I n the 30 years since gadolinium-based contrast agents (GBCAs) were first introduced to enhance MRI (1), their adoption into routine clinical practice has been prolific. Worldwide, more than 450 million doses of GBCAs have been administered and have yielded indispensable diagnostic information in virtually every organ system (2). The safety profile of GBCAs was relatively unblemished until their association with nephrogenic systemic fibrosis in 2006 (3). Clinical practice patterns were altered rapidly, and judicious use or avoidance of GBCAs in patients with

Anti-TNF-α therapy was associated with improvements in trabecular BMD and cortical structure. Improvements were greater in younger and growing participants, suggesting a window of opportunity for treatment of bone deficits.

Chronic kidney disease (CKD) is associated with increased fracture risk and skeletal deformities. The impact of CKD on volumetric bone mineral density (BMD) and cortical dimensions during growth is unknown. Tibia quantitative computed tomography scans were obtained in 156 children with CKD [69 stage 2–3, 51 stage 4–5, and 36 stage 5D (dialysis)] and 831 healthy participants, ages 5–21 years. Sex-, race-, and age- or tibia length-specific Z-scores were generated for trabecular BMD (TrabBMD), cortical BMD (CortBMD), cortical area (CortArea) and endosteal circumference (EndoC). Greater CKD severity was associated with higher TrabBMD-Z in younger participants (p < 0.001), compared with healthy children; this association was attenuated in older participants (interaction p < 0.001). Mean CortArea-Z was lower (p < 0.01) in CKD 4–5 [−0.49 (95% C.I. −0.80, −0.18)] and 5D [−0.49 (−0.83, −0.15)], compared with healthy children. Among CKD participants, parathyroid hormone (PTH) levels were positively associated with TrabBMD-Z (p < 0.01), and this association was significantly attenuated in older participants (interaction p < 0.05). Higher levels of PTH and biomarkers of bone formation (bone-specific alkaline phosphatase) and resorption (β-CTX) were associated with lower CortBMD-Z and CortArea-Z, and greater EndoC-Z (r = 0.18–0.36; all p ≤ 0.02). CortBMD-Z was significantly lower in CKD participants with PTH levels above vs. below the upper limit of the KDOQI CKD stage-specific target range: −0.46 ± 1.29 vs. 0.12 ± 1.14, p < 0.01. In summary, childhood CKD and secondary hyperparathyroidism were associated with significant reductions in cortical area and CortBMD, and greater TrabBMD in younger children. Future studies are needed to establish the fracture implications of these alterations and to determine if cortical and trabecular abnormalities are reversible.

Background: Concurrent with the evolving role of the department chair in academic medicine is the entry of women physicians into chair positions. Because implicit biases that stereotypically masculine behaviors are required for effective leadership remain strong, examining faculty members' perceptions of their chair's leadership in medical school departments with women chairs can provide insight into the views of women leaders in academic medicine and the complex ways in which gender may impact these chairs' leadership style and actions. Methods: We conducted semistructured interviews with 13 male and 15 female faculty members representing all faculty tracks in three clinical departments chaired by women. Inductive, qualitative analysis of the subsequent text allowed themes to emerge across interviews. Results: Four themes emerged regarding departmental leadership. One dealt with the leadership of the previous chair. The other three described the current chair's characteristics (tough, direct, and transparent), her use of communal actions to help support and mentor her faculty, and her ability to build power through consensus. Because all three chairs were early in their tenure, a wait and see attitude was frequently expressed. Faculty generally viewed having a woman chair as an indication of positive change, with potential individual and institutional advantages. Conclusions: This exploratory study suggests that the culture of academic medicine has moved beyond questioning women physicians' competence to lead once they are in top organizational leadership positions. The findings are also consonant with experimental research indicating that women leaders are most successful when they pair stereotypic male (agentic) behaviors with stereotypic female (communal) behaviors. All three chairs exhibited features of a transformational leadership style and characteristics deemed essential for effective leadership in academic medicine.

Background Dual-energy X-ray absorptiometry (DXA) techniques are limited in childhood chronic kidney disease (CKD) by the confounding effect of short stature and opposing parathyroid hormone effects on trabecular and cortical bone. Peripheral quantitative computed tomography (pQCT) is not subject to these limitations. Methods Lumbar spine (LS) and whole-body (WB) DXA and tibia pQCT scans were obtained in 88 stage 4–5 CKD and >650 healthy participants, ages 5–21 years. Sex- and race-specific Z-scores were generated for bone mineral density (BMD) and bone mineral content (BMC) by DXA, relative to age and adjusted for height Z-score (LS-BMD-Z and WB-BMC-Z), and compared to pQCT Z-scores for trabecular BMD (TrabBMD-Z) for age and cortical BMC (CortBMC-Z) for age and tibia length. Results LS-BMD-Z [0.50 (95% C.I. 0.28, 0.73), p<0.0001] and TrabBMD-Z [0.53 (0.27, 0.79), p<0.0001] were greater in CKD, and WB-BMC-Z [−0.36 (−0.53, −0.19), p<0.0001] and CortBMC-Z [−0.48 (−0.70, −0.27), p<0.0001] were lower, compared to reference participants. Z-scores were correlated at trabecular (LS-BMD-Z and TrabBMD-Z: R=0.36) and cortical (WB-BMC-Z and CortBMC-Z: R=0.64) sites in CKD; similar to correlations in reference participants. Conclusions Lumbar spine and whole-body DXA suggested greater trabecular BMD and lower cortical BMC in CKD, consistent with pQCT results; however, correlations were modest. Studies are needed to identify methods that predict fracture in childhood CKD.

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Short-term improvements in IGF-1 z scores predicted recovery of bone and muscle outcomes following initiation of anti-TNF-α therapy in pediatric CD. These data suggest that disease effects on growth hormone metabolism contribute to musculoskeletal deficits in CD.

Purpose Because stereotypically masculine behaviors are required for effective leadership, examining female chairs’ leadership in academic medicine can provide insight into the complex ways in which gender impacts on their leadership practices. The paper aims to discuss this issue. Design/methodology/approach The author interviewed three female clinical chairs and compared the findings to interviews with 28 of their faculty. Grounded theory analysis of the subsequent text gathered comprehensive, systematic, and in-depth information about this case of interest at a US top-tier academic medical center. Findings Four of five themes from the faculty were consistent with the chair’s narrative with modifications: Prior Environment (Motivated by Excellence), Tough, Direct, Transparent (Developing Trust), Communal Actions (Creating Diversity of Opinion), and Building Power through Consensus (an “Artful Exercise”) with an additional theme, the Significance (and Insignificance) of a Female Chair. While faculty members were acutely aware of the chair’s gender, the chairs paradoxically vacillated between gender being a “non-issue” and noting that male chairs “don’t do laundry.” All three female chairs in this study independently and explicitly stated that gender was not a barrier, yet intuitively used successful strategies derived from the research literature. Originality/value This study suggests that while their gender was highlighted by faculty, these women dismissed gender as a “non-issue.” The duality of gender for these three female leaders was both minimized and subtly affirmed.