Duration of Induction of Labor for Second-Trimester Medication Abortion and Adverse Outcomes.

OBJECTIVE: To evaluate the relationship between duration of labor during second-trimester medication abortion and adverse outcomes. METHODS: We conducted a retrospective cohort study including all individuals with a singleton gestation undergoing second-trimester medication abortion without evidence of advanced cervical dilation, rupture of membranes, or preterm labor at four centers. The primary exposure was duration of labor (ie, hours spent from receiving misoprostol to fetal expulsion). The primary outcome was composite morbidity , defined as uterine rupture, need for blood transfusion, clinical chorioamnionitis, intensive care unit admission, or need for readmission. We performed bivariate and multivariate negative binomial analyses. A post hoc subgroup analysis was performed to assess for the risk of the primary outcome by gestational age. We performed tests of homogeneity based on history of uterine scarring and parity. RESULTS: Six hundred eighty-one individuals were included. The median duration of labor was 11 hours (interquartile range 8-17 hours). One hundred thirty-one (19.2%) experienced the primary outcome. When duration of labor was evaluated continuously, a longer duration of labor was associated with an increased frequency of morbidity (adjusted ß=0.68, 95% CI, 0.32-1.04). When duration of labor was evaluated categorically, those experiencing the highest quartile of duration (ie, 17 hours or more) had a statistically higher risk for experiencing morbidity compared with individuals in all other quartiles (adjusted relative risk 1.99, 95% CI, 1.34-2.96). When we focused on components of the composite outcome, clinical chorioamnionitis was significantly different between those experiencing a longer duration and those experiencing a shorter duration of labor (26.2% vs 10.6%, P <.001). On subgroup analysis, gestational age was not associated with the risk of composite morbidity. Tests of homogeneity demonstrated no significant difference in the risk for morbidity among individuals with a history of uterine scarring or based on parity. CONCLUSION: Duration of labor was independently associated with risks for adverse maternal outcomes during second-trimester medication abortion, specifically clinical chorioamnionitis.

Training to Enhance the Knowledge and Comfort Level of Emergency Physicians Providing Care for Survivors of Sexual Assault.

INTRODUCTION: Although sexual assault (SA) is a substantial public health problem, emergency physicians do not universally undergo continuing education on caring for survivors of SA. The goal of this intervention was to develop a training course that improves physician understanding of trauma-sensitive care in the emergency department and equips physicians with knowledge of the specialized care required to treat SA survivors. METHODS: Thirty-nine attending emergency physicians underwent a 4-hour training on trauma-sensitive care for survivors of SA and completed prequestionnaires and postquestionnaires to assess training efficacy in improving knowledge base and comfort level providing care. The training consisted of didactic portions focused on the neurobiology of trauma, communication skills, and forensic evidence collection techniques and a simulation portion with standardized patients to practice evidence collection and a trauma-sensitive anogenital examination. RESULTS: Physicians demonstrated significantly improved performance (P < .05) on 12 of 18 knowledge-based questions. Physicians also showed significant improvement (P < .001) on 11 of 11 Likert scale questions that assessed comfort level communicating with survivors and using trauma-sensitive techniques during medical and forensic examinations. CONCLUSION: Physicians who received the training course demonstrated a significantly improved knowledge base and comfort level treating survivors of SA. Considering the prevalence of sexual violence, it is imperative that physicians are appropriately educated on trauma-sensitive care.

Complications of second-trimester medical termination of pregnancy for fetal anomalies compared with intrauterine fetal demise.

OBJECTIVE: To assess complication rates of patients undergoing a second-trimester medical termination for intrauterine fetal demise compared with fetal anomalies. METHODS: We performed a retrospective cohort study comparing patients undergoing medical termination for a fetal anomaly versus medical termination for intrauterine fetal demise (IUFD) before 24 weeks of gestation. Data were collected from two urban academic medical centers from 2009 to 2019. Institutional review board approval was obtained from both institutions and patient consent was not required. We included singleton gestations between 14.0 weeks and 23.6 weeks undergoing induction with mifepristone and misoprostol or misoprostol alone. Groups were matched based on gestational age with a 1:1 ratio. The primary outcome was composite complication rate (retained placenta requiring dilation and curettage, suspected infection, hemorrhage, failed induction requiring dilation and evacuation, intensive care unit admission, and readmission). RESULTS: Ninety-five patients were in each group. The groups differed in patient mean age (fetal anomaly 34 years versus 31 years for IUFD, P = 0.005) and mifepristone pretreatment (fetal anomaly 55% versus IUFD 5%, P < 0.001). Composite complication rate was similar (fetal anomaly 14% versus IUFD 17%), and specific complications did not differ. CONCLUSION: Second-trimester medical termination for IUFDs have similar complication rates as those undergoing induction terminations for fetal anomalies.

Association between Food Deserts and Gestational Diabetes Mellitus in a Large Metropolitan Area.

OBJECTIVE: The aim of this study is to determine the relationship between urban food deserts and frequency and obstetric outcomes related to gestational diabetes. STUDY DESIGN: We conducted a retrospective cohort study of singleton births in Chicago from 2010 to 2014. Birth certificate data were analyzed and geomapped by census tract. Census tracts were categorized as "food deserts" according to the USDA Food Access Research Atlas. The primary outcome was frequency of gestational diabetes. Secondary outcomes were assessed among women with gestational diabetes and their neonates. RESULTS: Of the 191,947 eligible women, 8,709 (4.5%) were diagnosed with gestational diabetes. Those in food deserts were more likely to be younger, obese, minority race/ethnicity, and multiparous. Women in food deserts were less likely to develop gestational diabetes (3.8 vs. 4.8%, p < 0.01; adjusted odds ratio 0.91, 95% confidence interval 0.86-0.96). Women with gestational diabetes did not experience worse maternal and neonatal outcomes after controlling for potential confounders. CONCLUSION: In contrast to prior work, women in Chicago living within food deserts were less likely to develop gestational diabetes and did not experience poorer outcomes, suggesting environmental factors other than food access contribute to perinatal outcomes.

Biomechanical Comparison of Ulnar Collateral Ligament Reconstruction With the Docking Technique Versus Repair With Internal Bracing.

BACKGROUND: The modified Jobe technique of ulnar collateral ligament (UCL) reconstruction has previously been biomechanically compared with primary repair augmented with internal bracing. However, the docking technique has not been compared with repair with internal bracing. HYPOTHESIS: Load to failure, gapping, and valgus opening angle are similar under valgus loading at 90° of flexion between repair with internal bracing and the docking technique for the UCL. STUDY DESIGN: Controlled laboratory study. METHODS: Nine matched pairs of fresh-frozen cadaveric elbows were potted with the forearm in neutral rotation. The palmaris longus tendon graft was harvested, and the bone was sectioned 14 cm proximal and distal to the elbow joint. First, native UCL testing was performed at 90° of flexion with 0.5 N·m preload, followed by a 5 N·m valgus moment to the elbow in cycles of 1, 10, 100, and 1000 at 1 Hz. The specimens were then loaded to failure at a rate of 0.2 mm/s. Next, the elbows were randomly divided into matched pairs to undergo either UCL reconstruction with docking technique or UCL repair augmented with internal bracing. Last, these specimens underwent testing as aforementioned. RESULTS: Load to failure, gapping, and valgus opening angle did not differ significantly between native ligaments that underwent reconstruction or repair with internal bracing, paired native ligaments and reconstructions, paired native ligaments and repairs augmented with internal bracing, or reconstructions and repairs augmented with internal bracing. CONCLUSION: UCL reconstruction with docking technique and repair augmented with internal bracing provides valgus stability to the medial elbow comparable to the native ligament at 90°. No significant differences were noted between docking reconstruction and repair techniques for load to failure, gapping, or valgus opening angle during cyclic loading at time zero. CLINICAL RELEVANCE: Our results suggest that UCL repair with internal bracing has a similar biomechanical profile at the time of initial fixation compared with the docking technique of UCL reconstruction.

Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry of model prebiotic peptides: Optimization of sample preparation.

RATIONALE: Depsipeptides, or peptides with a mixture of amide and ester linkages, may have evolved into peptides on primordial Earth. Previous studies on depsipeptides utilized electrospray ionization ion mobility quadrupole time-of-flight (ESI-IM-QTOF) tandem mass spectrometry; such analysis was thorough yet time-consuming. Here, a complementary matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) approach was optimized for rapid characterization of depsipeptide length and monomer composition. METHODS: Depsipeptide mixtures of varying hydrophobicity were formed by subjecting aqueous mixtures of α-hydroxy acids and α-amino acids to evaporative cycles. Ester and amide content of depsipeptides was orthogonally confirmed using infrared spectroscopy. MALDI-TOF MS analysis was performed on a Voyager DE-STR in reflection geometry and positive ion mode. Optimization parameters included choice of matrix, sample solvent, matrix-to-analyte ratio, and ionization additives. RESULTS: It was determined that evaporated depsipeptide samples should be mixed with 2,5-dihydroxybenzoic acid (DHB) matrix in order to detect the highest number of unique signals. Low matrix-to-analyte ratios were found to generate higher quality spectra, likely due to a combination of matrix suppression and improved co-crystallization. Using this optimized protocol, a new depsipeptide mixture was characterized. CONCLUSIONS: Understanding the diversity and chemical evolution of proto-peptides is of interest to origins-of-life research. Here, we have demonstrated MALDI-TOF MS can be used to rapidly screen the length and monomer composition of model prebiotic peptides containing a mixture of ester and amide backbone linkages.

Synthesis of ß-Peptide Standards for Use in Model Prebiotic Reactions.

A one-pot method was developed for the preparation of a series of ß-alanine standards of moderate size (2 to ≥12 residues) for studies concerning the prebiotic origins of peptides. The one-pot synthesis involved two sequential reactions: (1) dry-down self-condensation of ß-alanine methyl ester, yielding ß-alanine peptide methyl ester oligomers, and (2) subsequent hydrolysis of ß-alanine peptide methyl ester oligomers, producing a series of ß-alanine peptide standards. These standards were then spiked into a model prebiotic product mixture to confirm by HPLC the formation of ß-alanine peptides under plausible reaction conditions. The simplicity of this approach suggests it can be used to prepare a variety of ß-peptide standards for investigating differences between α- and ß-peptides in the context of prebiotic chemistry.

Implementation and evaluation of a dilation and evacuation simulation training curriculum.

OBJECTIVES: To evaluate obstetrics and gynecology resident physicians' performance following a simulation curriculum on dilation and evacuation (D&E) procedures. STUDY DESIGN: This study included two phases: simulation curriculum development and resident physician performance evaluation following training on a D&E simulator. Trainees participated in two evaluations. Simulation training evaluated participants performing six cases on a D&E simulator, measuring procedural time and a 26-step checklist of D&E steps. The operative training portion evaluated residents' performance after training on the simulator using mastery learning techniques. Intra-operative evaluation was based on a 21-step checklist score, Objective Structured Assessment of Technical Skills (OSATS), and percentage of cases completed. RESULTS: Twenty-two residents participated in simulation training, demonstrating improved performance from cases one and two to cases five and six, as measured by checklist score and procedural time (p<.001 and p=.001, respectively). Of 10 participants in the operative training, all performed at least three D&Es, while seven performed at least six cases. While checklist scores did not change significantly from the first to sixth case (mean for first case: 18.3; for sixth case: 19.6; p=.593), OSATS ratings improved from case one (19.7) to case three (23.5; p=.001) and to case six (26.8; p=.005). Trainees completed approximately 71.6% of their first case (range: 21.4-100%). By case six, the six participants performed 81.2% of the case (range: 14.3-100%). CONCLUSIONS: D&E simulation using a newly-developed uterine model and simulation curriculum improves resident technical skills. Simulation training with mastery learning techniques transferred to high level of performance in OR using checklist. The OSATS measured skills and showed improvement in performance with subsequent cases. IMPLICATIONS: Implementation of a D&E simulation curriculum offers potential for improved surgical training and abortion provision.

Differences among consumer segments with regard to perceptions of comparative effectiveness research.

AIM: To examine differences among health-related decision-making consumer segments with regard to knowledge, skills, attitudes, and behaviors pertinent to comparative effectiveness research. METHODS: Data were collected via an online survey from 603 adults with chronic conditions. Consumer segment was determined using a two-item tool. RESULTS: Active consumers (high skills and motivation) reported the highest levels of engagement in various behaviors. Passive consumers (low skills and motivation) reported the lowest levels of engagement in various behaviors. High-effort consumers (low skills, high motivation) reported more positive attitudes and opinions and more engagement in various behaviors than did complacent consumers (high skills, low motivation). CONCLUSION: Effective translation and dissemination of comparative effectiveness research will require the development of approaches tailored to consumers with varying levels of skills and motivation.

Development and evaluation of cesarean section surgical training using computer-enhanced visual learning.

BACKGROUND: Skilled performance of cesarean deliveries is essential in obstetrics and gynecology residency. A computer-enhanced visual learning module (CEVL Cesarean) was developed to teach cesarean deliveries. METHODS: An online module presented cesarean deliveries as a series of components using text, audio, video and animation. First-year residents used CEVL Cesarean and were evaluated intra-operatively by trained raters, then provided feedback about surgical performance. Clinical outcomes were collected for approximately 50 cesarean deliveries for each resident. RESULTS: From 2010 to 2011, 12 first-year residents participated in the study. About 406 unique observed cesarean deliveries were analyzed. Procedures up to each resident's 70th case were analyzed by grouping cases in 10 s (cases 1-10 and 11-20), or deciles. Resident performance significantly improved by decile [χ(2)(6) = 47.56, p < 0.001]. When examining each resident's performance, surgical skill acquisition plateaued by cases 21-30. Procedural performance, independent of resident, also improved significantly by decile [χ(2)(6) = 186.95, p < 0.001], plateauing by decile 4 (cases 31-40). Throughout the observation period, operative time decreased by 3.84 min (p = 0.006). CONCLUSIONS: Pre-clinical teaching using computer-based modules for cesarean sections is feasible to develop. Novice surgeons required at least 30 procedures before performing the procedure competently. When residents performed competently, operative time and complications decreased.

Creation and initial assessment of a second-trimester uterine model.

INTRODUCTION: Training for obstetrics and gynecology residents in second-trimester dilation and evacuation (D&E) procedures is extremely limited despite the Accreditation Council for Graduate Medical Education mandating all residents to receive abortion training. Simulation-based training improves surgical competence, but no second-trimester uterine models exist. The purposes of this study were to create a realistic, low-cost model and to assess the prototype. METHODS: A uterine model was created with 6 silicone cervixes of varying texture and dilations that are interchangeable. The uterus is neoprene and opens to allow for objects to be placed within it for extraction. At a national meeting, experienced D&E surgeons assessed the prototype by using the model and then completing a questionnaire. RESULTS: Twenty-one expert surgeons completed the questionnaires. Participants rated the prototype as "useful" or "very useful" for teaching extraction skills and for training in general. Subjects agreed this represented a clinical scenario they were likely to encounter and the model allowed for practicing the necessary steps for performing D&Es. The model cost approximately $35 to fabricate. CONCLUSIONS: Expert surgeons believe that this model accurately and realistically replicates a second-trimester uterus and cervix. This prototype may be used in simulation environments to train obstetrics and gynecology residents.

Changes in gait and balance parameters in elderly subjects attending an 8-week supervised Pilates programme.

Falls in the elderly have important clinical and economic costs and interventions that may reduce the risk of such problems are potentially important. Although evidence exists for a range of exercise interventions, few have looked at a Pilates-based intervention in a supervised community-based setting and none have specifically measured gait parameters as an outcome. This observational study investigated gait parameters including inter-stride variability (ISV) and postural sway in a group (n = 9) of elderly (age range, 60-76) subjects attending a weekly Pilates class over eight weeks. The results suggest that significant improvement in walking speed (0.14 m/s (95% CI: 0.06-0.21)), step cycle (0.07 m (95% CI: 0.01-0.14)) and length (0.10 m (95% CI: 0.05-0.15)) and a composite ambulation index (6.5% (95% CI: 1.85-11.26)) were seen post the intervention, while coefficients of variation decreased around 15%. In addition both anterior-posterior sway decreased along with a improvement in a fall risk index (FRI). Inter-stride variability on the other hand did not change. The results of this study suggest that a short Pilates program may have the potential to improve gait and sway parameters, including those associated with fall risk.

Chronic inhibition of mammalian target of rapamycin by rapamycin modulates cognitive and non-cognitive components of behavior throughout lifespan in mice.

Aging is, by far, the greatest risk factor for most neurodegenerative diseases. In non-diseased conditions, normal aging can also be associated with declines in cognitive function that significantly affect quality of life in the elderly. It was recently shown that inhibition of Mammalian TOR (mTOR) activity in mice by chronic rapamycin treatment extends lifespan, possibly by delaying aging {Harrison, 2009 #4}{Miller, 2011 #168}. To explore the effect of chronic rapamycin treatment on normal brain aging we determined cognitive and non-cognitive components of behavior throughout lifespan in male and female C57BL/6 mice that were fed control- or rapamycin-supplemented chow. Our studies show that rapamycin enhances cognitive function in young adult mice and blocks age-associated cognitive decline in older animals. In addition, mice fed with rapamycin-supplemented chow showed decreased anxiety and depressive-like behavior at all ages tested. Levels of three major monoamines (norepinephrine, dopamine and 5-hydroxytryptamine) and their metabolites (3,4-dihydroxyphenylacetic acid, homovanillic acid, and 5-hydroxyindolacetic acid) were significantly augmented in midbrain of rapamycin-treated mice compared to controls. Our results suggest that chronic, partial inhibition of mTOR by oral rapamycin enhances learning and memory in young adults, maintains memory in old C57BL/6J mice, and has concomitant anxiolytic and antidepressant-like effects, possibly by stimulating major monoamine pathways in brain.

The effect of turning and backrub on mixed venous oxygen saturation in critically ill patients.

OBJECTIVE: To examine the effect of a change in body position (right or left lateral) and timing of backrub (immediate or delayed) on mixed venous oxygen saturation in surgical ICU patients. METHODS: A repeated-measures design was used to study 57 critically ill men. Mixed venous oxygen saturation was recorded at 1-minute intervals for 5 minutes in each of three periods: baseline, after turning, and after backrub. Subjects were randomly assigned to body position and timing of backrub. Subjects in the immediate-backrub group were turned and given a 1-minute backrub. Mixed venous oxygen saturation was measured at 1-minute intervals for 5 minutes at two points: after the backrub and then with the patient lying on his side. For subjects in the delayed-backrub group, saturation was measured at 1-minute intervals for 5 minutes at two different points: after the subject was turned to his side and after the backrub. RESULTS: Both position and timing of backrub had significant effects on mixed venous oxygen saturation across conditions over time. Subjects positioned on their left side had a significantly greater decrease in saturation when the backrub was started. At the end of the backrub, saturation was significantly lower in subjects lying on their left side than in subjects lying on their right side. The pattern of change differed according to the timing of the backrub, and return to baseline levels of saturation after intervention differed according to body position. CONCLUSIONS: Two consecutive interventions (change in body position and backrub) cause a greater decrease in mixed venous oxygen saturation than the two interventions separated by a 5-minute equilibration period. Turning to the left side decreases oxygen saturation more than turning to the ride side does. Oxygen saturation returns to clinically acceptable ranges within 5 minutes of an intervention. In patients with stable hemodynamic conditions, the standard practice of turning the patient and immediately giving a backrub is recommended. However, it is prudent to closely monitor individual patterns of mixed venous oxygen saturation, particularly in patients with unstable hemodynamic conditions.