RESUMEN
For diagnosis of osteoporosis, a T-score of ≤-2.5 is recommended for all transgender and gender-diverse patients aged 50 years or older, regardless of hormonal status. This case series presents 3 transgender individuals younger than 50 years undergoing gender-affirming hormone therapy (GAHT) who had DXA scores suggestive of osteoporosis. We highlight possible discrepancies in DXA scan interpretations, especially in forearm bone mineral density measurements. We present the baseline (prior to beginning GAHT), 6-month, and 1-year follow-up DXA data along with pertinent labs to include 25-OH vitamin D, calcium, and alkaline phosphatase, for 2 transgender males (assigned female at birth) and 1 transgender female (assigned male at birth) undergoing GAHT who had low Z-scores and T-scores suggestive of osteoporosis. Multiple studies have analyzed the BMD data of individuals taking GAHT over time, which identify possible causes for low baseline Z-scores for transgender females, but less so for transgender males. Other than positional statements, guidelines remain unclear regarding diagnostic approaches to osteoporosis and low Z-scores in transgender individuals who are premenopausal or under 50 years of age. This case series addresses discrepancies in interpretation that may be encountered by clinicians with baseline and follow-up DXAs, especially involving the forearm, during the course of GAHT. This highlights the importance of establishing clearer guidelines for the diagnosis and treatment of osteoporosis and low BMD for chronological age in the transgender population.
RESUMEN
OBJECTIVE: Early, high-quality, minimally interrupted bystander cardio-pulmonary resuscitation (BCPR) is essential for out-of-hospital cardiac arrest survival. However, rates of bystander intervention remain low in many geographic areas. Community CPR programs have been initiated to combat these low numbers by teaching compression-only CPR to laypersons. This study examined bystander CPR and the cost-effectiveness of a countywide CPR program to improve out-of-hospital cardiac arrest survival. METHODS: A 2-year retrospective review of emergency medical services (EMS) run reports for adult nontraumatic cardiac arrests was performed using existing prehospital EMS quality assurance data. The incidence and success of bystander CPR to produce prehospital return of spontaneous circulation and favorable neurologic outcomes at hospital discharge were analyzed. The outcomes were paired with cost data for the jurisdiction's community CPR program to develop a cost-effectiveness model. RESULTS: During the 23-month study period, a total of 371 nontraumatic adult out-of-hospital cardiac arrests occurred, with a 33.4% incidence of bystander CPR. Incremental cost-effectiveness analysis for the community CPR program demonstrated a total cost of $22,539 per quality-adjusted life-year (QALY). A significantly increased proportion of those who received BCPR also had an automated external defibrillator (AED) applied. There was no correlation between witnessed arrest and performance of BCPR. A significantly increased proportion of those who received BCPR were found to be in a shockable rhythm when the initial ECG was performed. In the home setting, the chances of receiving BCPR were significantly smaller, whereas in the public setting a nearly equal number of people received and did not receive BCPR. Witnessed arrest, AED application, public location, and shockable rhythm on initial ECG were all significantly associated with positive ROSC and neurologic outcomes. A home arrest was significantly associated with worse neurologic outcome. CONCLUSIONS: Cost-effectiveness analysis demonstrates that a community CPR outreach program is a cost-effective means for saving lives when compared to other healthcare-related interventions. Bystander CPR showed a clear trend toward improving the neurologic outcome of survivors. The findings of this study indicate a need for additional research into the economic effects of bystander CPR.
