Medical students' perspectives on a longitudinal wellness curriculum: a qualitative investigation.

Introduction: There is growing concern about the mental health status of medical students. Medical students are at a higher risk for depression, anxiety, and burnout than non-medical students. The Undergraduate Medical Education (UGME) Office of Medical Learner Affairs at McGill University developed a Longitudinal Wellness Curriculum (LWC) to foster medical students' well-being, self-care, and adaptability. Methods: We conducted a qualitative descriptive study to explore students' experiences with the LWC. We conducted three semi-structured focus groups involving a total of 11 medical students. We used thematic framework analysis for data analysis. Results: We found four main themes related to participants' engagement with the curriculum: 1) diverse perceptions on curriculum relevance and helpfulness; 2) the benefits of experiential sessions, role model speakers, and supportive staff; 3) insights on student-friendly curriculum scheduling; and 4) the importance of wellness education and systemic interventions in medical education. Conclusions: Most participants found the curriculum valuable and supported its integration into the academic curriculum. Experiential and active learning, diverse approaches to wellness, small group sessions, role modeling, and student-centered approaches were preferred methods. Inconvenient curriculum scheduling and skepticism over system-level support were seen as barriers to curriculum engagement and uptake. The findings of our study contribute to the development and implementation of wellness curriculum efforts in medical education.

Introduction: L'état de santé mentale des étudiants en médecine est de plus en plus préoccupant. Les étudiants en médecine sont davantage exposés à la dépression, à l'anxiété et à l'épuisement professionnel que les étudiants des autres disciplines. Le Bureau des études médicales prédoctorales (EMPr) de l'Université McGill a mis au point un programme longitudinal sur le bien-être pour favoriser le bien-être, l'autonomie et la capacité d'adaptation des étudiants en médecine. Méthodes: Nous avons mené une étude qualitative descriptive pour explorer les expériences des étudiants relativement au programme. Nous avons organisé trois groupes de discussion semi-structurés auxquels ont participé 11 étudiants en médecine. Nous avons utilisé une analyse thématique pour l'analyse des données. Résultats: Nous avons dégagé quatre thèmes principaux liés à l'engagement des participants dans le programme d'études : 1) diverses perceptions de la pertinence et de l'utilité du programme ; 2) les avantages des séances expérientielles, des conférenciers modèles et du personnel de soutien ; 3) des idées sur la programmation du programme adapté aux étudiants et 4) l'importance de la formation en matière de bien-être et des interventions systémiques dans l'enseignement médical. Conclusions: La plupart des participants ont trouvé le programme intéressant et ont soutenu son intégration dans le programme universitaire. L'apprentissage expérientiel et actif, les diverses approches du bien-être, les séances en petits groupes, les modèles de rôle et les approches centrées sur l'étudiant étaient les méthodes préférées. Les horaires peu pratiques du programme et le scepticisme quant au soutien du système ont été considérés comme des obstacles à l'engagement et à l'adoption du programme. Les résultats de notre étude contribuent à l'élaboration et à la mise en œuvre de programmes de bien-être dans l'enseignement médical.

Transgender and Nonbinary Individuals' Perceptions Regarding Gender-Affirming Hormone Therapy and Cardiovascular Health: A Qualitative Study.

BACKGROUND: Transgender and nonbinary individuals face substantial cardiovascular health uncertainties. The use of gender-affirming hormone therapy can be used to achieve one's gender-affirming goals. As self-rated health is an important predictor of health outcomes, an understanding of how this association is perceived by transgender and nonbinary individuals using gender-affirming hormone therapy is required. The objective of this research was to explore transgender and nonbinary individuals' perceptions of cardiovascular health in the context of using gender-affirming hormone therapy. METHODS: In this qualitative study, English-speaking transgender and nonbinary adults using gender-affirming hormone therapy for 3 months or more were recruited from across Canada using purposive and snowball sampling methods. Semistructured interviews were conducted through videoconference to explore transgender and nonbinary individuals' perceptions of the association between gender-affirming hormone therapy and cardiovascular health between May and August 2023. Data were transcribed verbatim, and transcripts were analyzed independently by 3 reviewers using thematic analysis. RESULTS: Twenty-one participants were interviewed (8 transgender women, 9 transgender men, and 3 nonbinary individuals; median [range] age, 27 [20-69] years; 80% White participants). Three main themes were identified: cardiovascular health was not a primary concern in the decision-making process with regard to gender-affirming hormone therapy, the improved well-being associated with gender-affirming hormone therapy was felt to contribute to improved cardiovascular health, and health care provider knowledge and attitude facilitate the transition process. CONCLUSIONS: Gender-affirming hormone therapy in transgender and nonbinary individuals is perceived to improve cardiovascular health. Given the positive associations between care aligned with patient priorities, self-rated health, and health outcomes, these findings should be considered as part of shared decision-making and person-centered care.

Association between serum estradiol and cardiovascular health among transgender adults using gender-affirming estrogen therapy.

Gender-affirming estrogen therapy (GAET) is commonly used for feminization in transgender and nonbinary (TNB) individuals, yet the optimal rate of change (ROC) in estradiol levels for cardiovascular health is unclear. We examined the association between serum estradiol levels and cardiovascular-related mortality, adverse events, and risk factors in TNB adults using GAET. Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, and Web of Science were systematically searched (inception-April 2023) for original articles reporting serum estradiol levels and cardiovascular-related mortality, adverse events, and risk factors in TNB adults using GAET. Data extraction was completed in duplicate following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Stratified random effect meta-analyses using serum estradiol ROC (serum estradiolbaseline - serum estradiolfollow-up/study duration) was used to assess longitudinal studies (low, 0 < ROC ≤ 1 pg/mL/mo; moderate, 1 < ROC ≤ 3 pg/mL/mo; high, ROC ≥ 3 pg/mL/mo). Thirty-five studies (13 cross-sectional, 19 cohort, and 3 trials) were included. Two studies collectively reported 50 cardiovascular-related deaths, and four collectively reported 23 adverse cardiovascular events. Nineteen studies reporting cardiovascular risk factors were meta-analyzed by ROC stratum (low = 5; moderate = 6; high = 8), demonstrating an association between moderate [0.40, 95% confidence interval (CI): 0.22, 0.59 kg/m2, I2 = 28.2%] and high (0.46, 95% CI: 0.15, 0.78 kg/m2; I2 = 0.0%) serum estradiol ROC and increased body mass index. High (-6.67, 95% CI: -10.65, -2.68 mg/dL; I2 = 0.0%) serum estradiol ROC was associated with decreased low-density lipoproteins. Low (-7.05, 95% CI: -10.40, -3.70 mmHg; I2 = 0.0%) and moderate (-3.69, 95% CI: -4.93, -2.45 mmHg; I2 = 0.0%) serum estradiol ROCs were associated with decreases in systolic blood pressure. In TNB adults using GAET, serum estradiol ROC may influence cardiovascular risk factors, which may have implications for clinical cardiovascular outcomes.NEW & NOTEWORTHY In this systematic review and meta-analysis of 35 studies involving 7,745 participants, high rates of serum estradiol change were associated with small increases in body mass index. Moderate to high rates of change were associated with decreases in low-density lipoprotein. Low rates of change were associated with small decreases in systolic blood pressure. Rate of serum estradiol change in adults using gender-affirming estrogen therapy may influence cardiovascular risk factors, though further research is warranted.

A Holistic Framework for the Evaluation of Kidney Function in a Gender-Diverse Landscape.

The most commonly used equations to estimate glomerular filtration rate incorporate a binary male-female sex coefficient, which has important implications for the care of transgender, gender-diverse, and nonbinary (TGD) people. Whether "sex assigned at birth" or a binary "gender identity" is most appropriate for the computation of estimated glomerular filtration rate (eGFR) is unknown. Furthermore, the use of gender-affirming hormone therapy (GAHT) for the development of physical changes to align TGD people with their affirmed gender is increasingly common, and may result in changes in serum creatinine and cystatin C, the biomarkers commonly used to estimate glomerular filtration rate. The paucity of current literature evaluating chronic kidney disease (CKD) prevalence and outcomes in TGD individuals on GAHT makes it difficult to assess any effects of GAHT on kidney function. Whether alterations in serum creatinine reflect changes in glomerular filtration rate or simply changes in muscle mass is unknown. Therefore, we propose a holistic framework to evaluate kidney function in TGD people. The framework focuses on kidney disease prevalence, risk factors, sex hormones, eGFR, other kidney function assessment tools, and the mitigation of health inequities in TGD people.

Personalized Telehealth: Redesigning Complex Care Delivery for the 65+ During the COVID Pandemic: a Survey of Patients, Caregivers, and Health-care Providers.

Background: In the context of the ongoing COVID-19 pandemic, rapid transitions have been made towards telehealth. Optimal use of telehealth in elderly patients remains poorly understood and adaptation challenges persist. Our study aimed at identifying perceptions, barriers, and possible facilitators to telehealth use amongst elderly patients with comorbidities, their caregivers, and health-care providers (HCPs). Methods: Health-care providers, patients 65 years and older with multiple comorbidities, and caregivers were recruited from outpatient clinics and invited to complete an electronic self-administered or telephone-administered survey on their perceptions of telehealth and of barriers to its implementation. Results: A total of 39 health-care providers, 40 patients, and 22 caregivers responded to the survey. Most patients (90%), caregivers (82%), and HCPs (97%) had experienced telephone visits, but few were conducted via videoconference platforms. Patients and caregivers showed interest in pursuing some future telehealth visits (68%, 86%, respectively), but felt they lacked access to technology and skills (n=8, 20%), and some felt that telehealth visits may be inferior to in-person visits (n=9, 23%). HCPs showed interest in incorporating telehealth visits into practice (n=32, 82%), but identified challenges in lack of administrative support (n=37), lack of HCP (n=28) and patient (n=37) technological skills, and limited infrastructure (n=37)/internet access (n=33). Conclusions: Older patients, caregivers, and HCPs show interest in pursuing future telehealth visits but elucidate similar barriers. Facilitating access to technology, as well as to administrative and technology support guides, could promote high quality and equal access to virtual care for the older adult.

Improving the inclusion of transgender and nonbinary individuals in the planning, completion, and mobilization of cardiovascular research.

Cardiovascular disease is the leading cause of morbidity and mortality globally. Transgender and nonbinary (TNB) individuals face unclear but potentially significant cardiovascular health inequities, yet no TNB-specific evidence-based interventions for cardiovascular risk reduction currently exist. To address this gap, we propose a road map to improve the inclusion of TNB individuals in the planning, completion, and mobilization of cardiovascular research. In doing so, the adoption of inclusive practices would optimize cardiovascular health surveillance and care for TNB communities.

Serum oestradiol levels and risk of adverse cardiovascular events associated with gender-affirming oestrogen therapy: a protocol for a systematic review and meta-analysis.

INTRODUCTION: The use of gender-affirming oestrogen therapy (GAOT) is an integral part of the gender-affirming transition process for transgender women (assigned male at birth who identify as women) and gender-diverse individuals. However, its use may present significant cardiovascular implications, which may be influenced by systemic oestradiol levels. Therefore, we aim to establish the association between serum oestradiol levels and incidence of adverse cardiovascular events in individuals using GAOT. METHODS AND ANALYSIS: We will conduct a systematic review addressing the association between serum oestradiol levels and risk of adverse cardiovascular events in individuals using GAOT. Our primary outcome is the incidence of adverse cardiovascular events, our secondary outcome is the incidence of cardiovascular-related mortality and our tertiary outcome is cardiovascular-related risk factors. Electronic databases (Cochrane Central Register of Controlled Trials, Embase, MEDLINE and Web of Science) will be searched from inception until September 2022. Two investigators will independently complete screening to determine appropriateness of inclusion. Extracted data will include information on serum sex hormone levels (oestradiol and testosterone), participants, GAOT (route of administration, formulations, dosages and duration of exposure), incidence of cardiovascular outcomes, study quality and risk of bias. Inter-reviewer reliability will be calculated at both phases. Data will be presented both descriptively and meta-analysed using a random effects model, if appropriate. Heterogeneity will be explored and meta-regressed if noted. ETHICS AND DISSEMINATION: Ethics approval is not needed. We will disseminate findings through international conferences, distributions to transgender and gender-diverse support organisations, decision-makers and key stakeholders. The final systematic review will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: CRD42021247717.

Gender-affirming estrogen therapy route of administration and cardiovascular risk: a systematic review and narrative synthesis.

Transgender women (individuals assigned male sex at birth who identify as women) and nonbinary and gender-diverse individuals receiving gender-affirming estrogen therapy (GAET) are at increased cardiovascular risk. Nonoral (i.e., patch, injectable) compared with oral estrogen exposure in cisgender women (individuals assigned female sex at birth who identify as women) may be associated with lower cardiovascular risk, though whether this applies to transgender women and/or gender-diverse individuals is unknown. We sought to determine the association between the route of estrogen exposure (nonoral compared with oral) and cardiovascular risk in transgender women and gender diverse individuals. Bibliographic databases (MEDLINE, Embase, PsycINFO) and supporting relevant literature were searched from inception to January 2022. Randomized controlled trials and observational studies reporting cardiovascular outcomes, such as all-cause and cardiovascular mortality, adverse cardiovascular events, and cardiovascular risk factors in individuals using nonoral compared with oral gender-affirming estrogen therapy were included. The search strategy identified 3,113 studies, 5 of which met inclusion criteria (3 prospective cohort studies, 1 retrospective cohort study, and 1 cross-sectional study; n = 259 participants, range of duration of exposure of 2 to 60 mo). One out of five studies reported on all-cause and cardiovascular mortality or adverse cardiovascular events. All five studies reported lipid levels [low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides (TG), and total cholesterol (TC)], whereas only two studies reported systolic blood pressure (SBP) and diastolic blood pressure (DBP). Limited studies have examined the effect of the route of GAET on all-cause cardiovascular mortality, morbidity, and risk factors. In addition, there is significant heterogeneity in studies examining the cardiovascular effects of GAET.NEW & NOTEWORTHY This study is the first to summarize the potential effect of nonoral versus oral gender-affirming estrogen therapy use on cardiovascular risk factors in transgender women or nonbinary or gender-diverse individuals. Heterogeneity of studies in reporting gender-affirming estrogen therapy formulation, dose, and duration of exposure limits quantification of the effect of gender-affirming estrogen therapy on all-cause and cardiovascular mortality, adverse cardiovascular events, and cardiovascular risk factors. This systematic review highlights the needs for large prospective cohort studies with appropriate stratification of gender-affirming estrogen therapy by dose, formulation, administration route, and sufficient follow-up and analyses to limit selection bias to optimize the cardiovascular care of transgender, nonbinary, and gender-diverse individuals.

The Accessibility, Feasibility, and Safety of a Standardized Community-based Tele-Pulmonary Rehab Program for Chronic Obstructive Pulmonary Disease: A 3-Year Real-World Prospective Study.

Rationale: Few individuals with chronic obstructive pulmonary disease (COPD) are able to access pulmonary rehabilitation (PR) despite its importance. Barriers include increased travel time and lack of resources. Tele-PR has been proposed as a novel solution to overcome such barriers and improve access. Objectives: Our study aimed to provide information on implementing a novel province-wide standardized community-based tele-PR program and determine its accessibility, feasibility, and safety. Secondary objectives examined the effectiveness of tele-PR compared with standard PR and if clinical improvements were sustained over time. Methods: We conducted a concurrent prospective study of people with COPD enrolled in either standard PR or community-based tele-PR at satellite centers between January 2017 and January 2020. To determine accessibility and feasibility, we recorded the number of participating centers meeting eligibility criteria, centers remaining in the program over 3 years, number of delivered programs, and major adverse events. Participants had a 6-minute walk test (6MWT) and COPD assessment test (CAT) at baseline, immediately after PR and at 1, 3, 6, and 12 months. Descriptive analysis was performed for accessibility, feasibility, and safety. Mixed-effects random models were used to estimate change in 6MWT and CAT. Results: Seven tele-sites were recruited into the tele-PR program, with six continuing to participate at 3 years, delivering a total of 58 programs for 177 individuals with COPD. During that same period, the standard PR site delivered 15 programs for 89 individuals with COPD. Over 70% of participants completed each program, and no major adverse events were reported. There were significant improvements in the 6MWT and CAT scores in both groups immediately after PR with no between-group differences. Participants in both programs had persistent 6MWT improvement at 1, 3, 6, and 12 months after PR. Participants in tele-PR, but not those in standard PR, had persistent improvements of CAT scores beyond 1 month after PR. Conclusions: This study provides real-world evidence demonstrating successful implementation of tele-PR. The Canadian standardized tele-PR program is an accessible, feasible, safe, and effective model for delivering PR.

Implications for management of ovarian cancer in a transgender man: Impact of androgens and androgen receptor status.

A 36-year-old transgender man (assigned female at birth) on exogenous testosterone therapy was found to have stage IIA ovarian endometrioid carcinoma, and underwent adjuvant chemotherapy. Diffuse androgen receptor expression in the tumor initiated a multidisciplinary discussion regarding the safety of continuing exogenous testosterone as gender-affirming hormone therapy.

Providing Care for Transgender Persons With Kidney Disease: A Narrative Review.

PURPOSE OF REVIEW: Nephrologists are increasingly providing care to transgender individuals with chronic kidney disease (CKD). However, they may lack familiarity with this patient population that faces unique challenges. The purpose of this review is to discuss the care of transgender persons and what nephrologists should be aware of when providing care to their transgender patients. SOURCES OF INFORMATION: Original research articles were identified from MEDLINE and Google Scholar using the search terms "transgender," "gender," "sex," "chronic kidney disease," "end stage kidney disease," "dialysis," "transplant," and "nephrology." METHODS: A focused review and critical appraisal of existing literature regarding the provision of care to transgender men and women with CKD including dialysis and transplant to identify specific issues related to gender-affirming therapy and chronic disease management in transgender persons. KEY FINDINGS: Transgender persons are at an increased risk of adverse outcomes compared with the cisgender population including mental health, cardiovascular disease, malignancy, sexually transmitted infections, and mortality. Individuals with CKD have a degree of hypogonadotropic hypogonadism and decreased levels of endogenous sex hormones; therefore, transgender persons with CKD may require reduced exogenous sex hormone dosing. Exogenous estradiol therapy increases the risk of venous thromboembolism and cardiovascular disease which may be further increased in CKD. Exogenous testosterone therapy increases the risk of polycythemia which should be closely monitored. The impact of gender-affirming hormone therapy on glomerular filtration rate (GFR) trajectory in CKD is unclear. Gender-affirming hormone therapy with testosterone, estradiol, and anti-androgen therapies changes body composition and lean body mass which influences creatinine generation and the performance for estimated glomerular filtration rate (eGFR) equations in transgender persons. Confirmation of eGFR with measured GFR is reasonable if an accurate knowledge of GFR is needed for clinical decision-making. LIMITATIONS: There are limited studies regarding the intersection of transgender persons and kidney disease and those that exist are mostly case reports. Randomized controlled trials and observational studies in nephrology do not routinely differentiate between cisgender and transgender participants. IMPLICATIONS: This review highlights important considerations for providing care to transgender persons with kidney disease. Additional research is needed to evaluate the performance of eGFR equations in transgender persons, the effects of gender-affirming hormone therapy, and the impact of being transgender on outcomes in persons with kidney disease.

MOTIF DE LA REVUE: Dans leur pratique, les néphrologues sont de plus en plus appelés à traiter des personnes transgenres atteintes d'insuffisance rénale chronique (IRC). Une population de patients qui fait face à des défis particuliers et avec laquelle les spécialistes ne sont pas toujours familiers. L'objectif de cette revue est de discuter des soins prodigués aux personnes transgenres et des enjeux auxquels les néphrologues qui soignent ces patients devraient être sensibilisés. SOURCES: Les articles de recherche originaux ont été répertoriés sur MEDLINE et Google Scholar à l'aide des termes transgender (transgenre), gender (genre), sex (sexe), chronic kidney disease (insuffisance rénale chronique), end stage kidney disease (insuffisance rénale terminale), dialysis (dialyse), transplant (transplantation) et nephrology (néphrologie). MÉTHODOLOGIE: On a procédé à un examen ciblé et une évaluation critique de la documentation portant sur les soins aux personnes transgenres atteintes d'IRC, notamment la dialyse et la transplantation, afin de cerner les enjeux liés spécifiquement aux thérapies d'affirmation du genre et à la prise en charge de la néphropathie chronique chez les personnes transgenres. PRINCIPAUX RÉSULTATS: Les personnes transgenres courent un risque accru d'événements défavorables comparativement à la population cisgenre, notamment en matière de santé mentale, de maladies cardiovasculaires, de tumeurs malignes, d'infections transmissibles sexuellement et de mortalité. Les individus atteints d'IRC présentent un certain degré d'hypogonadisme hypogonadotrope et des taux réduits d'hormones sexuelles endogènes; les personnes transgenres atteintes d'IRC pourraient ainsi nécessiter un dosage réduit d'hormones sexuelles exogènes. L'estradiol exogène augmente le risque de thrombo-embolie veineuse et de maladies cardiovasculaires, un risque pouvant être augmenté davantage en contexte d'IRC. La testostérone exogène augmente le risque de polycythémie et doit être surveillée étroitement. L'impact de l'hormonothérapie d'affirmation du genre sur la trajectoire du débit de filtration glomérulaire (DFG) en IRC est encore mal connu. L'hormonothérapie d'affirmation du genre avec testostérone, estradiol et anti-androgène altère la composition corporelle et la masse maigre, ce qui influe sur la production de créatinine et la performance des équations calculant le DFG estimé (DFGe) chez les personnes transgenres. La confirmation du DFGe à l'aide du DFG mesuré est raisonnable si connaître la valeur précise du DFG est nécessaire pour la prise de décision clinique. LIMITES: Peu d'études se sont penchées sur l'intersection des personnes transgenres et de la néphropathie, et les études existantes consistent principalement en des rapports de cas. Les essais contrôlés randomisés et les études observationnelles en néphrologie ne font pas systématiquement de distinction entre les participants cisgenres et transgenres. CONCLUSION: Cette revue met en lumière des considérations importantes pour la prise en charge des personnes transgenres atteintes de néphropathies. D'autres recherches sont nécessaires pour évaluer la performance des équations calculant le DFGe, les effets de l'hormonothérapie d'affirmation du genre et l'incidence d'être transgenre sur les résultats des personnes atteintes de néphropathies.

Description of Participation in Daily and Social Activities for Individuals with COPD.

This study described the participation in daily and social activities and the perceived barriers and facilitators to participation of individuals with chronic obstructive pulmonary disease (COPD). Individuals, recruited from outpatient clinics, responded to a survey on their participation in, and barriers and facilitators towards, 26 daily and social activities, divided into 3 categories: (1) physical activity and movement (PAM); (2) self-care; and (3) social engagement. For each activity, chi-square analyses were used to examine participation differences by individuals': quartiles of airflow obstruction [percent predicted forced expiratory volume in 1 second (FEV1%predicted)] and breathlessness burden and exacerbation risk. Of the 200 participants (47% women; mean ± standard deviation age = 68 ± 9 years), most wanted to increase their participation in PAM activities (range 21-75%) and significant differences were found in 5/10 PAM activities for individuals' breathlessness burden and exacerbation risk (e.g., more individuals than expected in group A (modified Medical Research Council breathlessness score <2 and 0-1 exacerbations in past 12 months) participated in regular exercise as much as they wanted (χ(9)2=20.43, Cramer's V=.23)). Regardless of the degree of airflow obstruction or breathlessness burden and exacerbation risk, the most common barrier to participation was breathlessness (p<.001, η2p=.86) and the most common facilitator was engaging as part of their routine (p<.001, η2p=.75). Individuals with COPD want to increase their participation in daily and social activities but are limited by breathlessness. Strategies to alleviate breathlessness should be identified/prioritized and incorporated into individuals' daily routines to meet their self-reported participation objectives in daily and social activities.

Breast cancer in transgender female-to-male individuals: A case report of androgen receptor-positive breast cancer.

Highlight the challenges associated with managing breast cancer in female-to-male (FtM) transgender individuals. This is a rare entity, requiring nuanced decision-making regarding surgery as well as adjuvant therapies given the unique hormonal environment seen in individuals taking exogenous androgen as part of their gender identity. Contemporary case report derived from our clinical experience. Discussion focuses on a brief summation of all known cases of female-to-male breast cancer in FtM individuals described in the literature. A 48-year-old FtM transgender individual on exogenous testosterone for 19 years with stage IIA (pT1cN1M0), ER+(8/8), PR+(8/8), Androgen Receptor(AR)+(5%-8%), Her-2-negative invasive ductal carcinoma of the breast. Due to AR positivity in tumor, cessation of testosterone was chosen after careful consideration of potential ramifications from both a cancer treatment as well as gender identity standpoint. Endocrinology consultation reassured the patient that identity affirming changes of facial hair growth and voice depth would persist after cessation of testosterone. Patient did not wish to undergo chemotherapy and as such was treated with combination of radiation to the axilla, adjuvant Anastrozole and testosterone cessation. Although breast cancer is rare in FtM transgender individuals, it can occur. Many FtM individuals take exogenous testosterone. It is important to test the tumor for the androgen receptor as this may have important implications for both gender identity and treatment. Additionally, the mastectomy commonly performed for "top" surgery in this population is not adequate for oncologic control by itself and at present there is no guidance regarding postsurgical screening in this population, especially in those individuals with a strong family history of breast cancer.

Immediate Hypersensitivity to Contrast Agents: The French 5-year CIRTACI Study.

BACKGROUND: Iodinated and gadolinium-based contrast media (ICM; GBCM) induce immediate hypersensitivity (IH) reactions. Differentiating allergic from non-allergic IH is crucial; allergy contraindicates the culprit agent for life. We studied frequency of allergic IH among ICM or GBCM reactors. METHODS: Patients were recruited in 31 hospitals between 2005 and 2009. Clinical symptoms, plasma histamine and tryptase concentrations and skin tests were recorded. Allergic IH was diagnosed by intradermal tests (IDT) with the culprit CM diluted 1:10, "potentially allergic" IH by positive IDT with pure CM, and non-allergic IH by negative IDT. FINDINGS: Among 245 skin-tested patients (ICM = 209; GBCM = 36), allergic IH to ICM was identified in 41 (19.6%) and to GBCM in 10 (27.8%). Skin cross-reactivity was observed in 11 patients with ICM (26.8%) and 5 with GBCM (50%). Allergy frequency increased with clinical severity and histamine and tryptase concentrations (p < 0.0001). Cardiovascular signs were strongly associated with allergy. Non-allergic IH was observed in 152 patients (62%) (ICM:134; GBCM:18). Severity grade was lower (p < 0.0001) and reaction delay longer (11.6 vs 5.6 min; p < 0.001). Potentially allergic IH was diagnosed in 42 patients (17.1%) (ICM:34; GBCM:8). The delay, severity grade, and mediator release were intermediate between the two other groups. INTERPRETATION: Allergic IH accounted for < 10% of cutaneous reactions, and > 50% of life-threatening ones. GBCM and ICM triggered comparable IH reactions in frequency and severity. Cross-reactivity was frequent, especially for GBCM. We propose considering skin testing with pure contrast agent, as it is more sensitive than the usual 1:10 dilution criteria.

Effect of morphine on breathlessness and exercise endurance in advanced COPD: a randomised crossover trial.

The objective of the present study was to evaluate the effect of morphine on exertional breathlessness and exercise endurance in advanced chronic obstructive pulmonary disease (COPD).In a randomised crossover trial, we compared the acute effect of immediate-release oral morphine versus placebo on physiological and perceptual responses during constant-load cardiopulmonary cycle exercise testing (CPET) in 20 adults with advanced COPD and chronic breathlessness syndrome.Compared with placebo, morphine reduced exertional breathlessness at isotime by 1.2±0.4 Borg units and increased exercise endurance time by 2.5±0.9 min (both p≤0.014). During exercise at isotime, morphine decreased ventilation by 1.3±0.5 L·min-1 and breathing frequency by 2.0±0.9 breaths·min-1 (both p≤0.041). Compared with placebo, morphine decreased exertional breathlessness at isotime by ≥1 Borg unit in 11 participants (responders) and by <1 Borg unit in nine participants (non-responders). Baseline participant characteristics, including pulmonary function and cardiorespiratory fitness, were similar between responders and non-responders. A higher percentage of responders versus non-responders stopped incremental CPET due to intolerable breathlessness: 82 versus 33% (p=0.028).Immediate-release oral morphine improved exertional breathlessness and exercise endurance in some, but not all, adults with advanced COPD. The locus of symptom-limitation on laboratory-based CPET may help to identify patients most likely to benefit from morphine.

Barriers to care in patients with diabetes and poor glycemic control-A cross-sectional survey.

AIMS: To determine and quantify the prevalence of patient, provider and system level barriers to achieving diabetes care goals; and to examine whether barriers were different for people with poor glycemic control (HbA1c ≥ 10%; 86 mmol/mol) compared to fair glycemic control (7 to <8%; 53-64 mmol/mol). METHODS: We administered a survey by telephone to community-dwelling patients with diabetes, to examine patient-reported barriers and facilitators to care. We compared responses in individuals with HbA1c ≥ 10% (86 mmol/mol) against those with HbA1c between 7-8% (53-64 mmol/mol). We examined associations between HbA1c group and barriers to care, adjusting for sociodemographic factors and diabetes duration. RESULTS: The survey included 805 people with HbA1c ≥ 10% (86 mmol/mol), and 405 people with HbA1c 7-8% (53-64 mmol/mol). Participants with HbA1c ≥ 10% (86 mmol/mol) reported good access to care, however 20% of participants with HbA1c ≥ 10% (86 mmol/mol) felt that their care was not well-coordinated and 9.6% reported having an unmet health care need. In adjusted analysis, patients with HbA1c ≥10% (86 mmol/mol) were more likely to report lack of confidence and inadequate social support, compared to patients with HbA1c 7-8% (53-64 mmol/mol). They were also significantly more likely not to have drug insurance nor to have received recommended treatments because of cost. CONCLUSIONS: These results reinforce the importance of an individualized, yet multi-faceted approach. Specific attention to financial barriers seems warranted. These findings can inform the development of programs and initiatives to overcome barriers to care, and improve diabetes care and outcomes.

Lifetime risk of diabetes among First Nations and non-First Nations people.

BACKGROUND: Lifetime risk is a relatively straightforward measure used to communicate disease burden, representing the cumulative risk of an outcome during the remainder of an individual's life starting from a disease-free index age. We estimated the lifetime risk of diabetes among men and women in both First Nations and non-First Nations populations using a cohort of adults in a single Canadian province. METHODS: We used a population-based cohort consisting of Alberta residents from 1997 to 2008 who were free of diabetes at cohort entry to estimate the lifetime risk of diabetes among First Nations and non-First Nations people. We calculated age-specific incidence rates with the person-year method in 5-year bands. We estimated the sex- and index-age-specific lifetime risk of incident diabetes, after adjusting for the competing risk of death. RESULTS: The cohort included 70 631 First Nations and 2 732 214 non-First Nations people aged 18 years or older. The lifetime risk of diabetes at 20 years of age was 75.6% among men and 87.3% among women in the First Nations group, as compared with 55.6% among men and 46.5% among women in the non-First Nations group. The risk was higher among First Nations people than among non-First Nations people for all index ages and for both sexes. Among non-First Nations people, men had a higher lifetime risk of diabetes than women across all index ages. In contrast, among First Nations people, women had a higher lifetime risk than men across all index ages. INTERPRETATION: About 8 in 10 First Nations people and about 5 in 10 non-First Nations people of young age will develop diabetes in their remaining lifetime. These population-based estimates may help health care planners and decision-makers set priorities and increase public awareness and interest in the prevention of diabetes.