Objective
Agitation in children in acute care settings poses significant patient and staff safety concerns. While behavioral approaches are central to reducing agitation and oral medications are ...preferred, parenteral medications are used when necessary to promote safety. The goal of this systematic review was to evaluate the effectiveness and safety of an ultra‐short‐acting parenteral medication, droperidol, for the management of acute, severe agitation in children in acute care settings.
Methods
A systematic review of randomized controlled trials, observational studies, and case series/reports examined the effectiveness and safety of parenteral droperidol for management of acute agitation in patients ≤21 years old in acute care settings. Effectiveness outcomes included time to sedation and need for a subsequent dose of medication. Safety outcomes were adverse effects such as QTc prolongation, hypotension, respiratory depression, and dystonic reactions.
Results
A total of 431 unique articles were identified. Six articles met inclusion criteria: two in the prehospital setting, one in the emergency department, and three in the inpatient hospital setting. The articles included a prospective observational study, three retrospective observational studies, and two case reports. The largest study reported a median time to sedation of 14 min (interquartile range 10–20 min); other studies reported a time to sedation of 15 min or less. Across studies, 8%–22% of patients required a second dose of medication for ongoing agitation. The most frequent adverse effects were dystonic reactions and transient hypotension. One patient had QTc prolongation and another developed respiratory depression, but both had significant comorbidities that may have contributed. The risk of bias in included studies ranged from moderate to critical.
Conclusions
Existing data on droperidol for management of acute agitation in children suggest that droperidol is both effective and safe for acute, severe agitation in children. Data are limited by study designs that may introduce bias.
Transgender and gender diverse (TGD) are terms that refer to individuals whose gender identity differs from sex assigned at birth. TGD individuals may choose any variety of modifications to their ...gender expression including, but not limited to changing their name, clothing, or hairstyle, starting hormones, or undergoing surgery. Starting in the 1950s, surgeons and endocrinologists began treating what was then known as transsexualism with cross sex hormones and a variety of surgical procedures collectively known as sex reassignment surgery (SRS). Soon after, Harry Benjamin began work to develop standards of care that could be applied to these patients with some uniformity. These guidelines, published by the World Professional Association for Transgender Health (WPATH), are in their 8th iteration. Through each iteration there has been a requirement that patients requesting gender-affirming hormones (GAH) or gender-affirming surgery (GAS) undergo one or more detailed evaluations by a mental health provider through which they must obtain a “letter of readiness,” placing mental health providers in the role of gatekeeper. WPATH specifies eligibility criteria for gender-affirming treatments and general guidelines for the content of letters, but does not include specific details about what must be included, leading to a lack of uniformity in how mental health providers approach performing evaluations and writing letters. This manuscript aims to review practices related to evaluations and letters of readiness for GAS in adults over time as the standards of care have evolved
via
a scoping review of the literature. We will place a particular emphasis on changing ethical considerations over time and the evolution of the model of care from gatekeeping to informed consent. To this end, we did an extensive review of the literature. We identified a trend across successive iterations of the guidelines in both reducing stigma against TGD individuals and shift in ethical considerations from “do no harm” to the core principle of patient autonomy. This has helped reduce barriers to care and connect more people who desire it to gender affirming care (GAC), but in these authors’ opinions does not go far enough in reducing barriers.
The aim of this study was to assess mobility patterns among a sample of transgender women (n=14) in New York City via survey and Global Positioning System (GPS) monitoring. We found varying levels of ...concordance between the residential neighbourhood and each of the non-residential contexts: 64.3% considered the neighbourhood that they socialised in most often to be different from their residential neighbourhood. While participants' residences represented 10 zone improvement plan code tabulation areas (ZCTAs), GPS data were recorded in 124 of 263 ZCTAs (47.1%). Overall, 58.2% (n=373,262) were recorded in ZCTAs in the highest quartile of human immunodeficiency virus (HIV) prevalence. The association between place, community HIV prevalence, mobility, and factors that increase the vulnerability of transgender women to HIV infection are worthy of future investigation in reducing the burden of the HIV epidemic in these communities.
In June, 2020, the Department of Health and Human Services (DHHS) finalized a rule eliminating protections against health care discrimination based on gender identity.1 This protection from health ...care discrimination was previously afforded by section 1557 of the Affordable Care Act (ACA), with guidance by the Obama administration explicitly stating that transgender individuals were protected by this section. Undoubtedly, these risks are anticipated to worsen as structural barriers to care increase.4 Among transgender adults, 22% (32% among people of color) have no health insurance as compared with 12% of all adults.5 Even for those with insurance, 70% of transgender adults have faced discrimination in medical care and 27% have been refused the care that they need.6 Nearly a quarter avoided the doctor because of fear of mistreatment and denials of life-saving care are routine.7 This stigma and bias has led to chronic mental and physical health disparities among the transgender population. Forty percent of transgender adults have attempted suicide.7 There is an HIV prevalence of 14.1% among transgender women and 44% among black transgender women.10 Transgender adults have rates of cigarette smoking that are 50% higher than the general population.11 As providers caring for transgender youth, the treatment we provide is rooted in evidence demonstrating that individuals with access to care have improved mental health outcomes12,13 and reduced suicidality.14 Section 1557's previous protections for transgender Americans provided access to affirming medical and mental health care for countless citizens and removing these protections will lead to worsening outcomes and increased death.
Purpose:
To date, no studies utilizing global positioning system (GPS) technologies to measure mobility and environmental exposures have been conducted among a sample of transgender women despite the ...potential salient role neighborhood contexts may play in the health of this population. As such, the purpose of this study was to assess the acceptability and feasibility of a weeklong GPS protocol among a sample of transgender women in New York City.
Methods:
A sample of 14 transgender women residing in the New York City metropolitan area were recruited through community based methods to wear and charge a GPS device for 7 days to measure daily mobility. The acceptability of these methods was assessed using a pre- and postprotocol survey and their feasibility was measured using objective data derived from the GPS device. Pre- and postprotocol survey measures were compared using McNemar's test.
Results:
Participants reported high ratings of preprotocol acceptability, as well as few concerns regarding safety, appearance, and losing the device, all of which were maintained after completing the protocol. All 14 devices that were distributed were returned. In addition, all 14 participants had GPS data for at least 1 h on 1 day, and nine participants (64.3%) had at least 8 h of GPS data on all days.
Conclusion:
The findings of this pilot study demonstrate that the GPS methods are both acceptable and feasible among this sample of transgender women. GPS devices may be used in research among transgender women to understand neighborhood determinants of HIV and other STIs.
The study by Berk et al.
highlights potential trajectories of response and nonresponse to dialectical behavior therapy (DBT) as compared to individual and group supportive therapy (IGST) for teens ...with repeated self-harm and suicidal ideation. The authors also posit a testable function to predict responsiveness vs nonresponsiveness and provide critical guidance about when to reassess nonresponders and alter treatment. This is the fourth major article from a large federally funded, randomized controlled trial. Previous publications have highlighted superiority of DBT over IGST,
reported the moderating factors of treatment outcomes,
and explored the mechanism of effectiveness for DBT in the treatment of suicidal ideation and self-harm.
These articles provide useful information given the rising rates of suicidal ideation and suicide attempts among youth
and recent research suggesting the powerful role of social media in supporting contagion of suicidal behavior among youth.
PDF
