Jessica L. Bienstock

Racial Variation in Sex Steroid Hormones and the Insulin-Like Growth Factor Axis in Umbilical Cord Blood of Male Neonates

Background: To address whether umbilical cord blood concentrations of sex steroid hormones and the insulin-like growth factor (IGF) axis differ between African-American and White male neonates. Methods: In 2004 and 2005, venous cord blood samples were collected from 75 African-American and 38 White male full-term uncomplicated births along with birth weight, placental weight, mothers age and parity, and time of birth. Testosterone, androstanediol glucuronide, estradiol, and sex hormone binding globulin (SHBG) were measured by immunoassay, and IGF-I, IGF-2, and IGF binding protein (BP)-3 by ELISA. Crude and multivariable-adjusted geometric mean concentrations were computed. Results: Androstanediol glucuronide, estradiol, and SHBG concentrations did not differ by race; however, the molar ratio of testosterone to SHBG was higher in African-American than White male babies after adjustment (P = 0.01). Both before and after adjustment, Whites had higher concentrations of IGF-I (adjusted; White, African-American, 93.1, 71.9 ng/mL), IGF-2 (537.3-474.8 ng/mL), and IGFBP-3 (1,673-1,482 ng/mL) than African-Americans (P < 0.05), although the molar ratio of IGF-I plus IGF-2 to IGFBP-3 did not differ by race. Conclusion: The higher cord blood testosterone to SHBG ratio in African-American compared with White male babies after taking into account maternal and birth factors is compatible with the hypothesis that differences in androgen levels in utero contribute to their higher prostate cancer risk, although we would have expected crude differences as well. Lower cord blood IGF-I and IGF-2 levels in African-American compared with White male babies are not consistent with the hypothesis that differences in growth factor levels contribute to their higher prostate cancer risk. (Cancer Epidemiol Biomarkers Prev 2009;18(5):1484–91)

The recruitment phoenix: Strategies for attracting medical students into obstetrics and gynecology

In less than a decade, the popularity of obstetrics and gynecology as a career choice has declined significantly. The American College of Obstetricians and Gynecologists (ACOG) and the Association of Professors of Gynecology and Obstetrics (APGO) are working to develop a multifaceted approach aimed at reversing this trend. We report on the findings and action plan developed by the ACOG Medical Student Recruitment Task Force as well as the current activities of APGO related to recruitment. Strategies include improving the quality of the medical student clerkship, frankly addressing gender and lifestyle issues that dissuade students from choosing obstetrics and gynecology as a career, and engaging students early in their medical school careers through student interest groups and mentoring programs.

Successful in utero intervention for bilateral renal agenesis.

BACKGROUND: We report a case of bilateral renal agenesis treated with serial amnioinfusion in which the newborn survived the newborn period and was able to undergo peritoneal dialysis as a bridge to planned renal transplantation. CASE: A 34-year-old woman, gravida 1 para 0, presented at 23 1/7 weeks of gestation with a diagnosis of anhydramnios and bilateral renal agenesis. The patient underwent weekly serial amnioinfusion with the goal of improving fetal pulmonary development. At 28 weeks of gestation, the patient delivered a live newborn who required minimal respiratory support. The neonate is currently 9 months old and is undergoing daily peritoneal dialysis. CONCLUSION: Serial amnioinfusion appears to have mitigated the severe pulmonary compromise that has, in the past, led to the death of newborns with bilateral renal agenesis.

The Utility of Letters of Recommendation in Predicting Resident Success: Can the ACGME Competencies Help?

BACKGROUND The Accreditation Council for Graduate Medical Education (ACGME) core competencies are used to assess resident performance, and recently similar competencies have become an accepted framework for evaluating medical student achievements as well. However, the utility of incorporating the competencies into the resident application has not yet been assessed. PURPOSE The objective of this study was to examine letters of recommendation (LORs) to identify ACGME competency-based themes that might help distinguish the least successful from the most successful residents. METHODS Residents entering a university-based residency program from 1994 to 2004 were retrospectively evaluated by faculty and ranked in 4 groups according to perceived level of success. Applications from residents in the highest and lowest groups were abstracted. LORs were qualitatively reviewed and analyzed for 9 themes (6 ACGME core competencies and 3 additional performance measures). The mean number of times each theme was mentioned was calculated for each student. Groups were compared using the χ(2) test and the Student t test. RESULTS Seventy-five residents were eligible for analysis, and 29 residents were ranked in the highest and lowest groups. Baseline demographics and number of LORs did not differ between the two groups. Successful residents had statistically significantly more comments about excellence in the competency areas of patient care, medical knowledge, and interpersonal and communication skills. CONCLUSION LORs can provide useful clues to differentiate between students who are likely to become the least versus the most successful residency program graduates. Greater usage of the ACGME core competencies within LORs may be beneficial.

Small fetal abdominal circumference in the second trimester and subsequent low maternal plasma glucose after a glucose challenge test is associated with the delivery of a small-for-gestational age neonate.

To evaluate the predictive value of a combination of the 1 h 50‐g glucose challenge test (GCT) and second‐trimester ultrasound measurement of fetal abdominal circumference (AC) in identifying patients who will go on to deliver small‐for‐gestational age (SGA) neonates. The individual predictive power of these tests has been indicated by previous studies, but this study examines the combined use of these indicators in predicting SGA.

Empowering Women's Prenatal Communication: Does Literacy Matter?

This study was designed to evaluate the impact of an interactive computer program developed to empower prenatal communication among women with restricted literacy skills. A total of 83 women seeing 17 clinicians were randomized to a computer-based communication activation intervention (Healthy Babies Healthy Moms [HBHM]) or prenatal education (Baby Basics [BB]) prior to their prenatal visit. Visit communication was coded with the Roter Interaction Analysis System, and postvisit satisfaction was reported. Participants were on average 24 years of age and 25 weeks pregnant; 80% were African American. Two thirds scored ≤8th grade on a literacy screener. Women with literacy deficits were more verbally active, disclosed more medical and psychosocial/lifestyle information, and were rated as more dominant by coders in the HBHM group relative to their counterparts in the BB group (all ps < .05). Clinicians were less verbally dominant and more patient centered with literate HBHM relative to BB group women (p < .05); there was a similar, nonsignificant trend (p < .1) for lower literate women. Clinicians communicated less medical information and made fewer reassurance statements to lower literate women in the HBHM relative to the BB group (p < .05). There was a trend toward lower visit satisfaction for women with restricted literacy in the HBHM relative to the BB group (p < .1); no difference in satisfaction was evident for more literate women. The HBHM intervention empowered communication of all women and facilitated verbal engagement and relevant disclosure of medical and psychosocial information of women with literacy deficits. Satisfaction, however, tended to be lower for these women.

Managed care does not lower costs but may result in poorer outcomes for patients with gestational diabetes

OBJECTIVE Our purpose was to compare the costs of prenatal care and subsequent maternal and neonatal outcomes in patients with gestational diabetes cared for in an inner-city university hospital house staff clinic versus an inner-city managed care organization. STUDY DESIGN A retrospective cohort study was conducted. The groups consisted of 115 patients with gestational diabetes who were cared for in a house staff clinic and a demographically similar group of 85 patients cared for in a neighborhood managed care organization. The groups were examined regarding baseline demographics, intensity of prenatal care, maternal and neonatal outcomes, and total cost of the provision of care. RESULTS There was no difference between groups in the total cost of maternal-infant care. A larger percentage of patients in the house staff group saw the physician frequently. In contrast, patients cared for in the managed care organization underwent more tests of fetal well-being. There was a greater rate of neonatal macrosomia in the managed care organization group compared with the house staff group. CONCLUSIONS Managed care does not decrease the cost of caring for patients with gestational diabetes but does lead to a greater rate of neonatal macrosomia, which may reflect poorer glucose control.

Beyond the first trimester screen: can we predict who will choose invasive testing?

Purpose: The purpose of this study is to determine what factors, in addition to a positive first trimester aneuploidy screen, correlate with a pregnant patients decision to undergo invasive prenatal testing.Methods: We conducted a retrospective cohort study of singleton pregnancies referred to the Johns Hopkins Prenatal Diagnosis and Treatment Center between 2001 and 2009 with an indication of positive first trimester screen. We compared demographic factors and numerical first trimester screen results with invasive testing uptake. Risk difference calculations and linear modeling were used for analysis.Results: A total of 171 eligible patients were identified. Maternal age, race, residual risk, marital status, and year of first trimester screen correlated significantly with invasive testing uptake. Family history was predictive of invasive testing uptake for patients younger than 35 years only. Type of elevated risk (trisomy 21 vs. 18 and 13), assisted reproductive technology status, parity, and increase from age-related risk were not predictive. A general linear model for relative risk with Gaussian error showed significant interaction between the variables of age and family history, so the two traits were analyzed separately (P = 0.009).Conclusions: Among patients with positive first trimester screen results, several demographic traits are predictive of invasive testing uptake. This information can help providers to identify patients at increased risk of declining invasive testing and can help providers anticipate educational needs. Further investigation should be conducted to elucidate the causes of these differences, which may relate to misinformation about the testing options and differences in values systems.

Racial Variation in Umbilical Cord Blood Leptin Concentration in Male Babies

Background: We hypothesize that racial differences in utero contribute to the racial disparity in prostate cancer risk. Leptin is a candidate for evaluating this hypothesis because it influences fetal development and newborn growth. Methods: We measured leptin concentration by ELISA in venous cord blood collected from 70 African-American and 37 white male full-term babies. We measured sex steroid hormones and insulin-like growth factor (IGF) axis concentrations previously. Separately by race, we calculated the geometric mean leptin concentration and estimated the geometric mean adjusted for birth and placental weights, mothers age and parity, time of day and season of birth, and sex steroid hormone and IGF axis concentrations by linear regression. Results: Leptin was positively correlated with birth (r = 0.34) and placental (r = 0.25) weights, IGF-1 (r = 0.21), and IGF binding protein-3 (r = 0.29) adjusting for race. Unadjusted geometric mean leptin did not differ (P = 0.92) between African Americans (5,280 pg/mL; 95% CI: 4,322–6,451) and whites (5,187 pg/mL; 95% CI: 3,938–6,832). Adjusted geometric mean leptin was nonstatistically significantly higher (P = 0.15) in African Americans (5,954 pg/mL; 95% CI: 4,725–7,502) than in whites (4,133 pg/mL; 95% CI: 2,890–5,910). Conclusion: We observed a nonsignificantly higher adjusted cord blood leptin concentration in African-American male babies than in white male babies, although unadjusted levels were similar. Impact: These findings do not support the hypothesis that leptin level in utero contributes to the racial disparity in prostate cancer risk in adulthood. Cancer Epidemiol Biomarkers Prev; 20(4); 665–71. ©2011 AACR.

Argon beam coagulation facilitates management of placenta percreta with bladder invasion

BACKGROUND Placenta percreta with bladder invasion is a rare but potentially lethal complication of pregnancy. CASE A multigravida, with a history of two prior cesarean deliveries, presented with complaints of heavy vaginal bleeding near term. She had been previously diagnosed with an anterior placenta previa. A placenta percreta with bladder invasion was confirmed on cystoscopy. The patient underwent a successful cesarean hysterectomy using the argon beam coagulator. CONCLUSION Argon beam coagulation may successfully help manage placenta percreta with bladder invasion while minimizing blood loss.