Faculty Bibliography

BACKGROUND: To determine whether a 'lay' rater could assess clinical reasoning, interrater reliability was measured between physician and lay raters of patient notes written by medical students as part of an 8-station objective structured clinical examination. METHODS: Seventy-five notes were rated on core elements of clinical reasoning by physician and lay raters independently, using a scoring guide developed by physician consensus. Twenty-five notes were rerated by a 2nd physician rater as an expert control. Kappa statistics and simple percentage agreement were calculated in 3 areas: evidence for and against each diagnosis and diagnostic workup. RESULTS: Agreement between physician and lay raters for the top diagnosis was as follows: supporting evidence, 89% (kappa = .72); evidence against, 89% (kappa = .81); and diagnostic workup, 79% (kappa = .58). Physician rater agreement was 83% (kappa = .59), 92% (kappa = .87), and 96% (kappa = .87), respectively. CONCLUSIONS: Using a comprehensive scoring guide, interrater reliability for physician and lay raters was comparable with reliability between 2 expert physician raters

Abdominal myomectomies can be associated with a large amount of blood loss due to the vascular nature of fibroids. Laparoscopic management of fibroids is a difficult task in minimally invasive surgery given the extensive amount of suturing typically involved. The advantages of robotic surgery, including increased precision and fine motor coordination as well as excellent suturing capabilities, have led to its increased use in myomectomies. In comparision to conventional laparotomy, studies have shown reduced blood loss, complication rates, and length of stay with robotic myomectomies. This video demonstrates the improved precision in the enucleation of a myoma with attention to preserving fertility and the advantage of using monopolar and bipolar energy together to decrease blood loss. The ease of laparoscopic suturing shown in this robotic myomectomy due to increased fine motor coordination demonstrates a key advantage in robotic surgery in comparision to conventional laparoscopy

Minimally invasive surgery has been shown to decrease length of hospital stay, time to recovery, and postoperative pain scores. There has been a tremendous rise in the use of robotic surgery for high-precision surgeries, including gynecologic surgery for benign disease. It has been reported that one in nine women will eventually have a hysterectomy for benign indications, including symptomatic fibroids, adenomyosis, lower pelvic pain, and abnormal bleeding. Several studies have suggested advantages of robotic surgery over conventional laparotomy and laparoscopy regarding visualization, improved ergonomics, and fine motor coordination, although long-term patient outcomes have yet to be determined. This video explores the feasibility of robotic hysterectomy and the advantage of using monopolar and bipolar energy together with increased precision during dissection. In addition, we will show several conditions, including extensive pelvic adhesions and large uterine size, that can make a robotic hysterectomy more challenging

The complexity of the Human Papilloma Virus (HPV)-host interaction along with dense cervical cancer screening guidelines hamper students' easy learning of the subject. This online learning-module intends to provide a comprehensive overview of HPV infection to help students better understand the rationale behind the screening protocol. The content of this module summarizes key concepts such as viral structure and replication, human immune-defense, immunization strategy, pathogenesis of cervical pre-cancer and cancer, and finally, prevention and management strategy of HPV infection in gynecologic patients. The target audience will be primarily third-year medical students rotating through their OB-GYN clerkship. In-house training of residents or attending physicians could also benefit from the educational material contained in this module. The module takes advantage of the audio-visual effects to maximize student learning. It is organized in sessions of sub-topics with core text, embedded images, illustrations and recorded voice-over script. In addition, there is a video at the end of the module which simulates a patient encounter in a doctor's office to discuss cervical cancer screening and management. Pre-test and post-test questions help the viewer keep track of their progress upon completion

Study Objective: To determine the difference of surgical indication, type of procedures and complication of operative hysteroscopy between a public and a private teaching hospital within the same academic institution. Design: Retrospective analysis of operative hysteroscopy performed in both hospitals. Setting: Bellevue Hospital Center (BHC), public hospital and NYU Langone Medical Center (LMC), private hospital: both are university-based tertiary teaching hospitals of NYU School of Medicine in New York City. Patients: Two hundred fifty consecutive cases of operative hysteroscopy Medicaid patients were compared with 424 cases of patients with private insurance. Intervention: Operative hysteroscopy/other procedures. Measurements and Main Results: Presence of endometrial polypectomy detected by ultrasound remains the leading indication for an operative hysteroscopy in both hospitals, 198/250 (79.2%) at BHC and 316/424 (73.5%) at LMC. Hysteroscopic resection of submucosal fibroid represents the second most common surgery, 17/250 (6.8%) and 55/424 (13 %) at BHC and LMC, respectively. The BHC patients 49.9 +/-11 are older than LMC patients 47.1+/- 12 (P=0.0015). uterine perforation was the most common complication: 5/250 (2%) at BHC versus 4/424 (1%) LMC. There was a significantly higher percentage of incidental polyps taken for surgical removal in the LMC group 82/316(26%) when compared to BHC 22/198 (11.1%). Submucosal fibroid resection and procedures involving disposable devices are more often indicated in private than in Medicaid patients. Conclusion: Easier access to the health care is reflected in the early detection and surgical management of endometrial polyps in asymptomatic private patients. The difference of hospital resources and health care access is likely to influence the patient counseling and acceptance of temporary versus definite treatment for the management of uterine pathology. Further study with larger numbers of patients is needed to confirm our findings

Spontaneous rupture of an unscarred uterus in reproductive-age women is exceedingly rare, especially in the context of dysfunctional bleeding and a patent cervical canal. A 25-year-old nulligravida female, who reported recent onset of metromenorrhagia and anemia, was initially admitted for surgical management of unexplained hematometra requiring dilation and curettage. The patient remained with intermittent vaginal bleeding for the following six months on continuous progestin therapy. She then re-presented with enlarged hematometra and uterine rupture, which was surgically repaired. Despite exhaustive conservative treatment to preserve fertility, hysterectomy was eventually required due to recurrent uterine rupture. Idiopathic recurrent hematometra can result from the rare combination of uncontrolled dysfunctional bleeding and absence of outflow obstruction

Background: Appendiceal mucinous neoplasm may be complicated by rupture, leading to peritonitis and pseudomyxoma peritonei. Despite a thorough intraoperative examination, both the presence of appendiceal mucinous neoplasm and its rupture site may be overlooked. In such cases, the correct clinical diagnosis may be challenging. Case: We describe here a 52-year-old woman with a history of chronic pelvic pain and endometriosis, diagnosed initially as a left-sided endometrioma. She was admitted a few days later with worsening pain and fever that persisted despite treatment with antibiotics. Exploratory laparotomy revealed a pelvic abscess of unknown etiology. Appendectomy was performed, although the appendix appeared grossly normal. Pathology was consistent with rupture of an appendiceal mucinous cystadenoma. Conclusions: Although rare, ruptured appendiceal mucinous neoplasm should be considered in patients presenting with an unexplained pelvic abscess. 2010 Mary Ann Liebert, Inc

Study Objective: To compare the accuracy of histological prediction of adnexal pathology based on the interpretation of sonographic imaging between gynecologists with specialized training in women's health imaging (WHI) and general radiologists (GR) at Bellevue Hospital Center. Design: Retrospective analysis of 237 consecutive cases of adnexal surgery. Setting: University-based tertiary teaching hospital, Department of Obstetrics and Gynecology. Patients: Two hundred thirty seven women (ages 13-81 years) with sonographic diagnosis of adnexal pathology who subsequently underwent surgical intervention. Intervention: Laparoscopy and/or laparotomy. Measurements and Main Results: Of the 237 patients analyzed, 102 (43%) had their pelvic ultrasound performed by WHI and 135 (57%) by GR. Surgical specimens confirmed cancer or low malignant potential lesions in 31 (13%) patients while 206 (87%) had benign pathology. Overall, the positive predictive value (PPV) of ultrasound for identifying cancer was 46.4% and the negative predictive value (NPV) was 91.4%. When the ability to predict malignancy was compared between GR and WHI, the PPV and NPV was 39% versus 80% and 91% versus 92%, respectively. The ultrasound impression "cannot rule out malignancy" was used in 38 (28%) and 6 (6%) of GR and WHI reports, respectively, however, malignancy was found in 19 (14%) of GR and 12 (12%) of WHI groups. Conclusion: Both WHI and GR ultrasound reports have comparable accuracy in terms of prediction of benign adnexal disease. WHI reports appear to have better positive predictive value for the detection of malignancy and contain fewer equivocal conclusions. Gynecologic laparoscopists should be aware of the limitations of ultrasound when relying exclusively on ultrasound imaging for patient counseling and decision making regarding the management of adnexal masses