Utilization of physician offices by adolescents in the United States

The Role of Age in Delays to Rheumatological Care in Juvenile Idiopathic Arthritis

OBJECTIVE

To investigate the relationship between age and symptom duration at initial presentation to pediatric rheumatology for juvenile idiopathic arthritis (JIA).

METHODS

In children and young people (CYP) enrolled in the Childhood Arthritis Prospective Study prior to March 2018, an association between age at presentation (< 5, 5-11, and > 11 yrs) and symptom duration was tested by multivariable linear regression.

RESULTS

In 1577 CYP, 5- to 11-year-olds took 3.2 months longer and > 11-year-olds 6.9 months longer to reach pediatric rheumatology than < 5-year-olds.

CONCLUSION

Adolescents take longer to reach pediatric rheumatology, potentially affecting their longer-term outcomes given the window of opportunity for JIA treatment.

Patterns of Pediatric and Adolescent Gynecologic Problems in China: A Hospital-Based Retrospective Study of 97,252 Patients

STUDY OBJECTIVE

To describe the pattern and population characteristics of pediatric and adolescent gynecologic (PAG) problems in China DESIGN: A clinic-based retrospective study of gynecologic patients (aged 0-18 years) over a period of 13 years SETTING: Department of PAG in the Children's Hospital, Zhejiang University School of Medicine PARTICIPANT: The final analyses included 97,252 patients with gynecologic problems.

INTERVENTIONS/METHODS

Descriptive analysis was conducted to evaluate the pattern of PAG problems.

MAIN OUTCOME MEASURES

Spectrum of PAG problems RESULTS AND CONCLUSIONS: The number of first-visit PAG patients increased from 4,582 to 11,876 from 2006 to 2018. Overall, genital inflammation was the most common presentation (57.0%), followed by precocious puberty (18.2%). The disease pattern varied across age groups; the most common problems were genital inflammation for age 0-6 years, genital inflammation and precocious puberty for age 7-9 years, and consultation, genital inflammation, and menstrual disorders for age 10-18 years. Overall, genital inflammation, precocious puberty, consultation, and menstrual disorders were common issues for pediatric and adolescent patients with gynecologic problems in China.

Providing optimal care for active youth in Canada

Sports are important activities for youth, with millions of children and adolescents participating in organized sports and recreational activities every year. Sports participation has many benefits but can also cause injuries, accounting for two-thirds of all injuries in Canadian adolescents and resulting in hundreds of thousands of medical visits annually. Despite the frequency of sport-related injuries in youth, many practising pediatricians are not comfortable managing these issues, citing lack of teaching and clinical exposure during training. Many studies have found deficits in musculoskeletal (MSK) and sport and exercise medicine (SEM) training in residency programs in North America, including Canadian pediatric residency programs. To address this learning gap, Canadian pediatric residency programs should incorporate more MSK/SEM training and clinical exposure to these issues. A standardized national curriculum in MSK/SEM will help ensure that community pediatricians practicing in Canada are adequately prepared to care for active youth.

Effects of Child Protective Custody Status and Health Risk Behaviors on Health Care Use Among Adolescents

OBJECTIVE

To determine whether current protective custody status (ie, youth currently in the temporary or permanent custody of child protective services, eg, foster and kinship care) contributes to increased health care utilization compared to youth never in protective custody. Health characteristics (eg, mental health diagnoses) and behaviors (eg, substance use) were expected to account for differences in health care use among the two groups.

METHODS

Retrospective child welfare administrative data and linked electronic health records data were collected from a county's child welfare system and affiliated freestanding children's hospital between 2012 and 2017. Youth currently in protective custody (n = 2787) were identified and demographically matched to peers never in custody (n = 2787) who received health care from the same children's hospital. Health care use, health risk behaviors, and social, demographic, and diagnostic data were extracted and compared for both cohorts.

RESULTS

In baseline models, health care use was higher for youth in protective custody compared to peers. In adjusted models that included health risk behaviors and patient characteristics, protective custody status was associated with decreased primary and missed care, and no longer a significant predictor of other types of health care use.

CONCLUSIONS

Youth had significantly higher utilization while in protective custody than their demographically similar peers; however, health risk behaviors appear to account for most group differences. Identification of current custody status in pediatric settings and addressing health risk behaviors in this population may be important for health care systems interested in altering health care use and/or cost for this population.

Patterns of Cancer Care and Association with Survival among Younger Adolescents and Young Adults: A Population-Based Retrospective Cohort Study

BACKGROUND

Younger adolescents and young adults (AYA) may receive care from either adult or pediatric oncologists. We explored patterns of care in this population and whether survival is associated with provider type.

METHODS

Utilizing the California Cancer Registry, we examined a cohort of 9,993 AYAs diagnosed with cancer aged 15 to 24 years from 1999 to 2008. Provider type (adult/pediatric) was determined by individual physician identifiers. For provider type, multivariable logistic regression models were adjusted for age, sex, race/ethnicity, socioeconomic status, diagnosis, and stage. For observed survival, Cox proportional hazard models were additionally adjusted for provider type. ORs and HR with 95% confidence intervals (95% CI) were determined.

RESULTS

Most patients saw adult providers (87.3% overall; 72.7% aged 15-19 years). Patients with acute leukemia, sarcoma, and central nervous system (CNS) malignancies more often saw pediatric providers [OR (95% CI) adult versus pediatric 0.48 (0.39-0.59), 0.74 (0.60-0.92), 0.76 (0.60-0.96), respectively]; those with germ cell tumors and other cancers, including carcinomas, more often saw adult providers [2.26 (1.72-2.98), 1.79 (1.41-2.27), respectively]. In aggregate and for most cancers individually, there was no survival difference by provider type [overall HR (95% CI) 1.00 (0.86-1.18)]. Higher survival was associated with pediatric providers for CNS malignancies [1.63 (1.12-2.37)] and rhabdomyosarcoma [2.22 (1.03-4.76)], and with adult providers for non-Hodgkin lymphoma [0.61 (0.39-0.96)].

CONCLUSIONS

Most AYAs 15 to 24 years old are treated by medical oncologists. In general, survival was not associated with provider type.

IMPACT

Current patterns of care for this population support increased collaboration between medical and pediatric oncology, including joint clinical trials.

Effects and safety of acne vulgaris with external application of herbal medicines: A protocol for systematic review and meta analysis

BACKGROUND

Acne vulgaris (AV) is a common dermatologic disease. The morbidity is increasing annually. External application of herbal medicines (EAHM) has been pervasively used in the therapy of AV. EAHM , as the traditional Chinese therapy, is widely applied in clinical trials for AV. The aim of this review is to systematically evaluate the efficacy and safety of EAHM in the therapy for AV.

METHODS

We will conduct an electronic search of 13 databases from their inception to May, 2020, including PubMed, EMBASE, MEDLINE, Web of Science, Cochrane Library, SpringerLink, WHO International Clinical Trials Registry Platform, Wanfang China database, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, Chinese Scientific Journal Database, as well as China's Conference Papers Database and China Dissertation database. Other valid search strategies will also be retrieved to complete this review. All randomized controlled trials in which EAHM was used for the treatment of AV will be adopted. Two researchers will select eligible studies respectively according to a predefined protocol. Methodological quality will be assessed with Cochrane risk of bias by means of RevMan V.5.3.5 software.

RESULTS

This systematic view will present a high-quality synthesis based on current evidence of EAHM intervention for AV patients.

CONCLUSION

The summary of our systematic view will provide evidence to judge whether EAHM is an effective and safe intervention for AV patients.

The effect of public health insurance expansions on the mental and behavioral health of girls and boys

This paper examines the effects of public health insurance expansions on the mental health care utilization and mental and behavioral health of children 6-17 years old. We leverage major expansions in public health insurance eligibility for children and adolescents under Medicaid and the State Children's Health Insurance Program during 1997-2002 to examine mental health care utilization and outcomes for children in the National Survey of America's Families. The study examines these dynamics by gender of children due to their distinct mental health care patterns and risks. The expansions are associated with an estimated 30% reduction in mental health care utilization for girls, but no measurable effect for boys, which may partly be accounted for by increased well-child visits for girls. Mental health improves only for teenagers; boys in particular have an estimated 22 percent increase in their probability of the highest level of health. Parents experience spillovers of lower insurance coverage for themselves - likely from dropping private family coverage for public child-only coverage - but slightly better mental health.

Adolescents' Patterns of Well-Care Use Over Time: Who Stays Connected

INTRODUCTION

Well-care use can positively impact adolescents' current and future health. Understanding adolescents' longitudinal well-care use is critical to determine to whom and when to target engagement strategies to improve healthcare access. This study describes prospective well-care use patterns from childhood through adolescence stratified by sex.

METHODS

The sample (N=6,872) was drawn from the Child/Young Adult component of the household-based 1979 National Longitudinal Survey of Youth consisting of biological children born to female respondents (1980-1997). Well-care use (routine checkup with a doctor within last year) data were assessed from age 5 years (1986-2003) until age 17 years (1998-2015). Conducted in 2019, latent class analyses stratified by sex identified well-care use patterns reported over 7 biennial time points adjusted for cohort, race/ethnicity, urbanicity, maternal education, and insurance.

RESULTS

A total of 4 well-care use classes emerged for female adolescents: the majority belonged to Engaged (37%) and Moderately Engaged (39%) classes and the remainder belonged to Gradually Re-engaged (14%) and Disengaged-with-Rebound (10%) classes. A total of 3 classes emerged for male adolescents: the majority belonged to the Persistently Disengaged (48%) class and the remainder belonged to Engaged (34%) and Gradually Re-engaged (18%) classes. For both sexes, comparing each cohort with the first, Engaged class membership increased for subsequent cohorts. Less engaged well-care use classes had more non-Hispanic White adolescents living in rural areas with lower insurance coverage. Maternal education differentiated well-care use classes for male but not for female adolescents, being higher for male adolescents in the Engaged class than in other classes.

CONCLUSIONS

These findings highlight that well-care use patterns for both sexes changed during the transition from childhood to adolescence and that class membership differed by covariates. These results suggest that sex-specific strategies may be needed to enhance adolescents' well-care use engagement over time.

Identification and Management of Adolescent Depression in a Large Pediatric Care Network

OBJECTIVE

Primary care has been promoted as a setting to identify and manage adolescent depression. This study examined primary care-based adolescent depression identification and follow-up care when elevated symptoms were identified.

METHODS

Data came from a large pediatric care network with an organizational recommendation to screen for depression at age 16 well-visits using an electronic health record (EHR)-integrated standardized measure. Analyses examined rates of screening and elevated symptoms, pediatricians' initial responses to elevated scores, and types of follow-up care received over 1 year using retrospective EHR data extraction and manual chart reviews.

RESULTS

Across program sites, 76.3% (n = 6981) of patients attending their age 16 well-visits were screened. About one-quarter had an elevated score (19.2% mild and 6.7% moderate-to-severe), many of whom received active follow-up on their well-visit date. Over 1 year, three-fourths of patients with scores in the moderate-to-severe range and 40.0% of patients with scores in the mild range received follow-up care (e.g., antidepressant prescriptions) as per EHR extraction. Follow-up rates were higher as per manual chart reviews.

CONCLUSION

Routine adolescent depression screening is feasible across diverse primary care sites. Most patients with elevated scores were not already receiving behavioral health services, suggesting screening identified previously undetected concerns. In turn, many adolescents with elevated scores initiated treatment after screening, which indicates providing screen results at the point of care may facilitate pediatrician actions. Still, gaps in follow-up care demonstrate the need for greater investment in primary care-based behavioral health services to support high-quality treatment and ultimately decrease the burden of adolescent depression.

Menstrual characteristics and its association with socio-demographic factors and nutritional status: a study among the urban slum adolescent girls of West Bengal, India

Menstrual health is one of the major areas of concern in reproductive health, and affects a large number of women throughout their reproductive life from adolescence. Menstruation is a biological phenomenon imbued with social-cultural, nutritional and personal significance. The present study aims to focus on the menstrual characteristics and its association with socio-demographic factors and nutritional status among the urban slum adolescent girls of North 24 Parganas district, West Bengal. This community-based study was conducted among a group of 90 Bengali speaking Hindu adolescent girls aged between 16 to 18 years. A pre-tested structured schedule was used to collect detailed information about the socio-economic conditions and menstrual characteristics. All anthropometric measurements were taken using the standard procedures. Results of the study revealed that underweight girls attained menarche comparatively in later age (12.67±1.23) than that of healthy and overweight girls. Mean length of the menstrual cycle, mean duration of menstrual bleeding and mean number of days of peak discharge were maximum among the girls whose BMI was below 5th percentile, i.e. underweight. Majority of the underweight (75%) and healthy (50%) girls experienced heavy discharge during their menstrual days. Disorders like premenstrual syndrome (PMS) (78.8%) and dysmenorrhea (85.5%) were the major prevalent menstrual problems among these girls and occurrence of the symptoms of these disorders significantly varied based on their BMI. A highly significant difference (p<0.01) was found among underweight, healthy and overweight girls in terms of duration of menstrual bleeding, mean number of days of peak discharge and occurrences of PMS. Result of linear regression and step wise logistic regression (backward elimination) shows that various socio-economic and anthropometric variables are the influential predictors of menstrual characteristics like duration of menstrual discharge, cycle length, days of peak discharge as well as menstrual problems like cycle irregularity and heavy flow (p<0.05). Therefore, the present study unwraps a podium to focus on the menstrual health issues of the adolescent girls and enforce health education as well as instigates nutritional intervention programme to fortify the existing menstrual health status.

Dental Students' Readiness to Address Adolescent Risk Behaviors: A Pilot Study

Adolescents' engagement in risk-taking behaviors is well documented. However, the role of the dental practitioner in helping teenage patients understand and avert those behaviors is relatively unknown. The aim of this pilot study was to assess dental students' familiarity with adolescent risk behaviors, comfort level in discussing adolescent risk behaviors with teenage patients, and ratings of the relevance of these topics in dental education. Of the 373 University of Florida dental students across all four years who were invited to participate in 2017, 151 (40.5%) completed the survey. Among these respondents, 66% were female, 53% were from an underrepresented minority (URM) group, 40% were above the age of 25, 53% were in their preclinical years of education, and 47% were in their clinical years. In the results, the males had higher levels of comfort discussing adolescent risk behavior topics than the females, and the non-URM students had higher levels of comfort than the URM students. The clinical students showed statistically significant higher levels of comfort and ratings of the relevance of adolescent risk behaviors than the preclinical students. This pilot study assessed these students' comfort in discussing adolescent risk behaviors with patients and their level of agreement about the relevance of those topics in dental education across groups (age, gender, minority status, and educational level). Future studies are needed to examine pre- and posttest changes following interventions aimed at enhancing students' knowledge and comfort in discussing adolescent risk behaviors.

High dose vitamin D supplementation can improve menstrual problems, dysmenorrhea, and premenstrual syndrome in adolescents

Vitamin D has a crucial role in female reproduction, possibly through its effects on calcium homeostasis, cyclic sex steroid hormone fluctuations, or neurotransmitter function. We have assessed the effects of vitamin D supplementation on dysmenorrhea and premenstrual syndrome (PMS) in adolescents. In this study, 897 adolescent girls living in Mashhad and Sabzevar, Iran, received nine high-dose vitamin D supplements (as 50,000 IU/week of cholecalciferol) and were followed up over 9 weeks. We evaluated the effect of vitamin D supplementation on individuals in four categories: those with only PMS; individuals with only dysmenorrhea; subjects with both PMS and dysmenorrhea and normal subjects. The prevalence of PMS after the intervention fell from 14.9% to 4.8% (p < .001). Similar results were also found for the prevalence of subjects with dysmenorrhea (35.9% reduced to 32.4%), and in subjects with both PMS and dysmenorrhea (32.7% reduced 25.7%). Vitamin D supplementation was associated with a reduction in the incidence of several symptoms of PMS such as backache and tendency to cry easily as well as decrement in pain severity of dysmenorrhea (p < .05). High dose vitamin D supplementation can reduce the prevalence of PMS and dysmenorrhea as well as has positive effects on the physical and psychological symptoms of PMS.

Increasing Vaccination: Putting Psychological Science Into Action

Vaccination is one of the great achievements of the 20th century, yet persistent public-health problems include inadequate, delayed, and unstable vaccination uptake. Psychology offers three general propositions for understanding and intervening to increase uptake where vaccines are available and affordable. The first proposition is that thoughts and feelings can motivate getting vaccinated. Hundreds of studies have shown that risk beliefs and anticipated regret about infectious disease correlate reliably with getting vaccinated; low confidence in vaccine effectiveness and concern about safety correlate reliably with not getting vaccinated. We were surprised to find that few randomized trials have successfully changed what people think and feel about vaccines, and those few that succeeded were minimally effective in increasing uptake. The second proposition is that social processes can motivate getting vaccinated. Substantial research has shown that social norms are associated with vaccination, but few interventions examined whether normative messages increase vaccination uptake. Many experimental studies have relied on hypothetical scenarios to demonstrate that altruism and free riding (i.e., taking advantage of the protection provided by others) can affect intended behavior, but few randomized trials have tested strategies to change social processes to increase vaccination uptake. The third proposition is that interventions can facilitate vaccination directly by leveraging, but not trying to change, what people think and feel. These interventions are by far the most plentiful and effective in the literature. To increase vaccine uptake, these interventions build on existing favorable intentions by facilitating action (through reminders, prompts, and primes) and reducing barriers (through logistics and healthy defaults); these interventions also shape behavior (through incentives, sanctions, and requirements). Although identification of principles for changing thoughts and feelings to motivate vaccination is a work in progress, psychological principles can now inform the design of systems and policies to directly facilitate action.

Meeting Quality Measures for Adolescent Preventive Care: Assessing the Perspectives of Key Stakeholders

BACKGROUND

Health plans are increasingly implementing quality improvement strategies aimed at meeting adolescent clinical quality measures, yet clinics often struggle to meet these measures. This qualitative study was conducted to explore how efforts to meet the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) performance measure for adolescent well-care visits were perceived by a multidisciplinary group of stakeholders.

METHODS

The research team conducted 26 in-depth, semistructured interviews with participants from three stakeholder groups: clinic staff with direct patient contact, health care institutional leaders, and representatives of a payer organization. Interviews were about 45 minutes in duration, audio-recorded, and professionally transcribed. Framework analysis was used to identify and organize emergent themes, and Atlas.ti was used to facilitate data management and analysis.

RESULTS

Stakeholder groups diverged in their opinions regarding strategies for achieving adolescent quality measures. Stakeholders with no direct patient interaction touted transactional quality improvement strategies that directly incentivized patients and families. In contrast, clinic staff with direct patient contact believed that incentive-based efforts undermined patient-provider relationships and the clinics' focus on wellness.

CONCLUSION

A considerable disconnect exists between stakeholders with and without patient contact with regard to approaches to the delivery of well care and quality improvement strategies for meeting the adolescent well-care visit performance measure. Efforts to reconcile discordant perspectives and promote a mutual understanding between payers, institutional leaders, and clinic staff could inform the development of creative initiatives that are sustainable and effective at achieving adolescent and family engagement, as well as clinical performance benchmarks.

Polycystic Ovary Syndrome: An Under-recognized Cause of Abnormal Uterine Bleeding in Adolescents Admitted to a Children's Hospital

STUDY OBJECTIVE

To evaluate whether ovulatory dysfunction due to polycystic ovary syndrome (PCOS) is a common underlying etiology of abnormal uterine bleeding (AUB) in adolescents who require hospitalization and to explore etiology, treatment, and complications of AUB with severe anemia in adolescents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We identified female patients aged 8-20 years admitted to a children's hospital for treatment of AUB from January 2000 to December 2014. Our hospital protocol advises hormonal testing for PCOS and other disorders before treatment for AUB. We reviewed medical records and recorded laboratory evaluations, treatments, and final underlying diagnoses as well as recurrences of AUB and readmissions in the subsequent year.

RESULTS

Of the 125 subjects, the mean age was 16.5 ± 2.9 years; mean hemoglobin level was 7.0 ± 1.8 g/dL; 54% were overweight/obese; and 41% sexually active. PCOS accounted for 33% of admissions; hypothalamic pituitary ovarian axis immaturity 31%; endometritis 13%; bleeding disorders 10%. Girls with PCOS were more likely to be overweight/obese (74% vs 46%; P < .01) and girls with hypothalamic pituitary ovarian axis immaturity had lower hemoglobin levels (6.4 g/dL vs 7.4 g/dL; P < .05), than girls with all other etiologies of AUB. Treating physicians failed to diagnose endometritis as the etiology for AUB in 4 of 8 girls with positive tests for sexually transmitted infection and no other etiology.

CONCLUSION

PCOS was the most common underlying etiology in adolescents hospitalized with AUB. Screening for hyperandrogenemia is important for early diagnosis of PCOS to allow ongoing management and prevention of comorbidities. Endometritis was frequently underestimated as an etiology for AUB.

Receipt of Recommended Adolescent Vaccines Among Youth With Special Health Care Needs

We examined vaccination coverage among youth with special health care needs (YSHCN) using data from parents of adolescents (11-17 years) who responded to a statewide survey in 2010-2012 (n = 2156). Using a validated screening tool, we identified 29% of adolescents as YSHCN. Weighted multivariable logistic regression assessed associations between special health care needs and receipt of tetanus booster, meningococcal, and human papillomavirus (HPV) vaccines. Only 12% of youth had received all 3 vaccines, with greater coverage for individual vaccines (tetanus booster, 91%; meningococcal, 32%; HPV, 26%). YSHCN had greater odds of HPV vaccination than other youth (33% vs 23%, OR = 1.70, 95% CI = 1.16-2.50) but vaccination coverage was similar ( P ≥ .05) for other outcomes. In subgroup analyses, HPV vaccination also differed depending on the number and type of special health care needs identified. Findings highlight low levels of vaccination overall and missed opportunities to administer recommended vaccines among all youth, including YSHCN.

The prevalence of acne in Mainland China: a systematic review and meta-analysis

INTRODUCTION

Acne, a very common skin disease, can result in psychological distress and sustain impairment in quality of life. Data on the prevalence of acne and the differences in gender, region and age are limited. The aim of this review is to estimate the prevalence of acne in Mainland China comprehensively and to quantify its association with gender, region and age.

METHODS

We searched electronic databases with predetermined search terms to identify relevant studies published between 1 January 1996 and 30 September 2016. We pointed out repeated results using Note Express software and evaluated the studies for inclusion. Two independent reviewers extracted the data, followed with statistical analyses using Comprehensive Meta-Analysis software version 2.0. A random effects model was adopted to calculate the overall pooled prevalence and to merge categories, including gender (males and females), region (Northern China and Southern China) and age (primary and secondary students: 7-17 years old; undergraduates: 18-23 years old; overall: no limits of age) for subgroup analyses. Logistic meta-regression analysis was used to clarify the associations between acne and the predictors age, gender and region using OR and their associated 95% CI.

RESULTS

25 relevant studies were included in this meta-analysis. The overall pooled prevalence rates of acne were 39.2% (95% CI 0.310 to 0.479). The prevalence rates in different age groups were 10.2% overall (95% CI 0.059 to 0.171), 50.2% for primary and secondary students (95% CI 0.451 to 0.554), and 44.5% for undergraduates (95% CI 0.358 to 0.534); by gender, the prevalence rates were 35.7% for females (95% CI 0.275 to 0.448) and 39.7% for males (95% CI 0.317 to 0.482); and by region, the prevalence rates were 34.2% for Northern China (95% CI 0.242 to 0.458) and 46.3% for Southern China (95% CI 0.374 to 0.555). The associations between acne and the predictors age, gender and region were statistically significant.

CONCLUSIONS

In Mainland China, primary and secondary students exhibited higher prevalence rates than undergraduate students; males had higher prevalence rates of acne than females; and the prevalence rates of acne in Southern China was higher than Northern China.

Practical Approaches to Optimize Adolescent Immunization

With the expansion of the adolescent immunization schedule during the past decade, immunization rates notably vary by vaccine and by state. Addressing barriers to improving adolescent vaccination rates is a priority. Every visit can be viewed as an opportunity to update and complete an adolescent's immunizations. It is essential to continue to focus and refine the appropriate techniques in approaching the adolescent patient and parent in the office setting. Health care providers must continuously strive to educate their patients and develop skills that can help parents and adolescents overcome vaccine hesitancy. Research on strategies to achieve higher vaccination rates is ongoing, and it is important to increase the knowledge and implementation of these strategies. This clinical report focuses on increasing adherence to the universally recommended vaccines in the annual adolescent immunization schedule of the American Academy of Pediatrics, the American Academy of Family Physicians, the Centers for Disease Control and Prevention, and the American Congress of Obstetricians and Gynecologists. This will be accomplished by (1) examining strategies that heighten confidence in immunizations and address patient and parental concerns to promote adolescent immunization and (2) exploring how best to approach the adolescent and family to improve immunization rates.

The anatomy of E-Learning tools: Does software usability influence learning outcomes?

Reductions in laboratory hours have increased the popularity of commercial anatomy e-learning tools. It is critical to understand how the functionality of such tools can influence the mental effort required during the learning process, also known as cognitive load. Using dual-task methodology, two anatomical e-learning tools were examined to determine the effect of their design on cognitive load during two joint learning exercises. A.D.A.M. Interactive Anatomy is a simplistic, two-dimensional tool that presents like a textbook, whereas Netter's 3D Interactive Anatomy has a more complex three-dimensional usability that allows structures to be rotated. It was hypothesized that longer reaction times on an observation task would be associated with the more complex anatomical software (Netter's 3D Interactive Anatomy), indicating a higher cognitive load imposed by the anatomy software, which would result in lower post-test scores. Undergraduate anatomy students from Western University, Canada (n = 70) were assessed using a baseline knowledge test, Stroop observation task response times (a measure of cognitive load), mental rotation test scores, and an anatomy post-test. Results showed that reaction times and post-test outcomes were similar for both tools, whereas mental rotation test scores were positively correlated with post-test values when students used Netter's 3D Interactive Anatomy (P = 0.007), but not when they used A.D.A.M. Interactive Anatomy. This suggests that a simple e-learning tool, such as A.D.A.M. Interactive Anatomy, is as effective as more complicated tools, such as Netter's 3D Interactive Anatomy, and does not academically disadvantage those with poor spatial ability. Anat Sci Educ 9: 378-390. © 2015 American Association of Anatomists.

Teaching Trainees to Deliver Adolescent Reproductive Health Services

STUDY OBJECTIVE

Delivery of reproductive services to adolescents varies according to specialty and has been linked to differences in clinical training. Few studies have explored how different specialties' graduate medical education (GME) programs prepare providers to deliver adolescent reproductive services. We explored the perceptions of resident physicians regarding their training in delivering adolescent reproductive health services.

DESIGN

Between November 2008 and February 2009, 9 focus groups were conducted with graduate medical trainees in 3 specialties that routinely care for adolescents. The semistructured discussions were audio-recorded, transcribed, and analyzed using an inductive approach to content analysis.

SETTING

Large, urban academic medical center in Pittsburgh, Pennsylvania.

PARTICIPANTS

Fifty-four resident trainees in pediatrics, family medicine, and obstetrics/gynecology.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Trainees' perspectives regarding the didactic teaching and clinical training in providing adolescent reproductive services.

RESULTS

Five themes emerged, reflecting trainees' beliefs regarding the best practices in which GME programs can engage to ensure that trainees graduate with the belief that they are competent and will be comfortable delivering adolescent reproductive services. Trainees believed programs need to: (1) provide didactic lectures and diverse inpatient and outpatient clinical experiences; (2) have faculty preceptors skilled in providing and supervising adolescent reproductive services; (3) teach skills for engaging adolescents in clinical assessments and decision-making; (4) train providers to navigate confidentiality issues with adolescents and caregivers; and (5) provide infrastructure and resources for delivering adolescent reproductive services.

CONCLUSION

The 3 specialties differed in how well each of the 5 best practices were reportedly addressed during GME training. Policy recommendations are provided.

Developing a Predictive Score for Chronic Arthritis among a Cohort of Children with Musculoskeletal Complaints--The Chronic Arthritis Score Study

OBJECTIVE

To explore if features obtained from a carefully taken medical history can be predictors of the final diagnosis in children with musculoskeletal complaints.

STUDY DESIGN

We collected detailed clinical information on 178 children referred to our Pediatric Immunology and Rheumatology Unit by their primary care pediatrician for musculoskeletal complaints; a univariate logistic analysis was performed to identify variables correlated with the diagnosis of chronic arthritis. The variables identified were combined in a linear score that indicates the probability for a patient with musculoskeletal pain to receive the diagnosis of chronic arthritis.

RESULTS

The joint swelling pattern (P < .0001), the precipitating factors of pain (P = .001), the duration of morning stiffness (P < .0001) and the frequency of pain (P < .0001), were found to be independently correlated with the diagnosis of chronic arthritis and were used to develop a diagnostic score. This score had a sensitivity of 90.9% and specificity of 95.3%.

CONCLUSIONS

We developed a score that could be useful in the daily clinical routine to correctly direct the differential diagnosis in a child with musculoskeletal complaints, rationalizing time and resources necessary to reach a definitive diagnosis.

Epidemiology of musculoskeletal pain in a pediatric emergency department

The objectives of this study were (1) to determine the percentage of emergency department (ED) visits due to musculoskeletal pain (MSP) by children 3-14 years of age during a period of 1 year; (2) to determine the most frequent presenting complaints; and (3) to characterize their etiology. A cross-sectional study was performed on children aged 3-14(11/12) years attended at the ED of a tertiary hospital due to MSP. The demographic and clinical characteristics of the patients were reviewed 5 days each month for 12 consecutive months. Study days were selected by computer-generated simple random sampling. Out of 4,531 visits to the ED, 826 were due to MSP (18.2 %; 95 % CI 17.1-19.4 %). When compared with children with no skeletal complaints, children with MSP had a similar sex distribution but were older (mean ± SD 7 ± 3.5 years vs 9.9 ± 3.1 years; p < 0.0001). The most common complaints were pain at the wrist (19 %), ankle (19 %) and finger (15 %). The most common etiology was trauma (88.4 %), including contusions (38 %), fractures (21 %) and sprains (18 %). Children with hip (6.7 ± 3 years; p < 0.0001) and elbow (7.8 ± 3.5 years; p < 0.0001) complaints were younger than children with pain in other locations, whereas children with wrist pain (10.5 ± 2.6 years; p < 0.002) and joint sprains (10.7 ± 2.7 years; p < 0.0001) were older. Fractures were more frequent in boys (64 vs 36 %, p = 0.008; OR 1.6; CI 1.1-2.2). Visits to the ED due to MSP increased with age. Pain at three locations represented 50 % of the presenting complaints. Trauma was the principal etiology, but fractures only represented one-fifth of the total.

The child with joint pain in primary care

Joint pains are a common reason for children to present to primary care. The differential diagnosis is large including some diseases that do not primarily affect the musculoskeletal system. Although the cause for many patients will be benign and self-resolving, in rare cases the diagnosis is associated with long-term morbidity and mortality if not detected early and appropriately treated. These include primary and secondary malignancies, septic arthritis, osteomyelitis, inflammatory arthritis, slipped upper femoral epiphysis (SUFE) and non-accidental injury. We highlight the importance of a thorough history and directed yet comprehensive examination. A diagnostic algorithm is provided to direct primary care physicians' clinical assessment and investigation with the evidence base where available. In many cases, tests are not required, but if there is suspicion of malignancy, infection or inflammatory conditions, laboratory tests including full blood count, blood film, erythrocyte sedimentation rate, C-reactive protein and lactate dehydrogenase help to support or exclude the diagnosis. Autoimmune tests, such as antinuclear antibodies and rheumatoid factor, have no diagnostic role in juvenile idiopathic arthritis; therefore, we advise against any form of 'rheumatological/autoimmune disease screen' in primary care. Imaging does have a place in the diagnosis of joint pains in children, with plain radiographs being most appropriate for suspected fractures and SUFE, whilst ultrasound is better for the detection of inflammatory or infective effusions. The appropriate referral of children to paediatric rheumatologists, oncologists, orthopaedic surgeons and the emergency department are discussed.

Knowledge and attitudes about human papillomaviruses and immunization among Turkish pediatricians

BACKGROUND

Human papillomavirus (HPV) is one of the most common sexually transmitted infectious agents, and the effectiveness of vaccine delivery programs will depend largely upon whether providers recommend vaccines. The objectives of this study were to examine pediatrician characteristics, knowledge, and attitudes associated with HPV and HPV immunization.

MATERIALS AND METHODS

Attendees of the national pediatric meeting in 2011, were asked to complete a questionnaire that, aside from demographic information, elicited level of agreement with statements regarding HPV, its related diseases, and HPV vaccination. It also documented attitudes and beliefs about HPV vaccination.

RESULTS

Of the 480 attendees, 226 (47%) filled in the questionnaire. The level of pediatrician HPV-related knowledge varied. The majority (78%) were aware that HPV infection is the most common sexually transmitted infection, while 51% were unaware that a condom is ineffective protection against HPV infection. Between 60-80% of respondents were aware of the effectiveness of HPV vaccination for women. On the other hand, only 10% were aware of reasons why men should be vaccinated against HPV. The majority (75%) of Turkish pediatricians were likely to recommend HPV vaccination to their daughter, if they had one. Seventy percent of pediatricians agreed that the HPV vaccination should be added to the National Immunization Program (NIP) in Turkey. However, the respondents documented concerns about the cost of the vaccination.

CONCLUSIONS

Increasing pediatricians' knowledge and awareness of HPV and HPV vaccination may assist with the implementation of an effective NIP.

Acne vulgaris: prevalence and clinical forms in adolescents from São Paulo, Brazil

BACKGROUND

Acne is a common disease in adolescents, but there are no epidemiological data for acne in Brazil.

OBJECTIVES

To estimate the prevalence and degree of acne in adolescents from Sao Paulo and study socio-demographic factors, family history and lifestyle, associated with the disease.

METHODS

Cross-sectional study with 452 adolescents aged between 10 and 17 (mean=13.3 years), students from elementary and high school, examined by 3 independent evaluators.

RESULTS

62.4% were female, 85.8% white and 6.4% were aged 14. The prevalence was 96.0% and increased with age - all students over 14 had acne. The most prevalent form of acne was comedonal (61.1%), followed by mild (30.6%) and moderate (7.6%) papular-pustular, which affected mostly the face (97.5%). About half of the adolescents reported family history for acne in mother or father, and 20.6% reported previous treatment for acne. There was a higher chance of presenting non-comedonal acne with increased age (p<0.001).

DISCUSSION

The prevalence of acne in adolescents varies widely due to the clinical features and diagnostic methods used. Adolescents whose brothers/sisters had acne (OR=1.7-p=0.027) and those over 13 (OR=8.3-p<0.001), were more likely to have non-comedonal acne.

CONCLUSION

This study showed high prevalence of acne in adolescents from Sao Paulo, predominantly the comedonal form on the face, with a higher chance of presenting non-comedonal acne with increased age.

Youth health care utilization in Nova Scotia: what is the role of age, sex and socio-economic status?

OBJECTIVE

Youth have distinct health care needs that are not always met within a framework designed for children or adults. In Canada, little attention has been given to how youth utilize health care services and limited data are available. The aim of this study was to identify whether age, sex, socio-economic status (SES) and geographic location were significant mediators of youth health care utilization in Nova Scotia.

METHODS

The NSYOUTHS database comprises health care utilization information for all youth aged 12 to 24 years, resident in Nova Scotia between 1997 and 2007. We calculated health care utilization rates by provider, stratified by sex, age, SES, urban/rural residence and year. Negative binomial regression was used to model the variation in health care utilization by sex, SES and urban/rural location.

RESULTS

Health care utilization declined over time and varied by age. Females were more frequent users of services. Youth from lower SES areas had fewer family physician contacts but more outpatient, emergency and inpatient contacts compared to those from higher SES areas. Rural residents had fewer family physician and emergency contacts but more outpatient contacts than youth from urban areas. Ten percent of the youth were responsible for 32% of all health care contacts, whereas 11% had no health care contacts.

CONCLUSION

Specific subgroups, including youth from rural areas and of lower SES, utilize health care services differently than other youth. The challenge is to provide health care that is responsive to the needs of this heterogeneous population. Meeting this challenge requires accurate information on youth health care utilization.

Improving sexually transmitted infection results notification via mobile phone technology

PURPOSE

To improve adolescent notification of positive sexually transmitted infection (STI) tests using mobile phone technology and STI information cards.

METHODS

A randomized intervention among 14- to 21-year olds in a pediatric emergency department (PED). A 2 × 3 factorial design with replication was used to evaluate the effectiveness of six combinations of two factors on the proportion of STI-positive adolescents notified within 7 days of testing. Independent factors included method of notification (call, text message, or call + text message) and provision of an STI information card with or without a phone number to obtain results. Covariates for logistic regression included age, empiric STI treatment, days until first attempted notification, and documentation of confidential phone number.

RESULTS

Approximately half of the 383 females and 201 males enrolled were ≥18 years of age. Texting only or type of card was not significantly associated with patient notification rates, and there was no significant interaction between card and notification method. For females, successful notification was significantly greater for call + text message (odds ratio, 3.2; 95% confidence interval, 1.4-6.9), and documenting a confidential phone number was independently associated with successful notification (odds ratio, 3.6; 95% confidence interval, 1.7-7.5). We found no significant predictors of successful notification for males. Of patients with a documented confidential phone number who received a call + text message, 94% of females and 83% of males were successfully notified.

CONCLUSIONS

Obtaining a confidential phone number and using call + text message improved STI notification rates among female but not male adolescents in a pediatric emergency department.

The role of school-based health centers in increasing universal and targeted delivery of primary and preventive care among adolescents

BACKGROUND

School-based health centers (SBHC) can provide equitable and comprehensive care for adolescents; yet, few studies have described how patterns of health service utilization differ among groups. The purpose of this study was to investigate differences in utilization and perceptions of SBHC care among adolescents.

METHODS

This study sample included 414 adolescent respondents to the Healthy Schools, Healthy Communities User Survey. Three outcome measures represented utilization of care, while 4 represented perceptions of care. Multivariate logistic regressions modeled the effects of user characteristics on outcome measures.

RESULTS

There were few notable and significant differences in either utilization or perceptions of care, based on sociodemographic or health status characteristics.

CONCLUSIONS

SBHCs can eliminate differences in utilization based on sociodemographic characteristics. However, null findings show that they fall short in delivering comprehensive care to high-risk adolescents, and may not be capitalizing on opportunities to offer targeted services. Results showing positive perceptions of care suggest that adolescents would be amenable to additional counseling or education services offered at SBHCs. To foster positive health outcomes among adolescents, SBHC administrators should regularly evaluate their scope of services and support quality improvement efforts.

Military health care utilization by teens and young adults

OBJECTIVES

Adolescents and young adults are frequently uninsured (9.0% and 26.4%). Under the Affordable Care Act, the impact of insuring this population on health care utilization is unclear. We examined insurance records from >3.5 million non-pregnancy-related primary care visits in the Military Health System to describe health care utilization patterns among 467,099 non-active duty patients, aged 12 to 22, with access to free health care.

METHODS

We described association of age and gender with primary care utilization rates, clinic type, and primary and secondary diagnoses.

RESULTS

Adolescents and young adults were seen for 2.63 primary care visits per year. Use of Pediatric Clinics declined with age (51.6% to 1.8%) and increased for Family Medicine (45.5% to 91.1%). The top 3 diagnostic groups in our study were health maintenance (18.3%), health evaluation (17.3%), and respiratory/ear, nose, and throat (15.1%). Age-by-gender interactions had a significant association with health care utilization rates and diagnoses at primary care appointments. For example, the percent of all appointments accounted for by musculoskeletal injuries increased significantly (P < .001) with age for males (10.6%, 12-14 years; 12.8%, 15-18 years; 15.2%, 19-22 years) and decreased for females (10.3%, 9.2%, 7.5%).

CONCLUSIONS

Unlike previous studies of adolescents and young adults, we show that this population, especially female young adults, does use health care when it is available and largely free. Extrapolating from our Military Health System data, we expect implementation of the Affordable Care Act will result in an increased demand for health care, particularly in the areas of reproductive health care, respiratory/ear, nose, and throat issues, and routine health maintenance.

Relationship of menstrual irregularities to BMI and nutritional status in adolescent girls

Objective: To evaluate the effect of Body Mass Index and nutritional status on the menstrual pattern in adolescent girls

Methods: Four hundred one adolescent girls who attained menarche were selected from five schools in Hyderabad. The data was collected by trained medical undergraduate and postgraduates by interviewing adolescent school girls using a pre-designed pre-tested questionnaire. BMI was calculated using the formula: BMI (kg/m²) = Weight (kg) / Height 2 (m²). Hb was estimated by Sahlis method using a haemoglobinometer. Data was analyzed using SPSS 11.0.

Results: The mean age of the girls was 14.96 +/- 1.5 years. Three hundred and five (76%) of the girls had a normal menstrual cycle, twenty-eight (7 %) had frequent periods, fifty-two (13%) had infrequent periods and sixteen (4%) of the girls had totally irregular cycles and a pattern could not be determined. Three hundred and five (76%) of girls had a normal menstrual flow, sixty-eight (17%) had heavy flow and twenty-eight (7%) had scanty flow. One hundred fifty two (38%) of girls complained of premenstrual symptoms. Two hundred thirty one (60%) girls were clinically anemic. Two hundred and seventy seven (69%) had a BMI between 18.5 - 24.9 kg/m^2. One hundred and eight (27%) were underweight with a BMI of 14 – 18.49kg/m², while sixteen (4%) were overweight with BMI 25 – 29.99 kg/m². A statistically significant relationship was found between BMI and social class (P<0.001) and BMI and menstrual pattern P<0.001).

Conclusion: The study concludes that a majority of the girls had clinically obvious nutritional deficiency diseases. Out of the four hundred and one girls who were checked, two hundred thirty one were found to be anemic. Majority of the girls (84%) had a normal menstrual pattern, normal BMI and attained menarche before the age of 16. Overweight girls had infrequent periods.

Parental report of receipt of adolescent preventive health counseling services from pediatric providers

OBJECTIVE

Little is known about prevention-focused counseling health providers deliver to parents of adolescents. This study compared parental report of discussions with their adolescents' providers about a range of adolescent prevention topics.

METHODS

Between June and November 2009, a questionnaire was provided to parents accompanying adolescents aged 11-18 on outpatient clinic visits. Parents indicated, anonymously, which of 22 prevention topics they remembered discussing with their adolescent's provider. Hierarchical logistic regression models were used to identify correlates of parental recall.

RESULTS

Among the 358 participants, 83% reported discussing at least one prevention topic. More parents reported discussing general prevention topics than mental health or high-risk topics (e.g. sex). Adolescent gender, visit type, having a usual source of care, and parental beliefs about their adolescents' risk behaviors correlated with parental report of discussions about high-risk and mental health topics.

CONCLUSION

Most parents recalled discussing one or more topics with their adolescent's health provider. However, parental report of discussions about topics linked to significant adolescent morbidity was low.

PRACTICE IMPLICATIONS

Strategies to improve the frequency, timeliness and appropriateness of counseling services delivered to parents about adolescent preventive health are needed. Strategies that utilize decision support tools or patient education tools may be warranted.

Prevalence of musculoskeletal complaints and juvenile idiopathic arthritis in children from a developing country: a school-based study

INTRODUCTION

Musculoskeletal complaints are common in children. Studies from developed countries have found most to be non-inflammatory and juvenile idiopathic arthritis (JIA) to be less than 0.1%. However, there is limited data from developing countries such as India.

METHODS

This cross-sectional study was conducted from March 2010 to April 2011 among school children aged 6-17 years in northern India. Prevalence of musculoskeletal complaints and JIA were determined using a questionnaire on musculoskeletal complaints. This was filled either by parents (always in children < 14 years) or children themselves. Subsequently, all children were individually met and responses verified. An abbreviated musculoskeletal examination (GALS) was performed on every child. In cases of suspected inflammatory arthritis, further investigations were performed.

RESULTS

Of the 2059 children (851 girls, 1208 boys) who were included in this study, mean (± SD) age was 11.5 ± 2.9 years. Joint pain (more than 1 week) was present in 158 (7.6%), back pain in 63 (3.1%) and heel pain in 62 (3%) of them. Limb pains, suggestive of 'growing pains', were present in 45 (2.1%) children. There were six suspected cases of inflammatory musculoskeletal pain; however, only one child was confirmed as having JIA (enthesitis-related arthritis). The estimated prevalence of JIA was 48/100,000 in Indian children.

CONCLUSION

Musculoskeletal complaints were not uncommon in children from a developing country like India. Estimated prevalence of JIA was 48/100,000 (95%CI 10-280).

When coverage expands: children's health insurance program as a natural experiment in use of health care services

BACKGROUND

Expanding insurance coverage is designed to improve access to primary care and reduce use of emergency department (ED) services. Whether expanding coverage achieves this is of paramount importance as the United States prepares for the Affordable Care Act.

OBJECTIVES

Emergency and outpatient department use was examined after the State Children's Health Insurance Program (CHIP) coverage expansion, focusing on adolescents (a major target group for CHIP) versus young adults (not targeted). The hypothesis was that coverage would increase use of outpatient services, and ED use would decrease.

METHODS

Using the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), the years 1992-1996 were analyzed as baseline and then compared to use patterns in 1999-2009, after the CHIP launch. Primary outcomes were population-adjusted annual visits to ED versus nonemergency outpatient settings. Interrupted time series were performed on use rates to ED and outpatient departments between adolescents (11 to 18 years old) and young adults (19 to 29 years old) in the pre-CHIP and CHIP periods. Outpatient-to-ED ratios were calculated and compared across time periods. A stratified analysis by payer and sex was also performed.

RESULTS

The mean number of outpatient adolescent visits increased by 299 visits per 1,000 persons (95% confidence interval [CI] = 140 to 457), while there was no statistically significant increase in young adult outpatient visits across time periods. There was no statistically significant change in the mean number of adolescent ED visits across time periods, while young adult ED use increased by 48 visits per 1,000 persons (95% CI = 24 to 73). The adolescent outpatient-to-ED ratio increased by 1.0 (95% CI = 0.49 to 1.6), while the young adults ratio decreased by 0.53 across time periods (95% CI = -0.90 to -0.16).

CONCLUSIONS

Since CHIP, adolescent non-ED outpatient visits have increased, while ED visits have remained unchanged. In comparison to young adults, expanding insurance coverage to adolescents improved use of health care services and suggests a shift to non-ED settings. Expanding insurance through the Affordable Care Act of 2010 will likely increase use of outpatient services, but may not decrease ED volumes.

Menstrual Pattern among Unmarried Women from Northern India

BACKGROUND

Menstruation disorders are also responsible for emotional, physical, behavioural and dietary practice changes. These changes affect their normal functioning and social life. The present study was carried out to find the prevalence of menstrual problems among unmarried girls of Chandigarh, India and to compare their knowledge and beliefs regarding menstruation in different sub-groups.

METHODOLOGY

A community based cross-sectional study was conducted among 744 unmarried females in Rural, Urban and Slum strata of UT Chandigarh, India. Data were collected using a self-administered structured questionnaire on menstruation. Chi-square value was used for testing statistical significance.

RESULTS

The mean age of the respondents was 16.84±3.05 years. Maximum respondents (40.9%) were educated up to 10th standard/High school. 448 (60.2%) were aware of menstruation before starting of menarche. Awareness was found to be significantly associated (p=0.02) with age. Socio-economic status and prior knowledge of respondents was also found to be significantly associated (p< 0.001). 61% (454) of the respondents had a regular flow during menses. Normal flow was reported by 70.2 %(522) of the respondents. Dysmenorrhea was found to be the most common problem suffered by 429 (57.7%) respondents.

CONCLUSION

Menstrual hygiene is an issue that needs to be addressed at all levels. A variety of factors are known to affect menstrual behaviors, the most influential ones being economic status. It is essential to design a mechanism to address and for the access of healthy menstrual practices.

Impact of gender on sepsis mortality and severity of illness for prepubertal and postpubertal children

OBJECTIVE

To investigate differences in sepsis mortality between prepubertal and postpubertal males and females.

STUDY DESIGN

This was a retrospective review of the Virtual PICU Systems (VPS) database (including 74 pediatric intensive care units [PICUs]) for 2006-2008. We included prepubertal (aged 2-7 years) and postpubertal (aged 16-21 years) children with a primary diagnosis of sepsis admitted to a participating PICU.

RESULTS

Prepubertal females (n = 272; 9.9% mortality) and prepubertal males (n = 303; 10.9% mortality) had similar mortality and severity of illness (Pediatric Index of Mortality 2 risk of mortality [PIM 2 ROM]). Postpubertal females (n = 233; mortality, 5.6%) had lower mortality than postpubertal males (n = 212; mortality, 11.8%; P = .03). PIM 2 ROM was higher for postpubertal males than postpubertal females (P = .02). After controlling for hospital specific effects with multivariate modeling, in postpubertal children, female gender was independently associated with a lower initial severity of illness (PIM 2 ROM: OR, 0.77; 95% CI, 0.62-0.96; P = .02).

CONCLUSION

Sepsis mortality is similar in prepubertal males and females. However, postpubertal males have a higher sepsis mortality than postpubertal females, likely related to their greater severity of illness on PICU admission. These outcome differences in postpubertal children may reflect a hormonal influence on the response to infection or differences in underlying comorbidities, source of infection, or behavior.

Evaluating opportunities for text message communication: a survey of parents and teens

BACKGROUND

Text messaging is a widespread, cost-effective method for communicating. It is widely used by both parents and teens. The study objective was to survey teens and their parents to assess the capability and willingness of teens to receive healthcare-related text messages from their physician.

SUBJECTS AND METHODS

Parents and teens (12-17 years old) at an adolescent clinic were asked to complete surveys. Surveys were available in hard copy or electronically (via Survey Monkey) using computer kiosks in the waiting room. Approval was received from two local Institutional Review Boards.

RESULTS

Of the 93 pairs who began the survey, 47 pairs (51%) qualified and completed both the teen and parent surveys. Over 85% of teens were willing to receive texts from their doctor. Teens were most interested in appointment reminders (81%), immunization reminders (53%), and general test results (for example, strep [53%]). Parents' willingness to allow teens to receive text messages directly varied by content. Many parents preferred to also receive a copy of any text message sent to their teen.

CONCLUSIONS

Both parents and teens endorse using text messages for appointment reminders. Parents appear willing for their teens to receive some health information directly. Future research should evaluate the efficacy of using text messages for communication with teens to improve care and utilization of services for adolescents.

Employment of a needs assessment survey to shape a novel web-based pediatric rheumatology curriculum for primary care providers

BACKGROUND

Pediatric rheumatology faces many challenges due to the shortage of board certified physicians in the field and the imbalance in their geographic distribution. This shortage has required primary care physicians and adult rheumatologists to assume the care of children with rheumatologic diseases, though these physicians report significant discomfort doing so. We are addressing this issue through the development of a novel web-based curriculum aimed at primary care physicians.

METHODS

We pursued a needs assessment survey of Vanderbilt pediatric residency graduates (1981-2010) working in primary care. Our goals were to understand their perceptions of what the needs are and what educational interventions would be most effective.

RESULTS

Of 152 surveys sent successfully via Survey Monkey, we received 28 responses (18.4%). Responses suggest there to be a discrepancy between physicians' general assessment of their training and their self-reported ability to recognize specific diseases. Nearly 80% of respondents felt that additional education in pediatric rheumatology would improve their ability to co-manage children with the rheumatologist. Action plans for common rheumatologic complaints and potential emergencies were thought to be of potential benefit by a majority of respondents.

CONCLUSIONS

We will utilize our survey results to develop a learner centered curriculum to have the highest positive impact in assisting primary care providers in caring for children with rheumatologic diseases.

Bladder health across the life course

Influences on bladder health begin during infancy and continue throughout the lifespan. Bladder anatomy and physiology change as individuals age, and the risk and propensity for bladder conditions, including lower urinary tract symptoms, throughout life are related to factors specific to age, sex, and life events. Bladder habits and dysfunctions at one stage of life may affect bladder health in subsequent stages. However, bladder problems are neither a normal part of aging nor inevitable at any stage of life. Many of the factors that negatively impact bladder health at all ages may be modifiable, and healthy bladder habits may prevent or reverse bladder dysfunctions that can occur naturally or in response to life events. There are opportunities to further define and promote healthy bladder habits through focused research and heightened public awareness of the importance of bladder health, which may lead to improvements in overall health and quality of life. It is our hope that this paper will inform and encourage public health initiatives and research programs aimed at this goal.

Prevalence and predictors of drug use among adolescents with HIV infection acquired perinatally or later in life

We examined the prevalence and predictors of drug use among a diverse group of adolescents living with HIV infection acquired perinatally or through sexual risk behaviors ("behaviorally acquired"). Adolescents ages 13-21 (n = 166) who were receiving care at one of five pediatric/adolescent HIV clinics in three US cities (Baltimore MD, Washington DC, and New York NY) and were enrolled in a behavioral intervention were interviewed at baseline regarding lifetime drug use experiences and depression symptoms. A majority of study participants reported using alcohol (57.2%) and marijuana (51.2%); 48.8% reported tobacco/cigarette use. The mean age of onset of use for each type of drug was 14 years or younger. A larger proportion of participants with behaviorally acquired HIV than adolescents with perinatally acquired HIV reported lifetime use of alcohol (76.1 vs. 44.4%), marijuana (73.1 vs. 36.4%), tobacco (70.2 vs. 34.3%), and club drugs (22.4 vs. 3%) (all p < 0.001).

Longitudinal associations between depression and problematic substance use in the Youth Partners in Care study

Large-scale treatment studies suggest that effective depression treatment and reduced depression are associated with improved substance use outcomes. Yet information is limited regarding the longitudinal association between depressive symptoms and problematic substance use and its predictors, particularly in real-world practice settings. Using latent growth modeling, we examined the (a) longitudinal association between depressive symptoms and problematic substance use, (b) impact of depressive symptoms on problematic substance use, (c) impact of problematic substance use on depressive symptoms, and (d) role of co-occurring symptoms on depression and problematic substance use. Participants were part of the Youth Partners in Care study, an effectiveness trial evaluating a quality improvement intervention for youth depression through primary care. This ethnically diverse sample included youths aged 13 to 21 years screening positive for depression from 5 health care organizations. Participants were followed 4 times over an 18-month period and assessed for both depressive symptoms and problematic substance use. Both depressive symptoms and problematic substance use declined over time. Higher baseline depressive symptoms predicted a slower decline in problematic substance use, but baseline problematic substance use did not predict changes in depressive symptoms. These prospective associations remained robust controlling for co-occurring symptoms. Results support prior large-scale depression studies indicating depression burden negatively impacts substance use outcome and extends these findings to real-world practice settings. Findings underscore the importance of addressing depression severity in youth with concurrent substance use problems, even in the context of comorbid symptoms of anxiety, delinquency, and aggression.

A randomized trial of the effect of centralized reminder/recall on immunizations and preventive care visits for adolescents

OBJECTIVE

To assess the impact of a managed care-based patient reminder/recall system on immunization rates and preventive care visits among low-income adolescents.

METHODS

We conducted a randomized controlled trial between December 2009 and December 2010 that assigned adolescents aged 11-17 years to one of three groups: mailed letter, telephone reminders, or control. Publicly insured youths (n = 4115) were identified in 37 participating primary care practices. The main outcome measures were immunization rates for routine vaccines (meningococcus, pertussis, HPV) and preventive visit rates at study end.

RESULTS

Intervention and control groups were similar at baseline for demographics, immunization rates, and preventive visits. Among adolescents who were behind at the start, immunization rates at study end increased by 21% for mailed (P < .01 vs control), 17% for telephone (P < .05), and 13% for control groups. The proportion of adolescents with a preventive visit (within 12 months) was: mailed (65%; P < .01), telephone (63%; P < .05), and controls (59%). The number needed to treat for an additional fully vaccinated adolescent was 14 for mailed and 25 for telephone reminders; for an additional preventive visit, it was 17 and 29. The intervention cost $18.78 (mailed) or $16.68 (phone) per adolescent per year to deliver. The cost per additional adolescent fully vaccinated was $463.99 for mailed and $714.98 for telephone; the cost per additional adolescent receiving a preventive visit was $324.75 and $487.03.

CONCLUSIONS

Managed care-based mail or telephone reminder/recall improved adolescent immunizations and preventive visits, with modest costs and modest impact.

The challenge of access to care for soft tissue sarcomas bridging pediatric and adult age: the Italian pediatric oncology view

Synovial sarcoma and rhabdomyosarcoma are two high-grade soft tissue sarcoma subtypes that occur in adolescents and young adults. Managing these malignancies in patients in this age bracket poses various clinical problems, partly because different therapeutic approaches are sometimes adopted by pediatric and adult oncologists, even though they are dealing with the same condition. In this review, the doubts concerning how best to manage soft tissue sarcomas in patients between pediatric and adult ages lead up to a more general discussion of the issue of access to optimal cancer services for adolescents and young adults - a subset of patients acknowledged as being under-represented in clinical trials on therapies that may improve their outcome. The situation in Italy is described, along with action taken in an effort to bridge the gap and implement specific programs tailored to these patients.

Major health-care providers and the 10 leading reasons for adolescent ambulatory visits

BACKGROUND

Epidemiological research underpins the importance of effective health-care strategies for adolescents. This descriptive study compares the 10 most common diseases among Taiwanese adolescents for 2000 and 2009.

METHODS

Data for a total of 69,594 visits in 2000 and 65,802 visits in 2009 by adolescents aged between 10 and 20 years were collected from the National Health Insurance Research Database. A maximum of three outpatient diagnostic codes (International Classification of Disease, ninth revision) could be listed for every visit. The data categories were: principal diagnosis, patient age, and physician specialty.

RESULTS

  The middle adolescent age group utilized the least amount of medical services. Respiratory (46.2% in 2000, 40.5% in 2009) and digestive (16.5% in 2000 and 16.9% in 2009) tracts were the leading two diagnostic categories for adolescent ambulatory visits. Teeth (6.8%, 6.1%) and eye (4.0%, 3.1%) problems were also among the top 10 diseases. Family practitioners, ear-nose-throat specialists, and traditional Chinese medicine physicians were the major health-care providers for Taiwanese adolescents, especially in the middle and late groups. Although noted as the first option for consultation in the early group, the role of pediatricians with regard to adolescent health care declined in importance with age.

CONCLUSIONS

Nearly 99% of the population in Taiwan is covered under the national health insurance system. The different disease patterns and major health-care providers between Taiwan and other countries are compared.

Back disorders among Israeli youth: a prevalence study in young military recruits

BACKGROUND CONTEXT

Back problems are reported with increasing frequency in adults and adolescents. Most information is from self-reported questionnaires or studies with small sample sizes. Reports were usually focused on specific diseases and biased toward overdiagnosis.

PURPOSE

To assess the prevalence of common back disorders among a large cohort of 17-year-old males and females recruited by the Israel Defense Forces (IDF).

STUDY DESIGN

A retrospective cross-sectional prevalence study.

PATIENT SAMPLE

Seventeen-year-old Israeli male and female military recruits reporting as directed by the IDF for preinduction medical examination between January 01, 1998 and December 31, 2006.

OUTCOME MEASURES

Military functional limitation Grades 1 to 7 per diagnosis category.

METHODS

Military recruits were examined and classified based on medical and orthopedic diagnoses. They were referred for orthopedic consultation as necessary. Four orthopedic classifications were used: spinal deformity (including kyphosis and scoliosis), back pain (including neck and radicular syndromes), spondylolysis/olisthesis, and limitations resulting from trauma or spinal surgery. Data were coded into a central database, and descriptive statistics are presented.

RESULTS

The overall prevalence of back disorders among 828,171 17-year-old military recruits (61.5% male) was 16.8%. Back disorders resulting in significant functional limitation were diagnosed in 0.8% of recruits. The most prevalent diagnoses were spinal deformities (kyphosis and scoliosis, females 11.9%, males 11.5%) and back pain (females 3.0%, males 5.6%). Most of these diagnoses were rated as mild.

CONCLUSIONS

When using objective criteria, overall back disorders in a large population of 17-year-old recruits were 17%, considerably lower than most reports. Back morbidity severe enough to prevent combat duty occurred at a rate of less than 1%, suggesting that serious back morbidity is not a frequent finding in this age group.

LEVEL OF EVIDENCE

Symptom prevalence study, Level III.