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The goal of the present study is to understand whether youth with Noonan Syndrome Spectrum Disorder (NSSD) are at increased risk of neurocognitive difficulties when living in resource depleted communities. Youth (5-17 years; Mage = 9.48 years) with NSSD (n = 140) and unaffected youth (4-15 years; Mage = 9.63 years; n = 85) were included. We ascertained the Child Opportunity Index Health and Environment Index (COI H/E) national-level Z-scores and assessed academic achievement and executive function. Multiple regressions were run to analyze the effects of diagnosis (whether the child had NSSD), COI H/E Z-scores, and diagnosis × COI H/E Z-score interaction on academic achievement (i.e., word reading, math, spelling, and sentence comprehension) and executive skills (i.e., performance-based working memory and processing speed and parent-rated measure of daily executive skills). Diagnosis was a significant predictor in each model. COI H/E Z-score was a significant predictor of spelling and a marginally significant predictor of sentence comprehension scores. There was a significant diagnosis × COI H/E Z-score interaction for working memory, and marginally significant interactions for spelling and sentence comprehension scores. Higher H/E Z-scores were associated with better working memory in the NSSD group and better academic achievement in the unaffected group. While the effects of NSSD are large on all assessed domains, there is an additional burden of resource depletion on working memory abilities of youth with NSSD. Academic achievement in the NSSD group was lower than the unaffected group across resource-depleted/enriched environments, demonstrating the profound effects of NSSD on academic functioning.

Advance care planning (ACP) is a vital tool to align patients' goals and values with their medical care; however, ACP has low completion rates. Barriers to ACP include lack of continuity across care settings, consistent documentation, electronic health record (EHR) accessibility to ACP information, and need for clinician education. To address these barriers, system-wide healthcare initiatives are needed. Examine a health system-wide approach to improve ACP completion and continuity among adult patients within an academic medical center. Retrospective cohort study PARTICIPANTS: A total of 34,268 patients aged 65 years or older receiving healthcare at a single academic medical center. A multimodal initiative across care settings (ambulatory, transition of care, and emergency department/hospital) was implemented to include patient cohort identification, EHR enhancements, addition of ACP dedicated social workers to enhance continuity, and clinician education. ACP completion was the primary outcome and defined as (1) completion of a Medical Orders for Life-Sustaining Treatment (MOLST) or Advance Healthcare Directive document, (2) identification of a surrogate decision maker, or (3) documentation of conversations regarding ACP goals. Fifty-one percent of the cohort completed ACP during the study (Feb. 2021-Jan. 2024). ACP completion likelihood increased among patients with a positive surprise question screen (adj IRR 4.56, [CI 3.52, 5.90]) and those diagnosed with dementia (adj IRR 1.59 [CI 1.47, 1.72]), advance cancer (adj IRR 1.37 [CI 1.19, 1.58], and heart failure (adj IRR 1.11 [Cl 1.04, 1.19]. Compared to baseline, ACP completion increased during both operational implementation periods: first period adj IRR 1.24 (CI 1.16, 1.32) and second period adj IRR 3.54 (CI 3.38, 3.70). This multipronged approach to a system-wide ACP implemented across care settings at an academic medical center led to an increase in ACP completion and provides a framework for other academic medical centers.

The minority tax is an understudied phenomenon by which underrepresented in medicine (URiM) physicians are more often responsible for nonpromotable activities: mentorship, education, outreach, and committee service. This review aims to summarize definitions of minority tax, explore its possible impact in academic surgery, and present gaps in the literature. A systematic search across SCOPUS, MEDLINE, EMBASE, ERIC, and PsycINFO was conducted. Original research articles studying URiM individuals in academic medicine/surgery were eligible. A priori outcomes of interest were minority tax definition, promotable activities, detractors/facilitators, downstream impacts, and best practices for promotion related to the minority tax. Two reviewers independently screened records and abstracted data. Of 1263 articles identified, 13 met inclusion criteria, with moderate agreement for full-text review (κ = 0.59). Five studies explicitly defined the minority tax. Commonly impacted promotable activities were scholarly output and speaking invitations. Detractors amplifying the perceived effect of the minority tax included lack of mentorship, stigmatization, and disproportionate burden of diversity, equity, and inclusion service; facilitators mitigating the minority tax included supportive leadership, mentorship, and formal recognition of diversity, equity, and inclusion efforts. Downstream impacts were burnout, stigmatization, and hindered promotion. No studies explored depression/anxiety or substance abuse. Twelve studies proposed recommendations to mitigate minority tax in professional advancement, including faculty development, departmental reform, allyship/antiracism, and institutional resources. This review highlights the perceived impact of the minority tax, characterized by uncompensated service and disproportionate responsibilities for URiM faculty. Frameworks that equitably recognize faculty contributions and provide professional development resources are needed.

Compensation for interventional cardiologists varies substantially by patient population and practice setting, yet no prior study has compared lifetime, discounted earnings between pediatric and adult interventional cardiology. Understanding these differences is essential for workforce sustainability and equitable access to congenital heart interventions. We conducted an economic evaluation using benchmark compensation and productivity data from pediatric academic, adult academic, and adult private. Lifetime earnings were estimated using a net present value (NPV) framework over a 32-year career (age 35-67) at a 3% discount rate (2025 USD). Models incorporated academic promotion scenarios, private-practice fixed and ramp-up structures, and a 10,000-iteration Monte Carlo simulation varying salary percentile, career length, and promotion timing. Productivity was assessed using daily relative value unit (RVU) and NPV per career RVU. At the 50th percentile, lifetime NPVs were $8.03 million for pediatric academic, $10.45 million for adult academic, and $15.73 million for adult private practice-gaps of 30% and 96% relative to pediatrics. Median Monte Carlo NPVs were similar ($7.81 million, $10.29 million, and $15.01 million, respectively). Pediatric interventionalists generated fewer daily RVUs (20.6) than adult academic (41.0) and adult private (43.0) cardiologists, whereas compensation per RVU was comparable. These disparities reflect lower achievable procedural throughput and occur within an RVU framework that has repeatedly under-recognized the time and intensity of congenital work. Limited private-practice opportunities in pediatrics further widen earnings gaps. Pediatric interventional cardiologists experience pronounced lifetime earnings disadvantages compared with adult counterparts because of throughput constraints, RVU valuation shortcomings, and labor-market structure. Addressing these systemic inequities will be essential to sustaining the congenital interventional workforce and ensuring equitable access to advanced cardiovascular care for children.

Children who survive critical illness commonly experience long-term morbidities. Little is known about the association of critical illness with cognitive health due to lack of preillness and postillness assessments and an adequate comparison population. To use school-based testing to evaluate cognitive health outcomes among children treated in the pediatric intensive care unit (PICU) compared with non-PICU-exposed control students. This retrospective case-control study used statewide academic data and propensity score matching of 1088 patients admitted to the only PICU in Arkansas from January 1, 2008, to December 31, 2018, as well as controls matched on sociodemographic and pre-PICU admission academic factors. Statistical analysis was performed from March 2024 to September 2025. PICU admission. Primary outcomes were (1) return to standardized testing, assessed using multivariable logistic regression to assess the odds of having a standardized test within 2 years after PICU admission compared with controls, and (2) change in pre-PICU to post-PICU test scores for PICU patients compared with propensity-matched control students, assessed using multivariable linear regression. In this case-control study of 1088 school-aged patients (mean [SD] age, 12.1 [1.6] years; 566 girls [52.0%]), fewer PICU patients than controls had test scores after admission for math (80.6% [874 of 1085] vs 86.5% [938 of 1085]; adjusted odds ratio [AOR], 0.64 [95% CI, 0.51-0.81]) and reading (81.1% [877 of 1081] vs 87.1% [941 of 1081]; AOR, 0.64 [95% CI, 0.51-0.82]). PICU patients' preadmission z scores were below average in math (z = -0.23 [95% CI, -0.29 to -0.16]) and reading (z = -0.22 [95% CI, -0.29 to -0.15]) compared with Arkansas students in the same grade and year. In adjusted pre-post analyses, PICU patients had a small but significant decrease in reading relative to controls (-0.07 [95% CI, -0.14 to -0.01]). The change in math score was not statistically significant (-0.06 [95% CI, -0.13 to 0.003]). This study suggests that PICU patients were less likely to take standardized tests after discharge and that those who did had greater decreases in reading scores relative to matched controls. Future studies should identify risk factors for nonreturn to testing and score decrease.

Vascular anomalies (VAs) are rare disorders with abnormal development of blood and lymphatic vasculature and surrounding tissues. Understanding the genetic etiology of VAs guides treatment with targeted inhibitors. This study compares patterns and outcomes of genetic testing in VA populations at 2 centers. Of 421 patients (mean age, 10 years; 55.6% female), 61.7% underwent prior authorization (PA) for genetic testing, 84% had their testing approved, 93% completed the testing. About 70% of the completed tests had pathogenic or likely pathogenic results. A positive result was not associated with sample type (skin biopsy vs surgical pathology; fresh vs archived). Greater odds of initiating PA were associated with presence of skin findings and male sex, whereas lower odds were associated with higher Area Deprivation Index at 1 center. This study highlights that genetic testing effectively finds causative variants, but not all patients can complete it and advocates for increased access to genetic testing.

Community-Based Participatory Research (CBPR) is grounded in trusting, reciprocal, and authentic relationships. We aimed to identify key strategies and actionable next steps to establish and sustain high-quality community-academic partnerships that foster community-based health equity. Qualitative thematic analysis. We analyzed three recorded discussions from a roundtable session with community and academic partners from the Rapid Acceleration of Diagnostics-Underserved Populations (RADx-UP) program (2020-2025), which supported 142 community-engaged public health research projects aimed at reducing COVID-19-related health inequities. Key themes identified as most fundamental to support CBPR included establishing a long-term commitment, mutual co-learning among partners, flexible and sustained funding and resources, co-design of research and evaluation tools, and unwavering commitment to transparent communication and dissemination. Accurately assessing CBPR's impact requires using valid and reliable tools that assess whether community-academic partnerships are functioning well, identify opportunities to strengthen engagement, and measure both community- and system-level outcomes resulting from the partnerships. Advancing community-based health research through high-quality CBPR partnerships requires ongoing flexibility, mutual trust, shared learning, and collaborative design core elements to achieve sustainable and equitable public health outcomes. Through these initiatives we can pave the way for high-quality community-academic partnerships that address critical priorities in population health research and processes for advancing health equity.

Despite benefits of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), many eligible children remain unenrolled. This study evaluated responses to an electronic health record (EHR)-embedded federal nutrition program (FNP) participation screening and WIC referral tool implemented within eight clinics during <5-year-well visits. Structured EHR data from July 2020-October 2023 were extracted to summarize screening, referral acceptance, and WIC enrollment outcomes and patient demographics. Multivariable logistic regression examined patient-level predictors of WIC non-enrollment at first screening, referral acceptance, and enrollment among those accepting a referral, with stratified analyses by clinic type. Among 5,385 children, mean age at initial screening was 10.7 months (SD 14.2), 52% newborn-aged, 37% Hispanic, and 88% Medicaid-insured. Among screened patients (n=3,606), 34% were not enrolled in WIC at first screening (n=1,235). Medicaid coverage, academic clinic setting, and non-Hispanic Black or Hispanic race and ethnicity were associated with lower odds of WIC non-enrollment. Among those not enrolled with a documented response to referral (n=819), 59% accepted (n=488); acceptance was higher among non-Hispanic Black and Hispanic patients, newborn-aged patients, those with Medicaid coverage, and those seen in academic clinics. Among referral acceptors with follow-up (n=438), 61% were enrolled at last screening (n=265), with higher odds among newborn-aged patients and those in academic clinics. An EHR-based automated intervention can facilitate screening and referral to WIC. WIC participation at first screening, referral acceptance, and enrollment after referral varied by sociodemographic characteristics, suggesting opportunities to improve equitable access through health system-based approaches. Not applicable.

This report describes the process of collage creation designed for Michigan Youth Health (MYHealth) students to generate and prioritize research topics related to adolescent health and wellness challenges. MYHealth is a youth-partnered research training program grounded in youth participatory action research methods and designed to encourage high school students to explore STEM (Science, Technology, Engineering and Mathematics) and health research fields. Within the MYHealth program, students partner with academic health researchers to conduct their own research projects on an adolescent health topic. During the initial training, MYHealth students identify possible research topics that form the basis for research they conduct throughout the academic year. Integrating elements of arts-based, participatory, and narrative research methods, a collage creation process was used to stimulate, generate and prioritize research topics for future planned research with students. We detail the collage creation process and provide three illustrative examples of students' collages and how the collages helped students generate and prioritize research topics. We conclude with student reflections on the collage creation process and lessons learned regarding the successful use of this method to engage high school students in STEM and health research and to identify relevant research topics in a youth research education program.

Early career minoritized faculty face several academic challenges that negatively impact their success yet have demonstrated staying power and resilience in their institutional environments. Academic medicine has recognized pseudoleadership as a challenge for minoritized faculty. Using the framework provided by Coe et al., the authors define pseudoleadership across clinical, undergraduate medical education, research and graduate medical education leadership roles. They provide recommendations to decrease pseudoleadership to include prioritizing rank development for early career faculty over filling leadership positions, identifying and dismantling hidden curriculums, and employing a transdisciplinary approach to mentorship and sponsorship for leadership development.

Lumbar puncture (LP) remains a core emergency department (ED) procedure, though recent trends suggest a shift toward non-ED specialties. Within ED practice, trends in LP indications and procedural success are not well characterized. To evaluate longitudinal trends in LP procedural volume across departments within a tertiary care health system and to characterize trends in ED LP indications, success rates, and variables associated with success. We conducted a retrospective study at a single academic health system. LP volumes across clinical departments were assessed for calendar years (CYs) 2012-2024 using Poisson regression with incidence rate ratios (IRRs). ED-specific analyses included LPs performed from CYs 2014-2024, with temporal trends in indications evaluated using IRRs and multivariable logistic regression used to identify factors associated with LP success. Radiology performed the greatest number of LPs from 2012 to 2024, with a 4.4% annual increase (IRR 1.044, 95% CI 1.036-1.052). ED LP volume declined by 1.5% annually (IRR 0.985, 95% CI 0.972-0.999). A total of 1117 LPs were performed in the ED from 2014 to 2024 (mean 106 annually), with success decreasing from 93.1% to 76.3%. LPs for subarachnoid hemorrhage declined (IRR 0.78/year, p&#xa0;<&#xa0;0.001), while those for idiopathic intracranial hypertension (IIH) increased (IRR 1.29/year, p&#xa0;<&#xa0;0.001). Upright positioning was independently associated with higher odds of success compared with lateral decubitus (OR 2.2, 95% CI 1.2-4.0). LP volume shifted toward non-ED specialties, particularly Radiology, Internal Medicine, and Pediatrics. Within ED LP practice, indications shifted toward IIH and upright positioning was associated with greater LP procedural success.

Type 1 diabetes (T1D) complications may impair cognitive development, but evidence on cognitive skills in children and adolescents with T1D is inconsistent. This study aimed to document measures and outcomes used to assess cognitive skills in children with T1D and to examine the relationship between T1D and cognitive skills. A systematic literature search was conducted across five databases to identify studies that administered cognitive assessments to children and adolescents aged &#x2264;19 years with T1D. Study characteristics, cognitive skills assessments and outcomes and comparisons to non-T1D peers where available were synthesized on an evidence map. Random-effects meta-analysis was used to assess differences in Wechsler Full Scale Intelligence Quotient (IQ) test scores between T1D and non-T1D groups. From 2464 studies, 129 were included. Five main cognitive categories were identified, with comparisons to non-T1D peers-where available-yielding mixed results: academic performance (n=37; n=7/22 worse T1D), executive function (n=101; n=31/48 worse T1D), intelligence (n=73; n=22/37 worse T1D), language (n=30; n=7/20 worse T1D) and memory and learning (n=84; n=31/48 worse T1D). Large-scale studies (n&#x2265;1000) did not find significant differences between groups for academic performance (n=0/6 worse T1D) and language (n=0/3 worse T1D). In the meta-analysis of 16 studies (n=1594), children with T1D had slightly lower IQ scores than peers without T1D (mean difference -3.49, 95%&#x2009;CI (-6.16 to -0.82); p=0.010). T1D appears to be associated with slightly lower cognitive outcomes in some areas. Further research is needed to understand the impact of these findings on daily functioning and to inform screening for at-risk children.

There is a need to better understand the indications and safety profiles for therapeutic plasma exchange (TPE) in children. We aimed to assess pediatric TPE practice at a large academic center by retrospective chart review from 2011 to 2022. Patient demographics and clinical information including American Society for Apheresis (ASFA) category were analyzed. The cohort consisted of 438 patients, 52.1% female with a median age of 11.4&#x2009;years, who underwent 3385 TPE procedures. The adverse reaction rate was 6.8%, with hypotension being most common. Tandem circuits were used in 3.9% of procedures, and the adverse reaction rate was significantly higher, 16.1% (p&#x2009;=&#x2009;<&#x2009;0.05). Cryoprecipitate transfusion occurred in 29.0% of procedures for hypofibrinogenemia (median treatment number 3) and 19.1% of procedures required an RBC prime. Our findings highlight contemporary practical considerations for running a pediatric apheresis service, provide insight into managing tandem procedures, and may provide guidance for future research endeavors and clinical practice.

This AM Last Page provides a visual depiction of how to best implement successful hybrid learning practices in academic -medicine using the Community of Inquiry conceptual framework.

Chimeric antigen receptor (CAR) T cell therapy has transformed the treatment of hematological malignancies, offering durable responses in conditions such as diffuse large cell lymphoma, B-cell leukemias and multiple myeloma. However, access to this therapy is still limited in low- and middle-income nations, especially those in Latin America. This review discusses the challenges to use CAR-T cell therapy in Latin America and explores potential ways to expand access to this treatment. We discuss the high cost of the treatments, the complex manufacturing and logistical requirements, and the insufficient infrastructure for safe administration and managing side effects. Socioeconomic and geographical differences further limit access. Moreover, the under representation of Latin Americans in clinical trials, along with the region's genetic diversity, limits our understanding about the effectiveness and safety in such populations. New approaches include decentralized, point-of-care manufacturing models. These have shown over 90% cost reduction in pilot programs, along with collaborative projects and innovative technology. Examples of innovative technology are allogenic off-the-shelf CAR-T products and mRNA-based approaches. These methods aim to cut production times, lower cost and improve tolerability. We conclude that achieving equitable CAR-T cell access in Latin America requires a multifaceted strategy: harmonized regulatory frameworks, scalable academic manufacturing, investments in infrastructure and integration of population-specific immunogenomic profiling. Scientific innovation combined with policy reform and regional collaboration can transform CAR-T cell therapy from a high-cost intervention into a sustainable treatment option for a diverse patient population.

Current guidelines recommend consideration of germline genetic testing for patients with uterine serous carcinoma (USC) but real-world data are limited on completion rates of testing and pathogenic variant (PV) identification. This study aimed to evaluate the rate of genetic testing referral and completion in a cohort of patients with USC, determine the prevalence of clinically meaningful PVs found on testing and explore factors associated with genetics referral and testing completion. We retrospectively examined the medical records of all individuals diagnosed with USC between 2019 and 2024 seen at a single academic cancer centre. Outcomes of interest included referral for germline genetic testing, completion of testing and testing results. Of 131 individuals included, 5 (3.8%) had prior genetic testing and only 45 (34.4%) were recommended to undergo genetic testing or referred to cancer genetics. Younger individuals and those with a personal history of cancer other than USC or family history of breast or ovarian cancer were more likely to be referred. Nine (26.5%) of 34 individuals who completed germline testing had a PV identified in a cancer-related gene, including BRCA1, BRCA2, BRIP1, CHEK2, MSH6, PMS2 and ATM. Only a personal history of cancer other than USC was independently associated with the discovery of a PV on germline genetic testing. In those without a prior personal history of cancer, the PV prevalence was 5.6%. Given the high prevalence of PVs in this population, germline genetic testing for all patients diagnosed with USC can provide clinically meaningful benefit but is currently underused in practice.

Children with perinatally acquired HIV (CPHIV) are at increased risk of neurodevelopmental difficulties, including hearing-related impairments, despite early initiation of antiretroviral therapy (ART). Previous studies have reported a higher prevalence of hearing loss in CPHIV compared with uninfected children; however, the contribution of the central auditory system to these auditory differences remains unclear. Understanding central auditory processing in CPHIV is important, as even subtle auditory difficulties during childhood can negatively affect speech and language development, academic performance, and quality of life. Functional MRI was used to examine neural responses to auditory stimulation in 108 11-year-old children (60 CPHIV and 48 children without HIV). During scanning, participants listened to pure tones at low (500 Hz), middle (1,500 Hz), and high (4,000 Hz) frequencies. CPHIV demonstrated modestly elevated hearing thresholds (reflecting poorer hearing sensitivity) at several frequencies; however, the prevalence of clinically defined hearing loss did not differ between groups. Across all children, pure-tone stimulation elicited robust bilateral activation of the auditory cortices, with both the spatial extent and magnitude of activation decreasing as tone frequency increased. Relative to controls, CPHIV exhibited significantly reduced bilateral auditory cortex responses across frequencies. These group differences persisted after accounting for sex and handedness and after excluding children with hearing loss. Associations between hearing thresholds and auditory cortex activation were generally weak, except at 4,000 Hz in CPHIV, where poorer hearing was associated with stronger auditory cortex activation, consistent with a compensatory neural response. Despite largely normal peripheral hearing, CPHIV receiving ART exhibited reduced bilateral auditory cortex responses during pure-tone processing. These findings suggest that alterations within the central auditory system may contribute to auditory vulnerability in CPHIV.

Membership in the Alpha Omega Alpha (AOA) honor society has long-term professional benefits, including improved match outcomes, yet racial and socioeconomic disparities in membership are well-documented. AOA selection processes across schools lack standardization, complicating understanding of the meaning of membership. To analyze transparency and methodology of AOA selection processes nationally and describe chapters' acknowledgement of potential for bias. Researchers performed a mixed methods cross-sectional study of medical school websites describing AOA chapter eligibility and selection in the United States (US) from October 2023 to April 2024. Descriptive statistics were generated to characterize quantitative data, and thematic analysis was performed to identify patterns within extracted quotes. LCME-accredited, MD-granting medical schools in the US. Researchers iteratively refined a data extraction form focused on AOA chapter status, eligibility and selection criteria, and quotes acknowledging potential for bias. Both thematic and content analyses were used with extracted quotes, while descriptive statistics were calculated for quantitative data.&#xa0; KEY RESULTS: Of 157 medical schools nationally, 131 (83%) had an active AOA chapter. Of these, 98 (75%) referenced eligibility and/or selection procedures. Personal characteristics (55%), review of accomplishments (51%), and an academic cut-off (18%) were the most common selection criteria. Twenty-seven schools (17% of all schools, including four with recently closed chapters) acknowledged potential for bias, and eight themes were generated to characterize bias acknowledgement. Most medical school websites described AOA evaluation methods, which were variable across schools. Few schools acknowledged potential for bias. Given these findings, future studies should explore the current interpretation of AOA membership with emphasis on bias mitigation at the residency level and beyond. Not applicable.

Fluid overload is common after neonatal congenital cardiac surgery (CCS) and is frequently managed with continuous furosemide infusions requiring iterative dose titration. An interpretable prediction model could support more consistent early postoperative dosing decisions. We hypothesized that a novel, interpretable machine learning approach could accurately predict furosemide dosing decisions in neonates following CCS. We identified term neonates admitted to the Pediatric Cardiothoracic ICU at a large academic children's hospital between 8/1/2014 and 3/1/2023 following CCS with cardiopulmonary bypass. Demographic and clinical data from the first 48 postoperative hours were used to train, validate, and test a Tropical Geometry-Based Fuzzy Neural Network Regressor (TGFNN-R) tasked with predicting furosemide infusion dose changes after CCS. The TGFNN-R was primed with clinician heuristics and provides transparent explanations behind predictions. A held-out internal validation/testing cohort was drawn from the same single-center population. Data from 506 neonates were extracted; 398 received a continuous furosemide infusion. Mean age at surgery was 6.2 (&#xb1;&#x2009;5.1) days; 67.3% were White. The most common surgeries were Stage I (Norwood) (25.1%) and arterial switch operation (18.6%). There were 783 furosemide dose increases and 224 dose decreases. Test set performance was R&#xb2;=0.515, mean absolute error&#x2009;=&#x2009;0.119&#xa0;mg/kg/hr, and false positive rate&#x2009;=&#x2009;0.062. In this retrospective single-center cohort of neonates following CCS, an interpretable TGFNN-R model predicted and explained furosemide dose changes with good test performance. Next steps include external validation and nonclinical studies evaluating the model within clinical decision support and closed-loop paradigms to achieve prespecified fluid balance goals.