Military Family Perspectives on Enrollment and Engagement in the WIC Program.

INTRODUCTION: One in four U.S. service members endorses food insecurity. The Supplemental Nutrition Program for Women, Infants, and Children (WIC) is an invaluable, underutilized resource that can increase access to nutritious food for families with children under 5 years of age. Our research sought to evaluate military family perceptions and engagement with the WIC program. MATERIALS AND METHODS: We conducted a mixed-method study, recruiting from a convenience sample of military families who applied for financial assistance for child care. An 18-question survey and follow-up focus groups assessed participant demographics and experiences with WIC. We utilized descriptive statistics ordinal logistic regression analyses for quantitative data analysis. For qualitative data, descriptive content analysis with constant comparison and inductive and deductive coding of interviews identified emerging themes. This study was approved by the Uniformed Services University of the Health Sciences Institutional Review Board. RESULTS: Among the 399 survey respondents, 25% were currently enrolled in WIC and 39% had been previously enrolled. Service members and their partners learned about WIC from a variety of sources, and there was no significant association between the branch of service or rank and WIC enrollment. There were 40 total participants in 10 completed focus groups. Six themes emerged: (1) Military-specific factors create unique circumstances related to WIC engagement; (2) the WIC program facilitates access to formula supplementation and nutritious foods for military families; (3) lack of program awareness and misinformation are top barriers to WIC engagement in military families; (4) stigma impacts WIC program enrollment and engagement; (5) logistics of enrollment can impact WIC engagement among military families; and (6) the military can support WIC enrollment and engagement through standardization, education, and leadership commitment. CONCLUSIONS: Our findings suggest that unique circumstances related to military family life create a profound need for programs addressing food support, such as WIC. Interventions to improve WIC enrollment among military families need to be rooted in broad outreach efforts, not targeted at specific ranks, branches, or ages. Specific recommendations include increasing information dissemination, universally screening military families for WIC, decreasing logistical burdens, and involving military leadership.

A Decade of Firearm Injuries: Have We Improved?

BACKGROUND: Firearm injuries are a growing public health issue, with marked increases coinciding with the coronavirus disease 2019 (COVID-19) pandemic. This study evaluates temporal trends over the past decade, hypothesizing that despite a growing number of injuries, mortality would be unaffected. In addition, the study characterizes the types of centers affected disproportionately by the reported firearm injury surge in 2020. METHODS: Patients aged 18 years and older with firearm injuries from 2011-2020 were identified retrospectively using the National Trauma Data Bank (NTDB®). Trauma centers not operating for the entirety of the study period were excluded to allow for temporal comparisons. Joinpoint regression and risk-standardized mortality ratios (SMR) were used to evaluate injury counts and adjusted mortality over time. Subgroup analysis was performed to describe centers with the largest increases in firearm injuries in 2020. RESULTS: A total of 238,674 patients, treated at 420 unique trauma centers, met inclusion criteria. Firearm injuries increased by 31.1% in 2020, compared to an annual percent change of 2.4% from 2011-2019 (p = 0.01). Subset analysis of centers with the largest changes in firearm injuries in 2020 found that they were more often level I centers, with higher historic trauma volumes and percentages of firearm injuries (p < 0.001). Unadjusted mortality decreased by 0.9% from 2011-2020, but after controlling for demographics, injury characteristics and physiology, there was no difference in adjusted mortality over the same time period. However, among patients with injury severity scores ≥25, adjusted mortality improved compared to 2011 (SMR of 0.950 in 2020, 95% CI 0.916 - 0.986). CONCLUSIONS: Firearm injuries pose an increasing burden to trauma systems, with level I and high-volume centers seeing the largest growth in 2020. Despite increasing numbers of firearm injuries, mortality has remained unchanged over the past decade. LEVEL OF EVIDENCE: Level III, Prognostic/Epidemiologic.

Impact of the COVID-19 pandemic on care for anorexia and bulimia nervosa in US military-connected adolescents and young adults.

OBJECTIVE: This study examined the impact of the COVID-19 pandemic on healthcare engagement for anorexia nervosa (AN) and bulimia nervosa (BN) in a large, geographically diverse population. METHOD: This repeated monthly, cross-sectional study queried Military Health System records of individuals aged 10-21 before and during the pandemic (February 2019-January 2022). ICD-10 codes identified encounters for AN and BN. Monthly rates of care were modeled as the number of unique individuals with an ICD-10-identified eating disorder-related encounter per month divided by the enrolled population. Poisson regression analysis evaluated rates of care stratified by eating disorder, clinical setting, and sex. RESULTS: In a population of 1.76 million adolescents and young adults, 1629 individuals with AN or BN received care during the pre-pandemic period; 3256 received care during the pandemic. The monthly rate of care for females with AN during the pandemic increased in inpatient settings (adjusted relative risk [aRR]: 1.31 [1.16-1.49]) and outpatient settings (aRR: 1.42 [1.37-1.47]); monthly care rates in males with AN increased in the outpatient setting (aRR: 1.46 [1.28-1.67]). Females with BN had increased engagement in outpatient settings (aRR: 1.09 [1.03-1.16]); BN care for males showed no significant monthly changes during the pandemic period in either healthcare setting. DISCUSSION: With increased rates of AN and BN disorder-related care during the pandemic, screening for eating disorder symptomatology may allow for timely diagnosis and intervention in periods of heightened stress. Pandemic-related increases in healthcare engagement may strain limited resources, emphasizing a need to expand accessibility of clinical expertise. PUBLIC SIGNIFICANCE: This study indicates that monthly rates of healthcare engagement during the COVID-19 pandemic for AN and BN varied based on clinical setting and sex in an adolescent and young adult population. The increased number of individuals seeking eating disorder-related care, especially outpatient care, attributed to heightened stressors necessitates accessible professionals with eating disorder clinical expertise.

Evaluation of coagulopathy in cirrhotic patients: A scoping review of the utility of viscoelastic testing.

BACKGROUND: Cirrhosis causes significant coagulopathy. Traditional coagulation tests may not accurately measure coagulopathy in well-compensated patients with cirrhosis. Viscoelastic tests are functional tests that may better assess coagulopathy in cirrhotic patients. METHODS: We searched PubMed, ScienceDirect, Google Scholar, and grey literature using terms meaning viscoelastic testing and cirrhosis. After reviewing over 500 titles and abstracts, 40 full-text papers met inclusion criteria. RESULTS: Twenty-two papers found viscoelastic testing was a better indicator of baseline coagulation than traditional testing in cirrhosis. Nineteen additional papers evaluated the utility of peri-procedural viscoelastic testing and found they led to a reduction in blood product administration without increasing risk of hemorrhage, thrombotic events, or other complications. CONCLUSIONS: The usage of viscoelastic testing in patients with cirrhosis allows for better assessment of coagulopathy, resulting in improved outcomes. Educating physicians to optimize care of this high-risk group is necessary to further improve their treatment.

Opioid-Related Trends in Active Duty Service Members During the Coronavirus Disease 2019 Pandemic.

INTRODUCTION: The USA is experiencing an opioid epidemic. Active duty service members (ADSMs) are at risk for opioid use disorder (OUD). The Coronavirus disease 2019 (COVID-19) pandemic has disrupted health care and introduced additional stressors. METHODS: The Military Healthcare System Data Repository was used to evaluate changes in diagnosis of OUD, medications for OUD (MOUD), opioid overdose (OD), and opioid rescue medication. ADSMs ages 18-45 years enrolled in the Military Healthcare System between February 2019 and April 2022 were included. Joinpoint Trend Analysis Software calculated the average monthly percent change over the study period, whereas Poisson regression compared outcomes over three COVID-19 periods: Pre-lockdown (pre-COVID-19 period 0) (February 2019-February 2020), early pandemic until ADSM vaccination initiation (COVID-19 period 1 [CP1]) (March 2020-November 2020), and late pandemic post-vaccination initiation (COVID-19 period 2 [CP2]) (December 2020-April 2022). RESULTS: A total of 1.86 million eligible ADSMs received care over the study period. Diagnoses of OUD decreased 1.4% monthly, MOUD decreased 0.6% monthly, diagnoses of opioid OD did not change, and opioid rescue medication increased 8.5% monthly.Diagnoses of OUD decreased in both COVID-19 time periods: CP1 and CP2: Rate ratio (RR) = 0.74 (95% CI, 0.68-0.79) and RR = 0.72 (95% CI, 0.67-0.76), respectively. MOUD decreased in both CP1 and CP2: RR = 0.77 (95% CI, 0.68-0.88) and RR = 0.86 (95% CI, 0.78-0.96), respectively. Adjusted rates for diagnoses of opioid OD did not vary in either COVID-19 time period. Opioid rescue medication prescriptions increased in CP1 and CP2: RR = 1.09 (95% CI, 1.02-1.15) and RR = 6.02 (95% CI, 5.77-6.28), respectively. CONCLUSIONS: Rates of OUD and MOUD decreased, whereas rates of opioid rescue medication increased during the study period. Opioid OD rates did not significantly change in this study. Changes in the DoD policy may be affecting rates with greater effect than COVID-19 pandemic effects.

Evaluating WIC Engagement and Food Insecurity Among Active Duty Military Families.

INTRODUCTION: Nearly a quarter of active duty service members identified as food insecure in a 2022 Department of Defense report. Food insecurity impacts military readiness, retention, and recruitment. The Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federal food supplementation program that can mitigate food insecurity for service members with children less than 5 years of age. To date, there is a lack of standardized screening for WIC eligibility or enrollment for service members and their families. This project sought to evaluate WIC awareness and enrollment as well as the prevalence of food insecurity at Walter Reed National Military Medical Center. MATERIALS AND METHODS: A 26-question survey was developed to assess WIC awareness, source of WIC information, food insecurity, and nutritional insecurity. Our team developed and utilized a novel WIC screening algorithm to rapidly screen families for WIC eligibility. These tools were administered to families presenting for care at the Walter Reed National Military Medical Center pediatrics and obstetric outpatient clinics during the month of July 2022. This study was approved by the institutional review board at Walter Reed. RESULTS: A total of 108 (25%) of the 432 surveyed participants were eligible for WIC, with odds of WIC eligibility increasing for lower-ranking and younger service members. Of the 432 participants, 354 (81.9%) were aware of WIC. Enlisted service members were more likely than officers to know about WIC (P = 0.03), and of the 354 participants aware of WIC, a higher proportion of enlisted rank respondents learned about WIC from a military source (P = 0.01). Among the 108 participants eligible for WIC, only 38 (35.2%) reported being enrolled in WIC. Among WIC-eligible respondents who knew about WIC, being enrolled in the WIC program was not associated with rank, branch of service, sponsor gender, or sponsor age. CONCLUSIONS: Despite proven efficacy, WIC remains an underutilized resource for eligible military families. Our results show that a standardized screening approach at Walter Reed National Military Medical Center increased identification of WIC-eligible active duty service members by 180%, with approximately $150,000 a year in increased food supplementation benefits. Military healthcare and readiness leaders should embrace efforts to increase knowledge of, referral to, and enrollment in WIC to increase family health, well-being, and military family readiness.

Assessing mean corpuscular volume as a screening tool for gestational vitamin B12 deficiency based on NHANES.

Vitamin B12 can lead to neurological deficits. We assessed whether the mean corpuscular volume (MCV) could be a sufficiently sensitive measurement for abnormal serum methylmalonic Acid (MMA) and total plasma homocysteine (tHCY) (biomarkers of vitamin B12 or folate deficiency) and if so, at what cutoff value. A total of 26,397 participants (12,730 males and 13,667 females) were included in the analysis. Weighted analysis was performed using NHANES data to calculate crude/adjusted associations between MCV-MMA/tHCY, using linear regression. Unadjusted odds ratios (OR) 95% CIs were estimated from logistic regression models. Receiver Operating Curve and the Youden Index were used to identify the MCV level that most accurately distinguished those with abnormal MMA and tHCY (dependent variables) from those without. A positive and significant correlation between MCV-MMA/tHCY was found in the general population between ages 18-85, 0.95 (95% C.I. 0.75-1.17) and 2.61 (95% C.I. 2.15-3.08). In pregnant women, for every unit increase in MCV there was a 19% increase in odds of abnormal MMA, OR 1.19 (95% C.I. 1.08-1.31), p=0.001 and the Area Under the Curve for MCV as a test for abnormal MMA was 78%. An MCV cutoff of 93.1 correctly identified abnormal MMA in pregnant women with 81% sensitivity and 77% specificity. In the general population the MCV test performed poorly in identifying abnormal MMA/tHCY. MCV is an inexpensive measurement that may be useful to screen asymptomatic pregnant women for vitamin B12 abnormalities. This may have a significant impact on reducing adverse neurological outcomes in their children.

Predicting the RSV Surge: Pediatric RSV Patterns of the COVID Pandemic.

Historically, respiratory syncytial virus (RSV) infection trends have been predictable. The COVID-19 pandemic and associated precautions impacted RSV disease patterns. RSV infection trends during the first year of the COVID-19 pandemic may have predicted the 2022 surge in pediatric RSV infections. A continued emphasis on increased viral testing will allow for early recognition and preparation for future public health crises.

Examining the relationship between autism spectrum disorder and neural tube defects.

Folate and vitamin B12 deficiencies have been strongly associated with neural tube defects, preliminary research suggests folate and B12 deficiency may also be associated with autism spectrum disorder (ASD). We examined the association between neural tube defects and ASD as a further avenue to examine the hypothesis that ASD is related to maternal folate and B12 deficiency during pregnancy. A retrospective case-control study was performed using the Military Health System Data Repository. Cases and matched controls were followed from birth until at least 6 months after their first autism diagnosis. International Classification of Diseases, 9th Revision, codes were used to identify neural tube defects in the health records. A total of 8760 cases between the ages of 2 and 18 years were identified. The prevalence of any neural tube defect was 0.11% in children without ASD and 0.64% in children with ASD. Children with autism were over 6 times as likely to have a neural tube defect. The increased odds of neural tube defect in children diagnosed with ASD, found through our methodology, supports prior studies. Although additional studies are needed to elucidate the relationship between ASD and maternal folate and vitamin B12 deficiency during pregnancy this study supports their use during pregnancy.

Clinical Application of Thromboelastography in Patients With Cirrhosis: A Single Center Experience.

INTRODUCTION: Thromboelastography (TEG) is a functional test of coagulation used to guide transfusions. Despite literature supporting its utility, its use remains limited to select populations. In patients with cirrhosis, conventional coagulation tests are notoriously inaccurate, and TEG may be a better measure of coagulopathy. We aimed to assess the utilization of TEG in patients with cirrhosis to steward blood transfusions in this high-risk group. METHODS: A single-center retrospective chart review of all patients ≥18 y old with a diagnosis of liver cirrhosis who had TEG results documented in the electronic medical record from January 1 to November 1, 2021. RESULTS: There were 277 TEG results on 89 patients with cirrhosis. Overall, 91% of the TEGs performed were associated with a clinical indication for transfusion. However, of the patients who were transfused, abnormal TEG values, including elevated R time and reduced maximum amplitude, did not correspond to transfusion of indicated blood products (fresh frozen plasma and platelets). A reduction in alpha angle showed a statistically significant association with transfusion of cryoprecipitate (P < 0.05). When assessing conventional coagulation tests, abnormal values were not significantly associated with transfusion (P = 0.07). CONCLUSIONS: Despite TEG suggesting that transfusions could be avoided in many cirrhotic patients, patients are still being transfused platelets and fresh frozen plasma in the absence of evidence of coagulopathy on TEG. Our finding suggests the need for education about appropriate utilization of TEG. More research is needed to understand the role of these tests to guide transfusion practices in patients with cirrhosis.

The Impact of Having a Child With Special Healthcare Needs on Length of Military Service.

INTRODUCTION: In 2010, the National Survey of Children with Special Healthcare Needs revealed that parents of children with special healthcare needs (CSHCN) report employment decisions are influenced by healthcare coverage needs. The U.S. military healthcare system arguably offers service member parents of CSHCN with the most comprehensive, inexpensive, long-term healthcare in the country-potentially increasing their incentive to remain in the military. This study explored the effect of having a CSHCN on the length of parental military service. MATERIALS AND METHODS: A retrospective cohort was formed using the Military Health System database from 2008 to 2018. Included children were <10 years in 2010 and received ≥1 year of military healthcare between 2008 and 2010. The Pediatric Medical Complexity Algorithm categorized children as having special healthcare needs via ICD 9/10 codes as having complex chronic (C-CD), non-complex chronic (NC-CD), or no chronic disease (CD). Families were classified by the child with the most complex healthcare need. Duration of military healthcare eligibility measured parental length of service (LOS). ANOVA and linear regression analysis compared LOS by category. Logistic regression determined odds of parental LOS lasting the full 8-year study length. Adjusted analyses controlled for child age and sex, and military parent sex, rank, and marital status. RESULTS: Over 1.45 million children in 915,584 families were categorized as per the algorithm. Of individual children included, 292,050 (20.1%) were CSHCN including those with complex chronic and non-complex chronic conditions. After grouping by family, 80,909 (8.8%) families had a child/children with C-CD (mean LOS 6.39 years), 170,787 (18.7%) families had a child/children with NC-CD (mean LOS 6.41 years), and 663,888 (72.5%) families had children with no CD (mean LOS 5.7 years). In adjusted analysis, parents of children with C-CD and NC-CD served 0.4 [0.37-0.42] and 0.33 [0.31-0.34] years longer than parents of children with no CD; odds of parents serving for the full study period were increased 33% (1.33 [1.31-1.36]) in families of children with C-CD and 27% (1.27 [1.26-1.29]) in families of children with NC-CD. CONCLUSIONS: Findings indicate that military parents of CSHCN serve longer military careers than parents of children with no chronic conditions. Continued provision of free, high-quality healthcare coverage for dependent children may be important for service member retention. Retaining trained and experienced service members is key to ensuring a ready and lethal U.S. military.

Acid Suppression and Antibiotics Administered during Infancy Are Associated with Celiac Disease.

OBJECTIVE: To investigate why certain at-risk individuals develop celiac disease (CD), we examined the association of proton pump inhibitors (PPI), histamine-2 receptor antagonists (H2RAs), and antibiotic prescriptions in the first 6 months of life with an early childhood diagnosis of CD. STUDY DESIGN: A retrospective cohort study was performed using the Military Healthcare System database. Children with a birth record from October 1, 2001, to September 30, 2013, were identified. Outpatient prescription records were queried for antibiotic, PPI, and H2RA prescriptions in the first 6 months of life. Cox proportional hazards regression was used to calculate the hazard ratio (HR) of developing CD based on medication exposure. International Classification of Diseases, Ninth Revision, Clinical Modification codes identified children with an outpatient visit for CD. RESULTS: There were 968 524 children who met the inclusion criteria with 1704 cases of CD in this group. The median follow-up for the cohort was approximately 4.5 years. PPIs (HR, 2.23; 95% CI, 1.76-2.83), H2RAs (HR, 1.94; 95% CI, 1.67-2.26), and antibiotics (HR, 1.14; 95% CI, 1.02-1.28) were all associated with an increased hazard of CD. CONCLUSIONS: There is an increased risk of developing CD if antibiotics, PPIs and H2RAs are prescribed in the first 6 months of life. Our study highlights modifiable factors, such as medication stewardship, that may change the childhood risk of CD.

Retrospective Examination of Service Dog Training Program Participation and Mental Healthcare Utilization.

OBJECTIVE: To investigate the association between Service Dog Training Program (SDTP) participation and mental health care utilization. DESIGN: Retrospective cohort study. SETTING: Outpatient rehabilitation clinic at a large military treatment facility. PARTICIPANTS: Military Health System beneficiaries who attended at least 1 SDTP session at a large military treatment facility (N=597). SDTP program enrollment records identified participants. INTERVENTION: The SDTP, a unique application of animal-assisted therapy, is intended to improve the mental and cognitive health for individuals with war-related trauma. MAIN OUTCOME MEASURES: Negative binomial regression calculated the associations between the SDTP participation rate and 2 mental health care utilization outcomes: mental health encounter days and psychotropic medication months' supply. RESULTS: Most of the 597 participants were male, enlisted service members, and aged 25-34 years. Approximately 46% had a posttraumatic stress disorder diagnosis, 21% had a traumatic brain injury diagnosis, 47% had an opioid prescription, and 58% had a sleep aid prescription pre-SDTP participation. Participation was categorized into low (≤1 sessions), medium (>1 and ≤2 sessions), and high (>2 sessions) monthly participation. In adjusted analysis, high monthly SDTP participation was associated with 18% fewer post-SDTP mental health encounter days (rate ratio [RR], 0.82; 95% confidence interval [CI], 0.68-0.96) than low monthly SDTP participation. High monthly SDTP participation was also associated with a 22% fewer post-SDTP psychotropic prescription months' supply (RR, 0.78; 95% CI, 0.64-0.95) than low monthly SDTP participation in adjusted analysis. CONCLUSIONS: Results suggest that participants who attend more than 2 SDTP sessions monthly encounter mental health care differently post SDTP than participants who attended 1 or fewer monthly sessions. Adjunct therapies, such as the SDTP, may offer patients a nonstigmatizing way to engage in mental health care.

Trends in Well-Child Visits and Routine Vaccination among Children of U.S. Military Members: An Evaluation of the COVID-19 Pandemic Effects.

The COVID-19 pandemic has drastically impacted administration of healthcare including well-child visits and routine vaccinations. The purpose of this study was to determine the impact of COVID-19 pandemic disruption on childhood health maintenance: well-child visits and scheduled vaccinations. We queried the TRICARE Management Activity's Military Health System (MHS) database for outpatient well-child visits and vaccinations for all children 0 to 23 months of age eligible for TRICARE healthcare. The median rate of well-child visits, during the COVID-19 period (March 2020-July 2021), was significantly declined for all demographic groups: all ages, parental military ranks, sex, and regions as compared to the pre-COVID-19 period (February 2019-February 2020). Similar to rates of well-child visits, the rate of vaccinations declined during the COVID-19 period as compared to the pre-COVID-19 period for all demographic groups, except children 12-23 months. Rates of well-child visits for military dependent children under 2 years of age were decreased during the 16 month COVID-19 period, with large increases seen in the first 2 months of the pandemic; the consequences of missed well-child visits and vaccination are unknown.

Association of Gonadotropin-Releasing Hormone Analogue Use With Subsequent Use of Gender-Affirming Hormones Among Transgender Adolescents.

Importance: Gonadotropin-releasing hormone analogue (GnRHa) use during puberty improves mental health among transgender and gender-diverse (TGD) adolescents. In previous studies, most (96.5%-98.1%) TGD adolescents who started GnRHa subsequently started gender-affirming hormones (GAH), raising concerns that GnRHa use promotes later use of GAH. Objective: To determine whether GnRHa use among TGD adolescents is associated with increased subsequent GAH use. Design, Setting, and Participants: This is a retrospective cohort study of administrative records collected between 2009 and 2018. The current analysis was completed in August 2022. Participants were enrolled in the US Military Healthcare System (MHS) with an initial TGD-related encounter occurring between ages 10 and 17 years. Exposures: GnRHa use. Main Outcomes and Measures: Initiation of GAH. Results: The 434 patients were a mean (SD) of 15.4 (1.6) years old at the time of their first TGD-related encounter; 312 (71.9%) were assigned female at birth, and 300 (69.1%) had an enlisted insurance sponsor. GnRHa use was more common among patients who were assigned male at birth (28 patients [23.0%]) than those assigned female (42 patients [13.5%]), but GAH use was not. Socioeconomic status was not associated with GnRHa or GAH use. Compared with older patients (aged 14-17 years), those who were younger (aged 10-13 years) at the time of the initial TGD-related encounter had a higher rate of GnRHa use (32 patients [57.1%] vs 38 patients [10.1%]) and a longer median time to starting GAH. The median interval from the date of the initial encounter to starting GAH decreased over time, from 2.3 years (95% CI, 1.7-2.8 years) between October 2009 and December 2014 to 0.6 years (95% CI, 0.5-0.6 years) between September 2016 and April 2018. Patients who were prescribed GnRHa had a longer median time to starting GAH (1.8 years; 95% CI, 1.1-2.4 years) than patients who were not (1.0 years; 95% CI, 0.8-1.2 years) and were less likely to start GAH during the 6 years after their first TGD-related encounter (hazard ratio, 0.52; 95% CI, 0.37-0.71). Among 54 younger (aged 10-13 years) patients who were not eligible to start GAH at their first encounter, GnRHa use was associated with a longer median time to starting GAH, but age at the first TGD-related visit was not. Conclusions and Relevance: In this cohort study of TGD adolescents, GnRHa use was not associated with increased subsequent GAH use. These findings suggest that clinicians can offer the benefits of GnRHa treatment without concern for increasing rates of future GAH use.

Beyond Recidivism: Hospital-Based Violence Intervention and Early Health and Social Outcomes.

BACKGROUND: Hospital-based violence intervention programs (HVIPs) are aimed at decreasing recurrent injury and improving the social determinants of health. We hypothesized that the HVIP intervention should be evaluated by how well it can address the immediate health and social needs of patients after injury. Our study sought to describe the experience of our nascent HVIP. STUDY DESIGN: Case management records of patients treated by the HVIP of a level 1 trauma center from July 1, 2017 to October 1, 2020 were reviewed. Inclusion criteria were as follows: age between 18 and 60 with injury mechanisms that resulted from intentional violence. Patient-stated goals and social worker designation of patient services provided were analyzed. A subset of HVIP patients who completed the three planned study visit surveys at discharge and 1 and 3 months were compared with a cohort of violently injured patients to whom HVIP services were not available. Participants in both groups were asked to complete a battery of validated surveys to assess social outcomes and post-traumatic stress disorder (PTSD). Repeated-measures ANOVA was used to compare the two groups. RESULTS: Two hundred and ninety-five patients met the inclusion criteria. One hundred and forty-six patients (49%) achieved their stated goals within 6 months of hospital discharge. Sixteen patients who achieved their stated goals disengaged from the program. Engagement in the HVIP resulted in significantly less PTSD at the time of hospital discharge. HVIP patients also experienced higher positive affect at hospital discharge, as described in the Positive and Negative Affect Schedule. HVIP participants were significantly more likely to achieve early positive health outcomes, such as completion of victim of crime compensation and return to school. CONCLUSIONS: Our HVIP successfully achieved patient-stated short-term health and social goals in nearly half of all enrollees, indicating that HVIP patients are more likely to improve their social determinants of health than non-HVIP patients. Short-term health and social outcomes were improved in HVIP patients compared with non-HVIP patients, indicating increased engagement with the healthcare system. We suggest that these outcomes should replace recidivism as a metric for the efficacy of HVIP programs.

Continuation of Gender-affirming Hormones Among Transgender Adolescents and Adults.

INTRODUCTION: Concerns about future regret and treatment discontinuation have led to restricted access to gender-affirming medical treatment for transgender and gender-diverse (TGD) minors in some jurisdictions. However, these concerns are merely speculative because few studies have examined gender-affirming hormone continuation rates among TGD individuals. METHODS: We performed a secondary analysis of 2009 to 2018 medical and pharmacy records from the US Military Healthcare System. We identified TGD patients who were children and spouses of active-duty, retired, or deceased military members using International Classification of Diseases-9/10 codes. We assessed initiation and continuation of gender-affirming hormones using pharmacy records. Kaplan-Meier and Cox proportional hazard analyses estimated continuation rates. RESULTS: The study sample included 627 transmasculine and 325 transfeminine individuals with an average age of 19.2 ±â€…5.3 years. The 4-year gender-affirming hormone continuation rate was 70.2% (95% CI, 63.9-76.5). Transfeminine individuals had a higher continuation rate than transmasculine individuals 81.0% (72.0%-90.0%) vs 64.4% (56.0%-72.8%). People who started hormones as minors had higher continuation rate than people who started as adults 74.4% (66.0%-82.8%) vs 64.4% (56.0%-72.8%). Continuation was not associated with household income or family member type. In Cox regression, both transmasculine gender identity (hazard ratio, 2.40; 95% CI, 1.50-3.86) and starting hormones as an adult (hazard ratio, 1.69; 95% CI, 1.14-2.52) were independently associated with increased discontinuation rates. DISCUSSION: Our results suggest that >70% of TGD individuals who start gender-affirming hormones will continue use beyond 4 years, with higher continuation rates in transfeminine individuals. Patients who start hormones, with their parents' assistance, before age 18 years have higher continuation rates than adults.

High resuscitative endovascular balloon occlusion of the aorta procedural volume is associated with improved outcomes: An analysis of the AORTA registry.

BACKGROUND: The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) is controversial. We hypothesize that REBOA outcomes are improved in centers with high REBOA utilization. METHODS: We examined the Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery registry over a 5-year period (2014-2018). Resuscitative endovascular balloon occlusion of the aorta outcomes were analyzed by stratifying institutions into low-volume (<10), average-volume (11-30), and high-volume (>30) deployment centers. A multivariable model adjusting for volume group, mechanism of injury, signs of life, systolic blood pressure at initiation, operator level, device type, zone of placement, and hemodynamic response to aortic occlusion was created to analyze REBOA mortality and REBOA-related complications. RESULTS: Four hundred ninety-five REBOA placements were included. High-volume centers accounted for 63%, while low accounted for 13%. High-volume institutions were more likely to place a REBOA in the emergency department (81% vs. 63% low volume, p = 0.003), had a lower mean systolic blood pressure at insertion (53 ± 38 vs. 64 ± 40, p = 0.001), and more Zone I deployments (64% vs. 55%, p = 0.002). Median time from admission to REBOA placement was significantly less in patients treated at high-volume centers (15 [7-30] minutes vs. 35 [20-65] minutes, p = 0.001). Resuscitative endovascular balloon occlusion of the aorta mortality was significantly higher at low-volume centers (67% vs. 57%; adjusted odds ratio, 1.29; adj p = 0.040), while average- and high-volume centers were similar. Resuscitative endovascular balloon occlusion of the aorta complications were less frequent at high-/average-volume centers, but did not reach statistical significance (adj p = 0.784). CONCLUSION: Resuscitative endovascular balloon occlusion of the aorta survival is increased at high versus low utilization centers. Increased experience with REBOA may be associated with earlier deployment and subsequently improved patient outcomes. LEVEL OF EVIDENCE: Therapeutic/Care Management, level IV.

Draft Genome Sequence of the Yeast Ogataea degrootiae Strain UCD465, Isolated from Soil in Ireland.

Ogataea degrootiae is an ascomycete yeast that was first isolated in the Netherlands in 2017. It is a member of the Pichiaceae clade. Here, we present the genome sequence of O. degrootiae UCD465, which was isolated from soil in Ireland. This genome is 14.6 Mb and haploid.

Mental Healthcare Utilization of Transgender Youth Before and After Affirming Treatment.

OBJECTIVE: Transgender and gender-diverse (TGD) adolescents experience increased mental health risk compared to cisgender peers. Limited research suggests improved outcomes following gender-affirmation. This study examined mental healthcare and psychotropic medication utilization among TGD youth compared to their siblings without gender-related diagnoses and explored utilization patterns following gender-affirming care. METHOD: This retrospective cohort study used military healthcare data from 2010-2018 to identify mental healthcare diagnoses and visits, and psychotropic medication prescriptions among TGD youth who received care for gender dysphoria before age 18, and their siblings. Logistic and Poisson regression analyses compared mental health diagnosis, visits, and psychotropic prescriptions of TGD youth to their siblings, and compared healthcare utilization pre- and post-initiation of gender-affirming pharmaceuticals among TGD adolescents. RESULTS: 3,754 TGD adolescents and 6,603 cisgender siblings were included. TGD adolescents were more likely to have a mental health diagnosis (OR 5.45, 95% CI [4.77-6.24]), use more mental healthcare services (IRR 2.22; 95% CI [2.00-2.46]), and be prescribed more psychotropic medications (IRR = 2.57; 95% CI [2.36-2.80]) compared to siblings. The most pronounced increases in mental healthcare were for adjustment, anxiety, mood, personality, psychotic disorders, and suicidal ideation/attempted suicide. The most pronounced increased in psychotropic medication were in SNRIs, sleep medications, anti-psychotics and lithium. Among 963 TGD youth (Mage: 18.2) using gender-affirming pharmaceuticals, mental healthcare did not significantly change (IRR = 1.09, 95% CI [0.95-1.25]) and psychotropic medications increased (IRR = 1.67, 95% CI [1.46-1.91]) following gender-affirming pharmaceutical initiation; older age was associated with decreased care and prescriptions. CONCLUSION: Results support clinical mental health screening recommendations for TGD youth. Further research is needed to elucidate the longer-term impact of medical affirmation on mental health, including family and social factors associated with the persistence and discontinuation of mental healthcare needs among TGD youth. Hisle-Gorman E, Schvey NA, Adirim TA, et al. Mental Healthcare Utilization of Transgender Youth Before and After Affirming Treatment. J Sex Med 2021;18:1444-1454.