End-of-Rotation Examinations in Canadian Obstetrics and Gynaecology Residency Programs: The Perspectives of Faculty Members and Residents.

The Royal College Competence by Design curriculum in obstetrics and gynaecology will launch in 2019, and it will depend heavily on multiple tools for accurate resident assessment. Several Canadian obstetrics and gynaecology residency programs use rotation-specific examinations at the end of various rotations for formative feedback. The obstetrics and gynaecology residency program at the University of Toronto adopted end-of-rotation examinations (EOREs) in 2014. We conducted a national survey to assess the current use of EOREs across Canada and to examine the attitudes and beliefs of residents and program directors regarding their use. We discuss faculty and resident experiences with EOREs and their perceptions of them. We also consider the role and benefit of these examinations in the context of the educational literature, and how they may integrate with future competency-based medical education frameworks.

Development of a Night Float Call Model for Obstetrics and Gynaecology Residency: The Process and Residents' Perceptions.

The 2013 pan-Canadian consensus Report on Resident Duty Hours identified that traditional 24-hour duty periods pose risks to the well-being of residents and should be avoided. In anticipation of duty-hour restrictions, the Obstetrics and Gynaecology Residency Program at the University of Toronto developed and implemented a night float (NF) call model over a three-year span. Quarterly resident surveys have consistently shown that the NF system is preferred to traditional 24-hour call and has resulted in reduced fatigue and improved continuity of patient care. Through many iterations, the NF model achieved levels of resident morale, surgical experience, and impact on family relationships that are comparable to the 24-hour call system. We review here our process for developing an NF call model and the perceptions and experiences of residents, with the goal of providing insight for other residency programs that are considering or instituting NF call systems.

Pregnancy outcomes in women with polycystic ovary syndrome undergoing in vitro fertilization.

OBJECTIVE: To determine whether the diagnosis of polycystic ovary syndrome (PCOS) independently predicts increased rates of pregnancy complications relative to control subjects, after adjusting for important confounders. DESIGN: Retrospective cohort. SETTING: Not applicable. PATIENT(S): A review of all pregnancies after fresh IVF with or without intracytoplasmic sperm injection transfers from December 2006 to 2012 (n = 1,084) identified 394 eligible singleton births (71 women with PCOS; 323 controls without). INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Singleton births were assessed for selected adverse pregnancy and birth outcomes. RESULT(S): Women with PCOS demonstrated a higher risk of developing the following pregnancy complications after adjusting for differences in age, parity, body mass index, and time to conception: gestational diabetes (adjusted odds ratio [AOR] 3.15, 95% confidence interval [CI] 1.35-7.33), hypertensive disorders of pregnancy (AOR 4.25, 95% CI 1.94-9.32), preterm birth <37 weeks (AOR 2.30, 95% CI 1.07-4.97), and large for gestational age >90th percentile (AOR 2.77, 95% CI 1.21-6.35). The increased risk of preterm birth <37 weeks was eliminated after adjusting for development of hypertensive disorders of pregnancy, whereas the increased risk of large for gestational age remained significant after adjusting for gestational diabetes mellitus status. Time to conception did not differ significantly between groups, nor did rates of antepartum hemorrhage, cesarean section, or perinatal mortality. CONCLUSION(S): Polycystic ovary syndrome independently predicts higher risk of adverse pregnancy outcomes after adjusting for differences in maternal age, parity, body mass index, and time to conception. This new information may be of relevance in counseling and monitoring women with PCOS, although larger prospective studies may be needed to validate our findings.

Fibroid infected with Escherichia coli requiring surgical removal following uterine artery embolization.

BACKGROUND: Uterine fibroid necrosis and infection is a rare but potentially serious event following uterine artery embolization (UAE). We describe a case of surgical removal of an infected necrotic uterine fibroid. CASE: A 31-year-old Jehovah's Witness with severe anemia presented with sepsis following UAE. The uterus was preserved by performing transvaginal surgical removal. Final pathology demonstrated Escherichia Coli infection of the necrotic fibroid. The patient improved postoperatively. CONCLUSION: Surgical removal of an infected necrotic fibroid may be a preferred option for women wishing to avoid hysterectomy following UAE. Appropriate case selection and optimization of hemoglobin concentration before UAE is important to minimize complications.

Contexte : La nécrose et l'infection d'un fibromyome utérin constituent un événement rare, mais potentiellement grave, à la suite de l'embolisation de l'artère utérine (EAU). Nous décrivons un cas de retrait chirurgical d'un fibromyome utérin nécrosé et infecté. Cas : Une témoin de Jéhovah de 31 ans connaissant une anémie grave a présenté une sepsie à la suite d'une EAU. L'utérus a été préservé au moyen de l'exécution d'un retrait chirurgical transvaginal. L'examen pathologique final a démontré la présence d'une infection à Escherichia Coli dans le fibromyome nécrosé. L'état de la patiente s'est amélioré à la suite de l'opération. Conclusion : Le retrait chirurgical d'un fibromyome utérin nécrosé et infecté pourrait constituer l'option à privilégier pour les femmes qui souhaitent éviter l'hystérectomie à la suite d'une EAU. Avant la tenue d'une EAU, il s'avère important de bien sélectionner les patientes qui pourraient en tirer avantage et d'optimiser la concentration en hémoglobine, et ce, afin de minimiser les complications.

Pregnancy outcomes in women with spinal cord lesions.

OBJECTIVE: Women with spinal cord lesions present special challenges during pregnancy. We studied their pregnancy outcomes with regard to medical, obstetrical, and social concerns. METHODS: We reviewed the records of pregnant women with spinal cord injury who attended our institution between 1999 and 2009. RESULTS: Thirty-two women with a total of 37 pregnancies were identified. Most were nulliparous (65%) with either thoracic or lumbar spinal cord lesions due to neural tube defects (69%), trauma (19%), tumours (9%), or iatrogenic injury (3%). Most had undergone orthopedic surgery (63%) or neurosurgery (53%). The most common medical conditions were neurogenic bladder (53%), anemia (16%), autonomic hyperreflexia (9%), and elevated BMI > 30 (6%). Recurrent urinary tract infection occurred in 32%. Antibiotic suppression against bacteriuria was used in 35%. Antenatal hospitalization occurred in 46%, most often because of threatened preterm labour (19%). There were 33 live births and two stillbirths (6%). Preterm birth < 37 weeks occurred in 24%. Vaginal birth occurred in 33%. CONCLUSION: Pregnant women with spinal cord lesions generally have successful pregnancy outcomes. However, their pregnancies are at significant risk for preterm birth, infection, and Caesarean section. Coordinated multidisciplinary care is recommended for optimal management of these pregnancies.

Protocol development for ovarian cancer treatment in Kenya: a brief report.

INTRODUCTION: Ovarian cancer is a leading cause of cancer death for Kenyan women. Most women are diagnosed with an advanced stage of disease. The current North American standard of care includes surgery followed by carboplatin and paclitaxel. Neither drug is available for Kenyan women. We performed a literature search investigating chemotherapy in low resource countries with the aim to write an evidence-based chemotherapy protocol for women diagnosed with ovarian cancer in Eldoret, Kenya, at the Moi Teaching and Referral Hospital. METHODS: We systematically searched PubMed and EMBASE for articles describing chemotherapy treatment outcomes of ovarian epithelial cancer in low-resource settings. After data analysis, a secondary review was undertaken on randomized controlled trials(RCTs) aligning with chemotherapy availability in Kenya. RESULTS: We identified 1184 articles. Fourteen met our criteria: ovarian epithelial cancer,low resource, chemotherapy use, and survival or response data. No publications were RCTs or had a cohort larger than 100 patients. There was no consistency in drug choice between studies. After this search, we reviewed commonly quoted and relevant RCTs and meta-analyses conducted on ovarian cancer since the 1980s. Although RCTs in the developed world suggest carboplatin and taxol provide optimal survival benefit, these drugs are unavailable in Kenya. Cyclophosphamide and cisplatin provide the next most optimal survival benefit, with acceptable and manageable toxicity. Because these drugs are more available and affordable in Kenya, we have developed a protocol recommending their use, which has been accepted by the Moi Teaching and Referral Hospital. CONCLUSIONS: Currently, there is a paucity of published RCTs that may guide treatment in low-resource settings. One considerable barrier to establishing and evaluating chemotherapy protocols in low-resource settings may be the cost of chemotherapy drugs. There needs to be an international movement to make cancer chemotherapeutics available at lower prices in low-resource settings.

Reporting of serious adverse drug reactions of targeted anticancer agents in pivotal phase III clinical trials.

PURPOSE: Oncologists prescribe anticancer drugs based on results of phase III randomized clinical trials (RCTs), but some safety concerns appear only later in updated drug labels. Here, we analyze adverse drug reactions (ADRs) of targeted anticancer agents from updated drug labels and their reporting in corresponding pivotal RCTs. METHODS: We searched the US Food and Drug Administration (FDA) Web site for approved targeted anticancer drugs with updates of their labels related to safety in 2008 and 2009 and at least one RCT referenced in the updated drug label. For each drug, serious ADRs, including potentially fatal ADRs, were identified from the updated label. Published reports of RCTs referenced in the label were searched to determine whether they described these ADRs. RESULTS: We identified 12 eligible targeted anticancer agents with 36 corresponding RCTs referenced in updated drug labels. There were 76 serious ADRs reported in updated drug labels, and 50% (n = 38) were potentially fatal. Of these, 39% (n = 30) of all serious ADRs and 39% (n = 15) of potentially fatal ADRs were not described in any published report of RCTs, whereas 49% and 58%, respectively, were not described in initial drug labels. After a median 4.3 years between initial approval and update of drug labels, 42% (n = 5) of targeted cancer agents acquired one or more boxed warnings (the highest level of FDA alert). CONCLUSION: Published reports of pivotal RCTs and initial drug labels contain limited information about serious ADRs of targeted anticancer agents. Rare but serious ADRs may be important causes of morbidity and mortality in general oncologic practice.