Veteran Perspectives on Population-Based Suicide Risk Screening in VHA Primary Care: Mixed-Methods Study.

BACKGROUND: In late 2018, VHA implemented a multi-stage suicide risk screening and evaluation initiative, Suicide Risk Identification Strategy, or "Risk ID," in primary care settings. OBJECTIVE: The main objective of this study was to characterize VHA primary care patient perspectives regarding population-based suicide risk screening through the Risk ID program. DESIGN: Mixed methods; survey and qualitative interviews. PARTICIPANTS: Veterans screened for suicide risk using Risk ID in primary care (n = 868) participated in a survey of veteran attitudes about screening (45% response rate); thirty additionally participated in follow-up qualitative interviews. MAIN MEASURES: The quantitative survey consisted of three questions on attitudes about screening for suicidal thoughts in primary care. In qualitative interviews, veterans were asked about their experiences with the Risk ID processes and recommendations for improving Risk ID. KEY RESULTS: Over 90% of veterans reported that it is appropriate for primary care providers or nurses/medical assistants to ask veterans about thoughts of suicide during primary care visits. Approximately half of veterans indicated that veterans should be asked about suicidal thoughts at every visit. Qualitative findings revealed that while most veterans were generally supportive and appreciated VHA screening for suicidal thoughts, they also expressed concern for the potential for inadvertent harm. Participants expressed conflicting preferences for how screening should be handled and delivered. CONCLUSIONS: Findings suggest that most veterans support the integration of standardized suicide risk assessment into routine primary care visits. However, findings also suggest that population-based suicide risk assessment should further consider patient experiences and preferences. Specifically, additional guidance or training for staff conducting suicide risk screening may be warranted to ensure patients feel heard (e.g., eye contact, expressing empathy) and increase patient understanding of the purpose of the screening and potential outcomes. These patient-centered approaches may improve patient experience and facilitate disclosure of suicidal thoughts.

Adaptive weighting of taste and odor cues during flavor choice.

Colloquially referred to as "taste," flavor is in reality a thoroughly multisensory experience. Yet, a mechanistic understanding of the multisensory computations underlying flavor perception and food choice is lacking. Here, we used a multisensory flavor choice task in rats to test specific predictions of the statistically optimal integration framework, which has previously yielded much insight into cue integration in other multisensory systems. Our results confirm three key predictions of this framework in the unique context of flavor choice behavior, providing novel mechanistic insight into multisensory flavor processing.NEW & NOTEWORTHY The authors demonstrate that rats make choices about which flavor solution (i.e., taste-odor mixture) to consume by weighting the individual taste and odor components according to the reliability of the information they provide about which solution is the preferred one. A similar weighting operation underlies multisensory cue combination in other domains and offers novel insight into the computations underlying multisensory flavor perception and food choice behavior.

Multisensory interactions underlying flavor consumption in rats: the role of experience and unisensory component liking.

The mechanisms by which taste and odor are combined in determining food choice behavior are poorly understood. Previous work in human subjects has yielded mixed results, potentially due to differences in task context across studies, and a lack of control over flavor experience. Here, we used rats as a model system to systematically investigate the role of experience and unisensory component liking in the multisensory interactions underlying consumption behavior. We demonstrate that taste-smell mixture consumption is best explained by a linear average of component liking. The observed pattern of results was not dependent on prior experience with specific taste-smell combinations, and unique for multisensory as opposed to unisensory mixture consumption. The results are discussed with respect to existing models of flavor integration, and a maximum-likelihood integration model previously described for multisensory judgments in other systems.

Caffeine protects against experimental acute pancreatitis by inhibition of inositol 1,4,5-trisphosphate receptor-mediated Ca2+ release.

OBJECTIVE: Caffeine reduces toxic Ca2+ signals in pancreatic acinar cells via inhibition of inositol 1,4,5-trisphosphate receptor (IP3R)-mediated signalling, but effects of other xanthines have not been evaluated, nor effects of xanthines on experimental acute pancreatitis (AP). We have determined effects of caffeine and its xanthine metabolites on pancreatic acinar IP3R-mediated Ca2+ signalling and experimental AP. DESIGN: Isolated pancreatic acinar cells were exposed to secretagogues, uncaged IP3 or toxins that induce AP and effects of xanthines, non-xanthine phosphodiesterase (PDE) inhibitors and cyclic adenosine monophosphate and cyclic guanosine monophosphate (cAMP/cGMP) determined. The intracellular cytosolic calcium concentration ([Ca2+]C), mitochondrial depolarisation and necrosis were assessed by confocal microscopy. Effects of xanthines were evaluated in caerulein-induced AP (CER-AP), taurolithocholic acid 3-sulfate-induced AP (TLCS-AP) or palmitoleic acid plus ethanol-induced AP (fatty acid ethyl ester AP (FAEE-AP)). Serum xanthines were measured by liquid chromatography-mass spectrometry. RESULTS: Caffeine, dimethylxanthines and non-xanthine PDE inhibitors blocked IP3-mediated Ca2+ oscillations, while monomethylxanthines had little effect. Caffeine and dimethylxanthines inhibited uncaged IP3-induced Ca2+ rises, toxin-induced Ca2+ release, mitochondrial depolarisation and necrotic cell death pathway activation; cAMP/cGMP did not inhibit toxin-induced Ca2+ rises. Caffeine significantly ameliorated CER-AP with most effect at 25 mg/kg (seven injections hourly); paraxanthine or theophylline did not. Caffeine at 25 mg/kg significantly ameliorated TLCS-AP and FAEE-AP. Mean total serum levels of dimethylxanthines and trimethylxanthines peaked at >2 mM with 25 mg/kg caffeine but at <100 µM with 25 mg/kg paraxanthine or theophylline. CONCLUSIONS: Caffeine and its dimethylxanthine metabolites reduced pathological IP3R-mediated pancreatic acinar Ca2+ signals but only caffeine ameliorated experimental AP. Caffeine is a suitable starting point for medicinal chemistry.

Fatty acid ethyl ester synthase inhibition ameliorates ethanol-induced Ca2+-dependent mitochondrial dysfunction and acute pancreatitis.

OBJECTIVE: Non-oxidative metabolism of ethanol (NOME) produces fatty acid ethyl esters (FAEEs) via carboxylester lipase (CEL) and other enzyme action implicated in mitochondrial injury and acute pancreatitis (AP). This study investigated the relative importance of oxidative and non-oxidative pathways in mitochondrial dysfunction, pancreatic damage and development of alcoholic AP, and whether deleterious effects of NOME are preventable. DESIGN: Intracellular calcium ([Ca(2+)](C)), NAD(P)H, mitochondrial membrane potential and activation of apoptotic and necrotic cell death pathways were examined in isolated pancreatic acinar cells in response to ethanol and/or palmitoleic acid (POA) in the presence or absence of 4-methylpyrazole (4-MP) to inhibit oxidative metabolism. A novel in vivo model of alcoholic AP induced by intraperitoneal administration of ethanol and POA was developed to assess the effects of manipulating alcohol metabolism. RESULTS: Inhibition of OME with 4-MP converted predominantly transient [Ca(2+)](C) rises induced by low ethanol/POA combination to sustained elevations, with concurrent mitochondrial depolarisation, fall of NAD(P)H and cellular necrosis in vitro. All effects were prevented by 3-benzyl-6-chloro-2-pyrone (3-BCP), a CEL inhibitor. 3-BCP also significantly inhibited rises of pancreatic FAEE in vivo and ameliorated acute pancreatic damage and inflammation induced by administration of ethanol and POA to mice. CONCLUSIONS: A combination of low ethanol and fatty acid that did not exert deleterious effects per se became toxic when oxidative metabolism was inhibited. The in vitro and in vivo damage was markedly inhibited by blockade of CEL, indicating the potential for development of specific therapy for treatment of alcoholic AP via inhibition of FAEE generation.

Cancer cell-associated fatty acid synthase activates endothelial cells and promotes angiogenesis in colorectal cancer.

Upregulation of fatty acid synthase (FASN), a key enzyme of de novo lipogenesis, is associated with metastasis in colorectal cancer (CRC). However, the mechanisms of regulation are unknown. Since angiogenesis is crucial for metastasis, we investigated the role of FASN in the neovascularization of CRC. The effect of FASN on tumor vasculature was studied in orthotopic CRCs, the chick embryo chorioallantoic membrane (CAM) and Matrigel plug models using immunohistochemistry, immunofluorescent staining and confocal microscopy. Cell secretion was evaluated by ELISA and antibody arrays. Proliferation, migration and tubulogenesis of endothelial cells (ECs) were assessed in CRC-EC coculture models. In this study, we found that stable knockdown of FASN decreased microvessel density in HT29 and HCT116 orthotopic CRCs and resulted in 'normalization' of tumor vasculature in both orthotopic and CAM models. Furthermore, FASN regulated secretion of pro- and antiangiogenic factors, including vascular endothelial growth factor-A (VEGF-A). Mechanisms associated with the antiangiogenic activity noted with knockdown of FASN included: downregulation of VEGF(189), upregulation of antiangiogenic isoform VEGF(165b) and a decrease in expression and activity of matrix metalloproteinase-9. Furthermore, conditioned medium from FASN knockdown CRC cells inhibited activation of vascular endothelial growth factor receptor-2 and its downstream signaling and decreased proliferation, migration and tubulogenesis of ECs as compared with control medium. Together, these results suggest that cancer cell-associated FASN regulates tumor vasculature through alteration of the profile of secreted angiogenic factors and regulation of their bioavailability. Inhibition of FASN upstream of VEGF-A and other angiogenic pathways can be a novel therapeutic strategy to prevent or inhibit metastasis in CRC.

An association between socioeconomic deprivation and primary care antibiotic prescribing in Scotland.

OBJECTIVE: To evaluate the association between socioeconomic deprivation and antibiotic prescribing in Scotland. PATIENTS AND METHODS: Data for dispensed antibiotic prescriptions written by general practitioners were obtained for all Scottish National Health Service boards from 2010 to 2012. Deprivation was assessed linking dispensing events to the Scottish Index of Multiple Deprivation (SIMD) score for the patient's datazone (neighbourhood area). The relationship between the deprivation area and antibiotic use (items per 1000 persons per day) was stratified according to the patient's age and sex and the antibiotic class dispensed. A multivariate Poisson regression model was used to formally test the associations. RESULTS: Approximately 12 million prescription items during 2010-2012 were assessed. Patients in the most deprived SIMD quintile had an overall prescription rate that was 36.5% higher than those in the least deprived quintile. The effect of deprivation upon prescription rates was most pronounced for women aged 40-59 years, and for penicillins and metronidazole. CONCLUSIONS: Deprivation was found to have a consistent association with increased rates of antibiotic prescribing in Scotland, which may have significant implications for antimicrobial stewardship and public health campaigns.

Easing the Entry of Qualified International Medical Graduates to U.S. Medical Practice.

ABSTRACT: Almost one quarter of physicians and physicians-in-training in the United States are international medical graduates (IMGs), meaning they have graduated from a medical school not accredited in the United States. Some IMGs are U.S. citizens and others are foreign nationals. IMGs, many of whom have years of training and experience gained in their countries of origin, have long contributed to the U.S. health care system, especially by providing care to populations that have been historically underserved. Additionally, many IMGs contribute to the diversity of the health care workforce, which can enhance the health of the population. The diversity of the United States is increasing, and racial and ethnic concordance between a physician and a patient has been linked to improved health outcomes.IMGs must meet national- and state-level licensing and credentialing standards like any other U.S. physician. This assures the ongoing quality of the care provided by the medical workforce and protects the public. However, at the state level, variation in standards and standards that may be more challenging to meet than those for U.S. medical school graduates may hamper IMGs' contributions. IMGs who are not U.S. citizens also face visa and immigration barriers.In this article, the authors present insights gleaned from Minnesota's model IMG integration program as well as changes made in 2 states in response to the COVID-19 pandemic. Improving and streamlining processes for IMGs to be licensed and credentialed as well as the policies governing visas and immigration, where appropriate, can ensure that IMGs will be willing and able to continue to practice when and where they are needed. This, in turn, could increase the contribution of IMGs to addressing health care inequities, improving health care access through service in federally designated Health Professional Shortage Areas, and reducing the impact of potential physician shortages.

Treating Benign Ovarian Lesions in the Pediatric Population: A Single Institution's Retrospective Investigation of Laparoscopy Versus Open Repair.

Background: Benign ovarian lesions in the pediatric population have variable risk of recurrence or development of metachronous lesions, leading to variations in operative approach. Our study compares outcomes with differing surgical approaches to better elucidate risk of recurrent or metachronous lesions, time to development of these lesions, and hospital length of stay to determine if one operative approach has superior outcomes. Methods: We retrospectively examined data from Indiana University Health facilities from 2002 to 2020. Patients ≤18 years old who underwent surgical management of a benign ovarian lesion were included. Patients were categorized as undergoing oophorectomy versus ovarian sparing surgery (OSS), with open and laparoscopic approaches. Significance was defined as P < .05. Results: We identified 127 patients who underwent an open (n = 65) versus laparoscopic (n = 55) surgical approach. Patients undergoing open surgery had a greater mean size of lesion (P = .05) and longer length of stay (P < .01). Complication rates (P = .1), rates of developing a metachronous or recurrent lesion postoperatively (P = .47), and time to formation of additional lesions were similar between groups (P = .25). The incidence of identifying an additional lesion after surgery was 14.2% (n = 18) in the mean time of 29.5 ± 31.6 months [SEM 7.5]. Risk of developing a metachronous lesion was similar regardless of the operative approach. Surgery for recurrent ovarian lesions was rare and occurred in only 1 case. Conclusions: Laparoscopic surgery was performed for smaller lesions and was associated with a shorter length of hospital stay. Laparoscopic and OSS was found to have no increased risk of developing metachronous lesions nor increased reoperative risk compared with traditional open and oophorectomy techniques.

Maintaining Community During Disruption: Lessons From the Accelerating Change in Medical Education Consortium.

ABSTRACT: When the COVID-19 pandemic emerged early in 2020, the American Medical Association's (AMA) Accelerating Change in Medical Education Consortium focused on maintaining its community of 37 medical schools and 11 graduate medical education projects along with the core substance of its work. The initial response was to cancel events and reduce the workload of consortium members, but it quickly became clear that the consortium needed additional strategies. The constituents needed resources, support, and community. The authors, along with the rest of the AMA team, learned to maximize the benefits and minimize the drawbacks of operating virtually. These insights supported the continuation, and even expansion, of the consortium's innovations despite extremely stressful circumstances. In this Scholarly Perspective, the authors outline the actions that they and the AMA team took in 2020 and 2021 at the beginning of the pandemic and as that crisis progressed and was further intensified by the significant distress reflected in the protests after the murder of George Floyd. The goal of these actions was to maintain the consortium's core substance, innovation, momentum, and sense of community. The authors describe lessons learned in 2020 and 2021 via a novel model developed to facilitate ongoing collaboration and respond rapidly to the needs of overwhelmed medical educators. This model is composed of 4 phases: assessing needs, mining experts, convening people, and generating products. This model for leveraging a community of practice can help educators optimize collaboration, whether educators are pursuing innovation in the training of physicians or other health care professionals and whether in times of extreme stress or stability, the model provides a pathway for maintaining community. The prepandemic way of working will not return. Virtual participation and collaboration will remain a part of work and daily life for the foreseeable future and beyond.

Murine portal vein catheterization to analyze liver-directed therapies.

BACKGROUND: Small interfering RNA (siRNA) provides a highly selective method to target mutated pathways; however, its use is complicated by specific delivery to tumor cells. The aims of the present study were to develop a novel murine model of portal vein catheterization for the chronic delivery of therapeutic agents to liver metastases, determine the benefits of local delivery of siRNA to liver metastases, and determine the utility of epithelial cell adhesion molecule (EpCAM) as a selective target for siRNA delivery to colorectal cancer (CRC) metastases. MATERIALS AND METHODS: First, portal vein catheterization was performed through a midline laparotomy in 2 mo-old Balb/C mice. Second, the portal venous flow distribution and catheter patency were evaluated using fluorescent-labeled microspheres. Metastatic studies were performed by splenic injection of CT26 murine colon cancer cells. Uptake of DY-547-labeled siRNA was assessed by IVIS imaging, with delivery to the metastases confirmed using fluorescent microscopy. Finally, EpCAM expression was evaluated using immunohistochemical staining of human tissue microarrays. RESULTS: Successful portal vein catheterization was confirmed by saline injection and ultrasound. Fluorescent imaging of microspheres confirmed excellent distribution and catheter patency. Portal venous injection of DY547-labeled siRNA demonstrated a high level of fluorescence throughout the liver, with siRNA also identified within the liver metastases. Also, all primary CRCs and liver metastases stained strongly for EpCAM, with no expression in normal hepatocytes. CONCLUSIONS: Liver-directed therapy can provide the selective delivery of siRNA to CRC metastases. EpCAM expression in CRC, but not normal liver, could further selectively target hepatic metastases of epithelial origin.

Primary Care and Mental Health Staff Perspectives on Universal Suicide Risk Screening and Care Coordination.

Little is known about staff or patient perspectives on suicide risk screening programs. The objectives of this study were to characterize Veterans Health Administration (VHA) primary care and mental health staff perspectives regarding the VHA Suicide Risk Identification Strategy screening and assessment program and to describe coordination of suicide prevention-related care following positive screening results. Qualitative interviews were conducted with 40 primary care and mental health staff at 12 VHA facilities. An inductive-deductive hybrid approach was used to conduct a thematic analysis. Several key themes were identified. Primary care and mental health staff participants accepted having a structured process for screening for suicidal ideation and conducting risk assessments, but both groups noted limitations and challenges with initial assessment and care coordination following screening. Mental health staff reported more concerns than primary care staff about negative impacts of the screening and assessment process on treatment. Both groups felt that better training was needed for primary care staff to effectively discuss and evaluate suicide risk. The results suggested that additional modifications of the screening and assessment process are needed for patients already known to have elevated risk of suicide or chronic suicidal ideation.

Supporting Medical Education Innovation: Evaluation of a Grants Initiative.

PROBLEM: Medical education must evolve to meet the changing needs of patients and communities. Innovation is a critical component of that evolution. As medical educators pursue innovative curricula, assessments, and evaluation techniques, the impact of innovations may be limited by minimal funding. The American Medical Association (AMA) Innovation Grant Program, launched in 2018, seeks to address the gap in funding and stimulate educational innovation and research in medical education. APPROACH: In 2018 and 2019, the Innovation Grant Program targeted innovation in content areas including health systems science, competency-based medical education, coaching, learning environment, and emerging technology. The authors reviewed the content of applications and final reports for the 27 projects completed during the first 2 years of the program. They also noted measures of success (completion of project, achievement of grant objectives, development of transferrable educational product, dissemination). OUTCOMES: In 2018, the AMA received 52 submissions and funded 13 proposals, dispersing $290,000 ($10,000 and $30,000 grants). In 2019, the AMA received 80 submissions and funded 15 proposals, dispersing $345,000. Among the 27 completed grants, 17 (63%) supported innovations related to health systems science. Fifteen (56%) were used to create educational products that could be shared, such as new assessment tools, curricula, and teaching modules. Five grant recipients (29%) published articles and 15 (56%) presented at national conferences. NEXT STEPS: The grant program advanced educational innovations, particularly in health systems science. The next steps will involve examining the long-term outcomes and impact of the completed projects on medical students, patients, and the health system; the professional development of the grantees; and the adoption and dissemination of the innovations.

Evidence for metabolic cleavage of a PEGylated protein in vivo using multiple analytical methodologies.

PEGylation of therapeutic proteins is commonly used to extend half-lives and to reduce immunogenicity. However, reports of antibodies toward PEGylated proteins and of poly(ethylene glycol) (PEG) accumulation suggest that efficacy and safety concerns may arise. To understand the relationship among the pharmacology, immunogenicity, and toxicology of PEGylated proteins, we require knowledge of the disposition and metabolic fate of both the drug and the polymer moieties. The analysis of PEG by standard spectrophotometric or mass spectrometric techniques is problematic. Consequently, we have examined and compared two independent analytical approaches, based on gel electrophoresis and nuclear magnetic resonance (NMR) spectroscopy, to determine the biological fate of a model PEGylated protein, (40K)PEG-insulin, within a rat model. Both immunoblotting with an antibody to PEG and NMR analyses (LOD 0.5 µg/mL for both assays) indicated that the PEG moiety remained detectable for several weeks in both serum and urine following intravenous administration of (40K)PEG-insulin (4 mg/kg). In contrast, Western blotting with anti-insulin IgG indicated that the terminal half-life of the insulin moiety was far shorter than that of the PEG, providing clear evidence of conjugate cleavage. The application of combined analytical techniques in this way thus allows simultaneous independent monitoring of both protein and polymer elements of a PEGylated molecule. These methodologies also provide direct evidence for cleavage and definition of the chemical species present in biological fluids which may have toxicological consequences due to unconjugated PEG accumulation or immunogenic recognition of the uncoupled protein.

Review of experimental animal models of biliary acute pancreatitis and recent advances in basic research.

Acute pancreatitis (AP) is a formidable disease, which, in severe forms, causes significant mortality. Biliary AP, or gallstone obstruction-associated AP, accounts for 30-50% of all clinical cases of AP. In biliary AP, pancreatic acinar cell (PAC) death (the initiating event in the disease) is believed to occur as acinar cells make contact with bile salts when bile refluxes into the pancreatic duct. Recent advances have unveiled an important receptor responsible for the major function of bile acids on acinar cells, namely, the cell surface G-protein-coupled bile acid receptor-1 (Gpbar1), located in the apical pole of the PAC. High concentrations of bile acids induce cytosolic Ca(2+) overload and inhibit mitochondrial adenosine triphosphate (ATP) production, resulting in cell injury to both PACs and pancreatic ductal epithelial cells. Various bile salts are employed to induce experimental AP, most commonly sodium taurocholate. Recent characterization of taurolithocholic acid 3-sulphate on PACs has led researchers to focus on this bile salt because of its potency in causing acinar cell injury at relatively low, sub-detergent concentrations, which strongly implicates action via the receptor Gpbar1. Improved surgical techniques have enabled the infusion of bile salts into the pancreatic duct to induce experimental biliary AP in mice, which allows the use of these transgenic animals as powerful tools. This review summarizes recent findings using transgenic mice in experimental biliary AP.

The Interaction of Obesity and Reproductive Function in Adolescents.

Obesity is increasing worldwide, including in pediatrics. Adequate nutrition is required for initiation of menses, and there is a clear secular trend toward earlier pubertal onset and menarche in females in countries around the globe. Similar findings of earlier pubertal start are suggested in males. However, as individuals and populations have crossed into over-nutritional states including overweight and obesity, the effect of excess weight on disrupting reproductive function has become apparent. Hypothalamic hypogonadism and polycystic ovary syndrome are two conditions where reproductive function appears to directly relate to excess weight. Clinical findings in individuals with certain polygenic and monogenic obesity syndromes, which also have reproductive disruptions, have helped elucidate neurologic pathways that are common to both. Clinical endocrinopathies such as hypothyroidism or panhypopituitarism also aide in the understanding of the role of the endocrine system in weight gain. Understanding the intersection of obesity and reproductive function may lead to future therapies which can treat both conditions.

Development and Preliminary Evaluation of an Education Program for Primary Care Teams on Discussing Firearms Storage Safety with Veterans.

BACKGROUND: Reducing access to lethal means is one of the few empirically supported approaches for lowering suicide rates, and safe firearms storage practices have been associated with reduced risk of death by suicide. Although there is substantial opportunity for primary care to assist in addressing lethal means with veterans, approaches to intervention and educating staff are not well documented. We sought to 1) describe development of an education program for primary care teams to help them discuss firearms storage safety (FSS) with veterans during primary care visits; and 2) conduct a preliminary evaluation of the pilot education program. METHODS: We used an iterative process involving veterans and primary care staff stakeholders to develop program content, format, and supplemental materials. A grounded theory approach was used to analyze data from focus groups and individual interviews. Following piloting of the program with 71 staff members in two primary care clinics, we analyzed pre- and post-training participant surveys of program satisfaction and attitudes comfort related to firearms safety discussions. RESULTS: During the development phase, 68 veterans and 107 staff members participated in four veteran focus groups and four primary care focus groups, respectively, and/or individual interviews. The program that was developed, "'Just in Case': Discussing means safety with veterans at elevated risk for suicide," addresses knowledge and skills learning objectives, and includes video demonstrations and skills practice. Survey data obtained just prior to the pilot training sessions showed low self-reported rates of discussing firearms safety with veterans who may be at elevated risk for suicide. Immediate post-training data showed generally high satisfaction with the program and significant improvements in participant self-reported ratings of the importance of, and comfort with FSS. CONCLUSIONS: This interactive knowledge and skill-based means safety curriculum shows promise as a means for educating primary care staff to deliver messaging about firearms safety to veterans. Additional research is needed to refine and evaluate impacts of this or similar training programs on clinician and veteran behaviors over time.

Fertility Counseling Practices for Patients with Turner Syndrome in Pediatric Endocrine Clinics: Results of a Pediatric Endocrine Society Survey.

INTRODUCTION: Turner syndrome (TS) is associated with a high risk of primary ovarian insufficiency. Current guidelines recommend early fertility counseling for affected youth and their families. This study assessed clinical providers' (MD, NP, or PA) fertility counseling practices for girls with TS. METHODS: TS providers were invited to complete a survey via the Pediatric Endocrine Society listserv. Descriptive statistics summarized variables of interest. Correlations were used to identify associations between barriers/practice characteristics and fertility preservation (FP) referral. Thematic analysis was used to examine qualitative responses. RESULTS: 119 providers completed the survey. Seventy percent reported discussing fertility implications of TS routinely in pediatric care. Fifty-six percent reported often or always referring patients with spontaneous menarche to FP specialists, whereas only 19% reported often or always referring their patients without spontaneous menarche (p < 0.001). Barriers associated with FP referral frequency included unfamiliarity with FP options, belief that FP is not a possible goal for their patients, and absence of a local reproductive endocrinologist. Qualitatively, four referral barrier themes were identified: (1) questionable utility of referral, (2) lack of perceived interest among patients/families, (3) provider barriers (e.g., lack of knowledge), (4) logistical/structural barriers to accessing fertility-related care. DISCUSSION/CONCLUSION: Pediatric endocrinology providers report inconsistently discussing fertility implications of TS. The frequency of referral to an FP specialist and factors/barriers affecting the decision to refer remain variable. Future research should focus on expanding provider education, addressing barriers to high-quality fertility counseling and referral for patients with TS, and investigating FP outcomes in TS.

Beyond Training the Next Generation of Physicians: The Unmeasured Value Added by Residents to Teaching Hospitals and Communities.

Following medical school, most newly graduated physicians enter residency training. This period of graduate medical education (GME) is critical to creating a physician workforce with the specialized skills needed to care for the population. Completing GME training is also a requirement for obtaining medical licensure in all 50 states. Yet, crucial federal and state funding for GME is capped, creating a bottleneck in training an adequate physician workforce to meet future patient care needs. Thus, additional GME funding is needed to train more physicians. When considering this additional GME funding, it is imperative to take into account not only the future physician workforce but also the value added by residents to teaching hospitals and communities during their training. Residents positively affect patient care and health care delivery, providing intrinsic and often unmeasured value to patients, the hospital, the local community, the research enterprise, and undergraduate medical education. This added value is often overlooked in decisions regarding GME funding allocation. In this article, the authors underscore the value provided by residents to their training institutions and communities, with a focus on current and recent events, including the global COVID-19 pandemic and teaching hospital closures.