Hormone Therapy: Gender-Affirming Hormone Therapy.

Approximately 0.6% of adults (1 to 1.4 million adults) in the United States identify as transgender, and 2% of high school-aged individuals (150,000 to 300,000 individuals). Gender-affirming care for transgender and gender- diverse patients can include support with social transition or physical presentation, legal steps, and medical treatments (eg, hormone therapy) and surgeries. Adolescent and adult patients who request gender-affirming hormone therapy must meet several criteria. One is confirmed persistence of gender dysphoria or gender incongruence. Also, the patient must have reached the age of legal medical consent and be able to consent to therapy. For adolescent patients who are minors, meeting of additional criteria is recommended. In eligible adolescent patients, gender-affirming hormone therapy consists of two phases, pubertal suppression and then feminizing or masculinizing hormone therapy. Before puberty, hormone therapy is not recommended. When puberty begins, patients can receive a gonadotropin-releasing hormone agonist to suppress puberty (ie, puberty blocker). Feminizing or masculinizing hormone therapy, which usually is initiated at age 16 years, consists of estradiol or testosterone, respectively. For adult patients requesting gender-affirming hormone therapy, a thorough evaluation should be performed to assess for contraindications and conditions that may increase therapy-associated risks. Feminizing hormone therapy includes estrogen and an antiandrogen, and masculinizing therapy consists of testosterone. These patients should undergo regular monitoring. Cancer screening is based on risk factors, organ inventory, and screening guidelines.

Care of Diverse Families: Foster Care and Adoption.

Foster care is a service for children who cannot live with their families. There are many reasons for foster care, the most common of which is parental neglect and/or substance abuse. At any one time, more than 400,000 US children are in foster care. Although 59% are eventually reunited with their parents, some end up in other situations, including adoption. Children should undergo a physician evaluation within 72 hours of entering foster care, a comprehensive evaluation within 30 days, and a follow-up visit within 60 to 90 days, followed by routine care. Adoption occurs for 1 of every 50 children; approximately 1% of adoptees are from other countries. There are many forms of adoption, including open (birth parents have contact with the adopted child), closed (contact is not permitted), and kinship (adopting parents are relatives of the child). Approximately one-quarter of adoptions are transracial/transethnic. Adoptions by LGBTQIA+ (lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual/agender, and other identities) people also are common. Parents planning adoption should talk to the physician who will care for the child to review the child's health records, and continue with routine care after adoption. For international adoptions, numerous infectious disease tests are required before and after the child's arrival in the United States. Adoptees also should undergo developmental evaluation and screening for adverse childhood experiences and mental health issues.

Consistency and applicability of return to function guidelines in tactical-athletes with exertional heat illness. A systematic review.

OBJECTIVE: To assess the consistency of return to sport and occupation recommendations following EHI provided in published clinical practice guidelines, consensus statements, position statements, and practice alerts. The agreement between medical policies governing the return to duty following EHI between the branches of the United States Armed Forces and published recommendations was assessed. METHODS: Ovid MEDLINE, Web of Science, and CINAHL databases were searched for clinical practice guidelines and position statements published at any time that guided return to activity in individuals with EHI. Methodological quality was assessed, and the specific recommendations for clinical management were extracted. Consistency of recommendations was evaluated. Agreement between published guidelines and the policies governing return to activity in military tactical athletes with heat injury were also evaluated. RESULTS: Guidelines developed by two civilian sports medicine societies in the United States detailing recommendations for return to function following EHI were identified. There was consistency between guidelines regarding recommendations that addressed abstinence from activity; medical follow-up; graded resumption of activity; and return to function. Pertaining military policy, contemporary regulations published in recent years reflected the recommendations provided in the professional guidelines. The greatest incongruence was noted in older military policies. CONCLUSIONS: This systematic review highlights the need for consistent recommendations across all branches of the military and medical specialties pertaining to returning servicemembers to duty after EHI .

Diagnostic Uncertainty in Cervical Radiculopathy.

Cervical radiculopathy is defined as a pathological process affecting the cervical nerve root(s). While not an uncommon entity, this report describes a case of cervical radiculopathy in an active duty Marine with unique features to include the C5 nerve root as the primary point of injury with corresponding severe motor weakness that warranted expedited workup. This expedited workup included early referral to Neurology for nerve conduction and electromyography (EMG) studies that were ultimately diagnostic in the setting of equivocal Magnetic Resonance Imaging findings. This highlight of this case is the demonstration of the utility of EMG in cervical radiculopathy evaluation, which aided in an efficient and effective treatment course. We contend that in cases of cervical radiculopathy with a focal deficit of profound weakness with shoulder abduction and elbow flexion, obtaining nerve conduction studies and EMGs within the first 4 to 6 weeks of presentation should be viewed as essential for the long-term recovery and effective management of the injured service member, particularly when injury to the upper trunk of the brachial plexus can also account for these specific motor deficits. This report will cover a brief review of the pathophysiology, evaluation, and natural history of cervical radiculopathy with special attention paid to the timing and efficacy of EMG.

Accuracy of the Tuning Fork Test for Determination of Presence and Location of Tibial Stress Fractures in a Military Training Population.

INTRODUCTION: Stress fractures or bone stress injuries arise from trauma or overuse, often as a result of rapid increase in training. This rapid increase in training occurs frequently as military recruits begin their entry-level training, as many individuals are not accustomed to the level of activity required during boot camp. Tibial stress fractures are the most common bone stress injuries in the military setting. MRI is the gold standard test for identification of stress fractures, but MRI may not be available in field settings. Although limited evidence has suggested that a vibrating tuning fork may be beneficial in determining the presence of a stress fracture, the tuning fork has become a frequent tool used to detect or diagnose stress fractures. MATERIALS AND METHODS: Military personnel with suspected unilateral tibial stress fractures were asked to participate in evaluation of tuning forks as a diagnostic tool, in addition to receiving standard diagnostics and treatment. Points of maximal shin tenderness to palpation and vibration, followed by the application of a tuning fork, were evaluated. Each service member also underwent an abbreviated MRI evaluation with a 1.5T magnet consisting of coronal and sagittal STIR (Short Tau Inversion Recovery) and T1 (weighted longitudinal relaxation time) sequences. The results of tuning fork testing were compared to the MRI findings, considering grade 1 changes on MRI to represent a true stress fracture. A two-by-two table was used to determine the performance of tuning fork testing, relative to MRI findings, applying conventional definitions of sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS: Among 63 male active duty members with suspected tibial stress fractures, 39 had MRI-confirmed stress fractures. Tuning fork testing, relative to MRI, demonstrated overall sensitivity of 61.5%, specificity of 25.0%, positive predictive value of 57.1%, and negative predictive value of 28.6%. A sub-analysis restricting to grade 3 and grade 4 MRI findings did not improve the diagnostic performance of tuning forks. CONCLUSIONS: The tuning fork is an ineffective tool for diagnosing tibial stress fractures.

Recognizing Moral Injury: Toward Legal Intervention for Physician Burnout.

The writers respond to the commentary "Physician Burnout Calls for Legal Intervention," by Sharona Hoffman, in the November-December 2019 issue of the Hastings Center Report.