Learning How to Learn: An Innovative Medical School Orientation Activity.

PROBLEM: In 2018, Creighton University School of Medicine initiated a multiyear strategy to redesign the pedagogic approach of its educational program, transitioning from large-group, lecture-based experiences to small-group, active learning experiences using case-based learning (CBL) as required prework for team-based learning (TBL). In July 2019, the authors introduced their first-year medical students to the pedagogic and empiric underpinnings of the new curriculum they would experience. Initially, and ironically, this introduction was presented as a 30-minute didactic lecture, and students' ability to assimilate this information in any meaningful way was challenged. In addition, students required several sessions of the CBL-TBL activities during the official curriculum before they were able to effectively function as a team of learners. The authors created a novel introduction to their educational program that was active, meaningful, and efficient. APPROACH: In 2022, the authors created a 2-hour, small-group CBL activity using a fictional narrative of a medical student encountering their curriculum. During development, the authors recognized that the narrative was conducive to introduction of affective responses to medical education stressors, such as imposter phenomenon and Stanford duck syndrome. The CBL activity was given 4 hours during the formal 2022 orientation; 230 students participated. The CBL activity occurred on the second day of orientation and the TBL activity on the third (final) day of orientation. OUTCOMES: The results of the TBL activity indicate that students acquired a fundamental understanding of the attributes of active learning, features of imposter syndrome, substance abuse associated with Stanford duck syndrome, and peer evaluation. NEXT STEPS: This CBL-TBL activity will become a permanent part of orientation. The authors hope to evaluate the qualitative outcomes of this innovation on students' professional identity formation, institutional affiliation, and motivation. The authors will assess for any negative impact of this experience and the overall orientation.

Evidence of Spermatogenesis in the Presence of Hypothalamic Suppression and Low Testosterone in an Adolescent Transgender Female: A Case Report.

Objective: To report a novel case of semen cryopreservation after testicular sperm extraction in an adolescent transgender female without cessation of gonadotropin-releasing hormone (GnRH) agonist therapy and feminizing hormone therapy. Methods: This is a case report of a 16-year-old transgender female using leuprolide acetate for 4 years and estradiol for 3 years requesting semen cryopreservation at the time of gender-affirming orchiectomy. She desired to proceed without cessation of gender affirming hormone therapy. The patient's consent was obtained for written publication. Results: The patient underwent testicular sperm extraction followed by orchiectomy. The sample was processed and cryopreserved in a 1:1 Test Yolk Buffer. Multiple early and late spermatids were identified as well as spermatagonium in the TESE specimen. Conclusions: Advanced spermatogenesis may occur in the presence of a GnRH agonist. Cessation of GnRH agonist therapy may not be essential for semen cryopreservation in adolescent transgender females.

Sexual function remains persistently low in women after treatment for colorectal cancer and anal squamous cell carcinoma.

BACKGROUND: Women diagnosed with colorectal cancer (CRC) or anal squamous cell carcinoma (ASCC) are at high risk of sexual dysfunction after treatment, yet little is known about recovery and risk factors for chronic dysfunction. AIM: We aimed to describe sexual function and sexual activity among women who underwent definitive treatment for CRC or ASCC, examine relationships between time since treatment completion and sexual function, and explore factors associated with desire and changes in sexual desire over time. METHODS: As part of a prospective cohort study of patients with gastrointestinal cancer at the University of California San Francisco, female-identifying participants who finished definitive treatment for CRC or ASCC completed the Female Sexual Function Index (FSFI) at 6- to 12-month intervals. We used multivariable linear mixed models to explore factors associated with the FSFI desire subscale. OUTCOMES: Outcomes were rates of sexual activity, proportion at risk for sexual dysfunction (FSFI score <26.55), total FSFI score, and FSFI desire subscale. RESULTS: Among the 97 cancer survivors who completed at least 1 FSFI, the median age was 59 years, the median time since treatment end was 14 months, and 87% were menopausal. Fifty-five women (57%) had a history of colon cancer; 21 (22%), rectal cancer; and 21 (22%), ASCC. An additional 13 (13%) had a current ostomy. Approximately half the women were sexually active (n = 48, 49%). Among these 48 sexually active women, 34 (71%) had FSFI scores indicating risk for sexual dysfunction. Among the 10 sexually active women who completed a FSFI ≥2 years since end of treatment, the median total score was 22.6 (IQR, 15.6-27.3). None of the evaluated characteristics were associated with desire (age, tumor site, treatment, menopause status, or ostomy status). CLINICAL IMPLICATIONS: Consistent with prior studies, we found low desire scores after treatment for CRC or ASCC, with little recovery over time, suggesting that patients should not expect an eventual rebound of sexual function. STRENGTHS AND LIMITATIONS: Strengths of our study include longitudinal data and use of the validated FSFI. Women with ASCC composed 22% of our cohort, allowing for insight into this rare disease group. Limitations of this study include the small sample size, particularly for longitudinal analyses, and the enrollment of patients at variable times since treatment end. CONCLUSION: We observed a high prevalence of sexual health concerns, including low desire, after the treatment of CRC and ASCC that persisted for years after treatment was completed.

The Problematic Persistence of Tiered Grading in Medical School.

Issue: The evaluation of medical students is a critical, complex, and controversial process. It is tightly woven into the medical school curriculum, beginning at the inception of the medical student's professional journey. In this respect, medical student evaluation is among the first in a series of ongoing, lifelong assessments that influence the interpersonal, ethical, and socioeconomic dimensions necessary for an effective physician workforce. Yet, tiered grading has a questionable historic pedagogic basis in American medical education, and evidence suggests that tiered grading itself is a source of student burnout, anxiety, depression, increased competitiveness, reduced group cohesion, and racial biases. Evidence: In its most basic form, medical student evaluation is an assessment of the initial cognitive and technical competencies ultimately needed for the safe and effective practice of contemporary medicine. At many American medical schools, such evaluation relies largely on norm-based comparisons, such as tiered grading. Yet, tiered grading can cause student distress, is considered unfair by most students, is associated with biases against under-represented minorities, and demonstrates inconsistent correlation with residency performance. While arguments that tiered grading motivates student performance have enjoyed historic precedence in academia, such arguments are not supported by robust data or theories of motivation. Implications: Given the evolving recognition of the deleterious effects on medical student mental health, cohesiveness, and diversity, the use of tiered grading in medical schools to measure or stimulate academic performance, or by residency program directors to distinguish residency applicants, remains questionable. Examination of tiered grading in its historical, psychometric, psychosocial, and moral dimensions and the various arguments used to maintain it reveals a need for investigation of, if not transition to, alternative and non-tiered assessments of our medical students.

Public attitudes in the United States toward insurance coverage for in vitro fertilization and the provision of infertility services to lower income patients.

Objective: To assess attitudes and factors that influence public opinion in the general US population toward insurance coverage and provision of infertility care to lower income patients. Design: Cross-sectional survey. Setting: Online. Patients: A nationally representative sample of US residents. Interventions: Questionnaire with multiple choice and open response questions. Main Outcome Measures: Public attitudes toward in vitro fertilization and infertility care coverage for lower income patients. Results: A total of 1,027 (90.2%) participants completed the survey, among whom 620 (60.4%) had private insurance, 275 (26.8%) had Medicare/Medicaid, and 56 (5.5%) were uninsured. The majority (916, 89.2%) did not consider infertility a disease. Over half of the respondents (568, 55.3%) supported private insurance coverage of infertility services, including for in vitro fertilization. Most respondents, 735 (71.6%) believed that the prevalence and psychosocial impact of infertility were equal among the lower and higher income people. The majority of respondents with an opinion (512, 67.6%) believed that doctors should provide infertility treatments regardless of the income level of the patients. Of supporters, 40.1% believed in the right to have a family regardless of income, and 38.2% believed that doctors had a social responsibility to provide infertility services. After adjusting for covariates, age <45 years, noncollege graduates, desiring more children, believing that infertility was a disease, and residence in the Northeast region remained significant predictors for support of private insurance coverage. Conclusions: Public perception of infertility as a disease is one of the strongest predictors of support for insurance coverage for infertility services, underscoring the need for enhanced advocacy and education in the general public.

Poor reproducibility of percentage of normally shaped sperm using the World Health Organization Fifth Edition strict grading criteria.

Objective: To determine the reproducibility of the World Health Organization Fifth Edition (WHO5) strict grading methodology by comparing the percentage of morphologically normal sperm (PNS) recorded by the core laboratory with results obtained at the fertility centers participating in a multisite clinical trial. Design: Secondary cohort analysis of data from the Males, Antioxidants, and Infertility trial. Setting: Fertility centers. Patients: Semen values of 171 men participating in a multicenter, double-blind, randomized, placebo-controlled trial evaluating the effect of antioxidants on male fertility. Interventions: Not applicable. Main Outcome Measures: Strict morphology expressed as PNS as determined at each fertility center and the core central laboratory for the same semen sample. Results: No correlation was found in the PNS values for the same semen sample between the core laboratory and fertility center laboratories either as a group or by individual site. Interobserver agreement was similarly low (κ = 0.05 and 0.15) between the core and fertility laboratories as a group for strict morphology, categorized by the WHO5 lower reference limits of 4% and 0, respectively. Moderate agreement was found between the core and 2 individual fertility laboratories for the cutoff value of 0 (κ = 0.42 and 0.57). The remainder of the comparisons demonstrated poor to fair agreement. Conclusions: Strict morphology grading using the WHO5 methodology demonstrated overall poor reproducibility among a cohort of experienced fertility laboratories. This lack of correlation and agreement in the PNS values calls into question the reproducibility, and thereby the potential applicability, of sperm strict morphology testing.

Hematospermia is rarely associated with urologic malignancy: Analysis of United States claims data.

BACKGROUND: Hematospermia is an alarming symptom and can cause significant patient distress, but work-up is often negative. OBJECTIVE: To characterize the clinical evaluation of hematospermia and its association with the diagnosis of urologic malignancy. MATERIALS AND METHODS: Using MarketScan insurance claims database, we identified adult males 18-64 years old diagnosed with hematospermia from 2010 to 2018. Benign hematospermia was defined as the absence of hematuria and elevated prostate-specific antigen. Patients with urologic cancer prior to diagnosis of hematospermia were excluded. We identified those who were diagnosed with a urologic malignancy. RESULTS: The annual average incidence rate of hematospermia was 56.6 per 100,000 (95% confidence interval 55.4-57.8 per 100,000) in 2010 and increased to 73.6 per 100,000 (95% confidence interval 71.7-75.4 per 100,000) in 2018. A total of 56,157 patients presented with benign hematospermia. Most (57.5%) underwent at least one test, with the most common being urinalysis (51.7%), followed by prostate-specific antigen testing (11.9%). All other tests were performed in less than 3% of patients. Forty-seven patients were diagnosed with a urologic cancer, including 28 with prostate cancer (0.05%), nine with testicular cancer (0.016%), six with prostate carcinoma in situ (0.01%), and four with bladder cancer (0.007%). Stratified by age, there was only one cancer diagnosis (testicular) in 15,106 patients under 40 years (0.01%) and 46 cancer diagnoses in 40,611 patients 40 years old or above (0.11%). The median age of patients diagnosed with cancer was 56 years (interquartile range 52-61). DISCUSSION AND CONCLUSION: A small minority of patients with benign hematospermia were later diagnosed with urologic cancer in a large nationally representative sample. After excluding hematuria with urinalysis, physicians should conservatively manage and reassure patients with hematospermia, especially those under 40 years of age.

Two new pendulous epiphytic Columnea L. (Gesneriaceae) species from the Chocó forests of the Northern Andes.

Exploratory field expeditions to the Chocó forests in the northwestern slopes of the Ecuadorian and Colombian Andes resulted in the discovery of two new species of Columnea (Gesneriaceae). Columneafluidifolia J.L.Clark & F.Tobar, sp. nov., is described as a narrow endemic from Bosque Protector Mashpi and surrounding areas in the province of Pichincha in northern Ecuador. Columneapendens F.Tobar, J.L.Clark & J.F.Sm., sp. nov., is described from recently discovered populations in the provinces of Carchi and Santo Domingo de los Tsáchilas (Ecuador) and the departments of Cauca and Nariño in southwestern Colombia. The two new species are pendent epiphytes with elongate shoots and shallowly bilabiate to nearly tubular corollas. Descriptions, complete specimen citations, and a distribution map are provided. Based on IUCN guidelines, a preliminary conservation status of Critically Endangered (CR) is provided for C.fluidifolia and Endangered (EN) is provided for C.pendens.

ResumenLas expediciones de campo a los bosques del Chocó en las laderas noroccidentales de los Andes de Ecuador y Colombia dieron como resultado el descubrimiento de dos nuevas especies de Columnea (Gesneriaceae). Columneafluidifolia J.L.Clark & F.Tobar, sp. nov., descrita como endémica de una reducida área del Bosque Protector Mashpi y zonas circundantes en la provincia de Pichincha. Columneapendens F.Tobar, J.L.Clark & J.F.Sm., sp. nov., se describe a partir de poblaciones recientemente descubiertas en las provincias de Carchi, Santo Domingo de los Tsáchilas (Ecuador) y los departamentos de Cauca y Nariño en el suroeste de Colombia. Las dos nuevas especies son epífitas pendulares con brotes alargados y corolas ligeramente bilabiadas a casi tubulares. Descripciones, citaciones completas de los especímenes y mapa de distribución son incluidas. Basados en los criterios de la IUCN, se asigna un estado de conservación preliminar de En Peligro Critico (CR) para C.fluidifolia y a C.pendens se le asigna la categoría de En Peligro (EN).

Sperm deoxyribonucleic acid fragmentation: predictors, fertility outcomes, and assays among infertile males.

OBJECTIVE: To examine the factors associated with increased deoxyribonucleic acid fragmentation index (DFI), evaluate the pregnancy outcomes of men with increased DFI, and compare three independent DFI assays. DESIGN: Secondary analysis. SETTING: Nine US-based fertility centers. PATIENTS: Infertile men (N = 147) with sperm concentration ≤15 × 106/mL, motility ≤40%, or normal morphology ≤4% were enrolled. The female partners were ovulatory, ≤40 years old, and had documented tubal patency. INTERVENTIONS: At a baseline visit, the men provided a semen sample. The couples attempted conception without assistance for 3 months and with ovarian stimulation and intrauterine insemination in the subsequent 3 months. MAIN OUTCOME MEASURES: The DFI was analyzed using the sperm chromatin structure assay (SCSA) with increased DFI defined as >30%. The predictors of increased DFI were determined by a multivariable linear regression model. The pregnancy outcomes were compared using the χ2 test. The independent DFI assays (SCSA, deoxynucleotidyl transferase-mediated dUTP nick end labeling, and Comet) were compared with Pearson and Spearman correlations. RESULTS: The 19% of men with increased DFI were older (36.0 vs. 33.0 years) and had lower total sperm motility (38.2% ± 20.5% vs. 45.2% ± 15.6%). Increased male age was found to be a significant predictor of DFI (0.75, 95% confidence interval [0.06, 1.45]). Increased DFI was not associated with conception or live birth. There was a modest correlation of the deoxynucleotidyl transferase-mediated dUTP nick end labeling assay with the SCSA (r = 0.34) and Comet assay (r = 0.19). CONCLUSIONS: Older age was associated with increased DFI among infertile men. The DFI assays were only weakly correlated, indicating a standard definition of DFI is needed to truly interrogate how sperm deoxyribonucleic acid fragmentation impacts male fertility.

A higher-level nuclear phylogenomic study of the carrot family (Apiaceae).

PREMISE: The carrot family (Apiaceae) comprises 466 genera, which include many well-known crops (e.g., aniseed, caraway, carrots, celery, coriander, cumin, dill, fennel, parsley, and parsnips). Higher-level phylogenetic relationships among subfamilies, tribes, and other major clades of Apiaceae are not fully resolved. This study aims to address this important knowledge gap. METHODS: Target sequence capture with the universal Angiosperms353 probe set was used to examine phylogenetic relationships in 234 genera of Apiaceae, representing all four currently recognized subfamilies (Apioideae, Azorelloideae, Mackinlayoideae, and Saniculoideae). Recovered nuclear genes were analyzed using both multispecies coalescent and concatenation approaches. RESULTS: We recovered hundreds of nuclear genes even from old and poor-quality herbarium specimens. Of particular note, we placed with strong support three incertae sedis genera (Platysace, Klotzchia, and Hermas); all three occupy isolated positions, with Platysace resolved as sister to all remaining Apiaceae. We placed nine genera (Apodicarpum, Bonannia, Grafia, Haplosciadium, Microsciadium, Physotrichia, Ptychotis, Tricholaser, Xatardia) that have never previously been included in any molecular phylogenetic study. CONCLUSIONS: We provide support for the maintenance of the four existing subfamilies of Apiaceae, while recognizing that Hermas, Klotzschia, and the Platysace clade may each need to be accommodated in additional subfamilies (pending improved sampling). The placement of the currently apioid genus Phlyctidocarpa can be accommodated by the expansion of subfamily Saniculoideae, although adequate morphological synapomorphies for this grouping are yet to be defined. This is the first phylogenetic study of the Apiaceae using high-throughput sequencing methods and represents an unprecedented evolutionary framework for the group.

Male vitamin D status and male factor infertility.

OBJECTIVE: To determine the association between vitamin D levels in the male partner and fertility outcomes in couples with mild male factor infertility. DESIGN: Secondary analysis of a randomized, controlled trial. SETTING: Nine fertility centers in the United States. PATIENT(S): Men (n = 154) with sperm concentration between 5 and 15 million/mL, motility ≤40%, or normal morphology ≤4% were eligible. Female partners were ovulatory, ≤40 years old, and had documented tubal patency. INTERVENTION(S): Men provided semen and blood at baseline for semen analysis and 25-hydroxyvitamin D (25(OH)D) levels. They were randomly assigned to receive a vitamin formulation including vitamin D 2,000 IU daily or placebo for up to 6 months. Couples attempted to conceive naturally during the first 3 months and with clomiphene citrate with intrauterine insemination of the female partner in months 4 through 6. MAIN OUTCOME MEASURE(S): Primary: sperm concentration, motility, morphology, and DNA fragmentation at baseline. Secondary: cumulative pregnancy, miscarriage, and live birth rates. RESULT(S): Semen parameters and sperm DNA fragmentation were not statistically significantly different between men with vitamin D deficiency and men with 25(OH)D levels ≥20 ng/mL. In addition, clinical pregnancy and live birth rates were similar. Male 25(OH)D level <20 ng/mL was associated with a higher rate of pregnancy loss (adjusted odds ratio 9.0; 95% confidence interval 1.3 to 61.3). CONCLUSION(S): Vitamin D deficiency in the male partner did not significantly impact semen parameters or treatment outcomes. Further study is warranted to better characterize the rate of miscarriage in couples with male vitamin D deficiency.

Factors Influencing the Decision for Fresh vs Cryopreserved Microdissection Testicular Sperm Extraction for Non-Obstructive Azoospermia.

OBJECTIVE: To determine reproductive urologists' (RU) practice patterns for microdissection testicular sperm extraction (microTESE) and factors associated with use of fresh vs frozen microTESE for non-obstructive azoospermia. MATERIALS AND METHODS: We electronically surveyed Society for Study of Male Reproduction members with a 21-item questionnaire. Our primary outcomes were to determine RU preference for fresh or frozen microTESE and to understand barriers to performing microTESE. Pearson's chi-square and Fisher's exact tests were used to analyze categorical outcomes and candidate predictor variables. Firth logistic regression was performed to identify the predictors for preferring and performing fresh vs frozen microTESE. RESULTS: A total of 208 surveys were sent with 76 responses. Most (63.0%) primarily perform frozen microTESE for non-obstructive azoospermia, while 37.0% primarily perform fresh. However, in an ideal practice, 59.3% prefer fresh microTESE, 22.2% prefer frozen microTESE, and 18.5% had no preference. MicroTESE is performed most often (61.1%) at surgical centers not affiliated with a fertility practice. The most commonly reported barriers for both fresh and frozen microTESE are cost (42.6%), scheduling (33.3%), and andrologist unavailability (16.7%). There are no statistically significant differences between these barriers and performing fresh vs frozen microTESE. On multivariable analysis, reproductive endocrinology and infertility-based surgical center (OR 22.9; 95% CI 1.1-467.2; P = 0.04) and professional fee $2,500-$4,999 (OR 20.7; 95% CI 1.27-337.9; P = 0.03) are significant predictors of performing fresh microTESE. CONCLUSION: Frozen microTESE is performed more commonly than fresh, despite most RU preferring fresh microTESE in an ideal setting. Both fresh and frozen microTESE have a role in reproductive care. Barriers to performing fresh microTESE include cost, scheduling and andrologist availability.

One size does not fit all: variations by ethnicity in demographic characteristics of men seeking fertility treatment across North America.

OBJECTIVE: To compare racial differences in male fertility history and treatment. DESIGN: Retrospective review of prospectively collected data. SETTING: North American reproductive urology centers. PATIENT(S): Males undergoing urologist fertility evaluation. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Demographic and reproductive Andrology Research Consortium data. RESULT(S): The racial breakdown of 6,462 men was: 51% White, 20% Asian/Indo-Canadian/Indo-American, 6% Black, 1% Indian/Native, <1% Native Hawaiian/Other Pacific Islander, and 21% "Other". White males sought evaluation sooner (3.5 ± 4.7 vs. 3.8 ± 4.2 years), had older partners (33.3 ± 4.9 vs. 32.9 ± 5.2 years), and more had undergone vasectomy (8.4% vs. 2.9%) vs. all other races. Black males were older (38.0 ± 8.1 vs. 36.5 ± 7.4 years), sought fertility evaluation later (4.8 ± 5.1 vs. 3.6 ± 4.4 years), fewer had undergone vasectomy (3.3% vs. 5.9%), and fewer had partners who underwent intrauterine insemination (8.2% vs. 12.6%) compared with all other races. Asian/Indo-Canadian/Indo-American patients were younger (36.1 ± 7.2 vs. 36.7 ± 7.6 years), fewer had undergone vasectomy (1.2% vs. 6.9%), and more had partners who underwent intrauterine insemination (14.2% vs. 11.9%). Indian/Native males sought evaluation later (5.1 ± 6.8 vs. 3.6 ± 4.4 years) and more had undergone vasectomy (13.4% vs. 5.7%). CONCLUSION(S): Racial differences exist for males undergoing fertility evaluation by a reproductive urologist. Better understanding of these differences in history in conjunction with societal and biologic factors can guide personalized care, as well as help to better understand and address disparities in access to fertility evaluation and treatment.

Phylogenetics and comparative plastome genomics of two of the largest genera of angiosperms, Piper and Peperomia (Piperaceae).

Biological radiations provide unique opportunities to understand the evolution of biodiversity. One such radiation is the pepper plant family Piperaceae, an early-diverging and mega-diverse lineage that could serve as a model to study the diversification of angiosperms. However, traditional genetic markers lack sufficient variation for such studies, and testing hypotheses on poorly resolved phylogenetic frameworks becomes challenging. Limited genomic data is available for Piperaceae, which contains two of the largest genera of angiosperms, Piper (>2100 species) and Peperomia (>1300 species). To address this gap, we used genome skimming to assemble and annotate whole plastomes (152-161kbp) and >5kbp nuclear ribosomal DNA region from representatives of Piper and Peperomia. We conducted phylogenetic and comparative genomic analyses to study plastome evolution and investigate the role of hybridization in this group. Plastome phylogenetic trees were well resolved and highly supported, with a hard incongruence observed between plastome and nuclear phylogenetic trees suggesting hybridization in Piper. While all plastomes of Piper and Peperomia had the same gene content and order, there were informative structural differences between them. First, ycf1 was more variable and longer in Piper than Peperomia, extending well into the small single copy region by thousands of base pairs. We also discovered previously unknown structural variation in 14 out of 25 Piper taxa, tandem duplication of the trnH-GUG gene resulting in an expanded large single copy region. Other early-diverging angiosperms have a duplicated trnH-GUG, but the specific rearrangement we found is unique to Piper and serves to refine knowledge of relationships among early-diverging angiosperms. Our study demonstrates that genome skimming is an efficient approach to produce plastome assemblies for comparative genomics and robust phylogenies of species-rich plant genera.

Resolving species boundaries in a recent radiation with the Angiosperms353 probe set: the Lomatium packardiae/L. anomalum clade of the L. triternatum (Apiaceae) complex.

PREMISE: Speciation not associated with morphological shifts is challenging to detect unless molecular data are employed. Using Sanger-sequencing approaches, the Lomatium packardiae/L. anomalum subcomplex within the larger Lomatium triternatum complex could not be resolved. Therefore, we attempt to resolve these boundaries here. METHODS: The Angiosperms353 probe set was employed to resolve the ambiguity within Lomatium triternatum species complex using 48 accessions assigned to L. packardiae, L. anomalum, or L. triternatum. In addition to exon data, 54 nuclear introns were extracted and were complete for all samples. Three approaches were used to estimate evolutionary relationships and define species boundaries: STACEY, a Bayesian coalescent-based species tree analysis that takes incomplete lineage sorting into account; ASTRAL-III, another coalescent-based species tree analysis; and a concatenated approach using MrBayes. Climatic factors, morphological characters, and soil variables were measured and analyzed to provide additional support for recovered groups. RESULTS: The STACEY analysis recovered three major clades and seven subclades, all of which are geographically structured, and some correspond to previously named taxa. No other analysis had full agreement between recovered clades and other parameters. Climatic niche and leaflet width and length provide some predictive ability for the major clades. CONCLUSIONS: The results suggest that these groups are in the process of incipient speciation and incomplete lineage sorting has been a major barrier to resolving boundaries within this lineage previously. These results are hypothesized through sequencing of multiple loci and analyzing data using coalescent-based processes.

The Impact of Physician Productivity Models on Access to Subspecialty Care: A White Paper From the Society for the Study of Male Reproduction and the Society for Male Reproduction and Urology.

Male infertility is a common disease. Male infertility is also a core competency of urology training and clinical practice. In this white paper from the Society for the Study of Male Reproduction and the Society for Male Reproduction and Urology, we identify and define different physician productivity plans. We then describe the advantages and disadvantages of various physician productivity measurement systems for male infertility practices. We close with recommendations for measuring productivity that we hope urologists and administrators can use when creating productivity plans for male infertility practices.

Development and validation of a novel mail-in semen analysis system and the correlation between one hour and delayed semen analysis testing.

OBJECTIVE: To develop and validate a novel, mail-in semen analysis (SA) system. DESIGN: Prospective cohort. SETTING: Not applicable. PATIENT(S): Ejaculates from normospermic men. INTERVENTION(S): One-hour SA, then repeat SAs (on same ejaculate) over 52 hours using a novel technique for maintaining sperm viability. MAIN OUTCOME MEASURE(S): World Health Organization SA parameters. RESULT(S): One-hour SA on 104 ejaculates in the validation phase of the study demonstrated normal semen parameters. With up to 52 hours of observation and four subsequent SA measurements/ejaculate, concentration remained stable, motility decreased by 0.39%/h, and normal morphology decreased by 0.1%/h. Measured 1-hour and calculated motility (correlation coefficients 0.87) and morphology (correlation coefficients 0.82) strongly were correlated. CONCLUSION: This novel, mail-in, Clinical Laboratory Improvement Amendments-approved SA testing system demonstrates a strong degree of correlation between 1-hour and delayed SA testing. Given the linear motility and morphology decrease and stability of sperm concentration, this test may be used in clinical practice to evaluate semen quality for fertility evaluations. Furthermore, this approach significantly improves the ease, comfort, and efficiency of obtaining a SA, likely breaking down early barriers to accessing successfully a male fertility evaluation.

Ex vivo human testes as a practical model to simulate ultrasound-guided testicular cell transplantation for human fertility restoration.

OBJECTIVE: To develop an ex vivo model to practice ultrasound-guided injection of cellular material into human seminiferous tubules to simulate testicular cell transplantation (TCT). DESIGN: Simulated TCT injections were performed in human testes removed during orchiectomy. The rete testis was the target site of injection. Successful retrograde infiltration of injected material into the lumen of the seminiferous tubules was detected using ultrasound and confirmed with histology. SETTING: Single academic surgical center. PATIENT(S): Adult patients undergoing orchiectomy for nononcologic indications. INTERVENTION(S): The testes were injected with sonographic contrast (Optison), methylene blue, and fluorescent-labeled cells. MAIN OUTCOME MEASURE(S): A characteristic streaming pattern of sonographic contrast in the testis was used to define sonographic success, and the presence of methylene blue and fluorescent-labeled cells within the seminiferous tubules confirmed histologic success. RESULT(S): We performed simulated TCT injections in 30 testes obtained from 16 patients undergoing orchiectomy. We were able to achieve sonographic success in 57% of injections and confirmed that sonographic success is correlated with histologic success. CONCLUSION(S): Testicular cell transplantation injections can be practiced using human testes. As there appears to be a learning curve associated with this procedure, developing this infrastructure to practice these skills is critical before implementation in patients.

Disparities in fertility knowledge among women from low and high resource settings presenting for fertility care in two United States metropolitan centers.

BACKGROUND: Few studies have examined health literacy and fertility knowledge among women from low income, socio-culturally diverse communities presenting for fertility care in the United States. Our study sought to examine demographic predictors of fertility-related knowledge among infertile women from low and high-resource communities in two major metropolitan centers in the United States. METHODS: Fertility Knowledge Assessments were administered to women presenting for fertility care at county medical centers serving low-resource, largely immigrant patients and to women from largely affluent populations presenting to comprehensive fertility centers in two cities. The influence of demographic predictors on fertility knowledge was examined through regression analysis. RESULTS: A total of 143 women were included in our analysis. In the county hospital/low resource clinic (LR, n = 70), the mean age was 32.8 ± 6.1 years vs 35.0 ± 5.0 years in the fee-for-service/high resource clinic (HR, n = 73). Among the LR patients, 74% were immigrants, 71% had an annual income <$25,000 and 52% had completed high school. Among HR patients, 36% were immigrants, 60% had an annual income >$100,000, and 95% had some college or above. On average, women from HR settings scored 3.0 points higher on the Fertility Knowledge Assessment than their LR counterparts (p < 0.001). Upon multivariate analysis, education level remained the sole independent factor associated with fertility knowledge assessment score (p < 0.001). Stratifying by resource level revealed that income was highly associated with fertility knowledge (p < 0.01) among high resource individuals even when adjusting for education level. CONCLUSIONS: Women from low resource, largely immigrant communities, seeking fertility care have greater disparities in fertility knowledge and lower health literacy compared to women from high resource clinical settings. Further studies are needed to understand these barriers and to develop targeted inventions to lower disparities and improve care for these vulnerable populations.

Women's Reproductive Health Education in Catholic Academic Healthcare Institutions: Time for Transparency, Authenticity, and Reflection.

This article illustrates the tensions between the precepts of the Ethical and Religious Directives for Catholic Healthcare Services and the Accreditation Council for Graduate Medical Education as they apply to education in obstetrics and gynecology, and argues that moving forward, Catholic sponsorship of obstetric and gynecologic residencies now requires transparency, authenticity, and reflection in order to mitigate these inherent tensions.