POTD: The Transgender Patient

Alejandro Romero · January 6, 2020 · Special Topics

FAST FACTS

A transgender person is someone whose gender identity differs from their sex assigned at birth
“Gender identity” is self-identified and different from “sex” (i.e. “Sex is what’s between your legs, gender is what’s between your ears”)
Some people identify outside of the male-female binary (gender nonbinary, or gender fluid) and this includes people who identify as both, neither, or in between
Transgender identity is not a mental disorder
28% of transgender patients report postponing necessary medical care due to prior negative experiences
19% of transgender patients reported being denied care because they are transgender

HOW TO GREET THE TRANSGENDER PATIENT

“Hello, My name is Dr. ____________. What name do you go by? What pronouns do you use?”

PATIENT HISTORY and EXAMINATION

Prepare the patient for difficult questions by contextualizing why you’re asking them
Ask about gender-affirming hormones and surgeries if relevant
Determine sexual activity and pregnancy risk
As with any patient, do not perform invasive physical exams if not medically warranted (i.e., don’t do a genital exam on a patient presenting with a nose bleed)

HORMONES

Not every patient uses hormones for a variety of reasons, including lack of access
Masculinizing hormone: Testosterone - suppresses menses, increases libido, increases clitoral size, deepens voice, produces male pattern fat, muscle, and hair distribution, increases energy
Feminizing hormones: 17-beta-estradiol and anti-androgens such as spironolactone, finasteride, and gonadotropin-releasing hormone analogues
Testosterone does not provide a form of birth control

GENDER-AFFIRMING HORMONE THERAPY-RELATED COMPLICATIONS

Masculinizing Hormone Therapy
- Erythrocytosis - can increase risk of VTE and cerebrovascular disease
Feminizing Hormone Therapy
- Hypercoagulability (VTE)
- Electrolyte imbalances (hyperkalemia with spironolactone use)
- Prolactinoma
- Cardiovascular disease risk increase
Non-medically prescribed hormones
- Patients may take these due to lack of access
- Shared injectable hormones increase risk of HIV and hepatitis
- Birth control pills often used in place of prescribed estrogen

ISSUES AFFECTING TRANSGENDER PATIENTS

HIV and other STIs
Substance abuse (drug and alcohol)
Mental health disorders (depression, anxiety, SI)
Physical assault
Homelessness

Source: Tintinalli's Emergency Medicine, 9th Edition pp 1997-2000

POTD: Less Commonly Abused Hallucinogens

Alejandro Romero · January 3, 2020 · Toxicology

We’ve reviewed the most commonly abused hallucinogens in previous POTD, but how do you recognize and treat a patient that has “licked a toad”? And how would you treat a college student who got high off nutmeg? Here we discuss several less commonly abused hallucinogens:

Salvia
   ▪   Salvia divinorum
   ▪   a.k.a, “Salvia” “Sally” “Magic Mint”
   ▪   Smoked or chewed
   ▪   Not currently regulated under the U.S. Controlled Substances Act
   ▪   Symptoms/Effects: Visual hallucinations, object and body distortions, dysphoria, incoordination, dizziness, slurred speech
   ▪   Duration: Up to 30 minutes
   ▪   Treatment: Supportive

Bufotoxins
   ▪   bufotenine and 5-methoxy-dimethyltryptamine from venomous toads
   ▪   also contains cardioactive steroids, and catecholamines
   ▪   a.k.a., “love stone” “rock hard”
   ▪   Obtained from extract or “licking a toad”
   ▪   Symptoms/effects: Powerful psychedelic, GI irritation, salivation, n/v, cardiac toxicity similar to acute digoxin poisoning, hyperkalemia, bradycardia, AV block, Vtach, Vfib, cardiac arrest
   ▪   Serum digoxin immunoassay often positive
   ▪   Treatment: Atropine for bradyarrhythmias, may require pacemaker; antiarrhythmics for ventricular arrhythmia; dig-Fab Ab treatment has been effective

Morning Glory Seeds
   ▪   Ipomoea violacea, Ipomoea tricolor, etc
   ▪   Contain compounds similar to LSD
   ▪   Seeds ingested for their hallucinogenic effects
   ▪   Symptoms/effects: Similar to LSD
   ▪   Treatment: Reassurance, benzodiazepines in severe cases

Nutmeg
   ▪   Myristica fragrans
   ▪   Active compound: myristicin
   ▪   Large amounts of nutmeg (1-3 nutmeg seeds) can cause delirium with hallucinations
   ▪   Symptoms/effects: Hallucinations, tachycardia, flushing, dry mouth, nausea, abdominal pain
   ▪   May resemble anticholinergic poisoning, but pupils are small or normal
   ▪   Duration: 6 to 24 hours
   ▪   Treatment: Supportive

Jimson weed and Angel’s Trumpet
   ▪   Datura stramonium and Datura candida, respectively
   ▪   Contain atropine, scopolamine, and hyoscyamine
   ▪   Seeds/other parts of plant ingested or smoked
   ▪   Symptoms/effects: Delirium, hallucinations, seizures, anticholinergic effects
   ▪   GI emptying delayed and small seeds can become trapped in GI folds after ingestion
   ▪   Treatment: Consider GI decontamination in select cases with whole bowel irrigation for large ingestions, avoid anticholinergic medications, may try physostigmine

Source: Tintinalli’s Emergency Medicine, 9th Edition, Chapter 188: Hallucinogens pp 1247-1248

POTD: 3 Common Anti-Vaxxer Beliefs

Alejandro Romero · January 2, 2020 · Infectious Disease

“It is better to light a candle than to curse the darkness” - Carl Sagan

In an era where “fake news” threatens the fabric of our society, we as physicians have a duty to educate our patients and fight the insidious creep of disinformation. We often think of anti-vaxxers as granola-eating, compost pile-making eccentrics living off the grid somewhere in Montana, when the truth is that even some amongst own hospital colleagues may espouse these beliefs.

Here, we discuss three common arguments made by anti-vaxxers in supporting their stance and counterarguments based on empirical evidence we may use to challenge them.

FALSE: Vaccines cause undue harm due to antigenic overload

   ▪   A misconception propagated by Robert W. “Doctor Bob” Sears that holds infants are incapable of responding safely to the “large number” of vaccine antigens given and that antigenic overload results in a “cytokine storm” or “immune cascade” that triggers adverse health events.

   ▪   Not surprisingly, “Dr. Bob” failed to cite any data to support this claim.

Counterarguments:

   ▪   From the moment of their birth, infants encounter numerous microorganisms and their antigens at a level far exceeding the antigen exposure due to vaccines.

   ▪   Numerous studies show that vaccines are safe and efficacious at the routine vaccine schedule with no evidence of an “antigenic overload.”

   ▪   Infants and children today actually receive far less antigenic “exposure today” with routine vaccination than they did in the past. The smallpox vaccine given in the 1900s contained 200 proteins and the whole cell pertussis component of DTwP vaccine given in the US up until the 1990s contained approximately 3,000 proteins. Today, the entire schedule of 15 recommended vaccines from birth to age 5 contains no more than 150 proteins and polysaccharides.

FALSE: Vaccines can result in autoimmune diseases such as T1DM, MS, and GBS.

Counterarguments:

   ▪   A panel of experts of the Institute of Medicine recently reviewed more than 12,000 published reports and failed to find any evidence whatsoever for the development of any of these three autoimmune diseases as a result of vaccines.

   ▪   The diversity of antigens presented during “natural” infection support the counterclaim that infections are more likely than vaccines to result in autoimmune phenomena, such as influenza virus or Campylobacter infection causing GBS.

FALSE: Immunity produced by “natural infection” is safer than vaccine-induced immunity.

Counterarguments:

   ▪   Wild type influenza kills 1 in every 8,300 Americans. No deaths have been attributed to the flu vaccine.

   ▪   The flu vaccine does not cause myocarditis, PNA, bronchitis, sinusitis, or significant amounts of lost work and school time — but “natural” influenza certainly does.

   ▪   While “natural” measles virus infection does provide lifelong immunity, it also causes death in about 1 out of every 3,000 cases, as well as other non-lethal and disabling complications. The measles vaccine has not been associated with death or disabling complications, despite billions of vaccine doses given.

Harms done by the anti-vaccine movement

   ▪   The anti-vaccine movement has successfully pressured numerous countries to discontinue use of the pertussis vaccine. These countries now have a documented 10- to 100-fold increased in morbidity and mortality from pertussis.

   ▪   Doctor Bob Sear’s alternative vaccination schedule has resulted in under-vaccination and measurable increased rates of measles and pertussis.

   ▪   Europe, Australia, New Zealand, and the Americas are now seeing major outbreaks of measles as a result of Wakefield’s fraudulent study claiming a link between the MMR vaccine and measles.

   ▪   In a Wisconsin survey, 31% of parents who refused vaccination cited “autism” as their reason.

Poland et al (2012) “The clinician’s guide to the anti-vaccinationists’ galaxy.” Human Immunology, Volume 73, Issue 859-866