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Browsing by Author "Department of Obstetrics and Gynecology, IU School of Medicine"
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Item 30 Years of Cystocele/Rectocele Repair in the United States(Lippincott, Williams, and Wilkins, 2016-07) Stewart, James R.; Hamner, Jennifer J.; Heit, Michael H.; Department of Obstetrics and Gynecology, IU School of MedicineObjective: A growing body of evidence suggests an increased role for apical support in the treatment of pelvic organ prolapse regardless of phenotype. The objective of this study was to determine whether changes in cystocele/rectocele diagnosis and surgical management for the last 30 years reflect this changing paradigm. Methods: Data from the National Hospital Discharge Survey were mined from 1979 to 2009 for diagnosis and procedure codes. Records were categorized according to predefined combinations of diagnosis and procedure codes and weighted according to the National Hospital Discharge Survey data set. Pearson [chi]2 test was used to evaluate the changes in population proportions during the study interval. Results: The proportion of isolated cystocele/rectocele diagnoses decreased from 1979 to 2009 (56.5%, n = 88,548, to 34.8%, n = 31,577). The proportion of isolated apical defect diagnoses increased from 1979 to 2009 (38.4%, n = 60,223, to 60.8%, n = 55,153). There was a decrease in the frequency of isolated cystocele/rectocele repair procedures performed from 1979 to 2009 (96.3%, n = 150,980, to 67.7%, n = 61,444), whereas there was an increase in isolated apical defect repair procedures (2.5%, n = 3929, to 22.5%, n = 20,450). The proportion of cystocele/rectocele plus apical defect procedures also increased (1.2%, n = 1879, to 9.7%, n = 8806). Furthermore, 87.0% of all studied diagnostic groups were managed by cystocele/rectocele repair alone. Conclusions: Surgeons have responded to the increased contribution of apical support defects to cystocele/rectocele by modifying their diagnostic coding practices. Unfortunately, their surgical choices remain largely rooted in an older paradigm.Item Adoptive Transfer of Myeloid-Derived Suppressor Cells and T Cells in a Prostate Cancer Model(Bio-protocol LLC, 2015-08-20) Yan, Libo; Xu, Yan; Department of Obstetrics and Gynecology, IU School of MedicineThe adoptive transfer of immune cells for cancer, chronic infection, and autoimmunity is an emerging field that has shown promise in recent trials. The transgenic adenocarcinoma mouse prostate (TRAMP) is a classical mouse model of prostate cancer (PCa) and TRAMP cell lines were derived from a TRAMP mouse tumor. TRAMP-C2 is tumorigenic when subcutaneously (s.c.) grafted into syngeneic C57BL/6 host mice (Foster et al., 1997). This protocol will describe the adoptive transfer of purified CD11b(+)Gr1(+) double positive (DP) myeloid-derived suppressor cells (MDSC) and CD3(+) T cells in the TRAMP-C2 prostate cancer mouse model in order to establish the intrinsic functionality of these immune cells and to determine their role in tumorigenesis in vivo (Yan et al., 2014).Item Advanced Maternal Age and the Risk of Major Congenital Anomalies(Thieme, 2017-02) Goetzinger, Katherine R.; Shanks, Anthony L.; Odibo, Anthony O.; Macones, George A.; Cahill, Alison G.; Department of Obstetrics and Gynecology, IU School of MedicineObjective This study aims to determine if advanced maternal age (AMA) is a risk factor for major congenital anomalies, in the absence of aneuploidy. Study Design Retrospective cohort study of all patients with a singleton gestation presenting for second trimester anatomic survey over a 19-year study period. Aneuploid fetuses were excluded. Study groups were defined by maternal age ≤ 34 and ≥ 35 years. The primary outcome was the presence of one or more major anomalies diagnosed at the second trimester ultrasound. Univariable and multivariable logistic regression analyses were used to estimate the risk of major anomalies in AMA patients. Results Of 76,156 euploid fetuses, 2.4% (n = 1,804) were diagnosed with a major anomaly. There was a significant decrease in the incidence of major fetal anomalies with increasing maternal age until the threshold of age 35 (p < 0.001). Being AMA was significantly associated with an overall decreased risk for major fetal anomalies (adjusted odds ratio: 0.59, 95% confidence interval: 0.52–0.66). The subgroup analysis demonstrated similar results for women ≥ 40 years of age. Conclusion AMA is associated with an overall decreased risk for major anomalies. These findings may suggest that the “all or nothing” phenomenon plays a more robust role in embryonic development with advancing oocyte age, with anatomically normal fetuses being more likely to survive.Item Antenatal corticosteroids for fetal lung maturation: an overview of Cochrane reviews(Wiley, 2016) McGoldrick, Emma; Brown, Julie; Middleton, Philippa; McKinlay, Christopher J. D.; Haas, David M.; Crowther, Caroline A.; Department of Obstetrics and Gynecology, IU School of MedicineThis is the protocol for a review and there is no abstract. The objectives are as follows: The objective is to summarise the available evidence from Cochrane systematic reviews for the effectiveness and safety of antenatal corticosteroid therapy to improve infant outcomes.Item Comparing neonatal morbidity and mortality estimates across specialty in periviable counseling(Taylor & Francis, 2015-12) Edmonds, Brownsyne Tucker; McKenzie, Fatima; Panoch, Janet; Frankel, Richard M.; Department of Obstetrics and Gynecology, IU School of MedicineObjective To describe and compare estimates of neonatal morbidity and mortality communicated by neonatologists and obstetricians in simulated periviable counseling encounters. Methods A simulation-based study of 16 obstetricians (OBs) and 15 neonatologists counseling standardized patients portraying pregnant women with ruptured membranes at 23 weeks gestation. Two investigators tabulated all instances of numerically-described risk estimates across individuals and by specialty. Results Overall, 12/15 (80%) neonatologists utilized numeric estimates of survival; 6/16 (38%) OBs did. OBs frequently deferred the discussion of “exact numbers” to neonatologists. The twelve neonatologists provided 13 unique numeric estimates, ranging from 3% to 50% survival. Half of those neonatologists provided 2-3 different estimates in a single encounter. By comparison, six OBs provided 4 unique survival estimates (“50%”, “30-40%”, “1/3-1/2”, “<10%”). Only 2/15 (13%) neonatologists provided numeric estimates of survival without impairment. None of the neonatologists used the term ‘intact’ survival, while 5 OBs did. Three neonatologists gave numeric estimates of long-term disability and one OB did. Conclusion We found substantial variation in estimates and noteworthy omissions of discussions related to long-term morbidity. Across specialties, we noted inconsistencies in the use and meaning of terms like ‘intact survival.’ More tools and training are needed to improve the quality and consistency of periviable risk-communication.Item Comparing obstetricians' and neonatologists' approaches to periviable counseling(Nature Publishing Group, 2015-05) Tucker Edmonds, B.; McKenzie, F.; Panoch, J. E.; Barnato, A. E.; Frankel, R. M.; Department of Obstetrics and Gynecology, IU School of MedicineOBJECTIVE: To compare the management options, risks and thematic content that obstetricians and neonatologists discuss in periviable counseling. STUDY DESIGN: Sixteen obstetricians and 15 neonatologists counseled simulated patients portraying a pregnant woman with ruptured membranes at 23 weeks of gestation. Transcripts from video-recorded encounters were qualitatively and quantitatively analyzed for informational content and decision-making themes. RESULT: Obstetricians more frequently discussed antibiotics (P=0.005), maternal risks (<0.001) and cesarean risks (<0.005). Neonatologists more frequently discussed neonatal complications (P=0.044), resuscitation (P=0.015) and palliative options (P=0.023). Obstetricians and neonatologists often deferred questions about steroid administration to the other specialty. Both specialties organized decision making around medical information, survival, quality of life, time and support. Neonatologists also introduced themes of values, comfort or suffering, and uncertainty. CONCLUSION: Obstetricians and neonatologists provided complementary counseling content to patients, yet neither specialty took ownership of steroid discussions. Joint counseling and/or family meetings may minimize observed redundancy and inconsistencies in counseling.Item Cytogenetic features of human trophoblast cell lines SWAN-71 and 3A-subE(Elsevier, 2017-04) Reiter, Jill L.; Drendel, Holli M.; Chakraborty, Sujata; Schellinger, Megan M.; Lee, Men-Jean; Mor, Gil; Department of Obstetrics and Gynecology, IU School of MedicineImmortalization of primary cells with telomerase is thought to maintain normal phenotypic properties and avoid chromosomal abnormalities and other cancer-associated changes that occur following simian virus 40 tumor antigen (SV40 Tag) induced immortalization. However, we report that the human telomerase reverse transcriptase (hTERT)-immortalized SWAN-71 trophoblast cell line has a near pentaploid 103∼119,XXXX[cp20] karyotype. Additionally, DNA typing analysis indicated that SWAN-71 cells have acquired microsatellite instability. In comparison, the post-crisis SV40-transformed trophoblast cell line 3A-subE was hypertriploid 69∼81,XX[cp20]. Both cell lines contained multiple specific clonal rearrangements. These findings emphasize the need to monitor for genetic instability in hTERT-immortalized cells.Item "Doctor, what would you do?": physicians' responses to patient inquiries about periviable delivery(Elsevier, 2015-01) Tucker Edmonds, Brownsyne; McKenzie, Fatima; Panoch, Janet E.; Wocial, Lucia D.; Barnato, Amber E.; Frankel, Richard M.; Department of Obstetrics and Gynecology, IU School of MedicineOBJECTIVE: To qualitatively assess obstetricians' and neonatologists' responses to standardized patients (SPs) asking "What would you do?" during periviable counseling encounters. METHODS: An exploratory single-center simulation study. SPs, portraying a pregnant woman presenting with ruptured membranes at 23 weeks, were instructed to ask, "What would you do?" if presented options regarding delivery management or resuscitation. Responses were independently reviewed and classified. RESULTS: We identified five response patterns: 'Disclose' (9/28), 'Don't Know' (11/28), 'Deflect' (23/28), 'Decline' (2/28), and 'Ignore' (2/28). Most physicians utilized more than one response pattern (22/28). Physicians 'deflected' the question by: restating or offering additional medical information; answering with a question; evoking a hypothetical patient; or redirecting the SP to other sources of support. When compared with neonatologists, obstetricians (40% vs. 15%) made personal or professional disclosures more often. Though both specialties readily acknowledged the importance of values in making a decision, only one physician attempted to elicit the patient's values. CONCLUSION: "What would you do?" represented a missed opportunity for values elicitation. Interventions are needed to facilitate values elicitation and shared decision-making in periviable care. PRACTICE IMPLICATIONS: If physicians fail to address patients' values and goals, they lack the information needed to develop patient-centered plans of care.Item Doctor, What Would You Do?: An ANSWER for patients requesting advice about value-laden decisions(AAP, 2015-10) Edmonds, Brownsyne Tucker; Torke, Alexia M.; Helft, Paul; Wocial, Lucia D.; Department of Obstetrics and Gynecology, IU School of MedicineThis article presents a previously published framework, summarized in the mnemonic ANSWER (A, Active listening; N, Needs assessment; S, Self-awareness/reflection; W, Whose perspective?; E, Elicit values; R, Respond) for how to respond to the question, “Doctor, what would you do?” when considering medical decisions that are preference-sensitive, meaning there is limited or debatable evidence to guide clinical recommendations, or are value-laden, such that the “right” decision may differ based on the context or values of a given individual. Using the mnemonic and practical examples, we attempt to make the framework for an ethically appropriate approach to these conversations more accessible for clinicians. Rather than a decision rule, this mnemonic represents a set of points to consider when physicians are considering an ethically acceptable response that fosters trust and rapport. We apply this approach to a case of periviable counseling, among the more emotionally challenging and value-laden antenatal decisions faced by providers and patients.Item Documentation of specific mesh implant at the time of midurethral sling surgery in women with stress incontinence(Lippincott Williams & Wilkins, 2015-01) Kassis, Nadine C.; Thompson, Jennifer C.; Scheidler, Anne M.; Hale, Douglass S.; Department of Obstetrics and Gynecology, IU School of MedicineObjective: We aimed to assess documentation completeness of the operative record for mesh implanted at the time of midurethral sling surgery and to identify modifiable predictors of documentation completeness. Methods: A retrospective cross-sectional study of women with stress incontinence who underwent midurethral sling placement between January 2009 and December 2011 was conducted. Data from the dictated operative note and nursing operative record were extracted to determine if the specific mesh implanted during surgery was documented. The primary outcome was the rate of documentation of mesh implanted in the physician's dictated operative note and in the nursing record. Logistic regression was used to determine if any characteristics were associated with the rate of documentation while accounting for correlation of patients from the same dictating surgeon. Results: There were 816 surgeries involving the implantation of a midurethral sling during the study period. All surgeries were performed at 6 Indiana University hospitals. Fifty-two surgeons of varying specialties and levels of training dictated the operative notes. A urogynecologist dictated 71% of the operative notes. The rate of documentation completeness for mesh implanted in the physician's note was 10%. The rate of documentation completeness for mesh implanted in the nursing operative record was 92%. Documentation of mesh implanted in the physician's note was not significantly associated with the level of training, specialty, or year of surgery. Conclusions: Documentation completeness for specific mesh implant in the physician's note is low, independent of specialty and level of training. Nursing documentation practices are more rigorous. Postmarket surveillance, currently mandated by the Food and Drug Administration, may not be feasible if only the physician's note is available or if nursing practices are inconsistent. Development of documentation guidelines for physicians would improve the feasibility of surveillance.