Vania Rashidi

Facial Feminization: Systematic Review of the Literature

Background: Facial feminization surgery encompasses a broad range of craniomaxillofacial surgical procedures designed to change masculine facial features into feminine features. The surgical principles of facial feminization surgery can be applied to male-to-female transsexuals and anyone desiring feminization of the face. Although the prevalence of these procedures is difficult to quantify, because of the rising prevalence of transgenderism (approximately one in 14,000 men) along with improved insurance coverage for gender-confirming surgery, surgeons versed in techniques, outcomes, and challenges of facial feminization surgery are needed. This review is designed to critically appraise the current facial feminization surgery literature. Methods: A comprehensive literature search of the Medline, PubMed, and EMBASE databases was conducted for studies published through October of 2014 with multiple search terms related to facial feminization. Data on techniques, outcomes, complications, and patient satisfaction were collected. Results: Fifteen articles were selected and reviewed from the 24 identified, all of which were either retrospective or case series/reports. Articles covered a variety of facial feminization procedures. A total of 1121 patients underwent facial feminization surgery, with seven complications reported, although many articles did not explicitly comment on complications. Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction. Conclusions: Facial feminization surgery appears to be safe and satisfactory for patients. Further studies are required to better compare different techniques to more robustly establish best practices. Prospective studies and patient-reported outcomes are needed to establish quality-of-life outcomes for patients. However, based on these studies, it appears that facial feminization surgery is highly efficacious and beneficial to patients.

Del1 Knockout Mice Developed More Severe Osteoarthritis Associated with Increased Susceptibility of Chondrocytes to Apoptosis

Objective We identified significant expression of the matricellular protein, DEL1, in hypertrophic and mature cartilage during development. We hypothesized that this tissue-specific expression indicated a biological role for DEL1 in cartilage biology. Methods Del1 KO and WT mice had cartilage thickness evaluated by histomorphometry. Additional mice underwent medial meniscectomy to induce osteoarthritis, and were assayed at 1 week for apoptosis by TUNEL staining and at 8 weeks for histology and OA scoring. In vitro proliferation and apoptosis assays were performed on primary chondrocytes. Results Deletion of the Del1 gene led to decreased amounts of cartilage in the ears and knee joints in mice with otherwise normal skeletal morphology. Destabilization of the knee led to more severe OA compared to controls. In vitro, DEL1 blocked apoptosis in chondrocytes. Conclusion Osteoarthritis is among the most prevalent diseases worldwide and increasing in incidence as our population ages. Initiation begins with an injury resulting in the release of inflammatory mediators. Excessive production of inflammatory mediators results in apoptosis of chondrocytes. Because of the limited ability of chondrocytes to regenerate, articular cartilage deteriorates leading to the clinical symptoms including severe pain and decreased mobility. No treatments effectively block the progression of OA. We propose that direct modulation of chondrocyte apoptosis is a key variable in the etiology of OA, and therapies aimed at preventing this important step represent a new class of regenerative medicine targets.

Beyond Phonosurgery: Considerations for Patient-Reported Outcomes and Speech Therapy in Transgender Vocal Feminization.

Providing appropriate care for transgender women is essential as more seek gender confirmation treatment for gender dysphoria. A variety of nonsurgical and surgical interventions are available. In terms of voice, pitch elevation in transgender women can have a significant effect on gender confirmation. Both surgical and nonsurgical options for pitch elevation exist. Phonosurgery can be an effective treatment; however, it is not without risk, and alternative nonsurgical interventions like voice therapy should be considered. A recent meta-analysis by Song and Jiang confirmed that transgender phonosurgery can result in significantly increased fundamental frequency (F0). However, lacking from this study was a mention of speech therapy’s role and effectiveness. Primary literature suggests F0 can be increased after speech therapy in transgender women, but no review of these data has been compiled. With a minimal risk profile, speech therapy has an important role in vocal feminization. Cost of surgery and limited availability of surgical specialists may be other reasons to consider speech therapy. Patient centeredness is paramount in treatment decision making, as it is the patients’ perspective and happiness with their voice that is the ultimate arbiter of success, not solely the ability to raise F0 with either voice therapy or surgery. We argue that the primary outcome for pitch elevation interventions should be patient centered. Interventions to change physiologic aspects of the voice should be judged based on whether the patient achieves improved quality of life and sense of self. Ultimately, it is the patient’s goals and perceptions that are most important. Successful outcomes in gender-confirming surgery are largely defined based on patients’ ability to live and be perceived as their true gender in all aspects of life. To date, little data exist on patient-reported outcomes after gender-confirming surgery, and when evaluated, the data are often nonstandardized and analyzed unreliably. Song and Jiang acknowledge this limitation in outcome assessment in primary literature. A standardized and reliable assessment of patient-reported outcomes after pitch elevation could add substantially to our understanding of the outcomes of pitch elevation. Transgender patients are often discriminated against and marginalized in the health care field. As the benefits of gender-confirming therapies are becoming more established, it is imperative that our surgical research be rigorous, standardized, and balanced, recognizing that nonsurgical interventions like voice therapy should also be strongly considered and studied. While we strive to deliver improved surgical interventions to better the quality-oflife outcomes to our transgender patients, we must not overlook effective nonsurgical options.

Cultural Adaptation of a Survey to Assess Medical Providers’ Knowledge of and Attitudes towards HIV/AIDS in Albania

Though the HIV/AIDS epidemic in Southeastern Europe is one of low reported prevalence, numerous studies have described the pervasiveness of medical providers’ lack of knowledge of HIV/AIDS in the Balkans. This study sought to culturally adapt an instrument to assess medical providers’ knowledge of and attitudes towards HIV/AIDS in Albania. Cultural adaptation was completed through development of a survey from previously validated instruments, translation of the survey into Albanian, blinded back translation, expert committee review of the draft instrument, focus group pre-testing with community- and University Hospital Center of Tirana-based physicians and nurses, and test-retest reliability testing. Blinded back translation of the instrument supported the initial translation with slight changes to the idiomatic and conceptual equivalences. Focus group pre-testing generally supported the instrument, yet some experiential and idiomatic changes were implemented. Based on unweighted kappa and/or prevalence adjusted bias adjusted kappa (PABAK), 20 of the 43 questions were deemed statistically significant at kappa and/or PABAK ≥0.5, while 12 others did not cross zero on the 95% confidence interval for kappa, indicating their probable significance. Subsequently, an instrument to assess medical providers’ knowledge of and attitudes toward HIV/AIDS for an Albanian population was developed which can be expanded within Albania and potentially to other countries within the Balkans, which have an Albanian-speaking population.

Antiretroviral therapy adherence and predictors to adherence in Albania: a cross-sectional study

INTRODUCTION The possibility of an HIV/AIDS epidemic in southeastern Europe (SEE) is not improbable. Thus, an understanding of the current issues surrounding HIV/AIDS care, specifically antiretroviral therapy (ART) adherence, in countries within SEE is critical. This study was conducted to determine the ART adherence characteristics of Albanias HIV-positive population. METHODOLOGY This cross-sectional study reports initial demographic and adherence characteristics of patients receiving HIV/AIDS treatment in Albania. Retrospective review of pharmacy medications dispensed supplemented reported adherence behavior. Further, an adherence index was utilized to explore adherence more thoroughly. RESULTS Patient-reported adherence and pharmacy review showed adherence levels of 98.9±4.4% and 97.7±4.7%, respectively. Assessment by adherence index revealed an index level of 91.7±6.7. Factors associated with a score of < 95 on the adherence index were: being partnered (OR = 0.29, 95% CI = 0.09 - 0.98), history of depression (OR = 0.24, 95% CI = 0.08 - 0.76), increased number of barriers to care (OR = 0.80, 95% CI = 0.66 - 0.97), and increased number of current social and medical needs (OR = 0.72, 95% CI = 0.58 - 0.91). CONCLUSIONS Interventions aimed at reducing barriers to care, addressing current medical and social needs, and treating mental health issues may help improve adherence to ART in patients with HIV/AIDS in Albania. With little known about HIV/AIDS in SEE, this study provides guidance on how SEE countries can help prevent a possible rise in the prevalence of HIV given the close link of ART adherence and spread of HIV.

Clinical Findings in Albanian Patients with 2009 Influenza AH1N1 Admitted at the Intensive Care Unit

Due to the ease of cross-continent spread of infectious diseases, the 2009 influenza AH1N1 (H1N1) affected many countries. This observational prospective study looked at Albanian patients admitted with 2009 H1N1 at the ICU of the Department of Infectious Diseases at the University Hospital Center of Tirana, from November 2009 to March 2010. Demographic data, symptoms, comorbidities, and clinical outcomes were collected from each patient. The number of days spent in the ICU was recorded for each patient along with their radiological and laboratory findings, and outcome at discharge. Critical illness occurred in 31 patients admitted with confirmed 2009 H1N1. The median age of patients was 35 years. Five (16.1%) patients required endotracheal intubation; noninvasive oxygen therapy (NIV) was used in 15 (48.4%) patients via nasal tube; and continuous positive airway pressure (CPAP) and pressure support ventilation (PSV) oxygen masks were used in 11 (35.5%) patients. All patients were treated with oseltamivir. Four patients admitted and treated did not survive. Critical illness in the setting of 2009 H1N1 admitted in the ICU predominantly affected young adults. NIV could play a role in treating 2009 influenza H1N1 infection-related hypoxemic respiratory failure that was associated with severe hypoxemia, pneumonia, requirement for prolonged mechanical ventilation, and the frequent use of antiviral therapy.