A Rose by Any Other Name: Gender-Affirming Care and Severe Mental Illness

The transgender population has higher rates of psychiatric disorders and stigma within medical settings. Literature suggests that gender-affirming care is the standard when working with such patients. There are limited studies regarding treating these patients with severe mental illness (SMI). This article explores how to treat SMI that impacts patients' reality to the point where their assigned sex cannot be acknowledged. The case presented is that of a transgender woman, where clarification of her natal sex was crucial to treatment. The patient denied her natal sex, endorsing a history of miscarriage. Studies on treatment of transgender SMI patients are limited. Gender-affirming treatment is the standard of care for these patients. Training how to ask pertinent questions and communicate effectively is necessary to prevent misdiagnosis, unnecessary treatment, and agitation. [Psychiatr Ann. 2023;53(5):221–223.]

Hormone replacement therapy and COVID-19 outcomes in solid organ transplant recipients compared with the general population.

Exogenous estrogen is associated with reduced coronavirus disease (COVID) mortality in nonimmunosuppressed/immunocompromised (non-ISC) postmenopausal females. Here, we examined the association of estrogen or testosterone hormone replacement therapy (HRT) with COVID outcomes in solid organ transplant recipients (SOTRs) compared to non-ISC individuals, given known differences in sex-based risk in these populations. SOTRs ≥45 years old with COVID-19 between April 1, 2020 and July 31, 2022 were identified using the National COVID Cohort Collaborative. The association of HRT use in the last 24 months (exogenous systemic estrogens for females; testosterone for males) with major adverse renal or cardiac events in the 90 days post-COVID diagnosis and other secondary outcomes were examined using multivariable Cox proportional hazards models and logistic regression. We repeated these analyses in a non-ISC control group for comparison. Our study included 1135 SOTRs and 43 383 immunocompetent patients on HRT with COVID-19. In non-ISC, HRT use was associated with lower risk of major adverse renal or cardiac events (adjusted hazard ratio [aHR], 0.61; 95% confidence interval [CI], 0.57-0.65 for females; aHR, 0.70; 95% CI, 0.65-0.77 for males) and all secondary outcomes. In SOTR, HRT reduced the risk of acute kidney injury (aHR, 0.79; 95% CI, 0.63-0.98) and mortality (aHR, 0.49; 95% CI, 0.28-0.85) in males with COVID but not in females. The potentially modifying effects of immunosuppression on the benefits of HRT requires further investigation.

How Can I Keep Them Singing? Exploring 'Tumult and Strife' in Male Adolescent Voice Change

Within the field of music education, there is extensive literature that speaks to the importance of singing for an individual's musical development (Williams, 2019;Welch, 2012). Aside from its musical benefits, Welch (2012) identifies the role of singing in improved respiratory and cardiac function, communication skills, and sense of social inclusion. With a more thorough understanding of TIVC, music educators will be better equipped to assess their students' voices and address their vocal needs during voice change. By expanding vocal pedagogy lessons to include voice change and its impact on vocal anatomy, music educators can provide clarity for adolescent boys as they navigate their changing voices.

Premature ovarian insufficiency and infertility

[...]history * No significant medical history * No family history of early menopause or genetic disorders * Non-smoker * Two to three standard drinks per week * Taking a pregnancy vitamin supplement;no other medications or supplements * Goes to gym for 45 minutes twice per week;no other regular exercise * Up to date with cervical screening * Up to date with immunisations including rubella, varicella, influenza and COVID-19 Physical examination * Blood pressure 125/69 mmHg * Height 172 cm, weight 71 kg, body mass index 24 kg/m2 * No clinical hyperandrogenism, thyroid or pituitary disease * Urinary human chorionic gonadotropin (HCG) negative Susan's GP arranges the following initial investigations: * Serum HCG * Follicle-stimulating hormone (FSH) * Luteinising hormone (LH) * Oestradiol * Thyroid-stimulating hormone * Prolactin * Total testosterone, sex hormone binding globulin (SHBG) * Pelvic ultrasonography Investigation of secondary amenorrhoea The most common causes of secondary amenorrhoea are pregnancy, hypogonadotropic hypogonadism, polycystic ovary syndrome, hyperprolactinaemia and thyroid dysfunction. Results are as follows (laboratory reference ranges vary between laboratories): * HC G negative, FSH 51 IU/L (reference range follicular: 4-13 IU/L, mid-cycle: 5-22 IU/L, luteal: 2-8 IU/L, menopausal: 26-135 IU/L), LH 35 IU/L (reference range follicular: 2-10 IU/L, mid-cycle: 10-80 IU/L, luteal: 2-8 IU/L, menopausal: 8-59 IU/L), oestradiol <88 pmol/L (reference range follicular: <88-607 pmol/L, mid-cycle: 315-1828 pmol/L), luteal: 161-774 pmol/L, menopausal: <201 pmol/L), TSH normal, prolactin normal, testosterone low normal, SHBG normal * Pelvic ultrasound - normal uterine size, 'inactive ovaries' Testing of FSH is repeated four weeks later;the result is 45 IU/L. Risk factors for POI include: presence of specific genetic variants, positive family history, autoimmune disease, earlier menarche, chemotherapy, radiotherapy, pelvic surgery, smoking and being underweight.3 Adverse early life experiences, including childhood abuse and parental divorce, and low socioeconomic status are associated with lower age at menopause, though specific data for a relationship with POI are lacking.3 Observational studies have shown that POI is associated with an increased risk of osteoporosis, cardiovascular disease, depression, anxiety, diabetes mellitus, cognitive dysfunction, dementia and increased mortality. [...]with the current formulations of COCPs, although conception rates may be lower in the first three months post cessation of the COCP, they have normalised by 12 months.8 Taking the COCP may mask an underlying menstrual disorder. [...]women with four months of amenorrhoea post COCP cessation should be investigated for POI and not assumed to have post-pill amenorrhoea.

Attenuation of Human Growth Hormone-Induced Rash With Graded Dose Challenge.

Adult growth hormone (GH) deficiency is rare and requires replacement with extrinsic/synthetic injection. GH hypersensitivity has been reported; specifically, atopic patients may develop rashes from somatotropin therapy. Allergic and non-allergic skin reactions to recombinant human GH are uncommon and infrequently reported. We describe a graded-dose challenge with intravenous Norditropin® in a 65-year-old atopic adult woman who developed a severe whole-body rash with Norditropin FlexPro® administration on several occasions but was negative on skin-prick testing to Norditropin® percutaneously and intradermally, but the patch testing was positive for gold and nickel. The patient was registered as a direct admission to the emergency room at a university hospital for a rapid antigen coronavirus disease 2019 (COVID-19) testing after having received two COVID-19 vaccinations and re-testing four months after vaccination. She was then directly admitted to a non-COVID-19 intensive care unit with direct bedside supervision by a registered nurse and a physician board certified in internal medicine, allergy/immunology, and pulmonary diseases. The patient brought a Norditropin® pen which our pharmacy team attached to a compatible syringe for dilutions. A graded dose challenge at a final dosage of 0.1 mL was performed and the patient was monitored for allergic and other adverse drug reactions, which did not occur. At the time of writing this case report, the patient has been maintained on Norditropin FlexPro® 0.1 mL and has not experienced any adverse reactions, including recurrent skin eruptions. The case presented is the first to describe a patient who successfully tolerated a graded dose challenge of an adult patient to GH replacement therapy (as Norditropin®) under supervision in an intensive care unit, whereas prior to reporting of this case, a graded dose challenge to GH replacement therapy had only been successfully performed in a child using another formulation of somatotropin (Humatrope®). Hence, this case lends support that graded dose challenge with somatotropin analogs may be considered for patients with isolated GH deficiency such as in the case presented here.

Personalized approach to mammography screening during the COVID pandemic: how to make up for lost time without losing effectiveness

Background: The epidemic start of Coronavirus disease it expanded in the first months of 2020. Italy was among the first European countries to be affected and those affected more intensely: the first case was reported on 02.20.2020 The entire health system has been disrupted and reorganized due to the impact of the pandemic on hospitals The suspension of first-level screening services in Italy occurred in the months of March and April 2020 on throughout the national territory, starting from May 2020 the screening programs were reactivated albeit with different timing and intensity between the regions and within of each single region.

Seven days in medicine: 31 Aug to 6 Sep 2022

3 Pensions Consultation begins on NHS pension changes The UK government has launched a consultation on pension changes to make it easier for retired and partially retired NHS staff to return to the workforce or continue working over winter. Since March 2020 some of the pension scheme’s rules on retiring and returning have been suspended, but these measures apply only until 31 October. E-cigarettes are becoming especially popular with young people: 11% of 18-24 year olds use them, the highest rate by age group.6 Food safety Listeria is linked to ready-to-eat smoked fish The Food Standards Agency, Food Standards Scotland, and the UK Health Security Agency are reinforcing advice to vulnerable groups such as over 65s, anyone pregnant, or people with weakened immune systems, to ensure that ready-to-eat smoked fish is thoroughly cooked before they eat it. 9 Life expectancy US sees steepest decline in a century Life expectancy in the US fell for the second year running in 2021, said the Centers for Disease Control and Prevention.

Hormonal therapies and venous thrombosis: Considerations for prevention and management.

Background: Venous thromboses are well-established complications of hormonal therapy. Thrombosis risk is seen with both hormonal contraceptive agents and with hormone replacement therapy for menopause and gender transition. Over the past several decades, large epidemiological studies have helped better define these risks. Objectives: To review and discuss the differences in thrombosis risk of the many of hormonal preparations available as well as their interaction with patient-specific factors. Methods: We conducted a narrative review of the available literature regarding venous thrombosis and hormonal therapies including for contraception, menopausal symptoms, and gender transition. Results: Thrombosis risk with estrogen-containing compounds increases with increasing systemic dose of estrogen. While progesterone-only-containing products are not associated with thrombosis, when paired with estrogen in combined oral contraceptives, the formulation of progesterone does impact the risk. These components, along with patient-specific factors, may influence the choice of hormonal preparation. For patients who develop thrombosis on hormonal treatment, anticoagulation is protective against future thrombosis. Duration of anticoagulation is dependent on ongoing and future hormone therapy choice. Finally, the optimal management of hormone therapy for individuals diagnosed with prothrombotic illnesses such as COVID-19 remains unclear. Conclusions: When contemplating hormonal contraception or hormone replacement therapy, clinicians must consider a variety of factors including hormone type, dose, route, personal and family history of thrombosis, and other prothrombotic risk factors to make informed, personalized decisions regarding the risk of venous thrombosis.

Seven days in medicine: 27 July to 2 August 2022

Both studies, published as preprints, ruled out the likelihood of recent or prior SARS-CoV-2 infection as a direct cause for the acute hepatitis.1 (Full story doi:10.1136/bmj.o1876) Vitamin D Supplements “don’t reduce fractures in healthy elderly” Vitamin D supplementation did not result in a significantly lower risk of fractures than placebo in generally healthy middle aged and older adults who were not recruited on the basis of vitamin D deficiency, low bone mass, or osteoporosis, in a study reported in the New England Journal of Medicine.1 The 25 871 participants were followed for five years, and the researchers found no difference in the number of fractures in people taking vitamin D and those taking placebo. [...]of ambulance workers see deaths linked to delays A third of ambulance workers have been involved in cases where a patient’s death was linked to delays in receiving treatment, a poll by the GMB union found. Eye care guidance NICE rapid recommendation on eye condition treatment In final draft guidance the National Institute for Health and Care Excellence recommended brolucizumab (also known as Beovu and manufactured by Novartis) as an option for treating visual impairment due to diabetic macular oedema in adults, the main cause in the UK of sight loss in people with diabetes.

Estradiol and COVID-19: Does 17-Estradiol Have an Immune-Protective Function in Women Against Coronavirus?

Objective: Female sex hormones have a pro-inflammatory effect, which may help to minimize inflammation. Estrogen's immunoregulatory properties play a significant role in the bi-directional neuroendocrine-immune activity in females. As a result, sex hormones can play a role in men's high mortality rate from coronavirus-2019 (COVID-19). It is aimed to clarify the role of 17-estradiol (E2) in the battle against COVID-19. Materials and methods: Until April 2021, a study on PubMed was performed. COVID-19, 17-estradiol (E2), immunoregulatory properties, pregnancy, menopausal symptoms, hormonal therapy, ER/ expression on immune cells, and mortality were some of the concepts used in the search. Results: Regulation of pro-inflammatory immune processes against COVID-19 appears to be associated with increased immune function (pro-inflammatory), anti-inflammatory regulation, and antiviral defense. Women with a severe coronavirus infection had higher serum IgG antibody levels than men, and their IgG production was faster in the early stages of infection. 17-estradiol (E2) levels of blood will increase by 100-fold during pregnancy. COVID-19 in pregnant women had a 15-fold lower mortality rate than other women. While menopause replacement therapy (MRT) for pre/post-menopausal women and its effectiveness in reducing COVID-19 infection is debatable. Conclusion: MRT may be considered as a viable treatment option for pre/post-menopause women with coronavirus, referring to the fact that sex hormones reduce inflammatory responses and modulate ACE2 expression. The task's difficulty and achieving the desired outcome seem to be challenging.

Hormone replacement therapy and mammographic density: a systematic literature review.

PURPOSE: Hormone replacement therapy (HRT) is used to reduce climacteric symptoms of menopause and prevent osteoporosis; however, it increases risk of breast cancer. Mammographic density (MD) is also a strong risk factor for breast cancer. We conducted this review to investigate the association between HRT use and MD and to assess the effect of different HRT regimens on MD. METHODS: Two of authors examined articles published between 2002 and 2019 from PubMed, Embase, and OVID using Covidence systematic review platform. Any disagreements were discussed until consensus was reached. The protocol used in this review was created in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Quality of each eligible study was assessed using the Oxford Center for Evidence-Based Medicine (OCEBM) hierarchy. RESULTS: Twenty-two studies met the inclusion criteria. Six studies showed that using estrogen plus progestin (E + P) HRT was associated with higher MD than estrogen alone. Four studies reported that continuous estrogen plus progestin (CEP) users had higher MD than sequential estrogen plus progestin (SEP) and estrogen alone users. However, two studies showed that SEP users had slightly higher MD than CEP users and estrogen alone users. CONCLUSIONS: Epidemiological evidence is rather consistent suggesting that there is a positive association between HRT use and MD with the highest increase in MD among current users, and CEP users. Our results suggest that due to increase in MD and masking effect, current E + P users may require additional screening procedures, shorter screening intervals, or using advanced imaging techniques.