Facilitators and Barriers to the Adoption of Holistic Practices for Inclusive Recruitment in Graduate Medical Education.

OBJECTIVE: A diverse physician workforce ensures equitable care. The holistic review of residency applications is one strategy to enhance physician diversity; however, little is known about current adoption and the factors that facilitate/impede the adoption of holistic recruitment practices (HRPs) by graduate medical education (GME) residency, and fellowship program directors (PDs). To describe the current state and explore, the barriers/facilitators to the adoption of HRPs at our institution. METHODS: We disseminated information about HRP within our program between 2021 and 2022. In May 2022, a survey of 73 GME PDs assessed current recruitment practices and self-reported barriers to holistic recruitment. Holistic Recruitment Scores (HRSs) reflecting the adoption of best practices were tabulated for each program and compared to identify predictors of adoption. RESULTS: 73/80 (92%) of PDs completed the survey. Programs whose PDs had higher academic rank, total number of trainees, and female trainees in the past 3 years had higher HRSs. Program size was directly correlated with HRS. Most (93%) PDs felt their current efforts were aligned to increase diversity and 58% felt there were no barriers to the adoption of holistic review. The most reported barriers were lack of time and knowledge/expertise in diversity, equity, and inclusion (DEI), both reported by 16 out of 73 PDs (22%). CONCLUSION: While most PDs implemented some HRP, institutional and departmental support of program directors through the commitment of resources (eg, staffing help and subject matter experts/coaches hiring) are crucial to overcome barriers.

Advancing Equity in Graduate Medical Education Recruitment Through a Diversity Equity and Inclusion (DEI) Toolkit for Program Directors.

Objectives: To increase diversity and inclusion in graduate medical education (GME), the Accreditation Council for Graduate Medical Education (ACGME) issued new diversity standards requiring programs to engage in practices that focus on systematic recruitment and retention of a diverse workforce of trainees and faculty. The literature on how program directors (PDs) can incorporate and prepare for this standard is limited. Methods: We developed a diversity, equity, and inclusion (DEI) toolkit for PDs as an example of an institutional GME-led effort to promote inclusive recruitment and DEI awareness among residency and fellowship programs at a large academic center. Results: A survey was sent to 80 PDs before the launch of the toolkit and 6 months afterwards with response rates of 27% (22/80) and 97% (78/80), respectively. At baseline, 45% (10/22) anticipated that the DEI toolkit might provide better resources than those currently available to them and 41% (9/22) perceived that the toolkit might improve recruitment outcomes. At 6 months, 63% (49/78) found the toolkit helpful in the 2021-2022 recruitment season. By contrast, 2% (2/78) of PDs did not find the toolkit helpful, and 33% (26/78) said they did not access the toolkit. When asked if a PD changed their program's recruitment practices because of the toolkit, 31% (24/78) responded yes. Programs that changed recruitment practices started to require unconscious bias training for all faculty and residents involved in the residency interviews and ranking. Others worked on creating a standardized scoring rubric for interviews focused on four main domains: Experiences, Attributes, Competencies, and Academic Metrics. Conclusion: There is a need to support PDs in their DEI journey and their work to recruit a diverse workforce in medicine. Utilizing a DEI toolkit is one option to increase DEI knowledge, skills, awareness, and self-efficacy among PDs and can be adopted by other institutions and leaders in academic medicine.

An Online Resident-as-Teacher Curriculum Improves First-Year Residents' Self-Confidence Teaching in the Clinical Learning Environment.

We implemented an online Resident-as-Teacher curriculum for all incoming residents (PGY1s) to provide them with a basic foundation for effective teaching in the clinical learning environment. The curriculum consisted of 5 asynchronous modules delivered via the web from 2017-2021. Prior to starting the course, the PGY1s completed a self-assessment of their teaching ability (pre-test) and then again 7-8 months after completing the course (post-test). Analysis of the paired data from 421 PGY1s showed a statistically significant improvement in the self-ratings of their teaching from pre-test to post-test (p < 0.001). Our findings suggest that an online Resident-as-Teacher curriculum can produce lasting benefits in new residents' self-confidence as educators.

Leveraging Resident-As-Teacher Training for Health Equity Education: A Transformative Approach.

Issue: Resident teachers play an essential role in medical education and can support broader efforts to advance anti-racism and health equity in medicine. The Accreditation Council for Graduate Medical Education requires programs to provide education about health care disparities so residents can contribute to and lead work in this area. However, the literature includes few examples, frameworks, or strategies for preparing residents to develop the knowledge and skills needed to promote health equity, including in their role as clinical teachers. Evidence: In this article, the authors propose leveraging Resident-as-Teacher training to support residents in learning and teaching for health equity. Gorski's conceptualization of equity literacy provides an evidence-based framework for four main abilities (recognizing, responding, redressing, and cultivating/sustaining) residents and medical students can develop through co-learning about health equity in the clinical learning environment. The authors discuss preconditions, example activities, and assessments strategies for effective health equity education. Based on the principles of social learning theory, the authors recommend that Resident-as-Teacher training be part of an institutional strategy to cultivate a community of practice for health equity education. Implications: Incorporating health equity education into Resident-as-Teacher curriculum offers a potentially transformative part of the broader strategy needed to prepare the next generation of physicians to enact anti-racism and advance health equity.

Engaging All Stakeholders to Create a Trusted, Data-Driven, Process Improvement Approach to Addressing Learner Mistreatment.

Problem: Learner mistreatment has remained an ongoing challenge in academic medicine despite accreditation requirements mandating that every program has systems in place to prevent and respond to mistreatment. While efforts vary across institutions, much remains unanswered in the literature about best practices. Additionally, for the foreseeable future, challenges in the learning environment will likely continue and potentially worsen, given the confluence of multiple external stressors including the COVID-19 pandemic, faculty burnout and general political divisiveness in the nation. It is essential, therefore, to focus on indicators of improvement via process metrics such as knowledge and awareness of mistreatment policies and procedures, willingness to report, reasons for not reporting, and satisfaction with having made a report, while simultaneously focusing on the more complex challenge of eliminating mistreatment occurrences. Intervention: We describe the aspects of our mistreatment prevention and response system first implemented in 2017 along with process and outcome measures. The interventions included expanding our policy outlining appropriate conduct in the teacher-learner relationship; a graduated response protocol to allegations of mistreatment with a clear escalation approach; an online reporting system; a graduate medical education exit survey which mirrors the AAMC Graduation Questionnaire on mistreatment; a robust communication and professional development campaign; a comprehensive data dashboard; and a comprehensive summary report dissemination plan. Context: The interventions were implemented at the largest allopathic medical school in the U.S., with nine campuses across the state. The system is available to all learners, including medical students, graduate students, residents, and fellows. Impact: Both institutional and national data sources have informed the continuous improvement strategies. Data from internal reporting systems, institutional surveys, and national data are presented from 2017 to 2021. Findings include an increasing number of incidents reported each year, including confidential reports from students who include their contact information rather than report anonymously, which we view as an indicator of learner trust in the system. Our data also show consistent improvements in learners' awareness of the policy and procedures and satisfaction with having made a report. We also include other data such as the nature of complaints submitted and timeliness of our institutional response. Lessons Learned: We present several lessons learned that may guide other institutions looking to similarly improve their mistreatment systems, such as a close partnership between faculty affairs, diversity affairs, and educational affairs leadership; communication, professional development, and training through multiple venues and with all stakeholders; easily accessible reporting with anonymous and confidential options and the ability to report on behalf of others; policy development guidance; data transparency and dissemination; and trust-building activities and ongoing feedback from learners.

Serving on a Graduate Medical Education Diversity, Equity, Inclusion, and Justice Committee: Lessons Learned From a Journey of Growth and Healing.

Efforts toward achieving diversity, equity, inclusion, and justice (DEIJ) within graduate medical education (GME) often begin with the formation of a DEIJ committee that steers the work. Little is known about the experiences and the challenges faced by those serving on such committees. We sought to describe the experiences of members of our institutional GME DEIJ committee to gain knowledge that would propel this work forward. An open-ended survey was electronically administered to members of our institutional GME DEIJ committee. Responses were analyzed using a rapid qualitative analytical approach. Eighteen members (58%) responded. Of these, (67%) were women and five (28%) were Black. Six domains emerged: "motivation," "challenges," "emotional response," "highs," "facilitators," and "advice." Black respondents more often cited the need to increase diversity as a motivator to join this work. Women and Black respondents more often identified time constraints as a challenge to participation. Some members found the work emotionally draining; others described it as uplifting. Two themes emerged as high points of participation-pride and achievement around the work completed and the personal benefits of building a community with a shared purpose. Three themes emerged as facilitators: effective leadership, support, and establishing psychological safety during the meetings. Many arrived at the realization that change would take time and advocated for patience and perseverance. Protected time and DEIJ expertise were identified as integral to successful committee work. Our findings provide novel insights into the experience of serving on a GME DEIJ committee and highlights infrastructural and institutional prerequisites for success.

Outcome of Dopamine Agonist Therapy Withdrawal in Children with Prolactinomas.

BACKGROUND: Prolactinomas are rare in children and adolescents. As in adults, dopamine agonists (DAs) are the treatment of choice in the majority of patients. However, at what point children should be taken off of therapy and what the recurrence risk of hyperprolactinemia is following treatment withdrawal is not well described. OBJECTIVE: Our objective was to systematically review our experience with DA treatment withdrawal in children and adolescents with prolactinomas. METHODS: A retrospective review of patients followed for prolactinomas during the last 12 years was conducted. Variables analyzed included age, gender, initial serum prolactin levels, tumor characteristics, cabergoline dose, and results of treatment withdrawal. Clinical characteristics of patients who met eligibility criteria for DA withdrawal were compared with those who did not. Patients who underwent surgery were excluded. RESULTS: Of 47 patients identified, 42 were included in the study. Of those, DA withdrawal was attempted in 13 (31%) and was initially successful in 3 (21%). Patients who did not meet eligibility criteria for treatment withdrawal had higher baseline prolactin levels (p = 0.018) as well as larger (p = 0.03) and more invasive (p = 0.002) tumors. CONCLUSIONS: Less than half of our patients were eligible for DA treatment withdrawal and less than one-fourth achieved remission of hyperprolactinemia following cessation of therapy. This suggests that the overall recurrence rate of prolactinomas in pediatric patients may be higher than has been reported in adults.

Methimazole Desensitization in a 4-Year-Old With Refractory Graves Disease.

OBJECTIVE: To describe a 4-year-old girl with Graves disease and methimazole allergy who underwent desensitization, allowing continued methimazole use when other treatments were contraindicated. METHODS: We formulated a desensitization plan utilizing cetirizine and prednisone for a patient with previously diagnosed Graves disease who developed urticaria and arthralgias from methimazole. She was admitted for monitoring of rash, urticaria, angioedema, and anaphylaxis. Her methimazole dose was increased as tolerated and then titrated as an outpatient. RESULTS: A 4-year-old girl presented with a heart rate of 195 beats/minute, blood pressure of 145/108, and subsequent labs of undetectable thyroid stimulating hormone (TSH), free T4 5.8 ng/dL, thyroid peroxidase antibody 11.5 IU/ml, and TSH receptor antibody 39.03 IU/L, consistent with Graves disease. She developed urticaria and arthralgias after 2.5 weeks on methimazole, which resolved with drug cessation. Because of her age, the risks of radioactive iodine ablation and surgery were concerning; therefore, methimazole desensitization was attempted. Prednisone (1 mg/kg/day) and cetirizine (5 mg/day) were started prior to low-dose methimazole reintroduction and continued for 7 days. Methimazole was then gradually increased to a final dose of 15 mg daily (0.8 mg/kg/day). Free T4 normalized within a month (1.12 ng/dL), and her TSH normalized within 10 months (4.61 mcU/mL). Except for 2 possible breakthrough allergic responses that resolved with pulse steroids, she continues to tolerate methimazole. CONCLUSION: We describe a case of methimazole desensitization. In this patient, pretreatment with prednisone, coupled with daily cetirizine, successfully induced methimazole tolerance when other treatment modalities were contraindicated.

Whole exome sequencing and functional characterization increase diagnostic yield in siblings with a 46, XY difference of sexual development (DSD).

Pathogenic biallelic variants in HSD17B3 result in 17ß-hydroxysteroid dehydrogenase 3 (17ß-HSD3) deficiency, variable disruption of testosterone production, and phenotypic diversity among 46, XY individuals with differences of sexual development (DSDs). We performed quad whole exome sequencing (WES) on two male siblings with microphallus, perineal hypospadias, and bifid scrotum and their unaffected parents. Both male siblings were compound heterozygous for a rare pathogenic HSD17B3 variant (c.239 G > A, p.R80Q) previously identified among individuals with 17ß-HSD3 deficiency and a HSD17B3 variant (c.641A > G, p.E214 G) of uncertain significance. Following WES, the siblings underwent hCG stimulation testing with measurement of testosterone, androstenedione, and dihydrotestosterone which was non-diagnostic. To confirm pathogenicity of the HSD17B3 variants, we performed transient transfection of HEK-293 cells and measured conversion of radiolabeled androstenedione to testosterone. Both HSD17B3 variants decreased conversion of radiolabeled androstenedione to testosterone. As pathogenic HSD17B3 variants are rare causes of 46, XY DSD and hCG stimulation testing may not be diagnostic for 17ß-HSD3 deficiency, WES in 46, XY individuals with DSDs can increase diagnostic yield and identify genomic variants for functional characterization of disruption of testosterone production.

TESTOTOXICOSIS WITH AN EPISODIC COURSE: AN UNUSUAL CASE WITHIN A SERIES.

OBJECTIVE: To describe an unusual case of familial male precocious puberty (FMPP) characterized by periodic remission compared to a series of boys with typical testotoxicosis. METHODS: Medical records of boys with FMPP followed at our institution from 2001-2017 were reviewed. Variables analyzed included age, family history, physical exam, hormone levels, bone age, and treatment. RESULTS: A boy of age 2 years 10 months presented with growth acceleration and masturbatory behaviors. On exam, he had 6-mL testes, an enlarged phallus (10.5 × 2.5 cm), and Tanner 2 pubic hair. Testosterone was 242 ng/dL (normal level, ≤30 ng/dL). Genetic testing revealed an Asp578Gly luteinizing hormone receptor mutation confirming FMPP. Anastrozole 1 mg and bicalutamide 50 mg daily were started. During 7.5 years of follow-up, two periods of spontaneous remission occurred lasting >3 years and 10 months, respectively. Both were characterized by prepubertal testosterone levels (10 to 28 ng/dL) and arrested pubertal development off therapy. Relapses were marked by elevated testosterone, growth acceleration, and pubertal progression. Ten additional boys aged 3.46 ± 0.72 years with FMPP were identified, one of whom also had an Asp578Gly mutation. Average testosterone at presentation was 335 ± 193 ng/dL (range, 146 to 778 ng/dL) and average bone age/chronologic age was 2.02 ± 0.47. All were treated with bicalutamide and anastrozole or letrozole. CONCLUSION: We report a case of intermittent FMPP in contrast to a series of boys with a characteristic clinical course. To our knowledge, a similar case has not previously been reported. Our case expands the clinical spectrum of this rare condition.

CHARACTERIZATION OF SPONTANEOUS AND INDUCED PUBERTY IN GIRLS WITH TURNER SYNDROME.

OBJECTIVE: To characterize puberty in girls with Turner syndrome (TS) and determine whether specific patient characteristics are associated with the timing of menarche. We also sought to compare spontaneous versus induced puberty in these patients. METHODS: Medical records of girls followed in our Pediatric Endocrine clinic for TS from 2007 to 2015 were reviewed. RESULTS: Fifty-three girls were included, of whom 10 (19%) achieved menarche spontaneously and 43 (81%) received hormone replacement therapy (HRT). Of girls receiving HRT, a younger age at estrogen initiation correlated with a longer time to menarche (P = .02), and a mosaic karyotype was associated with a shorter time to menarche (P = .02), whereas no relationship was seen for body mass index, estrogen regimen, or maternal age at menarche. Nineteen girls (44%) receiving HRT had bleeding on estrogen alone at a wide dose range and were more likely to be on transdermal than oral preparations (P = .01). Girls with spontaneous puberty achieved menarche at a younger age (P<.01) and were more likely to have mosaic TS (P = .02). CONCLUSION: Significant variability in the timing of menarche exists among girls with TS. However, age at pubertal induction and karyotype were significantly correlated with age at menarche in our patients. A wide range of estrogen doses is seen in girls who bleed prior to progesterone, suggesting extreme variability in estrogen sensitivity among patients with TS. Girls achieving spontaneous menarche are younger and more likely to have a mosaic karyotype than those with induced menarche. Large-scale prospective studies are needed to confirm these results. ABBREVIATIONS: BMI = body mass index; HRT = hormone replacement therapy; TS = Turner syndrome.

Differential effects of hydrocortisone, prednisone, and dexamethasone on hormonal and pharmacokinetic profiles: a pilot study in children with congenital adrenal hyperplasia.

BACKGROUND: Little is known about the comparative effects of different glucocorticoids on the adrenal and growth hormone (GH) axes in children with congenital adrenal hyperplasia (CAH). We sought to compare the effects of hydrocortisone (HC), prednisone (PDN), and dexamethasone (DEX) in children with classic CAH and to investigate a potential role of pharmacogenetics. METHODS: Subjects were randomly assigned to three sequential 6-week courses of HC, PDN, and DEX, each followed by evaluation of adrenal hormones, IGF-1, GH, and body mass index (BMI). Single nucleotide polymorphism (SNP) analysis of genes in the glucocorticoid pathway was also performed. RESULTS: Nine prepubertal subjects aged 8.1 ± 2.3 years completed the study. Mean ACTH, androstenedione, and 17-hydroxyprogesterone (17-OHP) values were lower following the DEX arm of the study than after subjects received HC (p ≤ 0.016) or PDN (p ≤ 0.002). 17-OHP was also lower after HC than PDN (p < 0.001). There was no difference in IGF-1, GH, or change in BMI. SNP analysis revealed significant associations between hormone concentrations, pharmacokinetic parameters, and variants in several glucocorticoid pathway genes (ABCB1, NR3C1, IP013, GLCCI1). CONCLUSIONS: DEX resulted in marked adrenal suppression suggesting that its potency relative to hydrocortisone and prednisone was underestimated. SNPs conferred significant differences in responses between subjects. Although preliminary, these pilot data suggest that incorporating pharmacogenetics has the potential to eventually lead to targeted therapy in children with CAH.

INCIDENCE OF CENTRAL DIABETES INSIPIDUS IN CHILDREN PRESENTING WITH POLYDIPSIA AND POLYURIA.

OBJECTIVE: Polydipsia and polyuria are common reasons for referral to the Pediatric Endocrine clinic. In the absence of hyperglycemia, diabetes insipidus (DI) should be considered. The objectives of the study were to determine the prevalence of central DI (CDI) in a group of children presenting for evaluation of polydipsia and polyuria, and to determine if predictive features were present in patients in whom the diagnosis of DI was made. METHODS: The study was a retrospective chart review of children presenting to the endocrine clinic with complaints of polydipsia and polyuria over a 5-year period. RESULTS: The charts of 41 patients (mean age 4.9 ± 3.7 years, 28 males) were reviewed. CDI was diagnosed in 8 (20%) children based on abnormal water deprivation test (WDT) results. All but one patient had abnormal magnetic resonance imaging (MRI) findings, the most common being pituitary stalk thickening. Children with DI were older (7.86 ± 4.40 vs. 4.18 ± 3.20 years, P = .01) and had a higher propensity for cold beverages intake and unusual water-seeking behaviors compared to those without DI. Baseline WDT also revealed higher serum sodium (Na) and osmolality. CONCLUSION: The incidence of CDI in children presenting with polydipsia and polyuria is low. Factors associated with higher likelihood of pathology include older age, propensity for cold beverage intake, and higher baseline serum Na and osmolality on a WDT. ABBREVIATIONS: BMI = body mass index CDI = central diabetes insipidus DI = diabetes insipidus Na = sodium WDT = water deprivation test.

Hormone replacement therapy in children with hypogonadotropic hypogonadism: where do we stand?

OBJECTIVE: To characterize hormone replacement therapy in a cohort of adolescent males and females with hypogonadotropic hypogonadism (HH) with a focus on changes in management during the past 10 years. METHODS: Medical records of patients followed for HH during the past 10 years were reviewed. RESULTS: A total of 45 patients (22 female: 23 male) with HH were identified. The average age at HH diagnosis was 14.48 ± 2.02 years in females and 14.89 ± 1.64 years in males (P = .53). In females, the average age of pubertal induction was 14.53 ± 1.86 years. Conjugated equine estrogen was used in 54.5%, transdermal estradiol in 41%, and oral estradiol in 4.5%. The average duration to cycling was 1.96 ± 0.78 years. A progressive increase in the use of transdermal estradiol was noted over time, with 100% of females being started on this regimen since 2008. In males, the average age of induction was 15.22 ± 1.41 years. All were started on intramuscular testosterone cypionate at various doses. The average duration to full adult replacement was 1.95 ± 0.51 years. CONCLUSION: There is no current standard of care to guide pubertal induction in adolescents with HH. However, a significant increase in the use of transdermal estrogen was noted in females during the past 10 years. While much less variability in pubertal induction was seen in males, wide disparities in doses and escalation schedules were found. Prospective studies aimed at elucidating optimal strategies for sex steroid replacement in this pediatric population are badly needed.

Discrepancies between reported self-monitored blood glucose results and point-of-care hemoglobin A1c in children with diabetes: lessons to be learned.

BACKGROUND: The hemoglobin A1c (HbA1c) assay is considered the gold standard for assessing glycemic control in children and adolescents with type 1 diabetes mellitus (T1DM). In recent years, point-of-care (POC) testing has been more commonly used in the outpatient clinic. However, despite its popularity, little is known about the accuracy of the POC methods in children. PATIENTS AND METHODS: In this case series, we describe seven children-six with T1DM and one with type 2 diabetes mellitus-who had major discrepancies between measured POC HbA1c via A1cNow+(®) (Bayer Healthcare Metrika, Sunnyvale, CA) and self-monitored blood glucose records. RESULTS: In six subjects, the discrepancy was explained by the presence of the hemoglobin S trait, and an additional subject had the hemoglobin C trait. CONCLUSIONS: This report demonstrates that as with all laboratory tests, the HbA1c test is subject to limitations, particularly in children with hemoglobin variants. Increased awareness regarding these limitations among healthcare professionals is paramount, especially with the increased use of the HbA1c POC method in the medical community. Failure to recognize these limitations can lead to unnecessary medical, financial, and social interventions that could have profound impact on the patient-doctor relationship.

A comparison of referral patterns to the pediatric endocrine clinic before and after FDA approval of growth hormone for idiopathic short stature.

BACKGROUND: Short stature is a common reason for referral to the pediatric endocrine clinic. In 2003, the US Food and Drug Administration (FDA) approved the use of growth hormone (GH) for the treatment of children with idiopathic short stature (ISS). OBJECTIVE: To explore if this indication changed referrals for short stature (SS). DESIGN/METHODS: A retrospective chart review of children seen for SS in the pediatric endocrine clinic between July 1998 and June 1999 (interval one, n=138) and July 2005-June 2006 (interval two, n=268) was performed. Variables collected included age, gender, height (h), and parental heights. RESULTS: Average height standard deviation score (HT-SDS) was -2.11 +/- 0.9 in interval one and -2.14 +/- 0.83 in interval two (p=ns). No differences in age, gender distribution, relationship between child and parental heights, the proportion of subjects started on GH for ISS or in the HT-SDS of those treated between the two intervals were identified. Nearly half of all children referred in each interval did not meet the technical criteria for short stature. CONCLUSIONS: No differences in referral patterns for SS in our area following FDA approval of GH for ISS were identified. Although referrals appear unchanged, additional investigation of GH prescribing patterns before and after this new indication is needed. Continued education of primary care physicians and the general public regarding the definition of SS and the eligibility for GH therapy should be pursued.

Medical care of girls with Turner Syndrome: where are we lacking?

OBJECTIVE: To characterize the medical care of a large cohort of girls with Turner syndrome with a focus on changes in management since establishment of international consensus guidelines in 2007. METHODS: We reviewed medical records of patients followed up for Turner syndrome between 2000 and 2010. RESULTS: A total of 128 girls aged 13.2 ± 0.5 years were identified. Average age at diagnosis was 4.1 ± 5.1 years. Overall, medical assessments performed included a hearing test in 56%, thyroid screening in 95%, renal ultrasonography in 100%, and echocardiography in 100%. Before 2007, none of the patients had screening performed for celiac disease, dyslipidemia, or liver dysfunction, and none had routine electrocardiography or cardiac magnetic resonance imaging. Since 2007, 63% were screened for celiac disease, 54% for liver abnormalities, and 38% for dyslipidemia. Electrocardiography was performed in 23%, while cardiac magnetic resonance imaging was performed in 39%. Although conjugated equine oral estrogen was the main mode of estrogen replacement, a significant increase was noted in the use of transdermal estrogen during the past 2 years compared with that observed in the earlier interval (78% vs 10%, respectively). CONCLUSIONS: Although changes in medical practice have occurred since establishment of the international Turner syndrome guidelines, screening for associated comorbidities was deficient in greater than 50% of the patients in our study. This is the first study evaluating medical care in a large cohort of pediatric patients with Turner syndrome, and our findings emphasize the need for continual education of all physicians involved in the care of this population.