Minority Stressors, Social Provisions, and Past-Year Suicidal Ideation and Suicide Attempts in a Sample of Sexual Orientation and Gender Identity/Expression Minority People in Canada

Purpose: Mental health disparities in sexual orientation and/or gender identity and/or expression (SOGIE) minority groups are well-documented, with research consistently showing higher levels of suicidality, even in Canada, considered one of the world's most accepting countries of SOGIE minority groups. Adverse outcomes in these groups are often framed using minority stress theory, with social support frequently studied as an integral buffer to these outcomes. This analysis explores facets of minority stress and social support associated with past-year suicidal ideation and suicide attempts. Methods: A cross-sectional internet survey of SOGIE diverse people in Canada (n = 1542) was conducted. Binary logistic regression calculated bivariate and multivariate factors associated with past-year suicidal ideation and suicide attempts. Backward elimination (retaining sociodemographic factors and self-rated mental health) identified salient minority stress and social support (provisions) factors. Results: Over half (56.72%) of participants had ever thought of dying by suicide, with 24.84% having attempted suicide. During the past year, 26.80% had thought of dying by suicide, with 5.32% having attempted suicide. Victimization events, and guidance (e.g., someone to talk to about important decisions) and attachment (e.g., close relationships providing emotional security) social provision subscales remained salient after backward elimination procedures. Conclusion: Our findings emphasize that a fulsome, multilevel approach considering structural, community, and individual strategies to address overt discrimination, integrating social connections and guidance, is necessary to prevent dying by suicide.

'I don't want to have to teach every medical provider': barriers to care among non-binary people in the Canadian healthcare system

It is well-known that trans and non-binary individuals experience worse health outcomes due to experiences of violence and discrimination. For this reason, accessible healthcare for trans and non-binary people is crucial. There is a lack of Canadian literature on the experiences of non-binary people within the healthcare system. This study sought to understand barriers to healthcare among non-binary people living in a mid-sized urban/rural region of Canada. Interviews were conducted between November 2019 to March 2020 with 12 non-binary individuals assigned female at birth, living in Waterloo Region, Ontario, Canada, as a part of a larger qualitative study exploring experiences within the community, healthcare and employment. Three broad themes were developed: erasure, barriers to access to healthcare, and assessing whether (or not) to come out. Sub-themes included institutional erasure, informational erasure, general healthcare barriers, medical transition healthcare barriers, anticipated discrimination, and assessing safety. Policy and institutional changes are needed to increase the safety and accessibility of healthcare services to non-binary individuals.

Scrolling Through the COVID-19 Pandemic: Exploring the Perceived Effects of Increased Social Media Use on the Mental Health of Undergraduate University Students

Social media has become increasingly integrated into the lives of students for the past decade; however, the public health restrictions associated with the COVID-19 pandemic have led to a sharp increase in social media use in a short period of time. The purpose of this study was to investigate the effects of social media use on university students during the COVID-19 pandemic. Fifteen students from a mid-sized Canadian city were interviewed to share their experiences with social media during the COVID-19 pandemic. Purposive sampling was conducted to gather a diverse sample of participants, including individuals of various ages, gender and sexual identities, and ethnicities. Thematic analysis on the 15 interviews was completed using NVivo (version 12). Participants experienced both advantages and disadvantages associated with social media use. Ease of communication and stress relief were acknowledged as the strongest benefits. Social comparison, loneliness, development of bad habits, and lack of focus were cited as major disadvantages to social media use during the pandemic. Cost-benefit analysis of social media was common, and participants expressed the importance of using social media with moderation, balance, and awareness. Our study indicates that the focus on health with respect to the pandemic should not be solely based on physical health, rather the potential mental health risks associated with social media use during the pandemic should be recognized and addressed by healthcare providers.

‘Getting shut down and shut out’: Exploring ACB patient perceptions on healthcare access at the physician-patient level in Canada

Purpose

The experiences of African, Caribbean and Black (ACB) Canadians are seldom explored in the Canadian context. Family physicians act as a gateway to the rest of the healthcare system and are necessary to provide proper patient care. However, Canada’s history with colonialism may impact the socio-cultural context in which patients receive care.

Method

41 participants from Waterloo Region, Ontario, were engaged in eight focus groups to discuss their experiences in the healthcare system. Data were analysed following thematic analysis.

Results

Style of care, racism and discrimination and a lack of cultural competence hindered access. oor Inadequate cultural competence was attributed to western and biomedical approaches, poor understanding of patients’ context, physicians failing to address specific health concerns, and racism and discrimination. Participants highlighted that the two facilitators to care were having an ACB family physician and fostering positive relationships with physicians.

Conclusion

Participants predominantly expressed dissatisfaction in physicians’ approaches to care, which were compounded by experiences of racism and discrimination. Findings demonstrate how ACB patients are marginalized and excluded from the healthcare syste Iimplications for better access to care included utilizing community healthcare centres, increasing physicians’ capacity around culturally inclusive care, and increasing access to ACB physicians.

Knowledge of viral load, PrEP, and HIV-related sexual risk among men who have sex with men in the Waterloo region

Gay, bisexual, and other men who have sex with men (GBMSM) remain most disproportionately affected by HIV in Canada. HIV-related sexual risk behaviours have been linked to high HIV risk among GBMSM, but prior research has not focused on knowledge of viral load, and the risk it presents for HIV acquisition. The purpose of this study was to explore the relationship between HIV-related sexual risk behaviour and knowledge of viral load among GBMSM. A cross-sectional survey was conducted using a convenience sample of individuals age 16 and older who self-identified as LGBTQ and lived, worked, or resided in the Waterloo region, an urban-rural area in southwestern Ontario ( N = 526). Responses were analyzed from those identifying as GBMSM ( N = 269). Logistic regression models were created to explore sociodemographic, outness, social support, and HIV-related sexual risk variables associated with knowledge of viral load. Multivariable regression models were built to explore the same associations while controlling for confounders. HIV risk was not associated with knowledge of viral load in bivariate or multivariable analyses. Point estimates for low/negligible (odds ratio [OR] 1.10; 95% CI 0.46–2.51) and high risk (OR 1.88; 95% CI 0.68–5.20) suggest trends of higher knowledge with increased HIV risk. Men who engage in sexual risk behaviour may have increased sexual health literacy and awareness of biomedical interventions (e.g., pre-exposure prophylaxis, or PrEP) that reduce HIV risk. Policies are needed that promote acceptance of sexual orientation, improve awareness and access to PrEP, and ensure optimal delivery of HIV education to at-risk groups prior to engagement in higher risk activities.

Knowledge of viral load, PrEP, and HIV-related sexual risk among men who have sex with men in the Waterloo region

Gay, bisexual, and other men who have sex with men (GBMSM) remain most disproportionately affected by HIV in Canada. HIV-
related sexual risk behaviours have been linked to high HIV risk among GBMSM, but prior research has not focused on knowledge of viral load, and the risk it presents for HIV acquisition. The purpose of this study was to explore the relationship between HIV-related sexual risk behaviour and knowledge of viral load among GBMSM. A cross-sectional survey was conducted using a convenience sample of individuals age 16 and older who self-identified as LGBTQ and lived, worked, or resided in the Waterloo region, an urban-rural area in southwestern Ontario ( N = 526). Responses were analyzed from those identifying as GBMSM ( N = 269). Logistic regression models were created to explore sociodemographic, outness, social support, and HIV-related sexual risk variables associated with knowledge of viral load. Multivariable regression models were built to explore the same associations while controlling for confounders. HIV risk was not associated with knowledge of viral load in bivariate or multivariable analyses. Point estimates for low/negligible (odds ratio [OR] 1.10; 95% CI 0.46–2.51) and high risk (OR 1.88; 95% CI 0.68–5.20) suggest trends of higher knowledge with increased HIV risk. Men who engage in sexual risk behaviour may have increased sexual health literacy and awareness of biomedical interventions (e.g., pre-exposure prophylaxis, or PrEP) that reduce HIV risk. Policies are needed that promote acceptance of sexual orientation, improve awareness and access to PrEP, and ensure optimal delivery of HIV education to at-risk groups prior to engagement in higher risk activities.

Exploring community enabling factors associated with recent HIV testing in a regional sample of gay, bisexual, and other men who have sex with men

HIV testing and diagnosis are the gateway into treatment and eventual viral suppression. With gay, bisexual, and other men who have sex with men (GBMSM) persistently over-representing new HIV diagnoses in Canada, combined with the evolving nature of community social connection, an exploration of factors associated with recent HIV testing is warranted. As most studies of GBMSM rely on samples obtained from larger metropolitan regions, examining HIV testing from an under-researched region is necessary. With data collected from an online survey of LGBTQ+ persons 16 or older living, working, or residing in the Region of Waterloo, Ontario, Canada, we used multinomial logistic regression to explore socio-demographic, behavioural, and psychosocial factors associated with recent HIV testing for GBMSM. In the final multivariate multinomial logistic regression model: sense of belonging was associated with more recently testing, as was having an increasing proportion of LGBT friends, app use to find sex partners in the past 12 months, access to the local AIDS service organization, and general sense of belonging to local community, among other. This analysis highlights the continued importance of enabling and need factors when accessing testing, and suggests areas for further testing promotion in physical and virtual spaces frequented by GBMSM.

Experiences of trans patients in primary care settings: findings from The OutLook Study

BACKGROUND

Relationships between primary care providers (PCP) and trans patients remain important, necessitating discussions about gender identity, health and their intersections.

METHODS

Using an online survey, we explored socio-demographic and psycho-social factors associated with: (1) disclosing gender identity; (2) discussing gender identity-related health issues; and (3) comfort sharing gender identity with PCPs, among trans people (n=112) over 16years of age, sampled in Waterloo, Ontario, Canada. Bivariate and multivariate methods using modified Poisson regression generated effect estimates.

RESULTS

Age, birth presumed gender, employment status, family support, and transphobia were significantly associated with disclosing gender identity, discussing gender identity-related health issues, and comfortability sharing gender identity with PCPs.

CONCLUSION

Increasing PCPs' knowledge of trans-related health issues is stressed to improve access and quality for trans patients.

Experiences of Transgender Participants in Emergency Departments: Findings from the OutLook Study

Purpose: Even in cases of medical emergency, mistreatment and negative experiences in life or in medical settings can deter trans patients from seeking necessary care. The purpose of this study was to identify factors associated with trans persons' emergency department (ED) avoidance in the mixed urban-rural Region of Waterloo, Ontario, Canada. Methods: The OutLook Study was a community-based partnership that created an online, cross-sectional questionnaire for lesbian, gay, bisexual, transgender, and other sexual and gender minority community members. Participants in this analysis were 16 years of age or older, lived, worked, or attended school in Waterloo Region, and identified as trans (n=112). Binary logistic regression was used to test associations between sociodemographic, resilience, and risk variables, and ED avoidance. Sociodemographic variables statistically significant at p<0.05 at the bivariate level were included as controls to explore different combinations of resilience and risk factor in multivariable models. Results: Participants reporting complete or partially complete medical transitions were more likely to report ED avoidance, compared to those who had not initiated medical transition. Elevated transphobia was associated with greater likelihood of avoidance. However, increasing levels of social support decreased the likelihood of avoidance. In multivariable models, social support, support from a special person, and transphobia were always significant, regardless of controlled variables. Conclusion: Transphobia-enacted in the contexts of everyday life and health care-can deter patients from seeking care. Patient-centered care requires careful attention to trans identity and health needs, especially in emergency settings. In the absence of structural changes, providers can take steps to mitigate the erasure and discrimination trans patients experience and anticipate when accessing EDs.

Factors associated with interest in and knowledge of pre-exposure prophylaxis (PrEP) among gay, bisexual, and other men who have sex with men (GBMSM) in the Region of Waterloo, Ontario, Canada: Insights from the OutLook Study

Pre-exposure prophylaxis (PrEP) is an effective HIV-prevention tool for gay, bisexual, and other men who have sex with men (GBMSM), a group known to be disproportionately affected by HIV/AIDS. We aimed to identify sociodemographic, psychosocial, and health factors associated with awareness of PrEP or interest in PrEP among GBMSM in a mid-sized Canadian city, where PrEP availability is arguably more scarce compared to larger metropolitan regions. The OutLook Study was a comprehensive online survey of LGBTQ health and well-being that collected data from sexual minorities aged 16+ in the Region of Waterloo, Ontario, Canada. Participants were cisgender MSM with an unknown or negative HIV status (n = 203). Bivariate logistic regression was performed to analyze factors associated with both awareness of PrEP and interest in PrEP. Multivariate logistic regression explored sexual behaviours in the past 12 months while controlling for sociodemographic and psychosocial variables. Increasing number of sexual partners (OR: 1.10; 95% CI: 1.03–1.53) was significantly associated with interest in PrEP and lifetime experiences of homophobia remained significant from the bivariate model (ORs ranged from 1.11–1.12). Since GBMSM with low educational attainment were shown to have less knowledge about PrEP, educational campaigns could be targeted in high schools rather than colleges, universities, and trade schools. Prevention initiatives should be aimed at places where single or non-monogamous GBMSM frequent due to these men being disproportionately affected by HIV/AIDS. These findings provide insights for potential interventions targeting MSM from mid-sized cities.

Structured clinical decision making: Is it different ?

Introduction

The Psychiatrists are called to assess the level of risk in violent and sex offenders’ population. There are differing perceptions about formalising the severity and management of risk. The proponents of actuarial decision making propose that it is scientific and evidence based approach. The advocates of professional judgment however think that actuarial tools usually miss out on the interplay of compounding factors and can under or over estimate the level of risk.

Objectives

To review consecutive patient assessments and qualitatively compare it with HCR-20 and RSVP tools for violent and sex offending patients.

Aims

To report the difference in outcome in the domains of overall severity of risk, risk formulation and clinical decision making for management of the risk in these patient groups.

Methods

We aim to compare twenty consecutive patients where professional judgment of the clinician determined the severity of the risk, risk formulation and management. We then aim to use the information available to check for any differences in these areas when HCR-20 and RSVP are employed.

Results

The comparison and benefits of professional judgment and actuarial decision making are reported.

Conclusions

The professionals (providers) are being increasingly compelled by commissioners(purchasers) to evidence base their clinical decision making. The professional judgments are more likely to be challenged in the courts. People are easily impressed by decisions which are evidence based though they may have limited understanding of research environment and population studied.

Overlooked and Invisible: Everyday Experiences of Microaggressions for LGBTQ Adolescents

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) adolescents face a number of challenges in their lives related to heterosexism and cissexism. Drawing on the microaggressions framework, we conducted two focus groups with LGBTQ adolescents (n = 11; ages 14-18, six trans/genderfluid, one person of color) to (1) explore the type and nature of microaggressions experienced by LGBTQ adolescents; (2) assess the relevance of existing LGBTQ microaggression taxonomies for this group; and (3) understand the impact of microaggressions on LGBTQ adolescents. Participants' experiences of microaggressions reflected complex forms of discrimination emerging from the intersections of sexual and gender identity.

Hearing "That's So Gay" and "No Homo" on Campus and Substance Use Among Sexual Minority College Students

Sexual orientation microaggressions are common on college campuses and can contribute to negative outcomes; yet little is known about their relationship with substance use outcomes. Among a convenience sample of cisgender sexual minority college students (n= 574; 57.0% female, 24.9% people of color, 50.7% gay/lesbian; 72.4% public school) from 37 states (67.8% Midwest), this analysis investigates the association between hearing "that's so gay" and "no homo" on campus and hazardous alcohol use and the frequency of illicit drug use. Using multivariable regression analyses, the commonly heard phrases "that's so gay" and "no homo" were each found to significantly increase the risk for hazardous drinking and the frequency of drug use among students. Efforts should be made to create more welcoming campus climates for sexual minority students by reducing the use of these microaggressions and, in the meantime, offering supports to mitigate their harmful effects.

Identifying and Strengthening the Structural Roots of Urban Health in Canada: Participatory Policy Research and the Urban Health Agenda

An urban health research agenda for health promoters is presented. In Canada, urban issues are emerging as a major concern of policy makers. The voices raising these issues are from the non-health sectors, but many of these issues such as increasing income inequality and poverty, homelessness and housing insecurity, and social exclusion of youth, immigrants, and ethno-racial minorities have strong health implications as they are important social determinants of health. Emphasis on these and other social determinants of health and the policy decisions that strengthen or weaken them is timely as the quality of Canadian urban environments has become especially problematic. We argue for a participatory urban health research and action agenda with four components: a) an emphasis on health promotion and the social determinants of health; b) community-based participatory research; and c) drawing on the lived experience of people to influence d) policy analysis and policy change. Urban health researchers and promoters are urged to draw upon new developments in population health and community-based health promotion theory and research to identify and strengthen the roots of urban health through citizen action on public policy.

(Dis)integrated Care: Barriers to Health Care Utilization for Trans Women Living With HIV

Transgender (trans) women have been particularly impacted by HIV. To seek insights into the dynamics of health service utilization, interviews were conducted with trans women living with HIV (n = 14) as part of the Trans PULSE community-based research project in Ontario, Canada. Service providers (n = 10) were also interviewed to provide additional details about communication between trans women, social service providers, and clinicians. Results highlight how both problematic interactions with individuals and health systems navigation challenges affect access to services and impede the development of trans-specific HIV supports. Participants described discrimination, identified strategies for navigating a dysfunctional system, and outlined specific ways in which health and social services may be failing trans women living with HIV. Findings support the importance of coordinating HIV services and transition-related care, and providing training for service providers.

Enacted Stigma, Mental Health, and Protective Factors Among Transgender Youth in Canada

Purpose: We aimed to assess the Minority Stress Model which proposes that the stress of experiencing stigma leads to adverse mental health outcomes, but social supports (e.g., school and family connectedness) will reduce this negative effect. Methods: We measured stigma-related experiences, social supports, and mental health (self-injury, suicide, depression, and anxiety) among a sample of 923 Canadian transgender 14- to 25-year-old adolescents and young adults using a bilingual online survey. Logistic regression models were conducted to analyze the relationship between these risk and protective factors and dichotomous mental health outcomes among two separate age groups, 14- to 18-year-old and 19- to 25-year-old participants. Results: Experiences of discrimination, harassment, and violence (enacted stigma) were positively related to mental health problems and social support was negatively associated with mental health problems in all models among both age groups. Among 14-18 year olds, we examined school connectedness, family connectedness, and perception of friends caring separately, and family connectedness was always the strongest protective predictor in multivariate models. In all the mental health outcomes we examined, transgender youth reporting low levels of enacted stigma experiences and high levels of protective factors tended to report favorable mental health outcomes. Conversely, the majority of participants reporting high levels of enacted stigma and low levels of protective factors reported adverse mental health outcomes. Conclusion: While these findings are limited by nonprobability sampling procedures and potential additional unmeasured risk and protective factors, the results provide positive evidence for the Minority Stress Model in this population and affirm the need for policies and programs to support schools and families to support transgender youth.

Barriers and facilitators to HIV and sexually transmitted infections testing for gay, bisexual, and other transgender men who have sex with men

Transgender men who have sex with men (trans MSM) may be at elevated risk for HIV and other sexually transmitted infections (STI), and therefore require access to HIV and STI testing services. However, trans people often face stigma, discrimination, and gaps in provider competence when attempting to access health care and may therefore postpone, avoid, or be refused care. In this context, quantitative data have indicated low access to, and uptake of, HIV testing among trans MSM. The present manuscript aimed to identify trans MSM's perspectives on barriers and facilitators to HIV and STI testing. As part of a community-based research project investigating HIV risk and resilience among trans MSM, 40 trans MSM aged 18 and above and living in Ontario, Canada participated in one-on-one qualitative interviews in 2013. Participants described a number of barriers to HIV and other STI testing. These included both trans-specific and general difficulties in accessing sexual health services, lack of trans health knowledge among testing providers, limited clinical capacity to meet STI testing needs, and a perceived gap between trans-inclusive policies and their implementation in practice. Two major facilitators were identified: access to trusted and flexible testing providers, and integration of testing with ongoing monitoring for hormone therapy. Based on these findings, we provide recommendations for enhancing access to HIV and STI testing for this key population.

Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada

BACKGROUND

Across Europe, Canada, and the United States, 22-43 % of transgender (trans) people report a history of suicide attempts. We aimed to identify intervenable factors (related to social inclusion, transphobia, or sex/gender transition) associated with reduced risk of past-year suicide ideation or attempt, and to quantify the potential population health impact.

METHODS

The Trans PULSE respondent-driven sampling (RDS) survey collected data from trans people age 16+ in Ontario, Canada, including 380 who reported on suicide outcomes. Descriptive statistics and multivariable logistic regression models were weighted using RDS II methods. Counterfactual risk ratios and population attributable risks were estimated using model-standardized risks.

RESULTS

Among trans Ontarians, 35.1 % (95 % CI: 27.6, 42.5) seriously considered, and 11.2 % (95 % CI: 6.0, 16.4) attempted, suicide in the past year. Social support, reduced transphobia, and having any personal identification documents changed to an appropriate sex designation were associated with large relative and absolute reductions in suicide risk, as was completing a medical transition through hormones and/or surgeries (when needed). Parental support for gender identity was associated with reduced ideation. Lower self-reported transphobia (10(th) versus 90(th) percentile) was associated with a 66 % reduction in ideation (RR = 0.34, 95 % CI: 0.17, 0.67), and an additional 76 % reduction in attempts among those with ideation (RR = 0.24; 95 % CI: 0.07, 0.82). This corresponds to potential prevention of 160 ideations per 1000 trans persons, and 200 attempts per 1,000 with ideation, based on a hypothetical reduction of transphobia from current levels to the 10(th) percentile.

CONCLUSIONS

Large effect sizes were observed for this controlled analysis of intervenable factors, suggesting that interventions to increase social inclusion and access to medical transition, and to reduce transphobia, have the potential to contribute to substantial reductions in the extremely high prevalences of suicide ideation and attempts within trans populations. Such interventions at the population level may require policy change.

Complicating the coming out narrative: becoming oneself in a heterosexist and cissexist world

Traditional stage models of LGBTQ identity development have conceptualized coming out as a linear process from "closeted" to "out" that all queer/trans individuals must follow if they are to be considered healthy and well adjusted. These stage models have been critiqued for their rigidity and absence of a dynamic understanding of the coming out process. In this article we explore the findings from a qualitative photovoice study with 15 LGBTQ youths in a small urban center in Ontario that supports these critiques. We explore the efficacy of the photovoice technique in investigating questions of sexual and gender identity. This article identifies some contextual factors that are important in understanding coming out as a social (rather than internal) process; it also identifies some of the ways in which these youths' experiences challenge normative understandings of the "good, out queer."

Nonprescribed hormone use and self-performed surgeries: "do-it-yourself" transitions in transgender communities in Ontario, Canada

OBJECTIVES

We examined the extent of nonprescribed hormone use and self-performed surgeries among transgender or transsexual (trans) people in Ontario, Canada.

METHODS

We present original survey research from the Trans PULSE Project. A total of 433 participants were recruited from 2009 to 2010 through respondent-driven sampling. We used a case series design to characterize those currently taking nonprescribed hormones and participants who had ever self-performed sex-reassignment surgeries.

RESULTS

An estimated 43.0% (95% confidence interval = 34.9, 51.5) of trans Ontarians were currently using hormones; of these, a quarter had ever obtained hormones from nonmedical sources (e.g., friend or relative, street or strangers, Internet pharmacy, herbals or supplements). Fourteen participants (6.4%; 95% confidence interval = 0.8, 9.0) reported currently taking nonprescribed hormones. Five indicated having performed or attempted surgical procedures on themselves (orchiectomy or mastectomy).

CONCLUSIONS

Past negative experiences with providers, along with limited financial resources and a lack of access to transition-related services, may contribute to nonprescribed hormone use and self-performed surgeries. Promoting training initiatives for health care providers and jurisdictional support for more accessible services may help to address trans people's specific needs.

High heterogeneity of HIV-related sexual risk among transgender people in Ontario, Canada: a province-wide respondent-driven sampling survey

BACKGROUND

Studies of HIV-related risk in trans (transgender, transsexual, or transitioned) people have most often involved urban convenience samples of those on the male-to-female (MTF) spectrum. Studies have detected high prevalences of HIV-related risk behaviours, self-reported HIV, and HIV seropositivity.

METHODS

The Trans PULSE Project conducted a multi-mode survey using respondent-driven sampling to recruit 433 trans people in Ontario, Canada. Weighted estimates were calculated for HIV-related risk behaviours, HIV testing and self-reported HIV, including subgroup estimates for gender spectrum and ethno-racial groups.

RESULTS

Trans people in Ontario report a wide range of sexual behaviours with a full range of partner types. High proportions - 25% of female-to-male (FTM) and 51% of MTF individuals - had not had a sex partner within the past year. Of MTFs, 19% had a past-year high-risk sexual experience, versus 7% of FTMs. The largest behavioural contributors to HIV risk were sexual behaviours some may assume trans people do not engage in: unprotected receptive genital sex for FTMs and insertive genital sex for MTFs. Overall, 46% had never been tested for HIV; lifetime testing was highest in Aboriginal trans people and lowest among non-Aboriginal racialized people. Approximately 15% of both FTM and MTF participants had engaged in sex work or exchange sex and about 2% currently work in the sex trade. Self-report of HIV prevalence was 10 times the estimated baseline prevalence for Ontario. However, given wide confidence intervals and the high proportion of trans people who had never been tested for HIV, estimating the actual prevalence was not possible.

CONCLUSIONS

Results suggest potentially higher than baseline levels of HIV; however low testing rates were observed and self-reported prevalences likely underestimate seroprevalence. Explicit inclusion of trans people in epidemiological surveillance statistics would provide much-needed information on incidence and prevalence. Given the wide range of sexual behaviours and partner types reported, HIV prevention programs and materials should not make assumptions regarding types of behaviours trans people do or do not engage in.

Seeking safer sexual spaces: queer and trans young people labeled with intellectual disabilities and the paradoxical risks of restriction

Young lesbian, gay, bisexual, and transgender (LGBT) people labeled with intellectual disabilities have unique sexual health needs that are not being met. Denial by others of their right to pleasure and the exercise of heightened external control over their sexuality are commonplace. Current research indicates that these youth are at heightened risk for compromised sexual health. This study aimed to explore the ways in which social and environmental conditions influence vulnerability to adverse sexual health outcomes for this population. We used a community-based research approach to conduct qualitative interviews and focus groups with 10 young LGBT people (aged 17-26) labeled with intellectual disabilities. Participants reported multiple limitations on their autonomy that resulted in having sex in places where they did not feel comfortable and were unlikely to practice safer sex. Attempts by authority figures to protect youth through limits on their autonomy may be unintentionally leading to negative sexual health outcomes.

Community capacity to acquire, assess, adapt, and apply research evidence: a survey of Ontario's HIV/AIDS sector

Background

Community-based organizations (CBOs) are important stakeholders in health systems and are increasingly called upon to use research evidence to inform their advocacy, program planning, and service delivery. To better support CBOs to find and use research evidence, we sought to assess the capacity of CBOs in the HIV/AIDS sector to acquire, assess, adapt, and apply research evidence in their work.

Methods

We invited executive directors of HIV/AIDS CBOs in Ontario, Canada (n = 51) to complete the Canadian Health Services Research Foundation's "Is Research Working for You?" survey.

Findings

Based on responses from 25 organizations that collectively provide services to approximately 32,000 clients per year with 290 full-time equivalent staff, we found organizational capacity to acquire, assess, adapt, and apply research evidence to be low. CBO strengths include supporting a culture that rewards flexibility and quality improvement, exchanging information within their organization, and ensuring that their decision-making processes have a place for research. However, CBO Executive Directors indicated that they lacked the skills, time, resources, incentives, and links with experts to acquire research, assess its quality and reliability, and summarize it in a user-friendly way.

Conclusion

Given the limited capacity to find and use research evidence, we recommend a capacity-building strategy for HIV/AIDS CBOs that focuses on providing the tools, resources, and skills needed to more consistently acquire, assess, adapt, and apply research evidence. Such a strategy may be appropriate in other sectors and jurisdictions as well given that CBO Executive Directors in the HIV/AIDS sector in Ontario report low capacity despite being in the enviable position of having stable government infrastructure in place to support them, benefiting from long-standing investment in capacity building, and being part of an active provincial network. CBOs in other sectors and jurisdictions that have fewer supports may have comparable or lower capacity. Future research should examine a larger sample of CBO Executive Directors from a range of sectors and jurisdictions.

What Do People Living With HIV/AIDS Expect From Their Physicians? Professional Expertise and the Doctor-Patient Relationship

This qualitative study identifies the types of professional expertise that physicians are seen to possess in clinical encounters from the perspective of people living with HIV/AIDS (PLWHA). Respondents looked to their physicians for expert knowledge in 3 key areas: medical/clinical; legal/statutory; and ethical/moral. Physicians were seen to be authorities in each of these areas and their judgments, though not always agreed with, were taken seriously and influenced the health care decisions made by PLWHA. The authority that comes with professional expertise in each of the areas identified was experienced both positively and negatively by PLWHA. Understanding the expectations of patients in the medical encounter can assist physicians in providing optimal care in the management of HIV/AIDS.

Are we asking the right questions? A review of Canadian REB practices in relation to community-based participatory research

Access barriers to effective ethics review continue to be a significant challenge for researchers and community-based organizations undertaking community-based participatory research (CBPR). This article reports on findings from a content analysis of select (Behavioural, Biomedical, Social Sciences, Humanities) research ethics boards (REBs) in the Canadian research context (n = 86). Existing ethics review documentation was evaluated using 30 CBPR related criteria for their sensitivity to relevant approaches, processes, and outcomes. A linear regression was conducted to determine whether specific organizational characteristics have an impact on the CBPR sensitivity: (1) region of Canada, (2) type of institution (university or a healthcare organization), (3) primary institutional language (English or French) and (4) national ranking with respect to research intensiveness. While only research intensiveness proved statistically significant (p = .001), we recognize REB protocol forms may not actually reflect how CBPR is reviewed. Despite using a single guiding ethical framework, REBs across Canada employ a variety of techniques to review research studies. We report on these differences and varying levels of sensitivity to CBPR. Finally, we highlight best practices and make recommendations for integrating CBPR principles into existing ethics review.

Increasing accessibility for community participants at academic conferences

BACKGROUND

To decrease the gulf between academic and community perspectives, there has been an increased call among stakeholder groups to collaborate in solving complex urban health problems. Despite these recent shifts, however, community partners face barriers to participate in conferences, ultimately limiting exchange of ideas and uptake of research data. This paper reports on the evaluation of the strategy used to engage community participants at the 4th International Conference on Urban Health (ICUH) held in Toronto, Canada, in October, 2005.

METHOD

We surveyed participants (n = 98) and conducted follow-up interviews (n = 23) to assess factors that facilitated attendance at ICUH 2005 as well as the impact of the conference on their work.

RESULTS

Community registrants were drawn by accessible fee structures, scholarship opportunities, and preconference workshops relevant to their interests. Both community and academic registrants were drawn by the presence of a separate conference stream showcasing high-quality and rigorous community-based participatory research (CBPR). The conference provided valuable opportunities for networking with other community-based researchers by facilitating the development of relationships between community registrants and researchers, increased the profile and legitimacy of CBPR, and reinforced the value of community input in research. It also provided opportunities for capacity building-knowledge sharing and heightened awareness of CBPR.

CONCLUSION

The 4th ICUH had a significant impact on community registrants and provided valuable opportunities to bridge academic and community divides. These data support the need for comprehensive strategies for community engagement at health conferences.

Community-based knowledge transfer and exchange: helping community-based organizations link research to action

BACKGROUND

Community-based organizations (CBOs) are important stakeholders in health systems and are increasingly called upon to use research evidence to inform their advocacy, program planning, and service delivery efforts. CBOs increasingly turn to community-based research (CBR) given its participatory focus and emphasis on linking research to action. In order to further facilitate the use of research evidence by CBOs, we have developed a strategy for community-based knowledge transfer and exchange (KTE) that helps CBOs more effectively link research evidence to action. We developed the strategy by: outlining the primary characteristics of CBOs and why they are important stakeholders in health systems; describing the concepts and methods for CBR and for KTE; comparing the efforts of CBR to link research evidence to action to those discussed in the KTE literature; and using the comparison to develop a framework for community-based KTE that builds on both the strengths of CBR and existing KTE frameworks.

DISCUSSION

We find that CBR is particularly effective at fostering a climate for using research evidence and producing research evidence relevant to CBOs through community participation. However, CBOs are not always as engaged in activities to link research evidence to action on a larger scale or to evaluate these efforts. Therefore, our strategy for community-based KTE focuses on: an expanded model of 'linkage and exchange' (i.e., producers and users of researchers engaging in a process of asking and answering questions together); a greater emphasis on both producing and disseminating systematic reviews that address topics of interest to CBOs; developing a large-scale evidence service consisting of both 'push' efforts and efforts to facilitate 'pull' that highlight actionable messages from community relevant systematic reviews in a user-friendly way; and rigorous evaluations of efforts for linking research evidence to action.

SUMMARY

Through this type of strategy, use of research evidence for CBO advocacy, program planning, and service delivery efforts can be better facilitated and continually refined through ongoing evaluations of its impact.

"I don't think this is theoretical; this is our lives": how erasure impacts health care for transgender people

For people who are transgender, transsexual, or transitioned (trans), access to primary, emergency, and transition-related health care is often problematic. Results from Phase I of the Trans PULSE Project, a community-based research project in Ontario, Canada, are presented. Based on qualitative data from focus groups with 85 trans community members, a theoretical framework describing how erasure functions to impact experiences interacting with the health care system was developed. Two key sites of erasure were identified: informational erasure and institutional erasure. How these processes work in a mutually reinforcing manner to erase trans individuals and communities and produce a system in which a trans patient or client is seen as an anomaly is shown. Thus, the impetus often falls on trans individuals to attempt to remedy systematic deficiencies. The concept of cisnormativity is introduced to aid in explaining the pervasiveness of trans erasure. Strategies for change are identified.

Community-based research in AIDS-service organizations: what helps and what doesn't?

BACKGROUND

Community-based research (CBR) approaches have become commonplace in many North American HIV communities. In many large urban centers, AIDS-service organizations (ASOs) have become active research hubs, advocating for research dollars in community settings. While ASOs have historically integrated local knowledge into their prevention, care and advocacy initiatives, many are now initiating or collaborating in research which addresses emerging issues encountered in practice with clients.

OBJECTIVES

To investigate barriers and facilitating factors for ASO engagement in CBR.

METHODS

We conducted a survey (n=39) and one-on-one semi-structured telephone interviews (n=25) with executive directors and CBR coordinators from ASOs in Ontario, Canada. The survey queried four major areas of interest (organizational demographics, ASO CBR activities, potential barriers and facilitators for CBR engagement, and what roles stakeholders play in CBR initiatives). The interviews focused on exploring these issues in greater depth as well as understanding barriers and facilitating factors to people living with HIV/AIDS engaging in CBR.

RESULTS

ASOs in Ontario are moderately supportive of CBR in their organizations. However, our survey and one-on-one interviews indicate that funding and organizational resources are both important barriers and facilitators to ASO involvement in CBR projects. Attaining access to research ethics boards and concerns that CBR results will not be acted upon also emerged as barriers to CBR, particularly once funds and organizational resources have been attained. Initiatives designed to enhance the skills of research team members emerged as an another important facilitator.

CONCLUSION

Increasing emphasis from program funders on more rigorous evaluation and accountability, coupled with pull from increasingly empowered communities demanding much more active roles in setting research agendas, means that CBR is likely here to stay. Attending to barriers and facilitators will help with enhanced ASO engagement in CBR.

The Greater Involvement of People Living with AIDS principle: theory versus practice in Ontario's HIV/AIDS community-based research sector

Drawing on the Greater Involvement of People with HIV/AIDS (GIPA) principle, the HIV/AIDS movement began to "democratize" research in Canada in the mid-1990s. To date, there is little evidence about the success of the community-based research (CBR) movement in relation to the implementation of GIPA. We draw on findings from a larger study examining barriers and facilitating factors in relation to HIV-related CBR in Ontario, Canada. An online survey was completed by 39 senior managers in Ontario AIDS service organizations (ASOs). Twenty-five in-depth, semi-structured interviews were then conducted to further explore the survey findings. Survey respondents reported that, compared to researchers and frontline service providers, people living with HIV/AIDS (PLWHA) tended to be the least involved in all stages (input, process and outcome) of CBR projects. AIDS service organizations with a mandate that included serving rural and urban communities reported even lower levels of PLWHA involvement in CBR. Qualitative data reveal complex barriers that make meaningful PLWHA engagement in CBR difficult, including: HIV-related stigma; health-related challenges; "credentialism"; lack of capacity to engage in research; other issues taking priority; and mistrust of researchers. Facilitating factors included valuing lived experience; training and mentoring opportunities; financial compensation; trust building; and accommodating PLWHA's needs. While there is strong support for the GIPA principles in theory, practice lags far behind.

Survey Design From the Ground Up: Collaboratively Creating the Toronto Teen Survey

The Toronto Teen Survey is a community-based participatory research study whose aim is to gather information on the accessibility and relevance of sexual health services for diverse groups of urban youth (13 to 17 years of age). This information will be used to develop a proactive, citywide strategy to improve sexual health outcomes for Toronto adolescents. In this article, the authors focus on the processes of collaboratively developing a survey tool with youth, academics, and community stakeholders. An overview of the project and examples from the design stage are provided. In addition, recommendations are given toward developing best practices when working with young people on research and survey design.

Ethical dilemmas in community-based participatory research: recommendations for institutional review boards

National and international codes of research conduct have been established in most industrialized nations to ensure greater adherence to ethical research practices. Despite these safeguards, however, traditional research approaches often continue to stigmatize marginalized and vulnerable communities. Community-based participatory research (CBPR) has evolved as an effective new research paradigm that attempts to make research a more inclusive and democratic process by fostering the development of partnerships between communities and academics to address community-relevant research priorities. As such, it attempts to redress ethical concerns that have emerged out of more traditional paradigms. Nevertheless, new and emerging ethical dilemmas are commonly associated with CBPR and are rarely addressed in traditional ethical reviews. We conducted a content analysis of forms and guidelines commonly used by institutional review boards (IRBs) in the USA and research ethics boards (REBs) in Canada. Our intent was to see if the forms used by boards reflected common CBPR experience. We drew our sample from affiliated members of the US-based Association of Schools of Public Health and from Canadian universities that offered graduate public health training. This convenience sample (n = 30) was garnered from programs where application forms were available online for download between July and August, 2004. Results show that ethical review forms and guidelines overwhelmingly operate within a biomedical framework that rarely takes into account common CBPR experience. They are primarily focused on the principle of assessing risk to individuals and not to communities and continue to perpetuate the notion that the domain of "knowledge production" is the sole right of academic researchers. Consequently, IRBs and REBs may be unintentionally placing communities at risk by continuing to use procedures inappropriate or unsuitable for CBPR. IRB/REB procedures require a new framework more suitable for CBPR, and we propose alternative questions and procedures that may be utilized when assessing the ethical appropriateness of CBPR.

Identifying and strengthening the structural roots of urban health in Canada: participatory policy research and the urban health agenda

An urban health research agenda for health promoters is presented. In Canada, urban issues are emerging as a major concern of policy makers. The voices raising these issues are from the non-health sectors, but many of these issues such as increasing income inequality and poverty, homelessness and housing insecurity, and social exclusion of youth, immigrants, and ethno-racial minorities have strong health implications as they are important social determinants of health. Emphasis on these and other social determinants of health and the policy decisions that strengthen or weaken them is timely as the quality of Canadian urban environments has become especially problematic. We argue for a participatory urban health research and action agenda with four components: (a) an emphasis on health promotion and the social determinants of health; (b) community-based participatory research; and (c) drawing on the lived experience of people to influence (d) policy analysis and policy change. Urban health researchers and promoters are urged to draw upon new developments in population health and community-based health promotion theory and research to identify and strengthen the roots of urban health through citizen action on public policy.

Single-dose pharmacokinetics and tolerability of alendronate 35- and 70-milligram tablets in children and adolescents with osteogenesis imperfecta type I

CONTEXT

Alendronate (ALN) is a bisphosphonate compound that can be administered orally and has potential use in pediatric osteoporotic conditions.

OBJECTIVE

The objective was to evaluate the pharmacokinetics and single-dose tolerability of ALN in children with osteogenesis imperfecta.

DESIGN

ALN was administered iv and orally in a two-period, randomized crossover study, with doses separated by a 2-wk washout and follow-up carried out within 2 wk after the last ALN dose.

SETTING

The study was conducted at the pediatric metabolic bone research unit at the Shriners Hospital for Children, Montréal, Canada.

PATIENTS

Twenty-four children (aged 4-16 yr; eight girls) with osteogenesis imperfecta type I participated.

INTERVENTIONS

All patients received iv ALN at a dose of 125 mug. In addition, patients weighing less than 40 kg received an oral dose of ALN 35 mg, whereas those weighing 40 kg or more received ALN 70 mg orally.

MAIN OUTCOME MEASURES

Total urinary excretion and oral bioavailability of ALN, blood and urine safety parameters, and adverse events were the main outcome measures.

RESULTS

The total urinary excretion of ALN after the iv dose was similar for both weight groups. The mean oral bioavailability (95% confidence interval) was 0.43% (0.28, 0.64%) for patients weighing less than 40 kg and 0.56% (0.36, 0.87%) for patients weighing 40 kg or more. Eighteen patients reported a total of 44 clinical adverse experiences, none of which were serious. The most common adverse experiences were mild to moderate headache (n = 7), nausea (n = 7), fever (n = 5), and abdominal pain (n = 6). Eighty percent of the adverse experiences (35 of 44) occurred within 48 h of medication administration, 91% (40 of 44) lasted less than 24 h, and 84% (37 of 44) were reported after oral dosing. Laboratory safety monitoring revealed a marginal decrease in absolute lymphocyte count and serum alkaline phosphatase after the study compared with baseline for both weight categories.

CONCLUSIONS

The mean oral bioavailability of 35- and 70-mg ALN tablets was less than 0.6%, comparable to adult studies. Adverse experiences from single-dose ALN were minor, and the drug was generally well-tolerated.

Community-based HIV education and prevention workers respond to a changing environment

The purpose of this study was to understand the culture, values, skills and activities of staff involved in education and prevention activities in community-based AIDS Service Organizations (ASOs) in Ontario, Canada, and to understand the role of evaluation research in their prevention programming. In this qualitative study, 33 staff members from 11 ASOs participated in semi-structured interviews that were analyzed using the grounded theory approach. ASO staff experience tension between a historical grassroots organizational culture characterized by responsiveness and relevance and a more recent culture of professionalization. Target populations have changed from being primarily gay men to an almost unlimited variety of communities. Program emphasis has shifted from education and knowledge dissemination to a broadly based mandate of health promotion, community development, and harm reduction. Integration of evidence of effectiveness, social-behavioral theory, or systematic evaluation is uncommon. Understanding these points of tension is important for the nursing profession when it is engaged with ASOs in programming or evaluation research.

Osteopathia striata with cranial sclerosis: clinical, radiological, and bone histological findings in an adolescent girl

Osteopathia striata with cranial sclerosis (OS-CS) is a rare skeletal dysplasia characterized by linear striations of the long bones, osteosclerosis of the cranium, and extra-skeletal anomalies. We provide a comprehensive description of the skeletal phenotype in a French-Canadian girl with a moderate to severe form of sporadic OS-CS. Multiple medical problems, including anal stenosis and the Pierre-Robin sequence, were evident in the first few years of life. At 14 years, she was fully mobile, with normal intellect and stature. She suffered chronic lower extremity pain in the absence of fractures, as well as severe headaches, unilateral facial paralysis, and bilateral mixed hearing loss. Biochemical indices of bone and mineral metabolism were within normal limits. Bone densitometry showed increased areal bone mineral density in the skull, trunk, and pelvis, but not in the upper and lower extremities. An iliac bone biopsy specimen revealed an increased amount of trabecular bone. Trabeculae were abnormally thick, but there was no evidence of disturbed bone remodeling. In a cranial bone specimen, multiple layers of periosteal bone were found that covered a compact cortical compartment containing tightly packed haversian canals. Bone lamellation was normal in both the iliac and skull samples. Osteoclast differentiation studies showed that peripheral blood osteoclast precursors from this patient formed functional osteoclasts in vitro. Thus, studies of bone metabolism did not explain why bone mass is increased in most skeletal areas of this patient. Cranial histology points to exuberant periosteal bone formation as a potential cause of the cranial sclerosis.

Resolution of severe, adolescent-onset hypophosphatemic rickets following resection of an FGF-23-producing tumour of the distal ulna

Oncogenic hypophosphatemic osteomalacia (OHO) is an uncommon hypophosphatemic syndrome characterized by bone pain, proximal muscle weakness and rickets. It has been postulated that OHO results from overproduction of a humoral phosphaturic factor by an occult tumour. Recently, some OHO tumours have been shown to elaborate fibroblast growth factor-23 (FGF-23), which causes renal phosphate wasting when administered to mice. The purpose of this study was to undertake detailed investigations to confirm the diagnosis of OHO in a pediatric patient and to document the biochemical, radiographic and bone histological phenotype before and after tumour removal. We describe an 11-year-old, previously healthy girl with significant pain and functional disability associated with hypophosphatemic rickets. Circulating 1,25-(OH)(2) vitamin D was very low (14 pM; N: 40-140) while the FGF-23 serum level was markedly elevated [359.5 reference units (RU)/ml, N: 33-105]. An iliac bone biopsy revealed severe osteomalacia, but periosteocytic lesions, as are typical for X-linked hypophosphatemic rickets, were not seen. Sequence analyses of the PHEX and FGF23 genes were normal. A radiographic skeletal survey revealed a small exostosis of the left, distal ulnar metaphysis. A tumour was subsequently removed from this site and the pathology was consistent with benign, fibro-osseous tissue. Serum FGF-23 was normal when measured at 7 h post-operatively, while serum phosphate reached the low-normal range at 16 days following surgery. An iliac bone biopsy taken 5 months after the operation showed improvement, but not yet resolution, of the osteomalacia. Biochemical parameters of bone and mineral metabolism suggested that complete resolution of the osteomalacia was not achieved until 12 months following surgery. One year after tumour removal, the patient was pain-free and had resumed a normal level of activity. The rapid normalization of FGF-23 levels following removal of a benign tumour and the subsequent improvement in the biochemical and histological parameters of bone and mineral metabolism suggest that FGF-23 played a key role in this girl's disease.

Effect of gene dose and parental origin on bone histomorphometry in X-linked Hyp mice

X-linked hypophosphatemia (XLH) is characterized by rickets and osteomalacia and arises from mutations in the Phex and PHEX genes in mice (Hyp) and humans, respectively. The present study was undertaken to examine the effect of gene dose on the skeletal phenotype using a histomorphometric approach. Metrical traits (vertebral length, growth plate thickness, cancellous osteoid volume per bone volume, and cancellous, endocortical, and periosteal osteoid thickness) were compared in caudal vertebrae of mutant female (Hyp/+, Hyp/Hyp) and male (Hyp/Y) mice and their normal female (+/+) and male (+/Y) littermates. Mutant animals had trait values that differed significantly from those of normal animals. However, with the exception of vertebral length and cancellous osteoid thickness, values were not significantly different between the three mutant genotypes. We also examined the effect of gamete-of-origin on histomorphometric parameters in obligate Hyp/+ females derived from male or female transmitting parents. The metrical trait values in both groups of Hyp/+ mice were similar, with the exception of vertebral length and cancellous osteoid volume per bone volume. In summary, we demonstrate that the amount of osteoid per bone volume is similar in the three mutant genotypes and conclude that the extent and magnitude of the mineralization defect is fully dominant and likely not affected by gene dose. The differences in vertebral length in the mutants suggest that rickets and osteomalacia are not the only causes of decreased vertebral growth in Hyp mice and that Phex protein may influence bone growth and mineralization by distinct pathways.

Osteogenesis imperfecta type VII: an autosomal recessive form of brittle bone disease

Osteogenesis imperfecta (OI) is a heritable disease of bone with low bone mass and bone fragility. The disease is generally classified into four types based on clinical features and disease severity, although recently fifth and sixth forms have also been reported. Most forms of OI are autosomal dominant. Rarely, autosomal recessive disease has been described. We report the clinical, radiological, and histological features of four children (age 3.9-8.6 years at last follow-up; all girls) and four adults (age 28-33 years; two women) with a novel form of autosomal recessive OI living in an isolated First Nations community in northern Quebec. In keeping with the established numeric classification for OI forms, we have called this form of the disease OI type VII. The phenotype is moderate to severe, characterized by fractures at birth, bluish sclerae, early deformity of the lower extremities, coxa vara, and osteopenia. Rhizomelia is a prominent clinical feature. Histomorphometric analyses of iliac crest bone samples revealed findings similar to OI type I, with decreased cortical width and trabecular number, increased bone turnover, and preservation of the birefringent pattern of lamellar bone. The disease has subsequently been localized to chromosome 3p22-24.1, which is outside the loci for type I collagen genes. The underlying genetic basis for the disease remains to be determined.

The bone formation defect in idiopathic juvenile osteoporosis is surface-specific

We have previously shown that idiopathic juvenile osteoporosis (IJO) is characterized by a decreased cancellous bone volume and a very low bone formation rate on cancellous surfaces. Whether IJO similarly affects cortical bone is unknown. We therefore compared tetracycline double-labeled transfixing iliac-crest bone biopsies from eight children with typical clinical features of IJO (six girls; age 10-12 years) and from nine children (four girls; age 9-12 years) without metabolic bone disease. No differences in intracortical remodeling activity were detected. Both structural parameters reflecting intracortical remodeling (cortical porosity, active canal diameter, and quiescent canal diameter) and bone surface-based metabolic parameters (osteoid, osteoblast, mineralizing, osteoclast and eroded surfaces, and bone formation rate) were similar in IJO patients and controls (p > 0.2 each, t-test). Although the internal cortex of the biopsy was thinner in IJO patients than in controls (660 +/- 170 microm vs. 980 +/- 320 microm; p = 0.02), there was no difference in the width of the external cortex (p = 0.36). In growing children, both cortices exhibit an external modeling drift. Therefore, the difference in internal cortical width point to a decreased modeling activity on the endocortical surface of the internal cortex. In fact, bone formation rate on this surface was 48% lower in IJO patients than in controls (82 +/- 45 microm(3)/microm(2) per year vs. 159 +/- 162 microm(3)/microm(2) per year). However, this difference did not achieve statistical significance (p = 0.21) due to the high variability of bone formation rate on modeling surfaces. The disturbance of bone remodeling in IJO is limited to cancellous bone, but there may be a modeling defect affecting the internal cortex. Thus, the process causing IJO appears to mainly affect bone surfaces that are in contact with the bone marrow cavity.

Human fetal bone development: histomorphometric evaluation of the proximal femoral metaphysis

Quantitative data on metaphyseal bone histology during early human development are scarce. In the present study the proximal femoral metaphysis of 35 fetuses and newborns (gestational age 16-35 weeks) was analyzed by histomorphometry. Averaged over the entire metaphyseal area, the relative amount of bone and cartilage was higher in the third compared to the second trimester. Osteoid thickness increased with gestational age, whereas indices of bone resorption decreased. The relative amount of cartilage decreased with increasing distance from the growth plate, whereas the relative amount of bone increased. This was due to trabecular thickening, which occurred at an estimated rate of 3 microm/day in areas close to the growth plate. Despite this rapid rate of net bone gain, osteoid indices were relatively low, indicating that mineralization occurred very rapidly after bone deposition. These observations suggest that modeling, not remodeling, is the predominant mechanism responsible for the development of femoral metaphyseal cancellous bone in utero.