Faculty Bibliography

OBJECTIVES/OBJECTIVE:To assess efficacy and adverse outcomes of misoprostol 200mcg versus 400mcg every three hours buccal or vaginal for medication abortion (MAb) from 24-27 weeks' gestation. STUDY DESIGN/METHODS:This retrospective cohort study included MAbs from 24 0/7-27 0/7 weeks' gestation at Bellevue Hospital from 7/2022-6/2025. All patients received digoxin 2mg intraamniotic injection and mifepristone 200mg oral followed at 24-48hrs by misoprostol 200mcg or 400mcg every three hours buccal or vaginal based on hospital policy at time of admission. The primary outcome was time from first misoprostol dose to placental expulsion. Secondary outcomes were procedural complications. Primary statistical analysis was performed with Fisher's exact and Wilcox rank-sum tests. RESULTS:Of 55 patients, 27 (49%) received 200mcg doses of misoprostol and 28 (51%) received 400mcg doses of misoprostol. Median time to expulsion was 13hrs in the 200mcg group versus 9.5hrs in the 400mcg group (p=0.144). More patients in the 200mcg group versus the 400mcg group had blood loss ≥500mL (11.1% vs 0%, p=0.11) and retained placenta at four hours (3.7% vs 0%, p=0.49). No patients in either group had uterine rupture. CONCLUSIONS:Misoprostol 200mcg versus 400mcg every three hours buccal or vaginal for MAb from 24-27 weeks' gestation had overall similar outcomes. Although this single site retrospective study is underpowered to significantly differentiate between the two regimens, we observe that 200mcg dosing may be associated with higher risk of complications. Larger studies are needed to clarify optimal misoprostol dosing for 24-27 week MAb. IMPLICATIONS/CONCLUSIONS:For medication abortion from 24-27 weeks' gestation, serial doses of misoprostol 200mcg versus 400mcg every three hours have similar rates of complications, though there is a signal that 200mcg dosing may be associated with longer time to expulsion, higher blood loss, and more incidences of retained placenta.

The Patient-Oriented Eczema Measure (POEM) is a validated patient-reported outcome measure for atopic dermatitis (AD), though its use in routine pediatric dermatology practice remains underexplored. In this cross-sectional study of 297 pediatric patients with AD at a tertiary pediatric dermatology clinic, POEM scores were collected and compared with physician-rated investigator global assessment (IGA) and IGA × body surface area, as well as treatment selection. Older patients (> 12 years) had significantly higher mean POEM scores (17.5 vs. 10.4; p < 0.001) with no significant differences observed by race, ethnicity, or socioeconomic status; total POEM scores correlated strongly with IGA (r = 0.68) and moderately with IGA×BSA (r = 0.54), and higher severity scores were associated with more potent topical corticosteroids and systemic treatments (p < 0.001). POEM detected clinically relevant changes, aligned with physician-rated measures, and correlated with treatment intensity, underscoring its utility in both clinical practice and future predictive modeling applications.

IMPORTANCE/OBJECTIVE:Pelvic floor physical therapy (PFPT) is a first-line treatment for pelvic floor disorders, though it is frequently an uncovered benefit. Data on insurance acceptance among PFPT offices is limited; therefore, its true accessibility is unknown. OBJECTIVES/OBJECTIVE:Our primary objective was to characterize the effect of insurance coverage on access to PFPT in a national sample. Our secondary objective was to identify factors associated with Medicaid acceptance. STUDY DESIGN/METHODS:This cross-sectional analysis utilized a "secret shopper" methodology. Investigators contacted 200 PFPT offices across 8 states, 4 with expanded Medicaid access, using a script to evaluate insurance acceptance, wait times, and cost. The agreement between Medicaid and commercial insurance acceptance was tested using the McNemar test. Logistic regression identified factors associated with Medicaid acceptance. RESULTS:Of 200 PFPT offices, 141 (70%) accepted commercial insurance and 94 (47%) accepted Medicaid (χ2=35.8, P<0.001); 53 accepted neither (26.6%). Factors associated with Medicaid acceptance included location in nonexpansion states (adjusted odds ratio [aOR], 2.0; 95% CI, 1.02-4.00, P=0.045), acceptance of commercial insurance (aOR, 6.72, 95% CI; 2.22-20.38, P<0.001), academic affiliation (aOR, 17.54; 95% CI, 6.93-44.36, P<0.001), and nonurban location (aOR, 3.10, 1.23-7.18, P=0.016). Mean wait time for Medicaid was 4.6 weeks versus 3.1 weeks for non-Medicaid offices (P=0.004). In all, 117 PFPTs (58.5%) reported a cash cost for an initial visit: median cost was $190.62 (SD=73.77), range $70-$450. CONCLUSIONS:Our analysis reveals significant PFPT disparities for Medicaid beneficiaries, underscores barriers to access for Medicaid patients, and highlights opportunities for policy interventions to promote equity.

INTRODUCTION/UNASSIGNED:There is uncertainty about the benefits of cerclage in patients with transvaginal cervical length (TVCL) ≤10 mm and no prior spontaneous preterm birth. Our aim was to assess whether cervical cerclage in these patients was associated with prolonged pregnancy latency. METHODS/UNASSIGNED:This was an observational study of asymptomatic singleton pregnancies without a history of spontaneous preterm birth with extremely short cervix (TVCL ≤10 mm) in the second trimester. Exposure and outcome data were extracted manually from medical charts by obstetric providers, with all outcomes occurring prior to study initiation. All patients were prescribed vaginal progesterone and those with a cervical dilation >1.5 cm were excluded. The primary outcome was time interval from diagnosis to delivery (or 37 weeks' gestation, whichever occurred first). Secondary outcomes included gestational age at delivery, mode of delivery, and neonatal outcomes. We adjusted for parity and used log-binomial regression to estimate the relative risk for categorical variables and linear regression to estimate mean differences for continuous variables. RESULTS/UNASSIGNED:There were 247 patients with TVCL ≤10 mm during anatomy scan. After exclusions, 87 remained, of which 55 (63.2%) received cervical cerclage. At the time of diagnosis, the mean cervical length was 5.8 mm (cerclage group) versus 7.4mm (no cerclage group, difference: -1.6, 95% CI -0.6, -2.6) and the gestational age was 21.0 weeks (cerclage group) versus 22.1 weeks (no cerclage group, -1.1, 95% CI -1.8, -0.3). Mean pregnancy latency was longer in the cerclage group compared to the no cerclage group (13.4 vs 11.1 weeks, 2.2, 95% CI -0.3, 4.9), though there was a high level of uncertainty in the estimate. Term delivery occurred 30% more often in the cerclage group compared to the no cerclage group (RR 1.31, 95% CI 0.96, 1.79). CONCLUSION/UNASSIGNED:In our cohort, patients with extremely short cervix who received a cerclage had longer pregnancy latency than those who did not receive cerclage and more patients achieved term gestation, suggesting a potential benefit of cerclage in this population. However, given the high level of uncertainty of our estimates, additional research is needed to investigate these findings.

INTRODUCTION/UNASSIGNED:Pseudofolliculitis barbae (PFB) is a chronic inflammatory condition of hair follicles characterized by inflamed papules and pustules, with increased risk in individuals with curly or coarse hair. While psychiatric comorbidities in acne are well studied, limited research exists on PFB's psychological impact. METHODS/UNASSIGNED:dataset, which includes EHR data from US adults since 2018. RESULTS/UNASSIGNED:= 0.15). DISCUSSION/UNASSIGNED:Our study demonstrated a significant association between PFB and mood disorders like depression or anxiety. Future studies should examine PFB severity and treatment efficacy on psychological outcomes.

OBJECTIVES/OBJECTIVE:To examine how media, geography, race, and social factors shaped patient experiences to inform strategies for improving trust and care. DESIGN/METHODS:We conducted a cross-sectional online survey of experiences and perceptions of OB/GYN care and medical mistrust using a stratified, randomised sampling approach. SETTING/METHODS:The survey was distributed through Prolific. POPULATION/METHODS:Inclusion criteria included assigned female at birth, age between 18 and 40 years, and residing in the United States. MAIN OUTCOME MEASURES/METHODS:Gender preference of OB/GYN clinician, demographic association with negative OB/GYN experiences, and degree of medical mistrust. RESULTS:Of 579 respondents, 93% identified as women, 33.9% as LGBTQIA+, and 45.2% had a history of pregnancy. Anxiety was the most common (46.4%) emotion experienced when receiving OB/GYN care, and 25.8% reported negative experiences, primarily from minimization of concerns (68.5%). A majority (65.3%) preferred receiving care from a female OB/GYN. Identifying as Republican was associated with higher odds of having had a negative experience with an OB/GYN, whereas Asian race and lower education were linked to lower odds. Black, Asian, and multiracial participants were more likely to have a racial preference for clinicians. Medical mistrust was higher among Black respondents and those with lower education. Feeling heard by a clinician was the strongest predictor of care satisfaction. CONCLUSION/CONCLUSIONS:Anxiety and negative experiences were prevalent among participants. Feeling heard was the strongest predictor of patient satisfaction, highlighting the importance of patient-centred OB/GYN care to reduce mistrust and improve patient experiences, particularly for marginalised groups.

BACKGROUND:Varicocele severity has traditionally been associated with larger testicular vein size, but the true relationship to decreased fertility remains debatable. In clinical practice, the largest testicular vein diameter is an often-used parameter to screen for potential surgical intervention, even though current research provides weak support for this. More recent studies have found venous reflux patterns and total testicular volume (TTV) to be significantly associated with total motile sperm count (TMSC). This study compares largest testicular vein size and arterial flow rates, assessing the predictive value of each for identifying patients at risk for reduced semen analysis (SA) parameters. METHODS:We conducted a retrospective, single-institution chart review over 14 years of 487 Tanner V adolescents. Patients were included if they had a palpable, primary left-sided varicocele and underwent at least one SA and scrotal Doppler ultrasound (SDUS) to assess vein diameter and arterial blood flow including peak systolic and end-diastolic velocities. Abnormal TMSC was defined by WHO 2010 criteria. Descriptive statistics, ROC analysis and univariate as well as multivariate logistic regression analyses were performed using SPSS. RESULTS:148 Tanner V adolescent males were included. Mean age ± SD was 18.24 ± 1.38 years. Median diameter of largest vein on US was 3.5 mm (IQR 3.1-4.6), median peak systolic velocity (PSV) of the left testicular artery was 10.4 cm/s (IQR 9.1-12.5), median end-diastolic velocity (EDV) of the left testicular artery was 5.1 cm/s (IQR 4.3-5.9), and median value of PSV/EDV was 2.1 (IQR 1.8-2.3), with a median TMSC of 37.4 million sperm (IQR 15.8-84.2). On ROC analysis regarding prediction of abnormal TMSC (<9 million sperm/ejaculate), left testicular PSV was found to have the greatest AUC at 0.73 (95 % CI 0.62-0.85) with Youden index analysis determining an ideal cutoff of 10.22 cm/s. Based on this cutoff, the positive predictive value for identifying a patient with abnormal TMSC was 23.6 %, corresponding to a number needed to screen of approximately 4 patients to identify one with abnormal sperm parameters. Left testicle largest vein diameter was found to have an AUC of 0.48. On univariate logistic regression, PSV <10.22 cm/s was predictive of abnormal TMSC (OR: 5.51 [1.84-16.46], p = 0.002, which persisted on multivariate logistic regression with adjustment for age (OR: 5.49 [1.83-16.43], p = 0.002). CONCLUSION/CONCLUSIONS:Left testicular PSV was the parameter most significantly correlated with TMSC in this cohort. A PSV <10.22 cm/s was found to be predictive of an abnormally low TMSC. There was no significant predictive value of larger veins for abnormal TMSC. When assessing varicocele severity by US, left testicular artery PSV should be measured to help stratify future fertility risk and provide important context regarding shared decision making about potential surgical intervention.

Childhood adversity is increasingly recognized as a critical modifier of neurologic disorder development and disease severity, including in the neuroimmune disorder multiple sclerosis (MS). While previous studies have linked early-life adversity to increased MS susceptibility and more severe disease, the underlying biological mechanisms remain poorly understood. This study investigated associations between childhood adversity and MS clinical features, with a focus on two potential pathogenic mechanisms: allostatic load and epigenetic modifications. We evaluated 60 consecutively enrolled young adults with MS; 30 with paediatric-onset MS (POMS) and 30 with adult-onset MS (AOMS). At time of enrolment in this cross-sectional study, participants had MS disease duration of 6 years on average. POMS participants were mean 22.09 (2.66) years and AOMS participants were mean 32.41 (2.19) years old. 62% of participants were female. Childhood adversity was defined using a composite index of individual, family and socioeconomic measures captured by the adverse childhood experiences questionnaire, parental education level and estimated household income during childhood. Clinical outcomes included patient-reported SymptoMScreen questionnaire regarding MS symptom burden and MS neurologist-assessed disability using the Expanded Disability Status Scale (EDSS) of the participant's neurologic exam at the time of enrolment. Circulating biomarkers of allostatic load and genome-wide epigenetic profiles (DNA methylation via RRBS; reduced representation bisulfite sequencing) were also assessed. A history of high childhood adversity was associated with significantly greater patient-reported MS symptom burden (P = 0.001) and higher neurologist-reported EDSS disability scores (P = 0.028), independent of disease duration or timing of treatment initiation. There were no differences between childhood adversity and circulating biomarkers of allostatic load. While childhood adversity was not associated with global epigenetic changes across the entire cohort, stratified analysis revealed divergent methylation patterns by age of MS onset: POMS participants with childhood adversity had increased DNA methylation, whereas AOMS participants with childhood adversity showed decreased methylation compared to individuals without childhood adversity. None of the observed clinical and biologic differences were explained by differences in disease duration or the interval between symptom onset and treatment initiation. Our findings suggest that childhood adversity is associated with increased MS symptom burden and neurologic disability in young adults with MS. Childhood adversity may differentially shape the epigenome, depending on the age of MS onset, with potential implications for disease trajectory and therapeutic vulnerability. These results support the biological embedding of childhood adversity in MS and highlight the need for age- and exposure-sensitive approaches to understanding MS pathogenesis across the lifespan.

INTRODUCTION/BACKGROUND:Parental refusal of intramuscular (IM) vitamin K in newborns poses challenges, particularly for pediatric urologists assessing the safety of neonatal circumcision. Vitamin K deficiency bleeding (VKDB) is a known risk, with lack of prophylaxis increasing bleeding complications. This study evaluates the safety of neonatal circumcision without IM vitamin K, reviews guidelines, and explores alternative prophylaxis options. OBJECTIVE:To assess if neonatal circumcision can be safely performed on infants lacking IM vitamin K and to identify both optimal timing and alternative prophylactic approaches. METHODS:We conducted a literature review using PubMed and Google Scholar to gather data on neonatal circumcision and VKDB in the context of IM vitamin K refusal. Additionally, we searched for relevant guidelines from the American Urological Association (AUA), American Academy of Pediatrics (AAP), and other organizations. Our study included analysis of ten recent cases of neonatal circumcision without IM vitamin K, focusing on safety outcomes and timing. RESULTS:IM vitamin K is the most effective prophylaxis against VKDB, significantly reducing bleeding risk up to sixfold in neonatal circumcision. Oral vitamin K, sometimes used as an alternative in Europe, shows variable effectiveness and lacks standardization in the U.S. Newborn prothrombin (PT) levels fluctuate significantly in the first week: PT levels are high at birth, drop within 24 h, reach a nadir at 24-72 h, then rebound. Circumcisions performed at 14 days on ten patients without IM vitamin K showed no bleeding complications, suggesting that timing circumcisions after PT stabilization may be safer. CONCLUSIONS:IM vitamin K prophylaxis should remain standard care. In cases of refusal, alternative prophylaxis and timing circumcision after the PT nadir may improve safety. This study underscores the need for updated guidelines from professional organizations, including the AUA, to address the growing trend of IM vitamin K refusal and its implications for neonatal circumcision.

INTRODUCTION/BACKGROUND:It is known the prevalence of varicoceles in adolescent men is 14-29% but there is debate surrounding implications on fertility. As obtaining a semen analysis (SA) may be challenging, there is need for objective tests as measures of fecundity. Our aim was to investigate the relationship between testicular volume differential (TVD), varicocele grade, and total testicular volume (TTV) on seminal parameters including total motile sperm count (TMSC). MATERIALS AND METHODS/METHODS:We conducted a retrospective single-center chart review over 14 years of 486 Tanner V adolescent males. Three hundred and four met inclusion of palpable, non-operated left-sided varicocele who underwent at least one SA and ultrasound. Abnormal TMSC was defined by World Health Organization 2010 criteria for minimal reference ranges. Multivariate logistic regression, receiver operating characteristic analysis with Youden J-statistic and descriptive statistics were performed. RESULTS:Three hundred and four Tanner V adolescents with median age of 18.0 years (18.0-19.0), median TTV of 34.5 cc (28.9, 40.2) and median TMSC of 62.5 million/ejaculate (25.4, 123.4) were evaluated. TTV cutoff of 29.5 cc was found to predict TMSC of <9 million/ejaculate with negative predictive value of 96.2% and odds ratio of 6.08 ([2.13-17.42], p < 0.001). TVD greater than 20% did not reach statistical significance with an odds ratio of 1.66 ([0.41-6.62], p = 0.50). DISCUSSION/CONCLUSIONS:In clinical practice, each patient will need to have an individualized plan. Based on our data, for older adolescents (17 or 18 years) with varicocele and an abnormal TTV, clinicians may have a lower threshold for advising SA, and if unable to obtain, surgical intervention and/or closer surveillance should be stressed. Patients should be informed of their six-fold increase in abnormal SA. Patients with normal TTV should be advised they are at lower risk of having abnormal SA. Younger patients with varicocele and an initial TVD>20%, should be followed closely but intervention delayed until 17 or 18 to better assess TTV. The importance of trending patient data should be emphasized as a single measurement has low predictive value for developing adolescents. Limitations of our study include a retrospective design and the lack of uniform correlation between adolescent SA and paternity. CONCLUSIONS:Total testicular volume less than 29.5 cc increased odds of abnormal semen analysis by over six times and had a negative predictive value of 96.2%. Ultrasound results may be useful for risk stratification and counselling on appropriateness of surgical intervention.