Faculty Bibliography

PURPOSE: Research demonstrates a negative psychosocial impact of infertility among otherwise healthy adults, and distress among adolescents facing the prospect of future infertility due to various medical conditions and treatments that impair reproductive health. Guidelines state that providers should counsel transgender youth about potential infertility and fertility preservation (FP) options prior to initiation of hormone therapy. The purpose of this study was to examine the rates of fertility counseling and utilization of FP among a cohort of adolescents with gender dysphoria seen at a large gender clinic. METHODS: An Institutional Review Board-approved retrospective review of electronic medical records was conducted of all patients with ICD-9/10 codes for gender dysphoria referred to Pediatric Endocrinology for hormone therapy (puberty suppression and/or cross-sex hormones) from January 2014 to August 2016. RESULTS: Seventy-eight patients met inclusion criteria. Five children were prepubertal, no hormone therapy was considered, and they were therefore excluded. Of the remaining 73 patients, 72 had documented fertility counseling prior to initiation of hormone therapy and 2 subjects attempted FP; 45% of subjects mentioned a desire or plan to adopt, and 21% said they had never wanted to have children. CONCLUSIONS: Utilization rates of FP are low among transgender adolescents. More research is needed to understand parenthood goals among transgender youth at different ages and developmental stages and to explore the impact of gender dysphoria on decision-making about FP and parenthood. Discussions about infertility risk, FP, and other family building options should be prioritized in this vulnerable adolescent population.

We previously defined teaching domains necessary for successful inpatient medicine attending rounds from the trainees' perspective in Role Modeling, Learning Environment, Teaching Process and Team Management. We sought to understand whether trainee characteristics and daily fluctuations in workload influence the prioritization of these domains. We conducted a prospective observational study in general medicine inpatient wards at a university, Veterans Affairs, and a county hospital affiliated with one academic institution over the course of 6 months. All student and resident trainees on internal medicine inpatient wards were eligible to participate. We designed a daily assessment tool on which trainees were asked to identify the teaching domain most important to them, along with information on sex, training level, call-cycle day, patient census, and number of team members absent during rounds. We examined associations between training level and workload factors with the prioritized teaching domain using Pearson's chi-square analysis, adjusted for clustering effects. We collected 1,378 daily assessment cards evaluating 53 (91%) attending physicians. Students valued Teaching Process (𝑃 < 0.001), while senior residents sought Team Management (𝑃 < 0.001). On most days, Teaching Process was prioritized (𝑃 = 0.005). On post-call days and days with a high patient census, Team Management was prioritized (𝑃 < 0.001). Attending physicians may consider tailoring rounds in response to work-related pressures. Days with a high workload are better suited for demonstrating efficient and effective patient care skills.

BACKGROUND: Annexin A5 (A5) is a potent anticoagulant protein that shields anionic phospholipids from availability for coagulation reactions. Previous studies showed that antibodies from patients with antiphospholipid (aPL) syndrome (APS) interfere with A5 crystallization and anticoagulant activity. OBJECTIVE: The purpose of this study was to investigate whether reduction of the Annexin A5 Anticoagulant Ratio (A5R) assay (i.e. 'A5 resistance') is associated with adverse clinical events in aPL antibody-positive patients. PATIENTS/METHODS: In an initial discovery phase group of 679 patient samples from a 'real world' tertiary care hospital population who were tested for A5R. This was followed by a validation phase cohort of 71 asymptomatic patients with aPL antibodies and no prior history for an adverse clinical event whose baseline samples were tested for A5R then subsequently observed for up to 4 years. RESULTS: In the discovery phase group, we found a reduction of A5R in aPL antibody-positive patients with thrombosis and/or pregnancy complications compared to aPL antibody-negative patients and controls. In addition, reduced A5R values in both the discovery and validation phase cohorts correlated with the extent of multipositivity for standard APS tests, which has also been shown to be associated with risk for adverse clinical outcomes. CONCLUSION: Reduction of A5R levels was associated with a multipositivity profile in aPL antibody-positive patients within both groups and with the development of adverse clinical events

OBJECTIVE:The Eating Disorder Examination (EDE) was originally developed and validated in primarily white female samples. Since data indicate that eating pathology impacts black youth, elucidating the psychometric appropriateness of the EDE for black youth is crucial. METHODS:A convenience sample was assembled from seven pediatric obesity studies. The EDE was administered to all youth. Confirmatory factor analyses (CFA) were conducted to examine the original four-factor model fit and two alternative factor structures for black and white youth. With acceptable fit, multiple-group CFAs were conducted. For measurement invariant structures, the interactive effects of race with sex, BMIz, adiposity, and age were explored (all significance levels p < .05). RESULTS:For both black and white youth (N = 820; 41% black; 37% male; 6-18 years; BMIz -3.11 to 3.40), the original four-factor EDE structure and alternative eight-item one-factor structure had mixed fit via CFA. However, a seven-item, three-factor structure reflecting Dietary Restraint, Shape/Weight Overvaluation, and Body Dissatisfaction had good fit and held at the level of strict invariance. Girls reported higher factor scores than boys. BMIz and adiposity were positively associated with each subscale. Age was associated with Dietary Restraint and Body Dissatisfaction. The interactional effects between sex, BMIz, and age with race were not significant; however, the interaction between adiposity and race was significant. At higher adiposity, white youth reported greater pathology than black youth. CONCLUSION:An abbreviated seven-item, three-factor version of the EDE captures eating pathology equivalently across black and white youth. Full psychometric testing of the modified EDE factor structure in black youth is warranted.

OBJECTIVE: Given the prevalence of mental health (MH) conditions (MHC) in children, pediatricians should initiate treatment alone or in collaboration with a specialist for children with MHC. However, the majority of pediatricians do not manage or comanage common MHC even with an on-site MH provider. We examined which physician, practice, and training characteristics are associated with pediatricians' comanaging at least half of their patients with MHC. METHODS: We analyzed responses of general pediatricians (n = 305) from the American Academy of Pediatrics 2013 Periodic Survey. Practice characteristics include presence of an on-site MH provider and perceived access to services. Independent variables included sociodemographics, training experiences, and interest in further training. The outcome was comanagement of >/=50% of patients with MHC. Weighted univariate, bivariate, and multivariable analyses were performed. RESULTS: Of the pediatricians who reported comanaging >/=50% of their patients with MHC, logistic regression analysis showed that pediatricians who completed >/=4 weeks of developmental behavioral pediatrics training had 1.8 increased odds (95% confidence interval 1.06, 3.08, P = .03) of comanagement, those very interested in further education in managing/treating MHC had 2.75 increased odds (95% confidence interval 1.63, 3.08, P < .001), and those with more training in MH treatment with medications had 1.4 increased odds (95% confidence interval 1.12, 1.75, P = .004) of comanaging children with MHC. CONCLUSIONS: Specific educational experiences and interest in further education in managing or treating MHC were significantly associated with comanaging >/=50% of patients, suggesting that enhanced MH training among pediatricians could increase the comanagement of children with MHC.

Introduction: Many new markers are now available as an aid for decisions about prostate biopsy for men without prostate cancer, and/or to improve risk stratification for men with newly diagnosed prostate cancer. Methods: A literature review was performed on currently available markers for use in decisions about prostate biopsy and initial prostate cancer treatment. Results: Although total prostate-specific antigen cutoffs were traditionally used for biopsy decisions, PSA elevations are not specific. Repeating the PSA test, and adjusting for factors like age, prostate volume and changes over time can increase specificity for biopsy decisions. The Prostate Health Index (phi) and 4K Score are new PSA-based markers that can be offered as second-line tests to decide on initial or repeat prostate biopsy. The PCA3 urine test and ConfirmMDx tissue test are additional options for repeat biopsy decisions. For men with newly diagnosed prostate cancer, genomic tests are available to refine risk classification and may influence treatment decisions. Conclusions: Numerous secondary testing options are now available that can be offered to patients deciding whether to undergo prostate biopsy and those with newly diagnosed prostate cancer.

Lab-based experimental studies with humans and in animal models demonstrate that the relation between glucocorticoid (GC) levels and performance on measures of higher-order cognitive ability such as executive function (EF) is best described by an inverted U-shape curve. Moderate levels of GCs (cortisol/corticosterone) are associated with comparatively better performance relative to GC levels that are particularly high or low. Although findings from experimental studies are definitive and have high internal validity, the external validity of this association as an aspect of children's development is unknown. Here we analyze data from the Family Life Project (N=1292), a prospective longitudinal sample of children and families in predominantly low-income and rural communities followed longitudinally from infancy through age 60 months. Consistent with the prior experimental literature, we found evidence of an inverted-U relation. For children with relatively low cortisol levels, on average, between the ages 7, 15, 24, and 48 months, those illustrating moderate fluctuations in their cortisol levels over this span tended to show subsequently better EF performance at 60 months, than did children with either highly stable or highly variable temporal profiles. This curvilinear function did not extend to children whose cortisol levels were high, on average. These children tended to show lower EF performance, irrespective the stability of their cortisol levels over time.

OBJECTIVE: To explore and identify factors that influence physicians' decisions while monitoring patients with prostate cancer on active surveillance (AS). SUBJECTS AND METHODS: A purposive sampling strategy was used to identify physicians treating prostate cancer from diverse clinical backgrounds and geographic areas across the USA. We conducted 24 in-depth interviews from July to December 2015, until thematic saturation was reached. The Applied Thematic Analysis framework was used to guide data collection and analysis. Interview transcripts were reviewed and coded independently by two researchers. Matrix analysis and NVivo software were used for organization and further analysis. RESULTS: Eight key themes emerged to explain variation in AS monitoring: (i) physician comfort with AS; (ii) protocol selection; (iii) beliefs about the utility and quality of testing; (iv) years of experience and exposure to AS during training; (v) concerns about inflicting 'harm'; (vi) patient characteristics; (vii) patient preferences; and (viii) financial incentives. CONCLUSION: These qualitative data reveal which factors influence physicians who manage patients on AS. There is tension between providing standardized care while also considering individual patients' needs and health status. Additional education on AS is needed during urology training and continuing medical education. Future research is needed to empirically understand whether any specific protocol is superior to tailored, individualized care.

In view of the increasing burden of Type 2 diabetes on healthcare systems, considerable attention has been focused on identifying and treating individuals at high risk of the disease. This has led to the designation of 'prediabetes or intermediary hyperglycaemia', describing a fasting, 2-h plasma glucose (PG) or HbA1c level above the so-called normal range, but below that defining diabetes. According to the International Diabetes Federation, 318 million adults aged 20-79 years had prediabetes in 2015, and this is expected to rise to 481 million by 2040 [1]