Faculty Bibliography

OBJECTIVE:To evaluate the association of vaginal versus caesarean birth with neonatal and maternal outcomes for breech, singleton deliveries at 22 0/7 to 25 6/7 weeks of gestation. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Hospital births in the United States. POPULATION/METHODS:This study analysed non-anomalous, singleton, breech live births at 22 0/7 to 25 6/7 weeks of gestation identified in the linked birth-infant death records data from 2016 to 2021. METHODS:A propensity score analysis was conducted to establish pseudo-randomization based on the mode of delivery, matching vaginal to caesarean deliveries at a ratio of 1:2 using greedy nearest-neighbour matching. The propensity score estimation included year of delivery, maternal age, race/ethnicity, pre-pregnancy body mass index, parity, marital status, maternal education, insurance status, attendant at delivery, smoking status, hypertensive disorders, diabetes mellitus, gestational age, induction of labour and whether a trial of labour was attempted. We estimated the risk differences (RD) and odds ratios (OR) and associated 95% CIs, taking the matching into consideration. Multiple imputation was used to account for missing data. MAIN OUTCOME MEASURES/METHODS:Composite adverse neonatal and maternal outcomes. RESULTS:Of 21,461 periviable breech singleton births, 34.0% (n = 7289) were delivered vaginally. The median gestational age was 24 (IQR: 23-25) and 23 (IQR: 22-24) weeks in the vaginal and caesarean delivery groups, respectively. Earlier gestational age was associated with vaginal birth, while later gestational age was associated with caesarean births. After propensity score matching, the distributions of baseline factors, except for gestational age, were balanced between the vaginal and caesarean delivery groups. A composite of adverse neonatal outcomes occurred among 99.0% (n = 7213) of vaginal and 96.8% (n = 13,716) of caesarean breech births (aRD 1.8%, 95% CI 1.3 to 2.4; aOR 2.25, 95% CI 1.59 to 3.17). Neonatal mortality rates were higher among vaginal compared to caesarean breech births (72.6% versus 36.2%; aRD 26.8%, 95% CI 25.0 to 28.6; aOR 3.15, 95% CI 2.85 to 3.48). A composite of adverse maternal outcomes occurred in 1.6% of vaginal breech and 3.1% of caesarean births (aRD -1.7%, 95% CI -2.2 to -1.1; aOR 0.47, 95% CI 0.35 to 0.63). CONCLUSIONS:Vaginal breech birth between 22 0/7 and 25 6/7 weeks of gestation is associated with a lower risk of adverse maternal outcomes but a higher risk of neonatal adverse outcomes and mortality.

Evidence for an association between insulin-like growth factors (IGF) and multiple myeloma (MM) is inconsistent. We examined total IGF-I concentrations and risk of MM by combining baseline serological data among UK Biobank participants (n = 444 187; 732 incident MM) with a two-sample Mendelian randomisation (MR) analysis using identified genetic variants associated with circulating total IGF-I and IGF-binding protein 3 (IGFBP-3) in the InterLymph consortium (2434 MM and their 2567 controls). Finally, additional lymphoid neoplasm (LN) subtypes were included for comparison with the main hypothesis. Circulating IGF-I level was positively associated with MM risk Hazard ratio-HR-per one standard deviation-SD-increase (HR_1-SD = 1.11, 95% confidence interval [CI]: 1.01-1.22; p-value = 0.03), especially closer to diagnosis. Genetically inferred IGF-I levels were associated with increased MM risk (odds ratio [OR] = 1.27, 95% CI: 1.05-1.54) but not with any other LNs. Genetically inferred IGFBP-3 levels showed no associations with any LN evaluated. Corroborating previous findings, in a secondary analysis, IGF-I levels were associated with the risk of chronic lymphocytic leukaemia/small lymphocytic lymphoma (CLL/SLL) in males with higher body mass index (HR_{1-SD in obese male} = 1.36, 95% CI: 1.14-1.61). Our serological and MR analyses suggest a contributing role of IGF-I in the susceptibility of MM; the CLL/SLL findings warrant further investigation considering sex-specific adiposity.

BACKGROUND:The role of modifiable environmental factors in Alzheimer's disease (AD) risk remains poorly understood. Built environment features such as neighbourhood walkability (NW) may influence long-term cognitive health among women. METHODS:The New York University Women's Health Study recruited 14 273 cognitively healthy women aged 35-65 years between 1985 and 1991, with follow-up for over 30 years. We geocoded residential addresses for each participant to derive a validated four-item baseline NW measure and a two-item average annual NW index over the follow-up period. We conducted a nested case-control study of 1865 AD cases identified via linkage to Medicare claims during follow-up matched to 3730 controls on age, race/ethnicity and Medicare coverage using risk-set sampling. We used conditional logistic regression to estimate odds ratios (ORs) and 95% confidence intervals for AD in relation to tertiles of NW measures, adjusting for potential confounders. Subgroup analyses examined potential effect modification. RESULTS:Compared with women living in areas with the lowest baseline NW, those in the middle and highest tertiles had lower odds of having a diagnosis of AD during follow-up, with an OR of 0.95 (0.82-1.11) and 0.83 (0.71-0.98), respectively (P-trend = .03). Results were similar when using average annual NW. The association did not differ appreciably by age, smoking status, education or body mass index. CONCLUSIONS:Higher midlife NW was associated with reduced odds of AD later in life. These findings highlight the potential for built environment interventions to promote cognitive health and support healthy ageing in women.

PURPOSE/OBJECTIVE:Adolescent and young adult (AYA) oncology patients demonstrate an expressed need for improved sexual health (SH) communication with oncology clinicians, yet these conversations rarely take place, with clinicians identifying lack of education as a key barrier. This work describes the development and revision of a suite of educational modules aiming to improve clinician SH communication. METHODS:Literature review, data collected from prior research by the study team, and expert input from the Children's Oncology Group AYA Sexual Health Task Force were used to develop a series of interactive, online education modules. Clinicians, including physicians and advanced practice providers, were recruited by email across five academic institutions to review the modules and provide feedback through completion of an online open-ended survey. Themes derived from feedback guided module modifications. RESULTS:The initial curriculum consisted of three interactive modules that focused on the importance of addressing SH with AYA patients, how to discuss SH with AYAs, and contraception/safe sex practices during cancer treatment. Fourteen pediatric oncology clinicians reviewed the modules and provided feedback. Collectively, participants described the modules as informative, well-organized, visually appealing, and relevant to clinical practice. Opportunities for improvement included an option to modify the speed of narration, the incorporation of more interactive features to facilitate learner engagement, and the need for additional content on sexual dysfunction. CONCLUSION/CONCLUSIONS:This suite of clinician-focused SH education modules represents a key step in advancing AYA SH care throughout cancer treatment and survivorship. Future work will explore the efficacy of the modules on AYA-clinician SH communication.

Medical education plays a crucial role in shaping how future physicians understand and approach the prescribing of teratogenic medications to individuals with the capacity for pregnancy. The teaching that we, as medical students, experienced on this topic relied on blanket cautions derived from current guidelines that either warn students to never prescribe teratogenic medications for "women of childbearing age" or to adhere to rigid contraceptive mandates that lack guidance on contraceptive counseling, reproductive goals, or individual risk. This educational approach erases patient diversity and undermines the principles of reproductive justice. As students who are invested in reproductive health both from an educational and personal standpoint, and with our clinical education taking place in an institution and geographic and political context supportive of comprehensive reproductive health, we felt a better approach was possible. We have witnessed thoughtful, nuanced conversations between patients and providers surrounding the friction between patients' fertility goals and treatment options for other medical conditions. We outline three anecdotes that exemplify the discordance between the limited preclinical instruction most of our classmates receive and the clinical practices we have observed that foreground reproductive justice, inclusivity, and patient-provider trust. Moreover, there is a lack of empiric evidence regarding medical students' knowledge and capacity to conduct teratogenic medication counseling. Existing literature reveals a fragmented and simplified approach taken by many clinicians in prescribing these drugs. These shortcomings are related to those that exist in the context of our personal education, and it is likely that medical education on the topic of teratogenicity, contraception, and fertility is institution dependent. Given that best practices and instructions for approaching these counseling situations are not yet formalized, it is reasonable to assume that students are likely graduating from medical school with varied levels of confidence, skill, and training in this area. We find it necessary that reproductive counseling and contraceptive care for patients on teratogenic medications is taught comprehensively to students to reflect our responsibility as physicians to respect individual reproductive goals, provide inclusive and affirming care, and build trust. The individual tension we have identified within our educational experience sheds light on an area of instruction that may hold significant potential in shaping a generation of thoughtful, effective physicians.

PURPOSE/OBJECTIVE:To improve access to fertility care at the largest safety net hospital in New York City, fellows and residents run a reproductive endocrinology and infertility clinic that supports an ovulation induction (OI) program under attending physician supervision. Our objective was to evaluate OI pregnancy outcomes to describe the program's efficacy and guide quality improvement. METHODS:We performed a descriptive study of patients who completed at least one OI cycle from 6/1/2019 to 4/1/2023. Fellows and residents managed patient care, including the prescription of an OI agent (clomiphene citrate or letrozole), ultrasound monitoring, and trigger (human chorionic gonadotropin) followed by timed intercourse (TIC) or intrauterine insemination (IUI). Primary outcomes included the overall pregnancy rate (PR) and live birth rate (LBR). RESULTS:Two hundred twenty-eight patients were prescribed OI agents during the study period. Of these, 161 patients (70.6%) completed at least one OI cycle and were not lost to follow up. The PR and LBR per patient were 21.1% (34/161) and 11.2% (18/161). The PR and LBR per cycle were 9.0% (34/379) and 4.7% (18/379). Patients who achieved a pregnancy were younger (median 32.5 years vs. 36 years, p < 0.002), had a higher AMH (median 3.2 vs. 2.1 ng/mL, p < 0.03), and were more likely to have PCOS (35.3% vs. 18.9%, p < 0.04). Among the 228 patients ever-prescribed an OI agent, there were 22 (9.6%) patients with pregnancies that occurred without OI treatment. CONCLUSIONS:PRs from this low-resource OI program are comparable to published data, demonstrating that fellow and resident-run initiatives can be successful in bridging the gap in fertility care.

The rapid evolution of generative artificial intelligence (AI) is poised to transform medicine and medical education. Large language models (LLMs) have begun to demonstrate capabilities in reasoning, diagnosis, documentation, and patient communication that can rival or exceed those of clinicians. In medical education, AI is reshaping how students learn and how faculty teach-offering individualized, context-sensitive guidance at scale. This article outlines the current state of AI integration in health care, examines how systems can responsibly implement it to enhance patient care and education, and raises critical questions about ethics and safety as we harness its transformative potential.

The use of continuous glucose monitors (CGM) and insulin pumps has revolutionized the care of patients with type 1 diabetes (T1D). Few data are available regarding the use of diabetes technology use in the pregnant T1D population. This study was conducted to evaluate temporal trends of diabetes technology use and predictors of use among pregnant individuals with TID in the United States from 2009 to 2020.MarketScan Research Databases from 2009 to 2020 were used to identify pregnant individuals with T1D who were and were not using CGM and/or insulin pumps. Joinpoint regression analysis was used to estimate the average annual percent change (AAPC) in diabetes technology use over time. Unadjusted and adjusted log-linear Poisson regression models were developed to assess the associations between the outcomes of CGM and insulin pump use and demographic and clinical predictors. Associations were reported as adjusted risk ratios (ARR) with 95% confidence intervals (CI).Among 9,201 pregnancies with T1D, CGM use increased from 2.3% in 2009 to 13.7% in 2020 (AAPC: 13.9%; 95% CI: 11.7-17.1), while insulin pump use remained unchanged from 10.9% in 2009 to 11.8% in 2020 (AAPC: -2.4%; 95% CI: -4.4 to 0.4). Medicaid insurance and obesity were associated with a lower likelihood of CGM use and insulin pump use, while a high obstetric comorbidity index score was associated with a higher likelihood of insulin pump use (ARR: 1.26; 95% CI: 1.05-1.51).From 2009 to 2020, CGM use among pregnant individuals with T1D increased, while insulin pump use remained unchanged. Use varied by patient demographic and clinical factors, most notable for lower likelihood of CGM use and insulin pump use with Medicaid insurance. Although CGM use increased over time, overall CGM use remained lower than expected despite the known benefits of CGM use in improving neonatal outcomes in pregnancies complicated by T1D. · CGM use in pregnant individuals with T1D increased from 2.3 to 13.7%, but pump use was stable.. · Medicaid and obesity were associated with lower CGM and pump use in pregnant individuals with T1D.. · Low CGM use in pregnant T1D individuals highlights barriers and the need for equitable access..

CONTEXT/UNASSIGNED:Plasticizers such as bisphenols and phthalates are endocrine-disrupting chemicals and lead to development of metabolic diseases. OBJECTIVE/UNASSIGNED:To examine associations of prenatal exposure to bisphenols and phthalates with metabolic dysfunction. DESIGN/UNASSIGNED:This study was nested in the New York University (NYU) Children's Health and Environment Study, a prospective birth cohort. SETTING/UNASSIGNED:Participants were recruited at three NYU-affiliated hospitals. PATIENTS OR OTHER PARTICIPANTS/UNASSIGNED:Eligible participants were ≥18 years old, <18 weeks pregnant, and had a medically stable pregnancy. EXPOSURES/UNASSIGNED:Twelve phthalate metabolites and two bisphenols were measured in early and mid-pregnancy (<18 and 18-25 weeks) urine samples. Bisphenols were summed, and phthalate metabolites were grouped based by molecular weights and relevant parent compounds. MAIN OUTCOME MEASURES/UNASSIGNED:Logistic and linear regression models assessed chemicals groups' associations with gestational diabetes mellitus (GDM), glucose disturbance (including impaired glucose tolerance (IGT)), and blood glucose response to glucose challenge test (GCT), adjusting for sociodemographic and pregnancy-related factors. RESULTS/UNASSIGNED:Seventy-nine (6.8%) had GDM, 303 (26.1%) had IGT, and blood glucose response to GCT ranged from 22-386 mg/dL. Bisphenol A (BPA) was negatively associated with blood glucose response to GCT (-1.47 [-2.84, -0.10]), while diethylhexyl phthalate (DEHP; 2.67 [0.98, 4.36]) and high molecular weight phthalates (1.94, [0.17, 3.71]) were positively associated with blood glucose response to GCT. DEHP was also linked to glucose disturbance (1.16 [1.02, 1.31]). CONCLUSION/UNASSIGNED:Our findings suggest that phthalate exposure is associated with GDM. Further mechanistic studies are warranted, particularly given the inverse associations with BPA exposure.

Preimplantation genetic testing for aneuploidy (PGT-A) has become a widely adopted component of in vitro fertilization (IVF) practice. However, PGT-A is not a single, uniform test; its predictive value and clinical utility remain highly dependent on test performance and interpretation, both of which vary substantially between laboratories and platforms. This article aims to define the intended goals of PGT-A, evaluate methods for proper test validation, and explore how validation data impacts clinical counseling and decision-making. Particular attention is given to newer diagnostic categories such as mosaicism and segmental aneuploidy, for which clinical validation is limited and inter-laboratory variability is high. While PGT-A can reduce futile embryo transfers and support elective single embryo transfer, misapplication of unvalidated results may reduce IVF success rates. To ensure responsible use of PGT-A, clinicians must demand transparent, assay-specific validation data and use this information to guide evidence-based counseling for embryo transfer, storage, and disposition.