Microsoft word - residentresearchdayprogram060899.doc

Resident Research Day
Congratulations To
June 8, 1999
All Graduating
Ob/Gyn Chief Residents!
Economic Costs of Resident Education
John P. McHugh, M.D.
(consultation from Kevin Grumbach, MD and Linda Ennis, CNM) Objective: To estimate the cost of training a physician from baccalaureate
A.Eugene Washington, M.D., M.Sc.
degree through medical school and a four-year Ob/Gyn residency and compare this cost to that of training a midwife from baccalaureate to entry Ernest W. Page Memorial Lecture:
Methods: A review of the literature in medical education regarding
educational costs for training medical students (undergraduate medical Jeanette Brown, M.D.
education), residents (graduate medical education) and midwives was performed. Studies which provided cost/year estimates of undergraduate John McHugh, M.D.
medical education were included. Cost estimate of residency education were “Economic Costs of Resident Education” evaluated to support or reject the hypothesis that the existing Medicare Lisa Bernard, M.D.
subsidies for residency training exceeded the cost of resident education. The “Emergency Contraception Knowledge & Use Consumer Price Index was used to convert all estimates to current costs in an Inner-City Postpartum Population” Results: High and low estimates for the cost of medical school training
ranged from $198,000 to $472,000. Residency education costs could not be Stephanie Yap, M.D.
“The Effect of Herpes Simplex Virus (HSV) Reactivation evaluated similarly. A review of available data was conducted which on Plasma HIV-1 Infected PregnantWomen” suggests that the costs of residency education are less than existing Medicare subsidies (GME funding = $83,000/resident/yr). This figure was then used Ededet Udo, M.D.
as the high cost estimate for residency training costs. Data collected from all CNM programs nationally estimated the cost of midwifery training. Ratios of training costs reveal that for each trainee entering with a bachelors degree Eleanor Drey, M.D.
the cost to train one Ob/Gyn equals the cost to train 7 to 29 CNMs. “The Safety of Intra-amniotic Digoxin Before Conclusion: Physician training costs greatly exceed the personal economic
Lunch - Page Library, Room M-1486
investment of the trainee and are supported both by government revenue and subsidies within the academic medical centers. Costs of training non- Natasha Kahl, M.D.
physician providers including midwives are largely borne by the trainee and are substantially lower. As we enter into an era in which academic medical Caroline Peck, M.D.
centers are challenged to meet the high cost of training physicians, this analysis may affect the allocation of training resources. Yamilée Bermingham, M.D.
“The Case of P.W.: Choriocarcinoma Incidentally Diagnosed in a Patient Presenting for Scheduled DMPA”
3:15 - 4:00 p.m.
Emergency Contraception Knowledge and Use in an Inner City
The Effect of Herpes Simplex Virus2 (HSV2) Reactivation on
Post-Partum
Population
Plasma HIV-1 RNA Levels in HIV-1 Infected Pregnant Women
Lisa D. Bernard, M.D.
O.W. Stephanie Yap, M.D.
(in collaboration with Drs. Rebecca Jackson, Eleanor Schwarz, (in collaboration with Drs. Maureen Shannon and Karen P. Beckerman) Objective: Reactivation of HSV2 is encountered at high rates in HIV-
Objective: There are approximately 2.6 million unintended pregnancies in the US annually
1-infected pregnant mothers. Recent data suggest that maternal and 54% of those are electively terminated. Emergency Contraception (EC) in the form of the Yuzpe regimen is a simple, safe, well-tolerated, under-utilized method of contraception that plasma HIV-1 RNA levels are correlated with risk of vertical reduces the risk of an unintended pregnancy by 75%. This study assessed knowledge and use transmission. We sought to understand what interaction, if any, there of EC in an inner city post-partum population at risk for future unintended pregnancies. A might be between recurrent HSV2 during pregnancy and maternal secondary goal was to evaluate the demographic, contraceptive and pregnancy history plasma HIV-1 viremia and the risk of vertical transmission. predictors of knowledge and use of EC.
Methods: This is a descriptive and analytic study of data obtained during in-person scripted
interviews with English or Spanish speaking women who were eligible and willing to Methods: We identified eight patients who had reactivation of
participate in the study post delivery at San Francisco General Hospital. Bivariate analysis genital HSV2 during pregnancy, confirmed by culture of suspected and multiple logistic regression were used to determine the demographic, contraceptive and lesions and specific antibody testing, for whom serial plasma HIV-1 pregnancy history factors predictive of EC knowledge, willingness to use EC in the future, and past use. RNA measurements (Chiron bDNA 2.0) were available. All were Results: 371 women were interviewed. Overall, 71% of the women were Latina and 47%
subsequently placed on acyclovir prophylaxis. monolingual Spanish speakers. Their contraceptive history was notable for 70% having tried condoms and 51% OCPs. There were high rates of intercourse without contraception and low rates of consistent condom use. Their pregnancy histories were remarkable for 63% reporting Results: In five patients, whose maternal HIV-1 plasma viremia was
the most recent pregnancy unplanned and 44% reporting prior unwanted pregnancies. 35% of suppressed to undetectable levels while taking combination the sample had heard of EC, 19% had some knowledge of EC, 7% knew correct timing and antiretroviral therapy (ART), recurrent HSV2 was not correlated with only 3% had used it in the past. Importantly, 64% said they would use a hormonal method of detectable changes of their plasma HIV-1 RNA levels. In two of the post-coital contraception if it were available. Among those who had heard of EC, only 31% had learned of it from a health care provider. 32% incorrectly thought it worked as an three remaining women with detectable (>500 copies/mL) viral abortifacient. The most significant positive predictors of familiarity with EC were being a burdens, there was a temporal association between a single HSV2 teenager or >30 years of age, having tried condoms, or had a prior elective abortion. The most reactivation and an elevation in HIV-1 viremia. In the third patient, significant independent negative predictors of familiarity with EC were monolingual Spanish who had advanced HIV disease, plasma HIV-1 RNA increased by a speaking Latinas and multiparity.
Conclusion: Our findings are similar to other studies concerning knowledge and use of EC.
mean of 1.4 log10 during each of three distinct reactivation episodes Among our population, the level of significant knowledge that would allow women to use EC effectively was low. It appears that those patients with relatively higher socioeconomic status are more likely to know about EC. It also appears that teenagers and those with prior abortions or unplanned pregnancies are starting to get the message, reinforcing the idea that Conclusion: These data suggest that acyclovir prophylaxis in the
health care professionals may only be counseling those patients whom they feel are at highest setting of advanced or poorly controlled maternal HIV-1-disease not risk for unintended pregnancies. Not providing EC education during routine prenatal care is only reduces fetal exposure to infectious HSV2 vesicles during missing an important opportunity to prevent future unintended pregnancies. The majority of women were willing to use a post-coital hormonal method of EC. Clearly, we as health care pregnancy and labor but also may enhance control of maternal HIV-1 providers must take the educational initiative as well as develop better educational strategies plasma viremia. Our findings speak to a possible role for maternal for our non-English speaking patients. Improving access to effective contraceptive methods HSV prophylaxis in the prevention of pediatric AIDS. will allow women and their partners the ability to have children when they feel best prepared socially and financially to be parents, thus avoiding the social, emotional and physical costs of unintended pregnancies and abortions. Danazol Directly Inhibits TNFa Expression in Human
The progestogen R5020 has minimal direct inhibition of TNF-a Monocytes (U937) by Androgen Receptor-Mediated
gene expression through progestogen receptors (PR). Repression
Ededet A. Udo, M.D.

Objective: Endometriosis affects 5-15% of women of
reproductive age causing pelvic pain, dysmenorrhea and sub-
fertility. Medical or surgical treatments are available. Medical
treatment is based on the fact that the endometrium,
intrauterine or ectopic, is hormonally responsive. The aim of
medical treatment is to render the endometrium inactive.
Danazol has been used in such treatment. Recent studies
indicate danazol can modify immune cell function in
endometriosis. Tumor necrosis factor (TNF alpha), a cytokine,
is associated with the symptoms and signs of endometriosis. It
was then postulated that danazol may modulate TNF gene
expression.
Methods: Androgen receptor (AR) and progesterone receptors
(PR-a and PR-b) were added to the plasmid luciferase-TNF
alpha RE (responsive element). This mixture was added to
human monocyte U937 cells and the cells transfected. The cells
were then incubated for 24 hours with TNF and the respective
drugs under test. Controls were without TNF or drugs. The
cells were subsequently lysed and the supernatant assayed by
luciferase assay to quantify TNF-a gene expression.
Results: Danazol and testosterone, acting through AR,
suppressed TNF gene expression. Danazol acting through PR-a
and PR-b had no effect. The progestogen R5020 acting through
PR-a and PR-b had minimal TNF gene suppression.
Conclusion: The studies show that danazol inhibits gene
expression of TNF-a through androgen receptors (AR), but had
minimal effect through progestogen receptors (PR-a and PR-b).
Safety of Intra-Amniotic Digoxin Before Late Second-
Trimester Abortion by Dilation and Evacuation
Eleanor A. Drey, M.D.
Objective: To determine to what extent digoxin is absorbed
systemically by women who receive intra-amniotic digoxin
injection before pregnancy termination by dilation and
evacuation (D&E), and to assess digoxin-associated maternal
cardiac rhythm or clotting abnormalities.
Methods: Pregnant women between 19 and 23 weeks gestation
received 1.0 mg digoxin via amniocentesis and then had serum
digoxin levels drawn for 48 hours and Holter cardiac
monitoring for 24 hours. Clotting measurements were assessed
before digoxin injection and 24 hours later at the time of the
D&E.
Results: Eight patients completed the study. The mean digoxin
peak was 0.81 mcg/L (range 0.5-1.1, SD 0.22). The mean time to
peak digoxin concentration was 11.0 hours (range 4-20, SD 5.55).
Ambulatory cardiac monitoring showed no rhythm or
conduction abnormalities associated with digoxin. Pre- and
post-D&E PT, PTT and fibrinogen levels did not change
significantly (11.5-->11.4, 24.1-->24.4, 441-->475, respectively).
Conclusion: The maximum digoxin peak achieved after intra-
amniotic injection was in the low therapeutic range. No rhythm
or conduction abnormalities associated with digoxin were noted
by electrocardiography. Coagulation measurements did not
change significantly. Based upon its limited systemic
absorption and the absence of clinically significant cardiac or
clotting effects, intra-amniotic digoxin may be used safely
before late second-trimester pregnancy terminations.
7. Efficacy of Urinary Incontinence Therapy in Women
“The Case of P.W.: Choriocarcinoma Incidentally Diagnosed in
Caroline A. Peck, M.D.
a Patient Presenting for Scheduled DMPA”
(consultation from Leslee Subak, MD, Jeanette Brown, MD Yamilée O. Bermingham, M.D.
Objective: To assess the efficacy of behavioral, medical
and surgical therapy on urinary incontinence.
Methods: A retrospective chart review of 258 women with
urinary incontinence who were followed for one year at a
urogynecology referral center to assess subjective
outcomes of incontinence, micturition and nocturia before
and after therapy. Statistical analysis via t-test, paired t-
test and chi-square was performed.
Results: The use of behavioral and medical therapy
showed a statistically significant decrease in incontinence
episodes; however, the clinical significance of this finding
is questionable.
Conclusion: It is difficult to comment on the use of
surgical therapy as the sample size was very small.
The Ernest W. Page Memorial Lecture
Each year the Ernest W. Page Memorial Lecture is presented on Resident Research Day. The Lecture honors Dr. Page, Chairman of the Department of Obstetrics, Gynecology and Reproductive Sciences from 1956 to 1973. Dr. Page was a nationally and internationally recognized authority on preeclampsia and placental biology. This year’s Page Lecturer is:
E. Albert Reece, M.D,
1999 OB/GYN Resident Research Day
Co-Chair:
Residency Program Coordinator:
Medical Student Education Coordinator:

Source: http://obgyn.ucsf.edu/education/residency/pdfs/rrd/ResidentResearchDayProgram0608-99.pdf