Faculty Bibliography

OBJECTIVE:To determine the prevalence of nucleolar channel systems (NCSs) by uterine region, applying continuous quantification. DESIGN/METHODS:Prospective clinical study. SETTING/METHODS:Tertiary care academic medical center. PATIENT(S)/METHODS:Forty-two naturally cycling women who underwent hysterectomy for benign indications. INTERVENTION(S)/METHODS:NCS presence was quantified by a novel method in six uterine regions-fundus, left cornu, right cornu, anterior body, posterior body, and lower uterine segment (LUS)-with the use of indirect immunofluorescence. MAIN OUTCOME MEASURE(S)/METHODS:Percentage of endometrial epithelial cells (EECs) with NCSs per uterine region. RESULT(S)/RESULTS:NCS quantification was observer independent (intraclass correlation coefficient 0.96) and its intrasample variability low (coefficient of variation 0.06). Eleven of 42 hysterectomy specimens were midluteal, ten of which were analyzable with nine containing >5% EECs with NCSs in at least one region. The percentage of EECs with NCSs varied significantly between the LUS (6.1%; interquartile range [IQR] 3.0-9.9) and the upper five regions (16.9%; IQR 12.7-23.4), with fewer NCSs in the basal layer of the endometrium (17 ± 6%) versus the middle (46 ± 9%) and luminal layers (38 ± 9%) of all six regions. CONCLUSION(S)/CONCLUSIONS:NCS quantification during the midluteal phase demonstrates uniform presence throughout the endometrial cavity, excluding the LUS, with a preference for the functional luminal layers. Our quantitative NCS evaluation provides a benchmark for future studies and further supports NCS presence as a potential marker for the window of implantation.

BACKGROUND: Immediate postplacental insertion of intrauterine devices (IUDs) during cesarean delivery could reduce a substantial barrier to access to long-term effective contraception. Initiating IUD use prior to discharge from the hospital postpartum eliminates a 6-week postpartum waiting period and an additional office visit. STUDY DESIGN: This was a prospective cohort study of 90 patients undergoing cesarean delivery. After delivery of the placenta, a copper T380A IUD was inserted into the endometrial cavity through the incision. The study participants were followed up at 6 weeks and 6 months postpartum. This study was conducted at the Weiler Division of the Montefiore Medical Center and at the Jacobi Medical Center in the Bronx, NY. RESULTS: Forty-three (48%) women returned for their 6-week follow-up visits, and among those, no expulsions were recorded. Forty-two (47%) women were reached for phone follow-up at 6 months postpartum, and 80% reported being "happy" or "very happy" with their IUD. CONCLUSIONS: Immediate postplacental IUD insertion at the time of cesarean delivery is safe and acceptable.

OBJECTIVE:To assess the effectiveness of an educational program in visual inspection with acetic acid (VIA) for cervical cancer screening among healthcare providers in 2 low-resource countries. METHODS:A cohort of multidisciplinary healthcare workers in Uganda and El Salvador were recruited to the study. A pretest was administered before the intervention of a 5-day educational program on VIA. A posttest was performed immediately after the educational program and again at a 6-month follow-up visit to assess retention of knowledge. RESULTS:In total, 42 (93%) of the healthcare workers who participated in the educational program completed the initial posttest evaluation, and 18 (40%) healthcare workers completed the 6-month follow-up evaluation. Mean test scores increased after participation in the training session (62% versus 81%; P<0.001). The self-reported comfort level for identifying cellular abnormalities also increased (2.1 versus 3.3; P<0.001). At 6-month follow-up, the mean test score remained higher than pretest scores (79% versus 57%; P<0.001). There was no significant difference in the initial and 6-month posttest scores (80% versus 79%; P=0.20). CONCLUSION/CONCLUSIONS:The educational program in VIA provided healthcare workers with the tools potentially to decrease the morbidity and mortality of cervical cancer in the 2 low-resource countries.

OBJECTIVE:To assess whether a novel educational curriculum using a simulation teaching laboratory improves resident knowledge, comfort with, and surgical performance of hysteroscopic sterilization. DESIGN/METHODS:An educational prospective, pretest/posttest study. SETTING/METHODS:The Montefiore Institute of Minimally Invasive Surgery Laboratory. PATIENT(S)/SUBJECT(S): Thirty-four OB/GYN residents in an academic medical center. INTERVENTION(S)/METHODS:Hysteroscopic sterilization simulation laboratory and a brief didactic lecture. MAIN OUTCOME MEASURE(S)/METHODS:Differences in scores on validated skill assessment tools: Task specific checklist, Global Rating Scale (GRS), pass fail assessment, and a multiple-choice examination to evaluate knowledge and attitude. RESULT(S)/RESULTS:In the entire cohort improvements were observed on all evaluation tools after the simulation laboratory, with 31% points (SD+/-11.5, 95% confidence interval [CI] 27.3-35.3) higher score on the written evaluation; 63% points (SD+/-15.7, 95% CI 57.8-68.8) higher score on the task specific checklist; and 54% points (SD+/-13.6, 95% CI 48.8-58.3) higher score on the GRS. Higher PGY status was correlated with better pretest performance, but was not statistically significant in posttest scores. Residents reported an improvement in comfort performing the procedure after the laboratory. CONCLUSION(S)/CONCLUSIONS:Simulation laboratory teaching significantly improved resident knowledge, comfort level, and technical skill performance of hysteroscopic sterilization.

INTRODUCTION AND HYPOTHESIS/OBJECTIVE:We aimed to identify factors contributing to successful pessary use for over 1 year. METHODS:A chart review was conducted composed of 150 women at Montefiore Medical Center, using a pessary for over 1 year. Characteristics of those who continued pessary usage were compared with those who discontinued use by using Chi-square, Fisher's exact test, logistic regression model, receiver-operator characteristic curve, and Kaplan-Meier survival curves. RESULTS:Thirty-five women (23%) discontinued using pessaries (DP) after a year, while 115 women (77%) continued (CP). There was no difference in multiple characteristics. The DP group had more patients with stress incontinence, p = 0.17. Older age at pessary insertion showed higher continued use (OR = 1.083, CI: 1.033-1.136). Patients with a history of prolapse repair surgery were more likely to discontinue pessary use. CONCLUSIONS:Age greater than 72 years was associated with continued pessary use and history of hysterectomy or prolapse surgery, and stress incontinence were associated with discontinuation.

Most healthy women have normal pregnancies; however, even healthy women may experience serious morbidity during pregnancy. Women with chronic medical problems face increased pregnancy-related risks compared with their healthy peers. Planning pregnancy improves maternal and fetal outcomes; medical conditions can be stabilized, teratogens can be avoided, and early antenatal intervention and surveillance can be instituted. The safest and most effective forms of contraception should be offered to women with medical conditions. Overestimatation of risk associated with the use of contraception among clinicians and women limits access to effective contraception. Contraception decision making should include consideration of the risks and benefits of a given method vs. the consequences of an unintended pregnancy. Published guidelines can inform contraceptive management of women with chronic medical conditions. Patient counseling should focus on helping women understand the need for contraception while optimizing their health for pregnancy.