For transgender individuals, gender-affirming surgery can lead to long-term mental health benefits, according to new research published in the American Journal of Psychiatry. The study found that among transgender individuals with gender incongruence, undergoing gender-affirming surgery was significantly associated with a decrease in mental health treatment over time.

Researchers Richard Branstrom, Ph.D., and John E. Pachankis, Ph.D., with the Yale School of Public Health, New Haven, Connecticut, used the Swedish Total Population Register to identify more than 2.500 individuals who received a diagnosis of gender incongruence (i.e., transsexualism or gender identity disorder) between 2005 and 2015. Among individuals with gender incongruence, just more than 70% had received hormone treatment and nearly half (48%) had undergone gender-affirming surgical treatment during the 10-year follow-up period. Nearly all (97%) of those who had undergone surgery also received hormone treatment. Less than one-third had received neither treatment.

They analyzed mental health treatment in 2015 in relation to the length of time since gender-affirming hormone and surgical treatment, including distinguishing the potentially interrelated effects of the two treatments. The mental health measures included health care visits for mood and anxiety disorder, antidepressant and anti-anxiety prescriptions, and hospitalization after a suicide attempt.

Increased time since last gender-affirming surgery was associated with reduced likelihood of use of mental health treatment. The study found the odds of receiving mental health treatment were reduced by 8% for every year since receiving gender-affirming surgery over the 10-year follow-up period. They did not find the same association for hormone treatment.

The study also found that compared with the general population, transgender individuals with a gender incongruence were

• about six times as likely to have had a mood or anxiety disorder health care visit;
• more than three times as likely to have received prescriptions for antidepressants and anti-anxiety medication; and
• more than six times as likely to have been hospitalized after a suicide attempt.

Despite the reduced mental health treatment use after gender-affirming surgery, treatment use among transgender individuals continued to exceed that of the general population.

The authors conclude that “in this first total population study of transgender individuals with a gender incongruence diagnosis, the longitudinal association between gender-affirming surgery and reduced likelihood of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them.”

Not all fats are equal in how they affect our skin, according to a new study in the Journal of Investigative Dermatology, published by Elsevier. The investigators found that different ketogenic diets impacted skin inflammation differently in psoriasiform-like skin inflammation in mice. Ketogenic diets heavy in medium-chain triglycerides (MCTs) such as coconut, especially in combination with omega-3 fatty acids from fish oil and plant sources like nuts and seeds, exacerbated psoriasis.

‘This study leads to a broader understanding of possible effects of ketogenic diets with a very high fat content on skin inflammation and underlines the importance of the composition of fatty acids in the diet,” explained co-lead investigator, Barbara Kofler, PhD, Research Program for Receptor Biochemistry and Tumor Metabolism, Department of Pediatrics, Paracelsus Medical University, Salzburg, Austria. “We found that a well-balanced ketogenic diet, limited primarily to long-chain triglycerides (LCTs) like olive oil, soybean oil, fish, nuts, avocado, and meats, does not exacerbate skin inflammation. However, ketogenic diets containing high amounts of MCTs especially in combination with omega-3 fatty acids, should be used with caution since they may aggravate preexisting skin inflammatory conditions.”

Ketogenic diets are increasingly popular because of their promise to treat a number of diseases and promote weight loss. They are currently being evaluated as a potential therapy in a variety of diseases and have been suggested to act as an anti-inflammatory in certain conditions. Dietary products containing coconut oil (high in MCTs) or fish oil (high in omega-3 fatty acids), consumed as part of a ketogenic diet, are marketed and used by the general population because of their reported health promoting effects.

Previous studies have indicated that high-fat diets with a substantial amount of carbohydrates promote the progression of psoriasiform-like skin inflammation and development of spontaneous dermatitis in mice. The investigators therefore hypothesized that high-fat ketogenic diets would dampen psoriasiform-like skin inflammation progression and that partial supplementation of LCT with MCT and/or omega-3 fatty acids would further enhance these effects. Although the study did not confirm that hypothesis, it showed that an LCT-based ketogenic diet does not worsen skin inflammation.

Co-lead investigator Roland Lang, PhD, Department of Dermatology, Paracelsus Medical University, Salzburg, Austria, elaborated on the study’s results, “Ketogenic diets supplemented with MCTs not only induce the expression of pro-inflammatory cytokines, but also lead to an accumulation of neutrophils in the skin resulting in a worse clinical appearance of the skin of the mice. Neutrophils are of particular interest since they are known to express a receptor for MCTs and therefore a ketogenic diet containing MCTs may have an impact on other neutrophil-mediated diseases not limited to the skin.”

Mice used in the study were fed an extremely high-fat (77 percent) ketogenic diet, which is uncommon except for patients following a strict regime for medical conditions like drug-resistant epilepsy. “I think most people following a ketogenic diet don’t need to worry about unwanted skin inflammation side effects. However, patients with psoriasis should not consider a ketogenic diet an adjuvant therapeutic option, noted Dr. Kofler.”

Drinking small amounts of alcohol frequently is linked with a higher likelihood of atrial fibrillation than binge drinking, according to research published today in EP Europace, a journal of the European Society of Cardiology (ESC) (1).

‘Recommendations about alcohol consumption have focused on reducing the absolute amount rather than the frequency,’ said study author Dr. Jong-Il Choi, of Korea University College of Medicine and Korea University Anam Hospital, Seoul, Republic of Korea. ‘Our study suggests that drinking less often may also be important to protect against atrial fibrillation.’

Atrial fibrillation is the most common heart rhythm disorder and raises the risk of stroke by five-fold (^2). Symptoms include palpitations, racing or irregular pulse, shortness of breath, tiredness, chest pain and dizziness (^3).

A prior meta-analysis found a linear correlation between alcohol and atrial fibrillation: risk increased by 8% for every 12 g of alcohol (one drink) consumed per week (^4). But it was not clear which is more important: the total amount of alcohol or the number of drinking sessions.

This study examined the relative importance of frequent drinking versus binge drinking for new-onset atrial fibrillation. The analysis included 9,776,956 individuals without atrial fibrillation who underwent a national health check-up in 2009 which included a questionnaire about alcohol consumption. Participants were followed-up until 2017 for the occurrence of atrial fibrillation.

The number of drinking sessions per week was the strongest risk factor for new-onset atrial fibrillation. Compared with drinking twice per week (reference group), drinking every day was the riskiest, with a hazard ratio (HR) of 1.412, while drinking once a week was the least risky (HR 0.933). Binge drinking did not show any clear link with new-onset atrial fibrillation.

‘Our study suggests that frequent drinking is more dangerous than infrequent binge drinking with regard to atrial fibrillation,’ said Choi. ‘The number of drinking sessions was related to atrial fibrillation onset regardless of age and sex. Repeated episodes of atrial fibrillation triggered by alcohol may lead to overt disease. In addition, drinking can provoke sleep disturbance which is a known risk factor for atrial fibrillation.’

In keeping with other studies, weekly alcohol consumption was related to atrial fibrillation. There was a 2% increase in the risk of new-onset atrial fibrillation for each gram of alcohol consumed per week. Compared to mild drinkers, those who drank no alcohol, moderate, or high amounts had 8.6%, 7.7%, and 21.5% elevated risks respectively.

Choi said the protective effect of mild drinking needs to be confirmed. ‘It is not clear if this is a true benefit or a confounding effect of unmeasured variables,’ he said.

He concluded: ‘Atrial fibrillation is a disease with multiple dreadful complications and significantly impaired quality of life. Preventing atrial fibrillation itself, rather than its complications, should be our first priority. Alcohol consumption is probably the most easily modifiable risk factor. To prevent new-onset atrial fibrillation, both the frequency and weekly amount of alcohol consumption should be reduced.’

###

REFERENCES

1. Kim YG, Han KD, Choi JI, et al. Frequent drinking is a more important risk factor for new-onset atrial fibrillation than binge drinking: a nationwide population-based study. Europace. 2019. doi:10.1093/europace/euz256.
2. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37:2893-2962. doi:10.1093/eurheartj/ehw210.
3. Learn to recognise signs and symptoms of atrial fibrillation: https://www.afibmatters.org/en_GB/Signs-and-symptoms.
4. Larsson SC, Drca N, Wolk A. “Alcohol consumption and risk of atrial fibrillation: a prospective study and dose-response meta-analysis.” J Am Coll Cardiol. 2014;64:281-289. doi:10.1016/j.jacc.2014.03.048.

A study from Nationwide Children’s Hospital and the Central Ohio Poison Center found rates of suicide attempts by self-poisoning among youth and adolescents are higher in rural communities, higher during the academic school year and involve common medications found in many households.

The study, published online in Clinical Toxicology, expands on previous research that evaluated the incidence and outcomes from intentional suspected-suicide self-poisoning in children and young adults ages 10 to 24 years old from 2000-2018. In that 19-year time frame, there were more than 1.6 million intentional suspected-suicide self-poisoning cases in youth and young adults reported to US poison centers. The majority of cases were female (71%), and involved a pharmaceutical (92%).

“While most of these cases involved medications, with adolescents, any available medication can be a potential hazard,” said Henry Spiller, MS, D.ABAT, director of the Central Ohio Poison Center at Nationwide Children’s, and co-author of the study. “It’s not so much a matter of substance type, but rather a matter of access to the substance. Any type of medication can be misused and abused in ways that can unfortunately lead to very severe outcomes, including death.”

The two most common substance groups in all age groups were over-the-counter (OTC) analgesics – such as acetaminophen, ibuprofen and aspirin – followed by antidepressants. In youth and adolescents 10-12 and 13-15 years old, ADHD medications were common, and had the highest risk of serious medical outcomes. Opiates only accounted for 7% of cases with serious medical outcomes.

“Because medications are so readily available in homes, many families do not take precautions to store them safely. Our findings suggest this is a big problem,” said John Ackerman, PhD, clinical psychologist and suicide prevention coordinator for the Center for Suicide Prevention and Research at Nationwide Children’s, and co-author of the study. “Medications can be part of effective treatment, but they require an extra layer of care. The answer is not to stop prescribing medications to those who stand to benefit, but rather to emphasize the practice of safe storage and vigilance when administering any kind of medicine, especially when children and teens live in the home.”

The study also found that places with a lower population per square mile (rural areas) had a greater number of reported cases with all outcomes and serious medical outcomes. Results also revealed there was a significant decrease in the number of cases in school-aged individuals during non-school months of June through August (27.5% decrease in 10-12-year-olds; 27.3% decrease in 13-15-year-olds; and 18.3% decrease in 16-18-year-olds), compared with school months September through May.

This issue is worth highlighting for the LGBTQIA community because 50.8% of transmasculine adolescents between the ages of 11 and 19 have attempted suicide at least once, while 41.8% of nonbinary adolescents – those who don’t identify as exclusively male or exclusively female – have attempted suicide.

Nationwide Children’s Big Lots Behavioral Health experts recommend that parents check in with their children regularly, and ask them directly how they are doing and if they have ever had thoughts about ending their life. These direct questions are even more critical if warning signs of suicide are observed. Medications should be stored up, away and out of sight, preferably in a locked cabinet. Administration of medicine should always be supervised.

“It should concern us that youth in rural areas are about twice as likely as those living in urban areas to die by suicide. Although we are in dire need of more research to help us understand what places some people at more risk than others, available evidence indicates that include increased social isolation, stigma, access to lethal means and lack of appropriate mental health resources may play a role in this disparity,” said Ackerman. “It is vital that parents, teachers and other trusted adults start conversations about mental health early, and pay even closer attention during the school year, as rates of anxiety and depression are shown to increase during that time. Warning signs can often be detected and support is available for young people in crisis.”

Dr. Ackerman recommends parents start now to increase the dialogue and have important conversations as a family.

Male breast cancer (MBC) comprises one percent of all breast cancer cases, yet no prospective randomized clinical trials specifically focused on MBC have been successfully completed. Some studies suggest that the incidence of MBC may be rising, however, and there is an increasing appreciation that the tumor biology of MBC differs from that of female breast cancer.

To examine how MBC has been treated in recent years, and to identify factors associated with patient prognosis, a team led by Kathryn Ruddy, MD, MPH, and Siddhartha Yadav, MBBS, at Mayo Clinic in Rochester, analyzed information from the National Cancer Database on men diagnosed with stage I-III breast cancer between 2004 and 2014.

A recent analysis reveals that treatment of male breast cancer has evolved over the years. In addition, certain patient-, tumor-, and treatment-related factors are linked with better survival. The findings are published early online in CANCER, a peer-reviewed journal of the American Cancer Society.

For this study, a total of 10,873 patients with MBC were included, with a median age at diagnosis of 64 years. Breast-conserving surgery was performed in 24% of patients, and 70% of patients undergoing breast conservation received radiation. Forty-four percent of patients received chemotherapy, and 62% of patients whose tumors expressed the estrogen receptor received anti-estrogen therapy. During the study period, there was a significant increase in the rates of total mastectomy, contralateral prophylactic mastectomy, and post-breast conservation radiation, as well as an increase in the rate of genomic testing on tumors and the use of anti-estrogen therapy. Tamoxifen is the standard anti-estrogen medication recommended for treatment of hormonally sensitive MBC, but this study was not able to assess specific medications used.

Factors associated with worse overall survival were older age, black race, multiple comorbidities, high tumor grade and stage, and undergoing total mastectomy. Residing in higher income areas; having tumors that express the progesterone receptor; and receiving chemotherapy, radiation, and anti-estrogen therapy were associated with better overall survival.

The study “highlights unique practice patterns and factors associated with prognosis in MBC, furthering our understanding of the treatment and prognosis of MBC,” said Dr. Ruddy. “The racial, economic, and age-related health disparities we found could inform future efforts to target interventions to optimize outcomes in men with breast cancer.”

This is assuming members of the LGBTQIA community have accepting fathers, of course.

Lesbian, gay, and bisexual (LGB) individuals who report being discriminated against but who feel close to their fathers have lower levels of C-reactive protein (CRP), a measure of inflammation and cardiovascular risk–than those without support from their fathers, finds a new study from researchers at NYU College of Global Public Health.

The findings, published in the journal Psychoneuroendocrinology, suggest that fathers can play a role protecting against the negative effects of discrimination and, surprisingly, mothers may not play the same role. More generally, the study illustrates how prolonged exposure to stress can hurt sexual minorities.

LGB people experience stress and discrimination related to their sexual orientation, including dealing with stigma, microaggressions, and the process of coming out. Research shows that prolonged or repeated exposure to stress, including discrimination, leads to the production of inflammatory proteins such as CRP and raises one’s risk for heart disease.

“I’m interested in understanding how discrimination gets under the skin and is linked to poor health outcomes,” said Stephanie Cook, assistant professor of biostatistics and social and behavioral sciences at NYU College of Global Public Health and the study’s senior author. “What factors make people more resilient and can protect them from these health effects? We know that social support can act as a buffer, but wanted to better understand the role parents play in how their children experience discrimination and its health effects.”

In this study, the researchers analyzed data from the National Longitudinal Study of Adolescent to Adult Health. Adults 24 to 33 years old were surveyed about their sexual orientation, how close they felt with their mothers or mother-figures and fathers or father-figures, and whether they felt discriminated against or treated with less respect than others in their day-to-day lives. The researchers focused on 3,167 adults describing their relationships with their fathers and 3,575 describing their relationships with their mothers. Blood samples were used to measure CRP levels.

The researchers found that when LGB people felt discriminated against in their day-to-day lives but described being close to their fathers, they had lower CRP levels than other sexual minorities who were discriminated against but did not have close relationships with their fathers.

Relationships between LGB people and their fathers can act as either a buffer or an additional source of stress. On one hand, positive social support from a father appears to protect sexual minorities from harmful experiences related to discrimination. On the other, poor social support from one’s father–for instance, fathers who do not accept their children’s sexual orientation after they come out–may lead to exacerbated stress and less ability to shield against harmful experiences related to discrimination.

Interestingly, the researchers found that closeness with mothers did not act as a buffer for LGB or heterosexual individuals who experienced discrimination.

“We often talk about the importance of support from mothers and how mothers can help buffer the negative effects of discrimination on health broadly. But this study suggests that we’ve been neglecting the role of fathers, and their role is really important when it comes to their LGB children,” said Cook, who leads the Attachment and Health Disparities Research Lab at NYU College of Global Public Health.

“If we’re trying to understand the effects of discrimination on sexual minorities and figure out what we can do to intervene or prevent these outcomes, we should look beyond support from just peers and mothers to include fathers in our efforts,” said Erica Wood, a research scientist in the Attachment and Health Disparities Research Lab at NYU College of Global Public Health and the study’s first author. “For instance, professionals can work with fathers who reject their children because of their sexual identity to show them the importance of the father-child relationship in reducing the negative effects of stress.”