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Comprendre les enjeux de « la dysphorie de genre » et déchiffrer les raisons de sa croissance exponentielle chez les mineurs. Tout en se maintenant strictement sur le plan clinique et déontologique, afin de défendre une éthique médicale à distance des considérations idéologiques. L'objectif de cet article est donc de déchiffrer ce phénomène pandémique et de le questionner comme un phénomène peut-être plus social que médical. À partir de l'analyse de la littérature internationale, nous nous sommes focalisées sur les études épidémiologiques internationales, et sur les quelques données chiffrées à notre disposition en France. Nous confrontons ces données avec des témoignages d'adolescents en voie de « transition identitaire » ou de « détransition ». Cet ensemble est mis à l'épreuve des savoirs institués en psychopathologie de l'enfance et de l'adolescence et aux théories sexuelles infantiles. Les résultats nous invitent d'abord à distinguer fondamentalement le phénomène chez l'enfant et chez l'adolescent. Ensuite, à l'adolescence cette revendication identitaire concerne indiscutablement, en une très grande majorité, des filles. Enfin, cette demande, sexuée donc, peut être abordée comme une autre dysmorphophobie pubertaire , en plus d'une comorbidité importante fréquente. Nous constatons que ce phénomène se présente comme une épidémie sociale dans la jeunesse, renforcée par la place actuelle des revendications identitaires et des impacts de propagandes sur les réseaux sociaux en direction de la jeunesse. Un rappel sur la question particulière du corps, nous amènera à interroger le refus du féminin au XXIe siècle. La dimension mystique est argumentée et soulignée. Les pratiques médicales qui se sont spécialisées en « genre » aussi en France apparaissent à contre-temps et en contradiction avec les dernières déclarations des protagonistes de la WPATH. Nous rappelons l'importance d'une prise en charge psychothérapeutique et psychiatrique pour tous ces enfants. Nous recommandons d'agir avec la prudence et l'éthique nécessaires à ces âges de la vie. Any clinician cannot fail to wonder about the notion of "gender dysphoria" as a disease or as a disorder. The review of the few international epidemiological studies on gender transition requests leads to an attempt to "decipher" the reasons for the exponential growth of this new clinical category. Is it a psychopathological or a social phenomenon, or both? We will examine separately the cases of children and adolescents. Children experiencing hesitations about their sexual identity tend to give up requests for transitions; as for teenagers (12 girls for every boy), they seem to be largely influenced by social networks. We will position ourselves strictly on the clinical and deontological level, to defend medical ethics, at a distance from the ideological considerations disseminated by the media. Starting from the recognition of the very strong increase in France of requests to "change sex/gender" in children and adolescents in recent years, we will note that this claim of "gender dysphoria" is presented differently by children before and after puberty. From a clinical point of view, it is necessary to understand that gender dysphoria would be the result of different identification processes for children and adolescents; it also presents as a gendered behavior like other known behavioral disorders in adolescence. The objective of this article is therefore to decipher this pandemic phenomenon and to question it as a social rather than a medical phenomenon. We must then recommend great caution in medical procedures, sometimes irreversible, on these children. Based on an analysis of the international literature, we focused on international epidemiological studies and on the scarce data available to us in France. We compare these data with those from testimonies of adolescents in the process of "identity transition" or "detransition" in France and in other countries, because the complaints and claims are identical. These data were collected and studied until the end of 2021. These data and testimonies will be confronted with our knowledge in the domain of child and adolescent psychiatry and psychoanalysis, the latter being a theoretical construction of childhood sexuality. The results drawn from the analysis of these testimonies and from existing epidemiological studies show, firstly, that a fundamental distinction must be made between the phenomenon of "gender dysphoria" in children and in adolescents. The evolution of the demands is drastically different in terms of volume and environmental causality. Secondly, in adolescence, this demand for a change of identity indisputably concerns a very large majority of girls. Finally, this demand, therefore sexualized, can be seen as a fragile identity, added to other pathologies. It should also be considered with demands regarding identity and the impact of propaganda on social networks towards youth. These new demands for changes in gender identity should be discussed before administering lifelong medical and surgical treatments that have not proven their effectiveness and harmlessness, as is the case in Sweden and the U.K. Our discussion here focuses on some clinical and epidemiological elements that allow us to consider these new demands for recognition of "gender dysphoria" from adolescents as a "social epidemic" phenomenon. We will discuss the notion of gender and identification in children and adolescents, along with the frequent and worrying "associated disorders." A reflection on the particular question of the body will lead us to question the refusal of the feminine in the 21st century. we will also consider the impact of the choice of treatment and support provided, before concluding with a reflection on the requests of adolescent girls. We recall the importance of providing global psychological, psychodynamic, and psychiatric care for all these children. We recommend acting with the necessary prudence and ethics at these stages of life, and we defend the necessity for all children to develop thanks to the normal evolution of their chosen identifications. The diagnosis of "gender dysphoria" should not be understood as a diagnosis that would bind the child or adolescent in a gender (whether desired or not, conversion therapy is now forbidden in France), but, on the contrary, should allow the child or adolescent to be accompanied towards an emancipation in the face of these gender stereotypes in which he or she is most often trapped, or even kidnapped. Because the body is not sick, it is necessary to protect it against any deleterious transformation. But above all, by avoiding any stigmatization of identity, we can allow the child as well as the adolescent to reappropriate the image of her/his body and thus a psychic and anatomical unity. To thus preserve the freedom of choice amongst the multiple adult sexualities with which s/he will have to deal later on. It is obviously for lack of this protective psychological accompaniment that these young people prematurely put an end to any genital sexual life (homo- or heterosexual or other). [ABSTRACT FROM AUTHOR]

Soft tissue vascular anomalies may be composed of arterial, venous, and/or lymphatic elements, and diagnosed prenatally or later in childhood or adulthood. They are divided into categories of vascular malformations and vascular tumors. Vascular malformations are further divided into low-flow and fast-flow lesions. A low-flow lesion is most common, with a prevalence of 70%. Vascular tumors may behave in a benign, locally aggressive, borderline, or malignant manner. Infantile hemangioma is a vascular tumor that presents in the neonatal period and then regresses. The presence or multiple skin lesions in an infant can signal underlying visceral vascular anomalies, and complex anomalies may be associated with overgrowth syndromes. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation. [ABSTRACT FROM AUTHOR]

Urinary tract infection (UTI) is a frequent infection in childhood. The diagnosis is usually made by history and physical examination and confirmed by urine analysis. Cystitis is infection or inflammation confined to the bladder, whereas pyelonephritis is infection or inflammation of kidneys. Pyelonephritis can cause renal scarring, which is the most severe long-term sequela of UTI and can lead to accelerated nephrosclerosis, leading to hypertension and chronic renal failure. The role of imaging is to guide treatment by identifying patients who are at high risk to develop recurrent UTIs or renal scarring. This document provides initial imaging guidelines for children presenting with first febrile UTI with appropriate response to medical management, atypical or recurrent febrile UTI, and follow-up imaging for children with established vesicoureteral reflux. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation. [ABSTRACT FROM AUTHOR]

Interdisciplinary pediatric chronic pain programs are ideal treatment settings for youth with chronic pain who are complex from a biopsychosocial perspective. There is currently no evidence-based clinical decision support to guide nurses triaging patients to such programs, which increases the risk for haphazard triage decisions. To explore and describe the decision-making practices of and contextual influences on nurses triaging patients to interdisciplinary pediatric chronic pain programs. A qualitative exploratory descriptive design. Interdisciplinary Pediatric Chronic Pain Programs. In all, 12 nurses across 11 different interdisciplinary pediatric chronic pain programs participated in this study. Individual, semi-structured interviews were conducted, transcribed verbatim, and analyzed using concurrent content analysis, guided by the Cognitive Continuum Theory and the Theoretical Domains Framework. Findings focused on the complexity of the pediatric chronic pain population and the leading role nurses play in triage without evidence-based guidance. Analysis generated three prominent themes: (1) nurse-led triage determinants; (2) process of triage decision-making; and (3) external influences on triage decision-making. Triage decision making in the setting of interdisciplinary pediatric chronic pain programs is complex and often led by nurses. There is a desire amongst nurses to adopt an evidence-based clinical decision support triage tool (CDS), which may streamline the referral and triage process and foster a system whereby patients in highest need for interdisciplinary care are best prioritized. [ABSTRACT FROM AUTHOR]

Dyspnea and fatigue are characteristics of long SARS-CoV-2 (COVID)-19. Cardiopulmonary exercise testing (CPET) can be used to better evaluate such patients. How significantly and by what mechanisms is exercise capacity impaired in patients with long COVID who are coming to a specialized clinic for evaluation? We performed a cohort study using the Mayo Clinic exercise testing database. Subjects included consecutive long COVID patients without prior history of heart or lung disease sent from the Post-COVID Care Clinic for CPET. They were compared to a historical group of non–COVID patients with undifferentiated dyspnea also without known cardiac or pulmonary disease. Statistical comparisons were performed by t -test or Pearson's chi2 test controlling for age, sex, and beta blocker use where appropriate. We found 77 patients with long COVID and 766 control patients. Long COVID patients were younger (47 ± 15 vs 50 ± 10 years, P <.01) and more likely female (70% vs 58%, P <.01). The most prominent difference on CPETs was lower percent predicted peak V̇O 2 (73 ± 18 vs 85 ± 23%, p <.0001). Autonomic abnormalities (resting tachycardia, CNS changes, low systolic blood pressure) were seen during CPET more commonly in long COVID patients (34 vs 23%, P <.04), while mild pulmonary abnormalities (mild desaturation, limited breathing reserve, elevated V̇ E /V̇CO 2) during CPET were similar (19% in both groups) with only 1 long COVID patient showing severe impairment. We identified severe exercise limitation among long COVID patients. Young women may be at higher risk for these complications. Though mild pulmonary and autonomic impairment were common in long COVID patients, marked limitations were uncommon. We hope our observations help to untangle the physiologic abnormalities responsible for the symptomatology of long COVID. [ABSTRACT FROM AUTHOR]

Parathyroidectomy by a high-volume surgeon is associated with a reduced risk of perioperative complications and of failure to cure primary and secondary hyperparathyroidism. There are limited data on disparities in access to high-volume parathyroid surgeons in the United States. We used publicly available 2019 Medicare Provider Utilization and Payment data to identify all surgeons who performed >10 parathyroidectomies for Medicare fee-for-service beneficiaries, anticipating that fee-for-service beneficiaries likely represent only a subset of their high-volume practices. High-volume parathyroid surgeon characteristics and geographic distribution were evaluated. Inequality in the distribution of surgeons was measured by the Gini coefficient. The association between neighborhood disadvantage, based on the Area Deprivation Index, and proximity to high-volume parathyroid surgeons was evaluated using a one-way analysis of variance with Bonferroni-corrected pairwise comparisons. A sensitivity analysis was performed restricting to high-volume parathyroid surgeons within each hospital referral region, evidence-based regional markets for tertiary medical care. We identified 445 high-volume parathyroid surgeons who met inclusion criteria with >10 parathyroidectomies for Medicare fee-for-service beneficiaries. High-volume parathyroid surgeons were 71% male sex, and 59.8% were general surgeons. High-volume parathyroid surgeons were more likely to practice in a Metropolitan Statistical Area with a population >1 million than in less populous metropolitan or rural areas. The number of high-volume parathyroid surgeons per 100,000 fee-for-service Medicare beneficiaries in the 53 most populous Metropolitan Statistical Areas ranged from 0 to 4.94, with the highest density identified in Salt Lake City, Utah. In 2019, 50% of parathyroidectomies performed by high-volume parathyroid surgeons were performed by 20% of surgeons in this group, suggesting unequal distribution of surgical care (Gini coefficient 0.41). Patients in disadvantaged neighborhoods were farther from high-volume parathyroid surgeons than those in advantaged neighborhoods (median distance: disadvantaged 27.8 miles, partially disadvantaged 20.7 miles, partially advantaged 12.1 miles, advantaged 8.4 miles; P <.001). This association was also shown in the analysis of distance to high-volume parathyroid surgeons within the hospital referral region (P <.001). Older adults living in disadvantaged neighborhoods have less access to high-volume parathyroid surgeons, which may adversely affect treatment and outcomes for patients with primary and secondary hyperparathyroidism. This disparity highlights the need for actionable strategies to provide equitable access to care, including improved regionalization of high-volume parathyroid surgeon services and easing travel-related burdens for underserved patients. [ABSTRACT FROM AUTHOR]

Probabilistic sensitivity analysis (PSA) has been shown to reduce bias in outcomes of health economic models. However, only 1 existing study has been identified that incorporates PSA within a resource-constrained discrete event simulation (DES) model. This article aims to assess whether it is feasible and appropriate to use PSA to characterize parameter uncertainty in DES models that are primarily constructed to explore the impact of constrained resources. PSA is incorporated into a new case study of an Emergency Department DES. Structured expert elicitation is used to derive the variability and uncertainty input distributions associated with length of time taken to complete key activities within the Emergency Department. Potential challenges of implementation and analysis are explored. The results of a trial of the model, which used the best estimates of the elicited means and variability around the time taken to complete activities, provided a reasonable fit to the data for length of time within the Emergency Department. However, there was substantial and skewed uncertainty around the activity times estimated from the elicitation exercise. This led to patients taking almost 3 weeks to leave the Emergency Department in some PSA runs, which would not occur in practice. Structured expert elicitation can be used to derive plausible estimates of activity times and their variability, but experts' uncertainty can be substantial. For parameters that have an impact on interactions within a resource-constrained simulation model, PSA can lead to implausible model outputs; hence, other methods may be needed. • Probabilistic sensitivity analysis (PSA) is standard practice in health economic models, but it has rarely been used in resource-constrained cost-effectiveness simulation models. • Structured expert elicitation can be used to derive plausible estimates of resource-related parameters and their variability, but experts' uncertainty can be substantial, limiting their suitability for use in this context. • For some parameters, such as costs and utilities, existing PSA methods are likely applicable, but for parameters that have an impact on interactions within a resource-constrained simulation model, PSA can substantially alter and lead to implausible model outputs; hence, alternative methods may be needed. [ABSTRACT FROM AUTHOR]

Patient-reported outcomes (PROs) are increasingly utilized to evaluate the efficacy and value of spinal procedures. Among patients with cervical myelopathy, the modified Japanese Orthopaedic Association (mJOA) remains the standard instrument, with Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and patient satisfaction also frequently assessed. These outcomes have not all been directly compared using a large spine registry at 2 years follow-up for cervical myelopathic patients undergoing surgery. To determine the correlation and association of PROMIS PF, mJOA, and patient satisfaction outcomes in patients undergoing surgery for cervical myelopathy. Retrospective review of a multicenter spine registry database. Adult patients with cervical myelopathy who underwent cervical spine surgery between 2/26/2018 and 4/17/2021. PROMIS PF, mJOA, and North American Spine Society (NASS) patient satisfaction index. The MSSIC database was accessed to gather pre- and postoperative outcome data on patients with cervical myelopathy. Spearman's correlation coefficients relating mJOA and PROMIS PF were quantified up to 2 years postoperatively. The correlations between patient satisfaction with mJOA and PROMIS were determined. Kappa statistics were used to evaluate for agreement between those reaching the minimum clinically important difference (MCID) for mJOA and PROMIS PF. Odds ratios were calculated to determine the association between patient satisfaction and those reaching MCID for mJOA and PROMIS PF. Support for MSSIC is provided by BCBSM and Blue Care Network as part of the BCBSM Value Partnerships program. Data from 2,023 patients were included. Moderate to strong correlations were found between mJOA and PROMIS PF at all time points (p<.001). These outcomes had fair agreement at all postoperative time points when comparing those who reached MCID. Satisfaction was strongly related to changes from baseline for both mJOA and PROMIS PF at all time points (p<.001). Odds ratios associating satisfaction with PROMIS PF MCID were higher at all time points compared with mJOA, although the differences were not significant. PROMIS PF has a strong positive correlation with mJOA up to 2 years postoperatively in patients undergoing surgery for cervical myelopathy, with similar odds of achieving MCID with both instruments. Patient satisfaction is predicted similarly by these outcome measures by 2 years postoperatively. These results affirm the validity of PROMIS PF in the cervical myelopathic population. Given its generalizability and ease of use, PROMIS PF may be a more practical outcome measure for clinical use compared with mJOA. [ABSTRACT FROM AUTHOR]

Derived from the respiratory tracheae, bush-crickets' acoustic tracheae (or ear canals) are hollow tubes evolved to transmit sounds from the external environment to the interior ear. Due to the location of the ears in the forelegs, the acoustic trachea serves as a structural element that can withstand large stresses during locomotion. In this study, we report a new Atomic Force Microscopy Force Spectroscopy (AFM-FS) approach to quantify the mechanics of taenidia in the bush-cricket Mecopoda elongata. Mechanical properties were examined over the longitudinal axis of hydrated taenidia, by indenting single fibres using precision hyperbolic tips. Analysis of the force-displacement (F-d) extension curves at low strains using the Hertzian contact model showed an Elastic modulus distribution between 13.9 MPa to 26.5 GPa, with a mean of 5.2 ± 7 GPa and median 1.03 GPa. Although chitin is the primary component of stiffness, variation of elasticity in the nanoscale suggests that resilin significantly affects the mechanical properties of single taenidia fibres (38% of total data). For indentations up to 400 nm, an intricate chitin-resilin response was observed, suggesting structural optimization between compliance and rigidity. Finite-element analysis on composite materials demonstrated that the Elastic modulus is sensitive to the percentage of resilin and chitin content, their location and structural configuration. Based on our results, we propose that the distinct moduli of taenidia fibres indicate sophisticated evolution with elasticity playing a key role in optimization. In crickets and bush-crickets, the foreleg tracheae have evolved into acoustic canals, which transport sound to the ears located on the tibia of each leg. Tracheae are held open by spiral cuticular micro-fibres called taenidia, which are the primary elements of mechanical reinforcement. We developed an AFM-based method to indent individual taenidia at the nanometre level, to quantify local mechanical properties of the interior acoustic canal of the bush-cricket Mecopoda elongata , a model species in hearing research. Taenidia fibres were immobilized on a hard substrate and the indenter directly approached the epicuticle surface. This is the first characterization of the nano-structure of unfixed tracheal taenidia, and should pave the way for further in vivo mechanical investigations of auditory structures. [Display omitted] [ABSTRACT FROM AUTHOR]