Dissecting the Workforce and Workplace for Clinical Endocrinology, and the Work of Endocrinologists Early in Their Careers

[Excerpt] No national mechanism is in place for an informed, penetrating, and systematic assessment of the physician workforce such as that achieved by the National Science Foundation (NSF) for the periodic evaluation of the nation’s scientists and engineers. Likewise, knowledge of the workforce for clinical research is enigmatic and fragmentary despite the serial recommendations of “blue-ribbon” panels to establish a protocol for the recurrent assessment of clinical investigators early in their careers. Failure to adopt a national system for producing timely, high-quality data on the professional activities of physicians limits the application of improvement tools for advancing clinical investigation and ultimately improving clinical practice. The present study was designed as a pilot project to test the feasibility of using Web-based surveys to estimate the administrative, clinical, didactic, and research work of subspecialty physicians employed in academic, clinical, federal, and pharmaceutical workplaces. Physician members of The Endocrine Society (TES) were used as surrogate prototypes of a subspecialty workforce because of their manageable number and investigative tradition. The results establish that Web-based surveys provide a tool to assess the activities of a decentralized workforce employed in disparate workplaces and underscore the value of focusing on physician work within the context of particular workplaces within a subspecialty. Our report also provides a new and timely snapshot of the amount and types of research performed by clinically trained endocrinologists and offers an evidenced-based framework for improving the investigative workforce in this medical subspecialty

Oral contraceptive progestins and angiotensin-dependent control of the renal circulation in humans

Oral contraceptive (OC) use is associated with increased intra-renal renin-angiotensin-aldosterone system (RAA System) activity and risk of nephropathy, though the contribution of progestins contained in the OC in the regulation of angiotensin-dependent control of the renal circulation has not been elucidated. Eighteen OC users (8 non-diabetic, 10 Type 1 diabetic) were studied in high salt balance, a state of maximal RAA System suppression. Progestational and androgenic activity of the progestin in each OC was standardized to that of the reference progestin norethindrone. Renal plasma flow (RPF) was measured by paraaminohippurate clearance at baseline and in response to angiotensin converting enzyme (ACE)-inhibition. There was a positive correlation between OC progestational activity and the RPF response to ACE-inhibition (r=0.52, p=0.03). Similar results were noted with OC androgenic activity (r=0.54, p=0.02). On subgroup analysis, only non-diabetic subjects showed an association between progestational activity and angiotensin-dependent control of the renal circulation (r=0.71, p=0.05 non-diabetic; r=0.14, p=0.7 diabetic; p=0.07 between groups). Similar results were noted with respect to androgenic activity (r=0.88, p=0.005 non-diabetic; r=−0.33, p=0.3 diabetic; p=0.002 between groups). Our results suggest that the OC progestin component is a significant influence on the degree of angiotensin-dependent control of the renal circulation, though these findings may not apply to women with diabetes

Hypertension in Women of Reproductive Age in the United States: NHANES 1999-2008

Objective: To examine the epidemiology of hypertension in women of reproductive age. Methods: Using NHANES from 1999–2008, we identified 5,521 women age 20–44 years old. Hypertension status was determined using blood pressure measurements and/or self-reported medication use. Results: The estimated prevalence of hypertension in women of reproductive age was 7.7% (95% confidence interval (CI): 6.9%–8.5%). The prevalence of anti-hypertensive pharmacologic therapy was 4.2% (95% CI 3.5%–4.9%). The prevalence of hypertension was relatively stable across the study period; the age and race adjusted odds of hypertension in 2007–2008 did not differ significantly from 1999–2000 (odds ratio 1.2, CI 0.8 to 1.7, p = 0.45). Significant independent risk factors associated with hypertension included older age, non-Hispanic black race (compared to non-Hispanic whites), diabetes mellitus, chronic kidney disease, and higher body mass index. The most commonly used antihypertensive medications included diuretics, angiotensin-converting enzyme inhibitors (ACE), and beta blockers. Conclusion: Hypertension occurs in about 8% of women of reproductive age. There are remarkable differences in the prevalence of hypertension between racial/ethnic groups. Obesity is a risk factor of particular importance in this population because it affects over 30% of young women in the U.S., is associated with more than 4 fold increased risk of hypertension, and is potentially modifiable

Pregnancy complications as markers for subsequent maternal cardiovascular disease: Validation of a maternal recall questionnaire

Background: We designed and tested the validity of a questionnaire to characterize maternal recall of pregnancy complications associated with increased future cardiovascular disease risk, based on the 2011 American Heart Association (AHA) guidelines. Methods: A maternal recall questionnaire of pregnancy history was administered to 971 patients who had participated in a previous cohort study of 1,608 pregnant women. Medical records from the study pregnancy served as the gold standard. Prevalence, sensitivity (sens), specificity (spec), positive predictive value (PPV), negative predictive value (NPV), and/or Spearman's correlation coefficients (r) were calculated for each question. Results: A total of 526 (54%) individuals recontacted responded. Respondents were more likely to be older, white, educated, and nulliparous and were less likely to deliver low-birthweight infants in the study pregnancy than were individuals who did not respond. Mean length of recall was 4.35 years (standard deviation [SD] 0.46) postpartum. Maternal recall was most accurate for gestational diabetes (sens: 92%, spec: 98%, PPV: 79%, NPV: 99%), infant birthweight (r=0.95), and gestation length (r=0.85). Maternal recall was modest for preeclampsia (sens: 79%, spec: 97%, PPV: 68%, NPV: 98%) and pregnancy-associated hypertension, including preeclampsia or gestational hypertension (sens: 60%, spec: 95%, PPV: 64%, NPV: 94%). Conclusions: This validation study demonstrated that the majority of women could accurately recall a history of gestational diabetes, infant birthweight, and gestational age at delivery, 4 years postpartum on average. Recall of preeclampsia and pregnancy-associated hypertension overall was modest. Maternal report of these pregnancy conditions may help clinicians identify women at increased risk for cardiovascular disease

The association between phthalates and metabolic syndrome: the National Health and Nutrition Examination Survey 2001–2010

Background: Higher exposure to certain phthalates is associated with a diabetes and insulin resistance, with sex differences seen. Yet, little is known about the association between phthalates and metabolic syndrome (MetS), particularly with consideration for differences by sex and menopausal status. Methods: We analyzed data from 2719 participants in the National Health and Nutrition Examination Survey (NHANES) 2001–2010 aged 20–80 years. Five urinary phthalate metabolites (MEP, MnBP, MiBP, MBzP, and MCPP) and DEHP metabolites were analyzed by the Centers for Disease Control and Prevention and were evaluated as population-specific quartiles. MetS was defined by National Cholesterol Education Program’s Adult Treatment Panel III report criteria. Prevalence odds ratios (POR) and 95 % confidence intervals (CI) were calculated using multivariable logistic regression, adjusting for potential confounders and stratifying by sex and menopausal status. Results: Participants with MetS (32 % of the study population) had higher concentrations for all urinary phthalate metabolites. After full adjustment, higher DEHP metabolite concentrations were associated with an increased odds of MetS in men, but not women (adj. POR for men Q4 versus Q1: 2.20; 95 % CI: 1.32, 3.68 and adj. POR for women Q4 versus Q1: 1.50; 95 % CI: 0.89, 2.52). When evaluating by menopausal status, pre-menopausal women with higher concentrations of MBzP had close to a 4-fold increased odds of MetS compared to pre-menopausal women with the lowest concentrations of MBzP (adj POR: Q4 versus Q1: 3.88; 95 % CI: 1.59, 9.49). Conclusions: Higher concentrations of certain phthalate metabolites were associated with an increased odds of MetS. Higher DEHP metabolite concentrations were associated with an increased odds of MetS for men. In women, the strongest association was between higher concentrations of MBzP and MetS, but only among pre-menopausal women. Electronic supplementary material The online version of this article (doi:10.1186/s12940-016-0136-x) contains supplementary material, which is available to authorized users

Patient journey during and after a pre-eclampsia-complicated pregnancy:a cross-sectional patient registry study

OBJECTIVES: To gain insight into the patient journey through a pre-eclampsia-complicated pregnancy. DESIGN: Cross-sectional patient registry study. SETTING: Online patient registry initiated by the Preeclampsia Foundation. PARTICIPANTS: Women with a history of pre-eclampsia enrolled in The Preeclampsia Registry (TPR). PRIMARY AND SECONDARY OUTCOME MEASURES: Retrospective patient-reported experience measures concerning awareness of pre-eclampsia, timing and type of information on pre-eclampsia received, involvement in decision making regarding medical care, mental/emotional impact of the pre-eclampsia-complicated pregnancy and impact on future pregnancy planning. RESULTS: Of 3618 TPR-participants invited to complete the Patient Journey questionnaire, data from 833 (23%) responders were available for analysis. Most responders were white (n=795, 95.4%) and lived in the USA (n=728, 87.4%). Before their pre-eclampsia diagnosis, 599 (73.9%) responders were aware of the term ‘pre-eclampsia’, but only 348 (43.7%) were aware of its associated symptoms. Women with a lower level of education were less likely to have heard of pre-eclampsia (OR 0.36, 95% CI 0.21 to 0.62). Around the time of diagnosis, 29.2% of responders did not feel involved in the decision making, which was associated with reporting a serious mental/emotional impact of the pre-eclampsia experience (OR 2.46, 95% CI 1.58 to 3.84). Over time, there was an increase in the proportion of women who were aware of the symptoms of pre-eclampsia (32.2% before 2011 to 52.5% after 2016; p<0.001) and in the proportion of responders stating they received counselling about the later-life health risks associated with pre-eclampsia (14.2% before 2011 to 25.6% after 2016; p=0.005). CONCLUSIONS: This study demonstrates that improved patient education regarding pre-eclampsia is needed, that shared decision making is of great importance to patients to enhance their healthcare experience, and that healthcare providers should make efforts to routinely incorporate counselling about the later-life health risks associated with pre-eclampsia. TRIAL REGISTRATION NUMBER: NCT02020174

Feasibility of a postpartum web- and phone-based lifestyle program for women with a history of preeclampsia or gestational diabetes : A pilot intervention study

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Respecting Tribal Voices in the Development of a Gestational Diabetes risk reduction preconception counseling program for American Indian/Alaska Native adolescent females: a qualitative study

Background American Indians and Alaska Natives (AI/AN) are disproportionately affected by adolescent obesity, adolescent pregnancy and gestational diabetes mellitus (GDM). GDM is associated with increased risk for perinatal death, obesity, and subsequent type 2 diabetes (T2D) for the offspring. Moreover, mothers with GDM are also at increased risk for T2D post-partum. Yet few lifestyle interventions exist to reduce GDM risk prior to pregnancy. We describe the process of adapting an existing validated preconception counseling intervention for AI/AN adolescent girls at-risk for GDM and their mothers. Perspectives and recommendations were gathered from a diverse array of stakeholders to assure the new program called Stopping GDM was culturally responsive and developed with tribal voices and perspectives represented. Methods We conducted focus groups and individual interviews with multiple AI/AN stakeholders (n = 55). Focus groups and interviews were digitally recorded, transcribed verbatim, and analyzed using a thematic content approach to construct cross-cutting themes across the focus groups and interviews. Results Four key themes emerged reflecting issues important to planning a reproductive health intervention: 1) Limited awareness, knowledge, and health education resources about GDM; 2) The importance of acknowledging traditional AI/AN values and the diversity of traditions and culture among AI/AN tribes; 3) The need to cultivate healthy decision-making skills and empower girls to make safe and healthy choices; and 4) Lack of communication about reproductive health between AI/AN mothers and daughters and between AI/AN women and health care professionals. Conclusion Findings have been used to inform the cultural tailoring and adaptation of an existing preconception counseling program, originally designed for non-AI/AN adolescent girls with diabetes, for AI/AN adolescents at-risk for GDM in future pregnancies

Barriers to Follow-up for Women with a History of Gestational Diabetes

Women with gestational diabetes (GDM) are at increased risk for type 2 diabetes (T2DM), but many do not receive recommended follow-up. We sought to identify barriers to follow-up screening