Faculty Bibliography

The process of gender affirmation may have an impact on fertility. Counseling on the impact of affirmation and opportunities for fertility, future family building, and reproductive health is an important first step in the affirmation process. This article discusses the options for fertility preservation for transmen. The barriers and outcomes in this unique population are also considered. In addition, insights are provided on the future of fertility preservation and suggestions are made for how to build a comprehensive team for male transgender patients.

OBJECTIVE:To assess information needs of adults with Cystic Fibrosis and their families toward designing a patient decision aid about invasive mechanical ventilation (IMV) and lung transplant. METHODS:Focus groups and in-depth interviews explored participants' knowledge, prior clinical conversations, and decisions about IMV and lung transplant. Interviews and focus groups were recorded and transcribed for analysis. RESULTS:N = 24 participants were recruited. Themes identified were: prior communication with clinicians, decision-making process, and living with CF. Participants having prior conversations with CF clinicians regarding: lung transplant (N = 17/74%), and IMV (N = 3/13%). Most 15(65%) felt it was important to hear patients' real-life experience, others (3/13%) relied on their CF doctors for information. Most people (16/70%) believed hearing prognosis was helpful, but 5(22%) found this information frightening. High degrees of social isolation and a desire for more interaction with other CF adults were found. CONCLUSIONS:Qualitative methods helped identify areas important for decision making about IMV and LT for CF adults. Future directions include usability and feasibility testing of the decision aid. PRACTICE IMPLICATIONS/CONCLUSIONS:Because IMV is rarely discussed with CF adults, clinicians might approach this topic, as with transplant, as lung function begins to decline. CF-care teams should also foster CF patient-level information exchange.

Gestational trophoblastic disease (GTD), a rare complication of pregnancy, includes both benign and malignant forms, the latter collectively referred to as gestational trophoblastic neoplasia (GTN). When metastatic, the lungs are the most common site of initial spread. Beta-human chorionic gonadotropin, elaborated to some extent by all forms of GTD, is useful in facilitating disease detection, diagnosis, monitoring treatment response, and follow-up. Imaging evaluation depends on whether GTD manifests in one of its benign forms or whether it has progressed to GTN. Transabdominal and transvaginal ultrasound with duplex Doppler evaluation of the pelvis are usually appropriate diagnostic procedures in either of these circumstances, and in posttreatment surveillance. The appropriateness of more extensive imaging remains dependent on a diagnosis of GTN and on other factors. The use of imaging to assess complications, typically hemorrhagic, should be guided by the location of clinical signs and symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

This article examined longitudinal relations among socioeconomic risk, maternal language input, child vocabulary, and child executive function (EF) in a large sample (N = 1,009) recruited for a prospective longitudinal study. Two measures of maternal language input derived from a parent-child picture book task, vocabulary diversity (VOCD), and language complexity, showed variation by socioeconomic risk at child ages 15, 24, and 36 months. Maternal VOCD at child age 24 months and maternal language complexity at child age 36 months mediated the relation between socioeconomic risk and 48-month child EF, independent of parenting sensitivity. Moreover, 36-month child vocabulary mediated the relation between maternal language input and child EF. These findings provide novel evidence about mechanisms linking socioeconomic risk and child executive function.

Theoretical models of Attention deficit/hyperactivity disorder (ADHD) have long implicated executive function (EF) skills as contributing to the etiology, maintenance, and changes in ADHD symptomatology over time. Although there is interest making within-person inferences (i.e., deficits in EF skills give rise to ADHD behaviors), most of the evidence has been derived from studies that conflated between- and within-person sources of variance. Here, we use repeated-measures data to test within-person association between EF skills and ADHD behaviors. Participants included 1160 children from the Family Life Project, an ongoing prospective longitudinal study of child development in low-income, nonmetropolitan communities. We tested the magnitude of the association between EF skills and ADHD behaviors when children were 3, 4, and 5 years old. Consistent with meta-analyses, unadjusted bivariate associations between EF and ADHD (which reflect combined between- and within-person variation) were of moderate magnitude (rs = -0.20 to -0.30). However, after controlling for all time-invariant, between-person sources of variation, the within-person associations between EF skills and ADHD behaviors were weak (βs - 0.04 to -0.05, ps = 0.01). These results suggest that EF skills may contribute less prominently to ADHD behaviors in early childhood than is commonly assumed and provoke broader questions about developmental models of ADHD.

Late-life measures of white matter (WM) microstructural integrity may predict cognitive status, cognitive decline, and incident mild cognitive impairment (MCI) or dementia. We considered participants of the Atherosclerosis Risk in Communities study who underwent cognitive assessment and neuroimaging in 2011-2013 and were followed through 2016-2017 (n = 1775 for analyses of prevalent MCI and dementia, baseline cognitive performance, and longitudinal cognitive change and n = 889 for analyses of incident MCI, dementia, or death). Cross-sectionally, both overall WM fractional anisotropy and overall WM mean diffusivity were strongly associated with baseline cognitive performance and risk of prevalent MCI or dementia. Longitudinally, greater overall WM mean diffusivity was associated with accelerated cognitive decline, as well as incident MCI, incident dementia, and mortality, but WM fractional anisotropy was not robustly associated with cognitive change or incident cognitive impairment. Both cross-sectional and longitudinal associations were attenuated after additionally adjusting for likely downstream pathologic changes. Increased WM mean diffusivity may provide an early indication of dementia pathogenesis.

OBJECTIVES:Cardiac troponin T, measured using a high-sensitive assay (hs-cTnT), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are associated with increased stroke risk and perhaps with cognitive decline. However, few well-designed prospective studies with extended follow-up have been conducted. We aimed to estimate the association of hs-cTnT and NT-proBNP with 15-year cognitive change in the Atherosclerosis Risk in Communities (ARIC) study. DESIGN:Prospective cohort study. SETTING:Four US communities. PARTICIPANTS:A total of 9114 and 9108 participants from the Atherosclerosis Risk in Communities study for analyses of hs-cTnT and NT-proBNP, respectively. MEASUREMENTS:We examined association of hs-cTnT and NT-proBNP with 15-year change (1996-1998 to 2011-2013) in three cognitive tests of executive function (Digit Symbol Substitution Test), verbal learning memory (Delayed Word Recall Test), and semantic fluency (Word Fluency Test), and an overall score combining the three tests using multivariable linear mixed effect models. We conducted several sensitivity analyses including multiple imputations to address bias due to missing data and attrition, and we compared associations within groups combining hs-cTnT and NT-proBNP into a three-level categorical variable. RESULTS:At baseline (1996-1998), mean age was 63.4 (standard deviation [SD] = 5.7) years; 56.4% were women, and 17.5% were black. The hs-cTnT at baseline was not associated with cognitive change in any measure. Some evidence indicated accelerated decline in verbal learning and memory when comparing those in the highest with the lowest NT-proBNP quintiles; however, this association was not replicated when considering clinically relevant cutoffs or deciles of exposure in survivors. Sensitivity analyses were consistent with our primary analyses. There was little evidence to support effect modification by any considered factors. People with highest levels of both biomarkers had excessive decline in global z scores vs people with lowest levels (-.34; 95% confidence interval = -.63 to -.04). CONCLUSION:Markers of myocardial injury and stretch were not associated with cognitive decline following 15 years among survivors, but when combined together they were suggestive in post hoc analysis. Whether this represents targets of intervention should be examined in the future. J Am Geriatr Soc 67:2353-2361, 2019.

This report presents a new implementation of the Besag-York-Mollié (BYM) model in Stan, a probabilistic programming platform which does full Bayesian inference using Hamiltonian Monte Carlo (HMC). We review the spatial auto-correlation models used for areal data and disease risk mapping, and describe the corresponding Stan implementations. We also present a case study using Stan to fit a BYM model for motor vehicle crashes injuring school-age pedestrians in New York City from 2005 to 2014 localized to census tracts. Stan efficiently fit our multivariable BYM model having a large number of observations (n=2095 census tracts) with small outcome counts < 10 in the majority of tracts. Our findings reinforced that neighborhood income and social fragmentation are significant correlates of school-age pedestrian injuries. We also observed that nationally-available census tract estimates of commuting methods may serve as a useful indicator of underlying pedestrian densities.