Emergency Clinicians' Comfort Levels in Caring for Transgender Patients.

Objective: Transgender individuals report negative experiences in emergency department settings, but little is known about emergency clinicians' barriers to treating transgender patients. The purpose of this study was to explore emergency clinicians' experiences with transgender patients to better understand their comfort with caring for this population. Methods: We conducted a cross-sectional survey of emergency clinicians in an integrated health system in the Midwest. To assess the relationship between each independent variable and the outcome variables (i.e., comfort level generally and comfort level asking transgender patients about their body parts specifically), Mann-Whitney U test or Kruskal-Wallis analysis of variance was conducted for categorical independent variables and Pearson correlations were conducted for continuous independent variables. Results: Most participants (90.1%) were comfortable caring for transgender patients, whereas two-thirds (67.9%) were comfortable asking transgender patients about body parts. Although none of the independent variables was associated with increased clinician comfort level caring for transgender patients in general, White clinicians and those who were unsure how to ask patients about their gender identity or transgender-specific care they had received were less comfortable asking about body parts. Conclusion: Having skills to communicate with transgender patients was associated with emergency clinicians' comfort levels. In addition to offering traditional classroom-based didactics about transgender health care, providing opportunities for clinical rotations that allow clinicians-in-training to treat, and perhaps more importantly, learn from transgender patients will likely be higher yield in bolstering clinician confidence in serving this patient population.

Interplay of parathyroid hormone and aldosterone antagonist in prevention of heart failure hospitalizations in chronic kidney disease.

BACKGROUND: Aldosterone antagonists may mediate their effects on heart failure through parathyroid hormone (PTH) in chronic kidney disease (CKD) patients. METHODS: Patients with CKD on spironolactone were selected and matched for age, gender, race, use of a vitamin D analogue, the number of antihypertensive medications, and CKD stage. PTH levels before and after the first prescription of spironolactone were measured. A thorough chart review was conducted to assess for heart failure hospitalizations. An adjusted Cox proportional model was used to calculate the hazard ratio (HR) for heart failure hospitalizations among cases versus controls. RESULTS: There were a total of 950 (mean age 67±13 years, 40% men) patients with CKD. Of these, there were 48 hospitalizations for heart failure among the cases and 82 among the controls (HR 0.37; 95% confidence interval (CI) 0.19-0.74, p=0.005). We noted a more significant decrease in PTH levels among the cases when compared to the controls (p<0.0001). The adjusted hazard for heart failure hospitalization increased with higher PTH levels (p=0.002) and mediation analysis revealed change in PTH level as a significant mediator of heart failure hospitalization (p=0.04). CONCLUSION: Aldosterone antagonists may be helpful in preventing hospitalizations for heart failure exacerbation in CKD patients through a PTH-mediated effect.

Stoichiometry and Structure of Poly(amidoamine) Dendrimer-Lipid Complexes.

The energetics, stoichiometry, and structure of poly(amidoamine) (PAMAM) dendrimer-phospholipid interactions were measured with isothermal titration calorimetry (ITC), transmission electron microscopy (TEM), atomic force microscopy (AFM), dynamic light scattering (DLS), and molecular dynamics (MD) simulations. Dendrimers of sixth-generation and smaller interacted with the lipids at an average stoichiometry and enthalpy proportional to the number of primary amines per dendrimers (4.5 ± 0.1 lipids/primary amine and 6.3 ± 0.3 kJ/mol of primary amines, respectively). Larger dendrimers, however, demonstrated a decreased number of bound lipids and heat release per primary amine, presumably due to the steric restriction of dendrimer deformation on the lipid bilayer. For example, eighth-generation PAMAM dendrimers bound to 44% fewer lipids per primary amine and released 63% less heat per primary amine as compared to the smaller dendrimers. These differences in binding stoichiometry support generation-dependent models for dendrimer-lipid complexation, which are consistent with previously observed generation-dependent differences in dendrimer-induced membrane disruption. Dendrimers of seventh-generation and larger bound to lipids with an average stoichiometry consistent with each dendrimer having been wrapped by a bilayer of lipids, whereas smaller dendrimers did not.