Provider cultural competence and humility in healthcare interactions with transgender and nonbinary young adults.

PURPOSE: Transgender and nonbinary (TGNB) patients experience many barriers when seeking quality healthcare services, including ineffective communication and negative relationships with their providers as well as a lack of provider competence (including knowledge, training, and experience) and humility (engagement in the process of self-reflection and self-critique) in treating TGNB individuals. The purpose of this qualitative study was to identify factors associated with cultural competence and humility that facilitate and impede effective relationships between TGNB young adults and their healthcare providers. METHODS: Data came from individual interviews with 60 young adults aged 18 to 24 from Florida who self-identified as transgender or nonbinary. We analyzed the data using inductive thematic approaches, and a feminist perspective, to identify themes associated with patient-provider relationships. CONCLUSIONS: We identified 4 themes related to patient-provider relationships: (1) Participants indicated effective patient-provider communication and relationships are facilitated by providers requesting and utilizing TGNB patients' correct names and personal pronouns. (2) Participant narratives conveyed their preferences that providers "follow their lead" in terms of how they described their own anatomy, reinforcing the utility of cultural humility as an approach for interactions with TGNB patients (3) Participants discussed the detrimental effects of TGNB patients having to educate their own providers about their identities and needs, suggesting clinicians' competence regarding gender diversity is paramount to fostering and maintaining patient comfort. (4) Finally, participants' responses indicated concerns regarding the confidentiality and privacy of the information they provided to their providers, suggesting a lack of trust detrimental to the process of building rapport between patients and their providers. CLINICAL RELEVANCE: Our findings indicate balancing the use of cultural humility and cultural competence during clinical encounters with TGNB young adults can enhance patients' experiences seeking healthcare. Nursing education is often devoid of focus on caring for transgender and nonbinary persons. Additional provider training and education on approaching clinical encounters with TGNB patients with cultural humility and competence should improve patient-provider communication and relationships, leading to a higher quality of patient care.

Abortion as a Public Health Risk in COVID-19 Antiabortion Legislation.

During the early months of the COVID-19 pandemic, 12 states banned or restricted abortion access under elective-procedure restrictions. The rationale was preserving hospital capacity and personal protective equipment (PPE); however, abortions commonly take place in clinics and use less PPE than childbirth. This paper investigates the discursive construction of abortions, the people who get them, and the fetuses in this legislation. The authors analyzed 13 antiabortion documents using an iterative process of thematic coding and memo writing. Twenty-three percent of the legislation listed abortion as banned, whereas the remaining laws implied abortion within the terms "elective" or "nonessential." Legislation used common antiabortion tactics, such as the trivialization of abortion, risk discourses, and constructions of motherhood and fetal personhood. Discourses delegitimized abortion providers and used quasi-medical justifications for banning abortion. Finally, legislation constructed abortion clinics as sites of contagion and waste and consequently as risks to public health. The results highlight the vulnerability of abortion and the connection between abortion policy and other conservative policies, and they gesture toward a strategic attempt to ban abortion federally. These findings have several implications for a post-Roe United States and for stakeholders wishing to increase abortion access.

Exploring Conditions That Strengthen or Weaken the Ecological and Evolutionary Consequences of Phenological Synchrony.

AbstractClimate change-driven phenological shifts alter the temporal distributions of natural populations and communities, but we have little understanding of how these shifts affect natural populations. Using agent-based models, we show that the interaction of within-population synchrony (individual variation in timing) and timing of interspecific interactions shapes ecological and evolutionary dynamics of populations within a seasonal cycle. Low-synchrony populations had lower survival and biomass but relatively stronger individuals. These effects were surprisingly robust and did not require size-based competitive asymmetries. However, reducing population synchrony could either negatively or positively affect population demography depending on whether the phenology of the focal species was advanced or delayed relative to its competitor. Furthermore, selection for earlier hatching increased when the interspecific competitor arrived earlier and when population synchrony was high. These results emphasize the importance of variation in the phenology of individuals within populations to better understand species interactions and predict ecological and evolutionary outcomes of phenological shifts.

Group plus "mini" individual pre-test genetic counselling sessions for hereditary cancer shorten provider time and improve patient satisfaction.

BACKGROUND: Genetic counselling (GC) is an integral component in the care of individuals at risk for hereditary cancer predisposition syndromes (CPS). In many jurisdictions, access to timely counselling and testing is limited by financial constraints, by the shortage of genetics professionals and by labor-intensive traditional models of individual pre and post-test counselling. There is a need for further research regarding alternate methods of GC service delivery and implementation. This quality improvement project was initiated to determine if pretest group GC followed immediately by a 'mini' individual session, would be acceptable to patients at risk for hereditary breast and colon cancer. METHODS: Patients on waitlists for GC at the Provincial Medical Genetics Program in St. John's, NL, Canada (n = 112), were contacted by telephone and offered the option of a group counselling session (GGC), followed by a "mini" individual session, versus (TGC) traditional private appointments. GGC sessions consisted of a cancer genetics information session given to groups of 6-20 followed by brief 20 min "mini" individual sessions with the patient and genetic specialist. TGC individual appointments provided the same cancer genetics information and counselling to one patient at a time in the classic model. All but 2 participants selected group+mini session. A de-identified confidential 12-item, Likert scale survey was distributed at the conclusion of mini-sessions to measure perceptions of GGC and satisfaction with this counselling model. RESULTS: Sixty participants completed questionnaires. The majority of participants strongly agreed that they were comfortable with the group session (58/60); the explanation of cancer genetics was clear (54/59); they understood their cancer risks (50/60); and they would recommend such a session to others (56/59). 38/53 respondents disagreed or strongly disagreed that they would prefer to wait for a traditional private appointment. All 5 participating genetic counselors reported a preference for this model. At the end of the pilot project, the waitlist for counselling/testing was reduced by 12 months. CONCLUSIONS: Group pre-test genetic counselling combined with immediate "mini" individual session is strongly supported by patients and reduces wait times. Additional formal investigation of this approach in larger numbers of patients is warranted.

Social Connectedness Factors that Facilitate Use of Healthcare Services: Comparison of Transgender and Gender Nonconforming and Cisgender Adolescents.

OBJECTIVE: To compare social connectedness factors that facilitate use of primary, dental, and mental healthcare services among transgender and gender nonconforming (TGNC) and cisgender adolescents. METHODS: Data from the cross-sectional 2016 Minnesota Student Survey were used to examine protective social connectedness factors associated with use of different healthcare services among matched samples of 1916 TGNC and 1916 cisgender youth. Stratified, logistic regression analyses were used to examine background characteristics and social connectedness factors (parent connectedness, connections to other nonparental adults, teacher-student relationships, and friend connections) associated with use of each healthcare service within the last year. RESULTS: For TGNC youth, but not for cisgender youth, higher levels of parent connectedness were associated with receipt of primary (OR, 2.26; 95% CI, 1.40-3.66) and dental (OR, 3.01; 95% CI, 1.78-5.08) care services, and lower levels of connectedness to nonparental adults was associated with receipt of mental healthcare (OR, 0.55; 95% CI, 0.33-0.93). Among cisgender youth, no protective factors were significantly associated with receipt of primary care services, higher levels of friend connections were associated with receipt of dental services (OR, 1.85; 95% CI, 1.10-3.09), and lower levels of parent connectedness were associated with receipt of mental healthcare (OR, 0.20; 95% CI, 0.10-0.40). CONCLUSIONS: To promote the health of TGNC youth, clinicians should understand the distinct factors associated with obtaining healthcare among this population such as the need for tailored efforts focused on strengthening connectedness between TGNC youth and their parents to facilitate receipt of needed care.

Shifts in phenological distributions reshape interaction potential in natural communities.

Climate change has changed the phenologies of species worldwide, but it remains unclear how these phenological changes will affect species interactions and the structure of natural communities. Using a novel approach to analyse long-term data of 66 amphibian species pairs across eight communities, we demonstrate that phenological shifts can significantly alter the interaction potential of coexisting competitors. Importantly, these changes in interaction potential were mediated by non-uniform, species-specific shifts in entire phenological distributions and consequently could not be captured by metrics traditionally used to quantify phenological shifts. Ultimately, these non-uniform shifts in phenological distributions increased the interaction potential for 25% of species pairs (and did not reduce interaction potential for any species pair), altering temporal community structure and potentially increasing interspecific competition. These results demonstrate the potential of phenological shifts to reshape temporal structure of natural communities, emphasising the importance of considering entire phenological distributions of natural populations.

Place matters: the impact of place of residency on racial attitudes among regional and urban migrants.

Scholars have debated whether racial attitudes are socialized early in life and persist throughout one's lifetime or are open to influences from one's environment as an adult. This study introduces another approach that holds that place, as opposed to the timing of socialization, is an important consideration for the socialization of racial attitudes. Using data from the American National Election Study, we consider the effect of region and urban residency on racial attitudes by comparing lifelong residents of these locations to those who migrate into and out of them. Using improved measures of early life socialization and region of residency, we conclude that a place-based model can be used to explain the socialization of racial resentment. For regional migrants, those moving into and out of the non-South maintain levels of racial resentment similar to non-Southern stayers. For urban migrants, the lifelong openness model of socialization was most appropriate. These migrants were more likely to change and adopt the level of racial resentment similar to that of their destination peers. These findings generally persist across time.

Racializing Motherhood and Maternity Care in News Representations of Breastfeeding.

Racial inequalities in breastfeeding have been a U.S. national concern, prompting health science research and public discourse. Social science research reveals structural causes, including racism in labor conditions, maternity care practices, and lactation support. Yet research shows that popular and health science discourses disproportionately focus on individual and community factors, blaming Black women and communities for unequal breastfeeding rates. This study examines how scientific reports are communicated to the public through a critical analysis of 104 U.S. news articles reporting research on racial disparities in breastfeeding. Findings show that articles acknowledge unequal treatment within maternity care but justify it by presenting Black patients as overburdening the maternity care systems they use due to low socioeconomic status, welfare dependency, poor family support, and poor health. Through these representations, articles co-construct racialized motherhood and maternity care systems in ways that hide manifestations of obstetric racism and combat social support for systemic change.

Discursive constructions of breastfeeding in U.S. state laws.

Previous research has identified several ways that breastfeeding is constructed in public discourses, each with consequences for breastfeeding attitudes, policies, and practices. Researchers analyzed discursive constructions of breastfeeding in U.S. state laws regarding breastfeeding in public to see if common representations were replicated in law and to identify patterns among states that used similar language. Results indicated that laws varied in the level of protection they offered, with the least protective laws decriminalizing breastfeeding in public and the most protective laws criminalizing interference with breastfeeding. The least protective states were located in the Western and North-Central regions, Republican-leaning, and less urban, whereas the most protective states were located in the New England and North-Central regions, Democrat-leaning, and more urban. Most states that fell on either end of this continuum had breastfeeding rates above the national average. Laws also varied in the level of regulation implied in their language, with the most regulative laws specifying that "a mother" can breastfeed "her baby" only in certain places and under certain conditions (discreetly). The most regulative states were located in the Southern and North-Central regions and had low breastfeeding rates, whereas the least regulative states were Western and had high breastfeeding rates.

Kinetic studies that evaluate the solvolytic mechanisms of allyl and vinyl chloroformate esters.

At 25.0 °C the specific rates of solvolysis for allyl and vinyl chloroformates have been determined in a wide mix of pure and aqueous organic mixtures. In all the solvents studied, vinyl chloroformate was found to react significantly faster than allyl chloroformate. Multiple correlation analyses of these rates are completed using the extended (two-term) Grunwald-Winstein equation with incorporation of literature values for solvent nucleophilicity (NT) and solvent ionizing power (YCl). Both substrates were found to solvolyze by similar dual bimolecular carbonyl-addition and unimolecular ionization channels, each heavily dependent upon the solvents nucleophilicity and ionizing ability.

Extending the PAX1 spectrum: a dominantly inherited variant causes oculo-auriculo-vertebral syndrome.

Oculo-auriculo-vertebral syndrome (OAVS) is a clinically heterogeneous disorder, with both genetic and environmental contributors. Multiple genes have been associated with OAVS and common molecular pathways, such as retinoic acid and the PAX-SIX-EYA-DACH (PSED) network, are being implicated in the disease pathophysiology. Biallelic homozygous nonsense or hypomorphic missense mutations in PAX1 cause otofaciocervical syndrome type 2 (OTFCS2), a similar but more severe multi-system disorder that can be accompanied by severe combined immunodeficiency due to thymic aplasia. Here we have identified a multi-generational family with mild features of OAVS segregating a heterozygous frameshift in PAX1. The four base duplication is expected to result in nonsense-mediated decay, and therefore cause a null allele. While there was full penetrance of the variant, expressivity of facial and ear features were variable. Our findings indicate there can be monoallelic and biallelic disorders associated with PAX1, and further implicate the PSED network in OAVS.

Correlation of the rates of solvolysis of neopentyl chloroformate-a recommended protecting agent.

The specific rates of solvolysis of neopentyl chloroformate (1) have been determined in 21 pure and binary solvents at 45.0 °C. In most solvents the values are essentially identical to those for ethyl and n-propyl chloroformates. However, in aqueous-1,1,1,3,3,3-hexafluoro-2-propanol mixtures (HFIP) rich in fluoroalcohol, 1 solvolyses appreciably faster than the other two substrates. Linear free energy relationship (LFER) comparison of the specific rates of solvolysis of 1 with those for phenyl chloroformate and those for n-propyl chloroformate are helpful in the mechanistic considerations, as is also the treatment in terms of the Extended Grunwald-Winstein equation. It is proposed that the faster reaction for 1 in HFIP rich solvents is due to the influence of a 1,2-methyl shift, leading to a tertiary alkyl cation, outweighing the only weak nucleophilic solvation of the cation possible in these low nucleophilicity solvents.

Beyond control: body and self in women's childbearing narratives.

In the United States, childbearing is often conceptualised as a time when women lose self-control over their bodies. This project examines issues of bodily control through a social constructionist analysis of in-depth interviews with 18 predominantly white, working and middle class women who have recently given birth in the US. Findings indicate that many participants construct themselves as both in and out of control of their bodies during childbearing. Participants also describe body/self relationships in ways that transcend power and control, perceiving the body as autonomous, accommodating and collaborating. Accommodating and collaborating bodies were described here only among participants who gave birth in the midwifery model of care. The findings illuminate various ways of conceptualising the body and point to the use of different bodily discourses by women who give birth in medical and midwifery models.

The professional portfolio: an evidence-based assessment method.

Competency assessment is critical for a myriad of disciplines, including medicine, law, education, and nursing. Many nurse managers and educators are responsible for nursing competency assessment, and assessment results are often used for annual reviews, promotions, and satisfying accrediting agencies' requirements. Credentialing bodies continually seek methods to measure and document the continuing competence of licensees or certificants. Many methods and frameworks for continued competency assessment exist. The portfolio process is one method to validate personal and professional accomplishments in an interactive, multidimensional manner. This article illustrates how portfolios can be used to assess competence. One specialty nursing certification board's process of creating an evidence-based portfolio for recertification or reactivation of a credential is used as an example. The theoretical background, development process, implementation, and future implications may serve as a template for other organizations in developing their own portfolio models.

Shifts in phenological mean and synchrony interact to shape competitive outcomes.

Climate change-induced phenological shifts are ubiquitous and have the potential to disrupt natural communities by changing the timing of species interactions. Shifts in first and/or mean phenological date are well documented, but recent studies indicate that shifts in synchrony (individual variation around these metrics) can be just as common. However, we know little about how both types of phenological shifts interact to affect species interactions and communities. Here, we experimentally manipulated the hatching phenologies of two competing species of larval amphibians to address this conceptual gap. Specifically, we manipulated the relative mean hatching time (early, same, or late relative to competitor) and population synchrony (high, medium, or low levels of variation around the mean) in a full 3 × 3 factorial design to measure independent and interactive effects of phenological mean and population phenological synchrony on competitive outcomes. Our results indicate that phenological synchrony within a population strongly influences intraspecific competition by changing the density of individuals and relative strength of early- vs. late-arriving individuals. Individuals from high-synchrony populations competed symmetrically, whereas individuals from low-synchrony populations competed asymmetrically. At the community scale, shifts in population phenological synchrony interact with shifts in phenological mean to affect key demographic rates (survival, biomass export, per capita mass, and emergence timing) strongly. Furthermore, changes in mean timing of species interactions altered phenological synchrony within a population at the next life stage, and phenological synchrony at one life stage altered the mean timing of the next life stage. Thus, shifts in phenological synchrony within populations cannot only alter species interactions, but species interactions in turn can also drive shifts in phenology.

Extended Grunwald-Winstein analysis - LFER used to gauge solvent effects in p-nitrophenyl chloroformate solvolysis.

Specific rates of solvolysis at 25 degrees C for p-nitrophenyl chloroformate (1) are analyzed using the extended (two-term) Grunwald-Winstein equation. For 39 solvents, the sensitivities (l = 1.68+/-0.06 and m = 0.46+/-0.04) towards changes in solvent nucleophilicity (l) and solvent ionizing power (m) obtained, are similar to those previously observed for phenyl chloroformate (2) and p-methoxyphenyl chloroformate (3). The observations incorporating new kinetic data in several fluoroalcohol-containing mixtures, are rationalized in terms of the reaction being sensitive to substituent effects and the mechanism of reaction involving the addition (association) step of an addition-elimination (association-dissociation) pathway being rate-determining. The l/m ratios obtained for 1, 2, and 3, are also compared to the previously published l/m ratios for benzyl chloroformate (4) and p-nitrobenzyl chloroformate (5).

The International Quotidian Hemodialysis Registry: rationale and challenges.

Outcomes from conventional thrice-weekly hemodialysis (CHD) are disappointing for a life-saving therapy. The results of the HEMO Study show that the recommended minimum dose (Kt/V) for adequacy is also the optimum attainable with CHD. Interest is therefore turning to alternative therapies exploring the effects of increased frequency and time of hemodialysis (HD) treatment. The National Institutes of Health have sponsored 2 randomized prospective trials comparing short hours daily in-center HD and long hours slow nightly home HD with CHD. An International Registry has also been created to capture observational data on patients receiving short hours daily in-center HD, long hours slow nightly home HD, and other alternative therapies. Participation by individual centers, other registries and the major dialysis chains is growing and currently data from nearly 3000 patients have been collected. Pitfalls in data collection have been identified and are being corrected. A matched cohort (patients in other registries) study is planned to obtain information regarding hard outcomes expected from these therapies. The Registry may become the most important source of information required by governments, providers, and the nephrological community in assessing the utility of such therapies.

The International Quotidian Dialysis Registry: Annual report 2008.

Alternative hemodialysis (HD) schedules, including short-daily and nocturnal HD, continue to proliferate, with the hope of offering improved patient outcomes. Three nights per week and every other night, nocturnal HD are now being provided to more patients worldwide, both at home and in-center. However, alternative HD schedules are still experimental in most centers, and studies establishing the efficacy of these therapies with respect to major clinical outcomes are needed. Endorsed by the National Institutes of Health, the International Quotidian Dialysis Registry is an international collaboration that was established in 2002 to prospectively study large numbers of patients treated with alternate HD schedules. The Registry will ultimately allow alternate HD modalities to be compared to conventional thrice-weekly HD with respect to clinical endpoints, including mortality, using a prospective cohort study. To date, the Registry has enrolled 182, 1193, and 740 subjects from Canada, the United States, and Australia, respectively. This report is the fourth annual update and describes recruitment progress, baseline characteristics of enrolled patients, and worldwide prescription patterns.

The International Quotidian Dialysis Registry: annual report 2007.

In view of the need to study both intermediate and definitive outcomes associated with daily and extended-hours hemodialysis (HD), our group has undertaken the design and implementation of an international registry to collect data describing the treatments and outcomes of patients treated with these regimens. The International Quotidian Dialysis Registry began recruiting patients in June 2004. There are currently 229 patients enrolled in the registry, up from 199 last year. The projected growth is 2000 patients by 2008. This paper constitutes the third annual report of progress of patient and center recruitment, and includes descriptive data drawn from the 3 primary patient groups currently tracked by the registry: home nocturnal, home short-daily, and in-center short-daily HD. As the cohort grows, patients will be compared with control subjects drawn from their respective national registries, and comparative analyses will follow.