Resident duty-hour restrictions and their effect on operative experience in obstetrics and gynecology.

BACKGROUND/AIMS: To determine the effect of duty-hour restrictions on the operative experience of obstetrics and gynecology residents. METHODS: Operative numbers were obtained from graduates of Mayo Clinic (Rochester, Minn., USA) and Good Samaritan Hospital (Cincinnati, Ohio, USA). Mean operative numbers between graduates in 2007 and 2003 were compared. The following procedures were evaluated: spontaneous vaginal delivery, forceps-assisted vaginal delivery, vacuum-assisted vaginal delivery, cesarean delivery, surgery on antenatal patients, amniocentesis, total abdominal hysterectomy, total vaginal hysterectomy, laparotomy, incontinence or pelvic floor surgery, operative laparoscopy, hysteroscopy, cervical conization, and surgical sterilization. The number of procedures performed (total and as the primary surgeon) were evaluated. We analyzed each institution's residents separately. RESULTS: At Mayo Clinic, the 2007 graduates performed significantly fewer conizations than the 2003 graduates (p = 0.006). At Good Samaritan Hospital, the 2007 graduates performed significantly more vacuum-assisted vaginal deliveries (p = 0.002), cesarean deliveries (p = 0.002), and sterilizations (p < 0.001) than the 2003 graduates. The above findings were unchanged when evaluating procedures for which the resident was the primary surgeon. CONCLUSION: Duty-hour restrictions have not adversely affected the operative experience of obstetrics and gynecology residents. No significant differences in the number of the spontaneous vaginal deliveries, abdominal hysterectomies, or vaginal hysterectomies performed were observed.

Effects of an educational workshop on performance of fourth-degree perineal laceration repair.

OBJECTIVE: To develop a valid and reliable tool to objectively measure surgical skill necessary for repair of fourth-degree perineal lacerations and then to use this tool to measure improvement after a workshop. METHODS: We measured baseline surgical ability and clinical knowledge of 26 residents (postgraduate year [PGY]-1 to PGY-4) using the Objective Structured Assessment of Technical Skills (OSATS) and a written examination. The OSATS consists of a global surgical skills assessment (OSATS-G), a procedure checklist (OSAT-C), and pass/fail grade. Five weeks after our baseline evaluation, a 1.5-hour workshop was administered to approximately half of the 26 residents (n=14). One week after this intervention, the residents were re-examined using the same assessment tools. RESULTS: The OSATS demonstrated construct validity as scores on the examination increased on both the OSATS-G and the OSATS-C from PGY-1 through PGY-4 (P=.001 and P=.041, respectively). Reliability indices for the OSATS were high. Eighty-one percent of the residents failed the OSATS before intervention because of failure to identify and repair the internal anal sphincter. After educational intervention, senior residents improved on all assessments (OSATS-G, P=.041; OSATS-C, P=.004; written examination, P=.008), and all residents passed the OSATS. CONCLUSION: A valid and reliable OSATS and written examination were developed to assess surgical skills, knowledge, and judgment necessary to properly manage fourth-degree perineal lacerations. Residents improved on the OSATS and the written examination after undergoing a structured educational workshop. LEVEL OF EVIDENCE: II.

Vulvovaginal candidiasis from non-albicans species: retrospective study of recurrence rate after fluconazole therapy.

OBJECTIVE: To investigate the recurrence rate of vulvovaginal candidiasis from non-albicans species after fluconazole therapy. STUDY DESIGN: A retrospective cohort of 127 patients with symptomatic vulvovaginal candidiasis by nonalbicans species referred from primary care physicians were evaluated between 1995 and 2004. Complete history, physical examination, basic metabolic panel, and bacterial and fungal cultures were performed. All patients received a daily dose of fluconazole for 30 days. Follow-up evaluations were done at 1, 3, 6, and 12 months. RESULTS: The recurrence rate for all non-albicans vulvovaginitis was 40.2%, 46.5%, 50.4% and 54.2% at 1, 3, 6, and 12 months, respectively. Patients with symptomatic recurrences were more likely to be younger than 35 years of age, older than 65, nulliparous and fastidious vulvar cleaners and were more likely to have concomitant bacterial infections. CONCLUSION: The recurrence rate of symptomatic vulvovaginal candidiasis colonized by non-albicans species after fluconazole therapy was 50.4% at 6 months and 54.2% at 12 months. Nulliparity and age <35 or > 65 years and fastidious vulvar cleaning were positively associated with symptomatic recurrent episodes.

Total and subtotal abdominal hysterectomy.

Hysterectomy is one of the most frequently performed operations in the world, accounting for 500,000-600,000 procedures annually in the USA; the abdominal route for hysterectomy is the preferred route in 60-80% of these operations. Although the number of total abdominal hysterectomies performed annually has decreased, the number of subtotal abdominal hysterectomies increased by >400%. The major indications for abdominal hysterectomy include abnormal uterine bleeding, myomata uteri, adenomyosis, endometriosis, neoplasia, and chronic salpingitis. The basis for selection for subtotal versus total hysterectomy has little in the way of factual data to support it and may actually present some significant disadvantages, such as continued menstruation and cervical prolapse. The detailed technique for performing intrafascial abdominal hysterectomy relies heavily on precise knowledge of pelvic anatomy and compulsive detail to tissue handling. The consistent and correct usage of prophylactic antimicrobials, measures to prevent thromboemboli, and procedures to avoid urinary retention are key to the overall success of the surgery.

Post-menopausal recurrent vaginal candidiasis: effect of hysterectomy on response to treatment, type of colonization and recurrence rates post-treatment.

INTRODUCTION: Post-menopausal patients are still susceptible to be colonized by fungal organisms despite being estrogen-deprived. Symptomatic vulvovaginal candidiasis, although a rare occurrence in post-menopausal patients, can be diagnosed in about one third of the patients. The purpose of our study was to investigate in post-menopausal patients with recurrent vulvovaginal candidiasis the effect of hysterectomy on response to treatment, the type of colonization and the recurrence rates after treatment. MATERIALS: Forty-seven menopausal patients with symptomatic recurrent vulvovaginal colonization were evaluated between January 1995 and August 2002. The study was a retrospective cohort chart review and included complete history and physical examination, basic metabolic blood panel, colposcopy, wet mount, bacterial and fungal cultures. Twenty-three patients had hysterectomy and 24 were not hysterectomized. All the patients received daily fluconazole therapy for 30 days. They were then re-evaluated at 1, 3 and 6 months and retreated if symptomatic and culture positive. RESULTS: The 2 groups of patients were comparable regarding age, number of years of recurrent colonization, number of previous antifungal treatments and previous, current use of hormone replacement therapy. None used vaginal douching. The 2 groups of patients showed statistical differences regarding: colonization by Candida albicans (P<0.01), colonization by Candida glabrata (P<0.05), colonization by Candida stelloidea (P<0.01), recurrence after 3 months (P<0.05) and 6 months (P<0.05), response to one course of therapy (P<0.02) and need for multiple treatments (P<0.03). CONCLUSIONS: Hysterectomized post-menopausal patients with recurrent vulvovaginal fungal colonization seems to be more propense to harbor more aggressive and resistant fungi. Post-menopausal recurrent vaginal candidiasis: effect of hysterectomy on response to treatment, type of colonization and recurrence rates post-treatment.