Publications by authors named "Melissa Pawelczak"

11 Publications

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Incoming Interns Perceived Preparedness for Core Entrustable Professional Activities.

Med Sci Educ 2019 Mar 10;29(1):247-253. Epub 2019 Jan 10.

Department of Science Education and Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Blvd, Hempstead, NY 11549 USA.

Introduction: The AAMC described 13 core entrustable professional activities (EPAs) for which every graduating medical student should perform proficiently on day 1 of residency. We studied how prepared starting interns felt in the core EPAs.

Methods: Interns from a diverse health system were surveyed on how well medical school prepared them in the 13 core EPAs. Data were collected on type of medical school, participation in an acting/sub-internship (AI/SI), knowledge of EPAs, and participation in an EPA experience.

Results: We collected 224 surveys out of 384 (58%) interns. 61.2% attended allopathic, 14.6% attended osteopathic, and 24.2% attended international schools. 67% had not heard of EPAs. 29% had an EPA experience of which 82% were required. 80% or more felt prepared in all EPAs except orders (60.7%) and handovers (73%). Allopathic interns were significantly more likely to have heard of EPAs and participated in an EPA experience than international. Allopathic interns felt more prepared than international in oral presentations and evidence-based medicine. Interns who participated in an EPA experience felt more prepared for oral presentation and evidence-based medicine. There were small but significant differences in feeling prepared in certain EPAs and types of AI/SI taken.

Conclusion: The majority of interns entering residency have not heard of EPAs with fewer than 1/3 of interns participating in an EPA experience. International graduates were less likely to be aware or have experience with EPAs and report being less prepared in oral presentation and evidence-based medicine compared to allopathic graduates.
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http://dx.doi.org/10.1007/s40670-018-00685-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8368704PMC
March 2019

Program Director Perceptions of Proficiency in the Core Entrustable Professional Activities.

J Grad Med Educ 2017 Oct;9(5):588-592

Background: The Association of American Medical Colleges describes 13 core entrustable professional activities (EPAs) that every graduating medical student should be expected to perform proficiently on day 1 of residency, regardless of chosen specialty. Studies have shown wide variability in program director (PD) confidence in interns' abilities to perform these core EPAs. Little is known regarding comparison of United States Medical Licensing Examination (USMLE) scores with proficiency in EPAs.

Objective: We determined if PDs from a large health system felt confident in their postgraduate year 1 residents' abilities to perform the 13 core EPAs, and compared perceived EPA proficiency with USMLE Step 1 and Step 2 scores.

Methods: The PDs were asked to rate their residents' proficiency in each EPA and to provide residents' USMLE scores. Timing coincided with the reporting period for resident milestones.

Results: Surveys were completed on 204 of 328 residents (62%). PDs reported that 69% of residents (140 of 204) were prepared for EPA 4 (orders/prescriptions), 61% (117 of 192) for EPA 7 (form clinical questions), 68% (135 of 198) for EPA 8 (handovers), 63% (116 of 185) for EPA 11 (consent), and 38% (49 of 129) for EPA 13 (patient safety). EPA ratings and USMLE 1 and 2 were negatively correlated ((101) = -0.23,  = .031).

Conclusions: PDs felt that a significant percentage of residents were not adequately prepared in order writing, forming clinical questions, handoffs, informed consent, and promoting a culture of patient safety. We found no positive association between USMLE scores and EPA ratings.
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http://dx.doi.org/10.4300/JGME-D-16-00864.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5646915PMC
October 2017

Evaluation of the pro-inflammatory cytokine tumor necrosis factor-α in adolescents with polycystic ovary syndrome.

J Pediatr Adolesc Gynecol 2014 Dec 23;27(6):356-9. Epub 2014 Sep 23.

Division of Pediatric Endocrinology, Department of Pediatrics, New York University School of Medicine, New York, New York. Electronic address:

Background: Patients with polycystic ovary syndrome (PCOS) often suffer from comorbidities associated with chronic inflammation characterized by elevations in pro-inflammatory cytokines. There is limited data on markers of chronic inflammation, in particular Tumor Necrosis Factor-alpha (TNF-α), in adolescents with PCOS.

Objectives: To compare serum levels of TNF-α in overweight or obese adolescents with PCOS and obese controls. In the PCOS group, to correlate serum TNF-α levels with body mass index (BMI) z-score, severity of hyperandrogenism, degree of insulin resistance, and ovarian ultrasonographic characteristics.

Methods: We performed a cross-sectional retrospective analysis of clinical and biochemical findings in 23 overweight or obese adolescent females with PCOS (mean BMI z-score 2, mean age 15.2 yrs) and 12 obese age- and sex-matched controls (mean BMI z-score 2, mean age 14.1 y). All subjects were post-menarchal. Serum TNF-α levels were compared between groups. In the PCOS group, cytokine levels were correlated with BMI z-score, androgen levels, fasting insulin and glucose levels as well as ovarian ultrasonographic features.

Results: Both groups were comparable in age, BMI z-score, fasting glucose, and fasting insulin. Mean free testosterone was 9.76 ± 5.13 pg/mL in the PCOS group versus 5 ± 2.02 pg/mL in the control group (P = .0092). Serum TNF-α was 7.4 ± 4 pg/mL in the PCOS group versus 4.8 ± 3.16 pg/mL in the control group (P = .0468). There was no significant correlation between serum TNF-α and BMI z-score, free testosterone, fasting insulin, or fasting glucose. No correlation existed between serum TNF-α and ovarian follicle number, distribution, or volume.

Conclusions: Serum TNF-α is elevated in overweight/obese adolescents with PCOS. Chronic inflammation in adolescents with PCOS render them at a potential increased risk for the development of atherosclerosis, type 2 diabetes, cancer, infertility, and other comorbidities. Every effort should be made to identify adolescents with PCOS early and initiate aggressive therapy to prevent future complications.
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http://dx.doi.org/10.1016/j.jpag.2014.01.104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4536070PMC
December 2014

Elevated serum anti-Müllerian hormone in adolescents with polycystic ovary syndrome: relationship to ultrasound features.

J Pediatr Endocrinol Metab 2012 ;25(9-10):983-9

Department of Pediatrics, New York University School of Medicine, New York, NY, USA.

Context: Serum anti-Müllerian hormone (AMH) is linked to the ovarian follicle pool. Little is known about the relationship between serum AMH and ovarian ultrasound (US) features in adolescents with polycystic ovary syndrome (PCOS).

Objectives: To confirm that serum AMH is elevated in adolescents with PCOS and to correlate serum AMH with ovarian US features in this population are the objectives of this study.

Design: A retrospective chart review of clinical, biochemical, and ultrasonographic data in adolescents with PCOS and normal controls is the design of the study. Serum AMH was measured and compared between groups and correlated with ovarian US findings.

Setting: The study was done in two urban tertiary academic medical centers.

Participants: Study groups included 23 adolescent females with PCOS and 12 age and BMI-matched female controls.

Main Outcome Measures: We hypothesized that serum AMH would be elevated in the PCOS group compared with the controls and would positively correlate with the follicle number, distribution, and ovarian volume.

Results: Serum AMH was 6.78±3.55 ng/mL in the PCOS group vs. 3.38±1.48 ng/mL in the controls (p=0.0004). AMH positively correlated with ovarian volume (left ovary r=0.65, p=0.0007, right ovary r=0.55, p=0.0065) and peripheral follicle distribution (p=0.0027). Ten or more follicles were observed in 83% of USs.

Conclusions: There is a positive relationship between serum AMH and ovarian volume as well as peripheral follicular distribution in adolescents with PCOS. Our findings support the use of serum AMH as a useful marker to reflect ovarian US features typical of PCOS in cases where accurate USs are not available and for follow-up.
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http://dx.doi.org/10.1515/jpem-2012-0013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3763943PMC
April 2013

Improved long-term glucose control in neonatal diabetes mellitus after early sulfonylurea allergy.

J Pediatr Endocrinol Metab 2012 ;25(3-4):353-6

Division of Pediatric Endocrinology, Department of Pediatrics, New York University Langone Medical Center, New York, NY 10016, USA.

Background: Activating mutations of the ABCC8 gene can lead to permanent neonatal diabetes mellitus (PNDM). Glucose variability in infants with NDM treated with insulin can be extreme. We report long-term glycemic control in a patient with PNDM on sulfonylurea therapy, despite initial allergic reaction.

Methods: A Chinese girl presented on the first day of life with persistent hyperglycemia. Despite treatment with various insulin regimens, hemoglobin (Hb)A1c (normal 4.8%-6.3%) increased from 5.0% at 14 days of age to a peak of 9.7% at 15 months of age. Her average insulin dose was 0.5 units/kg/day. Genetic analysis revealed two novel ABCC8 gene activating mutations encoding the beta-cell sulfonylurea-1 receptor of the ATP-sensitive potassium channel. At age 3 years 2 months, transition from insulin to the oral sulfonylurea glyburide was initiated. After 8 days, she developed urticaria, palmar erythema, and a diffuse maculopapular rash, which resolved when medication was discontinued. At age 3 years 11 months, glyburide was reintroduced at a very low dose and was increased with concomitant weaning of insulin over the following 6 months.

Results: Normoglycemia (HbA1c 5.6%) was achieved on glyburide without any further allergic reaction at the age of 4 years 5 months with improved metabolic control. For the next 3 years, HbA1c measurements, and glucose means and variability were significantly lower compared with values during insulin therapy.

Conclusions: As compared with subcutaneous insulin, oral sulfonylureas improved long-term metabolic control in a patient with NDM caused by novel activating mutations in the ABCC8 gene. Desensitization permitted safe oral sulfonylurea therapy in our patient with NDM despite initial allergic reaction. Fewer episodes of hypoglycemia occurred on sulfonylurea than on insulin therapy, which is an advantage in a very young child.
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http://dx.doi.org/10.1515/jpem-2011-0449DOI Listing
July 2012

Age of onset of polycystic ovarian syndrome in girls may be earlier than previously thought.

J Pediatr Adolesc Gynecol 2011 Feb;24(1):15-20

Department of Pediatrics, New York University School of Medicine, New York, NY, USA.

Objectives: To study the age at diagnosis of polycystic ovarian syndrome (PCOS) in a pediatric population. To compare risk factors involved in causing PCOS in preadolescent and adolescent girls. To review the current literature on the reported age of PCOS in girls.

Design: A retrospective chart review and systematic review of the literature.

Participants: Patients included 58 girls (age ≤ 18 yrs) with a diagnosis of PCOS based on the Rotterdam criteria. Girls were grouped as preadolescents (<13 yrs) or adolescents (13-18 yrs). Clinical and biochemical data were reviewed from the time of diagnosis.

Main Outcome Measures: Age at diagnosis. Differences in risk factors for PCOS (Ethnicity, obesity, family history of PCOS, birth weight, age at pubarche, thelarche and menarche, evidence of hyperandrogenism and/or insulin resistance) were compared between the two groups.

Results: There were 26% (15/58) preadolescent girls (9-12 yrs) vs 74% (43/58) adolescents (13-18 yrs). There was no significant difference between the two groups in ethnicity, BMI z-score, family history of maternal PCOS, birth weight, hyperandrogenism, or insulin resistance. Preadolescents with PCOS had significantly earlier onset of pubarche and thelarche than adolescents with PCOS, by 1.9 and 1.5 yrs, respectively (P = 0.018, 0.030). In addition to earlier puberty, PCOS developed 2.1 years sooner after thelarche in preadolescents than in adolescents. (P = 0.008) Preadolescents were significantly taller for age than adolescents (72nd % vs 43rd %) (P = 0.005). A review of the 28 studies published in the last 3 years that included PCOS patients with age <=18 yrs described only 6.4% (27/425) of pediatric subjects with age <13 yrs. Four were primarily pediatric studies that included patients under the age of 13 yrs, with 9.4% (12/127) of the patients <13 yrs.

Conclusion: Increased awareness of PCOS in young females is needed. PCOS may occur at a younger age in girls who develop early pubarche and thelarche. Therefore, the diagnosis and workup should be considered in young girls with risk factors suggestive of PCOS.
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http://dx.doi.org/10.1016/j.jpag.2010.06.003DOI Listing
February 2011

Outcomes of children and adolescents with well-differentiated thyroid carcinoma and pulmonary metastases following ¹³¹I treatment: a systematic review.

Thyroid 2010 Oct;20(10):1095-101

Department of Pediatrics, Division of Pediatric Endocrinology, New York University School of Medicine, 530 1st Avenue, New York, NY 10016, USA.

Background: The optimal dose and efficacy of ¹³¹I treatment of children and adolescents with well-differentiated thyroid carcinoma (WDTC) and pulmonary metastases are not well established. A therapeutic challenge is to achieve the maximum benefit of ¹³¹I to decrease disease-related morbidity and obtain disease-free survival while avoiding the potential complications of ¹³¹I therapy.

Summary: We systematically reviewed the published literature on children and adolescents with WDTC and pulmonary metastases treated with ¹³¹I to examine outcomes after ¹³¹I administration and the risks and benefits of therapy. After reviewing 14 published articles, 9 articles met our inclusion criteria encompassing 112 pediatric and adolescent patients with WDTC and pulmonary metastases 21 years of age or younger at diagnosis spanning a follow-up period of 0.6–45 years. ¹³¹I therapy after surgery and thyrotropin suppression resulted in complete, partial, and no disease response in 47.32%, 38.39%, and 14.29% of patients, respectively. Five studies provided data on disease response in relation to ¹³¹I dose. In general, nonresponders received the highest ¹³¹I doses and complete responders received a higher dose than partial responders. The disease-specific mortality rate was 2.68%. Survival was 97.32%. A second primary malignancy occurred in one patient. One out of 11 patients studied experienced radiation fibrosis.

Conclusions: This review confirms that the majority of pediatric and adolescent patients with WDTC and pulmonary metastases treated with ¹³¹I do not achieve complete response to therapy, yet disease-specific morbidity and mortality appear to remain low. It is therefore prudent to use caution in the repeated administration of ¹³¹I to such patients to ensure that adverse effects of therapy do not cause more harm than good in a disease that has an overall favorable natural course. Long-term prospective studies are needed to analyze disease-specific morbidity and mortality, recurrence rate, dose-specific response, and dose-related adverse effects of ¹³¹I in this patient population.
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http://dx.doi.org/10.1089/thy.2009.0446DOI Listing
October 2010

Thyrotropin-secreting pituitary adenoma in an adolescent boy: challenges in management.

Pediatrics 2010 Aug 12;126(2):e474-8. Epub 2010 Jul 12.

Department of Pediatrics, New York University Medical Center, New York, NY 10016, USA.

Thyrotropinomas tend to be aggressive, invasive tumors that are difficult to resect because of their marked fibrosis and their proximity to vital structures such as the optic chiasm. The latter characteristic also limits the use of radiation therapy. In the few cases reported of children younger than 18 years whose thyrotropinomas were treated surgically, the results were disappointing. We present here the case of a 16-year-old boy with a thyrotropin-secreting pituitary macroadenoma who underwent partial resection via a transsphenoidal approach and was left with significant residual tumor and continued hyperthyroidism. He subsequently received 4 years of long-acting release somatostatin therapy, during which he has remained euthyroid without requiring antithyroid medication. To our knowledge, this is thus far the longest duration of somatostatin therapy in the pediatric age group. This regimen also achieved a decrease in compression of the optic nerve and prevented further tumor growth. We review here the current literature on somatostatin analog treatment including molecular mechanisms and promising new treatment modalities, such as the heterodimerization of dopamine and somatostatin receptors. We conclude that this has been a useful adjuvant treatment for our adolescent patient.
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http://dx.doi.org/10.1542/peds.2009-2354DOI Listing
August 2010

The prevalence of abnormal liver enzymes and metabolic syndrome in obese adolescent females with polycystic ovary syndrome.

J Pediatr Adolesc Gynecol 2009 Oct 2;22(5):318-22. Epub 2009 Jul 2.

New York University School of Medicine, New York, New York, USA.

Objectives: We sought to determine the prevalence of abnormal liver enzymes suggestive of nonalcoholic steatohepatitis and metabolic syndrome in obese adolescent females with polycystic ovary syndrome.

Design: A retrospective chart review.

Participants: Patients included 39 obese (body mass index Z score >/= 2) adolescent females with a diagnosis of polycystic ovary syndrome. Clinical and biochemical data in these patients were reviewed.

Main Outcome Measures: Aspartate and alanine aminotransferase levels, lipid panel, blood pressure, body mass index, and glucose intolerance were the main outcome measures of the study.

Results: The study showed that 15.4 % (6 of 39) of patients had elevated aminotransferase levels, suggestive of nonalcoholic steatohepatitis, and 43.6 % (17 of 39) of patients qualified as having metabolic syndrome. Finally, 10.2 % (4 of 39) of patients were found to have both liver dysfunction and metabolic syndrome.

Conclusion: Liver dysfunction consistent with nonalcoholic steatohepatitis and metabolic syndrome are prevalent in obese adolescent females with polycystic ovary syndrome. Therefore, early screening and further work-up for both disease states are warranted in cases of young adolescent females with polycystic ovary syndrome.
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http://dx.doi.org/10.1016/j.jpag.2009.03.003DOI Listing
October 2009

Evaluation of adolescents for polycystic ovary syndrome in an urban population.

J Clin Res Pediatr Endocrinol 2009 5;1(4):188-93. Epub 2009 May 5.

Department of Pediatric Endocrinology, New York University School of Medicine, New York, NY 10016, USA.

Objective: To assess the quality of diagnostic work-up received by patients with "possible" polycystic ovary syndrome (PCOS).

Design: A retrospective chart review.

Setting: A hospital based Pediatric Clinic in New York City.

Patients: Sixty female patients aged 13-19 years, with a primary ICD-9 diagnosis of ovarian dysfunction (256), menstrual irregularity (626), or hirsutism (704.1) were randomly selected for evaluation. In addition, 18 patients who were assigned the same ICD-9 codes at the Pediatric Endocrine Clinic were assessed.

Main Outcome: Rates of assessment for diagnostic criteria of PCOS and selected co-morbidities.

Results: Twenty-five percent (15/60) of the patients were evaluated for PCOS according to the Rotterdam Criteria, and only 2 were evaluated for common co-morbidities associated with PCOS. Of the 28 patients who presented with two or more signs of PCOS (menstrual irregularity plus either obesity, hirsutism and/or acne), 15 were evaluated for PCOS (54%), but only 7% were assessed for common co-morbidities. All patients referred to the Pediatric Endocrine Clinic received appropriate evaluation for PCOS. In addition, 89% of the study group underwent further assessment for selected complications of PCOS.

Conclusions: Patients presenting to an inner-city pediatric clinic with "possible" PCOS often do not receive a complete diagnostic evaluation. In addition, those evaluated for PCOS are often not adequately screened for the known health consequences associated with this condition. These findings suggest that PCOS is under evaluated and possibly under diagnosed in this pediatric population, which raises serious concerns regarding the potential for major longterm public health consequences.
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http://dx.doi.org/10.4274/jcrpe.v1i4.50DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3005652PMC
December 2011
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