Prescription Pain Reliever Misuse Among Transgender and Gender Diverse Adults

Purpose

Little is known about the prevalence and risks associated with transgender and gender diverse (TGD) persons' misuse of prescription pain relievers (PPRs). This study explores the relationship between PPR misuse and various sociodemographic identities and experiences of discrimination in health care among TGD adults.

Methods

TGD participants (n=595) were recruited in 2018 to participate in a cross-sectional statewide trans health survey through convenience sampling. Chi-square tests of independence and logistic regressions were conducted to explore associations between sociodemographics and experiences of discrimination among persons who had ever misused PPRs, or who had misused PPRs in the past year.

Results

Sociodemographics such as gender identity (odds ratio [OR]=0.44, p=0.01), race/ethnicity (OR=0.14, p<0.001), and sexual orientation influence TGD individuals likeliness of misusing PPRs (OR=0.40, p<0.001). Notably, those who were ever diagnosed with anxiety had a higher likeliness of having lifetime PPR misuse compared with those who were never diagnosed (OR=2.05, p=0.05), and those reporting past-year discrimination within the mental health care setting because of their gender identity were more than twice as likely to report past-year misuse than those who reported not experiencing it (OR=2.43, p=0.004).

Conclusion

Certain subpopulations of TGD individuals may be at elevated risk of PPR misuse. It is imperative to acknowledge the impact of multimarginalized identities as well as differences across various identities and experiences within the TGD community while working to address non-PPR misuse.

Newly self-administered two-step tool for screening cognitive function in an ageing Chinese population: an exploratory cross-sectional study

Background

Early screening of cognitive function is critical to dementia treatment and care. However, traditional tests require face-to-face administration and are often limited by implementation costs and biases.

Aims

This study aimed to assess whether the Thoven Cognitive Self-Assessment (TCSA), a novel, innovative two-step touchscreen-based cognition assessment tool, could identify early cognitive impairment due to dementia in older adults.

Methods

The TCSA was administered to 61 healthy controls (HCs), 46 participants with mild cognitive impairment (MCI) and 44 participants diagnosed with dementia recruited from Shanghai. Two outcome measures were generated from the TCSA test: the TCSA_{primary task} score and the TCSA_{secondary task} score.

Results

The total average scores in the control group for the TCSA_{primary task} and TCSA_{secondary task} were significantly higher than those in the MCI and dementia groups (TCSA_{primary task}: HCs vs MCI group vs dementia group, 8.58±1.76 vs 5.40±2.67 vs 2.74±2.11, F=75.40, p<0.001; TCSA_{secondary task}: HCs vs MCI group vs dementia group, 23.02±3.31 vs 17.95±4.93 vs 11.93±5.50, F=76.46, p<0.001). Moreover, receiver operating characteristic analysis showed that a score below 7.5 for the TCSA_{primary task} and a score below 22.5 for the TCSA_{secondary task} were indicators of MCI.

Conclusions

The TCSA appears to be efficacious for the detection of cognitive impairment in older adults. It demonstrates the potential for large-scale cognition screening in community service settings.

Gynecological Providers' Willingness to Prescribe Gender-Affirming Hormone Therapy for Transgender Patients

Purpose

Transgender individuals face barriers to accessing gender-affirming hormone therapy, yet little is known about gynecological providers' willingness to provide such care.

Methods

We surveyed gynecological providers in one healthcare system to determine their willingness to prescribe hormone therapy (HT) for transgender patients and factors associated with willingness to both initiate and refill HT.

Results

Among respondents (N = 60), 60.3% and 27.6% were willing to refill and initiate HT for transgender patients, respectively. Willingness to refill HT was associated with having met a transgender person and lower transphobia. Unwillingness was associated with lack of transgender health training, lack of staff knowledge about transgender health, and unfamiliarity with transition guidelines. Willingness to initiate HT was associated with younger age and resident status. Unwillingness was associated with unfamiliarity with transition guidelines.

Conclusion

While gynecological providers are qualified to prescribe HT for transgender patients, willingness to do so may be influenced by both personal and educational/training factors. Encouraging and training gynecological providers to provide gender-affirming HT will help to increase access for transgender individuals.

Dementia-friendly initiatives within the context of COVID-19 pandemic: Challenges and strategies perceived by service professional stakeholders from the USA and China

Purposes

Dementia-friendly initiatives (DFI) are community-based movements aimed to address stigma, exclusion, and discrimination associated with dementia. This study examined the challenges faced and strategies used by DFI prior to and during the COVID-19 pandemic from the perspectives of stakeholders in the USA and China.

Methods

Qualitative interviews with 17 stakeholders involved in DFI from the United States and mainland China were conducted via the Zoom platform. Semi-structured interview questions focused on DFI challenges and strategies prior to and during the pandemic. Thematic analysis was used to analyze the data.

Results

Three major challenges prior to the COVID-19 pandemic included low participation of persons with dementia, difficulties in building community collaborations, and limited funding and resources needed to sustain DFI. During the COVID-19 pandemic, challenges included exacerbated difficulties of involving persons with dementia and reduced policy support for DFI. Strategies implemented prior to COVID-19 included partnerships with community organizations to outreach and engage persons with dementia, and coordination of resources and diversification of funding sources to sustain DFI. Strategies during the COVID-19 pandemic centered on the implementation of person-centered technology to support persons with dementia and family caregivers, and the development of new programs that integrated efforts to address the impact of COVID-19.

Implications

DFI in the USA and mainland China shared similar challenges for DFI prior to and during COVID-19. During the COVID-19 pandemic, DFI in both countries showed resourcefulness through reliance on technology, community collaboration, and COVID-19–related resources to provide support and services. While it remains critical to advocate to the central government to fund DFI, DFI in both societies need to be open to other funding sources, hire persons with dementia as key staff members of DFI, and demonstrate its effectiveness through rigorous evaluation.

Suicide Attempts Among a Cohort of Transgender and Gender Diverse People

INTRODUCTION

Transgender and gender diverse people often face discrimination and may experience disproportionate emotional distress that leads to suicide attempts. Therefore, it is essential to estimate the frequency and potential determinants of suicide attempts among transgender and gender diverse individuals.

METHODS

Longitudinal data on 6,327 transgender and gender diverse individuals enrolled in 3 integrated healthcare systems were analyzed to assess suicide attempt rates. Incidence was compared between transmasculine and transfeminine people by age and race/ethnicity and according to mental health status at baseline. Cox proportional hazards models examined rates and predictors of suicide attempts during follow-up. Data were collected in 2016, and analyses were conducted in 2019.

RESULTS

During follow-up, 4.8% of transmasculine and 3.0% of transfeminine patients had at least 1 suicide attempt. Suicide attempt rates were more than 7 times higher among patients aged <18 years than among those aged >45 years, more than 3 times higher among patients with previous history of suicide ideation or suicide attempts than among those with no such history, and 2-5 times higher among those with 1-2 mental health diagnoses and more than 2 mental health diagnoses at baseline than among those with none.

CONCLUSIONS

Among transgender and gender diverse individuals, younger people, people with previous suicidal ideation or attempts, and people with multiple mental health diagnoses are at a higher risk for suicide attempts. Future research should examine the impact of gender-affirming healthcare use on the risk of suicide attempts and identify targets for suicide prevention interventions among transgender and gender diverse people in clinical settings.

TECHNOLOGY USE IN RURAL DEMENTIA CARE: PERSPECTIVES FROM FAMILY CAREGIVERS, PWD, AND SERVICE PROFESSIONALS

Purpose: The use of technology in dementia care has shown promising benefits for both people living with dementia and their family caregivers, however, little is known regarding how technology is used among families affected by dementia who reside in rural communities. The purpose of this study was to explore technology use and barriers among people living with dementia, family caregivers, and service professionals who live in rural areas of Michigan. Methods: This study was based upon focus group data from six groups of family caregivers (n=32); one group of people living with early stages of dementia (n=4), and one group of service professionals (n=4) recruited from rural counties in Michigan. Results: Technology use included assisting caregiving tasks (e.g., monitoring a wandering care recipient), facilitating treatment (e.g., access treatment through telemedicine), and providing social connection and support. Themes related to strategies included addressing educational needs of young older and old-older caregivers, providing step-by-step toolkits, and collaborating with multi-sectors (e.g., public libraries, grocery stores, and churches). Discussion: Findings suggest a great need to facilitate technology literacy and competency for rural family caregivers to access caregiving resources. To effectively reach out to this population, technology methods such as local TV news network, radio, and newspaper are still beneficial. Health and social service professionals should consider collaborations with public service institutions (e.g. libraries) and faith-based organizations to include educational workshops about technology in their curriculum and training programs for dementia family caregivers.

Management of tetralogy of fallot with pulmonary atresia

Tetralogy of Fallot with Pulmonary Atresia is an extreme form of tetralogy characterized by absence of flow from the right ventricle to the pulmonary arteries. Pulmonary blood flow is derived from a variety of sources, including native pulmonary artery branches and aorto-pulmonary collaterals with significant variability from patient to patient. Management must therefore be individualized to each patient's anatomy and physiology. Cardiac catheterization plays a crucial diagnostic and therapeutic role in this group of patients. This article is a concise review of the spectrum of anatomic variability seen in this lesion with an emphasis on diagnostic and therapeutic catheterization . It also highlights our staged surgical approach to this lesion and provides data on long-term outcome after complete intracardiac repair.

Results of the double switch operation in the current era

BACKGROUND

In patients with atrioventricular and arterioventricular discordance congenitally corrected transposition, the morphologically right ventricle may progressively deteriorate while functioning in the systemic circuit. The double switch operation has been proposed to limit this functional deterioration.

METHODS

From October 1993 to August 1998, the records of 27 patients with congenitally corrected transposition were reviewed. Age at operation ranged from 3 months to 55 years. Associated defects included ventricular septal defects in 18, pulmonary atresia in 7, and pulmonary stenosis in 11 patients. Twenty-two patients had double switch operations (10 arterial switch plus Senning procedures and 12 Rastelli plus Senning procedures). Five patients were not candidates for the double switch. Before the double switch, 6 patients required pulmonary artery banding and 10 had functioning systemic to pulmonary artery or cavopulmonary shunts.

RESULTS

There was no early or late mortality. Two patients required pacemaker implantation, both later regained normal sinus rhythm. Tricuspid valve function improved in all patients except one. Moderate left ventricular dysfunction developed 5 months postoperatively in 1 patient.

CONCLUSIONS

The double switch operation can be performed in selected patients with minimal early morbidity and mortality. Longer follow-up is necessary to determine whether this complex approach is indeed warranted.

Transcatheter coil occlusion of perivalvular mitral leaks associated with severe hemolysis

A 6-year-old malnourished child had persisting hemolysis after attempted valve repair and two surgeries for mitral valve replacement due to partial dehiscence of the valve ring. A modified catheter delivery system was utilized to deploy a total of six Gianturco coils. The hemolysis resolved and the patient was doing well 17 months later. The technique may be helpful in other patients with perivalvular mitral leaks. Cathet. Cardiovasc. Intervent. 49:64-67, 2000.

Transcatheter coil embolization of abnormal vascular connections using a new type of delivery catheter for enhanced control

A new type of delivery catheter, designed with a 0.033-inch distal tip that grips a 0.038-inch Gianturco coil, was used to occlude 61 abnormal vascular connections in 44 patients with a complete closure rate of 87%. Withdrawal (n = 6) or repositioning (n = 2) of an inappropriately positioned coil was necessary in 8 of 44 patients, and was successfully achieved in all by the delivery catheter without need for additional equipment.

Progressive tricuspid valve disease in patients with congenitally corrected transposition of the great arteries

BACKGROUND

The outcome of patients with corrected transposition of the great arteries (CTGA) is variably affected by associated intracardiac defects, tricuspid valve competence, and systemic right ventricular (RV) function. The relative importance of these factors in long-term outcome has not been evaluated.

METHODS AND RESULTS

Since 1958, 40 patients with CTGA were studied to determine risk factors for poor outcome, including age, open heart surgery, tricuspid insufficiency (TI), cardiac rhythm, pulmonary overcirculation, and RV dysfunction. Follow-up ranged from 7 to 36 years (mean 20 years). Intracardiac repair was performed in 21 patients; 19 were unoperated or had closed heart procedures. For the purposes of this study the designation TI(S) refers to at least moderately severe TI as delineated by echocardiogram and/or angiography. TI(s) was the only independently significant factor for death (P=0.01), and in turn, only the presence of a morphologically abnormal TV predicted TI(s)(P=0.03). Twenty-year survival without TI(S)was 93%, but only 49% with TI(S). Poor long-term postoperative outcome was due to TI(S) in all but 1 patient; 20-year survival rates for operated patients with and without TI(s)were 34% and 90%, respectively (P=0.002). Similarly, 20-year survival rates for unoperated patients with and without TI(s)were 60% and 100%, respectively, whether or not attempts to repair the TI were made (P=0.08).

CONCLUSIONS

TI(S)represents the major risk factor for CTGA patients; RV dysfunction appears to be almost always secondary to long-standing TI. Decisions related to surgical interventions with or without associated lesions must be strongly influenced by the status of the tricuspid valve.

Comparison of cost and clinical outcome between transcatheter coil occlusion and surgical closure of isolated patent ductus arteriosus

OBJECTIVE

The objective of this study was to compare the cost (measured as resource utilization by the institution) and clinical effectiveness of transcatheter coil occlusion and surgical patent ductus arteriosus (PDA) closure. Similar comparisons have been made previously with other devices no longer in use in the United States. No such comparison has been made for coil occlusion, which has been performed increasingly since 1992.

METHODS

All patients who underwent either coil or surgical closure of uncomplicated PDA at our institution between August 1993 and June 1996 were retrospectively identified. Patients were included in the study if they were eligible for either closure technique. Thus, they had a restrictive PDA (not associated with pulmonary hypertension) and no overt evidence of congestive heart failure. Patients were excluded if they had other significant cardiac or noncardiac problems. Total procedural and recovery costs (including labor, material, equipment, and overhead) incurred by the provider were determined using a cost accounting system called Transition Systems, Inc. To define further how costs differed for the two techniques, total costs were subdivided into the categories of professional, technical, inpatient hospital stay, postprocedure testing, and supplies and other miscellaneous costs. PDA closure rates and associated complications also were compared. Follow-up information was sought from outpatient visits to our institution or by contacting the referring physicians.

RESULTS

A total of 39 patients were identified, 3 of whom were excluded because of coexisting medical problems. The study group consisted of 36 patients; 24 underwent PDA coil occlusion and 12 surgical closure. Mean age and weight were 8.8 years and 28.5 kg for the coil patients, and 7.3 years and 32.8 kg for the surgical patients. Median procedural duration was 150 minutes for the coil group and 165 minutes for the surgical group. The total cost to the institution of coil occlusion was significantly lower than that of surgical closure ($5273 vs $8509). The largest difference lay in the cost of hospital stay ($398 vs $2566) and in the professional costs ($1506 vs $2782). Technical costs were similar ($2156 for coil, $2151 for surgery), although use of the catheterization laboratory per unit of time was more expensive than use of the operating room ($800 vs $400 per hour). Additional technical costs of the surgical procedure related to general anesthesia and postoperative care made up the difference. No patient in either group had a residual PDA murmur at hospital discharge or thereafter. Follow-up echocardiography was performed in all coil occlusion patients, and tiny residual leaks were detected in 17%. Only 42% of the surgical patients had postoperative echocardiography; none had residual leaks. There were no deaths or major complications in either group.

CONCLUSIONS

Transcatheter coil occlusion is as effective and less costly than surgical closure if silent residual leaks are not considered clinically significant. This information may be used increasingly in patient care decisions in the current era of managed medical care.

Use of balloon-expandable stents for coarctation of the aorta: initial results and intermediate-term follow-up

OBJECTIVES

In this study we report our preliminary results and intermediate-term follow-up (up to 3.5 years) of stent implantation for coarctation of the aorta (COA).

BACKGROUND

Balloon angioplasty has gained acceptance as a modality of treatment for COA. Some patients do not respond optimally to balloon angioplasty alone. Balloon-expandable stents have been used in pulmonary arteries and large systemic arteries such as the femoroiliac vessels, with a significant improvement in vessel patency and a reduction in the pressure gradient compared with balloon angioplasty alone.

METHODS

Nine patients (>10 years old) with COA in whom balloon dilation alone was thought to be ineffective underwent stent implantation. Seven patients had a previous operation or balloon dilation, or both, to relieve their coarctation but had a significant residual/recurrent gradient.

RESULTS

At the time of stent implantation, the systolic and mean gradients decreased from a mean (+/-SEM) of 37 +/- 7 and 14 +/- 3 mm Hg to 4 +/- 1 and 2 +/- 0.6 mm Hg, respectively (p < or = 0.002). The coarctation diameter increased from a mean of 9 +/- 1 to 15 +/- 1 mm (p < 0.002). The patients have been followed for up to 42 months (mean 18, median 13) with no complications; the stents remain in position with no fracture. One patient underwent further successful dilation 3 years after stent implantation because of an exercise-induced gradient. No other intervention has been required. The systolic gradient at latest follow-up is 7 +/- 2 mm Hg. Only two (a 44-year old with diabetes and a 50-year old with long-standing hypertension) of five patients previously requiring antihypertensive treatment still remain on medications for blood pressure control.

CONCLUSIONS

The use of stents in COA is a feasible alternative to surgical repair or balloon angioplasty in selected patients with an effective gradient reduction. Intermediate-term follow-up shows excellent gradient relief, with no complications in this group of patients.

Multicultural issues in organ transplantation: the influence of patients' cultural perspectives on compliance with treatment

The potential influence of racially or ethnically diverse cultural perspectives on patient compliance with post-transplant treatments is discussed. Domains of competency regarding culturally sensitive clinical practice are outlined to assist providers in better understanding the perspectives that may influence the views and behavior of culturally diverse patients.

Neuropsychologists' practice patterns in assessing premorbid intelligence

The current study surveyed practicing neuropsychologists about the methods they use to estimate premorbid levels of function, and their prior training with these methods. Doctoral level psychologists, who are members of the National Academy of Neuropsychology, were sent a questionnaire developed by the authors to assess these variables. Findings suggest that there is relatively little use of strategies specifically designed to assess premorbid ability. Demographics and training were not associated with methods used. Over one third of the respondents indicated that they believed their formal training had not been adequate in helping them to address this issue.

Intermediate-term outcome of transcatheter secundum atrial septal defect closure using the Bard Clamshell Septal Umbrella

Of 31 patients who underwent transcatheter atrial septal defect occlusion with the Bard Clamshell Septal Umbrella, only 1 had a clinically significant residual atrial septal defect at a mean follow-up of 41 months. All patients were asymptomatic despite the occurrence of device arm fractures in 84% of these patients.

Exploring multicultural competencies of occupational therapists: implications for education and training

The purpose of this investigation was to explore the influence of demographic and educational variables on self-reported multicultural competencies of occupational therapists. A sample of 94 occupational therapists currently working in the field participated in this investigation. Multicultural course work, seminars and workshops, percentage of minority patients worked with, and highest degree held were found to correlate significantly with self-reported multicultural competencies. Regression analyses found that highest degree held, percentage of minority patients worked with, multicultural course work, and participation in multicultural seminars and workshops accounted for about half of the variance in multicultural awareness. These findings are discussed in terms of academic courses and continued professional training and education for occupational therapists.