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This Viewpoint advocates for the inclusion of transgender and nonbinary persons in clinical trials and tumor registries.

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Anastomotic leak after lower gastrointestinal surgery is a complication with potential for high morbidity, mortality, and increased costs. A single-institution retrospective chart review was performed on all patients who underwent lower gastrointestinal surgery between June 2009 and June 2013. Fifty-seven variables were included in our analysis and their association with postoperative anastomotic leak was examined. Nine hundred fifty-two patients underwent 983 lower gastrointestinal anastomoses with an overall leak rate in this series of 6 per cent. Type of intestinal anastomosis created (P < 0.00005), operative indication (P < 0.015), operation performed (P < 0.014), intraoperative blood transfusion (P < 0.017), and intraoperative surgical drain placement (P < 0.022) were all predictive of anastomotic leak. Anastomotic leak rate increased by 1.3 times for every additional hour in the operating room after three hours. Both increasing operation time and intraoperative blood transfusions were associated with an increased rate of anastomotic leak. When operative time extends beyond three hours or in those cases were blood transfusions are given, surgeons should consider taking steps to minimize the risks of a potential anastomotic leak.

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PURPOSE: Approximately 1.6% of adult Americans identify as transgender (TG) or nonbinary (NB) and many take gender-affirming hormone therapy (GAHT). Little data exist to inform breast and cervical cancer risks, gender-specific screening guidelines, and inclusive cancer treatment algorithms that consider GAHT. We aimed to assess TGNB persons' perceptions on breast and cervical cancer development, screening knowledge and practices, and attitude toward GAHT in the setting of a hormone receptor–positive breast cancer diagnosis. METHODS: This single-institution survey study was conducted through an LGBTQ+ focused clinic from 2021 to 2022. Noncisgender patients age ≥ 18 years who were English speaking were eligible to participate. A 5-point Likert scale was used to assess concern of developing breast (all participants) and cervical cancer (those assigned female sex at birth). Demographic and quantitative variables were examined in comparison with responses via chi-squared tests. RESULTS: Eighty-six participants completed the survey: 43% TG men, 24% TG women, and 20% NB persons. Most (84.9%) were age < 40 years, and 86% were non-Hispanic White. The majority were unaware of breast (77%) or cervical (60%) cancer screening recommendations for their sex assigned at birth or their gender. Approximately 35% reported concern regarding breast cancer development and of those age > 40 years; only 50% had undergone screening mammography. Of those assigned female sex at birth with an intact cervix, 47% were concerned about cervical cancer development and 46.6% had a Papanicolaou smear within the past 5 years. Nearly all (87.2%) were on GAHT, and 35.1% reported they would not consider stopping GAHT if diagnosed with a hormone receptor–positive breast cancer. CONCLUSION: The findings support the need for patient and provider education on screening options and large prospective cohort data to elucidate optimal gender-specific screening guidelines and treatment algorithms.

Disruptive agitated behavior is common in demented patients and is often diEcult to manage.' Although neuroleptic medications are frequently administered to agitated patients, these agents only help in about one-third of cases, and their utility is limited by serious side effects.' A specific cause of agitated behavior in a demented patient is often not identified, and the behavior may sometimes be related to pain or discomfort from an unrecognized medical problem. In this report, we describe a demented woman whose agitated behavior was greatly reduced following treatment of her cervical dystonia with botulinum toxin A.Case report. A 49-year-old demented woman was hospitalized for management of progressively worsening irritability, combativeness, and crying episodes of 6 months' duration. She had been healthy until 5 years earlier, when she began to experience progressive memory loss and inability to function a t her job.Initial evaluations for treatable dementias had been nondiagnostic, and a right frontal lobe brain biopsy performed 3 years into her course revealed Alzheimer's disease and cortical Lewy bodies. The course of her dementia included global cognitive decline, cogwheel rigidity (antedating the use of neuroleptic medication), and one generalized convulsion.At the time of this hospitalization, she was receiving phenytoin and chlorpromazine. On examination, she was uncooperative and agitated. She could not answer simple questions and would frequently whine or cry. There was prominent cogwheel rigidity a n d cervical dystonia. Folstein's Mini-Mental S t a t e Examination score was zero. Her score on the short-form CohenMansfield Agitation Inventory3 (CMAI) was 54, indicating a severe degree of agitation. There was no clinical evidence of systemic infection, fecal impaction, decubitus ulcer, or fracture. Screening laboratory data revealed normal SMA 18, CBC, and urinalysis. Phenytoin level was 12.6 mcg/ml.In an attempt to alleviate her agitated behavior, risperidone was substituted for chlorpromazine, but after 1 week her condition had not changed. Divalproex sodium (in doses sufficient to produce a serum level of 68 mgA) was then substituted for phenytoin, but her agitated behavior did not improve during 10 days of this treatment. The patient was then referred for botulinum toxin injections in an effort to relieve her prominent leftward Iaterocollis. A total of 145 U of botulinum toxin A was injected into her hypertrophied left sternocleidomastoid, left scalenus, left splenius capitis, and left trapezius muscles. Analgesic t r e a t m e n t w i t h propoxyphene napsylate a n d acetaminophen was also given.Over the next few days, her dystonic cervical muscles relaxed considerably, and her agitated behavior significantly decreased. Her crying episodes stopped, her appetite improved, she became much less irritable, and she began making regular attempts at verbal communication. Her post-treatment CMAI score was 30, with marked improvement on items assessing repetitive actions, repetitive verbalizations, kick...

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