Pediatric sexual orientation and gender identity data collection in the electronic health record.

The systematic documentation of sexual orientation and gender identity data in electronic health records can improve patient-centered care and help to identify and address health disparities affecting sexual and gender minority populations. Although there are existing guidelines for sexual orientation and gender identity data among adult patients, there are not yet standard recommendations for pediatric patients. In this article, we discuss methods that pediatric primary care organizations can use to collect and document sexual orientation and gender identity information with children and adolescents in electronic health records. These recommendations take into consideration children's developmental stages, the role of caregivers, and the need to protect the privacy of this information. We also focus on the current limitations of electronic health records in capturing the nuances of sexual and gender minority identities and make suggestions for addressing these limitations.

"We're Moving in the Right Direction. Still a Long Way to Go": Experiences and Perceptions of the Climate for LGBTQ+ Employees at a Pediatric Hospital.

A positive LGBTQ+ (lesbian, gay, bisexual, transgender/nonbinary, queer) workplace climate is critical for healthcare employee satisfaction, productivity, and patient care. The current study assessed LGBTQ+ workplace climate among 791 employees from a large urban pediatric hospital. Several workplace climate domains were assessed in an online survey: employee attitudes, training, experiences related to working with LGBTQ+ colleagues, patients and families, and LGBTQ+-specific experiences. For most domains, half or more of respondents perceived an affirming LGBTQ+ climate. LGBTQ+ employees perceived a less affirming climate than cisgender heterosexual employees. LGBTQ+ employees, especially transgender/nonbinary employees, experienced numerous discriminatory situations. Over 90% of participants felt competent and qualified to work with LGB patients/families; 80% felt competent and qualified to work with TNB patients/families. Themes from open-ended survery responses reflected three LGBTQ+ climate components: systemic, interpersonal, and "grassroots" (affinity group) initiatives. Findings inform strategies to improve LGBTQ+ employee experiences and competency caring for LGBTQ+ patients and families.

Admitted for an Eating Disorder: Challenges Clinical Psychologists Face in Working with Patients and Their Families on a Consultation-Liaison Service in a Tertiary Pediatric Hospital.

Eating disorders are one of the most common causes of pediatric hospitalizations due to primary mental health diagnoses. The purpose of this article is to discuss the challenges clinical psychologists face in working with patients with eating disorders and their families during medical admissions. Using the Psychiatry Consultation Service at a tertiary pediatric academic medical center in the Northeast as a framework, authors present the responsibilities of clinical psychologists on this service and their role within the larger, interdisciplinary team. Topics addressed also include systemic challenges, medical and psychiatric comorbidities, and differential psychiatric diagnoses. Case examples are provided to highlight various challenges as well as potential solutions and approaches. Clinical implications, limitations, and directions for future research are also discussed.

Asynchronous Online Focus Groups for Health Research: Case Study and Lessons Learned.

Increasingly, social life-and accordingly, social research-is conducted in online environments. Asynchronous online focus groups (AOFGs) have emerged as an important tool to conduct remote research with geographically diverse populations. However, there remain few systematic accounts of AOFG methods to guide researchers' decision-making in designing and implementing studies. This paper seeks to address this gap by describing a recent study on body image and health among transgender and gender diverse (TGD) young adults. In this study, eight AOFGs were conducted in August-October 2019 with 66 TGD young adults residing in 25 U.S. states. Each AOFG lasted four consecutive days with two prompts posted by moderators per day. Overall, participant satisfaction with AOFGs was high: 98% reported their experience was excellent, very good, or good and 95% would be somewhat or very likely to sign up for another AOFG. This example is used to illustrate key methodological decision-points, acceptability of the method to participants, and lessons learned. The goal of this paper is to encourage other researchers, particularly health researchers, to consider using AOFGs and to engage with the method's strengths and limitations in order to develop new opportunities for online technologies to enrich the field of qualitative health research.

Prevalence, Patterns, and Correlates of Pain in Medically Hospitalized Pediatric Patients With Somatic Symptom and Related Disorders.

BACKGROUND: Somatic symptom and related disorders (SSRDs) and pain are highly comorbid in the pediatric population. Little is known about the prevalence of pain and factors that may predispose and perpetuate pain in hospitalized youth with SSRD. OBJECTIVE: To describe the prevalence of pain and widespread pain symptoms in hospitalized youth with SSRD and describe differences between patients who endorsed limited (1-4 sites) versus widespread (5-8 sites) pain. METHODS: Retrospective chart reviews were conducted of pediatric patients with SSRD seen over a 32-month period at a tertiary pediatric hospital and assessed by the psychiatry consultation service. During admission, patients completed the Childhood Somatization Inventory, which assessed pain and other physical symptoms. Descriptive statistics, one-way analysis of variances, Pearson's χ2, stepwise linear regressions, and internal consistency analyses were used. RESULTS: Of the 219 patients (aged 8-18 y), 97% reported pain symptoms, and of those reporting pain (n = 213), 48% reported widespread pain. Patients with widespread pain had greater rates of comorbid depression (P = 0.012), neglect (P = 0.016), family psychiatric history (P = 0.013), diagnostic tests/procedures (P = 0.012), and prescribed opioid use (P = 0.016), when other medical and demographic factors were considered. When compared dichotomously to youth with limited pain, there was no difference in prevalence of medical conditions; however, patients with widespread pain had higher rates of trauma and stressor-related disorders (P = 0.017), sexual abuse (P = 0.031), emotional abuse (P = 0.041), and prior child protective service involvement (P = 0.011). CONCLUSIONS: Pain symptoms and widespread pain are common in medically hospitalized youth with SSRD, with unique psychiatric and psychosocial factors associated with widespread pain.

Lumbar spine radiographs - is it time for widespread adoption of posteroanterior projection?

OBJECTIVE: Phantom studies and a prior patient study have shown up to 53% effective dose reduction when lumbar spine radiographs are acquired posteroanterior (PA) instead of anteroposterior (AP). Since November 2017, Taunton and Somerset NHS Foundation Trust has acquired all standing lumbar spine radiographs PA. The aim of this study was to locally evaluate dose and image quality in both projections and survey current UK practice. METHODS: 80 outpatients having a standing lumbar spine radiograph (40 AP; 40 PA) had their dose-area product recorded at a constant KV and focus film distance. Effective dose was calculated using PCXMC software. Each blinded radiograph was scored against an optimal reference image using European Guidelines criteria. The data were analyzed using Mann-Whitney U tests and linear regression. Eighty radiologists nationally were sent an anonymous survey to establish their current practice. RESULTS: A lumbar spine radiograph acquired PA instead of AP reduced effective dose by 41% (p < 0.001) with no difference in image quality (p = 0.9). 21 radiologists completed our survey and only 1 NHS Trust is currently using PA. CONCLUSION: PA lumbar spine radiography reduces patient radiation exposure with no affect on image quality, acquisition time or cost. The majority of NHS Trusts nationally are still using AP and it is time to standardize to PA. ADVANCES IN KNOWLEDGE: This patient study provides further good evidence of how reduction in exposure to ionizing radiation can be achieved in lumbar spine radiography and more widespread adoption of PA protocol could improve patient safety.

Psychotropic medication use trends in a large pediatric and young adult solid organ transplant population.

INTRODUCTION: This study describes psychotropic medication use in a pediatric and young adult solid organ transplant population. METHODS: We conducted a retrospective review of the lifetime incidence of psychotropic medication use and associated characteristics in patients seen over a 6-year period at a large pediatric transplant center utilizing univariate and multivariate statistical analyses. RESULTS: The lifetime incidence of psychotropic medication use was 36.5% in 393 patients. Transplant psychiatry provided psychopharmacological consultation to 21.9% of patients. Controlling for age and sex, there were significant associations between psychotropic use and thoracic organ disease (heart/lung) (AOR = 2.14; 95% CI: 1.2-3.8; P = 0.01), White race (P = 0.0002), histories of depressive/mood disorders (AOR = 3.68; 95% CI: 1.8-7.7; P = 0.0005), attention/learning disorders (AOR = 3.30; 95% CI: 1.6-6.9; P = 0.001), acute and post-traumatic stress disorders (AOR = 10.54; 95% CI: 2.6-42.8; P = 0.001), and experiencing bullying (AOR = 2.16; 95% CI: 1.03-4.55; P = 0.04). In unadjusted tests, significant associations were found between lifetime psychotropic usage and patient anxiety history (OR = 2.26; 95% CI: 1.5-3.5; P = 0.0002), end-of-life disease progression (OR = 3.04; 95% CI: 1.7-5.4; P = 0.0002), family psychiatric history (OR = 2.17; 95% CI: 1.4-3.4; P = 0.0007), and adherence concerns (OR = 2.67; 95% CI: 1.7-4.1; P < 0.0001). DISCUSSION: The lifetime incidence of psychotropic medication use among pediatric and young adult transplant patients is substantial. Patients with thoracic organ disease, end-of-life illness, individual/family psychiatric histories, trauma, and bullying histories have particularly high rates. Integrating child psychiatry as part of pediatric transplant teams should be an important consideration for the care of these patients.

Discovery Molecular Imaging Digital Ready PET/CT performance evaluation according to the NEMA NU2-2012 standard.

OBJECTIVES: The aim of this study was to evaluate and benchmark the performance characteristics of the General Electric (GE) Discovery Molecular Imaging (MI) Digital Ready (DR) PET/CT. MATERIALS AND METHODS: Performance evaluation against the National Electrical Manufacturers Association (NEMA) 2012 standard was performed on three GE Discovery MI DR PET/CT systems installed across different UK centres. The Discovery MI DR performance was compared with the Siemens Biograph mCT Flow, Phillips Ingenuity TF and GE Discovery 690 fully analogue PET/CT systems. In addition, as the Discovery MI DR is upgradable to the Digital MI with silicon photomultipliers, performance characteristics between analogue and digital were compared with assess potential benefits of a system upgrade. RESULTS: The average NEMA results across three Discovery MI DR scanners were: sensitivity 7.3 cps/kBq, spatial resolution full-width-half-maximum radial 5.5 mm, tangential 4.5 mm and axial 6 mm at 10 cm from the centre of the field-of-view, peak noise equivalent count rate 142 kcps, scatter fraction 37.1%, contrast recovery coefficients from the International Electrotechnical Commission phantom ranged from 52 to 87% for 10-37-mm diameter spheres. CONCLUSION: All three Discovery MI DR systems tested in this study exceeded the manufacturer's NEMA specification, yet variability between scanners was noted. Discovery MI DR showed similar performance to Discovery 690 and Ingenuity TF, but lower sensitivity and spatial resolution than Biograph mCT Flow. The Discovery MI DR showed lower spatial resolution and contrast recovery than the 20-cm field-of-view Digital MI.

Increased radiation dose and projected radiation-related lifetime cancer risk in patients with obesity due to projection radiography.

PURPOSE: Primarily to evaluate the radiation dose delivered to patients with obesity in projection radiography and its relationship to the patient's size. A secondary purpose is to estimate the subsequent projected radiation-related lifetime cancer risk to patients with obesity compared to normal-weight patients. METHOD AND MATERIAL: Data from 1964 patients from a bariatric clinic in the UK were reviewed with the relevant permission. 630 patients were identified to have a projection radiography history and were included in the study. Patients' dose area product (DAP) data were collected for all projection radiography. Multiple exams in one day including a single DAP reading and exams with no records of DAP and exposure factors were excluded. Correlations were calculated and data analysed to yield the third quartile for each examination using STATA 14. Absorbed doses were generated from PCXMC simulation, utilising DAP data from this study and the UK national diagnostic reference level (NDRL), to calculate the effective risk for patients with obesity compared to patients with normal-weight. RESULTS: Patients with obesity received higher DAPs for all examinations included in this study compared to NDRL. Abdominal and lumbar spine radiographs DAPs were the highest (17.6 and 30.31 Gy cm2) compared to the NDRL (2.5 and 4 Gy cm2). Only moderate to low correlations were found between patient's size and DAPs in the abdomen and chest radiographs. The projected radiation-related lifetime cancer risk for patients with obesity is up to 153% higher than for adult patients with normal weight. CONCLUSION: Patients with obesity receive higher DAPs than normal-weight adults which may be in excess of that expected due to their size. Therefore, radiation-related lifetime cancer risk is increased in patients with obesity as a result of medical radiation exposures. This indicates more dose optimisation research is needed in this group of patients to reduce dose rate and variation.

Behavioral health care in solid organ transplantation in a pediatric setting.

This study examined the demographic, medical, and psychiatric characteristics of transplant patients across organ groups seen by transplant psychology/psychiatry clinicians at a pediatric institution between 2008 and 2014. Chart reviews were conducted to better understand the behavioral health care provided to SOT patients and the role of transplant-dedicated psychology and psychiatry clinicians. Transplant psychology/psychiatry was consulted a total of 1060 times on 399 unique SOT patients over a 6-year period. There were no significant differences in the distribution of age, sex, or ethnicity across organ groups. Common reasons for a consultation included pretransplant evaluation, anxiety, depression, agitation, and general coping. Rates varied by organ groups. Twenty percent of consults also received a psychopharmacological evaluation, with differences in rates between organ groups. Roughly one-third of patients required high frequency of transplant psychology/psychiatry involvement. Lung and heart patients had the highest utilization. Psychiatric diagnosis rates were identified, with adjustment (41.0%) and anxiety disorders (30.1%) being the most common. Pediatric psychology and psychiatry clinicians offer developmentally informed biopsychosocial approaches to treatment for SOT patients. Clarifying the prevalence and nature of behavioral health care provided by organ group can help pediatric providers better understand appropriate psychosocial interventions and resources utilized by this patient population and ultimately guide centers toward a more unified approach to care.

Harmonizing standardized uptake value recovery between two PET/CT systems from different manufacturers when using resolution modelling and time-of-flight.

PET iterative reconstruction algorithms with resolution modelling (RM) can be used to improve spatial resolution in the images. However, RM has a significant impact on quantification, which raises issues for harmonization across multicentre networks or collaborations. This investigation compared quantification from two modern time-of-flight (TOF) PET/CT systems from different manufacturers with RM with the intention to harmonize recovery. Images of a National Electrical Manufacturers Association image quality phantom with a sphere-to-background concentration ratio of 4 : 1 were acquired on a GE Discovery 710 and a Siemens Biograph mCT and reconstructed with RM and TOF. Voxel dimensions and image noise (background coefficient of variation) were matched. One to five iterations were used with 2 and 4 mm Gaussian filters. Mean and maximum contrast recovery (CR) were measured for the 10, 13, 17 and 22 mm hot phantom spheres. Notable differences in CR for images reconstructed with matched reconstruction parameters were observed between the scanners. A set of parameters was found that reduced differences in CR between scanners. Using these parameters, relative differences for the Biograph compared with the Discovery were -8.1, -3.7, +7 and +0.7% for mean CR and -23.1, -6.9, +9.1 and +0.9% for maximum CR in the 10, 13, 17 and 22 mm spheres, respectively. This study has used a technique of harmonizing standardized uptake value recovery on PET/CT systems from different vendors with advanced reconstructions including TOF and RM using phantom data. Considerable quantitative differences may occur in images, which highlights the need to apply methods such as those used in this work for multicentre studies.

Imagining the future: Perspectives among youth and caregivers in the trans youth family study.

Future perspectives of transgender youth and their caregivers may be shaped by knowledge of discrimination and adverse mental health among transgender adults. Qualitative data from the Trans Youth Family Study were analyzed to examine how transgender and gender nonconforming (TGN) youth and their caregivers imagine the youth's future. A community-based sample of 16 families (16 TGN youth, ages 7-18 years, and 29 caregivers) was recruited from 2 regions in the United States. Participants completed in-person qualitative interviews and surveys. Interview transcripts were analyzed using grounded theory methodology for coding procedures. Analyses yielded 104 higher order themes across 45 interviews, with 8 prominent themes: comparing experiences with others, gender affirming hormones, gender affirming surgery, gender norms, questioning whether the youth is really transgender, expectations for romantic relationships, uncertainty about the future, and worries about physical and emotional safety. A conceptual model of future perspectives in TGN youth and caregivers is presented and clinical implications are discussed. (PsycINFO Database Record

Correlates of women's intentions to be screened for human papillomavirus for cervical cancer screening with an extended interval.

BACKGROUND: High-risk HPV DNA testing has been proposed as a primary tool for cervical cancer screening (HPV-CCS) as an alternative to the Papanicolaou cytology- method. This study describes factors associated with women's intentions to attend cervical cancer screening if high-risk HPV DNA testing (HPV-CCS) was implemented as a primary screening tool, and if screening were conducted every 4 years starting after age 25. METHODS: This online survey was designed using the Theory of Planned Behaviour to assess factors that impact women's intentions to attend HPV-CCS among women aged 25-69 upon exit of the HPV FOCAL trial. Univariate and regression analyses were performed to compare the demographic, sexual history, and smoking characteristics between women willing and unwilling to screen, and scales for intention to attend HPV-CCS. A qualitative analysis was performed by compiling and coding the comments section of the survey. RESULTS: Of the 981 women who completed the survey in full, only 51.4 % responded that they intended to attend HPV-CCS with a delayed start age and extended screening interval. Women who intended to screen were more likely to have higher education (AOR 0.59, 95 % CI [0.37, 0.93]), while both positive attitudes (AOR 1.26, 95 % CI [1.23, 1.30]) and perceived behavior control (AOR 1.06, 95 % CI [1.02, 1.10]) were significant predictors of intention to screen. Among women who provided comments in the survey, a large number of women expressed fears about not being checked more than every 4 years, but 12 % stated that these fears may be alleviated by having more information. CONCLUSIONS: Acceptability of increased screening intervals and starting age could be improved through enhanced education of benefits. Program planners should consider measures to assess and improve women's knowledge, attitudes and beliefs prior to the implementation of new screening programs to avoid unintended consequences.

Characteristics of medically hospitalized pediatric patients with somatoform diagnoses.

OBJECTIVES: To describe demographic, diagnostic, and psychosocial characteristics of medically admitted patients diagnosed with somatoform disorders. METHODS: Retrospective chart reviews were performed for pediatric patients (ages 3-18 years) seen by the Psychiatry Consultation Service in 2010 and 2011 on inpatient medical/surgical units and diagnosed with somatoform disorders. Data included demographic information; patient medical history, physical symptom characteristics, and service utilization; psychiatric diagnoses, history, and comorbidities, patient temperament, and coping style; family characteristics; and academic and social characteristics. RESULTS: Mean age for the 161 identified patients was 14.4 years. The majority of patients were female (75%) and white (73%). Chief physical symptoms were pain (58%) and neurologic symptoms (40%); 73% of patients had medical diagnoses, and 66% had a history of prior psychiatric treatment. The most common somatoform diagnoses, using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, were pain (50%) and conversion disorders (28%). Psychiatric comorbidities were predominantly mood and anxiety disorders (42% and 29%, respectively). Mean hospitalization length was 4.9 days, with 14% of patients readmitted with psychiatric reinvolvement during the study period. Patients had sensitive temperaments (80%) and internalizing coping styles (76%) and were described as "good children" (72%). School absences (55%), academic pressures (51%), and learning difficulties (36%) were reported. CONCLUSIONS: Clarifying the prevalence and nature of such characteristics can help pediatric providers improve patient care and minimize unnecessary medical interventions with early detection of risk for somatoform processes, provision of psychoeducation for patients and families, and early referral to mental health clinicians.

Somatoform disorders and trauma in medically-admitted children, adolescents, and young adults: prevalence rates and psychosocial characteristics.

OBJECTIVE: The purpose of this study is to describe past traumatic experiences in medically-admitted pediatric and young adult patients diagnosed with somatoform disorders and to explore the demographic, diagnostic, and psychosocial differences between those with and without trauma histories. METHODS: Retrospective medical record reviews were performed for patients (aged 3-29 years) seen by the Psychiatry Consultation Service (2010-2011) at a pediatric medical hospital and diagnosed with a somatoform disorder. Clinical data collected included demographics, medical history, current physical symptoms, psychiatric diagnoses and history, trauma history, coping styles, family psychiatric and medical history, peer and family factors, psychiatric disposition after discharge, and service utilization. RESULTS: The mean age of the 180 identified patients was 15.1 years. Most patients were girls (75.0%) and White (71.7%). Somatoform diagnoses were primarily pain (51.4%) and conversion disorders (28.9%). Rates of trauma were similar to national norms (29.7%). Trauma history did not correlate with age, sex, race, income, length of hospitalization, or type of somatoform disorders. However, patients with trauma histories had significantly higher rates of psychiatric comorbidities (76.0% vs. 50.8%), past psychiatric treatment (81.1% vs. 59.1%), parent mental illness (69.8% vs. 38.6%), and family conflict (52.8% vs. 37.0%) and were more likely to require inpatient psychiatric hospitalization on discharge (18.9% vs. 6.3%). CONCLUSION: Prevalence of trauma in a sample of medically-admitted pediatric and young adult patients with somatoform diagnoses was similar to national norms. However, patients with a history of trauma had unique psychiatric and psychosocial profiles compared to those without a history of trauma.

The British-flag technique of mesh insertion in transabdominal preperitonial laparoscopic inguinal hernia repair.

Imaging of early postoperative complications after mesh repair has shown "foldings" of the prosthetic mesh, leading to displacement and associated hernia recurrence. A rectangular two-dimensional mesh introduced into the abdomen and fitted into a concave three-dimensional cavity does not lie evenly and is susceptible to crumpling. Hence, we propose to introduce a geometrically corrected mesh design that would allow easier placement and compliment the anatomic shape of the abdominal cavity.