Patient-Centered Approaches to Cognitive Assessment in Acute TBI.

PURPOSE OF THE REVIEW: The purpose of this article is to help clinicians understand how underlying pathophysiologies and medical comorbidities associated with acute traumatic brain injury (TBI) can impact assessment of cognition during the initial stages of recovery. Clinicians can use information from this article to develop assessment plans rooted in patient-centered care. RECENT FINDINGS: The authors conducted a review of the literature related to the assessment of cognition in acute TBI, focusing on pathophysiology, medical comorbidities, and assessment approaches. Results indicated that TBI pathophysiologies associated with white and gray matter changes make many patients vulnerable to cognitive deficits. Acute comorbidities such as psychological and pain status influence cognitive abilities as well. The current approaches to cognitive assessment can be limited in many ways, though by using the patient's neuropathological profile, noted comorbidities, and other patient specific factors, clinicians can potentially improve the effectiveness of assessment.

Effects of a lifestyle intervention on depression and anxiety among adults at risk for diabetes in India: A secondary analysis of the Kerala Diabetes Prevention Program.

The impact of lifestyle interventions on diabetes and mental health conditions have been documented among people with diabetes. However, the mental health benefits of lifestyle interventions designed for diabetes prevention have not been systematically investigated among people at high risk of diabetes, particularly in low- and middle-income countries. We examined the effects of a 12-month peer support lifestyle intervention designed for diabetes prevention on depression and anxiety symptomology in the sample population of the Kerala Diabetes Prevention Program. Mixed-effects linear regression models were used to examine the effect of the intervention on depression and anxiety scores at 12 and 24 months in the total sample of 1007 adults at risk for diabetes and among those with mild-severe depressive or anxiety symptoms at baseline (n = 326 for depression; n = 203 for anxiety). Among all participants, the intervention group had a significantly higher reduction of depressive symptoms as compared to the control group at 12 months (mean diff score = -0.51; 95% CI: -0.95, -0.07; P = 0.02). This effect was not sustained at 24 months. There were no significant intervention effects for anxiety. Among those with mild-severe symptoms at baseline, the intervention group had a significantly higher reduction of depressive symptoms (mean diff score = -1.55; 95% CI -2.50, -0.6; P = 0.001) and anxiety symptoms (mean diff score = -1.64; 95% CI -2.76, -0.52; P = 0.004) at 12 months. The effect was sustained at 24 months for depression, but not anxiety. Lifestyle interventions designed for prevention of diabetes might improve depressive and anxiety symptoms in the short-term, particularly among those with mild-severe symptoms.

Emerging challenges in the evaluation of fever in cancer patients at risk of febrile neutropenia in the era of COVID-19: a MASCC position paper.

Patients with cancer are at higher risk of more severe COVID-19 infection and have more associated complications. The position paper describes the management of cancer patients, especially those receiving anticancer treatment, during the COVID-19 pandemic. Dyspnea is a common emergency presentation in patients with cancer with a wide range of differential diagnoses, including pulmonary embolism, pleural disease, lymphangitis, and infection, of which SARS-CoV-2 is now a pathogen to be considered. Screening interviews to determine whether patients may be infected with COVID-19 are imperative to prevent the spread of infection, especially within healthcare facilities. Cancer patients testing positive with no or minimal symptoms may be monitored from home. Telemedicine is an option to aid in following patients without potential exposure. Management of complications of systemic anticancer treatment, such as febrile neutropenia (FN), is of particular importance during the COVID-19 pandemic where clinicians aim to minimize patients' risk of infection and need for hospital visits. Outpatient management of patients with low-risk FN is a safe and effective strategy. Although the MASCC score has not been validated in patients with suspected or confirmed SARS-CoV-2, it has nevertheless performed well in patients with a range of infective illnesses and, accordingly, it is reasonable to expect efficacy in the clinical setting of COVID-19. Risk stratification of patients presenting with FN is a vital tenet of the evolving sepsis and pandemic strategy, necessitating access to locally formulated services based on MASCC and other national and international guidelines. Innovative oncology services will need to utilize telemedicine, hospital at home, and ambulatory care services approaches not only to limit the number of hospital visits but also to anticipate the complications of the anticancer treatments.

Epilepsy self-management behaviors among African Americans with epilepsy.

PURPOSE: Although self-management practices are heavily studied in the general population of adults with epilepsy, African American people with epilepsy (PWE) have been understudied. Improving understanding about epilepsy self-management among African Americans is warrantedbecause of the significantly greater mortality rates among this population compared withPWE from other racial/ethnic groups. The purpose of this study was to assess the reliability and validity of the Adult Epilepsy Self-Management Measurement Instrument (AESMMI) for Black/African American adults and describe their self-management behaviors. METHODS: This study was a cross-sectional survey of self-identified Black/African American adults who reported that a health provider diagnosed them as having epilepsy or a seizure disorder. Participants completed a cross-sectional survey between spring 2017 and fall 2018. The survey measured self-management behaviors (65-itemAESMMI), quality of life, depression, seizure severity, epilepsy history, and demographics. We ran descriptive analyses, computed scales, and ran reliability statistics for the AESMMI. Correlations were run between total AESMMI score and depression symptoms and quality of life to assess construct validity. RESULTS: Generally, participants (N = 114) were male (58.6%), from urban/suburban settings (90.5%), at least high school graduates (86.4%), and of lowerincome (90.3%). Their ages ranged from 19 to 64 years with a mean age of 53 years (standard deviation [SD] = 10.9). Participants had general (72.8%) and focal seizures (55.3%) primarily. Many were diagnosed at a young age (M = 10.9), were on antiepileptic medications (91.2%), and had seen a primary care doctor (68.4%) or general neurologist for treatment (54.4%). Sixty percent had visited a neurologist in the past year. African American participants had a low score on quality of life (Quality of Life in Epilepsy [QOLIE], M = 1.86) and low depression symptoms (Patient Health Questionnaire [PHQ-8], M = 3.13). Participants reported conducting self-management behaviors in the following domains more frequently: proactivity (M = 4.11), medication adherence (M = 3.92), healthcare communications (M = 3.91), and social support (M = 3.90). In contrast, they performed self-management behaviors related to treatment (M = 3.34), stress management (M = 3.56), and safety (M = 3.58) less frequently. The overall reliability of the AESMMI was 0.88. Adult Epilepsy Self-Management Measurement Instrument score was correlated with quality of life (r = 0.151). CONCLUSION: Findings are clinically relevant as knowing patients'self-management behaviors enables healthcare clinicians to support and encourage adults to improve the management of their epilepsy. Services or interventions related to coping with stress, safety, and adherence with treatment and medication may be warranted for African Americans with epilepsy.

Factors influencing recovery from mild traumatic brain injury.

PRIMARY OBJECTIVE: This study determined whether initial GCS score, head CT results, cognitive performance on IMPACT testing, or APOE genotype most effectively predicted 1-month functional outcome after mild traumatic brain injury (mTBI). This study tested the hypotheses that participants with poor performance on initial cognitive testing and those with an APOEe4 genotype would exhibit a poorer 1-month recovery after mTBI. RESEARCH DESIGN: Regression analysis determined which independent variables were most effective in predicting 1-month GOS-E or DRS score. Independent t-test procedures determined whether cognitive recovery varied across APOEe4 carriers. METHODS AND PROCEDURES: 49 participants admitted to the hospital with mTBI received cognitive evaluation within 48 hours after injury and again one month later. DNA analysis provided participant APOE genotype. MAIN OUTCOMES AND RESULTS: Results showed that no study variables significantly predicted GOS-E or DRS scores, however, differences were identified when APOE groups were compared. Participants who were noncarriers of APOEe4 had significantly slower reaction times compared to APOEe4 carriers. Participants who were homozygous APOEe4 carriers had significantly lower instances of impulsivity than noncarriers. CONCLUSIONS: Further research is needed to understand how APOE allele status and performance on initial cognitive testing may influence short-term recovery after mTBI.

Reduction of Intensive Care Unit Length of Stay: The Case of Early Mobilization.

Bed rest or immobilization is frequently part of treatment for patients in the intensive care unit (ICU) with critical illness. The average ICU length of stay (LOS) is 3.3 days, and for every day spent in an ICU bed, the average patient spends an additional 1.5 days in a non-ICU bed. The purpose of this research study was to analyze the effects of early mobilization for patients in the ICU to determine if it has an impact on the LOS, cost of care, and medical complications. The methodology for this study was a literature review. Five electronic databases were used, with a total of 26 articles referenced for this research. Early mobilization suggested a decrease in delirium by 2 days, reduced risk of readmission or death, and reduced ventilator-assisted pneumonia, central line, and catheter infections. Length of stay in the ICU was reduced with statistical significance in several studies examining early mobilization. Limited research on cost of ICU LOS indicated potential savings with early mobilization. When implementing early mobilization in the ICU, total costs were decreased and medical complications were reduced. Early mobilization should become a standard of care for critically ill but stable patients in the ICU.

Robotic joint replacement surgery: does technology improve outcomes?

Osteoarthritis is a common disease that leads patients to seek total joint replacement (TJR). Component misalignment leads to failure of TJR. Computer navigation enhances the precision of component alignment, but the addition of robotic guidance can boost TJR to a higher level of accuracy. Some 29 English-language peer-reviewed articles from 2002 to 2013 and 1 Web site were reviewed. A conceptual framework was adapted to explain benefits and barriers of adoption of robotic TJR. A total of 10 studies were reviewed with focus on more precise alignment, outcomes, length of stay, and costs. Cost to obtain robotic surgical equipment was found to be about $1 million with maintenance costs approaching $350 000. Robotic techniques compared with conventional orthopedic surgery showed slight variances in favor of robotic procedures. Although hospitals have the potential to reduce costs and improve outcomes with robotic TJR, the expenditure and maintenance have not been proven a clear return on investment. As surgical robotic technology evolves in accuracy and accessibility, joint replacement surgery may benefit from improved precision and decreased health care costs. However, equipment purchase and upkeep costs and surgeon training may impede use to its full potential in orthopedic surgery in the United States.

Reduction of intensive care unit length of stay: the case of early mobilization.

Bed rest or immobilization is frequently part of treatment for patients in the intensive care unit (ICU) with critical illness. The average ICU length of stay (LOS) is 3.3 days, and for every day spent in an ICU bed, the average patient spends an additional 1.5 days in a non-ICU bed. The purpose of this research study was to analyze the effects of early mobilization for patients in the ICU to determine if it has an impact on the LOS, cost of care, and medical complications. The methodology for this study was a literature review. Five electronic databases were used, with a total of 26 articles referenced for this research. Early mobilization suggested a decrease in delirium by 2 days, reduced risk of readmission or death, and reduced ventilator-assisted pneumonia, central line, and catheter infections. Length of stay in the ICU was reduced with statistical significance in several studies examining early mobilization. Limited research on cost of ICU LOS indicated potential savings with early mobilization. When implementing early mobilization in the ICU, total costs were decreased and medical complications were reduced. Early mobilization should become a standard of care for critically ill but stable patients in the ICU.

Medicare fraud in the United States: can it ever be stopped?

The majority of the United States health care fraud has been focused on the major public program, Medicare. The yearly financial loss from Medicare fraud has been estimated at about $54 billion. The purpose of this research study was to explore the current state of Medicare fraud in the United States, identify current policies and laws that foster Medicare fraud, and determine the financial impact of Medicare fraud. The methodology for this study was a literature review. Research was conducted using a scholarly online database search and government Web sites. The number of individuals charged with criminal fraud increased from 797 cases in fiscal year 2008 to 1430 cases in fiscal year 2011-an increase of more than 75%. According to 2010 data, of the 7848 subjects investigated for criminal fraud, 25% were medical facilities, and 16% were medical equipment suppliers. In 2009 and 2010, the Health Care Fraud and Abuse Control Program recovered approximately $25.2 million of taxpayers' money. Educating providers about the policies and laws designed to prevent fraud would help them to become partners. Many new programs and partnerships with government agencies have also been developed to combat Medicare fraud. Medicare fraud has been a persistent crime, and laws and policies alone have not been enough to control the problem. With investments in governmental partnerships and new systems, the United States can reduce Medicare fraud but probably will not stop it altogether.

Social determinants of health and diabetes: using a nationally representative sample to determine which social determinant of health model best predicts diabetes risk.

OBJECTIVES: Social determinants of health (SDOH) research demonstrates poverty, access to healthcare, discrimination, and environmental factors influence health outcomes. Several models are commonly used to assess SDOH, yet there is limited understanding of how these models differ regarding their ability to predict the influence of social determinants on diabetes risk. This study compares the utility of four SDOH models for predicting diabetes disparities. STUDY DESIGN: We utilized The National Longitudinal Study of Adolescent to Adulthood (Add Health) to compare SDOH models and their ability to predict risk of diabetes and obesity. METHODS: Previous literature has identified the World Health Organization (WHO), Healthy People, County Health Rankings, and Kaiser Family Foundation as the conventional SDOH models. We used these models to operationalize SDOH using the Add Health dataset. Add Health data were used to perform logistic regressions for HbA1c and linear regressions for body mass index (BMI). RESULTS: The Kaiser model accounted for the largest proportion of variance (19%) in BMI. Race/ethnicity was a consistent factor predicting BMI across models. Regarding HbA1c, the Kaiser model also accounted for the largest proportion of variance (17%). Race/ethnicity and wealth was a consistent factor predicting HbA1c across models. CONCLUSION: Policy and practice interventions should consider these factors when screening for and addressing the effects of SDOH on diabetes risk. Specific SDOH models can be constructed for diabetes based on which determinants have the largest predictive value.

COVID-19 Prevention and Mitigation Decision-Making Processes While Navigating Chronic Disease Care: Perspectives of Black Adults with Heart Failure and Diabetes.

BACKGROUND: Heart failure and diabetes are comorbidities that disproportionately contribute to high morbidity and mortality among Blacks. Further compounding the racial and ethnic disparities in COVID-19 health outcomes, Blacks with cardiometabolic diseases are at high risk of experiencing serious complications or mortality from COVID-19. This study aimed to assess how Blacks with heart failure and diabetes navigated chronic care management during the COVID-19 pandemic. METHODS: A mixed methods study including in-depth interviews and surveys with adults diagnosed with heart failure and diabetes (n = 17) was conducted in 2021-2022. Verbatim transcripts were analyzed using a thematic analysis approach. RESULTS: Participants reported that while the pandemic initially caused delays in access to health services, shifts to telemedicine allowed for continued care despite preferences for in-person appointments. Various sources of information were used in different ways to make decisions on how to best reduce health risks due to COVID-19, but individuals and institutions affiliated with science and medicine, or who promoted information from these sources, were considered to be the most trusted sources of information among those who relied on outside guidance when making health-related decisions. Individuals' self-awareness of their own high-risk status and perceived control over their exposure levels to the virus informed what COVID-19 prevention and mitigation strategies people used. CONCLUSION: Information backed by scientific data was an important health communication tool that alongside other factors, such as fear of mortality due to COVID-19, encouraged individuals to get vaccinated and adopt other COVID-19 prevention and mitigation behaviors.

Understanding Barriers and Facilitators to Integrated HIV and Hypertension Care in South Africa.

Background The burden of hypertension among people with HIV is high, particularly in low-and middle-income countries, yet gaps in hypertension screening and care in these settings persist. The objective of this study was to identify facilitators of and barriers to hypertension screening, treatment, and management among people with HIV seeking treatment in primary care clinics in Johannesburg, South Africa. Methods Using a cross-sectional study design, data were collected via interviews (n = 53) with people with HIV and hypertension and clinic managers and focus group discussions (n = 9) with clinic staff. A qualitative framework analysis approach guided by the Theoretical Domains Framework was used to identify and compare determinants of hypertension care across different stakeholder groups. Results Data from clinic staff and managers generated three themes characterizing facilitators of and barriers to the adoption and implementation of hypertension screening and treatment: 1) clinics have limited structural and operational capacity to support the implementation of integrated care models, 2) education and training on chronic care guidelines is inconsistent and often lacking across clinics, and 3) clinicians have the goal of enhancing chronic care within their clinics but first need to advocate for health system characteristics that will sustainably support integrated care. Patient data generated three themes characterizing existing facilitators of and barriers to clinic attendance and chronic disease self-management: 1) the threat of hypertension-related morbidity and mortality as a motivator for lifestyle change, 2) the emotional toll of clinic's logistical, staff, and resource challenges, and 3) hypertension self-management as a patchwork of informational and support sources. The main barriers to hypertension screening, treatment, and management were related to environmental resources and context (i.e., lack of enabling resources and siloed flow of clinic operations) the patients' knowledge and emotions (i.e., lack of awareness about hypertension risk, fear, and frustration). Clinical actors and patients differed in perceived need to prioritize HIV versus hypertension care. Conclusions The convergence of multi-stakeholder data regarding barriers to hypertension screening, treatment, and management highlight key areas for improvement, where tailored implementation strategies may address challenges recognized by each stakeholder group.

Association of collaborative care intervention features with depression and metabolic outcomes in the INDEPENDENT study: A mixed methods study.

AIMS: The INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) trial tested a collaborative care model including electronic clinical decision support (CDS) for treating diabetes and depression in India. We aimed to assess which features of this clinically and cost-effective intervention were associated with improvements in diabetes and depression measures. METHODS: Post-hoc analysis of the INDEPENDENT trial data (189 intervention participants) was conducted to determine each intervention feature's effect: 1. Collaborative case reviews between expert psychiatrists and the care team; 2. Patient care-coordinator contacts; and 3. Clinicians' CDS prompt modifications. Primary outcome was baseline-to-12-months improvements in diabetes control, blood pressure, cholesterol, and depression. Implementer interviews revealed barriers and facilitators of intervention success. Joint displays integrated mixed methods' results. RESULTS: High baseline HbA1c≥ 74.9 mmol/mol (9%) was associated with 5.72 fewer care-coordinator contacts than those with better baseline HbA1c (76.8 mmol/mol, 9.18%, p < 0.001). Prompt modification proportions varied from 38.3% (diabetes) to 1.3% (LDL). Interviews found that providers' and participants' visit frequencies were preference dependent. Qualitative data elucidated patient-level factors that influenced number of clinical contacts and prompt modifications explaining their lack of association with clinical outcomes. CONCLUSION: Our mixed methods approach underlines the importance of the complementarity of different intervention features. Qualitative findings further illuminate reasons for variations in fidelity from the core model.

Effect of composting on the fate of steroids in beef cattle manure.

In this study, the fate of steroid hormones in beef cattle manure composting is evaluated. The fate of 16 steroids and metabolites was evaluated in composted manure from beef cattle administered growth promotants and from beef cattle with no steroid hormone implants. The fate of estrogens (primary detected as estrone), androgens, progesterone, and the fusarium metabolite and implant α-zearalanol was monitored in manure compost piles. First-order decay rates were calculated for steroid half-lives in compost and ranged from 8 d for androsterone to 69 d for 4-androstenedione. Other steroid concentration data could not be fit to first-order decay models, which may indicate that microbial processes may result in steroid production or synthesis in composting systems. We demonstrate that composting is an effective strategy to remove steroid hormones from manure. Total steroid hormone removal in composted beef cattle manure ranged from 79 to 87%.

Advancing the use of theory in occupational therapy: a collaborative process.

BACKGROUND: Theory is important to the growth and evolution of occupational therapy. However, use of theory remains challenging for many therapists. PURPOSE: The aim was to develop a process that occupational therapists could apply to advance theory in practice. METHOD: Based on a review of the literature and using a qualitative instrumental case study design, 18 student occupational therapists and eight fieldwork educators completed online modules on the theory advancement concepts generated from the literature, wrote journals, and/or participated in online discussions during fieldwork. Following fieldwork, educators were interviewed and students participated in focus groups exploring their experiences. Directed content analysis was used to analyze the data. FINDINGS: Based on the data collected, we developed the Theory Advancement Process (TAP). The TAP is composed of four primary contexts, a climate of collaborative relationships with four key elements, and four essential processes. IMPLICATIONS: The TAP presents a collaborative process for students, faculty, and therapists to work together to advance the use of theory in practice.

Exploring the Social Determinants of Health and Health Disparities in Traumatic Brain Injury: A Scoping Review.

Traumatic brain injury (TBI) is a global health concern, that can leave lasting physical, cognitive, and/or behavioral changes for many who sustain this type of injury. Because of the heterogeneity of this population, development of appropriate intervention tools can be difficult. Social determinants of health (SDoH) are factors that may impact TBI incidence, recovery, and outcome. The purpose of this study is to describe and analyze the existing literature regarding the prevailing SDoH and health disparities (HDs) associated with TBI in adults. A scoping review, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework was used to explore three electronic databases-PubMed, Medline, and CINAHL. Searches identified peer-reviewed empirical literature addressing aspects of SDoH and HDs related to TBI. A total of 123 records were identified and reduced to 27 studies based on inclusion criteria. Results revealed race/ethnicity was the most commonly reported SDoH impacting TBI, followed by an individual's insurance status. Health disparities were noted to occur across the continuum of TBI, including TBI risk, acute hospitalization, rehabilitation, and recovery. The most frequently reported HD was that Whites are more likely to be discharged to inpatient rehabilitation compared to racial/ethnic minorities. Health disparities associated with TBI are most commonly associated with the race/ethnicity SDoH, though insurance status and socioeconomic status commonly influence health inequities as well. The additional need for evidence related to the impact of other, lesser researched, SDoH is discussed, as well as clinical implications that can be used to target intervention for at-risk groups using an individual's known SDoH.

"I was having an internal conflict with myself." COVID-19 vaccination decision-making processes among pregnant women.

BACKGROUND: Vaccination serves as an efficient primary means of control for infectious diseases. However, in the case of the COVID-19 pandemic, pregnant women within the United States had the lowest rates of COVID-19 vaccination and reported the lowest intent to vaccinate. OBJECTIVES: To explore the decision-making process for COVID-19 vaccination for people pregnant during the pandemic. DESIGN: A secondary analysis of data from a mixed-methods study that examined the impact of COVID-19 on experiences of prenatal care, birth support, and delivery in the Southern United States. METHODS: This study used a descriptive phenomenological approach to thematically analyze in-depth interviews (n = 20) with adult women who were pregnant by January 2020 and had their prenatal care and delivery during the pandemic beginning in March 2020. The transcripts were de-identified, coded, and thematically analyzed to saturation to identify drivers of COVID-19 vaccine decision-making based on COVID-19 vaccination status and timing. Comparative analyses were conducted to assess differences in decision-making processes based on race/ethnicity and parity. Participants also completed a sociodemographic survey that included their COVID-19 vaccination status. RESULTS: Two themes emerged, the weighing of parallel risks and priorities from different sources resulting in vaccine decisional conflict and the need to reconcile that conflict via multiple strategies. All participants weighed priorities and risks from multiple areas of their lives and described internal conflict around vaccination. Participants described tailoring decisions to household dynamics, reconciling public and private values around vaccination, and the impact of their identities on the decision-making process. While many described concerns over vaccine safety and fetal health, uniquely, many highlighted weighing the impact of prior pregnancy loss history, with some choosing other preventive measures like social distancing or mask-wearing, which they deemed less risky. CONCLUSION: Pregnant people make complex COVID-19 vaccination decisions, which must be considered in future vaccine messaging and advocacy for this group.

Emerging Ideas. A ripple effect: Does I-sharing with a stranger promote compromise in cohabiting couples?

Background: Living together harmoniously requires compromise. Research on the psychological factors that promote compromise frequently focuses on individual differences and interpersonal environment. The current research takes a different approach by asking what role I-sharing (i.e., the feeling that others share the same in-the-moment, subjective experience as oneself) plays in the success of a cohabiting couple's compromise efforts. Objective: Drawing from work on the prosocial outcomes associated with I-sharing, we asked whether I-sharing with a stranger enhances couples' ability to compromise. Method: Both members of a cohabiting couple privately reported the percentage of time they spend on household tasks (the Division of Household Labor inventory [DHL]) before undergoing a manipulation in which they either did or did not have an I-sharing experience with a stranger. Participants then completed the DHL again, this time working together with their cohabiting partner to reach a consensus in their responses. Finally, participants had another chance to complete the DHL in private, receiving the instruction to respond with their true beliefs. Results: When relationship partners worked together to complete the DHL at the second reporting, their responses were identical. At the third (private) DHL reporting, consistent with prediction, couples assigned to the I-share condition showed more agreement with their partner than couples assigned to the No I-share condition. Conclusion: This finding suggests that the prosociality generated by I-sharing can promote compromise in cohabiting couples. Implications: I-sharing holds promise as a therapeutic tool to promote compromise in treatment-seeking families and couples.

Gender Attributions by Cisgender and Gender Diverse Listeners Rating Vowels, Reading, and Monologues.

OBJECTIVES: To determine if listeners' attributions of speakers' gender vary by linguistic context and/or the listeners' gender identity. METHODS: Seventeen self-identified transgender adults assigned male at birth were audio-recorded prolonging /a/, reading sentences, and saying spontaneous monologues. Eighteen adults (10 cisgender and 8 gender-diverse individuals) listened and used a 1-5 scale (1: very masculine, 2: somewhat masculine, 3: androgynous, 4: somewhat feminine, and 5: very feminine) to rate the gender attribution of each speech sample. RESULTS: The intra-rater reliability was moderate to excellent (0.62-1.00). Ratings by cisgender and gender-diverse listeners were not significantly different. Ratings were not significantly different between different speech contexts of vowel, reading, and spontaneous monologue speech samples. CONCLUSIONS: Transwomen have many variables available to consider and use in their communication. The linguistic context (eg, reading a speech versus spontaneous monologue) or listener's gender does not appear to be highly influential factors in how listeners attribute gender.