Contraception Initiation in the Emergency Department: Adolescent Perspectives

PURPOSE

The purpose of this study was to identify factors affecting contraceptive intention and behavior among adolescent females in the pediatric Emergency Department.

METHODS

We conducted a qualitative interview study nested within a larger prospective cohort study examining adolescent contraceptive counseling for females ages 15-18 years at-risk of unintended pregnancy presenting to the pediatric Emergency Department. Interviews were conducted in a subset of participants. The ecologically expanded Theory of Planned Behavior, expert opinion, and literature review informed the interview guide. Interviews were recorded, transcribed, coded and monitored for thematic saturation.

RESULTS

Twenty-eight interviews were analyzed. Mean age was 17.1 years. Themes were mapped to ecologically expanded Theory of Planned Behavior constructs. Within health system influences, prior contraceptive experiences and patient-clinician interactions were described. Within community influences, contraceptive education, knowledge and misinformation, teen pregnancy norms, and social media impacts were described. Within attitudes influences, side-effect and safety concerns, contraceptive motivations and teen pregnancy beliefs were described. Within subjective norm influences, peer and family impacts were described. Within perceived behavioral control, Emergency Department (ED) counseling intervention impacts were described.

DISCUSSION

We identified factors affecting contraceptive initiation/behavior among an ED adolescent population that otherwise may not have received contraceptive education in similar detail as provided by study clinicians. Adolescents' prior contraceptive and clinician interactions, limited access to contraceptive education, knowledge and misinformation, and side-effect and safety concerns affected initiation. Peer/family sharing and social media were leading contraceptive information sources. Future studies should incorporate insights into adolescent ED intervention design to make optimal use of resources while maximizing potential benefit.

Contraceptive counseling for adolescents in the emergency department: A novel curriculum for nurse practitioners and physician assistants

ABSTRACT

Many adolescents use the emergency department (ED) as their primary source of health care. As a result, the ED serves as a unique opportunity to reach adolescents. Although many adolescent visits to the ED are related to reproductive health, ED providers report barriers to providing this care, including lack of training. Nurse practitioners (NPs) and physician assistants (PAs) serve a vital role in the provision of consistent care to adolescents in the ED. The purpose of this study was to create a curriculum to train NPs and PAs at two pediatric institutions to provide patient-centered contraceptive counseling to adolescents in the pediatric ED regardless of their chief complaint. To do this, we created a four-part webinar followed by an in-person training session. Participants completed training and then conducted counseling sessions with adolescents in the ED. Counseling sessions were recorded and reviewed for fidelity to delineated counseling principles, and data from post-counseling surveys were collected. 27 NPs and PAs completed the training and conducted 99 counseling sessions. Nearly all sessions incorporated essential content and communication principles such as shared decision making (90%) and teach-back methods (75%). All NPs and PAs who participated reported satisfaction and subjective improvement in knowledge and competence from the training. This curriculum offers a novel and feasible approach to train NPs and PAs to deliver patient-centered contraception counseling to adolescents in the ED setting, and it can serve as a model for how to educate different providers to incorporate reproductive health education into the busy ED visit.

Expanding Contraceptive Access for Teens-Leveraging the Pediatric Emergency Department

PURPOSE

Adolescents have limited access to sexual healthcare services, and the emergency department (ED) may be the only place some will seek care. We implemented an ED-based contraception counseling intervention to assess intervention feasibility, and adolescent intention to initiate contraception, contraception initiation, and follow-up visit completion.

METHODS

This prospective cohort study trained advanced practice providers in the EDs of two pediatric urban academic medical centers to deliver brief contraception counseling. A convenience sample of patients enrolled from 2019 to 2021 included females aged 15-18 not pregnant/desiring pregnancy and/or using hormonal contraception/an intrauterine device. Participants completed surveys to assess demographics and intention to initiate contraception (yes/no). Sessions were audiotaped and reviewed for fidelity. We ascertained contraception initiation and follow-up visit completion via medical record review and participant survey at 8 weeks.

RESULTS

Twenty-seven advanced practice providers were trained, and 96 adolescents were counseled/responded to surveys (mean age 16.7 years; 19% non-Hispanic White, 56% non-Hispanic Black; 18% Hispanic). Mean counseling duration was 12 minutes and >90% of reviewed sessions maintained fidelity to content/style. Most participants (61%) reported intention to initiate contraception, and these participants were older and more likely to report prior contraceptive use, compared to those without intention. One-third (33%) initiated contraception in the ED or after the follow-up visit.

DISCUSSION

Contraceptive counseling was feasible to integrate in the ED visit. Intention to initiate contraception was common and many adolescents initiated contraception. Future work should increase the pool of trained providers and supports for same-day contraception initiation for those desiring in this novel setting.

Feasibility of a Contraception Intervention for Hospitalized Adolescents and Young Adults

OBJECTIVES

Unintended pregnancy in adolescents and young adults (AYAs) is linked with negative outcomes. We sought to evaluate the feasibility, acceptability, and preliminary efficacy of a contraception intervention in the pediatric hospital.

METHODS

We conducted a pilot study of hospitalized AYA females aged 14 to 21 years who reported past or anticipated sexual activity. A health educator offered a tablet-based intervention to provide contraception education and medications, if desired. We assessed feasibility (ie, intervention completion, duration, disruption to care), acceptability (ie, proportion rating as acceptable or satisfactory) among AYAs, parents or guardians, and healthcare providers, as well as preliminary efficacy (eg, contraception uptake) at enrollment and 3-month follow up.

RESULTS

We enrolled 25 AYA participants; mean age was 16.4 ± 1.5 years. The intervention demonstrated high feasibility as all enrolled participants (n = 25, 100%) completed the intervention and median intervention duration was 32 (interquartile range 25-45) minutes. Among 11 nurses, 82% (n = 9) reported the intervention was not at all or minimally disruptive to their workflow. All AYAs were very or somewhat satisfied with the intervention and 88% (n = 7) of 8 parents and guardians surveyed felt it was acceptable for the educator to meet privately with their child. Eleven participants (44%) started hormonal contraception, most commonly the subdermal implant (n = 7, 64%), and 23 (92%) received condoms.

CONCLUSIONS

Our findings support the feasibility and acceptability of our contraception intervention in the pediatric hospital resulting in contraception uptake among AYAs. Efforts to expand access to contraception are important to reduce unintended pregnancy, especially as restrictions to abortion are increasing in some states.

Sexual behaviors, contraception use and barriers among adolescents and young adults in rural Haiti

BACKGROUND

Adolescents and young adults (AYAs) in Haiti experience a high unintended pregnancy rate, in part due to unmet contraception needs. Little is known about AYA opinions of and experiences with contraception that may explain remaining gaps in coverage. We aimed to describe barriers and facilitators to contraception use among AYAs in Haiti.

METHODS

We conducted a cross-sectional survey and semi-structured qualitative interviews with a convenience sample of AYA females aged 14-24 in two rural communities in Haiti. The survey and semi-structured interviews assessed demographics, sexual health and pregnancy prevention behaviors and explored contraception opinions and experiences according to Theory of Planned Behavior constructs: attitudes, subjective norms, and perceived behavioral control. We used descriptive statistics to report means and responses to Likert scale and multiple-choice questions. Guided by content analysis, we analyzed interview transcripts through inductive coding and team debriefing.

RESULTS

Among 200 survey respondents, 94% reported any past vaginal sexual activity, and 43% reported ever being pregnant. A large majority were trying to avoid pregnancy (75%). At last sexual activity, 127 (64%) reported use of any contraceptive method; Among them, condoms were the most common method (80%). Among those with previous condom use, most reported use less than half the time (55%). AYAs were concerned about parental approval of birth control use (42%) and that their friends might think they are looking for sex (29%). About one-third felt uncomfortable going to a clinic to ask for birth control. In interviews, AYAs desired pregnancy prevention but frequently noted concerns about privacy and parental, community and healthcare provider judgement for seeking care for reproductive health needs. AYAs also noted a lack of contraception knowledge, evident by frequent misconceptions and associated fears.

CONCLUSION

Among AYAs in rural Haiti, a large majority were sexually active and desire pregnancy avoidance, but few were using effective contraception due to numerous concerns, including privacy and fear of judgement. Future efforts should address these identified concerns to prevent unintended pregnancy and improve maternal and reproductive health outcomes in this population.

Contraception use among individuals with substance use disorder increases tenfold with patient-centered, mobile services: a quasi-experimental study

BACKGROUND

Individuals with substance use disorders (SUD) have disproportionately high rates of unintended pregnancy. Reducing harm associated with this risk and its biopsychosocial consequences requires evidence-based, non-coercive interventions that ensure access to contraception for individuals who choose to prevent pregnancy. We examined feasibility and impact of SexHealth Mobile, a mobile unit-based intervention that aimed to increase access to patient-centered contraceptive care for individuals in SUD recovery programs.

METHODS

We conducted a quasi-experimental study (enhanced usual care [EUC] followed by intervention) at three recovery centers with participants (n = 98) at risk for unintended pregnancy. EUC participants were offered printed information on community locations where they could access contraception care. SexHealth Mobile participants were offered same-day, onsite clinical consultation on a medical mobile unit and contraception if desired. The primary outcome was use of contraception (hormonal or intrauterine device) at one-month post-enrollment. Secondary outcomes were at two-weeks and three-months. Confidence in preventing unintended pregnancy, reasons for non-use of contraception at follow-up, and intervention feasibility were also assessed.

RESULTS

Participants (median age = 31, range 19-40) enrolled in the intervention period were almost 10 times more likely to be using contraception at one-month (51.5%) versus the those enrolled in the EUC period (5.4%) (unadjusted relative risk [URR] = 9.3 [95%CI: 2.3-37.1]; adjusted relative risk [ARR] = 9.8 [95%CI: 2.4-39.2]). Intervention participants were also more likely to be using contraception at 2-weeks (38.7% vs. 2.6%; URR = 14.3 [95%CI: 2.0-104.1]) and three-months (40.9% vs. 13.9%; URR = 2.9 [95% CI: 1.1-7.4]). EUC participants reported more barriers (cost, time) and less confidence in preventing unintended pregnancies. Mixed-methods feasibility data indicated high acceptability and feasible integration into recovery settings.

CONCLUSIONS

Mobile contraceptive care based on principles of reproductive justice and harm reduction reduces access barriers, is feasible to implement in SUD recovery settings, and increases contraception use. Expanding interventions like SexHealth Mobile may help reduce harm from unintended pregnancies among individuals in SUD recovery. Trial Registration NCT04227145.

Menstrual health among adolescents and young adults in rural Haiti

BACKGROUND

Adolescent and young adult (AYA) females in low- and middle-income countries often face disparities in menstrual health (MH). Poor MH and lack of sexual and reproductive health education leads to school absenteeism, increasing risk for adverse psychosocial and educational outcomes. Further, disasters (e.g., earthquakes) are linked with unsafe living environments and sanitation facilities for women. We sought to describe MH perspectives and practices among AYAs in rural Haiti.

METHODS

We conducted a cross-sectional survey in two rural communities in Haiti. AYA females aged 14-24 years completed questions on demographics, the Menstrual Practice Needs Scale (36 items; MPNS-36) and the Menstrual Practices Questionnaire (4 items). We performed descriptive statistics and Chi square or Fisher's Exact tests to compare responses among sub-groups.

RESULTS

Among 200 respondents, the median age was 20 years (IQR 17-22). 51% (95% CI 44%, 58%; 102/200) were currently attending school at least 3 days/week and 97% (94%, 99%; 193/200) were not married. According to the MPNS-36, 68% (62%, 74%; 136/200) of participants had unmet MH needs. Seventy-one (77%) reused some of their menstrual materials during their last menstruation. During their last menstruation, 44% (37%, 50%; 87/200) reported they often or always skipped school because they had their menses, and 31% (25%, 37%; 62/200) sometimes skipped. Many felt always or often worried that someone or something would harm them while they were changing their menstrual materials at home and at school.

CONCLUSIONS

Among AYAs in rural Haiti, three-quarters reported menses-related school absenteeism and two-thirds had unmet MH needs. AYA females often lacked a safe environment to change their menstrual materials. Given recent disasters in Haiti, (August 2021 earthquake), safe environments for MH are critically needed to offset risk for poor psychosocial and health outcomes. Future efforts to improve MH among AYAs in Haiti are needed to ensure access to MH resources and school attendance.

Understanding the Sexual and Reproductive Health Needs of Hospitalized Adolescent Males

OBJECTIVES

To describe sexual behaviors and acceptability of receiving sexual and reproductive health (SRH) services among hospitalized adolescent males.

METHODS

We performed a cross-sectional survey of hospitalized adolescents. Eligible participants were males aged 14 to 20 years admitted at 2 academic medical centers. Outcome measures included reported healthcare utilization, sexual health behaviors (eg, sexual activity), contraception use, and acceptability of SRH discussions during a hospitalization.

RESULTS

Among 145 participants, 42% reported a history of vaginal sex, 27% current sexual activity, 12% early sexual debut, and 22% 4 or more prior sexual partners. At last sex, condom use was reported by 63% and use of reversible contraception by 36%. Nearly half (45%) agreed that hospital-based SRH discussions were acceptable, particularly among those with history of sexual activity (P < .01). Some (12%) reported they had not accessed care in the past year when they felt they should.

CONCLUSIONS

Hospitalized males in our study had similar rates of sexual activity as compared with the general population but had higher rates of early sexual debut and number of prior partners, which are independently linked with negative sexual health outcomes (eg, sexually transmitted infections). Our participants found SRH discussions to be generally acceptable. These findings reveal opportunities to screen for unmet SRH needs and provide SRH education and services for adolescent males in the hospital.

Brief Motivational Intervention to Improve Adolescent Sexual Health Service Uptake: A Pilot Randomized Controlled Trial in the Emergency Department

OBJECTIVE

To test the hypothesis that our motivational sexual health intervention (SexHealth) would increase health service uptake when compared with control.

STUDY DESIGN

In a randomized controlled trial at a pediatric emergency department, sexually active adolescents received either the SexHealth intervention or printed materials (control). SexHealth, delivered by a health educator, was a tablet-based, interactive intervention that included motivational techniques to promote sexual health, condom skills training, and tailored service recommendations. We assessed feasibility (eg, intervention completion, recommendations discussed, intervention duration), acceptability (ie, proportion enrolled and rating intervention as satisfactory), and efficacy; secondary outcomes were sexual and care-seeking behaviors at 6 months. The efficacy outcome was completion of ≥1 service at the index visit (ie, counseling, condoms, emergency contraception for immediate or future use, pregnancy/sexually transmitted infection/HIV testing, sexually transmitted infection treatment, and clinic referral).

RESULTS

We enrolled 91 participants (intervention = 44; control = 47). The intervention demonstrated high feasibility: 98% completed the intervention; 98% of recommendations were discussed; duration was 24.6 minutes, and acceptability: 87% of eligible adolescents enrolled and 93% rated the intervention as fairly to very satisfactory. Compared with controls, intervention participants were more likely to complete ≥1 service (98% vs 70%, P < .001) including HIV testing (33% vs 6%, P = .02) and emergency contraception (80% vs 0%, P = .01). There were no meaningful differences between arms in behaviors at follow-up.

CONCLUSIONS

SexHealth was feasible to implement, acceptable to youth, and resulted in increased uptake of health services during the emergency department visit. Additional strategies may be needed to extend intervention effects over time.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; NCT03341975.

Sexual Health Behaviors and Pregnancy Risk Among Hospitalized Female Adolescents

OBJECTIVES

To describe sexual health behaviors, contraceptive use, and pregnancy risk among hospitalized female adolescents.

METHODS

We conducted a cross-sectional survey of hospitalized female patients aged 14 to 21 years at 2 academic medical centers to assess sexual health behaviors, contraceptive use, contraceptive counseling receipt, and factors associated with pregnancy complications (eg, diabetes, teratogenic exposure). We calculated the validated Pregnancy Risk Index (PRI) (number per 100 who will become pregnant in the next year).

RESULTS

Among 177 participants (mean age 16 years, SD 1.5), 75 (43%) were sexually active. At last vaginal sex, 65% reported condom use; 49%, reversible contraception; and 12%, long-acting reversible contraception (LARC). Past-year contraceptive counseling was reported by 73% of sexually active female participants and was associated with increased use of reversible (P = .001) and dual contraception (P = .03) but not LARC (P = .24). The mean PRI among all participants was 4.75. Nearly three-quarters (73%) had a medical comorbidity or teratogenic exposure. Those with teratogenic medication use had the lowest PRI of 0.32 (P < .05), with 88% using reversible contraception and 31% using LARC.

CONCLUSIONS

Hospitalized female adolescents had a PRI similar to that of adolescents in the general population. However, nearly three-quarters had a medical comorbidity and/or teratogenic exposure, which increased risk for pregnancy complications. Contraceptive counseling was associated with increased reversible and dual contraception use but not LARC use. Efforts to improve comprehensive contraceptive counseling, highlighting LARC, are critically needed in this population.

Justice System Involvement Among Adolescents in the Emergency Department

OBJECTIVE

To assess justice system involvement among adolescents in the pediatric emergency department and identify associations with risk and protective factors.

STUDY DESIGN

We conducted a cross-sectional, computerized survey of adolescents to assess for personal, justice system involvement, and nonhousehold justice system involvement (ie, important people outside of household). We assessed sexual behaviors, violent behaviors, substance use, school suspension/expulsion, parental supportiveness, and participant mood (score <70 indicates psychological distress). We compared differences between groups using the χ2 tests, Fisher exact tests, t tests, and performed multivariable logistic regression analyses.

RESULTS

We enrolled 191 adolescents (mean age 16.1 years, 61% female). Most (68%) reported justice system involvement: personal (13%), household (42%), and nonhousehold (40%). Nearly one-half (47%) were sexually active and 50% reported school suspension/expulsion. The mean score for mood was 70.1 (SD 18); adolescents with justice system involvement had had lower mood scores (68 vs 74, P = .03) compared with those without justice system involvement. In a multivariable model, school expulsion/suspension was significantly associated with reporting any justice system involvement (OR 10.4; 95% CI 4.8-22.4).

CONCLUSIONS

We identified the pediatric emergency department as a novel location to reach adolescents at risk for poor health outcomes associated with justice system involvement. Future work should assess which health promotion interventions and supports are desired among these adolescents and families.

Long-acting reversible contraceptives (LARCs) as harm reduction: a qualitative study exploring views of women with histories of opioid misuse

Background

The sharp rise in opioid use disorder (OUD) among women coupled with disproportionally high rates of unintended pregnancy have led to a four-fold increase in the number of pregnant women with OUD in the United States over the past decade. Supporting intentional family planning can have multiple health benefits and reduce harms related to OUD but requires a comprehensive understanding of women’s perspectives of preventing unintended pregnancies. The purpose of this study was to comprehensively evaluate the knowledge, attitudes and experiences as they relate to seeking contraception, particularly LARCs, among women with active or recovered opioid misuse.

Methods

In-depth interviews and focus group discussions with 36 women with current or past opioid misuse were recorded and transcribed. Transcripts were coded by ≥ 2 investigators. Themes related to contraceptive care seeking were identified and contextualized within the Health Belief Model.

Results

Our analysis revealed seven interwoven themes that describe individual level factors associated with contraceptive care seeking in women with current or past opioid misuse: relationship with drugs, reproductive experiences and self-perceptions, sexual partner dynamics, access, awareness of options, healthcare attitudes/experiences, and perceptions of contraception efficacy/ side effects. Overall, perceived susceptibility and severity to unintended pregnancy varied, but most women perceived high benefits of contraception, particularly LARC. However, perceived barriers were too high for most to obtain desired contraception to support family planning intentions.

Conclusions

The individual-level factors identified should inform the design of integrated services to promote patient-centered contraceptive counseling as a form of harm reduction. Interventions should reduce barriers to contraceptive access, particularly LARCs, and establish counseling strategies that use open, non-judgmental communication, acknowledge the continuum of reproductive needs, explore perceived susceptibility to pregnancy, and utilize peer educators.

Adolescent and Parent Perspectives on Confidentiality After Adolescent Relationship Abuse Disclosure

PURPOSE

This study aimed to assess adolescent and parent perspectives on parent notification after disclosure of adolescent relationship abuse (ARA) to a health care provider.

METHODS

A computerized survey was administered to a convenience sample of adolescents aged 14-18 years and their parents presenting to three Midwestern pediatric emergency departments. The survey assessed the acceptability of parent notification after hypothetical adolescent disclosure of different forms of ARA (i.e., physical, cyber, psychological and sexual ARA, reproductive coercion, controlling behavior, and feeling unsafe) to a health care provider. Chi-square and Fisher's exact tests were used to examine possible relationships between acceptability of parent notification and prior ARA victimization, adolescent dating relationship status, and demographic factors.

RESULTS

One-hundred fifty adolescent-parent dyads and 53 individual adolescents participated in this study. Most adolescents and parents found it acceptable to inform parents after disclosure of any type of ARA, although acceptability was higher among parents for all types of abuse assessed. Adolescent-parent dyads were more likely to both agree that parent notification was acceptable after disclosure of physical ARA, compared with other forms of ARA. Acceptability of parent notification after some types of ARA disclosure was less common among adolescents reporting previous sexual activity, prior ARA victimization, and adolescents currently in a dating relationship.

CONCLUSIONS

Most adolescents and parents found parent notification after ARA disclosure acceptable. However, adolescents most at risk, including those who reported previous sexual activity, prior ARA victimization, and those in a dating relationship, were less likely to find parent notification acceptable. Further study to assess barriers or concerns with parent involvement is crucial to optimizing provider response after ARA disclosure.

Self-reported and Documented Substance Use Among Adolescents in the Pediatric Hospital

BACKGROUND AND OBJECTIVES

Adolescent substance use is associated with numerous adverse health outcomes. A hospitalization represents an opportunity to identify and address substance use. We sought to describe self-reported and documented substance use among hospitalized adolescents.

METHODS

We conducted a cross-sectional survey of adolescents aged 14 to 18 years old admitted to two pediatric hospitals between August 2019 and March 2020. Using previously validated questions, we assessed the proportion of adolescents reporting ever, monthly, and weekly use of alcohol, marijuana, tobacco, electronic cigarettes, and other illicit drugs and nonmedical use of prescription medications. We reviewed medical records for substance use documentation.

RESULTS

Among 306 respondents, 57% were older (16-18 years old), 53% were female, and 55% were of non-Hispanic white race and ethnicity. The most frequently reported substances ever used were alcohol (39%), marijuana (33%), and electronic cigarettes (31%); 104 (34%) respondents reported ever use of >1 substance. Compared with younger adolescents, those aged 16 to 18 years were more likely to report ever use of alcohol (29% vs 46%; P = .002), marijuana (22% vs 41%; P < .001), and ≥2 drugs (26% vs 40%; P = .009). A positive substance use history was rarely documented (11% of records reviewed), and concordance between documented and self-reported substance use was also rare.

CONCLUSIONS

In this study of hospitalized adolescents, the most commonly reported substances used were alcohol, marijuana, and electronic cigarettes. Positive substance use documentation was rare and often discordant with self-reported substance use. Efforts to improve systematic screening for substance use and interventions for prevention and cessation in hospitalized adolescents are critically needed.

Recovering from substance use disorders during the early months of the COVID-19 pandemic: A mixed-methods longitudinal study of women in Kansas City

AIMS

During the early months of the U.S. COVID-19 outbreak, women suffered disproportionate burdens of pandemic-related psychological and economic distress. We aimed to describe the experiences of women in substance use disorder (SUD) recovery programs by (1) exploring the pandemic's impact on their lives, sobriety, and recovery capital and (2) tracking COVID-19 perceptions and preventative behaviors.

METHODS

We conducted monthly semistructured interviews with women in residential and outpatient SUD recovery programs in Kansas City in April, May, and June 2020. Participants described the pandemic's impact on their life and sobriety and completed survey items on factors related to COVID-19 preventative behaviors. We interpreted qualitative themes longitudinally alongside quantitative data.

RESULTS

In 64 interviews, participants (n = 24) described reduced access to recovery capital, or resources that support sobriety, such as social relationships, housing, employment, and health care. Most experienced negative impacts on their lives and feelings of stability in March and April but maintained sobriety. Four women described relapse, all attributed to pandemic stressors. Participants described relief related to societal re-opening in May and June, and increased engagement with their communities, despite rising infection rates.

CONCLUSIONS

For women recovering from SUDs during COVID-19, securing recovery capital often meant assuming greater COVID-19 risk. As substance use appeared to have increased during the pandemic and COVID-19 transmission continues, public health planning must prioritize adequate and safe access to recovery capital and timely distribution of vaccines to people struggling with SUDs.

Changes in opioid prescriptions for Medicaid-enrolled children and young adults, 2012-2016

OBJECTIVES

To describe current trends in filled opioid prescriptions for Medicaid-enrolled children, adolescents and young adults (AYAs) from 2012 to 2016, and to identify patient characteristics and clinical settings associated with a higher probability of filled opioid prescriptions.

DESIGN

Retrospective cohort study of children and young adults enrolled in Medicaid from 2012 to 2016.

SETTING

10-12 states participating in the Medicaid Marketscan claims database.

PARTICIPANTS

Medicaid-enrolled children and young adults (0-21 years old).

EXPOSURE

Healthcare encounter(s) that could result in a new opioid prescription.

MAIN OUTCOME MEASURE

"Opioid visits," defined as healthcare encounters associated with a new opioid prescription filled within 7 days. Each opioid visit was assigned to the clinical provider most likely to have prescribed an opioid.

RESULTS

There were 113,068,027 visits among 4,427,838 Medicaid-enrollees and 1 percent (n = 1,130,006) of these were considered an opioid visit. Adjusted probabilities decreased from 1.2 percent to 0.8 percent from 2012 to 2016. The most frequently prescribed opioids were hydrocodone (48 percent; n = 653,011), codeine (23 percent; n = 305,644), and oxycodone (14 percent; n = 189,700); most of these were in combination with acetaminophen. The high-est adjusted percentages by clinical setting were seen in dental surgery (29 percent), outpatient surgery (21 percent), and inpatient (upon discharge, 10 percent).

CONCLUSIONS

Opioid prescriptions filled for Medicaid-enrolled children, adolescents, and young adults are relatively rare and adjusted probabilities decreased from 2012 to 2016. Among opioids filled, combination opioids and those with pedi-atric safety warnings remain commonly prescribed. Further research is critical to better understand drivers of prescribing practices and clinical indications for appropriate opioid use to inform improvements in pain management guidelines in this population.

Expanding Contraception Access for Women With Opioid-Use Disorder: A Qualitative Study of Opportunities and Challenges

PURPOSE

As almost nine in ten pregnancies among women with opioid use disorder (OUD) are unintended, expanding access to contraception is an underutilized but potentially effective strategy in increasing reproductive agency and reducing the overall burden of neonatal abstinence syndrome. We aimed to identify where and how contraceptive services could be integrated into existing points-of-contact for women with OUD.

APPROACH

In-depth qualitative interviews.

SETTING

Three diverse catchment areas in Missouri.

PARTICIPANTS

Women with OUD (n = 15) and professional stakeholders (n = 16) representing five types of existing OUD service points: syringe exchange programs, recovery support programs, substance use treatment programs, emergency departments, and Federally Qualified Health Centers.

METHOD

Interviews were audio-recorded, transcribed, and thematically coded using Dedoose software.

RESULTS

Six themes emerged as essential components for integrating contraceptive services into existing points-of-contact for women with OUD: (1) reach women with unmet need; (2) provide free or affordable contraception; (3) maximize service accessibility; (4) provide patient-centered care; (5) employ willing, qualified contraceptive providers; and (6) utilize peer educators. Participants affirmed the overall potential benefit of contraceptive service integration and illuminated various opportunities and challenges relevant to each type of existing service point.

CONCLUSION

As health promotion initiatives look to increase access to contraception among women with OUD, these six' participant-identified components offer essential guidance in selecting advantageous points-of-contact and addressing remaining gaps in services.

Effort-reward balance and work motivation in rats: Effects of context and order of experience

Being motivated means exerting effort toward a goal. The 'law of least work' emphasizes a preference for exerting relatively less effort. The law crosses boundaries among species and between physical and mental work. Organisms should be highly sensitive to shifts in effort-reward balance (ERB) in order to make optimal choices. We used a free operant-foraging task to investigate changes in ERB on choice between options requiring more or less effort. Results showed a consistent preference for the option with less effort and insensitivity to shifts in ERB. A second aim explored the influence of order of experience on effort choice. Choice for the more effortful option significantly increased after experiencing an equal effort-reward relationship during the initial free operant-foraging session. This relative increase in choice for the effortful option persisted even after effort-reward imbalance. The findings highlight the importance of contextual factors such as order of experience when examining the impact of shifting effort-reward associations. Instead of ignoring or reducing order effects, the sequence of experience (e.g. for shifts in ERB) could be manipulated to enhance or reduce value of outcomes or effort itself.

Opioid Use to Treat Migraine Headaches in Hospitalized Children and Adolescents

OBJECTIVES

Prescription of opioids to treat pediatric migraine is explicitly discouraged by treatment guidelines but persists in some clinical settings. We sought to describe rates of opioid administration in pediatric migraine hospitalizations.

METHODS

Using data from the Pediatric Health Information System, we performed a cross-sectional study to investigate the prevalence and predictors of opioid administration for children aged 7 to 21 years who were hospitalized for migraine between January 1, 2016, and December 31, 2018.

RESULTS

There were 6632 pediatric migraine hospitalizations at 50 hospitals during the study period, of which 448 (7%) had an opioid administered during the hospitalization. There were higher adjusted odds of opioid administration in hospitalizations for non-Hispanic black (adjusted odds ratio [aOR], 1.68; P < .001) and Hispanic (aOR, 1.54; P = .005) (reference white) race and ethnicity, among older age groups (18-21 years: aOR, 2.74; P < .001; reference, 7-10 years), and among patients with higher illness severity (aOR, 2.58; P < .001). Hospitalizations during which an opioid was administered had a longer length of stay (adjusted rate ratio, 1.48; P < .001) and higher 30-day readmission rate (aOR, 1.96; P < .001). By pediatric hospital, opioid administration ranged from 0% to 23.5% of migraine hospitalizations. Hospitals with higher opioid administration rates demonstrated higher adjusted readmission rates (P < .001) and higher adjusted rates of return emergency department visits (P = .026).

CONCLUSIONS

Opioids continue to be used during pediatric migraine hospitalizations and are associated with longer lengths of stay and readmissions. These findings reveal important opportunities to improve adherence to migraine treatment guidelines and minimize unnecessary opioid exposure, with the potential to improve hospital discharge outcomes.

A Research Agenda for Emergency Medicine-based Adolescent Sexual and Reproductive Health

OBJECTIVE

The objective was to identify key questions for emergency medicine (EM)-based adolescent sexual and reproductive health and to develop an evidence-based research agenda.

METHODS

We recruited national content experts to serve as advisory group members and used a modified Delphi technique to develop consensus around actionable research questions related to EM-based adolescent reproductive and sexual health care. Author subgroups conducted literature reviews and developed the initial list of research questions, which were iteratively refined with advisory members. External stakeholders then independently rated each item for its importance in expanding the evidence base (1 = not important to 5 = very important) via electronic survey.

RESULTS

Our final list of 24 research questions included items that intersected all sexual and reproductive health topics as well as questions specific to human immunodeficiency virus/sexually transmitted infections (HIV/STIs), pregnancy prevention, confidentiality/consent, public health, and barriers and facilitators to care. External stakeholders rated items related to HIV/STI, cost-effectiveness, brief intervention for sexual risk reduction, and implementation and dissemination as most important.

CONCLUSIONS

We identified critical questions to inform EM-based adolescent sexual and reproductive health research. Because evidence-based care has potential to improve health outcomes while reducing costs associated with HIV/STI and unintended pregnancy, funders and researchers should consider increasing attention to these key questions.

Development of a Novel Computerized Clinical Decision Support System to Improve Adolescent Sexual Health Care Provision

OBJECTIVE

The objective was to develop an acceptable clinical decision support (CDS) system to facilitate evidence-based sexual health care for adolescents in the emergency department (ED).

METHODS

In this multiphased iterative process, we engaged an expert group to synthesize evidence on a wide range of sexual health services (e.g., contraception, condoms, identification and treatment of previously diagnosed sexually transmitted infection). We created a computerized questionnaire and embedded our decision tree, utilizing patient-entered responses to create tailored, evidence-based recommendations, and embedded links to study-related resources such as the emergency contraception (EC) quick guide. We utilized mixed methodology to explore perspectives of adolescents aged 14 to 19 years and clinicians at two general and two pediatric EDs after they interacted with the system. Clinicians reported usefulness (Likert scale 1 = not at all, 4 = very); adolescents reported acceptability. We used the chi-square test to compare responses between subgroups. We collected adolescents' verbatim responses to open-ended questions; clinicians self-entered responses. Four authors independently generated themes from qualitative responses before compiling key findings and achieving consensus on final themes.

RESULTS

Among 57 clinicians (23 physicians, 23 nurses, 11 nurse practitioners; 54% female; 65% aged < 40 years), the mean system usefulness rating was 3.4 ± 0.7. Sex, age, clinician role, or ED type were not associated with rating the system "somewhat/very" useful. Clinicians identified barriers (e.g., time constraints) that could be overcome by implementation considerations (e.g., training) as well as benefits including improved care. For future assessments, providers preferred computer (65%) over face-to-face interview (26%). Among 57 adolescents (mean age = 16.2 years; 75% female; 56% sexually experienced), nearly all (95%) reported that it was "very/somewhat easy" to complete the computerized questionnaire and to understand the questions. Most adolescents understood the EC quick guide and correctly identified that ulipristal, compared to levonorgestrel, required a prescription and was more effective. For future assessments, adolescents preferred computer (69%) over face-to-face interviews (9%).

CONCLUSIONS

We developed a sexual health CDS system that is easy to use and can facilitate evidence-based care to reduce health outcome gaps. Evaluation of system impact on service delivery and, ultimately, health outcomes is needed.

Adolescent Reproductive Health Care: Views and Practices of Pediatric Hospitalists

BACKGROUND AND OBJECTIVES

Many hospitalized adolescents are at increased risk for pregnancy complications due to an underlying medical condition, however sexual risk assessment is not consistently performed in this setting. While adolescents and their parents are supportive of sexual health discussion in the inpatient setting, a thorough understanding of factors that influence provision of this care among pediatric hospital physicians is lacking. This formative information is needed to facilitate efforts to improve and standardize clinical care provision. Our objective is to assess the frequency and factors that influence the provision of adolescent sexual and reproductive care by pediatric hospitalists.

METHODS

We performed a cross-sectional computerized survey of hospitalists at 5 pediatric hospitals who cared for ≥1 adolescent (14-21 years old) in the past year. Sexual and reproductive care practices were assessed by using a 76-item novel survey informed by the theory of planned behavior. We used descriptive statistics to summarize the data.

RESULTS

Sixty-eight pediatric hospitalists participated (49% response rate): 78% were women and 65% were aged <40 years. Most (69%) reported treating >46 adolescents annually, including many who are at an increased risk for pregnancy complications due to teratogenic medication use or a comorbid condition. A majority felt that sexual and reproductive services are appropriate, although many endorsed barriers, including concern about follow-up after emergency contraception (63%) and time constraints (53%). Most reported insufficient knowledge regarding contraception (59%), desired contraception education (57%), and were likely to increase contraceptive provision if provided education (63%). Hospitalists rarely provided condoms or referral for an intrauterine device.

CONCLUSIONS

Pediatric hospitalists frequently care for adolescents who are at risk for pregnancy complications and generally agree that reproductive care is appropriate in the inpatient setting. With these findings, we highlight the critical need for effective comprehensive reproductive health service interventions that are tailored to address the numerous actionable barriers identified in this study.

Adapting an HIV Risk Reduction Curriculum: Processes and Outcomes

Becoming a Responsible Teen (BART) is a community-based, HIV risk reduction curriculum shown to increase safer sex behaviors among African American adolescents. However, BART does not address common barriers to sexual health care access, which may limit program efficacy. We used a community-engaged adaptation process to maximize program relevance and health outcomes by incorporating a broad ecological perspective. Adolescent and staff advisory boards at a community-based organization recommended modifications (e.g., delete references to Kwanzaa, update language, localize incentives) and supported inclusion of critical on-site health services, such as sexually transmitted infection testing and condom provision. We conducted a trial of adapted BART (one session/week for 8 weeks) with 36 adolescents at two community organizations (mean age = 15.5 years, 52% female; 61% reported previous sexual intercourse). Most received on-site sexually transmitted infection testing (61%) and condoms (70%). Adolescents demonstrated significant improvements in self-efficacy for safer sexual practices (p < .02), AIDS risk knowledge (p < .001), condom knowledge (p < .001), and condom attitudes (p < .04). Adolescents and staff were satisfied with the revised curriculum and found on-site services acceptable. Based on improvements in constructs influencing behavior and the successful delivery of services essential for optimal health, future studies to assess efficacy and sustainability of the adapted curriculum appear warranted.

Emerging Tick-borne Rickettsia and Ehrlichia at Joint Base Langley-Eustis, Fort Eustis, Virginia

Four species of ticks known to parasitize humans (Amblyomma americanum (lone star tick), Dermacentor variabilis (American dog tick), Amblyomma maculatum (Gulf Coast tick), and Ixodes scapularis (black-legged tick)) were collected at Joint Base Langley-Eustis, Fort Eustis, Virginia during 2009. These ticks were tested individually (adults and nymphs) and in pools of 15 (larvae) for pathogens of public health importance within the genera: Rickettsia, Borrelia, and Ehrlichia, by quantitative real-time polymerase chain reaction (qPCR) assays and, where appropriate, multilocus sequence typing (MLST). Of the 340 A americanum ticks tested, a minimum of 65 (19%), 4 (1%), 4 (1%), and one (<1%) were positive for Rickettsia amblyommii, B lonestari, E ewingii and E chaffeensis, respectively. One of 2 (50%) A maculatum ticks collected was found to be positive for R parkeri by MLST and qPCR analyses. All 33 D variabilis ticks were negative for evidence of rickettsial infections. Likewise, no pathogenic organisms were detected from the single Ixodes scapularis tick collected. Pathogenic rickettsiae and ehrlichiae are likely emerging and cause under-recognized diseases, which threaten people who live, work, train, or otherwise engage in outdoor activities at, or in the vicinity of, Fort Eustis, Virginia.

Factors Associated With Interest in Same-Day Contraception Initiation Among Females in the Pediatric Emergency Department

PURPOSE

The purposes were to describe interest in hormonal contraception initiation among female adolescent in the emergency department (ED) and to assess for associations with factors known to increase pregnancy risk such as violence victimization.

METHODS

We used a computerized survey to assess sexual and dating practices, pregnancy history/likelihood, contraception use (including long-acting reversible contraception [LARC]) and concerns, contraception initiation interest, violence victimization, medical utilization, and demographics among sexually experienced females aged 14-19 years in our ED. The primary outcome was interest in contraception initiation. We compared responses between subgroups using the chi-square test.

RESULTS

A total of 168 adolescents participated (82% of approached; mean age 16.6 years; 41% white; 48% black; 21% commercial insurance). Interest in contraception initiation was high: 60% overall and 70% among those not using hormonal contraception (n = 96). Among those using non-LARC contraception (n = 59), 29% were interested in LARC initiation. Contraception/LARC interest was positively associated with lack of recent well care (p < .06) and concerns about cost (p < .01), privacy (p = .03), and where to obtain contraception (p < .01). Nearly all planned on avoiding pregnancy, although many (23%) used no contraception at last intercourse. One third (36%) reported violence victimization. Most (70%) reported ≥1 concern about contraception (most commonly cost).

CONCLUSIONS

Many reported behaviors and exposures, including violence victimization, that increase their risk for pregnancy and most expressed interest in same-day initiation of hormonal contraception, including LARC. These findings may inform novel strategies for increased adolescent access to contraception and pregnancy prevention through use of nontraditional sites such as EDs.

Rickettsia parkeri and Rickettsia montanensis, Kentucky and Tennessee, USA

We found that 14.3% (15/105) of Amblyomma maculatum and 3.3% (10/299) of Dermacentor variabilis ticks collected at 3 high-use military training sites in west-central Kentucky and northern Tennessee, USA, were infected with Rickettsia parkeri and Rickettsia montanensis, respectively. These findings warrant regional increased public health awareness for rickettsial pathogens and disease.

Vacancy-controlled ultrastable nanoclusters in nanostructured ferritic alloys

A new class of advanced structural materials, based on the Fe-O-vacancy system, has exceptional resistance to high-temperature creep and excellent tolerance to extremely high-dose radiation. Although these remarkable improvements in properties compared to steels are known to be associated with the Y-Ti-O-enriched nanoclusters, the roles of vacancies in facilitating the nucleation of nanoclusters are a long-standing puzzle, due to the experimental difficulties in characterizing vacancies, particularly in-situ while the nanoclusters are forming. Here we report an experiment study that provides the compelling evidence for the presence of significant concentrations of vacancies in Y-Ti-O-enriched nanoclusters in a nanostructured ferritic alloy using a combination of state-of-the-art atom-probe tomography and in situ small angle neutron scattering. The nucleation of nanoclusters starts from the O-enriched solute clustering with vacancy mediation. The nanoclusters grow with an extremely low growth rate through attraction of vacancies and O:vacancy pairs, leading to the unusual stability of the nanoclusters.

Prevalence of 3 sexually transmitted infections in a pediatric emergency department

OBJECTIVE

This study aimed to determine the prevalence of Chlamydia trachomatis, Neisseria gonorrheae, and Trichomonas vaginalis and to describe factors associated with sexually transmitted infection (STI) in a pediatric emergency department (ED).

METHODS

Adolescents aged 14 to 19 years presenting to a Midwestern pediatric ED were asked to provide urine for STI testing and complete a survey about previous sexual activity (PSA), high-risk behaviors, demographics, and visit reason (reproductive: genitourinary complaints, abdominal pain, or a female with vomiting). Comparisons between subgroups were analyzed using Χ test.

RESULTS

Among 200 subjects (64% of approached), mean age was 15.6 years; 63% were female. Eleven subjects (6%; 95% confidence interval, 2.3-8.7) tested positive for 1 or more STIs: 10 for C. trachomatis (one denied PSA), 3 for T. vaginalis (all coinfected with C. trachomatis), and 1 for N. gonorrheae. Half reported PSA; of these, 71% reported 1 or more high-risk behaviors, most commonly first sex before the age of 15 years (51%) and no condom at last sex (42%). Among those with PSA and nonreproductive visit (n = 73), 11.0% had 1 or more STIs (95% confidence interval, 3.4-18.1). Two factors were associated with greater likelihood of positive STI test result, namely, reporting PSA versus no PSA (10% vs 1%, P = 0.005) and last sex within 1 month or less versus more than 1 month (20% vs 0%, P = 0.001). In this sample, none of the following characteristics were associated with STI: insurance, race, high-risk behaviors, age, or ED visit reason.

CONCLUSIONS

Approximately 1 in 10 sexually active adolescent ED patients without reproductive complaints had 1 or more STIs. This suggests the need for strategies to increase STI testing for this population.

Views on human papillomavirus vaccination: a mixed-methods study of urban youth

While the human papillomavirus (HPV) vaccine has potential to protect against the majority of HPV-associated cancers, vaccination rates in the United States remain low. Racial/ethnic and economic disparities exist for HPV vaccination completion rates. We conducted a mixed-methods study using the theory of planned behavior framework to explore attitudes and beliefs about HPV vaccination among urban, economically disadvantaged adolescents. Fifty adolescents aged 14-18 years were recruited from community-based organizations to complete a written survey and participate in a focus group. The mean age was 15.5 ± 1.3 years; 98 % were African American or mixed race; 64 % were female; 52 % reported previous sexual intercourse; 40 % reported receipt of ≥1 HPV vaccine dose. The knowledge deficit about the HPV vaccine was profound and seemed slightly greater among males. Mothers, fathers and grandmothers were mentioned as important referents for HPV vaccination, but peers and romantic partners were not. Common barriers to vaccination were lack of awareness, anticipated side effects (i.e., pain), and concerns about vaccine safety. Characteristics associated with ≥1 vaccine dose were: having heard of the HPV vaccine versus not (65 vs. 20 %, p = 0.002) and agreeing with the statement "Most people I know would think HPV vaccine is good for your health" versus not (67 vs. 27 %, p = 0.007). Our work indicates a profound lack of awareness about HPV vaccination as well as the important influence of parents among urban, economically-disadvantaged youth. Awareness of these attitudes and beliefs can assist providers and health officials by informing specific interventions to increase vaccine uptake.

Accessing General and Sexual Healthcare: Experiences of Urban Youth

Urban adolescents face many barriers to health care that contribute to health disparities in rates of sexually transmitted infections (STIs) and unintended pregnancy. Designing interventions to increase access to health care is a complex process that requires understanding the perspectives of adolescents. We conducted six focus groups to explore the attitudes and beliefs about general and sexual health care access as well as barriers to care among urban, economically disadvantaged adolescents. Participants first completed a written survey assessing health behaviors, health care utilization, and demographics. The discussion guide was based on the Theory of Planned Behavior and its constructs: attitudes, subjective norms, and perceived behavioral control. Transcripts of group discussions were analyzed using directed content analysis with triangulation and consensus to resolve differences. Fifty youth participated (mean age 15.5 years; 64% female; 90% African American). Many (23%) reported missed health care in the previous year. About half (53%) reported previous sexual intercourse; of these, 35% reported no previous sexual health care. Youth valued adults as important referents for accessing care as well as multiple factors that increased comfort such as good communication skills, and an established relationship. However, many reported mistrust of physicians and identified barriers to accessing care including fear and lack of time. Most felt that accessing sexual health care was more difficult than general care. These findings could inform future interventions to improve access to care and care-seeking behaviors among disadvantaged youth.

Enhancing glass-forming ability via frustration of nano-clustering in alloys with a high solvent content

The glass-forming ability (GFA) of alloys with a high-solvent content such as soft magnetic Fe-based and Al-based alloys is usually limited due to strong formation of the solvent-based solid solution phase. Herein, we report that the GFA of soft magnetic Fe-based alloys (with >70 at.% Fe to ensure large saturation magnetization) could be dramatically improved by doping with only 0.3 at.% Cu which has a positive enthalpy of mixing with Fe. It was found that an appropriate Cu addition could enhance the liquid phase stability and crystallization resistance by destabilizing the α-Fe nano-clusters due to the necessity to redistribute the Cu atoms. However, excessive Cu doping would stimulate nucleation of the α-Fe nano-clusters due to the repulsive nature between the Fe and Cu atoms, thus deteriorating the GFA. Our findings provide new insights into understanding of glass formation in general.

Implementing motivational interviewing in a pediatric hospital

Motivational Interviewing is a collaborative style of communication designed to strengthen a person's own motivation and commitment to change. We report on our ongoing efforts to implement motivational interviewing to address health behavior change among several patient populations in our pediatric hospital, including sexual risk reduction among adolescents, increased self-care for patients with spina bifida, increased adherence for adolescents with Type 1 diabetes, and facilitation with transition from pediatric to adult care among gastroenterology patients.

Providing adolescent sexual health care in the pediatric emergency department: views of health care providers

OBJECTIVES

The purpose of this study was to explore health care providers' (HCPs') attitudes and beliefs about adolescent sexual health care provision in the emergency department (ED) and to identify barriers to a health educator-based intervention.

METHODS

We conducted focused, semistructured interviews of HCPs from the ED and adolescent clinic of a children's hospital. The interview guide was based on the theory of planned behavior and its constructs: attitudes, subjective norms, perceived behavioral control, and intention to facilitate care. We used purposive sampling and enrollment continued until themes were saturated. Interviews were recorded and transcribed. Transcripts were analyzed using directed content analysis.

RESULTS

Twenty-nine interviews were required for saturation. Participants were 12 physicians, 12 nurses, 3 nurse practitioners, and 2 social workers; the majority (83%) were female. Intention to facilitate care was influenced by HCP perception of (1) their professional role, (2) the role of the ED (focused vs expanded care), and (3) need for patient safety. Health care providers identified 3 practice referents: patients/families, peers and administrators, and professional organizations. Health care providers perceived limited behavioral control over care delivery because of time constraints, confidentiality issues, and comfort level. There was overall support for a health educator, and many felt the educator could help overcome barriers to care.

CONCLUSIONS

Despite challenges unique to the ED, HCPs were supportive of the intervention and perceived the health educator as a resource to improve adolescent care and services. Future research should evaluate efficacy and costs of a health educator in this setting.

Developing emergency department-based education about emergency contraception: adolescent preferences

OBJECTIVES

The objective was to identify adolescent preferences for emergency department (ED)-based education about emergency contraception.

METHODS

This was a cross-sectional computerized survey, using adaptive conjoint analysis (ACA). Patients were eligible if they were females ages 14 through 19 years old and were seeking care in one of two urban EDs. Patients were excluded if they were too ill to participate in the survey or if they were non-English speaking. Participants completed a computerized survey that used ACA, a technique that can be used to assess patients' relative preferences for services. ACA uses the individual's answers to update and refine questions through trade-off comparisons, so that each respondent answers a customized set of questions. The survey assessed preferences for the following attributes of emergency contraception education: who should deliver the education, if anyone (e.g., nurse, doctor); how the education should be delivered (e.g., by a person or via video); how often the education should be offered if patients were to frequent the ED (e.g., every time or only when asking for it); length (e.g., 5 minutes, 10 minutes); and chief complaint that would trigger the education (e.g., headache or stomach pain).

RESULTS

A total of 223 patients were enrolled (37.2% at Hospital 1 and 62.8% at Hospital 2). The mean (±SD) age of the participants was 16.1 (±1.3) years. Just over half (55%) reported a history of sexual activity; 8% reported a history of pregnancy. Overall, the participants preferred education that was delivered by a person, specifically a doctor or nurse. They preferred a slightly longer education session and preferred education directed at patients seeking care in the ED for complaints potentially related to sexual activity.

CONCLUSIONS

Adolescents have specific preferences for how education about emergency contraception would best serve their needs. This information can inform clinicians as they work to improve adolescents' knowledge about pregnancy prevention and emergency contraception in particular.

Pediatric emergency health care providers' knowledge, attitudes, and experiences regarding emergency contraception

OBJECTIVES

The objective was to describe knowledge, attitudes, and experiences regarding emergency contraception (EC) among pediatric emergency health care providers (HCPs).

METHODS

This multicenter, focus group study elicited thoughts and experiences from pediatric emergency HCPs about EC. Participants were physicians, nurse practitioners (NPs), and nurses in one of three urban, geographically distinct, pediatric emergency departments (EDs). A professional moderator used a semistructured format for sessions, which were audiotaped, transcribed, and analyzed for recurrent themes. Participants provided demographic information and completed a written survey evaluating EC knowledge.

RESULTS

Eighty-five HCPs (41 physicians, eight NPs, and 36 nurses) participated in 12 focus groups. Overall knowledge about EC was poor. Participants identified barriers including cost, privacy, knowledge, and provider refusal. Provision of EC for adolescents was supported by the majority of physicians and NPs; however, many nurses were not supportive, especially following consensual intercourse. The authors identified use of social judgment by nurses as a novel barrier to EC provision. The majority of HCPs did not support screening for potential EC need. The majority of physicians and NPs felt obligated to provide adolescents with all contraceptive options, while more nurses supported provider refusal to provide EC.

CONCLUSIONS

This study identified important HCP perceptions and barriers about EC provision in the pediatric ED. These findings may inform future efforts to improve EC provision for adolescents. Specifically, future studies to evaluate the differences in attitudes between nurses, physicians, and NPs, and the use of social judgment in EC provision, are warranted.

Detecting density variations and nanovoids

A combination of simulated and experimental data has been used to investigate the size range of nanovoids that can be detected in atom probe tomography data. Simulated atom probe tomography data have revealed that nanovoids as small as 1 nm in diameter can be detected in atom probe tomography data with the use of iso-density surfaces. Iso-density surfaces may be used to quantify the size, morphology and number density of nanovoids and other variations in density in atom probe tomography data. Experimental data from an aluminum-yttrium-iron metallic glass ribbon have revealed the effectiveness of this approach. Combining iso-density surfaces with atom maps also permits the segregation of solute to the nanovoids to be investigated. Field ion microscopy and thin section atom maps have also been used to detect pores and larger voids.

WITHDRAWN: A MVSA approach to mine information from APT data

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Recombinant human hyaluronidase-enabled subcutaneous pediatric rehydration

OBJECTIVES

The Increased Flow Utilizing Subcutaneously-Enabled (INFUSE)-Pediatric Rehydration Study was designed to assess efficacy, safety, and clinical utility of recombinant human hyaluronidase (rHuPH20)-facilitated subcutaneous rehydration in children 2 months to 10 years of age.

METHODS

Patients with mild/moderate dehydration requiring parenteral treatment in US emergency departments were eligible for this phase IV, multicenter, single-arm study. They received subcutaneous injection of 1 mL rHuPH20 (150 U), followed by subcutaneous infusion of 20 mL/kg isotonic fluid over the first hour. Subcutaneous rehydration was continued as needed for up to 72 hours. Rehydration was deemed successful if it was attributed by the investigator primarily to subcutaneous fluid infusion and the child was discharged without requiring an alternative method of rehydration.

RESULTS

Efficacy was evaluated in 51 patients (mean age: 1.9 years; mean weight: 11.2 kg). Initial subcutaneous catheter placement was achieved with 1 attempt for 46/51 (90.2%) of patients. Rehydration was successful for 43/51 (84.3%) of patients. Five patients (9.8%) were hospitalized but deemed to be rehydrated primarily through subcutaneous therapy, for a total of 48/51 (94.1%) of patients. No treatment-related systemic adverse events were reported, but 1 serious adverse event occurred (cellulitis at infusion site). Investigators found the procedure easy to perform for 96% of patients (49/51 patients), and 90% of parents (43/48 parents) were satisfied or very satisfied.

CONCLUSIONS

rHuPH20-facilitated subcutaneous hydration seems to be safe and effective for young children with mild/moderate dehydration. Subcutaneous access is achieved easily, and the procedure is well accepted by clinicians and parents.

Pediatric out-of-hospital emergency medical services utilization in Kansas City, Missouri

OBJECTIVES

The objective was to describe epidemiologic features and usage patterns of pediatric emergency medical services (EMS) transports in Kansas City, Missouri.

METHODS

The study consisted of a retrospective analysis of transports from January 1, 2002, to December 31, 2004, for Kansas City, Missouri, residents younger than 15 years of age (excluding interfacility transports. Data included demographics, insurance, day and time of transport, patient zip code, chief complaint, and number of individual transports. Rates were calculated using intercensal estimates for the denominator. All rates were expressed as number of transports per 1,000 persons per year (PPY).

RESULTS

A total of 5,717 pediatric transports occurred in the 3-year study period. Transport rates were 18 PPY for all users, 42 PPY for those <1 year old, 23 PPY for ages 1-4 years, 12 PPY for ages 5-9 years, and 14 PPY for ages 10-14 years. Infants <1 year were more likely than children aged 5-9 years to use EMS (relative risk [RR] = 3.7, 95% confidence interval [CI] = 3.4 to 4.0). Males were more likely than females to use EMS (RR = 1.2, 95% CI = 1.1 to 1.3). Most (64%) were insured by Medicaid. Transports peaked between 4 pm and 8 pm, and lowest usage was 4 am to 8 am (p < 0.001). Overall usage did not vary by weekday or season. Respiratory transports were more common in the fall and winter, while trauma transports were more common in the summer (p < 0.001). The most common diagnoses were trauma (27%), neurologic (19%), and respiratory (18%). Eleven percent of users accessed EMS more than once (26% of all transports). There was a significant inverse linear relationship between transport rate and median family income by zip code (r = -0.36, p < 0.001).

CONCLUSIONS

Children in zip codes with lower incomes, infants, and males were more likely to use EMS. Factors related to these increased transport rates are unknown.

Detection of two Bartonella tamiae-like sequences in Amblyomma americanum (Acari: Ixodidae) using 16S-23S intergenic spacer region-specific primers

Four hundred and sixty-six questing Amblyomma americanum (L.) (Acari: Ixodidae) from Carolina County, VA, and 98 questing A. americanum from Chatham County, NC, were screened by polymerase chain reaction (PCR) for the Bartonella 16S-23S intergenic spacer region. Two amplicons, approximately 270-280 bp, were detected in two ticks from Virginia. Based upon PCR and sequencing, an adult male and adult female tick harbored DNA sequences closely related to Bartonella tamiae (DQ395180). Bartonella DNA was not detected in A. americanum from North Carolina. Potential transmission of Bartonella spp. by A. americanum should be the focus of future experimental studies.

Atom probe specimen preparation with a dual beam SEM/FIB miller

Dual beam scanning electron microscope/focused ion beam (SEM/FIB) methods complement electropolishing methods and enable specimens to be made from a wider range of materials. Several methods have been developed to fabricate specimens from different forms of materials, including thin ribbons, mechanically ground sheet and fine powders. In addition, FIB-based methods can be used in conjunction with electropolishing methods to improve the shape, surface finish and taper angle of specimens. Several lift-out (LO) methods have been developed for selecting specific microstructural features or other regions of interest such as phases, interfaces, grain boundaries, subsurface or implanted regions and interdendritic regions. These LO methods make use of an in situ nanomanipulator and platinum deposition to transfer and attach the lifted out volume to a post for final annular milling into a needle-shaped specimen. In order to improve the efficiency and to facilitate the LO procedure, some special specimen mounts that hold both the specimen and the support post at the appropriate working distance have been developed.

Performance of local electrodes in the local electrode atom probe

The use of a local electrode in atom probe tomography has enabled higher rates of data acquisition and increased field of view compared to other variants of three-dimensional atom probes, but specimen fracture can result in damage to the local electrode. Specimens and local electrodes were examined before and after analyses that resulted in specimen failure. Most specimens were found to be melted after failure and as a result, material was found deposited onto the surface of the local electrode. Material transfer from the specimen to the local electrode was verified by energy dispersive spectrometry in a scanning electron microscope. After the fracture of brittle materials, some remnants were found embedded in the local electrode. For either failure mode, it is likely that the primary specimen rupture produced a sharp protrusion on the specimen or local electrode and this triggered an electrical discharge or uncontrolled field emission that melted a portion of the specimen. The lifetime of the local electrode was found to be dependent on the shape and position of the debris from the specimen failure rather than the number of ions collected or the number of specimens characterized. Local electrodes with smaller apertures were found to be more susceptible to failure.

Distribution of borreliae among ticks collected from eastern states

Lyme disease is the most commonly reported vector-borne disease in the United States and is transmitted by Borrelia burgdorferi-infected Ixodes species. The disease is typically characterized by an erythema migrans (EM) rash at the site of tick feeding. EM rashes have also been associated with feeding by Amblyomma americanum ticks despite evidence suggesting that they are incompetent vectors for Lyme disease. In 1996, a Borrelia organism only recently cultivated in the laboratory was described in A. americanum ticks and designated B. lonestari. This Borrelia is believed to be the etiologic agent of a novel Lyme-like disease, southern tick associated rash illness (STARI). This study examined ticks collected from eight eastern states to evaluate the epidemiology of B. lonestari, B. burgdorferi, and their tick hosts. Three hundred individual or small pool samples were evaluated from tick genera that included Amblyomma, Ixodes, and Dermacentor. DNA was extracted following tick homogenization and the polymerase chain reaction (PCR) was performed using primers derived from the flagellin gene that amplify sequences from both B. burgdorferi and B. lonestari. Species specific digoxigenin labeled probes were designed and used to differentiate between B. burgdorferi and B. lonestari. Borrelia DNA was detected in approximately 10% of the A. americanum and I. scapularis tick samples, but none was present in any of the Dermacentor samples tested. Positive samples were detected in ticks collected from Kentucky, Maryland, Massachusetts, New Jersey, New York, and Virginia. This is the first known report of B. lonestari from Massachusetts and New York and the first detection in I. scapularis. This suggests that B. lonestari and its putative association with STARI may be more widespread than previously thought.

Emergency department management and short-term outcome of children with constipation

BACKGROUND

Constipation is a common diagnosis made in the pediatric emergency department (ED). Specific evidence-based standards for evaluation and treatment are lacking.

OBJECTIVE

To describe variation in evaluation and treatment of constipation and characteristics and treatments associated with improvement.

METHODS

This single-site descriptive study examined constipated children discharged from the ED. Chart review provided history, examination, evaluation, and treatment. Symptoms and on-going treatment were assessed by telephone interview at 4 to 6 weeks. Patients were dichotomized to poor versus adequate responders. Poor responders had 2 or more of the following: overall constipation, persistent presenting symptom, bowel movement frequency of less than once every other day, painful defecation, and/or abdominal pain.

RESULTS

The study group had 121 patients, with mean age of 6.4 years; 54% were female. Abdominal pain was the most common complaint (66%); 46% reported hard/infrequent stools. Most (67%) had symptoms for less than 1 week. Many (41%) previously sought care for the same problem. Most (70%) had abdominal radiographs. One third received an enema in the ED, and most patients were prescribed laxatives, most commonly polyethylene glycol (80%). After an enema, 28% were discharged without constipation medication. At follow-up, 35% were using laxatives, and 27% had sought additional care. Nearly half (42%) were poor responders. Poor responders were younger (5.1 vs. 7.3 years; P < 0.01). There was no difference in response based upon sex, duration of symptoms, or ED treatment.

CONCLUSIONS

Although older children are more likely to improve, many constipated children continue to have symptoms. Type of ED therapy is unrelated to on-going symptoms at 4 to 6 weeks.