Erythrocytosis Is Rare With Exogenous Testosterone in Gender-Affirming Hormone Therapy.

CONTEXT: Studies have found a variable incidence of erythrocytosis among people using testosterone as part of gender-affirming hormone therapy (GAHT). OBJECTIVE: To examine the effect of using exogenous testosterone as GAHT on hematocrit in a large North American cohort. METHODS: We conducted a cross-sectional analysis of testosterone and hematocrit laboratory values in 6670 patients who were prescribed testosterone through Plume, a national provider of GAHT. The prevalence of erythrocytosis, the mean hematocrit at predetermined testosterone thresholds and with varying routes of testosterone administration were assessed. RESULTS: Among 6670 individuals, 560 (8.4%) had a hematocrit ≥50%, 182 ≥ 52% (2.7%), and 60 ≥ 54% (0.9%). There was significant variation (P < .001) in hematocrit between different clinically relevant testosterone thresholds (T < 50 vs T 50-299 vs T 300-999 vs T ≥ 1000 ng/dL) and when comparing serum testosterone in increments of 50 ng/dL within the target range for males (300-1000 ng/dL) (P < .001). Mean hematocrit ranged from 41.84% (T < 50 ng/dL) to 45.68% (T 900-949 ng/dL). Patients on intramuscular testosterone had a higher mean hematocrit than those on transdermal testosterone (44.96% vs 43.41%, P < .001). Both route of administration (P < .001) and testosterone level (P < .001) had statistically significant associations with hematocrit when controlling for each other. CONCLUSION: While the magnitude of change in hematocrit with serum level and route of administration of testosterone was statistically significant, the absolute levels were within the normal range, unlikely to be clinically meaningful. These findings, along with the low prevalence of erythrocytosis, should help allay concerns about the use of testosterone as GAHT.

Improving palliative and supportive care in advanced cirrhosis: the HepatoCare model of integrated collaborative care.

BACKGROUND: Patients with advanced cirrhosis experience an unpredictable disease trajectory but are infrequently referred to palliative care (PC) services and rarely undertake advance care planning (ACP). AIM: We assessed whether a novel model of care increased provision of meaningful PC in advanced cirrhosis compared with standard of care (SOC). METHODS: Thirty consecutive hepatology clinic outpatients with advanced cirrhosis, meeting one or more cirrhosis-related PC referral criteria, consented to treatment in the HepatoCare clinic (PC physician, specialist liver nurse, pharmacist) in parallel with usual specialist hepatology care. A control cohort of 30 consecutive outpatients with advanced cirrhosis undergoing SOC treatment was retrospectively identified for comparison. The primary outcome was provision of meaningful PC using HepatoCare versus SOC. Additional clinical outcomes were assessed over 12 months or until death and significant differences were identified. RESULTS: The intervention and control cohorts had similarly advanced cirrhosis (mean Child-Pugh scores 8.7 vs 8.2, P = 0.46; mean model for end-stage liver disease scores 14.4 vs 14.6, P = 0.88) but a lower 12-month mortality rate (33% HepatoCare vs 67% SOC; P = 0.02). The intervention cohort experienced higher uptake of formal ACP (100% vs 25% for the control cohort) and outpatient PC referral (100% vs 40%), and were more likely to die at home or in a PC bed/hospice (80% vs 30%). The majority of the HepatoCare cohort (81%) had medications safely deprescribed and experienced fewer unplanned admission days (470 vs 794). CONCLUSIONS: HepatoCare is a novel multidisciplinary model of care that integrates effective PC and specialist hepatology management to improve outcomes in advanced cirrhosis.

Confidence, Training and Challenges for Canadian Child Advocacy Center Staff When Working with Cases of Online and In-person Child Sexual Exploitation.

Child Advocacy Centers are interdisciplinary hubs that play a vital role in responding to child maltreatment, especially sexual abuse. Sexual abuse cases increasingly involve an online component, but no studies have examined the experience of Child Advocacy Center staff in dealing with online sexual exploiftation. This study surveyed 37 staff at five Child Advocacy Centers in Alberta, Canada to understand their ability to recognize and respond to concerns about online and in-person sexual exploitation of their clients. The majority of respondents (54%) dealt with cases that involved grooming, luring, sexual abuse and child sexual abuse imagery (also known as child pornography) in the last year. Staff were equally confident in their ability to recognize and respond to grooming, luring, sexual abuse and child sexual abuse imagery. However, staff were more likely to have formal training in identifying sexual abuse and less likely to encounter difficulties in responding to sexual abuse relative to grooming, luring or child sexual abuse imagery. Clinicians used similar therapies when working with youth impacted by sexual abuse versus child sexual abuse imagery. Given that most Child Advocacy Center staff in our sample dealt with online child sexual exploitation, additional training in this area may be warranted.

Experiences of Canadian mental health providers in identifying and responding to online and in-person sexual abuse and exploitation of their child and adolescent clients.

BACKGROUND: Sex offenders often use the internet to communicate with children to facilitate in-person sexual abuse or to create and distribute sexual images of children. Mental healthcare providers are a major source of referrals to child welfare authorities and are well-positioned to identify sexual exploitation. OBJECTIVE: This study investigated the perceived ability of mental healthcare workers to recognize and respond to concerns about online and in-person sexual exploitation of their pediatric clients. PARTICIPANTS AND SETTING: The authors administered a cross-sectional survey to 209 mental healthcare providers within the public health system of Alberta, Canada. METHODS: The survey contained four sections related to sexual exploitation: two of which can take place online or in-person (grooming and sexual abuse) and two of which require the internet or a digital device (luring and sexual image distribution). Each section asked whether the mental healthcare provider had experience working with clients affected by these concerns, what barriers they encounter, how confident they are in their abilities and whether they have formal training in a topic. RESULTS: The vast majority of participants (83%) worked with a client impacted by grooming, luring, sexual abuse or sexual image distribution in the last year. Participants reported more training, more confidence and fewer barriers when identifying and responding to sexual abuse as compared to grooming, luring or sexual image distribution. CONCLUSIONS: There is a need to improve mental health providers understanding of how technology is being utilized to exploit children, so that they can respond effectively to protect their clients.

Recommendations for youth engagement in Canadian mental health research in the context of COVID-19.

The COVID-19 pandemic has resulted in reduced access to in-person mental health services, and a shift to virtual platforms. Youth may be uniquely impacted by physical distancing requirements during the pandemic, including limited socialization opportunities, closures of educational institutions, a lack of meaningful extracurricular activities and adverse implications on key developmental milestones. Due to the potential impact of COVID-19 on youth well-being, the need to rapidly transform services to be accessible, and the potential risks associated with this rapid transformation, it is imperative that youth continue to be engaged in research and service development. Young people's perspectives, strengths and skills need to be considered to effectively adapt the delivery of mental health services. Continuing to center youth engagement in mental health research throughout the pandemic can ensure research questions, programs, and services align with the needs and preferences of youth. In this commentary, we pose three recommendations for conducting youth-engaged mental health research during the pandemic, including adapting youth engagement strategies when rapid decisions must be made, the use of tools for virtual engagement, and suggestions for evaluating youth engagement practices. These strategies and principles may be applicable to other scenarios where rapid research or system transformation would benefit from youth engagement, such as time-limited child research by trainees (e.g., dissertations) or natural disasters.

La pandémie de la COVID-19 a entraîné un accès réduit aux services de santé mentale en personne, et une transition aux plateformes virtuelles. Les jeunes peuvent être particulièrement touchés par les consignes de distanciation physique durant la pandémie, notamment par les occasions limitées de socialisation, la fermeture des institutions éducatives, le manque d'activités parascolaires et les implications néfastes sur les principales étapes du développement. Étant donné l'impact potentiel de la COVID-19 sur le bien-être des jeunes, le besoin de transformer rapidement les services pour les rendre accessibles, et les risques potentiels associés à cette transformation rapide, il est impératif que les jeunes continuent de participer à la recherche et au développement des services. Les perspectives, les forces et les talents des jeunes gens doivent être pris en considération afin d'adapter efficacement la prestation des services de santé mentale. Continuer d'axer la participation des jeunes dans la recherche en santé mentale durant la pandémie peut faire en sorte que les questions, les programmes et les services de la recherche correspondent aux besoins et aux préférences des jeunes. Dans le présent commentaire, nous énonçons trois recommandations pour mener une recherche en santé mentale avec la participation des jeunes durant la pandémie, notamment adapter les stratégies de participation des jeunes lorsqu'il faut prendre des décisions rapidement, l'utilisation des outils de participation virtuelle, et des suggestions pour évaluer les pratiques de participation des jeunes. Ces stratégies et principes peuvent s'appliquer à d'autres scénarios quand la recherche rapide ou la transformation du système bénéficierait de la participation des jeunes, comme la recherche sur les enfants en temps limité par les stagiaires (p. ex., dissertation) ou des catastrophes naturelles.

Capacity, confidence and training of Canadian educators and school staff to recognize and respond to sexual abuse and internet exploitation of their students.

BACKGROUND: Sexual exploitation of children online is an issue of growing public concern. This form of exploitation typically involves adults using the internet to communicate with children for sexual purposes or to distribute sexually explicit material involving children. To date, there is no research on the knowledge and skills of educators to recognize online sexual exploitation. This research is urgently needed since educators are well-positioned to detect, identify and report sexual exploitation of their students. OBJECTIVE: The study was conducted to understand the confidence and capacity of grade school educators to recognize and respond to online child sexual exploitation. PARTICIPANTS AND SETTING: This cross-sectional study surveyed 450 educators in Alberta, Canada between April and December 2018. METHODS: Vignettes were used to obtain experiences and attitudes surrounding four categories of exploitation or abuse: grooming, luring, sexual abuse, and sexual abuse imagery (also known as child pornography). RESULTS: Among school district staff, 28 % reported working with a student affected by sexual abuse in the last year, as compared to 25 % for grooming, 17 % for luring and 14 % for sexual abuse imagery. A minority of respondents expressed confidence in their ability to recognize if the internet was being employed for grooming (35 % of staff), luring (46 %) or sexual abuse (45 %) of their students. CONCLUSIONS: Educators encounter issues of online sexual exploitation of their students almost as often as contact sexual abuse. Child protection efforts in schools should be modernized to incorporate training in online safety of children and adolescents.

Family-based treatment for transition age youth: the role of expressed emotion and general family functioning.

The aim of this study was to investigate changes in family functioning and parental expressed emotion (EE) in parents and transition age youth (18 to 25 years old) with Anorexia Nervosa participating in Family-Based Treatment for Transition Age Youth (FBT-TAY). Further, we examined whether perceived family functioning and EE were associated with changes in eating disorder behaviour and weight in participants at end-of-treatment and three months post-treatment. Generalized estimating equations revealed that changes in family functioning significantly improved from baseline to end-of-treatment (p = .0001), and baseline to three months post-treatment (p = .0001) in parents; and from baseline to end-of-treatment (p = .011), and baseline to three months post-treatment (p = .0001) in transition age youth. The level of parental EE did not differ significantly from baseline to end-of-treatment (p = .379), or baseline to three months post-treatment (p = .185). A series of Ordinary Least Square regression models demonstrated that changes in perceived family functioning and EE were not significantly associated with changes in eating disorder behaviour and weight restoration of transition age youth at end-of-treatment and three months post-treatment. Overall, perceptions of family functioning improved during the course of FBT-TAY, but EE did not.

Shell Cross-Linked Micelles as Nanoreactors for Enantioselective Three-Step Tandem Catalysis.

Functionalized amphiphilic poly(2-oxazoline)-based triblock copolymers that assemble into shell cross-linked micelles (SCMs) are described. These micelles permit the site isolation of three incompatible catalysts through compartmentalization, thereby enabling three-step non-orthogonal tandem processes in one pot. In particular, the acid-catalyzed ketal hydrolysis to prochiral ketones proceeded in the hydrophilic corona, followed by the Rh-catalyzed asymmetric transfer hydrogenation to enantio-enriched alcohols in the cross-linked shell, and nucleophilic base-catalyzed acylation in the hydrophobic core. The catalysts are positioned in close proximity on a single micelle support to take advantage of the intramicellar substrate diffusion, yet they are sufficiently spaced apart from each other in physically distinct microenvironments. These compartmentalized micelles are substrate selective and, on a basic level, mimic compartmentalized catalytic architectures found in nature.

Family-based treatment for transition age youth: parental self-efficacy and caregiver accommodation.

BACKGROUND: Family-Based Treatment (FBT) is the first line of care in paediatric treatment while adult programs focus on individualized models of care. Transition age youth (TAY) with Anorexia Nervosa (AN) are in a unique life stage and between systems of care. As such, they and their caregivers may benefit from specialized, developmentally tailored models of treatment. METHODS: The primary purpose of this study was to assess if parental self-efficacy and caregiver accommodation changed in caregivers during the course of FBT-TAY for AN. The secondary aim was to determine if changes in parental self-efficacy and caregiver accommodation contributed to improvements in eating disorder behaviour and weight restoration in the transition age youth with AN. Twenty-six participants (ages 16-22) and 39 caregivers were recruited. Caregivers completed the Parents versus Anorexia Scale and Accommodation and Enabling Scale for Eating Disorders at baseline, end-of-treatment (EOT), and 3 months follow-up. RESULTS: Unbalanced repeated measures designs for parental self-efficacy and caregiver accommodation towards illness behaviours were conducted using generalized estimation equations. Parental self-efficacy increased from baseline to EOT, although not significantly (p = .398). Parental self-efficacy significantly increased from baseline to 3 months post-treatment (p = .002). Caregiver accommodation towards the illness significantly decreased from baseline to EOT (p = 0.0001), but not from baseline to 3 months post-treatment (p = 1.000). Stepwise ordinary least squares regression estimates of eating disorder behaviour and weight restoration did not show that changes in parental-self efficacy and caregiver accommodation predict eating disorder behaviour or weight restoration at EOT or 3 months post-treatment. CONCLUSIONS: Our findings demonstrate, albeit preliminary at this stage, that FBT-TAY promotes positive increases in parental self-efficacy and assists caregivers in decreasing their accommodation to illness behaviours for transition age youth with AN. However, changes in the parental factors did not influence changes in eating and weight in the transition age youth.

"I would love to have online support but I don't trust it": Positive and negative views of technology from the perspective of those with eating disorders in Canada.

This qualitative study aims to explore how individuals who are seeking help and support for eating disorders use various forms of technology. Fifteen participants, recruited from an Eating Disorder Program in a hospital setting and an eating disorder community support centre, voluntarily participated in focus groups and individual interviews in 2015. The authors used thematic analysis to code and analyse the qualitative data, and three themes were identified: safety, connection and technology development. This study identifies the need for technology use to be addressed and integrated into clinical services for eating disorders, as well as for safe and helpful technology tools to be developed for this population.