Practice Makes Perfect: Objective Structured Clinical Examinations Across the UME-to-GME Continuum Improve Care of Transgender Simulated Patients.

Background Residents lack confidence in caring for transgender individuals. More exposure and practice throughout training is needed. Objective To explore whether and how prior exposure to transgender health skills during medical school impacted competency with these skills during residency. Methods In 2022, all 101 internal medicine residents at New York University Grossman School of Medicine participated in an objective structured clinical examination (OSCE) station as part of their annual formative assessment where they cared for a standardized patient (SP) who identified as transgender. Three SPs who were members of the transgender community were recruited through online and social media forums. Two resident groups (continuum vs noncontinuum) differed in their prior experiences with transgender OSCEs during medical school. We analyzed SPs' ratings of resident performance using checklist data and SP open-ended feedback to compare performance between groups and resident post-OSCE evaluations to understand residents' perceptions of the educational value of the case. Results Residents with prior experience with transgender SPs (continuum) were more frequently recommended by SPs (88% [21 of 24] vs 70% [54 of 77]) to a family member or friend, were all rated professional (100% [24 of 24] vs 94% [72 of 94]) and scored better in pain information-gathering (92% vs 65%, mean summary score) and gender-affirming care skills (67% vs 52%, mean summary score). Noncontinuum residents lacked experience, missed opportunities to ask about gender identity, and needed work on demonstrating comfort and using proper language. Most residents completing a post-OSCE evaluation (80%, 41 of 51) rated the case as "very valuable." Conclusions Spaced practice and feedback through early exposure to transgender OSCEs were valuable for skill acquisition, giving continuum residents a learning advantage compared to noncontinuum residents.

Manhattan Veterans Affairs Medical Center Diabetes Prevention Clinic.

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes the establishment of a Diabetes Prevention Clinic for veterans with prediabetes.

Unexpected Hurdle in the Race: Hypophosphatasia Unmasked by the Female Athlete Triad.

Hypophosphatasia should be considered for any patient who presents with multiple metatarsal stress fractures and a low alkaline phosphatase.

The 1-h post-load plasma glucose as a novel biomarker for diagnosing dysglycemia.

Identifying the earliest moment for intervention to avert progression to prediabetes and diabetes in high-risk individuals is a substantial challenge. As ß-cell function is already compromised in prediabetes, attention should therefore be focused on identifying high-risk individuals earlier in the so-called pre-prediabetes stage. Biomarkers to monitor progression and identify the time point at which ß-cell dysfunction occurs are therefore critically needed. Large-scale population studies have consistently shown that the 1-h plasma glucose (1-h PG) ≥ 155 mg/dl (8.6 mmol/l) during the oral glucose tolerance test detected incident type 2 diabetes and associated complications earlier than fasting plasma glucose or 2-h plasma glucose levels. An elevated 1-h PG level appears to be a better alternative to HbA1c [5.7-6.4% (37-47 mmol/mol)] or traditional glucose criteria for identifying high-risk individuals at a stage when ß-cell function is substantially more intact than in prediabetes. Diagnosing high-risk individuals earlier proffers the opportunity for potentially reducing progression to diabetes, development of microvascular complications and mortality, thereby advancing benefit beyond that which has been demonstrated in global diabetes prevention programs.

Novel biomarkers for prediabetes, diabetes, and associated complications.

The number of individuals with prediabetes is expected to grow substantially and estimated to globally affect 482 million people by 2040. Therefore, effective methods for diagnosing prediabetes will be required to reduce the risk of progressing to diabetes and its complications. The current biomarkers, glycated hemoglobin (HbA1c), fructosamine, and glycated albumin have limitations including moderate sensitivity and specificity and are inaccurate in certain clinical conditions. Therefore, identification of additional biomarkers is being explored recognizing that any single biomarker will also likely have inherent limitations. Therefore, combining several biomarkers may more precisely identify those at high risk for developing prediabetes and subsequent progression to diabetes. This review describes recently identified biomarkers and their potential utility for addressing the burgeoning epidemic of dysglycemic disorders.

Reducing the prevalence of dysglycemia: is the time ripe to test the effectiveness of intervention in high-risk individuals with elevated 1 h post-load glucose levels?

Identifying the earliest time point on the prediabetic continuum is critical to avoid progressive deterioration in ß-cell function. Progressively rising glucose levels even within the "normal range" occur considerably late in the evolution to diabetes thus presenting an important opportunity for earlier diagnosis, treatment, and possible reversal. An elevated 1 h postprandial glucose level, not detected by current diagnostic standards, may provide an opportunity for the early identification of those at risk. When the 1 h post-load glucose level is elevated, lifestyle intervention may have the greatest benefit for preserving ß-cell function and prevent further progression to prediabetes and diabetes. In view of the considerable consistent epidemiologic data in large disparate populations supporting the predictive capacity of the1 h post-load value for predicting progression to diabetes and mortality, the time is therefore ripe to evaluate this hypothesis in a large, prospective multicenter randomized trial with lifestyle intervention.

Obesity is associated with sensorineural hearing loss in adolescents.

OBJECTIVES/HYPOTHESIS: Childhood obesity, defined as body mass index (BMI) ≥ 95%, is a significant health problem associated with a variety of disorders, and in adults it has been found to be a risk factor for hearing loss. We investigated the hypothesis that obese children are at increased risk of sensorineural hearing loss (SNHL). STUDY DESIGN: A complex, multistage, stratified geographic area design for collecting representative data from noninstitutionalized U.S. population. METHODS: Relevant cross-sectional data from the National Health and Nutrition Examination Survey, 2005 to 2006, for 1,488 participants 12 to 19 years of age was examined. Subjects were classified as obese if their BMI ≥ 95 th percentile. SNHL was defined as average pure-tone level greater than 15 dB for 0.5, 1, and 2 kHz (low frequency) and 3, 4, 6, and 8 kHz (high frequency). RESULTS: Compared to normal weight participants (BMI 5%-85%), obesity in adolescents was associated with elevated pure tone hearing thresholds and greater prevalence of unilateral low-frequency SNHL (15.2 vs. 8.3%, P = 0.01). In multivariate analyses, obesity was associated with a 1.85 fold increase in the odds of unilateral low-frequency SNHL (95% CI: 1.10-3.13) after controlling for multiple hearing-related covariates. CONCLUSIONS: We demonstrate for the first time that obesity in childhood is associated with higher hearing thresholds across all frequencies and an almost 2-fold increase in the odds of unilateral low-frequency hearing loss. These results add to the growing literature on obesity-related health disturbances and also add to the urgency in instituting public health measures to reduce it.

A case of primary breast angiosarcoma.

Angiosarcoma of the breast is a rare malignancy that may be easily misdiagnosed. Of the two forms, the more common form presents in patients (typically postmenopausal0 with a history of breast cancer, secondary to irradiation or chronic lymphedema. In contrast, the rarer form, primary angiosarcoma, arises sporadically in premenopausal women who present with palpable masses. Primary angiosarcoma accounts for 1 in 2,500 cases (0.04%) of breast cancer (1). The described patient presented with primary breast angiosarcoma. Ultrasound, mammography, and magnetic resonance imaging findings are presented.

Surgical management of facial nerve paralysis in the pediatric population.

BACKGROUND: In the pediatric patient population, both the pathology and the surgical managements of seventh cranial nerve palsy are complicated by the small size of the patients. Adding to the technical difficulty is the relative infrequency of the diagnosis, thus making it harder to become proficient in the management of the condition. The magnitude of the functional and aesthetic deficits these children manifest is significantly troubling to both the patient and the parents, which makes immediate attention, treatment, and functional restoration essential. METHODS: A literature search using PubMed (http://www.pubmed.org) was undertaken to identify the current state of surgical management of pediatric facial paralysis. RESULTS: Although a multitude of techniques have been used, the ideal reconstructive procedure that addresses all of the functional and cosmetic needs of these children has yet to be described. Certainly, future research and innovative thinking will yield progressively better techniques that may, one day, emulate the native facial musculature with remarkable precision. CONCLUSION: The necessity for surgical intervention in children with facial nerve paralysis differs depending on many factors including the acute/chronic nature of the defect as well as the extent of functional and cosmetic damage. In this article, we review the surgical procedures that have been used to treat pediatric facial nerve paralysis and provide therapeutic facial reanimation.

Danish health care providers' perception of breastfeeding difficulty experienced by women who are obese, have large breasts, or both.

Maternal obesity is associated with short duration of breastfeeding, and many obese women also have large breasts. To determine if health professionals who support lactating women can distinguish between these maternal characteristics as obstacles to breastfeeding, the authors conducted a mail survey of 242 Danish health professionals. They thought that initiating was more difficult (P < .0001) than continuing breastfeeding for women with large breasts and/or obesity. These difficulties were thought to be lowest for women with large breasts, higher for obese women, and highest for obese women with large breasts (P < .0001). These difficult ratings were significantly related in a complex manner to the respondents' personal characteristics and type of training. These findings indicate the importance of recognizing and treating large breasts and maternal obesity as separate obstacles to successful breastfeeding and that interventions to reduce these obstacles should be designed to account for characteristics of the person providing them.

Suspected nonalcoholic Fatty liver disease is not associated with vitamin d status in adolescents after adjustment for obesity.

This study investigated a potential independent association between hypovitaminosis D and suspected nonalcoholic fatty liver disease (NAFLD) in a nationally representative sample of the US adolescents. Data from 1630 subjects 12-19 years of age were examined using the National Health and Nutrition Examination Survey, 2001-2004. The vitamin D status of subjects was categorized into quartiles of serum 25-hydroxyvitamin D. Subjects with serum ALT > 30 U/L were classified as having suspected NAFLD. Data regarding age, sex, race, BMI, and poverty level were also analyzed in bivariate and multivariate analyses using SAS and SUDAAN software. Suspected NAFLD was identified in 12.1% of adolescents in the lowest quartile compared to 6.9% of adolescents in the second quartile, 8.0% in the third quartile, and 13.17% in the highest quartile of serum 25(OH)D concentrations (P = .05). In analyses utilizing vitamin D as a continuous variable, no independent association was found between Vitamin D levels and rates of elevated ALT levels. In multivariate analyses, higher risks for suspected NAFLD were observed in males and overweight adolescents; however, vitamin D status was not found to be independently associated with suspected NAFLD after adjusting for obesity.