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Passive acoustic monitoring (PAM) is a cost-effective method for monitoring cetacean populations compared to techniques such as aerial and ship-based surveys. The C-POD (Cetacean POrpoise Detector) has become an integral tool in monitoring programmes globally for over a decade, providing standardised metrics of occurrence that can be compared across time and space. However, the phasing out of C-PODs following development of the new F-POD (Full waveform capture Pod) with increased sensitivity, improved train detection, and reduced false positive rates, represents an important methodological change in data collection, particularly when being introduced into existing monitoring programmes. Here, we compare the performance of the C-POD with that of its successor, the F-POD, co-deployed in a field setting for 15 months, to monitor harbour porpoise (Phocoena phocoena). While similar temporal trends in detections were found for both devices, the C-POD detected only 58% of the detection positive minutes (DPM), recorded by the F-POD. Differences in detection rates were not consistent through time making it difficult to apply a correction factor or directly compare results obtained from the two PODs. To test whether these differences in detection rates would have an effect on analyses of temporal patterns and environmental drivers of occurrence, generalised additive models (GAMs) were applied. No differences were found in seasonal patterns or the environmental correlates of porpoise occurrence (month, diel period, temperature, environmental noise, and tide). However, the C-POD failed to detect sufficient foraging buzzes to identify temporal patterns in foraging behaviour that were clearly shown by the F-POD. Our results suggest that the switch to F-PODs will have little effect on determining broad-scale seasonal patterns of occurrence, but may improve our understanding of fine-scale behaviours such as foraging. We highlight how care must be taken interpreting F-POD results as indicative of increased occurrence when used in time-series analysis.

Congenital adrenal hyperplasia (CAH) encompasses a range of autosomal recessive inherited enzyme deficiencies that impact cortisol biosynthesis pathways. Although reported as a rare and lifelong di...

Several large-scale surveys around the world show the most frequently reported mental health diagnoses among people with intersex variations include depression, anxiety and PTSD. Wellbeing risks are also high, with individuals with intersex variations citing suicidal thoughts or attempts across their life-course – specifically on the basis of issues related to having congenital sex variations. The population mostly attributed their wellbeing risks to negative social responses from others, difficulties around having undergone interventions, or issues around gender/identity. In the Canadian context, there is a lack of formalised, charitable Canadian wide intersex networks, advocacy groups, universal mental health care approaches, or provincial signposting to services similar to those developed elsewhere. Using a life-cycle lens, a group of international researchers came together in this collaborative Canadian study to explore health care transitions that people with intersex variations might need or desire, at various stages of their life. A key finding from this ongoing study is that transition phases have the capacity to be especially difficult in the context of mental health, such that integrating person-centred and trauma-informed approaches into care with this population is both wanted and needed. This paper specifically takes a case study approach which analyses data from two participants who identified three major themes regarding mental health impacts: ‘worth, mastery, and adequacy’, ‘isolation and inferiority’, and ‘identity and integrity’. The fourth and final theme drew on integrated medicine to celebrate emerging ‘resilience and generativity’; a positive experience that had emancipatory benefits across the lifespan.

Purpose Fellows in Pediatric Surgery need to learn to manage a variety of gynecologic conditions. We completed a needs assessment of Pediatric Surgery training programs to inform development of a standardized gynecology curriculum. Methods A survey was sent to Program Directors of Canadian Pediatric Surgery training programs with 27 questions that focused on the fellowship program, surgical practice, and trainee exposure to pediatric gynecology, and how the envision a standardized gynecology curriculum. Results Six of eight Program Directors responded. All respondents had treated ovarian-related conditions and genital injuries in the past 5 years, and most felt trainees received adequate training in managing these conditions. Most respondents felt trainees had minimal or inadequate training in imperforate hymens, Mullerian anomalies, vulvar abscesses, vaginal foreign bodies, and labial adhesions. Program Directors currently allot an average of 3.5 h to delivering the gynecology objectives. All Program Directors expressed interest in a formal gynecology curriculum delivered through some combination of case-based teaching and/or simulation. Conclusion There is a need for a standardized gynecology curriculum for Pediatric Surgery trainees. Most Pediatric Surgeons will manage gynecological conditions as part of their practice and current Program Directors feel that training is inadequate for a number of gynecological conditions. Type of Study Observational Cross-Sectional Study. Level of Evidence Level IV.

IntroductionSex variations comprise a heterogeneous group of medical conditions. These include congenitaladrenal hyperplasia (CAH), androgen insensitivity syndrome, Turner syndrome, and more,reportedly affecting approximately two percent of the population. These conditions can involvelifelong management. However, no research has examined the experiences nor the healthcarepractices used with these individuals in their transitions through healthcare in Canada. Further, themajority of research on healthcare transitions from other countries focuses on the pediatric to adultcare transfer, despite transitions taking place across the lifespan. Aims Objectives Theory or MethodsFirstly, we aimed to investigate the current context of care for individuals with sex variations through an environmental scan of the current care pathways and guidelines for transition used by health providers. This included a search of 13 Canadian Children’s Hospital websites, a survey sent to providers, and freedom of information requests submitted to these hospitals. Secondly, we sought to learn from the experiences of individuals with sex variations and their families in transitioning through care, along with their providers’ understandings of transition for this group. Thus, we conducted engagement sessions in BC and Ontario applying a community-participatory learning approach Highlights or Results or Key FindingsThrough the environmental scan, we found no hospital-specific resources used by healthcare providers for guiding care transitions for individuals with sex variations. Our engagement sessions consisted of in-person focus groups and virtual interviews with individuals from Ontario and British Columbia. We also included secondary data from a small BC study with women with CAH. Altogether, data from 17 individuals (15 with sex variations and two caregivers) was included. Interviews highlighted three important themes: (1) transition is a lifespan activity – individuals faced different healthcare challenges that required transition as they aged, (2) the building of personal agency, and (3) wellness promotion and healing in this population. An additional output from the study included the co-development of a small advisory group of adults identifying with sex variations, involved in work around health education and consultation. ConclusionsCanadian care guidelines for managing transition with sex variations are lacking. For individuals with sex variations there is little information to support individual health literacy and selfmanagement. There exists an opportunity for these individuals and their providers to begin building a visible network that can inform care delivery and policy.Implications for applicability/transferability sustainability and limitations A limitation of this study was failure to adopt inclusive terminology at study conception (e.g., ourwebsite domain, dsdtransition.ca). We learnt that intersex or sex variation is preferred by thecommunity. We encourage use of inclusive terminology in healthcare and the co-development oftransition guidelines with Canadians with sex variations

Hematopoietic stem cell transplantation is used to treat many chronic and acute malignant and nonmalignant conditions. We review hematopoietic stem cell transplantation and its effect on the gynecologic health of pediatric and adolescent patients, including pretransplantation evaluation, contraception, menstrual suppression, sexual health, fertility, primary ovarian insufficiency, and graft vs host disease. Comprehensive and team-based care provides optimal anticipatory counseling, evaluation, and management of acute and ongoing gynecologic issues.

Objective Accuracy of ultrasound in diagnosis of ovarian torsion remains controversial, with some studies reporting correct diagnosis in only 23% to 66% of cases. Normal Doppler flow does not necessarily exclude an ovarian torsion; in fact, it may lead to missing the diagnosis and has been show to delay management. The objective of our study was to assess sensitivity and specificity of ultrasound diagnosis of ovarian torsion and to analyze the factors contributing to correct and incorrect diagnosis. Methods All women presenting with abdominal pain and admitted for urgent/emergent surgery to the gynaecology service at a major teaching hospital between September 2010 and August 2015 were reviewed. Of those, 55 cases of surgically proven ovarian torsion and 48 control cases were selected. Ultrasound reports were reviewed and analyzed. Results Sixty-one percent of right ovarian torsion case and 27% of left ovarian torsion cases had normal Doppler flow. Presence of ovarian cysts was significantly associated with torsion. Sensitivity of ultrasound was 70% and specificity was 87%. Conclusion While ultrasound can be used to support a diagnosis of ovarian torsion, it is a clinical diagnosis that requires integration of many factors, especially patient presentation and exclusion of other non-gynaecological pathologies. Doppler flow is not a useful variable to diagnose or exclude ovarian torsion and we recommend it should not be used to exclude a diagnosis of ovarian torsion.

Self-confidence is the belief in one’s ability to perform and can be enhanced by training. Surgical education should aim to optimize trainee confidence. We designed three procedure-specific competency-based modules to teach vaginal hysterectomy (VH), anterior (AR) and posterior repair (PR) to novice gynecology residents. We hypothesized each module would improve self-confidence and satisfaction during index procedure performance in the operating room. This was an ancillary analysis of a larger randomized-controlled trial of gynecologic educational interventions. Residents at three Canadian universities were included if they had previously performed fewer than five index procedures independently. Intervention residents received educational modules; controls engaged in self-directed learning. All residents performed one or more of the three surgeries and filled out a validated Self-Confidence Scale and a Satisfaction Scale. Scores were compared between groups. Correlations were sought between self-confidence and various variables. Forty-six residents at three Canadian universities were randomized (21 intervention, 25 control). Most residents had never performed the index procedure. Overall, self-confidence was significantly higher (p = 0.021) in the intervention group for VH, but not for AR and PR (p = 0.94 and p = 0.12, respectively). Compared with controls, self-confidence was also significantly higher in intervention residents who had never performed VH (p = 0.026) or PR (p = 0.027) and in first and second year intervention residents. There was a positive correlation between self-confidence and satisfaction. Surgical modules improved self-confidence preferentially in the most junior residents and for more complicated procedures. The wide self-confidence ranges observed suggest that optimization should be an important goal for surgical educators.

Female genital cosmetic surgery includes many procedures undertaken at the request of the woman and is the fastest-growing area of cosmetic surgery, despite calls for avoidance or extreme caution from professional organizations responsible for women’s health. Low genital self-image is presumed to drive requests, but root causes have not been studied. The vast majority of these surgeries are not indicated medically, have unknown long-term effects, and are being performed in a private-pay environment in a context of significant ethical concerns regarding informed consent, autonomy and beneficence, and conflict of interest. This chapter explores normal physiologic development of female genitalia as it pertains to knowledge of what is “normal,” self-image and the drivers of genital self-image, concerns about specific procedures, and statements of professional organizations. Ethical tensions and dilemmas for clinicians highlight physicians’ ethical responsibility to provide accurate information about potential harms and benefits of these procedures.

Background An 18-month-old female toddler presented with severe vulvar ulcers and pancytopenia with investigations revealing Pseudomonas aeruginosa bacteremia. Case A previously healthy 18-month-old female toddler presented with 6 days of fevers, vulvar rash, and ulcers. Vulvar cultures showed Staphylococcus aureus and P aeruginosa. Bloodwork showed pancytopenia and P aeruginosa bacteremia. She started receiving broad-spectrum antibiotics. Bone marrow aspirate revealed a hypocellular marrow with erythroid dysplasia. Vulvar ulcers progressed rapidly, therefore magnetic resonance imaging was performed to rule out necrotizing fasciitis. She was diagnosed with ecthyma gangrenosum (EG). Three months after initial presentation, she was diagnosed with precursor B-cell acute lymphoblastic leukemia. Summary and Conclusion This case highlights that health care providers should suspect EG when severe vulvar ulcers are present with P aeruginosa infection and neutropenia. Because EG poses significant morbidity and mortality, its presence should prompt aggressive antimicrobial therapy and mobilization of a multidisciplinary team to initiate workup for an underlying immunodeficiency syndrome or malignancy. This case also illustrates that surgical debridement might be avoided in certain patients with EG as long as meticulous wound care and close monitoring with a multidisciplinary team are in place.

Objectives Obstetricians and Gynecologists (ObGyn) in Canada provide care for women from infancy to adulthood, regardless of their sexual orientation or gender identity. Currently, we do not knowhow Canadian ObGyn resident physicians receive lesbian, gay, bisexual, transgender, queer, 2-spirit, intersex, or asexual(LGBTQ2SIA+) health training to achieve competence in LGBTQ2SIA+ care. The objectives of the current study were to determine if and how Canadian ObGyn residents are receiving LGBTQ2SIA+ health training during their residency and program director interest in increasing exposure to resident LGBTQ2SIA+ training, including preferred methods of instruction. Methods An online prospective survey was sent to program directors of all 16 Canadian postgraduate ObGyn programs. Results Completed surveys were received from 7 program directors. Three programs reported formal teaching on sexual minority health and 4 on gender minority health. All 7 programs were interested in increasing the level of resident exposure to sexual minority health and 6 programs were interested in the same for gender minority health. All program directors expressed interest in implementing a formal curriculum or module, if it was developed, on these topics. The most desired methods of instruction, in order of preference, were case-based presentations, e-modules, didactic lectures, and patient advocacy groups. Conclusions Of the 7 Canadian ObGyn residency program directors included in this study, there is considerable interest in increasing resident exposure to LGBTQ2SIA+ health teaching. These results support the importance of developing a standardized Canadian Reproductive Health curriculum specific to ObGyn residents on sexual and gender minority health.

Resume Objectif Fournir des lignes directrices aux fournisseurs de soins quant a l'utilisation de modes de contraception pour la prevention de la grossesse et quant a la promotion d'une sexualite saine. Issues Orientation des praticiens canadiens en ce qui concerne l'efficacite globale, le mecanisme d'action, les indications, les contre-indications, les avantages n'etant pas lies a la contraception, les effets indesirables, les risques et le protocole de mise en œuvre des modes de contraception abordes; planification familiale dans le contexte de la sante sexuelle et du bien-etre general; methodes de counseling en matiere de contraception; et accessibilite et disponibilite des modes de contraception abordes au Canada. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans MEDLINE et The Cochrane Library entre janvier 1994 et janvier 2015 au moyen d'un vocabulaire controle (p. ex. contraception , sexuality , sexual health ) et de mots cles (p. ex. contraception , family planning , hormonal contraception , emergency contraception ) appropries. Les resultats ont ete restreints aux analyses systematiques, aux etudes observationnelles et aux essais comparatifs randomises / essais cliniques comparatifs publies en anglais entre janvier 1994 et janvier 2015. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en juin 2015. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats a ete evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau).

Objective To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. Outcomes Guidance for Canadian practitioners on overall effectiveness, mechanism of action, indications, contraindications, non-contraceptive benefits, side effects and risks, and initiation of cited contraceptive methods; family planning in the context of sexual health and general well-being; contraceptive counselling methods; and access to, and availability of, cited contraceptive methods in Canada. Evidence Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis and incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

Objective To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. Outcomes Guidance for Canadian practitioners on overall effectiveness, mechanism of action, indications, contraindications, non-contraceptive benefits, side effects and risks, and initiation of cited contraceptive methods; family planning in the context of sexual health and general wellbeing; contraceptive counselling methods; and access to and availability of cited contraceptive methods in Canada. Evidence Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis and incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality.Guidance for Canadian practitioners on overall effectiveness, mechanism of action, indications, contraindications, non-contraceptive benefits, side effects and risks, and initiation of cited contraceptive methods; family planning in the context of sexual health and general well-being; contraceptive counselling methods; and access to, and availability of, cited contraceptive methods in Canada.Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis and incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Chapter 1: Contraception in Canada Summary Statements 1. Canadian women spend a significant portion of their lives at risk of an unintended pregnancy. (II-2) 2. Effective contraceptive methods are underutilized in Canada, particularly among vulnerable populations. (II-2) 3. Long-acting reversible contraceptive methods, including contraceptive implants and intrauterine contraception (copper-releasing and levonorgestrel-releasing devices/systems), are the most effective reversible contraceptive methods and have the highest continuation rates. (II-1) 4. Canada currently does not collect reliable data to determine the use of contraceptive methods, abortion rates, and the prevalence of unintended pregnancy among reproductive-age women. (II-2) 5. A universal subsidy for contraceptive methods as provided by many of Canada's peer nations and a few Canadian provinces may produce health system cost-savings. (II-2) 6. Health Canada approval processes for contraceptives have been less efficient than those of other drug approval agencies and Health Canada processes for other classes of pharmaceuticals. (II-2) 7. It is feasible and safe for contraceptives and family planning services to be provided by appropriately trained allied health professionals such as midwives, registered nurses, nurse practitioners, and pharmacists. (II-2) Recommendations 1. Contraceptive counselling should include a discussion of typical use failure rates and the importance of using the contraceptive method consistently and correctly in order to avoid pregnancy. (II-2A) 2. Women seeking contraception should be counselled on the wide range of effective methods of contraception available, including long-acting reversible contraceptive methods (LARCs). LARCs are the most effective methods of reversible contraception, have high continuation rates, and should be considered when presenting contraceptive options to any woman of reproductive age. (II-2A) 3. Family planning counselling should include counselling on the decline of fertility associated with increasing female age. (III-A) 4. Health policy supporting a universal contraception subsidy and strategies to promote the uptake of highly effective methods as cost-saving measures that improve health and health equity should be considered by Canadian health decision makers. (III-B) 5. Canadian health jurisdictions should consider expanding the scope of practice of other trained professionals such as nurses, nurse practitioners, midwives, and pharmacists and promoting task-sharing in family planning. (II-2B) 6. The Canadian Community Health Survey should include adequate reproductive health indicators in order for health care providers and policy makers to make appropriate decisions regarding reproductive health policies and services in Canada. (III-B) 7. Health Canada processes and policies should be reviewed to ensure a wide range of modern contraceptive methods are available to Canadian women. (III-B) Chapter 2: Contraceptive Care and Access Summary Statements 8. Although there are many contraceptive options in Canada, only a narrow range of contraceptive methods are commonly used by those of reproductive age. (II-3) 9. Condom use decreases with longer relationship tenure and when the sexual partner is considered to be the main partner, likely due to a lower perceived risk of sexually transmitted infection in that relationship. Condom use may also decrease markedly as an unintended consequence when an effective non-barrier method, such as hormonal contraception or intrauterine contraception, is initiated. (II-3) 10. Family planning counselling provides a natural segue into screening for concerns about sexual function or intimate partner violence. (III) 11. Well-informed and well-motivated individuals who have developed skills to practise safer sex behaviours are more likely to use contraceptive and safer sex methods effectively and consistently. (II-2) Recommendations 8. Comprehensive family planning services, including abortion services, should be accessible to all Canadians regardless of geographic location. These services should be confidential, non-judgemental, and respectful of individuals' privacy and cultural contexts. (III-A) 9. A contraceptive visit should include history taking, screening for contraindications, dispensing or prescribing a method of contraception, and exploring contraceptive choice and adherence in the broader context of the individual's sexual behaviour, reproductive health risk, social circumstances, and relevant belief systems. (III-B) 10. Health care providers should provide practical information on the wide range of contraceptive options and their potential non-contraceptive benefits and assist women and their partners in determining the best user-method fit. (III-B) 11. Health care providers should assist women and men in developing the skills necessary to negotiate the use of contraception and the correct and consistent use of a chosen method. (III-B) 12. Contraceptive care should include discussion and management of the risk of sexually transmitted infection, including appropriate recommendations for condom use and dual protection, STI screening, post-exposure prophylaxis, and Hepatitis B and human papillomavirus vaccination. (III-B) 13. Health care providers should emphasize the use of condoms not only for protection against sexually transmitted infection, but also as a back-up method when adherence to a hormonal contraceptive may be suboptimal. (I-A) 14. Health care providers should be aware of current media controversies in reproductive health and acquire relevant evidence-based information that can be briefly and directly communicated to their patients. (III-B) 15. Referral resources for intimate partner violence, sexually transmitted infections, sexual dysfunction, induced abortion services, and child protection services should be available to help clinicians provide contraceptive care in the broader context of women's health. (III-B) Chapter 3: Emergency Contraception Summary Statements 12. The copper intrauterine device is the most effective method of emergency contraception. (II-2) 13. A copper intrauterine device can be used for emergency contraception up to 7 days after unprotected intercourse provided that pregnancy has been ruled out and there are no other contraindications to its insertion. (II-2) 14. Levonorgestrel emergency contraception is effective up to 5 days (120 hours) after intercourse; its effectiveness decreases as the time between unprotected intercourse and ingestion increases. (II-2) 15. Ulipristal acetate for emergency contraception is more effective than levonorgestrel emergency contraception up to 5 days after unprotected intercourse. This difference in effectiveness is more pronounced as the time from unprotected intercourse increases, especially after 72 hours. (I) 16. Hormonal emergency contraception (levonorgestrel emergency contraception and ulipristal acetate for emergency contraception) is not effective if taken on the day of ovulation or after ovulation. (II-2) 17. Levonorgestrel emergency contraception may be less effective in women with a body mass index25 kg/m2 and ulipristal acetate for emergency contraception may be less effective in women with a body mass index35 kg/m2. However, hormonal emergency contraception may still retain some effectiveness regardless of a woman's body weight or body mass index. (II-2) 18. Hormonal emergency contraception is associated with higher failure rates when women continue to have subsequent unprotected intercourse. (II-2) 19. Hormonal contraception can be initiated the day of or the day following the use of levonorgestrel emergency contraception, with back-up contraception used for the first 7 days. (III) 20. Hormonal contraception can be initiated 5 days following the use of ulipristal acetate for emergency contraception, with back-up contraception used for the first 14 days. (III) Recommendations 16. All emergency contraception should be initiated as soon as possible after unprotected intercourse. (II-2A) 17. Women should be informed that the copper intrauterine device (IUD) is the most effective method of emergency contraception and can be used by any woman with no contraindications to IUD use. (II-3A) 18.

Objective Competency-based surgical education relies on operative models to teach surgical skills within a curriculum. Low fidelity simulation has been shown to improve surgical performance. Our objectives were: to develop procedure-specific models to teach anterior repair (AR), posterior repair (PR), and vaginal hysterectomy (VH) to junior residents; to establish model reliability and validity. Design Residents were randomized to control (no training) and intervention (model training) groups. They were filmed while performing a series of tasks. Experts were also filmed. Each video was scored by 2 blinded raters. Setting Multicenter collaboration within the Western Society of Pelvic Medicine (Vancouver, Calgary, and Edmonton). Face and content validity were evaluated. A standard scoring tool was developed for performance evaluation. Interrater reliability was assessed using intraclass correlation coefficient. Cronbach α was calculated for internal consistency. Jonckheere-Terpstra test verified whether the scores increased with operator skill level. Participants A total of 14 junior gynecology residents, 2 urogynecology fellows, and 3 staff urogynecologists were rated by a total of 6 gynecologic surgeons who scored 42 videos each. Results Experienced pelvic surgeons from 3 participating sites agreed the models captured essential elements of real surgical skills (face validity) and of the true procedures (content validity). Intraclass correlation coefficient was adequate (AR = 0.86, PR=0.90, and VH=0.87). Cronbach α for the total scores was adequate (AR = 0.85, PR=0.8, and VH=0.71). Performance score increased with operator skill level for all 3 procedures (AR, p= Conclusions Our low fidelity procedure-specific vaginal surgery models had adequate initial validity. Future research will investigate transferability of acquired skills to the operating room.

High school Support Teachers (Learning Difficulties) (STLDs) have a strategic role in enhancing outcomes for students with learning difficulties. This paper will explore the ways in which STLDs work. Firstly, this paper will discuss the four main ways in which STLDs may work, which combination of these ways is considered as best practice from the research literature and which ways of working are suggested in NSW government policy and support documents. It has been suggested by several research studies that some STLDs in NSW do not work in ways that are consistent with best practice and policy. There may be many reasons for this, however, this paper explores the possibility that particular school factors influence the work of STLDs. Each school factor is described and its possible influence on the way STLDs work is illustrated. This paper concludes with possibilities for modifying school factors where these factors may be negatively affecting the way in which a STLD works. Ultimately, the improved effectiveness of a STLD will impact on the education of students with learning difficulties.