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 as few studies have examined gender-affirming hormone continuation rates among TGD individuals.
We performed a secondary analysis of 2009-2018 medical and pharmacy records from the U.S. Military Healthcare System. We identified TGD patients who were children and spouses of active-duty, retired, or deceased military members using ICD-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.
The study sample included 627 transmasculine and 325 transfeminine individuals with an average age of 19.2 ± 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 (HR 1.69 (1.14-2.52) were independently associated with increased discontinuation rates.
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, prior to age 18 have higher continuation rates than adults.
Pediatricians render care in an increasingly complex environment, which results in multiple opportunities to cause unintended harm. National awareness of patient safety risks has grown since the ...National Academy of Medicine (formerly the Institute of Medicine) published its report "To Err Is Human: Building a Safer Health System" in 1999. Patients and society as a whole continue to challenge health care providers to examine their practices and implement safety solutions. The depth and breadth of harm incurred by the practice of medicine is still being defined as reports continue to reveal a variety of avoidable errors, from those that involve specific high-risk medications to those that are more generalizable, such as patient misidentification and diagnostic error. Pediatric health care providers in all practice environments benefit from having a working knowledge of patient safety language. Pediatric providers should serve as advocates for best practices and policies with the goal of attending to risks that are unique to children, identifying and supporting a culture of safety, and leading efforts to eliminate avoidable harm in any setting in which medical care is rendered to children. In this Policy Statement, we provide an update to the 2011 Policy Statement "Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care."
Abstract
Background
Widely published findings from the COVID-19 pandemic show adverse effects on body mass index (BMI) and behavioral health in both adults and children, due to factors such as ...illness, job loss, and limited opportunity for physical and social activity. This study investigated whether these adverse effects were mitigated in adolescents from military families, who are universally insured with consistent access to healthcare, and who generally have at least one parent who must adhere to physical and mental fitness as a condition of employment.
Methods
We conducted a cohort study using two groups of adolescents receiving care in the U.S. Military Health System during the COVID-19 pandemic; one for changes in Body Mass Index (BMI) and the second for changes in behavioral health diagnoses, using TRICARE claims data. Beneficiaries (160,037) ages 13 to 15 years in fiscal years 2017–2018, were followed up during October 2020 to June 2021.
Results
Among the BMI cohort, 44.32% of underweight adolescents moved to healthy weight, 28.48% from overweight to obese, and 3.7% from healthy weight to underweight. Prevalence of behavioral disorders showed an overall 29.01% percent increase during the study period, which included in mood (86.75%) and anxiety (86.49%) disorders, suicide ideation (42.69%), and suicide attempts (77.23%). Decreases in percent change were observed in conduct disorders (-15.93%) and ADD/ADHD (-8.61%).
Conclusions
Adolescents in military families experienced adverse health outcomes during the pandemic at approximately the same rates as those in non-military families, suggesting that universal insurance and military culture were not significantly mitigating factors. Obesity and underweight present significant opportunities to intervene in areas such as exercise and food access. Decreased conduct disorders and ADD/ADHD may reflect lower prevalence due to favorable home environment, or lower rates of diagnosis and referral; however, increased rates of anxiety, mood disorders, suicide ideation and attempt are especially concerning. Care should be taken to ensure that adolescents receive consistent opportunity for physical activity and social interaction, and those at risk for suicide should receive active monitoring and appropriate referral to behavioral healthcare providers.
The Military Health System is one of the largest integrated health care systems in the United States. It is composed of a "direct care" system of military treatment facilities managed in a federated ...manner by the Army, Navy, Air Force, and Defense Health Agency and a "purchased care" component that consists of a network of health care providers managed through TRICARE. The system is undergoing significant reform and transformation. In 2017 Congress directed the Department of Defense (DoD) to consolidate all DoD military treatment facilities of the Army, Navy, and Air Force under the Defense Health Agency, while at the same time DoD civilian leaders put additional pressure on the system to accelerate reform efforts across the enterprise. Similar to other health systems, the Military Health System is under pressure to achieve greater efficiencies and reduce costs. This article portrays the drivers for consolidation of the three medical departments-those of the Army, Navy, and Air Force-under one agency and reflects on the impacts of this transformation in light of the DoD's unique mission.
It is estimated that 30 million children in the US participate in organised sports programmes. As more and more children participate in sports and recreational activities, there has been an increase ...in acute and overuse injuries. Emergency department visits are highest among the school-age to young adult population. Over one-third of school-age children will sustain an injury severe enough to be treated by a doctor or nurse. The yearly costs have been estimated to be as high as 1.8 billion US dollars. There are physical and physiological differences between children and adults that may cause children to be more vulnerable to injury. Factors that contribute to this difference in vulnerability include: children have a larger surface area to mass ratio, children have larger heads proportionately, children may be too small for protective equipment, growing cartilage may be more vulnerable to stresses and children may not have the complex motor skills needed for certain sports until after puberty. The most commonly injured areas of the body include the ankle and knee followed by the hand, wrist, elbow, shin and calf, head, neck and clavicle. Contusions and strains are the most common injuries sustained by young athletes. In early adolescence, apophysitis or strains at the apophyses are common. The most common sites are at the knee (Osgood-Schlatter disease), at the heel (Sever's disease) and at the elbow (Little League Elbow). Non-traumatic knee pain is one of the most common complaints in the young athlete. Patellar Femoral Pain Syndrome (PFPS) has a constellation of causes that include overuse, poor tracking of the patellar, malalignment problems of the legs and foot problems, such as pes planus. In the child, hip pathology can present as knee pain so a careful hip exam is important in the child presenting with an insidious onset of knee pain. Other common injuries in young athletes discussed include anterior cruciate ligament injuries, ankle sprains and ankle fractures. Prevention of sports and recreation-related injuries is the ideal. There are six potential ways to prevent injuries in general: (i) the pre-season physical examination; (ii) medical coverage at sporting events; (iii) proper coaching; (iv) adequate hydration; (v) proper officiating; and (vi) proper equipment and field/surface playing conditions.
ABSTRACTThe purpose of this article is to commemorate the 30th anniversary of the Emergency Medical Services for Children (EMSC) program. For the last 30 years, the EMSC has had a significant impact ...on transforming emergency care for children. The program has contributed to the creation of pediatric emergency medicine as a subspecialty and, importantly, has institutionalized pediatrics into the nation’s emergency medical services systems.This article describes the history of the program, its components, and the return on investment over the years. The EMSC has undergone many changes since its inception, and now, because the health care system is rapidly changing, the EMSC must continue to ensure that children and their families receive the best emergency care possible. The EMSC community is poised to envision and adapt its mission to leverage opportunities in this rapidly changing environment to ensure that children receive and continue to receive high-quality emergency care services.
ABSTRACTA 10-year-old girl with a 2-week history of atraumatic back pain presented to the emergency department with difficulty ambulating and a history of 2 episodes of urinary incontinence in the ...past week. Her examination was significant for pain with movement, tenderness to palpation in the lower thoracic spine, and no neurological deficits. In this case, the child was found to have a Schmorl node at T8 in the superior aspect of the vertebral body. Schmorl nodes are protrusions of the cartilage of the intervertebral disc through the vertebral body endplate and into the adjacent that is more commonly reported in the adult population. In this child, radiographic findings were normal, with no evidence of the Schmorl node. The diagnosis was made by magnetic resonance imaging. The childʼs symptoms significantly resolved with ibuprofen anti-inflammatory therapy. In children with atraumatic back pain lasting greater than 2 weeks with a sudden increase in severity and associated with a neurological deficit, advanced imaging is strongly recommended.
This study examines how the rate at which transgender and gender-diverse youth have sought gender-affirming health care from the military health services between 2010 and 2017.
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