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Surgical training in the simulation lab can develop basic skills that translate to the operating room. Standardized, basic skills programs that are supported by validated assessment measures exist for open, laparoscopic, and endoscopic surgery; however, there is yet to be a nationally recognized and widely implemented basic skills program specifically for vaginal surgery.Develop a vaginal surgical simulation system; evaluate robust validity evidence for the simulation system and its related performance measures; and establish a proficiency score that discriminates between novice and experienced vaginal surgeon performance.In this 3-phased study, we developed the Fundamentals of Vaginal Surgery simulation system consisting of (1) the Fundamentals of Vaginal Surgery Trainer, a task trainer; (2) a validated regimen of tasks to be performed on the trainer; and (3) performance measures to determine proficiency. In Phase I, we developed the task trainer and selected surgical tasks by performing a needs assessment and hierarchical task analyses, with review and consensus from an expert panel. In Phase II, we conducted a national survey of vaginal surgeons to collect validity evidence regarding test content, response process, and internal structure relevant to the simulation system. In Phase III, we compared performance of novice (first and second year residents) and experienced (third and fourth year residents, fellows, and faculty) surgeons on the simulation system to evaluate relevant relationships to other variables and consequences. Performance measures were analyzed to set a proficiency score that would discriminate between novice and expert (faculty) vaginal surgical performance.A novel task trainer and 6 basic vaginal surgical skills were developed in Phase I. In Phase II, the survey responses of 48 participants (27 faculty surgeons, 6 fellows, and 14 residents) were evaluated on the dimensions of test content, response process, and internal structure. To support evidence of test content, the participants deemed the task trainer and surgical tasks representative of intended surgical field and supportive of typical surgical actions (mean scores, 3.8-4.4/5). For response process, rater-data analysis revealed high rating variability regarding prototype color. This early evidence confirmed the value of a white prototype. For internal structure, there was high agreement among rater groups (obstetricians and gynecologists generalists vs Female Pelvic Medicine and Reconstructive Surgery specialists: interclass correlation coefficient range, 0.59-0.91; learners vs faculty interclass correlation coefficient range, 0.64-1.0). There were no differences in ratings across institution type, surgeon volume, expertise (P.14). In Phase III, we analyzed performance from 23 participants (15 [65%] obstetricians and gynecologists residents, 3 [13%] fellows, and 5 [22%] Female Pelvic Medicine and Reconstructive Surgery faculty). Experienced surgeons scored significantly higher than novice surgeons (median, 467.5; interquartile range, [402.5-542.5] vs median, 261.5; interquartile range, [211.5-351.0]; P.001). Based on these data, setting a proficiency score threshold at 400 results in 0% (0/6) novices attaining the score, with 100% (5/5) experts exceeding it.We present validity evidence relevant to all 5 sources which supports the use of this novel simulation system for basic vaginal surgical skills. To complement the system, a proficiency score of 400 was established to discriminate between novices and experts.

As an academic department, we sought to identify effective strategies to engage our faculty and staff in diversity, equity, and inclusion initiatives and programs to build an inclusive department that would address our needs and those of our community and partners. Over a 4-year period, our faculty and staff have participated in town hall meetings, focus group discussions, surveys, and community-building activities to foster stakeholder engagement that will build a leading academic department for the future. We noted that our faculty and staff were committed to building diversity, equity, and inclusion, and our mission and vision were reflective of this. However, communication and transparency may be improved to help support a more inclusive department for all. In the future, we hope to continue with the integration of diversity, equity, and inclusion into our department's business processes to achieve meaningful, sustained change and impact through continued focus on recruitment, selection, retention, development, and wellness of faculty and staff-in addition to the continued recruitment of faculty and staff from underrepresented minority groups. Our findings should serve as a call to action for other academic obstetrics and gynecology departments to improve the health and well-being of the individuals we serve.

Fatty acid amide hydrolase (FAAH) hydrolyzes several bioactive lipids including the endocannabinoid anandamide. Synthetic FAAH inhibitors are being generated to help define the biological role(s) of this enzyme, the lipids it degrades in vivo, and the disease states that might benefit from its pharmacological modulation. AZ513 inhibits human FAAH (IC50 = 551 nM), is 20-fold more potent against rat FAAH (IC50 = 27 nM), and is inactive at 10 μM against the serine hydrolases acetylcholinesterase, thrombin, and trypsin. In contrast to most other potent FAAH inhibitors, AZ513 showed no evidence of covalently modifying the enzyme and displayed reversible inhibition. In an enzyme cross-competition assay, AZ513 did not compete with OL-135, an inhibitor that binds to the catalytic site in FAAH, which indicates that AZ513 does not bind to the catalytic site and is therefore noncompetitive with respect to substrate. AZ513 has good cell penetration as demonstrated by inhibition of anandamide hydrolysis in human FAAH-transfected HEK293 cells (IC50 = 360 nM). AZ513 was tested in a rat spinal cord slice preparation where CB1 activation reduces excitatory post-synaptic currents (EPSCs). In this native tissue assay of synaptic activity, AZ513 reduced EPSCs, which is consistent with inhibiting endogenous FAAH and augmenting endocannabinoid tone. AZ513 has a unique biochemical profile compared with other published FAAH inhibitors and will be a useful tool compound to further explore the role of FAAH in various biological processes.

BACKGROUND: Prolapse of the anterior and posterior vaginal walls has been generally associated with apical descent and levator ani muscle defects. However, the relative contributions of these factors to the pathophysiology of descent in the different vaginal compartments is not well understood. Furthermore, symptoms uniquely associated with prolapse in these compartments have not been well-characterized. OBJECTIVES: Compare associations between: 1) apical support, 2) levator ani muscles, and 3) pelvic floor symptoms in women with posterior-predominant prolapse, anterior-predominant prolapse, and normal support. STUDY DESIGN: This is a cross-sectional study with two case arms: 60 women with posterior prolapse, 90 with anterior prolapse, and a referent control arm with 103 asymptomatic subjects with normal support, determined from pelvic organ prolapse quantification examinations. Levator muscle defects were graded from magnetic resonance imaging. Vaginal closure forces above resting were measured with an instrumented speculum during maximal contraction. Pelvic floor symptoms were measured via the Pelvic Floor Distress Inventory – Short Form. RESULTS: Mean Point C location in controls was −6.9 cm [1.5] (mean [standard deviation]); and was higher in posterior prolapse (−4.7 cm [2.7], 2.2 cm below controls) than the anterior prolapse group (−1.2 cm [4.1]; 5.6 cm below controls, p

Our objective was to perform a meta-analysis of randomized controlled trials of dopamine agonists (DA) as monotherapy as well as adjunctive therapy for the early treatment of Parkinson's disease (PD). A systematic literature search was conducted through April 2007. Both efficacy and safety endpoints were evaluated. DA monotherapy showed superior efficacy but more frequent adverse events compared to placebo. In addition, DA demonstrated inferior efficacy to levodopa, but was associated with fewer motor complications. However, DAs were associated with a greater incidence of nuisance side effects, such as hallucinations, somnolence and dizziness. The use of DA is an effective treatment option for the treatment of early PD and appears especially useful among PD patients with wearing-off phenomenon or dyskinesias on levodopa; however it may result in more adverse events and higher withdrawal rates.

This article on treatment of early idiopathic Parkinson's disease (PD) addresses the therapeutic management of the signs and symptoms of PD. It should be read with the understanding that there is more than one way to initiate and manage the early stages of PD.

Many patients with advanced Parkinson's disease (PD) experience motor complications, which negatively impact quality of life, despite optimized oral therapy. It is important for patients to have a treatment option that may provide rapid relief from "off" episodes. In three pivotal, randomized, placebo-controlled trials, subcutaneous apomorphine was effective in acutely treating "off" episodes, significantly improving Unified Parkinson Disease Rating Scale motor scores and reducing the number of "off" hours per day, with a significantly shorter time to patient-declared onset of relief than placebo. Thus, clinical trial data support the efficacy of intermittent subcutaneous apomorphine as a rapid acute treatment for "off" episodes in advanced PD.

Objective The purpose of this study was to determine the severity of anal incontinence and its impact on quality of life and sexual function in women after anal sphincteroplasty. Study design Eighty-six women who underwent anal sphincteroplasty during the years 1993 to 2004 were mailed validated survey instruments to evaluate continence status, health-related quality of life, and sexual functioning. Demographic and perioperative data were obtained from patient charts. Results At a mean follow-up time of 5.6 ± 3.0 years, 6 women (11%) were totally continent; 8 women (15%) were incontinent of flatus only, and 41 women (75%) were incontinent of liquid and/or solid stool. Sexual function scores were not correlated with continence scores; 24% vs 4% of subjects who had undergone an overlapping sphincteroplasty versus an end-to-end sphincteroplasty reported pain during intercourse ( P = .04). Conclusion Anal continence rates 5 years after anal sphincteroplasty are disappointing, adversely impact quality of life, yet do not appear to relate to sexual function.

Becoming a good surgical educator takes time, patience, and dedication. Providing effective feedback is essential to improving the mentee's surgical skills. The operating room is a costly, high-risk classroom. Residents must come to the operating room prepared. Using a surgical skills laboratory can help in that preparation but is only effective when feedback is given regarding performance. While in the operating room, the attending physician must constantly direct, critique, and actively teach.

Objective The study was undertaken to identify factors contributing to the poor student perception of the obstetrics and gynecology clerkship. Study design Third-year medical students at the University of Michigan complete an annual questionnaire about the overall quality of their clinical experiences. In addition, at the end of each rotation, the students complete an evaluation form assessing various aspects of their learning experience. We reviewed data collected from 2000 to 2002. We calculated effect sizes using mean scores and SDs to compare individual aspects of the learning environment across the clerkships. Results Twenty-six percent of the third-year medical students at the University of Michigan rated the strength of their obstetrics and gynecology experience as very or exceptionally strong. Compared with the other 6 clerkships, the rotation had one of the lowest ratings for overall quality. Aspects of the clerkship experience we identified as potentially explaining this overall poor rating include the clarity of the clerkship goals and objectives, clarity of expectations for student performance, accessibility of faculty, experiences in learning history-taking skills, experiences in learning physical examination skills, and student perception that they were treated in a respectful/professional manner. Conclusion Aspects of the clerkship experience identified by this study as potentially explaining the low ratings of the obstetrics and gynecology rotation should be studied in greater detail. Addressing these factors will be critical for improving the overall student perception of the obstetrics and gynecology clerkship.

The purpose of this study was to estimate the incidence of urinary and bowel incontinence in relation to anal sphincter laceration in primiparous women and to identify factors that are associated with anal sphincter laceration in a unit that uses primarily midline episiotomy.From January 1, 1997, to March 30, 2000, 2941 questionnaires concerning pelvic floor function 6 months after delivery were mailed to primiparous women who were delivered vaginally at the University of Michigan Medical Center. Charts were reviewed for 2858 deliveries to assess the use of episiotomy and the degree of perineal trauma, along with demographic and pertinent delivery variables. There were 943 women who completed the urinary function questionnaire and 831 women who completed the bowel function questionnaire. Univariate analysis was performed on all covariates. Multiple logistic regression was used for the analysis of the presence of third- or fourth-degree lacerations as the outcome.Nineteen percent of the women who completed the survey had sustained third- or fourth-degree lacerations during childbirth. The women in the sphincter laceration group were more likely (23.0%) to have bowel incontinence than the women in the control group (13.4%) (P.05). The incidence of worse bowel control was nearly 10 times higher in women with fourth-degree lacerations (30.8%) compared with women with third-degree lacerations (3.6%, P.001). Macrosomia (odds ratio, 2.19; 95% CI, 1.61, 2.99), forceps-assisted delivery (odds ratio, 4.75; 95% CI, 3.43, 6.57), and vacuum-assisted delivery (odds ratio, 3.51; 95% CI, 2.64, 4.66) were associated with higher risks of third- and fourth-degree lacerations. Midline episiotomy (odds ratio, 2.24; 95% CI, 1.81, 2.77), but not mediolateral (odds ratio, 0.66; 95% CI, 0.375, 1.19), episiotomy was associated with anal sphincter lacerations. More than one half of the women had new onset of urinary incontinence after delivery and reported several lifestyle modifications to prevent leakage.Women with third- and fourth-degree lacerations were more likely to have bowel incontinence than women without anal sphincter lacerations. Fourth-degree lacerations appear to affect anal continence greater than third-degree lacerations.

The purpose of this study was to determine the relationship between patient report and physician assessment of urinary incontinence severity and to compare these assessments to a validated severity instrument.A sequential sample of 153 women with urinary incontinence was enrolled over 12 months. Patients completed a detailed health questionnaire that included a medical comorbidity scale, 12-item short-form health survey (SF-12) the incontinence quality of life instrument, the PRIME-MD patient health questionnaire, and a patient incontinence severity assessment. The patient incontinence severity assessment is a single question that asks the patient to rate the severity of her incontinence symptoms on a 5-point Likert scale (range: 1 [mild] to 5 [severe]). After the physicians completed a detailed history, a physical examination, and a review of a 3-day voiding diary, they assigned a physician incontinence severity assessment score. The physician incontinence severity assessment is a physician rating of the severity of the patient's incontinence on a 5-point Likert scale (range: 1 [mild] to 5 [severe]). A validated severity index was computed and used for comparison. This is a multiplicative index that is based on frequency (4 levels) and amount of leakage (2 levels), which yields an index value of 1 to 8. Spearman correlation coefficients were calculated for patient incontinence severity assessment, the physician incontinence severity assessment scores, and the severity index values. Chi-square tests were used to determine differences between patient incontinence severity assessment and physician incontinence severity assessment ratings.Spearman correlation coefficients for patient incontinence severity assessment and physician incontinence severity assessment were 0.62 (P.001), for patient incontinence severity assessment and the severity index was 0.61 (P.001), and for physician incontinence severity assessment and the severity index was 0.66 (P.001). Agreement between patient assessment and physician assessment for different severity levels on the patient incontinence severity assessment and physician incontinence severity assessment are provided.There is a high correlation between patient report and physician assessment of urinary incontinence severity. Both patient reports (patient incontinence severity assessment) and physician assessments (physician incontinence severity assessment) correlate well with a validated severity index. The agreement between patient and physician ratings is very high for mild incontinence but decreases as incontinence severity progresses.

Objective: The purpose of this study was to determine the prevalence and impact of major depression and panic disorder in women with urinary incontinence. Study Design: Participants were 218 consecutive women with urinary incontinence over a 14-month period. Major depression and panic disorder diagnoses, symptom perception, incontinence-specific quality of life, functional status, and urinary incontinence type were assessed. Results: The overall prevalence of major depression and panic disorder was 16% and 7%, respectively. In a comparison to patients with stress urinary incontinence, the odds of having major depression were 9.2 for patients with urge and 13.5 for patients with mixed urinary incontinence. Although clinically similar to patients who did not have depression, patients with depression rated their urinary incontinence as significantly more severe and had greater quality of life and functional status impairment. Conclusion: Current major depression and panic disorder are highly prevalent in women with urinary incontinence. Patients with urge and mixed urinary incontinence are significantly more likely to have coexistent psychiatric illness. Comorbid major depression significantly impacts a patient's urinary incontinence symptom reporting, incontinence-specific quality of life, and functional status. (Am J Obstet Gynecol 2002;187:80-7.)

OBJECTIVE: This study analyzed the clinical presentation, incidence, characteristics as demonstrated by defecating proctography, and surgical outcomes of sigmoidoceles. STUDY DESIGN: Defecating proctograms were obtained on all women with clinical evidence of pelvic floor defects between June 1, 1991, and June 30, 1995. The proctograms were retrospectively reviewed for the presence of a sigmoidocele and concomitant pelvic hernias. The distance between the maximum point of sigmoid descent with strain and the perineal body was measured. A chart review was performed to obtain clinical history, physical examination results, surgical treatment, and outcome. RESULTS: Nine sigmoidoceles (4.0%) were noted in 234 defecating proctograms. The leading edge of the sigmoid hernia ranged from 3.8 cm beyond the perineal body to 8 cm above the perineal body. All nine patients were found to have concomitant rectoceles by proctography, whereas only three were found to have enteroceles. Physical examination before proctography suggested that six patients had vaginal vault prolapse with enterocele, one patient had uterine prolapse with enterocele, and two patients had rectoceles alone. Five of the seven patients clinically diagnosed with an enterocele showed no small bowel herniation on defecography. No sigmoidoceles were suspected by physical diagnosis alone. All rectoceles were diagnosed by clinical examination. All patients except one, who had concomitant rectal prolapse, complained of constipation. Two patients required manual pressure to the perineum or vagina to defecate. Seven of the nine patients underwent pelvic reconstructive surgery. The surgical procedure for sigmoidocele was determined by severity of constipation, degree of prolapse, and sigmoid redundancy at the time of surgery. Two patients underwent sigmoid resection with sigmoidopexy, one patient had sigmoidopexy alone, and four patients had Halban obliteration of the cul-de-sac. Two patients are successfully using pessaries. Follow-up from 4 months to 2 years (mean 12 months) showed no recurrence of an apical defect by clinical examination. One patient had a recurrent rectocele to the hymenal ring with strain. Five patients had no complaints of constipation, whereas two noted improvement but continued symptoms. Both these patients had Halban procedures only, and one had the recurrent rectocele. CONCLUSIONS: Sigmoidoceles are an uncommon but not rare finding with apical support defects. Physical examination alone does not make the diagnosis. All patients had a rectocele, which substantiates a posterior vaginal support defect. In these patients there was a strong association with constipation that responded to surgical correction, but the degree of anatomic distortion did not always correlate with functional impairment. (Am J Obstet Gynecol 1996;175:1438-42.)

The transobturator posterior anal sling (TOPAS) system is a posterior anal sling that is a minimally invasive, self-fixating polypropylene mesh intended to treat fecal incontinence (FI) in women who have failed conservative therapy.We are reporting 1-year outcome in a prospective, multicenter study under investigational device exemption, evaluating this new treatment modality.A total of 152 women were implanted with the TOPAS system at 14 centers in the United States. FI was assessed preoperatively and at the 12-month follow up with a 14-day bowel diary, Cleveland Clinic Incontinence Scores, and FI Quality of Life questionnaires. Treatment success was defined as reduction in number of FI episodes of ≥50% compared to baseline. Missing bowel diary data were considered treatment failures. The Wilcoxon signed rank test was used to compare changes observed at 12 months vs baseline.Mean age was 59.6 years old (SD 9.7). The mean duration of FI was 110 mo (range 8-712) months. Mean length of the implant procedure was 33.4 (SD 11.6) minutes. Mean EBL was 12.9 (SD 10.5) mL. Average follow-up was 24.9 months. At 12 months, 69.1% of patients met the criteria for treatment success, and 19% of subjects reported complete continence. FI episodes/wk decreased from a median of 9.0 (range 2-40) at baseline to 2.5 (range 0-40) (P.001). FI days decreased from a median of 5.0 (range 1.5-7) at baseline to 2.0 (range 0-7) (P.001) over a 7-day period. FI associated with urgency decreased from a median at baseline of 2.0 (range 0-26) to 0 (range 0-14.5) (P.001). The mean Cleveland Clinic Incontinence Scores decreased from 13.9 at baseline to 9.6 at 12 months (P.001). FI Quality of Life scores for all 4 domains improved significantly from baseline to 12 months (P.001). A total of 66 subjects experienced 104 procedure- and/or device-related adverse events (AEs). Most AEs were short in duration and 97% were managed without therapy or with nonsurgical interventions. No treatment-related deaths, erosions, extrusions, or device revisions were reported. The most common AE categories were pelvic pain (n = 47) and infection (n = 26). Those subjects experiencing pelvic pain had a mean pain score (0-10 scale, 0 = no pain) during the 12-month follow-up of 1.2 (SD 2.4).The TOPAS system provides significant improvements in FI symptoms and quality of life with an acceptable AE profile and may therefore be a viable minimally invasive treatment option for FI in women.

Despite recommendation for ovarian conservation in low-risk, premenopausal women, bilateral oophorectomy is often performed. The purpose of this study was to investigate factors associated with removal of normal ovaries at the time of hysterectomy for benign indication in women age51 years.Demographics, indication for surgery, adnexal pathology, and surgical approach were analyzed for hysterectomies from a voluntary, statewide surgical quality collaborative. Cases were excluded if the surgical indication was cancer, pelvic mass, or obstetric, or if age was50 years. Cases were categorized according to pathology of the adnexal specimen as cancer, benign findings, normal ovary, or no ovarian specimen. Variables including demographics, medical comorbidities, and surgical characteristics were analyzed to identify characteristics associated with oophorectomy at the time of hysterectomy. A logistic regression model was then developed to identify factors independently associated with removal of normal ovaries.A total of 6789 subjects were included. Oophorectomy was performed in 44.2% of women (n = 3002). In all, 23.1% (n = 1565) had normal ovaries on pathology. Incidental ovarian cancer was found in 0.2% (n = 12), and benign pathology was found in 21% (n = 1425). Removal of normal ovaries was less likely when the surgical approach was vaginal (18%) as opposed to laparoscopic (23.1%) or abdominal (26.0%). With adjustment, abdominal (odds ratio [OR], 1.73; 95% confidence interval [CI], 1.43-2.09]) and laparoscopic (OR, 1.27; 95% CI, 1.08-1.50) approach showed significantly higher odds of normal ovary removal compared to vaginal hysterectomy. Age 46-50 years was also significantly associated (OR, 1.78; 95% CI, 1.53-2.07). Surgical indications associated with increased oophorectomy with normal resultant pathology were family history of cancer (OR, 3.09; 95% CI, 1.94-4.94), endometrial hyperplasia (OR, 2.36; 95% CI, 1.38-4.01), endometriosis (OR, 2.01; 95% CI, 1.30-3.09), and cervical dysplasia (OR, 1.91; 95% CI, 1.12-3.28).Removal of histologically normal ovaries is performed in nearly 1 of every 4 women age51 years undergoing hysterectomy for benign indications. Factors associated include age closer to menopause, surgical approach, and certain indications for hysterectomy. Reducing the rate of elective oophorectomy in low-risk, premenopausal women may be a target for quality improvement efforts. Future work should continue to evaluate this practice, associated factors, physician counseling, and patient decision-making.

OBJECTIVES: The Association of Professors of Gynecology and Obstetrics and the Council on Resident Education in Obstetrics and Gynecology have proposed a fourth-year medical school curriculum for a student interested in pursuing a residency in obstetrics and gynecology. STUDY DESIGN: Faculty members and residents in North Carolina, Illinois, and Michigan were surveyed as to the ideal curriculum that they would recommend for fourth-year students. The committee members representing the Council on Resident Education in Obstetrics and Gynecology and the Association of Professors of Gynecology and Obstetrics then reviewed these surveys and proposed a final curriculum. RESULTS: A core curriculum of general medicine as an acting internship, an intensive care unit rotation, neonatology, and emergency medicine was recommended. Additional courses strongly considered were ambulatory obstetrics-gynecololgy, acting internship in obstetrics-gynecology, endocrinology, and general surgery. CONCLUSION: The committee recommends a curriculum that is broad and balanced in general medical education.

Selegiline is a monoamine-B specific inhibitor used to treat Parkinson’s disease. A Zydis sublingual preparation has more efficient absorption and less first pass amphetamine metabolites. We conducted an open label oral to Zydis switch study to evaluate tolerability of rapid switch, and relative efficacy, in 48 subjects from 5 sites. Overall patients preferred the Zydis preparation. Per clinician global impressions, fluctuations improved and the “on” UPDRS part II scores improved. Total UPDRS and measures of fatigue and sleep were unchanged. Adverse events were mild. Patients generally preferred the Zydis selegiline preparation but the modest difference is of unclear clinical significance given the open label nature of the trial.