Direct and vicarious exposure to healthcare discrimination and erasure among transgender and gender independent individuals: Testing the indirect effect of mistrust in healthcare on utilization behaviors.

RATIONALE: Direct exposure to gender identity-related discrimination and erasure among the transgender and gender independent (TGI) population are associated with healthcare underutilization, which may further exacerbate the health disparities that exist between this population and cisgender individuals in the United States (U.S.). Although the impacts of direct exposure to healthcare discrimination and erasure may have on TGI individuals are known, exposure to such harm vicariously (i.e., through observation or report) is underexplored. OBJECTIVE: The present study examined the relationships among direct and vicarious gender identity-related healthcare discrimination and erasure exposure and past-year healthcare utilization. METHOD: Gender identity-based mistrust in healthcare was also assessed, as a mechanism through which direct and vicarious gender identity-related healthcare discrimination and erasure predict healthcare utilization behaviors among a sample (N = 385) of TGI adults in the U.S., aged 18 to 71 recruited online. RESULTS: Results indicated direct lifetime and vicarious healthcare discrimination and erasure exposure significantly predicted past-year healthcare underutilization when participants anticipated encountering gender identity-related healthcare discrimination. Mediational analyses indicated that higher levels of exposure to direct lifetime and vicarious healthcare discrimination and erasure were related to higher levels of mistrust in healthcare, through which past-year underutilization was significantly related. CONCLUSIONS: These findings are vital to informing healthcare practice and policy initiatives aimed at ensuring the barriers that deleteriously influence the accessibility of healthcare among TGI individuals are ameliorated.

Multiple Sclerosis and MyChart Messaging: A Retrospective Chart Review Evaluating Its Use.

BACKGROUND: Understanding patterns of MyChart (Epic Systems Corporation) messaging has the potential to alter clinical practice. However, because most research evaluating its use has been conducted in limited contexts, utilization patterns in patients with multiple sclerosis (MS) remain unclear. We characterized factors associated with high rates of MyChart messaging for patients with MS at an academic outpatient clinic. METHODS: We performed a retrospective cross-sectional analysis of 439 patients in our center's database. Inclusion criteria were 1 or more clinic visits and MS diagnosis. We extracted demographic data, disease-specific characteristics, and MyChart messaging information. RESULTS: Of the patients in the database, 324 (74%) were MyChart users. MyChart users were more often younger (mean ± SD age, 50.1 ± 12.6 vs 55.0 ± 13.7 years; P < .001), had shorter mean ± SD duration since diagnosis (11.9 ± 8.3 vs 15.8 ± 10.8 years; P = .0013), had lower mean ± SD Patient-Determined Disease Steps scale scores (2.8 ± 2.3 vs 3.5 ± 2.5; P = .0107), and were more likely to be using high-efficacy disease-modifying therapies (χ2 1,323 = 6.7; P = .009). Messaging rates correlated positively with total number of unique medications (R = 0.17; P = .003) and negatively with age (R = -0.11; P = .018). CONCLUSIONS: Although previous research has implicated arm-hand disability and impaired vision as barriers to patient portal use, these findings suggest the relationship between MS-specific disease burden and MyChart utilization is also a function of underlying medical complexity beyond physical disability. These data may serve as groundwork for investigations in other disease-specific settings and for quality improvement research to mitigate these high rates in at-risk patients to optimize provider time investment, clinic productivity, and patient safety and minimize health care provider burnout.

Unusual wrist tremor: unilateral isometric tremor?

BACKGROUND: Tremors may be difficult to classify. CASE REPORT: An 83-year-old male presented with an unusual left wrist tremor. The tremor could be reproducibly elicited by making a fist or carrying a weighted object (e.g., a shopping bag, bottle of water) of approximately 1 lb or more, and it intensified with heavier weights. The tremor was difficult to classify, although it shared features with isometric tremor. DISCUSSION: This specific presentation of tremor has not been reported previously. We hope that the detailed description we provide will aid other neurologists who encounter this or similar tremors in their clinics.

Update on treatment of essential tremor.

OPINION STATEMENT: Essential tremor is one of the most common movement disorders in the world. Although millions of people worldwide are affected by ET, only one medication, propranolol, is approved by the United States Food and Drug Administration to treat it. None of the medications currently used as ET therapy were developed specifically for this purpose, and select antihypertensive and antiepileptic medications remain at the forefront of ET therapy. Propranolol and primidone are considered "effective" agents that treat ET; topiramate, atenolol, and alprazolam are "probably effective", and nimodipine, nadolol, and clonazepam are "possibly effective". Medications that probably do not adequately treat ET include levetiracetam and pregabalin. Gabapentin appears to improve ET when used as monotherapy, but not when used as adjunct therapy. Sotalol has been found to be "probably effective" in treating ET in previous reviews, but it may be associated with arrhythmias and should not be routinely recommended. Botulinum toxin A may reduce limb tremor, but may cause dose dependent weakness. Deep brain stimulation (DBS) of the VIM is used as an alternative to pharmacological therapy of ET in patients who fail to adequately respond to medical therapy. The magnitude of effect from DBS is greater than from medical management, but more severe side effects are possible with surgery. Future treatment options for ET will depend on valid animal models, and a better understanding of its pathophysiology.

A school-based expressive writing intervention for at-risk urban adolescents' aggressive behavior and emotional lability.

This school-based randomized controlled trial tested the efficacy of 2 expressive writing interventions among youth living in high-violence urban neighborhoods. Seventeen classrooms (n = 258 seventh graders; 55% female; 91% African American/Black) from 3 public schools were randomized to 3 conditions in which they wrote 8 times about a nonemotional topic (control condition) or about experiencing and witnessing violence following either a standard or an enhanced expressive writing protocol. Outcomes were assessed 1 month prior and 2 and 6 months postintervention and included teacher-rated emotional lability and aggressive behavior and child-rated physical aggression. Intent-to-treat, mixed-model analyses controlled for preintervention measures of outcomes, sex, race, and family structure. At 2 months postintervention, relative to controls, students in the standard expressive writing condition had lower levels of teacher-rated aggression and lability (d = -.48). The beneficial effects of the writing interventions on aggression and lability were stronger at higher levels of community violence exposure.

Connecting youth violence prevention, positive youth development, and community mobilization.

Several disconnects serve to weaken the use of evidence based programming in community settings. Communities face the need to address the challenges of multiple risk behaviors faced by adolescents in their communities, but must also work to support successful transitions to adulthood and the broader positive development of their youth. The stronger integration of positive youth development and prevention of youth risk at the community level may offer an opportunity to support the implementation and ongoing development of evidence-based practices (EBPs). This article provides an overview of the VCU Clark-Hill Institute for Positive Youth Development Institute's community mobilization effort in Richmond, Virginia and reports preliminary findings from our integrated mobilization efforts. First, we review the role of our Community Advisory Council in their collaborative work to support positive youth development and reduce risk for youth violence. Next, we present examples of institute efforts in providing technical assistance relevant to supporting the use and development of EBPs. We then discuss the adaptation of an evidence-based program to target positive youth development. We also present overviews from qualitative investigations examining barriers and supports that inform and are relevant to the implementation of EBPs. Finally, we consider ways in which community efforts inform and shape institute efforts to develop EPBs. Taken together, these activities provide examples of how community-based mobilization efforts can integrate and inform the implementation of EBPs and the role and use of prevention science as a tool in supporting effective programming to promote positive youth development and prevent youth violence.

Environmental influences on fighting versus nonviolent behavior in peer situations: a qualitative study with urban African American adolescents.

This qualitative study explored environmental factors that influence adolescents' responses to problem situations involving peers. Interviews were conducted with 106 middle school students (97% African American) from an urban school system. Participants were asked to describe factors that would make it easier and those that would make it more difficult for adolescents to make specific responses to problem situations. Two types of responses were presented: nonviolent responses identified as effective in a previous study, and fighting responses. Qualitative analysis identified 24 themes representing family, peer, school, and neighborhood and broader social factors that were related to both nonviolent behavior and fighting. The identification of environmental influences on fighting and nonviolent responses has important implications for efforts to reduce aggression and promote effective nonviolent responses to problem situations encountered by adolescents.

Individual factors influencing effective nonviolent behavior and fighting in peer situations: a qualitative study with urban African American adolescents.

This qualitative study examined individual-level factors that influence adolescents' responses to problem situations involving peers. Interviews were conducted with 106 middle school students (97% African American) from an urban school system. Participants described factors that would make it easier and those that would make it more difficult for adolescents to make specific responses to problem situations. Responses included effective nonviolent responses and fighting. Qualitative analysis identified 17 individual-level themes representing personal resources, beliefs and values, perceived consequences, and appraisal of the situation. The identification of factors that influence fighting and nonviolent behavior has important implications for efforts to reduce aggression and promote effective nonviolent responses to problem situations.

Choosing to be violence free in middle school: the student component of the GREAT Schools and Families Universal Program.

This paper describes the theoretical basis and content of the universal student component of the Guiding Responsibility and Expectations for Adolescents for Today and Tomorrow (GREAT) Schools and Families' middle school violence prevention program for changing school climate. The GREAT Student Program builds on and extends the content of the sixth grade Responding In Peaceful and Positive Ways (RIPP-6) social-cognitive violence prevention program through an expanded conceptual framework that focuses on changing school norms and explicitly incorporates cultural and contextual goals. The program consists of twenty 40-minute lessons taught by a trained facilitator on a weekly basis during the school day.

The influence of dual-identity development on the psychosocial functioning of African-American gay and bisexual men.

To examine the influence of racial-ethnic and sexual identity development on the psychosocial functioning of African-American gay and bisexual men (AAGBM), 174 AAGBM completed questionnaire packets designed to assess their levels of racial-ethnic and sexual identity development, self-esteem, social support, male gender role stress, HIV prevention self-efficacy, psychological distress, and life satisfaction. The results indicate that AAGBM who possess more positive (i.e., integrated) self-identification as being African American and gay reported higher levels of self-esteem, HIV prevention self-efficacy, stronger social support networks, greater levels of life satisfaction, and lower levels of male gender role and psychological distress than their counterparts who reported less positive (i.e., less well integrated) African American and gay identity development. Although higher levels of racial-ethnic identity development were associated with greater levels of life satisfaction, sexual identity development was not.