Characterizing the use of osteopathic manipulative medicine in the obstetric population by trimester and indications for use

Context

Osteopathic manipulative medicine (OMM) has been shown to successfully alleviate some pregnancy-related pain. However, most of the published data focuses on the third trimester and postpartum period or musculoskeletal indications.

Objective

To explore OMM use among obstetrical providers and determine the frequency of use by trimester and by clinical indications across multiple types of women's healthcare practices in Southern and Central Maine.

Methods

An anonymous, 43-item survey, presented in English, was emailed to 172 eligible providers (physicians, nurse practitioners, and certified nurse midwives with obstetrics privileges at one of two main delivery centers in southern and central Maine) via an encrypted database system in January 2018. Follow-up email reminders were sent weekly for three weeks. Questions addressed use of OMM for specific indications, knowledge of OMM, and perceived barriers use of OMM.

Results

The survey response rate was 73 of 172 (42%); 95% of respondents were physicians (n=69). Due to the low response rate of non-physicians, only data from physicians was included in the study. Data were summarized descriptively as frequencies (n [%]). The highest rates of OMM utilization were during the third trimester (35 [51.5%]) and postpartum (41 [60.3%]) periods, while the lowest rates of utilization were in the intrapartum (eight [11.9%]) and first trimester periods (26 [38.3%]). Osteopathic physicians (n=19) used OMM more frequently in the first, second, and third trimesters, as well as the intrapartum period (10 [52.6%]; 11 [57.9%]; 14 [73.7%]; and six [31.6%], respectively) compared with their allopathic physician (n=50) counterparts (nine [8%]; 15 [30%]; 21 [42%]; and two [4%], respectively). While osteopathic physicians reported higher frequencies of OMM use and referral for non-musculoskeletal indications such as constipation, edema, and nasal congestion (13 [68.4%]; 11 [57.9%]; 10 [52.6%], respectively), musculoskeletal complaints were the most frequently cited indication for OMM use among both osteopathic and allopathic physicians (low back, 67 [97.1%]; pelvis, 65 [94.2%]; coccyx, 50 [72.5%]; and head, 49 [71%]).

Conclusion

These results suggest that more education is needed about OMM use in the obstetric population, particularly during early trimesters and the intrapartum period, as well as for visceral and lymphatic complaints of pregnancy.

Study Strategies for General Surgery Residents Preparing for the American Board of Surgery In-Training Examination: What to Keep, Discard, and Adopt

OBJECTIVE

Undergraduate and graduate education research has stratified study strategies from low-utility to high-utility with respect to durable learning. The purpose of this study was to determine the prevalence of these evidence-based learning strategies among surgery residents in preparation for the American Board of Surgery In-Training Examination (ABSITE).

DESIGN

A 23-item survey was administered during individual interviews. It assessed whether they had a study plan, and the average length and frequency of their independent study, both during the year and the month prior to the ABSITE. Data were also collected on their primary resources and study strategies. Residents rated their usage of those strategies based on a 5-point Likert scale.

SETTING

Maine Medical Center, an academic tertiary care center located in Portland, ME.

PARTICIPANTS

All residents in the Department of Surgery.

RESULTS

Residents (n= 23) intensified their preparation for the ABSITE in the month prior to the exam compared to the remainder of the year, adopting study plans (87% vs 61%, p = 0.53) and increasing the time spent studying (median, 420 vs 120 minutes per week, p < 0.001). Primary resources used were textbooks (65%), ABSITE review books (26%) and online question banks (9%). All residents (100%) often or always used testing, but fewer residents often or always used spacing (24%), both considered high-utility strategies. Most residents (60%) often or always used highlighting, considered a low-utility strategy. There were no relationships between study strategies and ABSITE scores.

CONCLUSIONS

All residents use self-testing as a study strategy. Most underuse spacing and overuse highlighting. Further research is needed to establish the relationship between these study strategies and ABSITE scores.

BIOM-23. MOLECULAR PROFILING IDENTIFIES NOVEL BIOMARKERS IN A RURAL COHORT OF PATIENTS WITH GLIOBLASTOMA

BACKGROUND

The rural state of Maine has one of the highest incidences of primary malignant brain cancer in the United States. We sought to investigate the genomic landscape of glioblastoma (GBM) in Maine.

METHODS

Targeted next generation sequencing of 209 cancer related genes was performed on tumor samples from 60 patients diagnosed with GBM at our institution between 2014 and 2019. We compared mutation frequencies between patients grouped according to the published median overall survival for GBM: &lt; 14 months (n = 14) and ≥ 14 months (n = 43, including 23 patients still alive). We excluded patients who were alive but diagnosed less than 14 months prior to analysis (n = 3).

RESULTS

Across all groups frequent molecular markers included EGFR (49%), TP53 (38%), CDKN2A (17.5%), PIK3R1 (15.8%), PDGFRA (12.2%), PIK3CA (10.5%), PTEN (19%), NF1 (10.5%) and IDH1/2 (10%); frequencies did not differ significantly between groups. MGMT methylation was similar between groups (6/14 (42.9%) in shorter survivors and 18/41 (43.9%) in longer survivors). FANC group mutations were more frequent in longer survivors (13/43 [30%] versus 0/14 [0%], p = 0.025). Among shorter survivors CDKN2A deletions were slightly more frequent (5/14 (45%) versus 5/43 (11%), p = 0.099). FES, KIAA1524, FLT (all 5/43,11.6%) and EPH (6/43, 14.0%) were only observed in longer survivors. These mutations co-occurred with 4/5 CDKN2A deletions in longer survivors. After excluding those 4 cases, CDKN2A deletions were significantly associated with shorter survival (5/14 [35.7%] versus 1/39 [2.6%]), p=0.004.

CONCLUSION

FANC group mutations may be a novel prognostic biomarker for longer survival in a rural cohort with GBM. CDKN2A deletions may be associated with shorter survival, but this may be ameliorated by co-occurring FES, KIAA1524, FLT, and EPH mutations.

Does Deep Neuromuscular Blockade Improve Operating Conditions during Minimally Invasive Anterolateral Total Hip Replacements?: A Randomized Controlled Trial

Background

Neuromuscular blockade (NMB) is thought to improve operative conditions during certain procedures. Published descriptions of minimally invasive hip replacement techniques specify the need for “excellent relaxation”, however, the optimal degree of NMB required for such cases has not been studied. We performed a randomized, single-blind study comparing the effect of moderate and deep neuromuscular blockade on surgical conditions and operating time during minimally invasive anterolateral hip replacement. Vecuronium was administered to maintain moderate NMB (train-of-four count of 1-2) or deep NMB (train-of-four count of 0, post-tetanic count of 1-2).

Methods

In this study, 116 patients were randomized to receive moderate or deep neuromuscular blockade; depth of blockade was monitored using acceleromyography. The primary outcome was the number of requests from the surgeon for additional blockade intraoperatively. Secondary outcomes included operative times and assessment of the operative conditions by the surgeon utilizing the Leiden-Surgical Rating Scale.

Results

Cases with additional requests for blockade did not differ between the deep and moderate NMB groups (11/58, 19.0% vs 8/58, 13.8%); relative risk, 1.22 (95% CI [confidence interval], 0.70-2.15), p=0.62. Neither time from incision to prosthesis reduction (33.8±1.2 min vs. 32.6 ±1.2 min; difference in geometric mean, 0.96 [95% CI, 0.90-1.04] minutes, p=0.33), nor the surgeon’s assessment of operative conditions (p=0.88), differed between the deep or moderate NMB groups, respectively. 

Conclusions

Deep NMB did not produce significantly improved operative conditions compared with moderate NMB. Routine use of deep NMB during minimally invasive anterolateral hip arthroplasty is not supported by this study.

Adolescent-to-Mother Psychological Aggression: The Role of Father Violence and Maternal Parenting Style

BACKGROUND

Adolescent-to-parent psychological aggression is often a precursor to physical aggression toward their parents. Recently, there have been 4 high-profile matricide cases that happened in China. To date, there is limited research in Confucian filial piety culture on child-to-parent psychological aggression, especially toward the mother who is overwhelming the target of children's aggression.

OBJECTIVE

The goal of this study is to explore the prevalence of adolescent-to-mother psychological aggression and examine the role of father violence and maternal parenting style in contributing to these behaviors in Confucian filial piety culture.

METHODS

Participants were 1134 students from 7 to 12 grade (M = 14 years, SD = 1.5) in Qingdao located in Shandong Province in east side of China where the Confucian Culture began. The instruments used were a demographics questionnaire, adolescent-to-mother psychological aggression questionnaire, father's violent behavior questionnaire and maternal parenting style questionnaire.

RESULTS

Two types of adolescent-to-mother psychological aggression were assessed: contempt and rebellion. The prevalence of adolescent-to-mother contempt and rebellion was 30.7% and 18.7%, respectively. Results from multiple regression analyses indicated that father's conflict with grandparents, maternal control and over-protection were positively associated with adolescent's contempt for mother. Parents divorced, father's conflict with grandparents, father-to-mother physical violence and maternal rejection were positively associated with adolescent's rebellion against mother. Maternal emotional warmth was negatively associated with adolescent's contempt and rebellion against mother.

CONCLUSION

Adolescent-to-mother psychological aggression occurs within a broader family context of violence and disharmony. Observational learning of father's conflict with grandparents or violent behaviors toward mother maybe the mechanism of violence passing from generations. However, maternal emotional warmth buffered the negative association between father's conflict with grandparents and adolescent's contempt for mother. But maternal control and over-protection exacerbated the positive relationships between father's conflict with grandparents and adolescent's contempt for mother.

Using problem formulation for fit-for-purpose pre-market environmental risk assessments of regulated stressors

Pre‐market/prospective environmental risk assessments (ERAs) contribute to risk analyses performed to facilitate decisions about the market introduction of regulated stressors. Robust ERAs begin with an explicit problem formulation, which involves among other steps: (1) formally devising plausible pathways to harm that describe how the deployment of a regulated stressor could be harmful; (2) formulating risk hypotheses about the likelihood and severity of such events; (3) identifying the information that will be useful to test the risk hypotheses; and (4) developing a plan to acquire new data for hypothesis testing should tests with existing information be insufficient for decision‐making. Here, we apply problem formulation to the assessment of possible adverse effects of RNA interference‐based insecticidal genetically modified (GM) plants, GM growth hormone coho salmon, gene drive‐modified mosquitoes and classical biological weed control agents on non‐target organisms in a prospective manner, and of neonicotinoid insecticides on bees in a retrospective manner. In addition, specific considerations for the problem formulation for the ERA of nanomaterials and for landscape‐scale population‐level ERAs are given. We argue that applying problem formulation to ERA maximises the usefulness of ERA studies for decision‐making, through an iterative process, because: (1) harm is defined explicitly from the start; (2) the construction of risk hypotheses is guided by policy rather than an exhaustive attempt to address any possible differences; (3) existing information is used effectively; (4) new data are collected with a clear purpose; (5) risk is characterised against well‐defined criteria of hypothesis corroboration or falsification; and (6) risk assessment conclusions can be communicated clearly. However, problem formulation is still often hindered by the absence of clear policy goals and decision‐making criteria (e.g. definition of protection goals and what constitutes harm) that are needed to guide the interpretation of scientific information. We therefore advocate further dialogue between risk assessors and risk managers to clarify how ERAs can address policy goals and decision‐making criteria. Ideally, this dialogue should take place for all classes of regulated stressors, as this can promote alignment and consistency on the desired level of protection and maximum tolerable impacts across regulated stressors.

Association of Early-Life Exposure to Income Inequality With Bullying in Adolescence in 40 Countries

IMPORTANCE

While the association between income inequality and interpersonal violence has been attributed to the psychosocial effects of inequality (eg, increased class anxiety, reduced social capital), longitudinal evidence for this pathway is limited by a reliance on small ecological studies and cross-sectional data. The developmental consequences of early-life inequality for subsequent involvement in violence have not been investigated.

OBJECTIVE

To examine the association between income inequality during infancy and early childhood and adolescents' involvement in bullying others, experiences of being bullied, or both.

DESIGN, SETTING, AND PARTICIPANTS

The Health Behavior in School-aged Children survey study was conducted in European and North American schools. This analysis used individual data on bullying (being bullied, bullying others, or both) from 6 consecutive school-based surveys of 11-year-old to 15-year-old students carried out in 40 countries between February 1994 to March 2014. Data analysis occurred from March 2018 to January 2019.

EXPOSURE

National Gini indices of income inequality for every year of life spanning a 35-year period (1979 to 2014).

MAIN OUTCOMES AND MEASURES

Being bullied, bullying others, and both outcomes were measured using a common definition and questions adapted from the Bully-Victim Questionnaire and translated to many languages.

RESULTS

The sample included 425 938 male students and 448 265 female students from 162 country-survey year groups in 29 196 schools. Linear regression coefficients indicated that early-life income inequality from birth to 4 years was positively associated with being bullied (male students: linear regression coefficient, 18.26 [95% CI, 11.04-25.47]; P < .001; female students: linear regression coefficient, 15.67 [95% CI, 10.02-21.33]; P < .001), and dual involvement in being bullied and bullying others (male students: linear regression coefficient, 5.55 [95% CI, 2.67-8.44]; P < .001; female students: linear regression coefficient, 2.45 [95% CI, 0.93-3.97]; P < .001), after differences in lifetime mean income inequality (from birth to when bullying was measured), national per capita income, family socioeconomic position, age, and cohort were controlled. No such association was found with bullying others after differences in being bullied were controlled.

CONCLUSIONS AND RELEVANCE

Being bullied is associated with early-life exposure to income inequality. Although further research on the underlying pathways is needed to guide intervention, these results suggest temporality in the association between inequality and violence and suggest that growing up in areas of high income inequality is associated with victimization in adolescence.

Functional connectivity across social inclusion and exclusion is related to peer victimization and depressive symptoms in young adults

BACKGROUND

Peer victimization is associated with increased risk for depression, as well as increased neural response to social exclusion in the anterior cingulate cortex (ACC) and the amygdala. Altered functional connectivity (FxC) of fronto-limbic circuitry is associated with risk for various affective disorders. The present study examined the relationship between fronto-limbic FxC during social exclusion, prior peer victimization experience and depressive symptoms.

METHODS

Three mutually exclusive groups were formed: peer victimized (with a history of peer victimization), defenders (history of defending peers), and controls (no prior peer victimization experience) (n = 15/group; M_age = 17.7 years). Functional Magnetic Resonance Imaging data were collected while participants completed the Cyberball paradigm (simulating the experience of social exclusion). FxC between the Medial Prefrontal Cortex (MPFC), ACC, right insula and left amygdala, was compared between groups and examined in relation to depressive symptoms.

RESULTS

Prior peer victimization experience was associated with differences in fronto-limbic FxC across social inclusion and exclusion. Defenders displayed distinct shifts in FxC across the transition from being included to excluded. Peer victimized individuals exhibited a unique pattern of amygdala-specific FxC during inclusive interaction with peers, and in the continuous FxC across inclusion and exclusion. FxC of the MPFC-amygdala across inclusion and exclusion moderated the relationship between peer victimization and depressive symptoms.

LIMITATIONS

Small sample size and cross-sectional design limit interpretation of the findings.

CONCLUSIONS

Peer victimized individuals who exhibit continuous positive FxC of the MPFC-left amygdala across inclusion and exclusion may be at greater risk for depressive symptoms.

The Role of Shame in the Relation Between Peer Victimization and Mental Health Outcomes

Youth who experience peer victimization are at risk of developing mental health problems. However, little is known about the emotional causal mechanisms linking peer victimization with these negative outcomes. This study investigated whether shame mediated this relationship. At three time points (T1-T3), 396 10- to 13-year-olds completed measures of peer victimization, shame (characterological, bodily, and behavioral; shame proneness), and mental health (depression, social anxiety, and externalizing behavior). Three multiple mediation models tested the indirect effects of T1 victimization on T3 mental health through the four T2 shame-related variables. Analyses revealed indirect effects for the shame-related mediators on depression, social anxiety, and externalizing behaviors. Specifically, indirect positive effects for characterological and bodily shame on depression and social anxiety were found, with greater bodily shame linked to higher levels of social anxiety in girls but not boys. In addition, an indirect negative effect for behavioral shame on externalizing problems was found, with higher levels of externalizing problems in victimized boys but not in girls. Finally, an indirect positive effect for shame proneness and externalizing problems was found. To clarify the directionality, three additional mediation models were run with mental health symptoms as predictors of shame and subsequent victimization. Indirect effects for the shame-related mediators were found for all outcomes, specifically bodily shame and shame proneness as mediators between internalizing and externalizing symptoms and victimization. These three models were compared and contrasted with the hypothesized models. In sum, findings support the role of shame as an underlying emotional mechanism of peer victimization, and may guide intervention programs to address the mental health concerns of victimized youth.

Quantitative Analysis of Surgical Residency Reform: Using Case-Logs to Evaluate Resident Experience

BACKGROUND

Curricular changes at a mid-sized surgical training program were developed to rebalance clinical rotations, optimize education over service, decrease the size of service teams, and integrate apprenticeship-type experiences. This study quantifies the operative experience before and after implementation as part of a mixed-methods program evaluation.

STUDY DESIGN

Retrospective review of case-log data and data from the Accreditation Council for Graduate Medical Education (ACGME) and the American College of Surgeons National Surgical Quality Improvement Program: quality in-training initiative to evaluate case volume pre- and postintervention.

RESULTS

11,365 cases, excluding "first-assistant" and "endoscopic" cases, were logged for an average of 291 and 263 cases/resident pre- and postintervention, respectively. Average case volume increased significantly for postgraduate year (PGY) 3 residents and decreased significantly for PGY 4 residents between the two time periods. Variability was observed among residents at the same PGY level both pre- and postintervention, with coefficients of variation of 6.0% to 34.1% in 2014 to 2015 and 11.2% to 66.8% in 2015 to 2016. Inter-resident variability persisted when comparing a specific procedure between ACGME case-log and quality in-training initiative data sets.

CONCLUSION

The data suggest that inter-resident variability in case load is not an artifact of case logging behavior alone, but may reflect personal preferences and choices in case selection that are not impacted by curriculum change. Logging behavior and accuracy of case-logs may contribute to variability. The shift in case load from PGY 4 to PGY 3 after curriculum implementation requires validation by ongoing analysis of ACGME case-log data.

1319. Examining PrEP Knowledge and Prescribing Likelihood Among Medical Residents Before and After PrEP Education

Background

Pre-exposure prophylaxis (PrEP) is effective for HIV prevention, but prescribing rates remain low. We examined the effect of an educational intervention on PrEP knowledge and prescribing likelihood among medical residents.

Methods

This was a prospective study using a convenience sample of Internal Medicine and Internal Medicine-Pediatrics residents at a tertiary care center in Portland, Maine. Participants attended a resident-led teaching session on PrEP and completed pre- and post-session surveys. PrEP knowledge was measured with five questions (definition, evidence, patient selection criteria, medication choice, and guidelines), and prescribing likelihood was assessed on a Likert scale. Participants identified motivating factors and barriers to prescribing. Survey data were analyzed with McNemar’s test or a paired Student’s t test as appropriate.

Results

Thirty residents completed the study; of these, 24 (83%) had at least 1 patient that they considered at high risk for HIV, and 14 (46%) reported having >5 such patients. None had ever prescribed PrEP. Average PrEP knowledge score increased after the intervention (pre = 2.33 vs. post = 4.1, P < 0.001). After the intervention, more participants reported that they would be likely to prescribe PrEP (pre = 76% vs. post = 90%, P = 0.014), fewer identified unfamiliarity with PrEP guidelines as a barrier (pre = 73% vs. post = 27%, P < 0.001), and Òother residents are prescribing PrEPÓ became a significant motivating factor (pre = 47% vs. post = 70%, P = 0.04). Preceptor comfort with prescribing PrEP was a consistently important influence on prescribing likelihood (90% vs. 82%, P = 0.22).

Conclusion

Familiarity with PrEP is relevant to resident practice, and an educational intervention is effective in the short term for addressing inadequate knowledge as a barrier to offering PrEP. Resident practice is influenced by preceptors and peers, suggesting that it may be helpful to include attending physicians in future PrEP education efforts at our institution.

Disclosures

All authors: No reported disclosures.

The role of shame in chronic peer victimization

Emotional reactions to peer victimization may increase risk for subsequent peer victimization. In the present study, we investigated whether shame mediated the development of chronic peer victimization, i.e., young people's experiences of being bullied persistently across time. We used a multiple mediation model to test the indirect effects of Time-1 victimization on Time-3 victimization (1 year later) through 4 Time-2 shame-related variables (characterological, bodily, and behavioral shame; shame proneness) for 396 youth (10-13 years of age). The total indirect effect of Time-1 victimization on Time-3 victimization through the 4 shame-related mediators was statistically significant. Analyses revealed specific indirect positive effects for bodily shame and shame proneness. Findings suggest that shame may be an emotional mechanism underlying chronic peer victimization. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Brief Report: Do You See What I See? The Perception of Bullying in Male Adolescents with Autism Spectrum Disorder

Although there is evidence to suggest that adolescents with autism spectrum disorder (ASD) have difficulty interpreting complex social situations, little is known about their understanding of bullying. Given the high rates of victimization in this population, it is important to investigate how adolescents with ASD comprehend bullying. Male adolescents with ASD and IQ-matched typically-developing (TD) controls (M_age = 14.62, SD = 1.91) watched six videos portraying bullying scenarios and were interviewed after each video. The interviews were coded for the participants' understanding of the bullying scenarios. Results indicated that adolescents with ASD had significantly lower bullying understanding scores than TD adolescents. These novel findings suggest that male adolescents with ASD understand bullying differently than their TD peers. Implications for experiences with victimization are discussed.

A Curriculum-Based Approach to Teaching Biosafety Through eLearning

Anyone working in biosafety capacity enhancement faces the challenge of ensuring that the impact of a capacity enhancing activity continues and becomes sustainable beyond the depletion of funding. Many training efforts face the limitation of one-off events: they only reach those people present at the time. It becomes incumbent upon the trainees to pass on the training to colleagues as best they can, whilst the demand for the training never appears to diminish. However, beyond the initial effort to establish the basic content, repeating capacity enhancement events in different locations is usually not economically feasible. Also, the lack of infrastructure and other resources needed to support a robust training programme hinder operationalizing a "train-the-trainer" approach to biosafety training. One way to address these challenges is through the use of eLearning modules that can be delivered online, globally, continuously, at low cost, and on an as-needed basis to multiple audiences. Once the modules are developed and peer-reviewed, they can be maintained on a remote server and made available to various audiences through a password-protected portal that delivers the programme content, administers preliminary and final exams, and provides the administrative infrastructure to register users and track their progress through the modules. Crucial to the implementation of such an eLearning programme is an approach in which the modules are intentionally developed together as a cohesive curriculum. Once developed, such a curriculum can be released as a stand-alone programme for the training of governmental risk assessors and regulators or used as accredited components in post-graduate degree programmes in biosafety, at minimal cost to the government or university. Examples from the portfolio of eLearning modules developed by the International Centre for Genetic Engineering and Biotechnology (ICGEB) are provided to demonstrate these key features.

The Far Ultra-Violet imager on the ICON mission

ICON Far UltraViolet (FUV) imager contributes to the ICON science objectives by providing remote sensing measurements of the daytime and nighttime atmosphere/ionosphere. During sunlit atmospheric conditions, ICON FUV images the limb altitude profile in the shortwave (SW) band at 135.6 nm and the longwave (LW) band at 157 nm perpendicular to the satellite motion to retrieve the atmospheric O/N2 ratio. In conditions of atmospheric darkness, ICON FUV measures the 135.6 nm recombination emission of O+ ions used to compute the nighttime ionospheric altitude distribution. ICON Far UltraViolet (FUV) imager is a CzernyTurner design Spectrographic Imager with two exit slits and corresponding back imager cameras that produce two independent images in separate wavelength bands on two detectors. All observations will be processed as limb altitude profiles. In addition, the ionospheric 135.6 nm data will be processed as longitude and latitude spatial maps to obtain images of ion distributions around regions of equatorial spread F. The ICON FUV optic axis is pointed 20 degrees below local horizontal and has a steering mirror that allows the field of view to be steered up to 30 degrees forward and aft, to keep the local magnetic meridian in the field of view. The detectors are micro channel plate (MCP) intensified FUV tubes with the phosphor fiber-optically coupled to Charge Coupled Devices (CCDs). The dual stack MCP-s amplify the photoelectron signals to dominate the CCD noise and the rapidly scanned frames are co-added to digitally create 12-second integrated images. Digital on-board signal processing is used to compensate for geometric distortion and satellite motion and to achieve data compression. The instrument was originally aligned in visible light by using a special grating and visible cameras. Final alignment, functional and environmental testing and calibration were performed in a large vacuum chamber with a UV source. The test and calibration program showed that ICON FUV meets its design requirements and is ready to be launched on the ICON spacecraft.

Serum Testosterone Concentrations Remain Stable Between Injections in Patients Receiving Subcutaneous Testosterone

Purpose:

Intramuscular (IM) testosterone is the most common modality for testosterone therapy of both male hypogonadism and female-to-male (FTM) gender transition. However, IM injections can be painful and often are not self-administered by the patient. The objective of this study was to further characterize subcutaneous (SC) administration of testosterone as an effective and safe alternative to IM injections by evaluating the pharmacodynamics of serum total and free testosterone concentrations between weekly testosterone injections.

Methods:

Eleven FTM transgender patients already receiving weekly SC testosterone cypionate with documented therapeutic levels prior to enrollment had free and total serum testosterone levels measured at eight different time points during a 1-week dosing interval.

Results:

Mean levels of total and free testosterone were stable and remained well within the normal range between injections. Overall mean ± standard deviation levels for the seven samples taken between injections were 627 ± 206 ng/dL (range, 205 to 1410) for total testosterone and 146 ± 51 pg/mL (range, 38 to 348) for free testosterone. No adverse effects were encountered.

Conclusions:

The results of this study support use of SC testosterone to achieve therapeutic and stable serum testosterone levels for the purpose of gender transition. It is anticipated that these results can be extended to hypogonadal men. This route may be preferred over IM testosterone because it is relatively painless and easy to self-inject thus allowing for the convenience and economy of patient self-administration.

Subcutaneous Injection of Testosterone Is an Effective and Preferred Alternative to Intramuscular Injection: Demonstration in Female-to-Male Transgender Patients

CONTEXT

Testosterone (T) is commonly administered intramuscularly to treat hypogonadal males and female-to-male (FTM) transgender patients. However, these injections can involve significant discomfort and may require arrangements for administration by others.

OBJECTIVE

We assessed whether T could be administered effectively and safely subcutaneously as an alternative to intramuscular (IM) injections.

DESIGN

Retrospective cohort study.

SETTING

Outpatient reproductive endocrinology clinic at an academic medical center.

PATIENTS

Sixty-three FTM transgender patients aged >18 years electing to receive subcutaneous (SC) T therapy for sex transition were included. Fifty-three patients were premenopausal.

INTERVENTION

Patients were administered T cypionate or enanthate weekly at an initial dose of 50 mg. Dose was adjusted if needed to achieve serum total T levels within the normal male range.

MAIN OUTCOME MEASUREMENTS

Serum concentrations of free and total T and total estradiol (E2), masculinization, and surveillance for reactions at injection sites.

RESULTS

Serum T levels within the normal male range were achieved in all 63 patients with doses of 50 to 150 mg (median, 75/80 mg). Therapy was effective across a wide range of body mass index (19.0 to 49.9 kg/m2). Minor and transient local reactions were reported in 9 out of 63 patients. Among 53 premenopausal patients, 51 achieved amenorrhea and 35 achieved serum E2 concentrations <50 pg/mL. Twenty-two patients were originally receiving IM and switched to SC therapy. All 22 had a mild (n = 2) or marked (n = 20) preference for SC injections; none preferred IM injections.

CONCLUSIONS

Our observations indicate that SC T injections are an effective, safe, and well-accepted alternative to IM T injections.

Why Worry about Bullying?

In this article, the authors review research to identify bullying as a critical public health issue for Canada. Drawing from recent World Health Organization surveys, they examine the prevalence of Canadian children and youth involved in bullying others or being victimized. There is a strong association between involvement in bullying and health problems for children who bully, those who are victimized and those involved in both bullying and being victimized. Health problems can manifest as physical complaints (e.g., headaches), mental health concerns (e.g., depression, anxiety) and psychosocial problems (e.g., substance use, crime). In Canada, there has recently been a disturbing incidence of Canadian children who have committed suicide as a result of prolonged victimization by peers. Healthcare professionals play a major role in protecting and promoting the health and well-being of Canadian children and youth. Given the significant mental and physical health problems associated with involvement in bullying, it is important that clinicians, especially primary care healthcare professionals, be able to identify signs and symptoms of such involvement. Healthcare professionals can play an essential role supporting children and their parents and advocating for the safety and protection for those at risk. By understanding bullying as a destructive relationship problem that significantly impacts physical and mental health, healthcare professionals can play a major role in promoting healthy relationships and healthy development for all Canadian children and youth. This review provides an overview of the nature of bullying and the physical and psychological health problems associated with involvement in bullying. The review is followed by a discussion of the implications for health professionals and a protocol for assessing the potential link between bullying and a child's physical and psychological symptoms.

The View From the Bottom: Relative Deprivation and Bullying Victimization in Canadian Adolescents

We investigated the relation between relative deprivation (RD)-disparity in affluence between adolescents and their more affluent schoolmates-and involvement in bullying among 23,383 students (aged 9-19) in 413 schools that participated in the 2010 Canadian Health Behavior in School-Aged Children survey. Students reported family affluence and frequency of bullying victimization and perpetration during the previous 2 months. Using the Yitzhaki index of RD and multinomial logistic regression analysis, we found that RD positively related to three types of bullying victimization (physical, relational, and cyberbullying) and to two types of perpetration (relational and cyberbullying) after differences in absolute affluence were held constant. These findings suggest that RD uniquely contributes to risk of bullying involvement.

Perceptions of Parents, Mental Health, and School Among Canadian Adolescents from the Provinces and the Northern Territories

The authors examined whether perceptions of parents and personal mental health significantly influenced perceptions of school achievement and enjoyment in a large sample of Canadian adolescents. Responses from more than 10,000 Canadian adolescents in the Health Behaviour in School-Aged Children (HBSC) survey were used to create a Parental Support Index, a Mental Health Index, and a School Index. They found a significant, medium-sized effect between the parent index and the school index. They found a similar but smaller effect for mental health. The findings were consistent for adolescents across the 10 southern provinces. However, among adolescents from the two northern territories the Parental Support Index was not significant whereas demographic factors and mental health played a larger role in predicting scores on the School Index.