Reducing discrepancies between actual and ideal affect across adulthood: the roles of activity flow conduciveness, pleasantness, and familiarity.

Previous findings demonstrate that people often do not feel how they want to feel, supporting the distinction between "actual affect" and "ideal affect." But are there certain activities that reduce the discrepancy between actual and ideal affect? Based on flow theory and socioemotional selectivity theory, we examined whether the discrepancy between people's actual and ideal positive affect would be smaller during activities that were more conducive to flow (a state of intense absorption and concentration), pleasant, and familiar. In Study 1, U.S. participants aged 17-79 (N = 393) reported their ideal affect and how they felt during activities with varying degrees of challenges and skills. For both low-arousal positive affect (LAP) and high-arousal positive affect (HAP), participants reported smaller actual-ideal affect discrepancies during flow-conducive activities (when skills matched challenges). Study 2 was a 14-day experience sampling study, in which Hong Kong participants aged 18-83 (Nindividual = 109) reported their momentary actual and ideal affect, and how pleasant and familiar their activities were (Nexperience = 3,815). Greater activity familiarity was associated with smaller discrepancies in actual-ideal LAP, while greater activity pleasantness was associated with smaller discrepancies in actual-ideal HAP. These findings provide insights on the activities that help people achieve their ideal affect more easily.

Varenicline induced auditory hallucinations in a young female with bipolar disorder: a case report.

BACKGROUND: Creating appropriate and sustainable treatment plans for patients with concurrent disorders presents a challenge to psychiatrists and addiction medicine specialists alike. Although varenicline has been found to be the most effective medication for smoking cessation and abstinence when compared to results from placebo medications, nicotine patches and bupropion, caution is needed when starting patients on this medication. With the high prevalence of concurrent mental health and substance use disorders in vulnerably-housed populations in Canada, it becomes increasingly important to advocate for increased guidance and research into treating concurrent disorders. CASE PRESENTATION: In this case, a young female patient provisionally diagnosed with bipolar I disorder was hospitalized for a manic episode in the context of substance use and medication noncompliance. She also endorsed a long history of tobacco, alcohol, cocaine, cannabis and ketamine use. Perceptual abnormalities, including auditory hallucinations, were not recorded at admission. In addition to being stabilized for bipolar diagnosis, the patient was started on nicotine replacement therapy on Day 7 of admission followed by initiation of varenicline for smoking cessation on Day 14 of admission. Soon after the varenicline treatment was started, the patient developed auditory hallucinations, paranoia and referential beliefs. However, her insight was intact, and she had minimal thought form disorganization. In this case, these symptoms were thought to be secondary to varenicline after the consideration of potential alternative contributors. CONCLUSION: The occurrence of side effects as a result of varenicline use in patients with diagnosed mental health conditions is rare and underlying psychiatric illness is not labeled as an absolute contraindication in the prescription of varenicline. However, it is important to advocate for increased guidance and research on the treatment of substance use disorders in patients with bipolar I disorder. Patients may also benefit from increased collaboration between psychiatric and addiction services as that may allow for earlier recognition and intervention of symptoms to minimize distress.

Engaging youth and parents in clinical pediatric research: A case-based example.

Background: Youth and parent engagement is a key component of clinical research. There are many ways to actively and meaningfully engage youth and parents as integral members of research teams, for example, through ad-hoc committees, advisory councils, or as co-leads on projects. When youth and parents are actively and meaningfully engaged in research projects, they share knowledge from their lived experiences to improve the quality and relevance of research. Methods: We describe a case-based example of engaging youth and parent research partners when co-designing a questionnaire to assess preferences for pediatric headache treatments, from both a researcher and youth/parent perspective. We also summarize best practices in patient and family engagement from the literature and pertinent guidelines to assist researchers with integrating patient and family engagement into their studies. Results: As researchers, we felt that the integration of a youth and parent engagement plan into our study significantly altered and strengthened questionnaire content validity. We encountered challenges throughout the process and detailed these experiences to help educate others about challenge mitigation and best practices in youth and parent engagement. As youth and parent partners, we felt that engaging in the process of questionnaire development was an exciting and empowering opportunity, and that our feedback was valued and integrated. Conclusions: By sharing our experience, we hope to catalyze thought and discussion around the importance of youth and parent engagement in pediatric research, with the goal of stimulating more appropriate, relevant, and high-quality pediatric research and clinical care in the future.

Towards an International Consensus on the Prevention, Treatment, and Management of High-Risk Substance Use and Overdose among Youth.

Background and Objectives: Now more than ever, there is an obvious need to reduce the overall burden of disease and risk of premature mortality that are associated with mental health and substance use disorders among young people. However, the current state of research and evidence-based clinical care for high-risk substance use among youth is fragmented and scarce. The objective of the study is to establish consensus for the prevention, treatment, and management of high-risk substance use and overdose among youth (10 to 24 years old). Materials and Methods: A modified Delphi technique was used based on the combination of scientific evidence and clinical experience of a group of 31 experts representing 10 countries. A semi-structured questionnaire with five domains (clinical risks, target populations, intervention goals, intervention strategies, and settings/expertise) was shared with the panelists. Based on their responses, statements were developed, which were subsequently revised and finalized through three iterations of feedback. Results: Among the five major domains, 60 statements reached consensus. Importantly, experts agreed that screening in primary care and other clinical settings is recommended for all youth, and that the objectives of treating youth with high-risk substance use are to reduce harm and mortality while promoting resilience and healthy development. For all substance use disorders, evidence-based interventions should be available and should be used according to the needs and preferences of the patient. Involuntary admission was the only topic that did not reach consensus, mainly due to its ethical implications and resulting lack of comparable evidence. Conclusions: High-risk substance use and overdoses among youth have become a major challenge. The system's response has been insufficient and needs substantial change. Internationally devised consensus statements provide a first step in system improvement and reform.

A systematic review of the latent structure of the Center for Epidemiologic Studies Depression Scale (CES-D) amongst adolescents.

BACKGROUND: The Centre for Epidemiologic Studies Depression Scale (CES-D) is a commonly used psychometric scale of depression. A four-factor structure (depressed affect, positive affect, somatic symptoms, and interpersonal difficulties) was initially identified in an American sample aged 18 to 65. Despite emerging evidence, a latent structure has not been established in adolescents. This review aimed to investigate the factor structure of the CES-D in adolescents. METHODS: We searched Web of Science, PsychINFO and Scopus and included peer-reviewed, original studies assessing the factor structure of the 20-item CES-D in adolescents aged ≤18. Two independent researchers screened results and extracted data. RESULTS: Thirteen studies met the inclusion criteria and were primarily from school-based samples in the USA or Asia. Studies that conducted confirmatory factor analysis (CFA; n = 9) reported a four-factor structure consistent with the original factor structure; these studies were primarily USA-based. Conversely, studies that conducted exploratory factor analysis (EFA) reported distinct two or three factor structures (n = 4) and were primarily based in Asia. LIMITATIONS: Studies in a non-English language and those that included individuals aged > 18 years were excluded. Ethnic or cultural differences as well as different analytical methods impacted generalisability of results. The use of CFA as the primary analysis may have biased towards a four-factor structure. CONCLUSIONS: A four-factor CES-D structure was an appropriate fit for adolescents in Western countries; further research is required to determine the fit in in Asian countries. This has important implications for clinical use of the scale. Future research should consider how cultural differences shape the experience of depression in adolescents.

Ten Global Surgical Care Statements for Children: examining our commitment to the future.

BACKGROUND: The lack of access to essential surgery for many of our world's children is a global health crisis. A third of all deaths in the pediatric population are due to surgical conditions. In low- and middle-income countries, an average of nine in ten children lack access to basic surgical care. METHODS: This review examines ten commitment statements ratified by numerous global pediatric surgical organizations aimed at addressing existing gaps in global surgical care for children. They are substantiated by a review of literature and represent over-arching principles. RESULTS: They prompt the recognition of childhood surgical disease as a global health priority and advocate for availability to safe surgical and anesthetic care. Calls to action highlight the importance of capacity building in the areas of education, data gathering, workforce, research, and international collaborations. DISCUSSION: Eventually, there is the hope for widespread approval of the guiding principles they represent and that the statements themselves, as encapsulations of these beliefs, may act as a continued call for advocacy and action for the necessary work, resources, and funding to mitigate global pediatric surgical disparities.

The era of virtual care: Perspectives of youth on virtual appointments in COVID-19 and beyond.

In response to COVID-19, paediatric providers have shifted to providing outpatient health care appointments through telehealth. Youth perspectives on changes to health care access during the pandemic are important to consider when optimizing care for paediatric patients. Youth who contributed to this commentary reported that major benefits of virtual care included time savings, ease of access, continuity of care, and ability to participate in health appointments from the comfort of one's own home without a risk of COVID-19 exposure. These youth also recognized limitations to virtual care, including the inability to complete laboratory or imaging tests, and the lack of physical examination capabilities. Additionally, they stressed the importance of visual components of virtual appointments and health care providers needing to consider privacy restrictions youth may have. Overall, our cohort of youth feel positive about virtual care and hope care providers can work with youth individually to determine the best solution for them.

Convenience and comfort: reasons reported for using drugs alone among clients of harm reduction sites in British Columbia, Canada.

BACKGROUND: North American communities are severely impacted by the overdose crisis, particularly in British Columbia (BC), which has the highest toxic drug overdose death rate in Canada. Most fatal overdoses in BC occurred among individuals using alone and in private residences. This study aimed to assess prevalence and reasons for using drugs alone among people accessing harm reduction services in BC. METHODS: We recruited harm reduction supply distribution site clients from 22 communities across BC. Descriptive statistics and multivariable logistic regression were used to describe factors associated with using alone. Thematic analysis of free-text responses providing reasons for using alone were grouped with survey data and additional themes identified. RESULTS: Overall, 75.8% (n = 314) of the study sample (N = 414) reported using drugs alone within the last week. Those that reported using alone did not differ from those that did not by gender, age, urbanicity, or preferred drug use method. Among those that used alone, 73.2% (n = 230) used opioids, 76.8% (n = 241) used crystal meth, 41.4% (n = 130) used crack/cocaine, and 44.6% (n = 140) used alcohol in the past week. Polysubstance use involving stimulants, opioids, and/or benzodiazepines was reported by 68.5% (n = 215) of those that used alone. Additionally, 22.9% (n = 72) of those that used alone had experienced an opioid and/or stimulant overdose in the past 6 months. In a multivariable logistic regression model, having no regular housing and past week crack/cocaine use were associated with using alone (adjusted odds ratio (AOR): 2.27; 95% CI 1.20-4.27 and AOR: 2.10; 95% CI 1.15-3.82, respectively). The most common reason reported for using alone was convenience and comfort of using alone (44.3%). Additional reasons included: stigma/hiding drug use (14.0%); having no one around (11.7%); safety (9.6%); and not wanting to share drugs with others (8.6%). CONCLUSIONS: Using drugs alone, particularly for convenience and comfort, is ubiquitous among people accessing harm reduction services. Overdose prevention measures that go beyond individual behaviour changes, including providing a safer supply of drugs and eliminating stigma, are paramount to mitigate harms. These interventions are especially necessary as emergence of coronavirus disease may further exacerbate unpredictability of illicit drug content and overdose risk.

Dimethyl fumarate activates the prostaglandin EP2 receptor and stimulates cAMP signaling in human peripheral blood mononuclear cells.

Dimethyl fumarate (DMF) was recently approved by the FDA for the treatment of relapsing remitting MS. The pathology of MS is a result of both immune dysregulation and oxidative stress induced damage, and DMF is believed to have therapeutic effects on both of these processes. However, the mechanisms of action of DMF are not fully understood. To determine if DMF is able to activate signaling cascades that affect immune dysregulation, we treated human peripheral blood mononuclear cells with DMF. We discovered that DMF stimulates cyclic adenosine monophosphate (cAMP) production after 1 min treatment in vitro. cAMP is a small molecule second messenger that has been shown to modulate immune response. Using pharmacological inhibitors, we determined that adenylyl cyclase mediates DMF induced cAMP production; DMF activated the prostaglandin EP2 receptor to produce cAMP. This response was not due to increased endogenous production of prostaglandin E2 (PGE2), but was enhanced by addition of exogenous PGE2. Furthermore, we determined that the bioactive metabolite of DMF, monomethyl fumarate (MMF), also stimulates cAMP production. These novel findings suggest that DMF may provide protection against MS by inhibiting immune cell function via the cAMP signaling pathway.

Architecture and Development Framework for a Web-Based Risk Assessment and Management Platform Developed on WordPress to Address Opioid Overdose.

The number of overdose-related fatalities continues to reach historic levels across Canada, despite ongoing efforts by authorities. To reduce mortality, a clinical trajectory ranging from preventative measures to crisis intervention, skill training to treatment, and risk assessment to risk management needs to be supported. The web-based Risk Assessment and Management Platform (RAMP) was developed to realize this concept and to empower people who use drugs through an integrated tool that allows them to better understand and manage their risk of overdose. This paper outlines the architecture and development of RAMP, which is built on the WordPress platform. WordPress components are mapped onto a 3-tier architecture that consists of presentation, application, and database layers. The architecture facilitates the development of a modular software that includes several features that are independent in functionality but interact with each other in an integrated platform. The relatively low coupling and high coherence of the features may reduce the cost of maintenance and increase flexibility of future developments. RAMP's architecture comprises a user interface, conceptual framework, and backend layers. The RAMP front end effectively uses some of the WordPress' features such as HTML5, CSS, and JavaScript to create a mobile, friendly, and scalable user interface. The RAMP backend uses several standard and custom WordPress plug-ins to support risk assessment and monitoring, with the goal of mitigating the impacts and eliminating risks together. A rule-based decision support system has been hard-coded to suggest relevant modules and goals to complement each user's lifestyle and goals based on their risk assessment. Finally, the backend uses the MySQL database management system and communicates with the RAMP framework layer via the data access layer to facilitate a timely and secure handling of information. Overall, RAMP is a modular system developed to identify and manage the risk of opioid overdose in the population of people who use drugs. Its modular design uses the WordPress architecture to efficiently communicate between layers and provide a base for external plug-ins. There is potential for the current system to adopt and address other related fields such as suicide, anxiety, and trauma. Broader implementation will support this concept and lead to the next level of functionality.

Systematic review on intentional non-medical fentanyl use among people who use drugs.

Objectives: Fentanyl is a highly potent opioid and has, until recently, been considered an unwanted contaminant in the street drug supply among people who use drugs (PWUD). However, it has become a drug of choice for an increasing number of individuals. This systematic review evaluated intentional non-medical fentanyl use among PWUD, specifically by summarizing demographic variance, reasons for use, and resulting patterns of use. Methods: The search strategy was developed with a combination of free text keywords and MeSH and non-MeSH keywords, and adapted with database-specific filters to Ovid MEDLINE, Embase, Web of Science, and PsychINFO. Studies included were human studies with intentional use of non-medical fentanyl or analogues in individuals older than 13. Only peer-reviewed original articles available in English were included. Results: The search resulted in 4437 studies after de-duplication, of which 132 were selected for full-text review. Out of 41 papers included, it was found that individuals who use fentanyl intentionally were more likely to be young, male, and White. They were also more likely to have experienced overdoses, and report injection drug use. There is evidence that fentanyl seeking behaviours are motivated by greater potency, delay of withdrawal, lower cost, and greater availability. Conclusions: Among PWUD, individuals who intentionally use fentanyl have severe substance use patterns, precarious living situations, and extensive overdose history. In response to the increasing number of individuals who use fentanyl, alternative treatment approaches need to be developed for more effective management of withdrawal and opioid use disorder. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42021272111.

A territory-wide real-world efficacy and toxicity analysis of abiraterone acetate versus docetaxel in 574 Asian patients with metastatic hormone-sensitive prostate cancer.

INTRODUCTION: Abiraterone acetate (ABI) or docetaxel (DOC), in addition to androgen-deprivation therapy (ADT), are current treatment options for metastatic hormone-sensitive prostate cancer (mHSPC). No randomized head-to-head trial has compared these 2 mHSPC treatments, and real-world data regarding their outcomes in Asian patients are lacking. PATIENTS AND METHODS: The medical records of mHSPC patients who began upfront ABI or DOC treatment in addition to ADT at seven public oncology centers in Hong Kong between 2015 and 2021 were reviewed. The primary endpoint was progression-free survival (PFS). Secondary endpoints included overall survival (OS), prostate-specific antigen (PSA) response, and toxicities. Kaplan-Meier and multivariate Cox regression analyses were performed. RESULTS: A total of 574 patients were included, of whom 419 received DOC and 155 received ABI. The median follow-up duration was 22.4 (DOC group: 23.8; ABI group: 17.3) months. The ABI group demonstrated significantly better PFS than the DOC group (not reached vs. 15.1 months: hazard ratio = 0.37; 95% confidence interval = 0.28-0.50; P < .001). No significant OS difference was observed (P = .58). Failure to achieve a ≥ 90% decline in PSA level at 3 months and failure to achieve an undetectable PSA nadir were each associated with unfavorable PFS and OS. Patients who received DOC had a higher rate of febrile neutropenia, whereas those who received ABI had higher rates of grade ≥ 3 hypokalemia and elevated alanine transaminase. Treatment discontinuation due to toxicities was more common in the DOC (3.6%) than the ABI (0.6%) group. CONCLUSION: In Asian mHSPC patients, upfront ABI + ADT was associated with better PFS than DOC + ADT, with no significant OS difference. PSA kinetics may help stratify the prognosis for treatment intensification. Toxicity profiles were different, with a higher rate of toxicity-related treatment discontinuation in the DOC group.

Safety and tolerability of intramuscular and sublingual ketamine for psychiatric treatment in the Roots To Thrive ketamine-assisted therapy program: a retrospective chart review.

Background: In the last few years, ketamine is becoming increasingly common in the treatment of mental health conditions, but there is a lack of safety data informing intramuscular and sublingual dosing in a community-focused group psychotherapy setting. The Roots To Thrive ketamine-assisted therapy (RTT-KaT) program is a unique 12-week RTT-KaT program with 12 community of practice (a form of group therapy) sessions and three ketamine medicine sessions. Objectives: This study reports on adverse effects of intramuscular and sublingual ketamine dosing in a community group psychotherapy setting among 128 participants across four cohorts. Design: Retrospective chart review. Methods: A chart review of the RTT-KaT Program was performed retrospectively on four cohorts (n = 128) that participated in 448 sessions running between September 2020 and December 2021. Baseline characteristics and adverse events were captured including medication administration before, during, and after RTT-KaT sessions. Analyses by session and by individual were conducted. Chi-square test with Yates' continuity correction was used to assess side effects in subgroups from ketamine administration. Results: RTT-KaT was well tolerated with none of the 128 participants dropping out of the program. Primarily, of the 448 sessions, 49.16% had elevated blood pressures post-KaT session by session. In terms of other adverse effects, 12.05% of participant-sessions experienced nausea, 2.52% had an episode of vomiting, 3.35% had a headache, and seven participant-sessions experienced dizziness. Analysis by individual revealed congruent findings. Conclusion: These findings suggest good safety and tolerability for RTT-KaT among individuals seeking treatment for mental health issues. The majority of participants did not experience adverse reactions and the adverse events that were recorded involved transient symptoms that were resolved with rest and/or medications. The group therapy model described provides a comprehensive approach and presents a promising model for operating a KaT program in a community setting.

A Pilot Study Comparing a Community of Practice Program with and without Concurrent Ketamine-Assisted Therapy.

The prevalence of depression, anxiety, and post-traumatic stress disorder (PTSD) has increased among healthcare providers, while the effectiveness of conventional treatments remains limited. Ketamine-assisted therapy offers a promising alternative; however, few have integrated ketamine with a group-based therapeutic modality. We report a retrospective, secondary analysis of a 12-week pilot of a Community of Practice (CoP) oriented group therapy program with optional, adjunct ketamine for depression, anxiety, and PTSD in a sample of 57 healthcare providers. All participants moved through the treatment as one group, with 38 electing to also receive three adjunct ketamine sessions in addition to the weekly CoP. Symptoms were assessed at baseline and pilot completion with the PHQ-9 for depression, GAD-7 for anxiety, and PCL-5 for PTSD. We observed significant reductions in the mean change among all participants, suggesting that benefit was derived from the CoP component, with or without ketamine as an adjunct. PHQ-9 scores decreased by 6.79 (95% CI: 5.09-8.49, p < .001), GAD-7 scores decreased by 5.57 (CI: 4.12-7.00, p < .001), and PCL-5 scores decreased by 14.83 (CI: 10.27-19.38, p < .001). Reductions were larger, but statistically nonsignificant, among those receiving ketamine. Further research is required to assess the impact of ketamine as an adjunct in group-based therapies.

Psilocybin's Potential Mechanisms in the Treatment of Depression: A Systematic Review.

Evidence suggests that psilocybin has therapeutic benefit for treating depression. However, there is little consensus regarding the mechanism by which psilocybin elicits antidepressant effects. This systematic review summarizes existing evidence. Ovid MEDLINE, EMBASE, psychINFO, and Web of Science were searched, for both human and animal studies, using a combination of MeSH Terms and free-text keywords in September 2021. No other mood disorders or psychiatric diagnoses were included. Original papers in English were included. The PRISMA framework was followed for the screening of papers. Two researchers screened the retrieved articles from the literature search, and a third researcher resolved any conflicts. Of 2,193 papers identified, 49 were selected for full-text review. 14 articles were included in the qualitative synthesis. Six supported psilocybin's mechanism of antidepressant action via changes to serotonin or glutamate receptor activity and three papers found an increase in synaptogenesis. Thirteen papers investigated changes in non-receptor or pathway-specific brain activity. Five papers found changes in functional connectivity or neurotransmission, most commonly in the hippocampus or prefrontal cortex. Several neuroreceptors, neurotransmitters, and brain areas are thought to be involved in psilocybin's ability to mitigate depressive symptoms. Psilocybin appears to alter cerebral blood flow to the amygdala and prefrontal cortex, but the evidence on changes in functional connectivity and specific receptor activity remains sparse. The lack of consensus between studies suggests that psilocybin's mechanism of action may involve a variety of pathways, demonstrating the need for more studies on psilocybin's mechanism of action as an antidepressant.

Co-designing clinical trials alongside youth with chronic pain.

Youth have a right to participate in research that will inform the care that they receive. Engagement with children and young people has been shown to improve rates of enrollment and retention in clinical trials as well as reduce research waste. The aim of the study is to gain practical insight on the design of trials specifically on (1) recruitment and retention preferences, (2) potential barriers to research, and (3) study design optimization. Based on this youth engagement, we will co-design two clinical trials in headaches with youth. Two recruitment strategies were used to recruit 16 youth from across Canada (aged 15-18 years) from an existing youth group, the KidsCan Young Persons' Research Advisory Group (YPRAG) and a new youth group in collaboration with Solutions for Kids in Pain (SKIP). Four virtual, semi-structured discussion groups were held between April and December 2020, which included pre-circulated materials and utilized two distinct upcoming planned trials as examples for specific methods feedback. Individual engagement evaluations were completed following the final group session using the Public and Patient Engagement Evaluation Tool. Descriptive results were shared with participants prior to publication to ensure appropriate interpretation. The discussion was centred around three themes: recruitment and retention preferences, potential barriers to participation, and study design optimization. Youth indicated that they would prefer to be contacted for a potential study directly by their physician (not over social media), that they would like to develop rapport with study staff, and that one of the barriers to participation is the time commitment. The youth also provided feedback on the design of the clinical trial including outcome measurement tools, data collection, and engagement methods. Feedback on the virtual format of the engagement events indicated that participants appreciated the ease of the online discussion and that the open-ended discussion allowed for easy exchange of ideas. They felt that despite a gender imbalance (towards females) it was an overall inclusive environment. All participants reported believing that their engagement will make a difference to the work of the research team in designing the clinical trials. Perspectives from a diverse group of youth meaningfully improved the design and conduct of two clinical trials for headaches in children. This study provides a framework for future researchers to engage youth in the co-design of clinical trials using online engagement sessions.

Reflecting on earlier affected areas that shaped COVID-19 mental health efforts.

The COVID-19 pandemic is a serious public health threat that many countries in the world are facing. While several measures are being taken to minimize the spread of infection, mental health efforts must address psychological challenges due to the pandemic. This commentary reflects on original research from earlier epicenters of COVID-19 and identifies effective practices and suggestions applicable to mental health interventions in the North American context. Tailored mental health services need to be provided for populations that are at high risk of infection. Suggested interventions targeting specific population groups, such as healthcare workers, COVID-19 patients, and vulnerable populations, are discussed.

Youth, Caregiver, and Provider Perception of the Transition from Pediatric to Adult Care for Youth with Chronic Diseases.

OBJECTIVE: Youth with chronic diseases are required to transition from pediatric to adult care across the world at variable ages in their adolescent years. The aim of this study is to examine perspectives of young patients, caregivers, and physicians in the transition process. METHODS: This 3-phase mixed methods research study gathered data using an iterative approach with the collaboration of youth coresearchers. Physician opinions were gathered through a survey. Further data were collected through 15 semistructured, standardized interviews of adolescent medicine physicians. Perspectives of adolescents and young adult (AYA) patients and their caregivers were gathered independently using a 20-item survey. Quantitative data were analyzed with descriptive statistics and sorted by theme. RESULTS: In phase 1, respondents rated current transition processes as an average 5.19/10 on a 10-point Likert scale (1 = poor and 10 = excellent) with no participants rating 9 or 10 of 10. The top barrier identified was a lack of communication between pediatric and adult doctors (71.0%). The top ranked strategy for improvement was to provide formal transition guidelines (69.8%). In phase 2, specific concerns include lack of insurance coverage, lack of physicians available to take on youth transitioning to adult care who are also knowledgeable regarding pediatric conditions, and lack of funding or staff support for transition clinics. In phase 3, most of the youth surveyed (52%) reported that their physicians have not involved them in conversations about transitioning. AYA patients prefer the point of transfer to occur with other life transitions such as graduation, and caregivers prefer transfer to happen during times of stability where their children can dedicate adequate time to their health. CONCLUSION: Fulfilling youth desire for increased patient autonomy and ownership can help overcome their poor perception of the transition process. Increased physician training in adolescent health and improvements in post-transition community plans may be beneficial to prevent loss to follow-up among young patients across medical disciplines. Successful transition into adult care requires a unique process for each youth and requires adequate preparation from the pediatric front, empowerment of young patients and their families, and continuity of care by adult providers.

Outcomes Following Gender Affirming Phalloplasty: A Systematic Review and Meta-Analysis.

INTRODUCTION: Phalloplasty is one of the genital genders affirming surgeries sought by transmasculine transgender patients during transition. Despite current advances in surgical techniques, the lack of consistency in outcomes evaluation for phalloplasty leads to significant challenges in guiding patients in clinical decision making. AIMS: This systematic review and meta-analysis aims to assess outcomes for different phalloplasty surgical techniques. METHODS: The literature was searched using Medical Literature Analysis and Retrieval System Online (MEDLINE; PubMed), Excerpta Medica database, and Cochrane Database of Systematic Reviews. All English-language randomized control trials, prospective and retrospective cohort studies, case series, and case reports of at least 4 patients were included. The primary outcome was postoperative complications, and the secondary outcomes were functional and aesthetic results. Proportional meta-analysis was used to pool complication rates using a random-effects model. RESULTS: Database searching generated 39 final articles, with 19 case series, 3 cross-sectional studies, and 17 retrospective cohort studies. A total of 1731 patients underwent phalloplasty, with the most common type of reconstruction performed being the radial forearm free flap (75.1%). Overall complication rate was high at 76.5%, of which urethral complications were high in all reconstructive subgroups (urethral fistula rate of 34.1% and urethral stricture rate of 25.4%). Postoperative functional outcomes were reported in 57.6% of patients, finding that most had tactile sensation (93.9%) and can void while standing (92.2%). Aesthetic outcomes were only reported in 6.3% of patients, with mean length achieved being 12.26 cm (SD = 0.81 cm) and mean circumference being 10.18 cm (SD = 3.69 cm). CONCLUSION: In the transmasculine transgender population, current evidence of the various phalloplasty surgical techniques and their expected postoperative outcomes is weak. Future research may consider developing a standardized core outcome set to improve clinical decision making. Wang AMQ, Tsang V, Mankowski P, et al. Outcomes Following Gender Affirming Phalloplasty: A Systematic Review and Meta-Analysis. Sex Med Rev 2022;10:499-512.

Impacts of economic inequality on healthcare worker safety at the onset of the COVID-19 pandemic: cross-sectional analysis of a global survey.

OBJECTIVES: To assess the extent to which protection of healthcare workers (HCWs) as COVID-19 emerged was associated with economic inequality among and within countries. DESIGN: Cross-sectional analysis of associations of perceptions of workplace risk acceptability and mitigation measure adequacy with indicators of respondents' respective country's economic income level (World Bank assessment) and degree of within-country inequality (Gini index). SETTING: A global self-administered online survey. PARTICIPANTS: 4977 HCWs and healthcare delivery stakeholders from 161 countries responded to health and safety risk questions and a subset of 4076 (81.2%) answered mitigation measure questions. The majority (65%) of study participants were female. RESULTS: While the levels of risk being experienced at the pandemic's onset were consistently deemed as unacceptable across all groupings, participants from countries with less income inequality were somewhat less likely to report unacceptable levels of risk to HCWs regarding both workplace environment (OR=0.92, p=0.012) and workplace organisational factors (OR=0.93, p=0.017) compared with counterparts in more unequal national settings. In contrast, considerable variation existed in the degree to which mitigation measures were considered adequate. Adjusting for other influences through a logistic regression analysis, respondents from lower middle-income and low-income countries were comparatively much more likely to assess both occupational health and safety (OR=10.91, p≤0.001) and infection prevention and control (IPC) (OR=6.61, p=0.001) protection measures as inadequate, despite much higher COVID-19 rates in wealthier countries at the time of the survey. Greater within-country income inequality was also associated with perceptions of less adequate IPC measures (OR=0.94, p=0.025). These associations remained significant when accounting for country-level differences in occupational and gender composition of respondents, including specifically when only female care providers, our study's largest and most at-risk subpopulation, were examined. CONCLUSIONS: Economic inequality threatens resilience of health systems that rely on health workers working safely to provide needed care during emerging pandemics.