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Teaching LGBTQ+ Health: 10 Clinical Pearls

lgbtq+ health teaching course

Are you confident in your skills when taking care of LGBTQ+ patients? Are you able to teach principles of LGBTQ+ health to trainees in your clinical practice and the classroom setting? Learners across the health professions demand improved LGBTQ+ health content and additional training opportunities in their schools’ curricula. However, most clinician educators received little, if any, training in LGBTQ+ health when they were students.

10 Clinical Pearls on Teaching About LGBTQ+ Health

The following are some sneak-peak clinical pearls from the Teaching LGBTQ+ Health online course that just launched. This open access, interactive, CME course was published in conjunction with National LGBT Health Awareness Week (March 22-26, 2021). It was developed by Stanford Medicine and designed by Dr. Michael Gisondi (Stanford Emergency Medicine), Timothy Keyes (Stanford SOM), Shana Zucker (Tulane SOM), and Deila Bumgardner (Stanford EdTech) in collaboration with the Medical Student Pride Alliance. 

  1. LGTBQ+ health encompasses so much more than the historical, one-dimensional portrayals of gay men previously used to teach about HIV/AIDS.
  2. Treat your LGBTQ+ patients with dignity and respect by correctly using LGBTQ+ health vocabulary. 
  3. Language is both fluid and deeply personal—not all LGBTQ+ patients refer to themselves with similar terms, and the ways in which these terms are used may change over time.
  4. Sex, gender, and sexual orientation are related but distinct concepts. 
  5. Intersecting minority statuses have a synergistic effect on the health and health-seeking behaviors of LGBTQ+ patients.
  6. The CDC recommends the use of ‘The 5 P’s of Sexual Health’ framework for obtaining a sexual history.
  7. In accordance with the PARTNER2 study, ‘undetectable = untransmittable.’
  8. Compliance with PrEP (pre exposure prophylaxis) for HIV reduces the risk of acquiring HIV by approximately 99%.
  9. Transmasculine patients seek routine primary care and Pap testing less frequently than cisgender patients.
  10. Create inclusive clinical environments that are affirming to queer patients, staff, and students.

Online Course: Teaching LGBTQ+ Health

Teaching LGBTQ+ Health is a new, online, faculty development course designed to bridge the gap between the expectation of faculty teaching competency and a lack of previous training. The intended audience includes educators across the health professions, though the content is also made freely available to all providers, students, patients, and other interested individuals.

This course serves as an introductory primer that assumes no prior knowledge of LGBTQ+ health issues. The course includes both LGBTQ+ health content and recommendations for teaching this material to trainees in any discipline or clinical department. Educators may freely download portions of the course for use in their daily clinical teaching or their school’s curriculum.

This online course is divided into modules that review topics such as LGBTQ+ Vocabulary, Social and Behavioral Determinants of Queer Health, Disease Prevention, and Teaching Strategies, among others. A comprehensive glossary of key terms and 3 interactive, clinical case examples are provided to reinforce key concepts. The entire course is evidence-based and extensive references to medical literature are provided. 

If you learn something new by from our course, we respectfully ask that you share the course within your clinical department and with a few colleagues outside your institution.

By |2021-03-19T10:57:09-07:00Mar 23, 2021|CME, Public Health|
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EMRad: Radiologic Approach to the Pediatric Traumatic Elbow X-ray

This is EMRad, a series aimed at providing “just in time” approaches to commonly ordered radiology studies in the emergency department [1]. When applicable, it will provide pertinent measurements specific to management, and offer a framework for when to get an additional view, if appropriate. We recently covered the adult elbow, here we will cover the approach to the pediatric elbow.

Learning Objectives

  1. Interpret traumatic pediatric elbow x-rays using a standard approach
  2. Identify clinical scenarios in which an additional view might improve pathology diagnosis

Why the pediatric elbow matters and the radiology rule of 2’s

The Pediatric Elbow

  • 10% of all pediatric fractures involve the elbow [2].
  • Missed injuries can cause significant deformity, pain, or functional/neurologic complications [2].

Before we begin: Make sure to employ the rule of 2’s [3]

  • 2 views: One view is never enough.
  • 2 abnormalities: If you see one abnormality, look for another.
  • 2 joints: Image above and below (especially for forearm and leg).
  • 2 sides: If unsure regarding a potential pathologic finding, compare to another side.
  • 2 occasions: Always compare with old x-rays if available.
  • 2 visits: Bring the patient back for repeat films.

An approach to the traumatic pediatric elbow x-ray

  1. Adequacy / Alignment
  2. Effusions or Fat Pads
  3. Bones, Growth Plates, and Ossification Centers
  4. Consider an additional view

1.   Adequacy / Alignment

2.   Effusions or Fat Pads

  • An anterior fat pad can be normal, but is considered pathologic if excessively prominent (usually around ≥20 degrees from the humerus, or “sail sign”).
  • A clearly visualized posterior fat pad is always pathologic.
  • If either the sail sign or posterior fat pad is present, consider a supracondylar fracture or intra-articular fracture (e.g. lateral condyle fracture )

Sail sign

Figure 1: Measurement of apical angle of the anterior fat pad ≥ 20 degrees, concerning for sail sign. There is also a visible posterior fat pad. Case courtesy of Dr. Ian Bickle, Radiopaedia.org. Annotations by Daniel Ichwan, MD.

3.   Bones, Growth Plates, and Ossification Centers

Elbow x-ray

Figure 2: Lateral and AP x-rays of the elbow demonstrating humerus (green), radius (violet), and ulna (blue). Case courtesy of Dr. Jeremy Jones, Radiopaedia.org. Annotations by Daniel Ichwan, MD.

  • Immature bones with open growth plates (physes) are susceptible to injuries (Salter-Harris fractures) with important growth implications.
    • The Salter-Harris classification is as follows below:
      • Salter-Harris Type 1 (“Slipped”) – epiphysis (part of bone between the growth plate and adjacent joint) separates from metaphysis (neck portion of a long bone).
        • Pearl: Can appear radiographically normal, but tender on physical exam.
        • Requires splinting and ortho follow-up.
      • Type 2 (“Above”) – involves metaphysis (“above the physis”).
        • Requires splinting and ortho follow-up.
      • Type 3 (“Lower”) – involves epiphysis (“below the physis”).
        • Consult orthopedics in the department.
      • Type 4 (“Through”) – involves both the metaphysis and epiphysis.
        • Consult orthopedics in the department.
      • Type 5 (“Erasure”) – crushing of physis. May appear normal or focal narrowing of physis.
        • Consult orthopedics in the department

Figure 3: Salter-Harris Classification. Case courtesy of Dr. Matt Skalski, Radiopaedia.org.

  • Pediatric bones have a stronger periosteum than the underlying incompletely ossified bones.
    • Watch out for bowing, torus, greenstick, or avulsion injuries.
  • Trace each bone’s cortex carefully on both AP and lateral views.
  • Pay close attention to all aspects of the humerus, radius, and ulna.
  • Locate each expected ossification center per the patient’s age.
    • If there is one missing or seemingly prematurely present, consider a fracture.

Figure 4: Ossification centers on (a) AP pediatric elbow x-ray (case courtesy of Dr. Leonardo Lustosa, Radiopaedia.org) and (b) lateral pediatric elbow x-ray. Note that not all ossification centers are visible in this view (case courtesy of Dr. Ian Bickle, Radiopaedia.org. Figure 6 (b) annotations by Daniel Ichwan, MD

 

Table 1: Order and timing of appearance of elbow ossification centers. Some people remember this order by using the mnemonic “CRITOE”: capitellum, radial head, internal (medial) epicondyle, trochlea, olecranon, and external (lateral) epicondyle.

4.  Consider an Additional View

Oblique View

  • When: Sometimes included as the 3rd view in a series
  • Why: This is better at seeing the radiocapitellar joint, medial epicondyle, radioulnar joint, and coronoid process. Consider obtaining this view if there is a high suspicion for a subtle lateral condyle fracture or radial head fracture.

Elbow xray

Figure 6: Lateral oblique x-ray of the elbow. Case courtesy of Dr. Craig Hacking, Radiopaedia.org.

X-rays of Contralateral Elbow

  • Given variation among patients, sometimes it might be necessary to image the contralateral extremity to clarify whether the questionable finding is pathologic or actually normal.

References

  1. Schiller, P. et al. Radiology Education in Medical School and Residency. The views and needs of program directors. Academic Radiology, Vol 25, No 10, October 2018. PMID: 29748045
  2. DeFroda SF, Hansen H, Gil JA, Hawari AH, Cruz AI Jr. Radiographic Evaluation of Common Pediatric Elbow Injuries. Orthop Rev (Pavia). 2017;9(1):7030. Published 2017 Feb 20. PMID: 28286625
  3. Chan O. Introduction: ABCs and Rules of 2. In: ABC of Emergency Radiology. John Wiley & Sons, Ltd; 2013:1-10.
  4. Blumberg SM, Kunkov S, Crain EF, Goldman HS. The predictive value of a normal radiographic anterior fat pad sign following elbow trauma in children. Pediatr Emerg Care. 2011 Jul;27(7):596-600. PMID: 21712751
  5. Black KL, Duffy C, Hopkins-Mann C, Ogunnaiki-Joseph D, Moro-Sutherland D. Musculoskeletal Disorders in Children. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. McGraw-Hill; Accessed December 22, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109408415
By |2021-05-15T12:49:15-07:00Mar 19, 2021|EMRad, Orthopedic, Pediatrics, Radiology, Trauma|
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SplintER Series: Venous Thoracic Outlet Syndrome

 

A 29-year-old male presents with right shoulder pain, throbbing, and swelling. He states that a bulge has appeared over his right anterior shoulder recently (Image 1). While he was doing pushups today, he began to have numbness, tingling, and weakness in his right arm. While in the waiting room, his symptoms have completely resolved.

axillary varix

Image 1: Bedside ultrasound of the anterior shoulder at the site of the bulge. AA=axillary artery. AV=axillary vein. Author’s image.

 

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By |2021-03-16T18:12:40-07:00Mar 17, 2021|Expert Peer Reviewed (Clinical), Orthopedic, SplintER|
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Does the Combination of Parenteral Olanzapine with Benzodiazepines for Agitation in the ED Increase the Risk of Adverse Events?

A previous EM Pharm Pearl focused on the adverse events associated with the use of IV olanzapine for agitation. This pearl addresses concerns around using parenteral (IV or IM) olanzapine with parenteral benzodiazepines.

Background

Olanzapine has two FDA boxed warnings, one for increased mortality when used long-term in older adults with dementia-related psychosis and another pertaining to adverse effects of extended release IM olanzapine. However, there exists a potential risk of excess sedation and respiratory depression when IM/IV olanzapine is administered with parenteral benzodiazepines for agitation. The European Medicines Agency recommends separating the administration of IM/IV olanzapine and parenteral benzodiazepines by at least 60 minutes. The FDA does not have a specific recommendation regarding separation of the 2 medications, but cautions against co-administration citing a lack of data. Currently, IM olanzapine is the only second generation antipsychotic with a precaution listed in its FDA prescribing information. This advisory is the result of 160 post-marketing adverse events, including 29 fatalities, associated with IM olanzapine [1].

Literature

When the above cases submitted to the FDA are thoroughly investigated, the problem appears to be related to polypharmacy rather than an olanzapine/benzodiazepines alone [2, 3]. This FOAMcast podcast provides an excellent summary of the data (Table 1). Additionally, the timing of fatalities after the last dose of olanzapine is prolonged in many cases (Table 2) and many of the causes of death are unattributable to olanzapine [1]. Several ED studies have used IV/IM olanzapine in combination with parenteral benzodiazepines to treat agitated patients without an increased signal of airway compromise [4-6].

Table 1: Summary of Fatalities Associated with Olanzapine (n=29)
Olanzapine AloneOlanzapine

+ Benzodiazepines

Olanzapine

+ Benzodiazepines

+ Other Medications

3/291/2925/29

Adapted from FOAMcast podcast: Olanzapine + Benzodiazepines – What is the FDA warning about? [1]

 

 

Table 2: Timing of Fatalities Following Last Olanzapine Dose (n=29)
≤ 1 hour1-12 hours12-24 hours> 24 hoursUnknown
3/294/298/2911/293/29

Marder [1]

 

Bottom Line

Separating IV/IM olanzapine from parenteral benzodiazepines by 60 minutes is likely a safe practice, if co-administration of these medications is necessary or desired to treat agitated patients. Patients with ethanol on board are at a higher risk of adverse events [7, 8]. Monitoring should be commensurate with the patient situation and medication(s) chosen.

Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.

References

  1. Marder SR, Sorsaburu S, Dunayevich E, et al. Case reports of postmarketing adverse event experiences with olanzapine intramuscular treatment in patients with agitation. J Clin Psychiatry. 2010;71(4):433-441. doi: 10.4088/JCP.08m04411gry. PMID: 20156413. 
  2. Williams AM. Coadministration of intramuscular olanzapine and benzodiazepines in agitated patients with mental illness. Ment Health Clin. 2018;8(5):208-213. doi: 10.9740/mhc.2018.09.208. PMID: 30206503.
  3. Khorassani F, Saad M. Intravenous olanzapine for the management of agitation: review of the literature. Ann Pharmacother. 2019;53(8):853-859. doi: 10.1177/1060028019831634. PMID: 30758221.
  4. Chan EW, Taylor DM, Knott JC, Phillips GA, Castle DJ, Kong DCM. Intravenous droperidol or olanzapine as an adjunct to midazolam for the acutely agitated patient: a multicenter, randomized, double-blind, placebo-controlled clinical trial. Ann Emerg Med. 2013;61(1):72-81. doi: 10.1016/j.annemergmed.2012.07.118. PMID: 22981685.
  5. Cole JB, Moore JC, Dolan BJ, et al. A prospective observational study of patients receiving intravenous and intramuscular olanzapine in the emergency department. Ann Emerg Med. 2017;69(3):327-336.e2. 10.1016/j.annemergmed.2016.08.008. PMID: 27823873.
  6. Martel ML, Klein LR, Rivard RL, Cole JB. A large retrospective cohort of patients receiving intravenous olanzapine in the emergency department. Acad Emerg Med. 2016;23(1):29-35. doi: 10.1111/acem.12842. PMID: 26720055.
  7. Wilson MP, MacDonald K, Vilke GM, Feifel D. Potential complications of combining intramuscular olanzapine with benzodiazepines in emergency department patients. J Emerg Med. 2012;43(5):889-896.
    doi: 10.1016/j.jemermed.2010.04.012. PMID: 20542400
  8. Wilson MP, MacDonald K, Vilke GM, Feifel D. A comparison of the safety of olanzapine and haloperidol in combination with benzodiazepines in emergency department patients with acute agitation. J Emerg Med. 2012;43(5):790-797. doi: 10.1016/j.jemermed.2011.01.024. PMID: 21601409.
By |2021-08-19T14:19:38-07:00Mar 13, 2021|EM Pharmacy Pearls, Psychiatry|
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Computerized Adaptive Screen for Suicidal Youth (CASSY) study

CASSY PECARN suicide screening tool

Adolescent suicide rates in the United States, partly augmented by the COVID-19 pandemic, are steadily increasing [1, 2]. A commonly used screening tool is the 4-question Ask Suicide-Screening Questions (ASQ) instrument, which has a sensitivity and specificity of 60% and 92.7%, respectively, in predicting suicide-related events within 3 months. This was derived from a retrospective study of 15,003 pediatric patients (age 10-18 years) [3]. Given the morbidity and mortality associated with suicide attempts, is there a better screening tool with a higher sensitivity than 60%, while also maintaining adequate specificity? A higher sensitivity rate ensures that we have fewer misses.

The CASSY tool

In JAMA Psychiatry 2021, the Pediatric Emergency Care Applied Research Network (PECARN) researchers report derivation and external validation data for their suicide screening tool, called the Computerized Adaptive Screen for Suicidal Youth (CASSY) [4]. This publication was actually two studies in one: a derivation of the tool and then an external validation.

Terminology

This paper assumes that the reader understands certain predictive analytics methodologies and test design concepts. Let’s briefly review some of the foundational terminology used:

  • Item response theory [Wikipedia]: “It is a theory of testing based on the relationship between individuals’ performances on a test item and the test takers’ levels of performance on an overall measure of the ability that item was designed to measure.” Of note, each item may be weighted differently based on how well it correlates with the overall outcome measure, which in this study was suicide attempt within 3 months.
  • Computerized adaptive testing [Wikipedia]: This computer testing strategy, also known as tailored testing, presents questions based on the individual’s response to a prior question.
  • Receiver operator characteristics (ROC): “The performance of a diagnostic test in the case of a binary predictor can be evaluated using the measures of sensitivity and specificity. However, in many instances, we encounter predictors that are measured on a continuous or ordinal scale. In such cases, it is desirable to assess performance of a diagnostic test over the range of possible cutpoints for the predictor variable. This is achieved by a receiver operating characteristic (ROC) curve that includes all the possible decision thresholds from a diagnostic test result.” [5] In other words, test sensitivities can be calculated for set specificities of, for instance, 70%, 80%, and 90%. Based on the purpose of the diagnostic test, the binary predictor threshold would be set accordingly.
  • Area under the curve (AUC): Calculating the AUC for the ROC is an effective means to determine a diagnostic test’s accuracy. The AUC ranges from 0 to 1 with 0.5 meaning no discrimination (i.e., the test can not diagnose patients with and without the disease based on the test). Generally, an AUC value of 0.7-0.8 is acceptable, 0.8 to 0.9 is excellent, and >0.9 is outstanding [5].

Study 1: CASSY derivation

A total of 6,536 adolescents (age 12-17 years) from 13 PECARN emergency departments were enrolled and a subset were randomly received follow-up in 3 months to assess for a suicide attempt. These patients responded to 92 questions on a computer tablet. Using a multidimensional item response theory approach, the more correlated questions (72) were used to create the CASSY tool.

Test characteristic results:

  • AUC: 0.89 (excellent)
  • Using the ROC curve, the CASSY sensitivity was 83% and 61% for the fixed specificity of 80% and 90%, respectively.

Study 2: CASSY validation

A total of 4,050 adolescents from 14 PECARN emergency departments were enrolled, and all received 3-month follow-up assessing for a suicide attempt. These patients completed the CASSY tool, as well as a subset of questions from study 1 for comparison. The frequency of questions used in the adaptive screen are itemized in the paper.

Test characteristic results:

  • AUC 0.87 (excellent)
  • Using the ROC curve and at the 80% specificity cutoff from study 1, the CASSY sensitivity was 82.4% and specificity was 72.5%.

CASSY figure ROC

Limitations

Although there was strong study rigor by deriving and independently validating the tool in separate, multicenter populations, it should be noted that generalizability may be affected.

  1. The study was conducted in academic pediatric emergency departments.
  2. There was quite a few patients who were lost to follow up (27.1% in study 1, 30.5% in study 2), which may have skewed the results.
  3. Selection bias may have occurred because of patients declining to participate in the study (62% enrollment rate in study 1, 62.2% in study 2)

Bottom line

The CASSY tool accurately serves as a screening predictive tool for adolescents at risk for a suicide attempt in 3 months. Rather than having patients complete exhaustively long (and practically unfeasible) screening questions in the emergency department, this computerized adaptive tool required only a mean of 11 questions, which took a median time of 1.4 minutes (IQR 0.98-2.06 minutes) to complete.

How can you implement CASSY in your emergency department?

We asked the authors this question, and the answer is in the podcast below.

Podcast

Listen more with author Dr. Jacqueline Grupp-Phelan talking with ALiEM podcast host, Dr. Dina Wallin, about this landmark paper and behind-the-scenes issues not included on the paper.

This blog post was expert peer-reviewed by Drs. King and Grupp-Phelan, who authored the paper.

References

  1. Hill RM, Rufino K, Kurian S, Saxena J, Saxena K, Williams L. Suicide Ideation and Attempts in a Pediatric Emergency Department Before and During COVID-19 [published online ahead of print, 2020 Dec 16]. Pediatrics. 2020;e2020029280. PMID: 33328339
  2. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS). Published 2020.
  3. DeVylder JE,Ryan TC, Cwik M, et al. Assessment of selective and universal screening for suicide risk in a pediatric emergency department. JAMA Netw Open. 2019;2(10):e1914070-e1914070. PMID 31651971
  4. King CA, Brent D, Grupp-Phelan J, et al. Prospective Development and Validation of the Computerized Adaptive Screen for Suicidal Youth [published online ahead of print, 2021 Feb 3]. JAMA Psychiatry. 2021; 10.1001/jamapsychiatry.2020.4576. doi:10.1001/jamapsychiatry.2020.4576. PMID 33533908
  5. Mandrekar JN. Receiver operating characteristic curve in diagnostic test assessment. J Thorac Oncol. 2010;5(9):1315-1316. doi:10.1097/JTO. 0b013e3181ec173d

Listen to all the PECARN podcasts

By |2021-07-01T21:15:43-07:00Mar 5, 2021|Expert Peer Reviewed (Clinical), Pediatrics, Psychiatry|
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SplintER Series: Keep Your Knees Up

patella alta

A 27-year-old female presents with left knee pain after a low-speed motor vehicle collision in which her knee hit the dashboard. She is tender over the patella without significant effusion and has an intact extensor mechanism. The above x-ray was obtained (Image 1. X-ray left knee. Case courtesy of Dr. M. Mourits, Radiopaedia.org, rID: 14476). 

 

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By |2021-02-25T15:41:03-08:00Mar 3, 2021|Expert Peer Reviewed (Clinical), Orthopedic, SplintER, Uncategorized|
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