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Study Objective: This is the first study to document racial and socioeconomic disparities in access to minimally invasive hysterectomy (MIH) at a large urban academic hospital and to propose stakeholder-invested interventions to address identified disparities. Retrospective cohort study. Large academic hospital. The study included 4,663 women who underwent hysterectomy for benign indications between 2009 and 2022. Vaginal hysterectomies and those performed for the indication of prolapse or by Urogynecologists or Gynecologic Oncologists were excluded from analysis. Following the identification of disparities, a series of stakeholder meetings involving gynecologic surgeons and quality, safety, and equity experts were convened where we reviewed potential interventions to address disparities and improve equitable access to care. Disparities in access to MIH were observed, with Black patients having lower odds of undergoing MIH compared to White patients in an analysis adjusting for potential confounders, including uterine weight and prior surgeries. However, these differences were no longer significant after adjusting for the social vulnerability index (SVI) and insurance type. Within the Minimally Invasive Gynecologic Surgery (MIGS) division, racial disparities were not observed. Proposed interventions aimed to improve education for both clinicians and patients, enhance counseling regarding minimally invasive options, establish a surgical review committee, and optimize workforce utilization. This study identified disparities in access to MIH at BWH and suggests that the role of systemic factors plays a central role in perpetuating racial inequities. By implementing targeted interventions we aim to improve access to MIH for all patients. This collaborative effort represents a model for addressing disparities in gynecologic surgery and underscores the importance of systemic change in achieving equitable healthcare delivery. Future work will assess the effectiveness of these interventions and explore access to other minimally invasive gynecologic procedures such as myomectomy. [ABSTRACT FROM AUTHOR]

Investigate potential racial/socioeconomic disparities in access to minimally invasive myomectomy (MIM). Retrospective cohort study. Large academic hospital. Women undergoing myomectomy for benign leiomyomata between 2016 and 2022. Cases involving previous hysterectomy, preoperative leiomyosarcoma diagnosis, hysteroscopic myomectomy, emergency myomectomy, or missing race/ethnicity data were excluded. MIM ((hand-assisted) laparoscopic or robotic) and abdominal myomectomy (AM). 1243 cases were identified. Racial/ethnic composition was 44.5% White, 38.8% Black, 7.3% Hispanic, and 9.4% Asian. 830 (66.8%) of cases were MIM and 413 (33.2%) AM. MIM rate was highest in the White group (77.6%) and lowest in the Black group (53.5%). Black women had highest BMI (mean 29.4±6.4 kg/m2), prior surgery rate (45.0%), fibroid weight (median 278; IQR 142-561 grams), and number of fibroids (median 8; IQR 3-17). In our regression analysis we sought to control for both fibroid weight and number, somewhat collinear variables affecting clinical decision making. When we added both variables along with other potential confounders to a regression model, there were no significant racial disparities in access to MIM (aOR 0.96, 95% CI 0.72-1.28). A regression with weight but not number showed persistence of disparities (aOR 0.58, 95% CI 0.45-0.75), while one with number not weight showed resolution of disparities (aOR 0.90, 95% CI 0.68-1.18). Social vulnerability index (SVI) did not significantly change outcomes upon incorporation into the regression model. Within our hospital, disparities exist as Black women have less access to MIM compared to White. Black women had higher fibroid weights and more fibroids which greatly influenced surgery route, and when both factors were added to regression analysis, disparities nullified. In contrast to our hysterectomy disparities study, SVI did not influence outcomes. Our results may reflect delays in care. Future studies and stakeholder meetings will focus on ensuring earlier recognition and surgery referral. [ABSTRACT FROM AUTHOR]

This study aims to investigate disparities in minimally invasive hysterectomy (MIH) based on geographic location among a diverse population in Florida. A cross-sectional analysis was conducted using data from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) and State Ambulatory Surgery Databases (SASD) from Florida for the year 2019. The study utilized data from all-payer population-based databases capturing inpatient hospital discharge abstracts and encounters for ambulatory surgery and outpatient services from hospital-owned facilities in Florida. Patients aged 18 or older who underwent hysterectomy for benign indications were included in the study. Patients with a diagnosis of gynecologic cancer and those with missing data on urban-rural classification were excluded. The primary exposure of interest was living in a rural county based on population density thresholds less than 50,000. The primary outcome was the type of hysterectomy, comparing abdominal with minimally invasive procedures. Among the 34,228 patients included, there was no significant difference in the distribution of surgery types between rural and urban residents. Age, race/ethnicity, primary payer type, obesity, and indication for hysterectomy were significantly associated with the type of surgery received. Racial disparities were observed, with Black patients, Hispanic patients, and patients from other racial backgrounds having lower odds of receiving MIS compared to White patients. While geographic area did not significantly influence the type of surgery received, demographic, clinical, and insurance-related factors played significant roles. Efforts to address disparities in access to minimally invasive gynecologic surgery should consider the interplay of various factors influencing surgical decision-making, aiming for equitable access across diverse patient populations. Overall, the study underscores the importance of ensuring equitable access to minimally invasive gynecologic surgery and future work could further investigate the role that geographic location plays in access to care. [ABSTRACT FROM AUTHOR]

Dual diagnosis has been a label used to describe the multiple and complex problems of a population that is characterized by two distinct diagnostic entities. This research explores the use of established assessment instruments to identify possible depression and alcohol abuse or dependence. A sample of 45, non-psychotic persons completed two depression instruments (BDI and Hamilton) and two alcohol instruments (MAST and SAAST). The research also investigates whether the results of these assessments are predictive of the working diagnosis of these individuals in an in-patient treatment unit located in a large urban public hospital. Findings suggest that over 44% of the sample are identified as having possible moderate to severe depression and probable alcoholism. Assessing and recognizing the existence of comorbidity is central to an effective treatment planning process. The inability to recognize and assess all disorders renders successful treatment a magical happening, rather than a directed, empirically-based decision process. [ABSTRACT FROM AUTHOR]

Importance: Patients in the US have persistent needs for safe, evidence-based care. Physicians in the US report fear of liability risk and the need to practice "defensive medicine." In 2024, the American Law Institute revised the legal standard for assessing medical negligence. Understanding the implications of this change is crucial for balancing patient safety, physician autonomy, and the legal system's role in health care., Observations: The updated standard from the American Law Institute shifts away from the traditional reliance on customary practice toward a more patient-centered concept of reasonable medical care. Although this revised standard still includes elements of prevailing medical practice, it defines reasonable care as the skill and knowledge regarded as competent among similar medical clinicians under comparable circumstances and acknowledges that, in some cases, juries can override customary practices if they fall short of contemporary standards. The restatement also embraces evidence-based practice guidelines, while leaving questions open about the variations in the quality of those guidelines. The restatement makes additional recommendations regarding informed consent and other aspects of physician-patient communication., Conclusions and Relevance: The new standard of care from the American Law Institute represents a shift away from strict reliance on medical custom and invites courts to incorporate evidence-based medicine into malpractice law. Although states may adopt the recommendations from the American Law Institute at different times and to varying degrees, the restatement offers health professionals and the organizations in which they practice an opportunity to reconsider how medical negligence will be assessed, and to focus more directly on promoting patient safety and improving care delivery. Nonetheless, physicians should recognize that, at least for now, many courts will continue to rely significantly on prevailing practice in assessing medical liability.

Office-based gynecologic procedures (OBGPs) are reimbursed at lower rates than similar office urology and dermatology procedures. But there is a broader "hidden curriculum" in health professions training that perpetuates clinicians' and organizations' acceptance of these patterns of poor reimbursement, disincentivizes research on improving OBGP pain management, and exacerbates tolerance of poor control of patients' OBGP pain. This article suggests strategies for equitable reimbursement that would also likely motivate better, more equitable OBGP pain control., (Copyright 2025 American Medical Association. All Rights Reserved.)

Residency selection is a challenging process for medical students, one further complicated in the USA by the recent Dobbs v Jackson Women's Health Organization ( Dobbs ) decision over-ruling the federal right to abortion. We surveyed medical students to examine how Dobbs is influencing the ideological, personal and professional factors they must reconcile when choosing where and how to complete residency.Between 6 August and 22 October 2022, third-year and fourth-year US medical students applying to US residency programmes were surveyed through social media and direct outreach to medical schools. Analysis of quantitative and qualitative data from 494 responses was performed to assess downstream effects of Dobbs on residency applicants' family, health and career choices.Most respondents said changes in abortion access would likely or very likely influence their decision regarding location of considered residency programme (76.9%), where to start a family (72.2%) and contraceptive planning for them or their partner (57.9%). Cis-gender females were more influenced by Dobbs regarding where (5 (4, 5) p<0.001) and when (3 (3, 5) p<0.001) to start a family. In qualitative responses, medical trainees highlighted the importance of abortion access for their patients, themselves and their loved ones.Medical trainees are incorporating state abortion access into their residency programme choices. Future physicians care about both the quality of care they will be able to provide and their own health. For personal and professional reasons, reproductive healthcare access is now a key factor in residency match decisions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

This invited commentary provides an in-depth critique and analysis of "Abortion is healthcare: In what sense?" (Martsolf, Tollefsen, and Curlin). We reject the claims put forth in their piece on three distinct grounds. First, the language used throughout the manuscript is imprecise and ableist. Next, the false and simplistic dichotomy of pregnancy as a state of health, while positioning abortion as exclusively harmful and risky is scientifically inaccurate. Finally, the authors fail to grapple with nursing as either technical or moral; and never address it as a profession with a social contract. We end our analysis with suggestions to continue this conversation and to engage readers in participation., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Study Objective: To examine the outcomes of surgery performed for bowel endometriosis including shaving, discoid resections with hand-sewn closure, and segmental resection., Design: Retrospective cohort study., Setting: Large academic hospital., Patients: All patients with bowel wall endometriosis who underwent surgical excision with the Division of Minimally Invasive Gynecologic Surgery between 2009 and 2022., Interventions: No interventions administered., Measurements and Main Results: From 2009 to 2022, a total of 112 patients underwent laparoscopic excision of endometriosis involving the rectum. From this cohort, 82 underwent shaving, 23 underwent discoid excision, and 7 had segmental bowel resection. The discoid excisions were closed in multiple layers with hand sewing and were not closed with a staple device. Average lesion size on preoperative imaging was 20.9 mm in the shave group, 22.5 mm in the discoid group, and 38.5 mm in the segmental group. Complication requiring reoperation for anastomotic leak occurred in 3 cases (3.66%) of the shave group and 1 case (4.35%) of the discoid excision group, but did not occur in any of the segmental resections. The number of layers of closure and type of suture used did not appear to have an effect on complication rate, however, this study was not powered to detect a meaningful difference., Conclusion: Our data shows a similar rate of anastomotic leak complication for each closure type as that reported in the literature (2.2%, 9.7%, and 9.9% reported for shave, discoid and segmental resection, respectively). While our study is underpowered, these findings support that hand sewing for discoid excision is a safe and reasonable alternative to circular stapler closures and can be considered with an experienced surgeon. Further study is warranted to confirm safety and explore potential cost savings associated with this technique as well as applications in areas with less resources available., Competing Interests: Declaration of Competing Interest J.I.E. is a consultant for Arthrex. The remaining authors report no conflict of interest., (Copyright © 2024 AAGL. Published by Elsevier Inc. All rights reserved.)

Third- and fourth-year U.S. medical students applying to residency were surveyed between August 6 and October 22, 2022, to assess the impact of Dobbs v. Jackson Women's Health Organization (Dobbs) on medical student residency application location choices. Across all medical specialties, most respondents were unlikely or very unlikely to apply to one or more residency programs located in a state with abortion restrictions (57.9%) and were considering changes in state abortion access when choosing the location of residencies to apply to (77.0%). Respondents in states with no abortion restrictions were less likely to apply to a program in a state with abortion restrictions (2 [1, 3] p < .001). The Dobbs decision significantly impacts residency application decisions for medical students in all specialties. Students are choosing to avoid or target states with restrictive abortion legislation based on their personal views., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Maternal Cardiovascular Health Post-DobbsPregnancy is associated with increasing morbidity and mortality in the United States. In the post-Dobbs era, many pregnant patients at highest risk no longer have access to abortion, which has been a crucial component of standard medical care.

Case law and statutory provisions ensure marital rules of paternity apply when artificial insemination is associated with the pregnancy. Virtually all jurisdictions in the United States provide for gamete donors to remain anonymous. Much of this has been challenged with access to donor information via 23 and me. A breach of trust and a number of lawsuits involving physician provider(s) have resulted. We provide case law examples related to artificial insemination and the identification of the sperm donor. Proposed future legislation to protect patients and offspring from harm in relation to the process of donor sperm inseminations is provided., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Financial Disclosure Erin T. Carey has provided expert witness testimony. Kelly N. Wright has received compensation from Aqua Therapeutics, Ethicon, Caldera Medical, Hologic, and Karl Storz. Louise P. King is a consultant for Johnson and Johnson. The other authors did not report any potential conflicts of interest.

Decision making during reproduction is complex for a variety of medical and social reasons. Anyone who has had a conversation with a family member about the "best time" to have a baby can attest to this - there is no "best time" or "best way." Multiple pressures from any number of sources combine in a minefield of hazards made ever more complicated by restrictive laws in the US. Add to this a screening result of potential chromosomal aneuploidy and decision making becomes ever more complex. Societal stigma and lack of adequate and accurate information during counseling certainly plays a role in the high number of terminations in the setting of diagnosed chromosomal aneuploidy, yet other factors also push families in this direction including medical considerations and the abysmal lack of social support programs.

Study Objective: The objective of this case series is to evaluate the rates of ureteral injury at the time of laparoscopic hysterectomy among high-volume fellowship-trained surgeons., Design: A retrospective chart review was performed, evaluating laparoscopic hysterectomy cases between 2009 and 2019 performed exclusively by fellowship-trained surgeons., Setting: Division of Minimally Invasive Gynecologic Surgery (MIGS) at the Brigham and Women's Hospital and Brigham and Women's Faulkner Hospital, a Harvard Medical School teaching hospital in Boston., Patients: All patients undergoing laparoscopic hysterectomy by one of 5 surgeons with fellowship training in MIGS., Interventions: None., Measurements and Main Results: A total of 5160 cases were handled by MIGS surgeons between 2009 and 2019 at our institution. Of these cases, 2345 were laparoscopic hysterectomy cases with available intraoperative and postoperative documentation. Most patients had undergone previous surgeries, and the most common indications for hysterectomy included uterine myomas, pelvic pain/endometriosis, and abnormal uterine bleeding. At the time of hysterectomy, 1 ureteral injury (0.04%) was noted. No additional delayed ureteral injuries were observed. Most patients were discharged home the same day (64.9%) and did not have any postoperative complications (63.9%) as designated by the Clavien-Dindo classification., Conclusion: Ureteral injury, although rare, is more prevalent in gynecologic surgery than in other surgical disciplines that have some focus on the pelvis. No study to date has evaluated the effect of surgical training and volume on rates of ureteral injuries. This study retrospectively examined ureteral injury rates for one group of high-volume fellowship-trained surgeons and found their rates to be lower than the national average. Proposals are presented for optimizing training and delivery of gynecologic surgical care to minimize complications., (Copyright © 2022 AAGL. Published by Elsevier Inc. All rights reserved.)

Wu et al. found a strong positive association between cumulative daily county-level COVID-19 mortality and long-term average PM 2.5 concentrations for data up until September 2020. We replicated the results of Wu et al. and extended the analysis up until May 2022. The association between PM 2.5 concentration and cumulative COVID-19 mortality fell sharply after September 2020. Using the data available from Wu et al.'s "updated&#95;data" branch up until May 2022, we found that the effect of a 1 μg/m 3 increase in PM 2.5 was associated with only a +0.603% mortality difference. The 95% CI of this difference was between -0.560% and +1.78%, narrow bounds that include zero, with the upper bound far below the Wu et al. estimate. Short-term trends in the initial spread of COVID-19, not a long-term epidemiologic association, caused an early correlation between air pollution and COVID-19 mortality.

International financial organisations like the International Monetary Fund (IMF) play a central role in shaping the developmental trajectories of fiscally distressed countries through their conditional lending schemes, known as 'structural adjustment programmes'. These programmes entail wide-ranging domestic policy reforms that influence local health and welfare systems. Using novel panel data from 187 countries between 1990 and 2017 and an instrumental variable technique, we find that IMF programmes lead to over 70 excess deaths from respiratory diseases and tuberculosis per 100,000 population and that IMF-mandated privatisation reforms lead to over 90 excess deaths per 100,000 population. Thus structural adjustment programmes, as currently designed and implemented, are harmful to population health and increase global infectious disease burdens., Competing Interests: The authors have declared that no competing interests exist.

Geographical inequalities in life and death are among the world's most pronounced in the United States. However, the driving forces behind this macroscopic variation in population health outcomes remain surprisingly understudied, both empirically and theoretically. The present article steps into this breach by assessing a number of theoretically informed hypotheses surrounding the underlying causes of such spatial heterogeneity. Above and beyond a range of usual suspects, such as poverty, unemployment, and ethno-racial disparities, we find that a hitherto neglected explanans is prison incarceration. In particular, through the use of previously unavailable county-level panel data and a compound instrumentation technique suited to isolating exogenous treatment variation, high imprisonment rates are shown to substantially increase the population-wide risk of premature death. Our findings contribute to the political economy of population health by relating the rise of the carceral state to the amplification of geographically anchored unequal life chances.

The ongoing COVID-19 pandemic has spotlighted the role of America's overcrowded prisons as vectors of ill health, but robust analyses of the degree to which high rates of incarceration impact population-level health outcomes remain scarce. In this paper, we use county-level panel data from 2927 counties across 43 states between 1983 and 2014 and a novel instrumental variable technique to study the causal effect of penal expansion on age-standardised cause-specific and all-cause mortality rates. We find that higher rates of incarceration have substantively large effects on deaths from communicable, maternal, neonatal, and nutritional diseases in the short and medium term, whilst deaths from non-communicable disease and from all causes combined are impacted in the short, medium, and long run. These findings are further corroborated by a between-unit analysis using coarsened exact matching and a simulation-based regression approach to predicting geographically anchored mortality differences., Competing Interests: None of the authors have any conflicts of interest or financial disclosures to declare., (© 2021 Published by Elsevier Ltd.)

Advocates have long suggested making shackling incarcerated people during childbirth illegal. Yet exceptions would likely still allow prison personnel to implement restraint and leave clinicians no course for freeing a patient. This article argues that clinicians' assessments of laboring individuals' clinical needs must be prioritized, ethically and legally. This article also explains that, without strong policies in place, some clinicians will not feel empowered to demand that a patient be freed during labor. Beyond prohibiting restraint of laboring individuals, health care organizations must support clinicians seeking to execute their ethical duties to care well and justly for patients. Toward this end, this article proposes a model policy., (© 2021 American Medical Association. All Rights Reserved.)

In this commentary, we describe historical and other influences that drive "double discrimination" in gynecologic surgery-lower pay in the area of surgery that boasts the largest proportion of female surgeons and is focused on female patients and explore how it results in potentially lower quality care. Insurers reimburse procedures for women at a lower rate than similar procedures for men, although there is no medically justifiable reason for this disparity. The wage gap created by lower reimbursement rates disproportionately affects female surgeons, who are disproportionately represented among gynecologic surgeons. This contributes to a large wage gap in surgery for women. Finally, poor reimbursement for gynecologic surgery pushes many obstetrics and gynecology surgeons to preferentially perform obstetric services, resulting in a high prevalence of low-volume gynecologic surgeons, a metric that is closely tied to higher complication rates. Creating equity in reimbursement for gynecologic surgery is one important and ethically required step forward to gender equity in medicine for patients and surgeons., Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest., (Copyright © 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Among the many drivers of health inequities, this article focuses on important, yet insufficiently understood, international-level determinants: economic globalization and the organizations that spread market-oriented policies to the developing world. One such organization is the International Monetary Fund (IMF), which provides financial assistance to countries in economic trouble in exchange for policy reforms. Through its 'structural adjustment programs,' countries around the world have liberalized and deregulated their economies. We examine how policy reforms prescribed in structural adjustment programs explain variation in health equity between nations-approximated by health system access and neonatal mortality. Our empirical analysis uses an original dataset of IMF-mandated policy reforms for a panel of up to 137 developing countries between 1980 and 2014. We employ regression analysis to evaluate the relationship between these reforms and health equity, taking into account the non-random selection and design of IMF programs. We find that structural adjustment reforms lower health system access and increase neonatal mortality. Additional analyses show that labor market reforms drive these deleterious effects. Overall, our evidence suggests that structural adjustment programs endanger the attainment of Sustainable Development Goals in developing countries., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Adnexal surgery is believed to be more complex in patients with prior hysterectomy; however, there is little data regarding surgical outcomes. Understanding of individualized risks improves counseling, informed consent, and preoperative planning., Methods: We performed a retrospective cohort study with a control group; we evaluated 744 patients undergoing laparoscopic adnexal surgery at an academic tertiary care center from 2011 to 2015. Comparisons were made using Chi square, Fisher's exact, or Wilcoxon-rank sum tests. We used log-binomial regression to calculate risk ratio and 95% confidence interval., Results: Patients with prior hysterectomy were more likely to have intraoperative or postoperative complications at the time of laparoscopic adnexal surgery when compared to patients without prior hysterectomy [17.7% vs. 10.2%, p = 0.02, risk ratio (RR) 1.7, 95% confidence interval (CI) 1.1-2.7]. Patients with prior hysterectomy were four times more likely to have intraoperative complications (3.2% vs. 0.8%, p = 0.047, RR 4.0, 95% CI 1.1-14.7), and five times more likely to have conversion to laparotomy (5.6% vs. 1.1%, p = 0.004, RR 5.0, 95% CI 1.8-14.0). Patients with prior hysterectomy were more likely to need additional procedures, including lysis of adhesions (69.4% vs. 26.0%, p < 0.001), ureterolysis (15.3% vs. 4.8%, p < 0.001), and cystoscopy (28.2% vs. 8.1%, p < 0.001). They had longer operative time [101.5 min (IQR 59.5-135.0) vs. 78.0 min (IQR 53.0-109.0, p < 0.001)], and were less likely to have outpatient surgery (56.5% vs. 84.8%, p < 0.01). Postoperative complications were also more common (15.3% vs. 9.4%, p = 0.046)., Conclusions: Patients with prior hysterectomy were 70% more likely to have a complication at the time of laparoscopic adnexal surgery than patients without hysterectomy. Increased risk of complications in subsequent adnexal surgery may influence the informed consent process or decisions regarding ovarian conservation. Awareness of potential need for additional surgical procedures may guide availability of equipment, choice of operating site, or referral to an advanced pelvic surgeon.

Importance: Few gynecologic surgeons understand the mechanism by which surgical instruments are approved for human use and marketing or do they appreciate the central role they play in postmarket surveillance and reporting after instruments have come to market., Objective: Using the experience with the uterine morcellator, this review will detail the Food and Drug Administration (FDA) system for approving surgical instruments and the potential pitfalls of this process., Evidence Acquisition: Literature review and public documents from the FDA., Results: The FDA 510(k) approval process for surgical instruments relies largely on postmarket surveillance as exemplified by the uterine power morcellator, which was approved before sufficient evidence was available regarding its potential harms., Conclusions: The current system currently transfers the responsibility of ensuring safety and efficacy to the public, patients, and providers. To minimize potential harm, the FDA needs to incorporate a greater standard of evidence into its framework for the approval and regulation of medical devices. The burden of these requirements should be borne at least in part by the companies bringing equipment to market., Relevance: It is incumbent on all surgeons to be vigilant in their objective critical assessment of new instrumentation and report their outcomes after they come to market.

Background: Drug use disorders are an increasing cause of disability and early death in the USA, with substantial geographical variation. We aimed to investigate the associations between economic decline, incarceration rates, and age-standardised mortality from drug use disorders at the county level in the USA., Methods: In this observational analysis, we examined age-standardised mortality data from the US National Vital Statistics System and the Institute for Health Metrics and Evaluation, household income data from the US Census Bureau, and county-level jail and prison incarceration data from the Vera Institute of Justice for 2640 US counties between 1983 and 2014. We also extracted data on county-level control variables from the US Census Bureau, the National Center for Health Statistics, and the US Centers for Disease Control and Prevention. We used a two-way fixed-effects panel regression to examine the association between reduced household income, incarceration, and mortality from drug use disorders within counties over time. To assess between-county variation, we used coarsened exact matching and a simulation-based modelling approach., Findings: After adjusting for key confounders, each 1 SD decrease in median household income was associated with an increase of 12·8% (95% CI 11·0-14·6; p<0·0001) in drug-related deaths within counties. Each 1 SD increase in jail and prison incarceration rates was associated with an increase of 1·5% (95% CI 1·0-2·0; p<0·0001) and 2·6% (2·1-3·1; p<0·0001) in drug-related mortality, respectively. The association between drug-related mortality and income and incarceration persisted after controlling for local opioid prescription rates. Our model accounts for a large proportion of within-county variation in mortality from drug use disorders (R 2 =0·975). Between counties, high rates of incarceration were associated with a more than 50% increase in drug-related deaths., Interpretation: Reduced household income and high incarceration rates are associated with poor health. The rapid expansion of the prison and jail population in the USA over the past four decades might have contributed to the increasing number of deaths from drug use disorders., Funding: None., (Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

The majority of obstetrician-gynecologists in practice operate very infrequently. Most residents graduate with strong surgical skill sets, given residency requirements. Nonetheless, their practices become dominated by obstetrics, and their gynecologic surgical skills deteriorate. While cesarean sections are surgical in nature, the skill sets needed in these surgeries differ from the skills used in general gynecologic surgery. As gynecology has taken a back seat to obstetrics in our specialty, not only surgical skills but also diagnostic and management skills have deteriorated., (© 2019 The Hastings Center.)

This article highlights an important yet insufficiently understood international-level determinant of inequality in the developing world: structural adjustment programs by the International Monetary Fund (IMF). Studying a panel of 135 countries for the period 1980 to 2014, we examine income inequality using multivariate regression analysis corrected for non-random selection into both IMF programs and associated policy reforms (known as 'conditionality'). We find that, overall, policy reforms mandated by the IMF increase income inequality in borrowing countries. We also test specific pathways linking IMF programs to inequality by disaggregating conditionality by issue area. Our analyses indicate adverse distributional consequences for four policy areas: fiscal policy reforms that restrain government expenditure, external sector reforms stipulating trade and capital account liberalization, financial sector reforms entailing inflation-control measures, and reforms that restrict external debt. These effects occur one year after the incidence of an IMF program, and persist in the medium term. Taken together, our findings suggest that the IMF's recent attention to inequality neglects the multiple ways through which the organization's own policy advice has contributed to inequality in the developing world., (Copyright © 2019 Elsevier Inc. All rights reserved.)

An unprecedented mortality crisis befell the former socialist countries between 1989 and 1995, representing one of the greatest demographic shocks of the period after the Second World War. While it is likely that country-level variation in the post-socialist mortality crisis in Eastern Europe can be explained by a constellation of political and socio-economic factors, no comprehensive review of the existing scholarly attempts at explaining these factors exists. We review 39 cross-national multi-variable peer reviewed studies of social determinants of mortality in post-socialist Europe in order to assess the social factors behind the post-socialist mortality crisis, determine the gaps in the existing literature and to make suggestions for future research. We propose a novel methodology to determine the relative importance of variables based on the ratio of significant to insignificant findings for each variable. The literature identifies inequality, welfare payments, religious composition, democracy, economic performance and unemployment as the leading factors that have a significant influence on mortality outcomes. Existing cross-country studies fail to establish a definitive connection between mortality and diets, drinking patterns, liberalisation, trust, health expenditure and war. We also point out that the level of analysis is not a neutral methodological choice but might influence the results themselves., (© 2018 Foundation for the Sociology of Health & Illness.)

It is becoming increasingly clear that surgeon volume affects surgical outcomes. High-volume surgeons demonstrate reduced perioperative complications, shorter operative times, and reduced blood loss during multiple modalities of benign gynecologic surgery. Furthermore, high-volume surgeons consistently demonstrate higher rates of minimally invasive approaches, low rates of conversion to laparotomy, and lower per-procedure case costs. It is suggested that surgeons who have completed postresidency training have improved surgical outcomes, although these data are limited. Surgical exposure in obstetrics and gynecology residency is varied and does not consistently meet demonstrated surgical learning curves. Deficiencies in residency surgical training may be related to the volume-outcome relationship. We suggest reforming residency surgical training and tracking postresidency practice to provide optimal surgical care. Additionally, surgeons may have an ethical obligation to inform patients of their surgical volume and outcomes, with options for referrals if needed., (Copyright © 2018. Published by Elsevier Inc.)

Objectives: To evaluate clarity and usefulness of MRI reporting of uterine fibroids using a structured disease-specific template vs. narrative reporting for planning of fibroid treatment by gynaecologists and interventional radiologists., Methods: This is a HIPAA-compliant, IRB-approved study with waiver of informed consent. A structured reporting template for fibroid MRIs was developed in collaboration between gynaecologists, interventional and diagnostic radiologists. The study population included 29 consecutive women who underwent myomectomy for fibroids and pelvic MRI prior to implementation of structured reporting, and 42 consecutive women with MRI after implementation of structured reporting. Subjective evaluation (on a scale of 1-10, 0 not helpful; 10 extremely helpful) and objective evaluation for the presence of 19 key features were performed., Results: More key features were absent in the narrative reports 7.3 ± 2.5 (range 3-12) than in structured reports 1.2 ± 1.5 (range 1-7), (p < 0.0001). Compared to narrative reports, gynaecologists and radiologists deemed structured reports both more helpful for surgical planning (p < 0.0001) (gynaecologists: 8.5 ± 1.2 vs. 5.7 ± 2.2; radiologists: 9.6 ± 0.6 vs. 6.0 ± 2.9) and easier to understand (p < 0.0001) (gynaecologists: 8.9 ± 1.1 vs. 5.8 ± 1.9; radiologists: 9.4 ± 1.3 vs. 6.3 ± 1.8)., Conclusion: Structured fibroid MRI reports miss fewer key features than narrative reports. Moreover, structured reports were described as more helpful for treatment planning and easier to understand., Key Points: • Structured reports missed only 1.2 ± 1.5 out of 19 key features, as compared to narrative reports that missed 7.3 ± 2.5 key features for planning of fibroid treatment. • Structured reports were more helpful and easier to understand by clinicians. • Structured template can provide essential information for fibroids treatment planning.

Best practices for teaching morally and spiritually charged topics, such as abortion, to those early in their medical training are elusive at best, especially in our current political climate. Here we advocate that our duty as educators requires that we explore these topics in a supportive environment. In particular, we must model respectful discourse for our learners in these difficult areas., (© 2018 American Medical Association. All Rights Reserved.)

Background: The health gap between the top and the bottom of the income distribution is widening rapidly in the USA, but the lifespan of America's poor depends substantially on where they live. We ask whether two major developments in American society, deindustrialization and incarceration, can explain variation among states in life expectancy of those in the lowest income quartile., Methods: Life expectancy estimates at age 40 of those in the bottom income quartile were used to fit panel data models examining the relationship with deindustrialization and incarceration between 2001 and 2014 for all US states., Results: A one standard deviation (s.d.) increase in deindustrialization (mean = 11.2, s.d. = 3.5) reduces life expectancy for the poor by 0.255 years [95% confidence interval (CI): 0.090-0.419] and each additional prisoner per 1000 residents (mean = 4.0, s.d. = 1.5) is associated with a loss of 0.468 years (95% CI: 0.213-0.723). Our predictors explain over 20% of the state-level variation in life expectancy among the poor and virtually the entire increase in the life expectancy gap between the top and the bottom income quartiles since the turn of the century., Conclusions: In the USA between 2001 and 2014, deindustrialization and incarceration subtracted roughly 2.5 years from the lifespan of the poor, pointing to their role as major health determinants. Future research must remain conscious of the upstream determinants and the political economy of public health. If public policy responses to growing health inequalities are to be effective, they must consider strengthening industrial policy and ending hyper-incarceration., (© The Author 2017; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association.)

Respect for autonomy is a central value in reproductive ethics, but it can be a challenge to fulfill and is sometimes an outright puzzle to understand. If a woman requests the transfer of two, three, or four embryos during fertility treatment, is that request truly autonomous, and do clinicians disrespect her if they question that decision or refuse to carry it out? Add a commitment to justice to the mix, and the challenge can become more complex still. Is it unfair for insurance policies to exclude from coverage the costs of giving fertility to those who lack it or restoring fertility in those who have lost it? What does "just reproduction" look like in the face of multifarious understandings of both justice and autonomy and in light of increasingly complex and costly reproductive technologies? In today's dialogue about reproduction, medicine, and ethics in the United States, old ethical issues-such as whether women ought to be allowed to access pregnancy termination-are more contested than they have been in decades, while new technologies-like those used to edit the genes of human embryos-suggest that our species could face unprecedented questions about who should exist. As we considered the discussions accompanying these issues and contemplated a special report responding to them, we found ourselves consistently circling back to two ethical commitments: respect for autonomy and the pursuit of justice. As one of the nine essays in this collection asks, why should certain women receive help to establish a pregnancy while others are thrown in jail when they miscarry or their child is stillborn? Respect for autonomy is required where individuals have the ability to make fully informed and voluntary choices. Yet does respecting autonomy require acceding to all the choices of patients or consumers of medical care? We consider these and related questions in this special report from the Hastings Center Report., (© 2017 The Hastings Center.)

As a gynecologic surgeon with a focus on infertility, I frequently hold complex discussions with patients, exploring with them the risks and benefits of surgical options. In the past, we physicians may have expected our patients to simply defer to our expertise and choose from the options we presented. In our contemporary era, however, patients frequently request options not favored by their physicians and even some they've found themselves online. In reproductive endocrinology and infertility, the range of options that may be offered or that patients may themselves seek out is continuously widening. Physicians certainly seek to find the option that will result in the best outcome for their patients, but the information to guide us in achieving the best outcome can be vague or conflicting. Add to this the financial and emotional pressures bearing on patients seeking assisted reproduction. In this essay, I explore the extent to which clinicians in reproductive medicine should follow patient requests with which they disagree or instead try to persuade the patient to do something else or simply refuse outright to meet the request. And if persuasion is to be used, what would be legitimate methods? Clearly, coercion is unacceptable, but the line between persuasion and coercion can be elusive. At what point can or should clinicians resist such requests-and to what degree?, (© 2017 The Hastings Center.)