Patient Experiences and Provider Perspectives on Accessing Gender-Affirming Surgical Services in the Veterans Health Administration.

BACKGROUND: Transgender and gender diverse (TGD) veterans have a greater prevalence of suicide morbidity and mortality than cisgender veterans. Gender-affirming surgery (GAS) has been shown to improve mental health for TGD veterans. In 2021, the Veterans Health Administration (VHA) announced the initiation of a rulemaking process to cover GAS for TGD patients. OBJECTIVE: This study explores patients' and providers' perspectives about access to GAS and other gender-affirming medical interventions not offered in the VHA including barriers, facilitators, and clinical and policy recommendations. PARTICIPANTS: TGD patients (n = 30) and VHA providers (n = 22). APPROACH: Semi-structured telephone interviews conducted from August 2019 through January 2020. Two TGD analysts used conventional and directed content analysis to code transcribed data. KEY RESULTS: VHA policy exclusions were the most cited barrier to GAS. Additional barriers included finding information about GAS, traveling long distances to non-VHA surgeons, out-of-pocket expenses, post-surgery home care, and psychological challenges related to the procedure. Factors facilitating access included surgical care information from peers and VHA providers coordinating care with non-VHA GAS providers. Pre- and post-operative care through the VHA also facilitated receiving surgery; however, patients and providers indicated that knowledge of these services is not widespread. Respondents recommended disseminating information about GAS-related care and resources to patients and providers to help patients navigate care. Additional recommendations included expanding access to TGD mental health specialists and establishing referrals to non-VHA GAS providers through transgender care coordinators. Finally, transfeminine patients expressed the importance of facial GAS and hair removal. CONCLUSIONS: A policy change to include GAS in the VHA medical benefits package will allow the largest integrated healthcare system in the United States to provide evidence-based GAS services to TGD patients. For robust and consistent policy implementation, the VHA must better disseminate information about VHA-provided GAS-related care to TGD patients and providers while building capacity for GAS delivery.

Performance improvement in sport through vitamin D - a narrative review.

OBJECTIVE: It is well known that vitamin D deficiency can lead to various health problems. However, it is not common knowledge among athletes and doctors that vitamin D deficiency is prevalent in sports. This deficiency can severely impact performance, while vitamin D supplementation can alleviate this effect and potentially improve performance. MATERIALS AND METHODS: This narrative review aims to compile the current state of knowledge about the importance of vitamin D in increasing performance for active people. To this end, we searched the 'Scopus' and 'PubMed' databases for the terms 'vitamin D - athlete - performance' with an end date of 30 June 2022. RESULTS: Study results indicated that the therapeutic impact of vitamin D on aerobic capacity, recovery, strength and sprint performance remains controversial. CONCLUSIONS: Based on the previous findings on recovery, strength and performance, 4,000-5,000 IU of vitamin D per day may be a safe dose that can improve athletic performance.

"He Gave Me Spirit and Hope": Client Experiences with the Implementation of Community Health Worker Programs in HIV Care.

Community health workers (CHWs) are members of the frontline health workforce who serve as intermediaries between health services and communities. In the United States, the role of CHWs has begun to expand as they have been shown to improve outcomes and reduce inequities in care for chronic conditions. This study used qualitative methods to explore the experiences of clients in CHW programs to inform their implementation in HIV care. Thirty clients from 6 Ryan White HIV/AIDS Program care settings across the United States participated in individual semistructured interviews to learn more about their experiences working with a CHW. Four key themes arose from the client perspective. First, CHWs embodied key qualities. Some of the qualities clients attributed to CHWs included being caring and supportive, along with capable of fostering personal connections. Second, CHWs met clients where they were. Clients described the CHW approach as more holistic compared with other care team members; they emphasized CHWs were able to focus on whatever was needed in that moment. Third, CHWs occupied a unique role in the HIV care team. Clients noted CHWs had more time to dedicate to their interactions; they also saw CHWs as representing a different level of authority. Finally, CHWs influenced how clients engaged with care and accessed resources. This included empowering clients to access resources independently in the future. Overall, clients' perceptions of CHWs in terms of their qualities, approach, role, and influence on the HIV care experience suggest they are a valuable resource on the care team.

Opioid pain medication misuse, concomitant substance misuse, and the unmet behavioral health treatment needs of transgender and gender diverse adults.

BACKGROUND: Limited research has explored risk factors for opioid pain medication misuse, concomitant substance misuse, and the unmet behavioral health treatment (BHTx) needs of transgender and gender diverse (TGD) adults. METHODS: In 2019, TGD adults (N = 562) in Massachusetts and Rhode Island were purposively recruited and completed a psychosocial and behavioral health survey (95 % online; 5% in-person). Multivariable logistic regression was used to examine factors associated with past 12-month opioid pain medication misuse and unmet BHTx needs. RESULTS: Overall, 24.4 % of participants were trans women; 32.0 % trans men; and 43.6 % were non-binary. Past-year substance misuse included: marijuana (56.8 %), hazardous drinking (37.5 %), hallucinogens (9.8 %), benzodiazepines (8.2 %), and opioid pain medication (8.0 %). Among participants with past-year substance misuse and BHtx need (n = 326), 81.3 % received BHtx and 18.7 % had unmet BHtx needs. Being a trans woman, having HIV, stigma in healthcare, and number of substances misused were associated with increased odds of past-year opioid pain medication misuse; high social connectedness was associated with decreased odds of opioid pain medication misuse (p-values<0.05). Younger age, stigma in healthcare, and misusing opioid pain medications were associated with increased odds of unmet BHTx needs; post-traumatic stress disorder and family support were associated with decreased odds of unmet BHtx needs (p-values<0.05). CONCLUSIONS: Addressing disparities in opioid pain medication misuse among TGD people requires systematic improvements in healthcare access, including efforts to create TGD-inclusive BHtx environments with providers who are equipped to recognize and treat the social and structural drivers of TGD health inequities, including opioid pain medication misuse.

Development of observational rating scales for evaluating patient-centered communication within a whole health approach to care.

CONTEXT: Teaching and evaluating patient-centered communication (PCC) skills that incorporate holistic approaches are increasingly relevant. OBJECTIVE: This study describes the development of the Observational Whole Health Measure (OWHM) for evaluating the extent to which primary care providers in the Veterans Health Administration engaged in PCC in the context of a holistic approach to care known as "Whole Health." DESIGN AND SETTING: Observational rating scales were created based on content from a national whole health clinical education program in the VA and refined from audio recordings of patient-provider interactions in primary care clinical encounters. Unpaired t-tests and Cohen's d were conducted to measure overall quality of what really matters and whole health goal setting and plan development. PARTICIPANTS: 65 clinical encounters across 8 providers before and after participating in the training were included for analysis. INTERVENTION: The intervention used for creating rating scales is a 2.5 day whole health clinical education program designed to teach providers PCC skills to identify what matters most for the patients and develop a patient-centered health plan that incorporates integrative health approaches to care. MAIN OUTCOME MEASURE: Quality scores (0-4) were used to measure number of instances and extent to which providers explored what matters most to patients, dimensions of whole health, and development of a whole health plan tailored to patient's goals. RESULTS: We developed the Observational Whole Health Measure (OWHM) that captures changes in provider communication. Significant differences in overall quality of whole health goal setting and plan development were detected between pre- and post-encounters, demonstrating a sensitivity to change. With the rise of integrative health approaches being adopted across clinical settings, the observational rating scales created in this study are likely to have increasing relevance.

Echinacea purpurea supplementation stimulates select groups of human gastrointestinal tract microbiota.

BACKGROUND AND OBJECTIVE: The objective of this research was to determine the effects of the dietary supplement Echinacea purpurea on aerobic and anaerobic bacteria common to the human gastrointestinal (GI) tract. Botanical extracts have shown in vitro antimicrobial effects against certain pathogenic bacteria. It is uncertain if medicinal herbs have any effect against pathogenic bacteria or on the native GI microbiota. METHODS: Fifteen human subjects consumed 1000 mg of standardized E. purpurea for 10 days. Faecal samples were collected at baseline, 10 days and 17-18 days following supplementation. Samples were tested for select aerobic and anaerobic bacteria using plate culture microbiological methods. RESULTS AND DISCUSSION: Significant increases were found for total aerobic bacteria, Bacteroides group and Bacteroides fragilis after E. purpurea exposure. Supplementation did not significantly alter the number of enteric bacteria, enterococci, lactobacilli, bifidobacteria or total anaerobic bacteria. CONCLUSION: Echinacea supplementation has altered the GI microbiota. The health consequences associated with this change are unknown but previous research has shown increased Bacteroides concentrations associated with diarrhoea, inflammatory bowel disease and increased risk of colon cancer. Additional research should delineate the role of Echinacea in the stimulation of Bacteroides and describe the effects of other botanical supplements to the GI microbiota.

Phosphorus uptake into algal biofilms in a lowland chalk river.

This paper examines the growth and uptake of phosphorus into algal biofilms in the River Kennet, a lowland chalk (Cretaceous-age) stream in southern England. Algal biofilms were grown on artificial plastic substrates (templates) placed (i) on the riverbed and (ii) within the mid-water column. Experiments were set up to examine differences in growth rates of newly colonising biofilms compared with biofilms left to accumulate for periods of up to 6 months. Rates of algal biofilm production were measured by the chlorophyll a concentration that had accumulated per cm2 over the number of days that the biofilm template had been immersed in the river water. An algal biofilm bloom occurred in early spring, prior to peak suspended chlorophyll a concentrations within the water column. Biofilm samples collected in February and March had the highest chlorophyll a and total phosphorus concentrations. The biofilm bloom corresponded with increased solar radiation and declining river flow conditions. Periodic increases in soluble reactive phosphorus concentrations in the overlying river water did not correspond with any significant increase in biofilm production. These results suggest that light, rather than phosphorus is a key factor for biofilm growth in the River Kennet. Higher rates of chlorophyll a development in mid-water column biofilms may be linked to greater light exposure; however, maximum total-P concentrations were similar for both bed and water column biofilms. Newly colonising biofilms exhibited higher chlorophyll a and total-P concentrations than biofilms left to accumulate over longer terms, suggesting that fresh substrate availability promotes high rates of biofilm growth. Both 'condensed and organic' P (stored in biomass) and 'inorganic' (mineral) P fractions within the biofilms were present in varying proportions, although the early spring biofilm bloom resulted in maximum proportions and absolute concentrations of 'condensed and organic' P. Calcite was the only crystalline mineral detected within the biofilms. Ratios of Ca:inorganic P are largely consistent with the presence of CaCO3-P co-precipitates, although one very low value suggested that there may also be additional sources of inorganic P, possibly P adsorbed to clays or organics within the biofilm. However, poor linkages between CaCO3 and inorganic P concentrations suggest that, although the inorganic P fraction within the biofilm may be derived largely from CaCO3-P co-precipitation, the subsequent processes controlling overall CaCO3 and inorganic P concentrations in the biofilm are complex.

Refinement of the PARK3 locus on chromosome 2p13 and the analysis of 14 candidate genes.

Parkinson's disease (PD) is a common neurodegenerative disorder with clinical features of bradykinesia, rigidity, resting tremor and postural instability resulting from the deficiency of dopamine in the nigrostriatal system. Previously we mapped a susceptibility gene for an autosomal dominant form of PD to a 10.6 cM region of chromosome 2p (PARK3; OMIM 602404). A common haplotype shared by two North American kindreds (Families B and C) genealogically traced to Southern Denmark and Northern Germany suggested a founder effect. Here we report progress in the refinement of the PARK3 locus and sequence analysis of candidate genes within the region. Members of families B and C were genotyped using polymorphic markers, reducing the minimum common haplotype to eight markers spanning a physical distance of 2.5 Mb. Analysis of 14 genes within the region did not reveal any potentially pathogenic mutations segregating with the disease, implying that none of these genes are likely candidates for PARK3.

Carbon supply for storage-product synthesis in developing seeds of oilseed rape.

The aim of this work was to find out how the sugars in the endosperm of oilseed rape contribute to the flux of oil synthesis. While the hexose content of the liquid endosperm decreased during development the sucrose content increased. It is important to understand the relative rates of use of the endosperm sugars for two reasons. Firstly we need to know which sugars are used, and at what stages in development, in order to understand the roles of enzymes involved in their metabolism. Secondly, changes in sugar concentration have been implicated in the regulation of expression of genes determining storage-product synthesis [see Weber, Borisjuk and Wobus (1997) Trends Plant Sci. 2, 169-174, for review]. The rate of consumption of sugar is one factor governing its concentration. We present data showing both the concentration-dependence of conversion of sugar to oil, and the in vivo concentrations of sugars; we relate these data sets to each other and discuss the effects of the intracellular pool of sucrose. Glucose, fructose and sucrose are all substrates for oil synthesis, but the rates of their use (particularly sucrose) are underestimated because of dilution by sucrose from the intracellular pool.

Coloring outside the lines.

Creativity facilitates the continuous expansion of nurses' interpretations of their nursing practice and is the essence of holistic care. In this study, the concept of creativity was explored by addressing the question, "When student nurses are given complete freedom to design nursing care for a patient, what types of activities will they include?" The students were provided with a case scenario involving a comatose Native American male patient and asked to complete an "Exercise to Stretch Your Mind." Forty-eight students completed the exercise for a total of 343 responses. Qualitative data analysis was completed, and the nursing process was used to conceptually link the patterns of interventions that emerged. These interventions involved using the sensory modalities of physical and emotional feeling, hearing, and smelling to provide contextual experiences for the patient to connect and reconnect with himself. The connecting context included six areas: the outside, his nurse, his family, his spirit, the familiar, and the future.

Technique integration. Therapeutic touch and theory-based mental health nursing.

Acceptance of therapeutic touch (TT) by the nursing community has become widespread. Nurses are advancing the pioneering work of Krieger (1973) through practice, research, education, and, most recently, through the development of theory-based nursing practice. The purpose of this article is to contribute to the development of theory-based nursing practice by introducing integration of TT with mental health nursing approaches. The Science of Unitary Human Beings (Rogers, 1986) is used to explain the relationship between TT and mental health nursing practice. The use of TT in practice is demonstrated through case examples from experiences with students and clients.

Tube feeding enteral nutritional support in patients receiving radiation therapy for advanced head and neck cancer.

A retrospective study evaluated the role of tube feeding enteral nutritional support in patients receiving radiation therapy (RT) for Stage III and IV squamous cell carcinoma of the head and neck. Tube feeding (TF) by either nasogastric, cervical esophagostomy, or gastrostomy route was based on individual physician preference and patient acceptance. TF feeding starting before and continuing through RT (planned TF) was completed in 17 patients, whereas 9 patients did not receive TF until they lost weight during RT (interventional TF). No tube feeding was performed in 63 patients. By the end of RT, the planned TF group lost an average of 4.8% of initial body weight, compared to 7.1% in the no TF group and 9.4% in the interventional TF group. At the end of RT, only 6% of the planned TF group had lost over 10% of initial body weight, compared to 24% of the no TF group and 44% of the interventional group. Excluding patients who continued to lose weight after the end of RT due to rapidly recurrent tumor, 49% of the no TF group had a post-RT nadir weight loss over 10% of initial body weight, compared to 0% of the planned RT group. However, failure to receive the full RT dose and/or lengthy rest periods during RT were just as likely to occur in the planned TF group as in the no TF group. This retrospective review also could not demonstrate improved survival in the planned TF group. Complications, including peptic ulcer disease, aspiration pneumonia, cervical stoma abscess, and hepatic encephalopathy, occurred in 7 of the 26 patients (27%) receiving either planned or interventional TF. We conclude that TF will help minimize weight loss due to side effects of RT for head and neck cancer, particularly when TF is instituted before the onset of significant weight loss due to RT side effects. Survival differences, however, were not apparent.

Use of I-131 labeled, murine Fab against a high molecular weight antigen of human melanoma: preliminary experience.

High molecular weight antigen (HMWA) is a tumor-associated proteoglycan of human malignant melanoma. I-131 labeled Fab fragments of these specific antibodies were used for preliminary feasibility studies for radioimmunodetection and therapy of human subjects who had inoperable metastatic melanoma. Ten patients received tracer doses of 5-13 mCi (185-481 MBq) of I-131 (anti-HMWA) Fab. All patients (8/8) who had melanoma lesions greater than 1 cm by correlative diagnostic methods had one or more lesions that had localization to tumor of the radiolabeled Fab. In all, 17 of 23 (74%) documented metastases were seen. There were no false positives in this series. Two patients who had avid uptake received potentially radiotherapeutic doses of 142 mCi (5,254 MBq) (one patient) and 181 mCi (6,697 MBq) and 193 (7,141 MBq) (total: 374 mCi or 13,838 MBq) (one patient). For both of these patients, whole body imaging studies showed that the localization of the high dose I-131 Fab was predominantly in tumor. The patient who received the larger dose showed a greater than 50% reduction in the size of pelvic and pericaval nodes, with stabilization of disease at the smaller nodal size for a period of three months. On whole body images, the anti-Fab HMWA appears to be more tumor selective than Fab preparations that target the p97 antigen for melanoma, and there is less uptake in liver.

Localization of 131I-labeled p97-specific Fab fragments in human melanoma as a basis for radiotherapy.

33 patients with advanced malignant melanoma were studied after intravenous administration of 131I-labeled Fab fragments specific for p97, an oncofetal glycoprotein of human melanoma. In all, 47 gamma camera imaging studies were performed for the purpose of localization of metastatic deposits. In addition to tumor, 131I-Fab uptake was also seen in liver and kidney. 20 of these studies included simultaneous administration of both an 131I-labeled Fab specific for p97, and an 125I-labeled Fab not specific for p97. Blood clearance of p97-specific Fab was significantly more rapid than for nonspecific Fab. Eight of these patients had biopsies of subcutaneous nodules at 48 and 72 h postinjection in order to assess whether localization of radioactivity was antigen specific. Antigen-specific localization was observed with average ratios of specific/nonspecific uptake of 3.7 (48 h) and 3.4 (72 h); uptake was strongly correlated with tumor p97 concentration (r = 0.81, P less than 0.01). Also, imaging studies of the bio-distribution of 131I-labeled anti-p97 Fab in patients selected for high p97 tumor concentration showed avid tumor uptake and more prolonged retention of labeled Fab in tumor than in normal tissues. Based on these studies, we estimated that total 131I doses of 500 mCi could be safely given to patients before dose-limiting toxicity would be observed. Accordingly, in seven selected patients, phase I radiotherapeutic trials were begun. For improved radiation safety, we developed automated methods to label Fab fragments with up to 200 mCi of 131I. So far, a total of 12 individual therapeutic doses, ranging from 34 to 197 mCi of 131I-labeled to 5 to 10 mg of Fab, have been administered with excellent tumor localization and without major target organ toxicity. Cumulative doses ranged from 132 to 529 mCi 131I. Side effects attributable to the radiation were mild, with a transient drop slightly greater than 50% in platelet and absolute neutrophil counts being observed in the two patients who received cumulative doses greater than 500 mCi. In the combined series of 47 diagnostic and 12 therapeutic studies, four acute reactions were observed: one episode each of transient chills and fever; flushing and hypotension; and two skin rashes. All of these reactions responded promptly to symptomatic therapy. After multiple administrations of 131I-(anti-p97) Fab (IgG1), isotype-specific immunity was observed in three patients. In two of these patients it was possible to successfully reinfuse after immunity had developed with 131I-(anti-p97) Fab of a different isotype (IgG2a). Dosimetry estimates were performed based on the biodistribution of (131)I-Fab in these patients,and for every 100 mCi of (131)I-Fab given, tumor receives 1,040 rads; liver. 325 rads; and bone marrow, 30 rads. Marrow would be expected to be the critical organ, if doses >500 mCi (131)I-Fab are given. These studies demonstrated that, with proper precautions, large doses (of an (131)I-labeled murine Fab fragments immunologically specific for a human melanoma-associated antigen) could be safely given to humans by using repetitive intravenous injections.

Effectiveness of low-dose continuous intravenous insulin infusion in diabetic ketoacidosis. A prospective comparative study.

Twenty pediatric patients with diabetic ketoacidosis were randomly assigned in equal numbers to receive insulin either as a low-dose continuous intravenous infusion or as high-dose intermittent subcutaneous injections. Blood was obtained hourly for determinations of total CO2, plasma glucose, and osmolality, and, in previously untreated patients, plasma insulin. Serum values of beta hydroxybutyrate, electrolytes, and acetone were monitored every two hours. Plasma insulin levels were in the therapeutically effective range with each method of administration. There were no statistically significant differences in rate of correction of ketoacidosis, rate of reduction of plasma glucose, or decline in plasma osmolality. The incidence and the severity of hypokalemia were increased in the patients receiving subcutaneous insulin. There was less variation in the rate of reduction of plasma glucose in the infusion group. Low-dose continuous intravenous infusion of insulin is at least as effective in treating diabetic ketoacidosis as the traditional high-dose intermittent subcutaneous injection of insulin and offers some definite advantages.