birth (54%) rates and these rates were significantly higher than those of cycles where only poor quality embryos were available for transfer (10% implantation, 17% clinical pregnancy, and 8% live birth rates, respectively; P<.05).

CONCLUSION(S)

The most reliable predictive factors for pregnancy in oocyte donation cycles are the quality of the embryos transferred and the recipient's mid-cycle endometrial thickness. Recipient monitoring should minimally include ultrasound assessment of endometrial thickness.

A delayed-early gene activated by fibroblast growth factor-1 encodes a protein related to aldose reductase

The addition of polypeptide mitogens to quiescent cell lines induces the expression of various gene products, some of which are likely to perform functions critical for cell cycle progression, DNA synthesis, and mitosis. We have used a differential display approach to identify fibroblast growth factor (FGF)-1-inducible genes in NIH-3T3 cells. One of these genes, termed FGF-regulated (FR)-1, encodes a 316-amino acid protein with approximately 82% amino acid sequence identity to an abundant protein expressed in mouse vas deferens and approximately 70% identity to human aldose reductase. The function of the vas deferens protein is unknown; however, aldose reductase is an NADPH-dependent monomeric oxidoreductase implicated in the pathogenesis of diabetic complications. FGF-1 induction of FR-1 mRNA expression is first detectable at 4 h after mitogen addition and is dependent on de novo RNA and protein synthesis. FGF-2 or phorbol ester treatment can also increase FR-1 mRNA levels; in contrast, whole blood serum or individual growth factors present in serum have only minimal effects on FR-1 mRNA expression. FR-1 mRNA is detectable in a number of mouse tissues but is most abundant in newborn liver and in adult intestine, ovary, and testis. These results raise the possibility that aldose reductase-related proteins may play a role in FGF-1- and FGF-2-stimulated mitogenesis.

Structural and functional characterization of full-length heparin-binding growth associated molecule

Heparin-binding growth-associated molecule (HB-GAM) was purified from adult bovine brain and chicken heart. The yield of HB-GAM is increased by 5- to 10-fold when 250 mM NaCl is added to the homogenization buffer, indicating that HB-GAM may exist as a complex with an insoluble component of the tissue. The complete amino acid sequence of the brain-derived HB-GAM was established by automated Edman degradation of the intact protein and chemically or enzymatically derived fragments. The mass of bovine HB-GAM as determined by plasma desorption time-of-flight mass spectrometry is 15,291 mass units, which compares favorably with the calculated mass of 15,289 based on the amino acid sequence. Therefore, HB-GAM has not undergone any major post-translational modifications other than cleavage of the signal peptide. These results indicate that previous amino acid sequence analysis of this protein was carried out using truncated HB-GAM. Full-length HB-GAM is not a mitogen for Balb/3T3 clone A31, Balb MK, NRK, or human umbilical vein endothelial cells. HB-GAM does, however, have adhesive properties and neurite extension activity for chick embryo cerebral cortical derived neurons when presented to these cells as a substrate. HB-GAM had little neurite extension activity when presented as a soluble factor.