Exposure to passive heat and cold stress differentially modulates cerebrovascular-CO2 responsiveness.

Heat and cold stress influence cerebral blood flow (CBF) regulatory factors (e.g., arterial CO2 partial pressure). However, it is unclear whether the CBF response to a CO2 stimulus (i.e., cerebrovascular-CO2 responsiveness) is maintained under different thermal conditions. This study aimed to compare cerebrovascular-CO2 responsiveness between normothermia, passive heat, and cold stress conditions. Sixteen participants (8 females; 25 ± 7 yr) completed two experimental sessions (randomized) comprising normothermic and either passive heat or cold stress conditions. Middle and posterior cerebral artery velocity (MCAv, PCAv) were measured during rest, hypercapnia (5% CO2 inhalation), and hypocapnia (voluntary hyperventilation to an end-tidal CO2 of 30 mmHg). The linear slope of the cerebral blood velocity (CBv) response to changing end-tidal CO2 was calculated to measure cerebrovascular-CO2 responsiveness, and cerebrovascular conductance (CVC) was used to examine responsiveness independent of blood pressure. CBv-CVC-CO2 responsiveness to hypocapnia was greater during heat stress compared with cold stress (MCA: +0.05 ± 0.08 cm/s/mmHg/mmHg, P = 0.04; PCA: +0.02 ± 0.02 cm/s/mmHg/mmHg, P = 0.002). CBv-CO2 responsiveness to hypercapnia decreased during heat stress (MCA: -0.67 ± 0.89 cm/s/mmHg, P = 0.02; PCA: -0.64 ± 0.62 cm/s/mmHg; P = 0.01) and increased during cold stress (MCA: +0.98 ± 1.33 cm/s/mmHg, P = 0.03; PCA: +1.00 ± 0.82 cm/s/mmHg; P = 0.01) compared with normothermia. However, CBv-CVC-CO2 responsiveness to hypercapnia was not different between thermal conditions (P > 0.08). Overall, passive heat, but not cold, stress challenges the maintenance of cerebral perfusion. A greater cerebrovascular responsiveness to hypocapnia during heat stress likely reduces an already impaired cerebrovascular reserve capacity and may contribute to adverse events (e.g., syncope).NEW & NOTEWORTHY This study demonstrates that thermoregulatory-driven perfusion pressure changes, from either cold or heat stress, impact cerebrovascular responsiveness to hypercapnia. Compared with cold stress, heat stress poses a greater challenge to the maintenance of cerebral perfusion during hypocapnia, challenging cerebrovascular reserve capacity while increasing cerebrovascular-CO2 responsiveness. This likely exacerbates cerebral hypoperfusion during heat stress since hyperthermia-induced hyperventilation results in hypocapnia. No regional differences in middle and posterior cerebral artery responsiveness were found with thermal stress.

Targeting workload to ameliorate risk of heat stress in industrial sugarcane workers.

OBJECTIVE: The aim of this study was to quantify the physiological workload of manual laborers in industrial sugarcane and assess the effect of receiving a rest, shade, and hydration intervention to reduce heat stress exposure risk. METHODS: In an observational study, physiological workload was evaluated for burned cane cutters (BCC), seed cutters (SC) and drip irrigation repair workers (DIRW) using heart rate (HR) recorded continuously (Polar®) across a work shift. Workers' percentage of maximal HR (%HRmax), time spent in different HR zones, and estimated core temperature (ECTemp) were calculated. The effect of increasing rest across two harvests was evaluated for BCC and SC. RESULTS: A total of 162 workers participated in this study [52 BCC (all male), 71 SC (13 female) and 39 DIRW (16 female)]. Average %HRmax across a work shift was similar between BCC and SC (BCC: 58%, SC: 59%), but lower in DIRW (51%). BCC and SC spent similar proportions of work shifts at hard/very hard intensities (BCC: 13%, SC: 15%), versus DIRW who worked mostly at light (46%) or light-moderate (39%) intensities. SC maximum ECTemp reached 38.2°C, BCC 38.1°C; while DIRW only reached 37.7°C. Females performed at a higher %HRmax than males across work shifts (SC 64% versus 58%; DIRW 55% versus 49%). An additional rest period was associated with a lower average %HRmax across a work shift in BCC. CONCLUSION: In this setting, BCC and SC both undertake very physiologically demanding work. Females maintained a higher workload than male co-workers. Regulated rest periods each hour, with water and shade access, appears to reduce physiological workload/strain.

Menstrual phase influences cerebrovascular responsiveness in females but may not affect sex differences.

Background and aims: Sex differences in the rate and occurrence of cerebrovascular diseases (e.g., stroke) indicate a role for female sex hormones (i.e., oestrogen and progesterone) in cerebrovascular function and regulation. However, it remains unclear how cerebrovascular function differs between the sexes, and between distinct phases of the menstrual cycle. This study aimed to compare cerebrovascular-CO2 responsiveness in 1) females during the early follicular (EF), ovulatory (O) and mid-luteal (ML) phases of their menstrual cycle; and 2) males compared to females during phases of lower oestrogen (EF) and higher oestrogen (O). Methods: Eleven females (25 ± 5 years) complete experimental sessions in the EF (n = 11), O (n = 9) and ML (n = 11) phases of the menstrual cycle. Nine males (22 ± 3 years) completed two experimental sessions, approximately 2 weeks apart for comparison to females. Middle and posterior cerebral artery velocity (MCAv, PCAv) was measured at rest, during two stages of hypercapnia (2% and 5% CO2 inhalation) and hypocapnia (voluntary hyperventilation to an end-tidal CO2 of 30 and 24 mmHg). The linear slope of the cerebral blood velocity response to changes in end-tidal CO2 was calculated to measure cerebrovascular-CO2 responsiveness.. Results: In females, MCAv-CO2 responsiveness to hypocapnia was lower during EF (-.78 ± .45 cm/s/mmHg) when compared to the O phase (-1.17 ± .52 cm/s/mmHg; p < .05) and the ML phase (-1.30 ± .82; p < .05). MCAv-CO2 responsiveness to hypercapnia and hypo-to-hypercapnia, and PCAv-CO2 responsiveness across the CO2 range were similar between menstrual phases (p ≥ .20). MCAv-CO2 responsiveness to hypo-to hypercapnia was greater in females compared to males (3.12 ± .91 cm/s/mmHg vs. 2.31 ± .46 cm/s/mmHg; p = .03), irrespective of menstrual phase (EF or O). Conclusion: Females during O and ML phases have an enhanced vasoconstrictive capacity of the MCA compared to the EF phase. Additionally, biological sex differences can influence cerebrovascular-CO2 responsiveness, dependent on the insonated vessel.

A Systematic Review and Meta-Analysis Examining Whether Changing Ovarian Sex Steroid Hormone Levels Influence Cerebrovascular Function.

Sex differences in cerebrovascular disease rates indicate a possible role for ovarian sex steroid hormones in cerebrovascular function. To synthesise and identify knowledge gaps, a systematic review and meta-analysis was conducted to assess how ovarian sex steroid hormone changes across the lifespan affect cerebrovascular function in women. Three databases (EMBASE, MEDLINE and Web of Science) were systematically searched for studies on adult cerebrovascular function and ovarian sex steroid hormones. Forty-five studies met pre-defined inclusion criteria. Studied hormone groups included hormone replacement therapy (HRT; n = 17), pregnancy (n = 12), menstrual cycle (n = 7), menopause (n = 5), oral contraception (n = 2), and ovarian hyperstimulation (n = 2). Outcome measures included pulsatility index (PI), cerebral blood flow/velocity (CBF), resistance index (RI), cerebral autoregulation, and cerebrovascular reactivity. Meta-analysis was carried out on HRT studies. PI significantly decreased [-0.05, 95% CI: (-0.10, -0.01); p = 0.01] in post-menopausal women undergoing HRT compared to post-menopausal women who were not, though there was considerable heterogeneity (I 2 = 96.8%). No effects of HRT were seen in CBF (p = 0.24) or RI (p = 0.77). This review indicates that HRT improves PI in post-menopausal women. However, there remains insufficient evidence to determine how changing ovarian sex steroid hormone levels affects cerebrovascular function in women during other hormonal phases (e.g., pregnancy, oral contraception).

The effect of social media interventions on physical activity and dietary behaviours in young people and adults: a systematic review.

BACKGROUND: The objectives of this systematic review were to update the evidence base on social media interventions for physical activity and diet since 2014, analyse the characteristics of interventions that resulted in changes to physical activity and diet-related behaviours, and assess differences in outcomes across different population groups. METHODS: A systematic search of the literature was conducted across 5 databases (Medline, Embase, EBSCO Education, Wiley and Scopus) using key words related to social media, physical activity, diet, and age. The inclusion criteria were: participants age 13+ years in the general population; an intervention that used commercial social media platform(s); outcomes related to changes to diet/eating or physical activity behaviours; and quantitative, qualitative and mixed methods studies. Quality appraisal tools that aligned with the study designs were used. A mixed methods approach was used to analyse and synthesise all evidence. RESULTS: Eighteen studies were included: randomised control trials (n = 4), non-controlled trials (n = 3), mixed methods studies (n = 3), non-randomised controlled trials (n = 5) and cross-sectional studies (n = 3). The target population of most studies was young female adults (aged 18-35) attending college/university. The interventions reported on positive changes to physical activity and diet-related behaviours through increases in physical activity levels and modifications to food intake, body composition and/or body weight. The use of Facebook, Facebook groups and the accessibility of information and interaction were the main characteristics of social media interventions. Studies also reported on Instagram, Reddit, WeChat and Twitter and the use of photo sharing and editing, groups and sub-groups and gamification. CONCLUSIONS: Social media interventions can positively change physical activity and diet-related behaviours, via increases in physical activity levels, healthy modifications to food intake, and beneficial changes to body composition or body weight. New evidence is provided on the contemporary uses of social media (e.g. gamification, multi-model application, image sharing/editing, group chats) that can be used by policy makers, professionals, organisations and/or researchers to inform the design of future social media interventions. This study had some limitations that mainly relate to variation in study design, over-reliance of self-reported measures and sample characteristics, that prevented comparative analysis. Registration number: PROPSERO; CRD42020210806 .

Corrigendum: Cerebral Hemodynamic and Neurotrophic Factor Responses Are Dependent on the Type of Exercise.

[This corrects the article DOI: 10.3389/fphys.2020.609935.].

Cerebral Hemodynamic and Neurotrophic Factor Responses Are Dependent on the Type of Exercise.

This study examined acute cerebral hemodynamic and circulating neurotrophic factor responses to moderate intensity continuous exercise (MICT), guideline-based high intensity interval exercise (HIIT), and sprint interval exercise (SIT). We hypothesized that the pattern of middle cerebral artery velocity (MCAv) response would differ between interval and continuous exercise, with SIT inducing the smallest increase from rest, while increases in neurotrophic factors would be intensity-dependent. In a randomized crossover design, 24 healthy adults (nine females) performed three exercise protocols: (i) MICT (30 min), (ii) HIIT (4 × 4 min at 85% HRmax), and (iii) SIT (4 × 30 s supramaximal). MCAv significantly increased from rest across MICT (Δ13.1 ± 8.5 cm⋅s-1, p < 0.001) and all bouts of HIIT (Δ15.2 ± 9.8 cm⋅s-1, p < 0.001), but only for the initial bout of SIT (Δ17.3 ± 11.6 cm⋅s-1, p < 0.001). Immediately following each interval bout, MCAv increased (i.e., rebounded) for the SIT (9-14% above rest, p ≤ 0.04), but not HIIT protocol. SIT alone induced significant elevations from rest to end-exercise in vascular endothelial growth factor (VEGF; Δ28 ± 36%, p = 0.017) and brain-derived neurotrophic factor (BDNF, Δ149% ± 162%, p < 0.001) and there were greater increases in lactate than in either other protocol (>5-fold greater in SIT, p < 0.001), alongside a small significant reduction at the end of active recovery in insulin-like growth factor 1 (IGF-1, Δ22 ± 21%, p = 0.002). In conclusion, while the nature of the response may differ, both guideline-based and sprint-based interval exercise have the potential to induce significant changes in factors linked to improved cerebrovascular and brain health.

The decline in attitudes toward physician-nurse collaboration from medical school to residency.

While interprofessional collaboration is a critical aspect of optimal patient care, practicing physicians often have sub-optimal attitudes regarding the importance of collaboration with their nursing colleagues. The impact of clinical training on medical students' and residents' attitudes toward physician-nurse collaboration has not been investigated. The primary goal of our study was to examine if learners at different stages in their medical training had more or less favorable attitudes regarding interprofessional collaboration (IPC). A secondary goal was to compare residents in procedural versus non-procedural specialties to determine if attitudes toward IPC varied by specialty type. Third-year medical students and residents at a large public university completed the Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration. Student (n = 129) and resident (n = 292) scores were compared using Student's t-tests. Resident responses were further analyzed by specialty type. Students' perceptions of the physician-nurse relationship were significantly more favorable than the views of residents, particularly in the "Authority" and "Responsibility" domains. Residents in procedural specialties had less favorable attitudes toward physician-nurse collaboration than those in non-procedural specialties. Our findings highlight the importance of developing effective interventions for improving interprofessional collaboration during medical training.

Effects of Shared Decision Making on Opioid Prescribing After Hysterectomy.

OBJECTIVE: To evaluate the effects of shared decision making using a simple decision aid for opioid prescribing after hysterectomy. METHODS: We conducted a prospective quality initiative study including all patients undergoing hysterectomy for benign, nonobstetric indications between March 1, 2018, and July 31, 2018, at our academic institution. Using a visual decision aid, patients received uniform education regarding postoperative pain management. They were then educated on the department's guidelines regarding the maximum number of tablets recommended per prescription and the mean number of opioid tablets used by a similar cohort of patients in a previously published study at our institution. Patients were then asked to choose their desired number of tablets to receive on discharge. Structured telephone interviews were conducted 14 days after surgery. The primary outcome was total opioids prescribed before compared with after implementation of the decision aid. Secondary outcomes included opioid consumption, patient satisfaction, and refill requests after intervention implementation. RESULTS: Of 170 eligible patients, 159 (93.5%) used the decision aid (one patient who used the decision aid was subsequently excluded from the analysis owing to significant perioperative complications), including 110 (69.6%) laparoscopic, 40 (25.3%) vaginal, and eight (5.3%) abdominal hysterectomies. Telephone surveys were completed for 89.2% (n=141) of participants. Student's t-test showed that patients who participated in the decision aid (post-decision aid cohort) were discharged with significantly fewer oral morphine equivalents than patients who underwent hysterectomy before implementation of the decision aid (pre-decision aid cohort) (92±35 vs 160±81, P<.01), with no significant change in the number of requested refills (9.5% [n=15] vs 5.7% [n=14], P=.15). In the post-decision aid cohort, 76.6% of patients (n=121) chose fewer tablets than the guideline-allotted maximum. Approximately 76% of patients (n=102) reported having leftover tablets. CONCLUSION: This quality improvement initiative illustrates that a simple decision aid can result in a significant decrease in opioid prescribing without compromising patient satisfaction or postoperative pain management.

Identifying Medical Student Mistreatment in the Obstetrics and Gynecology Clerkship.

OBJECTIVE: To characterize the mistreatment identified within the University of Michigan's Obstetrics and Gynecology (Ob/Gyn) clerkship and compare the rates of mistreatment to that of other clerkships in an effort to improve the learning environment. DESIGN: This is a retrospective cohort study looking at multiple sources of data from 2015 to 2018 about student mistreatment including end-of-rotation and teaching evaluations completed by students, as well as an online reporting system available to medical students. For evaluations, students were asked to rate their agreement with statements on a 5-point Likert scale (1 = strongly disagree, to 5 = strongly agree). Narrative comments were also solicited and evaluated. SETTING: University of Michigan Medical School and Michigan Medicine Ob/Gyn Department, Ann Arbor, Michigan. PARTICIPANTS: A total of 513 students rotated through the Ob/Gyn clerkship between 2015 and 2018 and were asked to complete evaluations. RESULTS: Five hundred and five of the 513 students completed evaluations between 2015 and 2018. In response to the statement, "Students are treated in a professional/respectful manner in this clerkship," the Ob/Gyn clerkship's mean scores on a 5-point scale were 4.45 (in 2015-2016), 4.52 (in 2016-2017), and 4.27 (in 2017-2018). These means, as well as the means to 3 other professionalism questions, were lower than the range of 4.42 to 4.84 for all other third-year clerkships over this time. The mean scores were also lower for Ob/gyn when compared to the Surgery clerkship. A total of 32 narrative comments were submitted by students between 2015 and 2017 related to mistreatment or unprofessional behavior. Frequent themes included students being treated as "stupid" or discouraged from asking questions (8 comments), being treated in an unprofessional manner by staff (7 comments), feeling ignored or marginalized by faculty (4 comments), and faculty unprofessional behavior toward others (4 comments). CONCLUSIONS: Students on the Ob/Gyn clerkship reported a higher rate of mistreatment compared to other clerkships. Efforts are being made by the Ob/Gyn department to communicate these data on mistreatment to educators in order to improve the Ob/Gyn culture and learning environment for medical students.

Opioid Prescribing Patterns, Patient Use, and Postoperative Pain After Hysterectomy for Benign Indications.

OBJECTIVE: To quantify physician prescribing patterns and patient opioid use in the 2 weeks after hysterectomy at an academic institution and to determine whether patient factors predict postsurgical opioid use and pain recovery. METHODS: We conducted a prospective quality initiative study by recruiting all English-speaking patients undergoing hysterectomy for benign, nonobstetric indications at a university hospital between August 2015 and December 2015, excluding those with major medical morbidities or substance abuse. Before hysterectomy, patients completed the Fibromyalgia Survey, a validated measure of centralized pain. After hysterectomy, opioid use (converted to oral morphine equivalents) and pain scores (0-10 numeric rating scale) were collected by a daily diary and a structured telephone interview 14 days after surgery. Primary outcomes were total opioid prescribed and consumed in the 2 weeks after hysterectomy. Secondary outcomes included daily opioid use and daily pain severity for 14 days after hysterectomy. RESULTS: Of 103 eligible patients, 102 (99%) agreed to participate, including 44 (43.1%) laparoscopic, 42 (41.2%) vaginal, and 16 (15.7%) abdominal hysterectomies. Telephone surveys were completed on 89 (87%) participants; diaries were returned from 60 (59%) participants. Diary nonresponders had different baseline characteristics than nonresponders. Median amount of opioid prescribed was 200 oral morphine equivalents (interquartile range 150-250). Patients reported using approximately half of the opioids prescribed with a median excess of 110 morphine equivalents (interquartile range 40-150). The best fit model of total opioid consumption identified preoperative Fibromyalgia Survey Score, overall body pain, preoperative opioid use, prior endometriosis, abdominal hysterectomy (compared with laparoscopic), and uterine weight as significant predictors. Highest tertile of Fibromyalgia Survey Score was associated with greater daily opioid consumption (13.9 [95% CI 3.0-24.8] greater oral morphine equivalents at baseline, P=.02). CONCLUSION: Gynecologists at a large academic medical center prescribe twice the amount of opioids than the average patient uses after hysterectomy. A personalized approach to prescribing opioids for postoperative pain should be considered.

Patients' Knowledge and Perceptions of Morcellation.

BACKGROUND AND OBJECTIVES: Morcellation has received increased media and professional attention, but it remains unclear how much the average patient knows about this topic. We sought to evaluate patients' knowledge of morcellation, assess their perceptions of the risks and benefits, and determine how these perceptions affect their decision regarding the route of surgery. METHODS: Anonymous paper surveys were administered to 500 patients attending gynecologic appointments at the University of Michigan. Survey questions gathered demographic information and assessed knowledge of various surgical approaches for hysterectomy and myomectomy. Questions regarding patients' knowledge of morcellation explored various types of morcellation and the risks and benefits of this procedure. RESULTS: Of the 500 surveys administered, 396 patients answered at least 1 survey question resulting in a response rate of 79.2%. The mean ± SD age of respondents was 47.0 ± 14.1 years, 80.8% were white, and 83.1% had completed some college. Only 8.3% of patients reported that they had ever heard of morcellation. Even among women who were actively considering a hysterectomy or myomectomy (n = 33) or those who had undergone a hysterectomy or myomectomy (n = 98), only 12.1 and 7.1%, respectively, had heard of morcellation. Of those who had heard of morcellation (n = 32), only 9.4% correctly identified the definition in a multiple-choice question. Only 4.0% of women would choose an abdominal approach to avoid morcellation. CONCLUSIONS: Patients have very little knowledge about morcellation and most patients have never heard of the procedure. Very few patients would refuse morcellation and opt for an abdominal surgery instead.

Risk Factors for Emergency Department Visits After Hysterectomy for Benign Disease.

OBJECTIVE: To identify the incidence, indications, and risk factors for emergency department visits that do not result in readmission within 30 days of hysterectomy for benign disease. METHODS: We conducted a secondary data analysis of hysterectomies for benign disease using the Michigan Surgical Quality Collaborative, a statewide group of hospitals that voluntarily reports perioperative outcomes. Hysterectomies for benign disease were abstracted from January 1, 2013, to July 2, 2014. We examined the incidence of emergency department visits within 30 days after hysterectomy for benign disease and constructed a multivariable logistic regression model to identify risk factors for these visits. We focused on emergency department visits that did not result in readmission because they are more likely to represent avoidable encounters. RESULTS: Among the 10,274 women who underwent hysterectomy for benign disease during the study period, 932 (9.1%) presented to the emergency department and were not readmitted to the hospital. Based on a multivariable regression model, risk factors for emergency department visits after hysterectomy for benign disease were younger age, higher parity, Medicaid or self-pay insurance, prior venous thromboembolism, chronic obstructive pulmonary disease, preoperative surgical indication of chronic pelvic pain, and postoperative day 1 pain scores greater than 4 on a 0-10 numeric rating scale. The most common primary emergency department International Classification of Diseases, 9th Revision diagnoses were for pain (29.5% [n=275]), gastrointestinal (12.8% [n=118]), and genitourinary (10.7% [n=99]) complaints. CONCLUSION: Approximately 1 in 11 women present to the emergency department, but do not result in readmission within 30 days of hysterectomy for benign disease. Emergency department visits might be avoided with expanded perioperative education and improved communication pathways for high-risk patients.

Nonobstructive Reproductive Tract Anomalies: A Review of Surgical Management.

Müllerian anomalies include a spectrum of anatomic variants of the genital tract arising from abnormal embryologic development, ranging from incomplete resorption of uterine septa to complete vaginal agenesis. Nonobstructive anomalies are often recognized later than obstructive anomalies, because women do not present with pain. However, nonobstructive anomalies frequently have a negative impact on sexual and reproductive health, and careful evaluation and management of these disorders is warranted. This review focuses on the surgical management of nonobstructive Müllerian anomalies.

Obstructive Reproductive Tract Anomalies: A Review of Surgical Management.

Müllerian anomalies are anatomic disorders affecting the female reproductive tract, leading to a variety of physical symptoms, findings, and reproductive outcomes. Such anomalies are sufficiently common that most gynecologists will encounter women affected by them. Patients with obstructive müllerian anomalies generally present in adolescence with pain associated with the obstruction of menstrual outflow; thus, these disorders are frequently managed surgically. This review focuses on the surgical management of obstructive müllerian anomalies.

Laparoscopic Removal of a Retroperitoneal Hysteroscopic Microinsert Using Fluoroscopy.

Perforation during placement of hysteroscopic microinserts for permanent sterilization occurs in approximately .9% to 2.6% of women undergoing the procedure. Most of the time perforation results in intraperitoneal placement of the hysteroscopic microinsert requiring laparoscopy or laparotomy for removal of the device. Herein we present a case of hysteroscopic microinsert perforation with subsequent retroperitoneal identification of the device. This is the first such case to our knowledge of retroperitoneal identification and retrieval of a perforated device that required real-time fluoroscopy during laparoscopy.

Improving the medical school-residency transition.

BACKGROUND: In response to calls to improve the continuum between undergraduate and graduate medical education, many medical schools are creating electives designed to prepare students for residency training. There is a need for data that link improvements from these residency preparation courses to residency itself. Data is needed that links improvements from these residency preparation courses to residency OBJECTIVE: To examine senior medical student performance on the Association of Professors of Gynecology and Obstetrics (APGO) Preparation for Residency Knowledge Assessment before and after an obstetrics and gynaecology residency preparation elective, and to determine whether the knowledge improvements persisted to the start of the residency. METHODS: All 13 students enrolled in the course completed the APGO knowledge assessment on the first and last day of the elective. Three months later, the students were asked to re-take the assessment immediately prior to the start of their residency. RESULTS: There was improvement in mean scores from the pre-test score of 66.4 per cent to the post-test score of 77.4 per cent. At the time of the pre-test, three of the 13 students (23%) had passing scores (70% or greater), and at the time of the post-test, 11 of the 13 (85%) had passing scores. Nine of the 13 students (69%) completed the APGO knowledge assessment immediately prior to the start of their residency. Those nine students had a mean pre-residency score of 76.4 per cent. Eight of the nine students (89%) passed the pre-residency test. CONCLUSIONS: Our data support the value of residency preparation electives for improving knowledge, and suggest that senior medical school electives can help to bridge the continuum between undergraduate and graduate medical education.

Risk Factors and Outcomes for Conversion to Laparotomy of Laparoscopic Hysterectomy in Benign Gynecology.

OBJECTIVE: To estimate the incidence and factors for conversion to laparotomy in women scheduled for laparoscopic hysterectomy for benign gynecologic indications and to examine the effect of conversion on patient outcomes. METHODS: A retrospective cohort study of a Michigan multicenter prospective database was abstracted from January 1, 2013, through July 2, 2014. Participants were collected from an all-payer quality and safety database maintained by the Michigan Surgical Quality Collaborative. Women with a preoperative indication of cancer or obstetric indications were excluded. A logistic regression model was used to calculate odds of conversion using patient preoperative and intraoperative attributes. RESULTS: During the study period, 6,992 women underwent an attempted laparoscopic hysterectomy with 3.93% (n=275) converted to laparotomy. After adjusting for socioeconomic differences, hysterectomy indication, and intraoperative factors, there were decreased odds of conversion to laparotomy with use of robotic-assisted laparoscopy compared with traditional laparoscopy (adjusted odds ratio [OR] 0.14, 95% confidence interval [CI] 0.07-0.25) with a predicted risk of conversion of 0.8% compared with 5.4% (P<.001). High-volume surgeons were less likely to convert to laparotomy compared with low- and medium-volume surgeons (adjusted OR 0.66, 95% CI 0.47-0.92) with a predicted risk of conversion of 1.4% compared with 2.25% (P=.015). Conversion was associated with moderate or severe adhesive disease and increasing specimen weight. Conversion was associated with increased rates of surgical site infection, blood transfusion, severe sepsis, and reoperation. CONCLUSION: This analysis demonstrates that conversion to laparotomy is associated with increased odds of postoperative morbidity, and robotic assistance and surgeon volume are strongly associated with decreased odds of conversion.

A Favorability Score for Vaginal Hysterectomy in a Statewide Collaborative.

STUDY OBJECTIVE: Because it is associated with fewer complications and more rapid recovery, the vaginal approach is preferred for benign hysterectomy. Patient characteristics that traditionally favor a vaginal approach include adequate vaginal access, small uterine size, and low suspicion for extrauterine disease. However, the low proportion of hysterectomies performed vaginally in the United States suggests that these data are not routinely applied in clinical practice. We sought to analyze the association of parity, prior pelvic surgery, and uterine weight with the use of the vaginal, laparoscopic, robotic, and abdominal approaches to hysterectomy. DESIGN: A retrospective cohort study (Canadian Task Force classification II-2). SETTING: The Michigan Surgical Quality Collaborative is a statewide organization of 52 academic and community hospitals in Michigan funded by Blue Cross and Blue Shield of Michigan/Blue Care Network, including patients from all insurance payers. PATIENTS: Five thousand six hundred eight women undergoing hysterectomy for benign gynecologic conditions from January 1, 2013, through December 8, 2013, and included in the Michigan Surgical Quality Collaborative. INTERVENTIONS: To assess potential for vaginal hysterectomy, a favorability score of 0, 1, 2, or 3 was calculated by summing 1 point each for parity ≥1, no prior pelvic surgery, and uterine weight <250 g. Frequencies of surgical approaches to hysterectomy were compared using chi-square tests across favorability scores. MEASUREMENTS AND MAIN RESULTS: The use of robotic hysterectomy was most frequent (41.9%, n = 2349/5608) followed by abdominal (19.7%, n = 1103/5608), laparoscopic (14.4%, n = 809/5608), vaginal (13.5%, n = 758/5608), and laparoscopic-assisted vaginal (10.5%, n = 589/5608) hysterectomy. With favorability scores of 0, 1, 2, and 3, vaginal hysterectomy was performed in 0.6% (n = 1/167), 5% (n = 66/1324), 13.7% (n = 415/3036), and 25.5% (n = 276/1081) of cases and abdominal hysterectomy in 41.9% (n = 70/167), 30.8% (n = 408/1324), 17.5% (n = 531/3036), and 8.7% (n = 94/1081), respectively. There was little variation in the rates of laparoscopic hysterectomy (13.3%-16.8%, p = .429) and robotic hysterectomy (39.5%-42.4%, p = .518) across favorability scores. CONCLUSION: In a population of women undergoing hysterectomy in the state of Michigan, the use of vaginal and abdominal hysterectomy varied with respect to parity, prior pelvic surgery, and uterine weight, but there was little variation in the use of laparoscopic and robotic approaches. The favorability score could potentially be used as a quality improvement tool to evaluate practice patterns with respect to the use of various surgical approaches to hysterectomy.