Binge eating symptomatology in adolescents with polycystic ovary syndrome

Several factors may contribute to binge eating behaviors in PCOS. However, findings are contradictory and studies in the adolescence are limited. We aimed to evaluate the eating attitudes of adolescents with PCOS and the possible etiological factors underlying the association between PCOS and binge eating symptomology. Between 2019 and 2022, 46 newly diagnosed adolescents with PCOS and 56 controls matched for age and BMI z-score were included. The Eating Disorder Examination Questionnaire, Three Factor Eating Questionnaire-R18, and a questionnaire assessing postprandial reactive hypoglycemia symptom severity were given. Binge eating symptomology, in terms of over, uncontrolled, and emotional eating, were more prevalent in the PCOS group. Uncontrolled, emotional, and binge eating were positively correlated with postprandial reactive hypoglycemia symptom score. Overeating was also associated with clinical hyperandrogenism. Improving the disease outcome and reducing the future complications requires early recognition and management of emotional and uncontrolled eating behaviors in adolescents with PCOS.

Menstrual characteristics of atypical anorexia nervosa

OBJECTIVE

While menstrual irregularities are acknowledged in restrictive-type eating disorders (EDs), the menstrual characteristics specific to atypical anorexia nervosa (AAN) remain inadequately defined. This study aims to compare the menstrual features of anorexia nervosa (AN) and AAN.

METHOD

Adolescents diagnosed with AN or AAN who exhibited secondary amenorrhoea at presentation and had their menstrual cycles restored during follow-up were eligible for this study. Clinical and menstrual data at admission and during follow-up were obtained from patient files, and compared between the AN and AAN cohorts.

RESULTS

The study included a total of 77 patients (38 with AN and 39 with AAN). The extent of weight loss and the disease duration until the onset of amenorrhoea were comparable in the two groups. However, the duration of illness and the time since the last menstrual period at admission were shorter in the AAN group. Moreover, amenorrhoea manifested at a higher body mass index, and the return of menses occurred more rapidly with less weight gain in the AAN group after the onset of clinical follow-up. Additionally, the AAN group exhibited a shorter overall duration of amenorrhoea.

CONCLUSIONS

This study highlights the significance of recognising amenorrhoea in restrictive disorders, even when individuals maintain a normal weight. The faster return of menstrual cycles and shorter duration of amenorrhoea observed in adolescents with AAN emphasise the significance of early diagnosis and prompt initiation of treatment. Regardless of the patient's presenting complaint and weight status, obtaining a comprehensive ED history is essential when addressing concerns regarding amenorrhoea or menstrual irregularities.

Prevalence of suicide attempt, suicide ideation and self-harm at diagnosis in adolescents with eating disorders

BACKGROUND

Data concerning the suicide prevalence of eating disorder (ED) subtypes and predictive factors are lacking in youth. This study aimed to examine suicide attempts (SA), suicide ideation (SI) and self-harm (SH) upon diagnosis in adolescents with EDs.

METHODS

The prevalence of SA, SI and SH in ED subtypes was evaluated by retrospectively assessing the Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicidal ideation and Safety (HEEADSSS) instrument of adolescents diagnosed with an ED. Clinical predictors of SI in anorexia nervosa (AN) and atypical AN (AAN) were assessed.

RESULTS

Among all participants (398), 41 (10.3%) reported SA, 126 (31.7%) SI and 60 (15.1%) SH. While SA did not differ statistically between ED subgroups (p = .123), they were two times more prevalent in the bulimia nervosa (BN) group (17.5%) than in the AN group (8.5%). In the BN group, SI was 2.3 times more prevalent than in the AN group (p = .001). The AN and ARFID groups exhibited substantially less SH (p = .036). Having a higher body mass index (BMI) was the only significant predictor of SI.

CONCLUSIONS

This study demonstrates that adolescents with EDs are at an increased risk for suicidality, highlighting the need for close screening, particularly in those with BN, AN-BP and AN with a higher BMI.Key pointsAdolescents with eating disorders have higher rates of suicidality than the general population.Bulimia nervosa had the highest risk for a suicide attempt, suicide ideation and self-harm at diagnosis.A higher body mass index (BMI) percentage was associated with an increased risk of suicidality in the anorexia nervosa group.

Problematic video gaming is negatively associated with bone mineral density in adolescents

Adolescent bone health may be negatively impacted by problematic video gaming (PVG) due to factors such as prolonged screen time, poor sleep quality, and increased depression. Although sedentary behaviors have been linked to decreased bone mass, there is limited research on how PVG impacts bone health. We aimed to evaluate the association between PVG and bone mineral density (BMD) in adolescents by comparing the BMD z-scores of adolescents with and without PVG and by identifying PVG-related risk factors that may affect low BMD scores. This cross-sectional study took place between May 2019 and August 2021 with 110 adolescents who played video games for at least two hours per day. Data on screen time, game genre, tobacco, alcohol, caffeine consumption, and vigorous physical activity status were recorded. PVG was assessed using the Internet Gaming Disorder-Short Form (IGDS9-SF), with scores ≤ 16 comprising the control group and > 16 the PVG group. Sleep quality was assessed by Pittsburgh Sleep Quality Index, and depression was evaluated by Children's Depression Inventory. Dual-energy X-ray absorptiometry measurements of femoral neck and lumbar spine BMD were compared between the two groups. The mean age of the participants was 14.2 ± 1.8 years, and 86.4% were males. The PVG group exhibited lower femoral neck z-scores (p = 0.013) and a higher proportion of adolescents with low femoral neck BMD risk (27.8% vs 9.7%, p = 0.041). Lumber spine z-scores did not differ (p = 0.271). Despite poorer depressive symptoms and sleep quality in the PVG group, they were not associated with low BMD risk (OR 1.02, 95% CI 0.97-1.08, p = 0.398 and OR 1.00, 95% CI 0.87-1.18, p = 0.972, respectively). Among all PVG-related risk factors, video game time (aOR = 1.22, 95% CI = 1.06-1.41, p = 0.006) and vigorous physical activity amount (aOR = 2.86, 95% CI = 0.93-8.76, p = 0.080) showed the strongest associations with femoral neck z-scores.  Conclusion: The results of this study, showing a negative association between PVG and femoral neck BMD in adolescents, underscore the importance evaluating, monitoring, and supporting lower extremity bone health in adolescents with PVG. What is Known: • Adolescents with problematic video gaming are at risk for depression, impaired sleep; sedentary lifestyle; consumption of tobacco, alcohol, and drugs; and high caffeine intake. • These risk factors might lead to compromised bone health. What is New: • Problematic video gaming is associated with the low femoral neck bone mineral density risk in adolescents. • Extended video game time and reduced physical activity are found to be the primary risk factors.

The impact of the prolonged COVID-19 pandemic on adolescents with eating disorders: a follow-up study from Türkiye

BACKGROUND

At the onset of the pandemic, we conducted a study on adolescents with eating disorders (EDs) and found no deterioration in ED symptoms. The objective of this subsequent study was to conduct a follow-up evaluation of the same cohort and investigate the consequences of the prolonged pandemic.

METHODS

This longitudinal study was conducted one year after the first study between May 2021 and June 2021 with 37 adolescents aged 12-18 years (pre-existing EDs). The reassessment included an evaluation of sociodemographic and clinical characteristics, the impact of pandemic-related restrictions on ED behaviors, well-being, and quality of life. All the participants underwent a re-administration of the ED examination questionnaire (EDE-Q), Beck Depression Inventory, the State Anxiety Inventory for Children, and the Maudsley Obsessive Compulsive Inventory.

RESULTS

No significant difference was observed in the EDE-Q scores or the ED examination questionnaire scores between the initial (T1) and subsequent (T2) study. The ED-related quality of life was seen to have slightly improved in the later stage. While depression (T1: 18, T2: 15, p=0.883) and obsession scores (T1: 11, T2: 14, p: 0.536) showed no disparity between the studies, anxiety scores (T1: 38, T2: 43, p:0.011) exhibited a significant increase.

CONCLUSIONS

Consistent with the early phase, no exacerbation of ED symptoms in adolescents was observed during the later stages of the pandemic. Close clinical monitoring during the pandemic might have been protective against the deteriorating effects of the pandemic. During social isolation, it is important to monitor adolescents with EDs continously for depression and anxiety.

Suicidal ideation and attempts among adolescents from a tertiary hospital in Turkey: A comparative study of pre and postpandemic periods

AIM

This study aims to compare changes in rates of suicidal ideation (SI) and attempts (SA) among adolescents during pre, mid and later periods of the pandemic.

MATERIAL AND METHOD

This study included adolescents who presented to the adolescent medicine clinic in Turkey between March-May 2019 (prepandemic = T0), March-May 2021(mid period of the pandemic = T1) and March-May 2022 (late period year of the pandemic = T2). SI and SA data were assessed through the electronic hospital records of the "HEEADSSS" inventory.

RESULTS

The charts of 2113 adolescents were evaluated. The rates of both SI (p = .015) and SA (p = .026) were determined to be higher during the pandemic (T1+T2) compared to the pre-pandemic period, with a 1.4-fold increase in SI and a 1.5-fold increase in SA. The rates of SI did not differ according to gender, (p = .090). In contrast, SA rate was significantly higher in females (7.3%) than males (3.6%) (p = .001).

CONCLUSION

This study reveals an increase in SI and SA among adolescents during the first 2 years of the pandemic. In challenging times, health professionals should prioritize the identification and treatment of mental health issues, including screening for depression and suicide risk.

Eating disorder visits increase among adolescents during the COVID-19 pandemic

AIM

The study aimed to assess changes in adolescent visits due to eating disorders (EDs) during the pandemic.

METHOD

A retrospective evaluation of adolescents diagnosed with an ED during two periods: June 2019-February 2020 (pre-pandemic) and June 2021-February 2022 (during the pandemic) at an adolescent medicine clinic in Tukey was conducted. The number of patients diagnosed with an ED between these dates was compared with the number of overall attended outpatient appointments. Baseline data for patients with Anorexia Nervosa (AN) and the requirement of hospitalization for all cases were compared.

RESULTS

Of the 3708 visits in the pre-pandemic period 46 (1.2%) were diagnosed with an ED. This was 69 (2.2%) of 3149 visits during the pandemic which was statistically significant (p = 0.003). The percentage of males to females changed from 2.2% to 11.6% (p = 0.065). Distribution of the type of ED did not change (p = 0.280), although the percentage of atypical AN increased from 6.5% to 17.4%. Mean age, BMI, calorie intake and hospital admissions did not significantly change.

CONCLUSION

Our findings support the increase in adolescent EDs during COVID-19. Particular attention should be given to males and Atypical AN cases.

Tamoxifen Treatment for Pubertal Gynecomastia: When to Start and How Long to Continue

Introduction

Pubertal gynecomastia is a common clinical condition among male adolescents, and in most cases, it regresses spontaneously. However, tamoxifen treatment is recommended in selected cases. We aimed to evaluate the indications, safety, and efficacy of tamoxifen treatment in adolescents with pubertal gynecomastia.

Methods

The data of 83 adolescents with pubertal gynecomastia who were treated with tamoxifen between 2006 and 2018 were evaluated retrospectively. The clinical and laboratory data, initial complaint, tamoxifen treatment indication, duration, and dose were recorded along with the treatment outcome.

Results

The gynecomastia disc diameter's monthly reduction rate was significantly higher in adolescents with an initial disc diameter ≥3 cm. The significant reduction of the disc started after the fourth month of tamoxifen treatment and continued to significantly reduce, extending to the sixth month.

Conclusion

Tamoxifen treatment in pubertal gynecomastia was found to be effective and safe. One of the current indications for tamoxifen treatment is having a disc size ≥4 cm, and the recommended treatment duration is 4-6 months. However, this study suggests that treatment should be continued for at least 6 months to achieve the optimal effect. In addition, we recommend that the disc diameter threshold for starting tamoxifen needs to be ≥3 cm.

Assessing the menstrual cycle and related problems in adolescents with a Genetic Syndrome associated with Intellectual Disability

STUDY OBJECTIVE

This study aimed to assess the experience and quality of life related to menstruation in adolescents with a genetic syndrome accompanying intellectual disability (ID).

METHODS

This prospective cross-sectional study was conducted on 49 adolescents with a genetic syndrome accompanied by ID, which was defined by the Wescher Intelligence scale for children-Revised and 50 unaffected controls. In a survey created by the authors, demographic information, menstrual history, and information regarding menstrual difficulties, school abstinence, dysmenorrhea, and premenstrual changes were collected. The Childhood health assessment questionnaire was utilized to evaluate physical impairment, whereas the QoL scale was utilized to evaluate QoL in general and during menstruation. Data was collected from caregivers and additionally from the participants with mild ID, whereas in the control group, data was collected from the participants.

RESULTS

Menstrual history were similar between the two groups. Menstruation related school absenteeism was higher among the ID group (8%vs.40.5%, p<0.001). Mothers reported that 73% of their daughters need help with menstruation care. Social, school, psychosocial functioning, and total QoL scores during menstruation were significantly lower in the ID group when compared with the controls. A significant decrease in physical, emotional, social, psychosocial functioning and total QoL score occurred during menstruation in the ID group. None of the mothers requested menstrual suppression.

CONCLUSION

Although menstrual patterns in two groups were similar, QoL decreased significantly while menstruating in the ID group. Despite a decrease in QoL, an increase in school absenteeism and a high percentage of needing assistance while menstruating none of the mothers requested menstrual suppression.

Adolescent male soccer players have higher growth rates and risk of injury is associated with biological maturity

BACKGROUND

The objective of this study was to ascertain disparities in growth and maturation between male adolescents engaged in soccer and their non-athletic counterparts, as well as to examine the injury features specific to young soccer players.

METHODS

A total of 206 soccer players between the ages of 11-16 years, and 208 non-athletic peers were enrolled. Height, weight, body mass index (BMI), annual growth rate, and skeletal age evaluated using a left handwrist x-ray were determined. Biological and sexual maturation were evaluated using skinfold thickness, body composition, and Tanner stages. The game positions, initial age for playing soccer, the number of games per/ week, the number of sports injuries, date of injury, duration for return to activity, the site, nature, mechanism, and rate of injury were recorded for soccer players. Using an injury card, the characteristics of soccer player injuries were recorded.

RESULTS

The mean age of the participants was 13.6 ± 1.5 years. There was no difference in the growth rates between the groups at the ages of 11.0, 12.0, and 15.0 but at the ages of 13.0 and 14.0 years growth rates were higher in the soccer group. The soccer players were taller than the controls. For all Tanner stages, soccer players had a lower BMI and total body fat percentage, as well as a faster growth rate. Injuries occurred at a rate of 39.3% per year among soccer players. The most common being toe injuries, and playing soccer increased the risk of multiple injuries. Additionally, injuries occurred more frequently in soccer players who were taller, heavier, with higher total body fat and/or higher growth rate, and most commonly occurred during Tanner stage 4. Futhermore, Tanner stage 4 had a higher incidence of two or more injuries than the other stages.

CONCLUSIONS

Adolescent male soccer players have higher growth rates than their non-athletic peers, and their biological maturity status is associated with an increased risk of injury.

The effects of the COVID-19 lockdown on adolescents with an eating disorder and identifying factors predicting disordered eating behaviour

AIM

To evaluate the impact of the COVID-19 lockdown on adolescents with eating disorders (ED) and identify factors predicting ED behaviour.

METHOD

This study took place during an age-stratified lockdown for those under 20 years in Turkey. Participants completed a survey developed to evaluate the effects of the lockdown on ED behaviour, well-being and quality of life (QoL) and additionally the eating disorder examination questionnaire (EDE-Q), and scales for depression, anxiety and obsessive-compulsive behaviour. The relationship between the EDE-Q-global score and other variables related to ED was examined. Linear regression analysis was performed to examine the predictive power of these variables on ED behaviour.

RESULTS

Thirty-eight ED patients with a mean age of 15.12 ± 1.56 years were included in the study. Of participants, 42.1% reported feeling an improvement in ED symptomatology, 71.0% reported none or rare conflict with parents due to eating, 39.5% reported often or always complying with their meal plan. Of participants, 92.0% agreed to 'understanding the value of being healthy' and stated realizing that 'they were in control' due to the pandemic. Of participants 36.9% scored 'bad' for both overall and ED related QoL. In the stepwise regression analysis depression score had the highest predictive value for ED behaviour.

CONCLUSION

Almost half of the participants felt an improvement in their ED and a majority reported rare parental conflict. However, less than half reported meal plan compliance. As depression had the highest positive predictive value for ED behaviour additional screening for depression during the pandemic maybe warranted in ED patients.

Investigation of androgen receptor gene CAG repeat length polymorphism in pubertal gynecomastia

OBJECTIVES

Androgen receptor gene CAG repeat, AR (CAG)_n, polymorphism is thought to have an effect on male reproductive functions and a relationship between long AR (CAG)_n and decreased androgenic activity has been shown. Therefore, we hypothesized that in adolescents with long AR CAG repeat the prevalence of pubertal gynecomastia (PG) will be higher and we aimed to investigate the association between AR (CAG)_n polymorphism and PG in Turkish adolescents.

METHODS

Adolescents with PG between 11 and 19 years of age were enrolled as the study group and healthy individuals without a history of PG, who were at least 14 years of age and Tanner 4 or 5 were enrolled as the control group. The AR (CAG)_n length was detected by direct DNA sequencing analysis and reproductive hormones were measured by standardized analyses.

RESULTS

The mean AR (CAG)_n was 22.3 ± 2.6 (mean ± SD) in the PG group (n=101) and 21.9 ± 3.1 (mean ± SD) in the control group (n=88) (p=0.276). The adolescents with short AR (CAG)_n had lower body mass index standard deviation scores (BMI SDS) compared to the adolescents with intermediate and long repeat numbers (p=0.029).

CONCLUSIONS

The results of this study showed a lack of direct association between AR (CAG)_n and PG. However, the significant relationship between the AR (CAG)_n quartiles and BMI SDS suggests that long AR (CAG)_n might cause PG indirectly. Further studies are needed to better clarify this relationship.

Identification of impulsive adolescents with a functional near infrared spectroscopy (fNIRS) based decision support system

Background.The gold standard for diagnosing impulsivity relies on clinical interviews, behavioral questionnaires and rating scales which are highly subjective.Objective.The aim of this study was to develop a functional near infrared spectroscopy (fNIRS) based classification approach for correct identification of impulsive adolescents. Taking into account the multifaceted nature of impulsivity, we propose that combining informative features from clinical, behavioral and neurophysiological domains might better elucidate the neurobiological distinction underlying symptoms of impulsivity.Approach. Hemodynamic and behavioral information was collected from 38 impulsive adolescents and from 33 non-impulsive adolescents during a Stroop task with concurrent fNIRS recordings. Connectivity-based features were computed from the hemodynamic signals and a neural efficiency metric was computed by fusing the behavioral and connectivity-based features. We tested the efficacy of two commonly used supervised machine-learning methods, namely the support vector machines (SVM) and artificial neural networks (ANN) in discriminating impulsive adolescents from their non-impulsive peers when trained with multi-domain features. Wrapper method was adapted to identify the informative biomarkers in each domain. Classification accuracies of each algorithm were computed after 10 runs of a 10-fold cross-validation procedure, conducted for 7 different combinations of the 3-domain feature set.Main results.Both SVM and ANN achieved diagnostic accuracies above 90% when trained with Wrapper-selected clinical, behavioral and fNIRS derived features. SVM performed significantly higher than ANN in terms of the accuracy metric (92.2% and 90.16%, respectively,p= 0.005).Significance.Preliminary findings show the feasibility and applicability of both machine-learning based methods for correct identification of impulsive adolescents when trained with multi-domain data involving clinical interviews, fNIRS based biomarkers and neuropsychiatric test measures. The proposed automated classification approach holds promise for assisting the clinical practice of diagnosing impulsivity and other psychiatric disorders. Our results also pave the path for a computer-aided diagnosis perspective for rating the severity of impulsivity.

Menstrual Cycle Pain Is Independent of Ovulation in Adolescents With Primary Dysmenorrhea

STUDY OBJECTIVE

This study aimed to evaluate the presence of anovulation in adolescents with primary dysmenorrhea (PD).

DESIGN

Prospective cohort study.

SETTING

Hacettepe University Children's Hospital, Adolescent Medicine outpatient clinic between September 2018 and September 2019.

PARTICIPANTS

Healthy female adolescents (between 11 and 18 years of age), with regular menstruation with a score of 1-3 according to the Numerical Rating Scale (NRS) and grade 0 (no limitation for daily activities, no analgesic need and systemic symptoms) according to the Verbal Multidimensional Scoring System (VBSS) were recruited as a control group. The participants who met the diagnostic criteria for PD with an NRS score ≥4, had analgesic need in at least the last 3 menstrual cycles, had defined moderate-to-severe PD according to VMSS (Grade 2-3), and had analgesic need every time were accepted as the PD group.

INTERVENTION AND MAIN OUTCOME MEASURES

For the determination of ovulation, suprapubic pelvic ultrasound and luteal SP levels were used. The first day of menstruation (DOM) was accepted as the first day of the menstrual cycle. The participants were called to the outpatient clinic for a total of 3 visits during 1 cycle; the first visit was for the suprapubic pelvic ultrasound imaging on the 12^th-18^th DOM, the second visit was for the first SP level measurement on the 21^st-24^th DOM, and the third visit was for the second SP level measurement on the 28^th-31^st DOM, if the next expected menstruation has not started yet. Participants' anthropometric measurements, menstrual history, family history of dysmenorrhea, and additional symptoms accompanying pain were recorded.

RESULTS

Anovulatory cycle rates according to 2 different references for SP threshold values (3 and 5 ng/mL) were 31.7% and 36.6% in the PD group, and 44.4% and 55.6% in the control group, respectively (P = .250, P = .095). In the PD group, NRS scores were similar for the ovulatory and anovulatory cycles for both SP threshold values (P = .320, P = .205). When the reference value for SP threshold was accepted as ≥5 ng/mL, the NRS score was significantly higher in the ovulatory group (P = .0017). When the distribution percentages of SP levels were evaluated among all participants, the median value was 5.5 ng/mL.

CONCLUSION

Contrary to classical information, anovulatory cycles are not rare in PD patients, and pain severity is at the same level in these cycles. The pathogenesis of PD in adolescents requires further study.

Predictors of bone mineral density in adolescents with atypical anorexia nervosa

INTRODUCTION

We aimed to evaluate the bone mineral density (BMD) z scores of adolescents with atypical anorexia nervosa (AAN) and investigate the potential predictors of low BMD risk.

MATERIALS AND METHODS

Potential factors that might have an effect on the femoral neck and lumbar spine dual energy X-ray absorptiometry data of adolescents (11-18 years) with AAN were retrospectively evaluated.

RESULTS

Among adolescents with AAN, 13 (34.2%) had a z score lower than - 1 and 25 (65.8%) had a z score equal or greater than - 1. When adolescents with a BMD score lower and higher than - 1 were compared, normal BMD group had a significantly higher mean lifetime maximum BMI (p = 0.0035). Similarly previous overweight history was significantly higher in the normal BMD group (p = 0.005). A positive correlation was found between femoral neck (p = 0.002, r: 0.546) and lumbar spine (p: 0.002, r: 0.505) z scores and lifetime maximum BMI. There was also a positive correlation between lumbar spine BMD scores and BMI at admission (p = 0.001, r: 0.540). Lumbar spine z scores and amenorrhea duration were negatively correlated (p: 0.002, r:  - 10.867).

CONCLUSION

In the adolescent period similar to AN, AAN cases are also at risk for disordered bone health. In adolescents with AAN, BMI prior to the illness was estimated to be the significant parameter for the risk of low BMD. Special attention should be paid to the bone health of adolescents with AAN, especially for those who do not have a previous overweight history.

AB0737 THE NAIL FOLD CAPILLAROSCOPIC FINDINGS OF ADOLESCENTS WITH ANOREXIA NERVOSA AND BULIMIA NERVOSA

Background:

The nail fold video capillaroscopy (NVC) is usually performed on patients with microcirculation problems, such as Raynaud’s phenomenon. It is also used to distinguish between primary and secondary Raynaud’s Phenomenon and identify the scleroderma pattern.

Objectives:

To describe the acute phase nail fold capillaroscopic findings of adolescents with anorexia nervosa (AN) and bulimia nervosa (BN) and to compare these findings with adolescents diagnosed with primary Reynaud’s phenomenon (RP).

Methods:

We included 17 AN, 2 BN patients and 6 adolescents with primary RP as a control group. The nail fold video capillaroscopy (NVC) data of three study groups were compared. AN and BN patients were classified according to DSM-5. The participants in these two groups were assessed for the presence of Reynaud’s phenomenon/acrocyanosis and the weight loss history (amount and duration), daily calorie intake, vital signs, hydration status, amenorrhea presence and time, the presence and frequency of compensatory behaviors, and drug usage were recorded. Adolescents with primary RP were diagnosed according to ‘International consensus criteria for the diagnosis of RP. The initial NVC was performed at the acute phase of AN and BN. For AN acute phase is defined as the period where the nutritional rehabilitation has not yet taken place. The NVC analysis was be performed with a digital USB microscopy by an expert blinded to the participant’s clinical status and diagnosis. Eight fingers were evaluated for each patient and average of all fingers’ scores were used as quantitative measures.

Results:

Among adolescents with AN, 14 of them had enlarged capillaries (capillary diameter 20-50 μm) and 6 of them had mild tortuosity (<50%) which were considered as minor capillaroscopic changes. 5 patients had at least one giant capillary (>50μm), 3 of them had microhemorrhages, 4 of them had capillary ramifications, and 1 of them had capillary disorganization which were considered as major capillaroscopic changes. Two adolescents had capillary loss (6 capillaries/mm). None of them had active or late phase scleroderma findings. In the primary RP group, there were minor findings as five adolescents had mild capillary dilation (capillary diameter 20-50 μm), and 5 had mild tortuosity (<50%). However, none had scleroderma (early-active-late phase) findings. Microangiopathy assessment scores revealed no difference between the AN patients with and without RP and primary RP patients.(Table 1) A positive correlation was found between capillary ramification scores and initial daily calorie intake (r: -0.47; p=0.04).

Table 1.

Measurements of capileroscopy findings according to patient groups

AN+RP+n=4AN+RP-n=13BNn=2Primer RP kontroln=6pMicroangiopathy score0.84 (IQR 0.98)0.92 (IQR 0.96)0.710.65 (IQR0.23)0.62•Capillary loss score0.22 (IQR 0.62)0.06 (IQR 0.41)0.150.0 (IQR 0.26)0.58•Capillary ramification score0.18 (IQR 0.25)0.13 (IQR 0.25)0.090.09 (IQR 0.18)0.88•Disorganized capillaries score0.38 (IQR 0.48)0.56 (IQR 0.68)0.460.43 (0.32)0.98Enlarged capillaries score (20-50 μm)0.56 (IQR 0.78)0.31 (IQR 0.72)0.730.58 (IQR 0.42)0.60Giant capillaries score (>50 μm)0.06 (IQR 0.22)0.00 (IQR 0.03)0.180.03 (0.14)0.14Microhaemorrhage score0.000.000.000.010.67

Conclusion:

Preliminary results of our study suggest that adolescents with AN are at risk for vasculopathy especially during the acute phase of the disease.

References:

[1]Smith V, et al Autoimmun Rev. 2020 Mar;19(3):102458.

[2]American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (DSM-5). American Psychiatric Pub, Arlington

Acknowledgements:

Muserref Kasap-Cuceoglu and Melis Pehlivanturk-Kizilkan contributed equally.

Disclosure of Interests:

None declared

Psychological burden of asthma in adolescents and their parents

INTRODUCTION

Asthma, a common chronic disease in adolescents is impacted by factors affecting quality of life. This study aimed to determine the psychosocial factors of adolescents with asthma and their parents.

METHODS

The study included 122 adolescents with asthma, 82 healthy controls, and their parents who completed the Asthma Control Test (ACT), Pediatric Asthma Quality of Life Questionnaire (PAQLQ) and the Brief Symptom Inventory (BSI).

RESULTS

The mean age was 14.2 ± 1.9 years. ACT score was high and depression was low in patients with good treatment compliance. As the age of the first asthma symptoms/diagnosis increased, somatization, anxiety, hostility and general psychopathology scores increased, as did the somatization score of parents. Parental anxiety score was not related with adolescent BSI scores in the controls but in the study group when it was higher, the anxiety, depression, somatization, and general psychopathology scores were higher. PAQLQ showed that anxiety, negative self-esteem, somatization, depression, and general psychopathology were higher in patients concerned about asthma. Depression and somatization scores were higher in the parents of patients who perceived that "Treatment does not contribute to asthma control." Somatization scores were higher among parents of patients who noted: "Asthma will not pass in the long-term" and "I cannot control asthma."

CONCLUSION

Higher scores of asthma patients who were anxious about the disease and families who were despondent about treatment demonstrate that health care providers should spend more time informing patients and caregivers. Increasing patient treatment compliance during early adolescence will lessen the psychological burden of the disease.

Bladder and voiding dysfunction in adolescents with anorexia nervosa: a novel finding and potential causes

PURPOSE

This study aimed to investigate the bladder capacity (BC) and bladder dynamics of adolescents with anorexia nervosa (AN).

METHODS

The participants consisted of 15 adolescents newly diagnosed with AN according to the DSM 5 criteria and in the acute weight loss period who were questioned about the symptoms of lower urinary tract (LUT) dysfunction. Functional bladder capacity (FBC) and voided volume with uroflowmetry were measured for each subject; the larger volume of the two was chosen for the bladder capacity. Uroflowmetry was used to obtain uroflow curves for the participants whose patterns were labeled as pathologic if they were outside the bell-shape.

RESULTS

Fourteen (93.3%) of the patients exhibited at least one of the LUT dysfunction symptoms (pathologic voiding symptom/urinary incontinence/pathologic uroflow pattern). BC was observed to increase in 86.6% (n = 13) of the patients. Eighty% of the patients (n = 12) showed pathological uroflow patterns. In patients with pathological uroflow patterns, which showed insufficiency of bladder contraction, assistance of abdominal muscles was needed during voiding.

CONCLUSION

The novel findings presented in this study are the increase of BC in adolescents with AN, the presence of at least one type of voiding or bladder dysfunction, and the pathology of uroflow patterns of most patients show that the bladder dynamics is affected in AN. The most important contribution of this study to the literature is that impaired bladder dynamics was determined to be a medical complication of AN.

LEVEL OF EVIDENCE

Case-control analytic study, Level III.

Is There Any Association Between Hirsutism and Serum Zinc Levels in Adolescents?

Zinc has shown to have an anti-androgenic effect through 5 alpha-reductase enzyme activity inhibition in skin. However, there are contradicting findings concerning the effect of zinc on hirsutism mainly from studies including adult women with polycystic ovary syndrome (PCOS). The aim of our study was to investigate the association between serum zinc levels and hirsutism in adolescents. Between October 2017 and June 2018, 51 female adolescents with hirsutism (mean age: 16.11 ± 1.47 years) and 51 healthy female controls were included in the study (mean age: 15.5 ± 1.40 years). Adolescents with hirsutism were classified under two groups; PCOS (n = 34, 66.7%) and idiopathic causes of hirsutism (idiopathic hirsutism (n = 9, 17.6%) and idiopathic hyperandrogenemia (n = 8, 15.7%)). The serum zinc levels were measured via atomic absorption spectrophotometry. The mean zinc levels of adolescents with hirsutism (102.02 ± 11.64 μg/dl) and the control group (101.72 ± 16.71 μg/dl) were similar (p = 0.915). Additionally, there was no significant difference among the mean zinc levels of the hirsutism sub-groups and the control group (p = 0.979). While some studies demonstrated low zinc levels in women with hirsutism, some studies similar to ours showed no association. Adolescence is a developmental phase where generally isolated mild hirsutism is not associated with hyperandrogenism and more studies are needed to evaluate the effect of zinc on hirsutism in this age group.

Assessment of academic performance of licensed athletes

Objectives Physical activity and sports can be used to reduce stress and anxiety by increasing aerobic capacity and muscle endurance, gain positive behavioral changes and improve their self-discipline, use time well, adopt positive lifestyle such as regular eating and sleeping, which will result in an increase in school success. There are no comprehensive study that examines the academic performance of licensed student athletes and the factors influencing their success rates. The aim of this study was to evaluate the academic performance and related factors in licensed athletes. Methods One hundred eleven licensed athletes at junior high school level were enrolled. Participants filled out questionnaires specifically designed to assess for factors affecting academic performance, where personal and familial factors as well as school performance was taken into consideration. Their academic success rates were evaluated out of mean grade points before as well as after professional sports activities. Academic fields that were graded were, namely, mathematics, life sciences, language, and grammar studies as well as social sciences. Fifty one of participants lived in Ankara (Group 1) and the other 60 lived in Kahramanmaraş (Group 2). The effects of sport and other factors that may affect school success in all groups and between the groups were evaluated before and after sports. Results The age of the athletes were 14.1 ± 2.3 years, 49.5% were male. The grades of athletes before they started competing in professional sports were 80.4 ± 10.6 for mathematics, 80.5 ± 12.5 for sciences, 82.7 ± 9.5 for language studies, and 83.6 ± 9.3 for social sciences. Following a mean period of 4.3 ± 3.1 years of professional sports, the grades of athletes were, with the same order for respective discipline were, 81.6 ± 10.9, 82.4 ± 11.9, 84.3 ± 9.4, and 85.5 ± 8.5. Following sports activities, academic performance in life sciences, language, and grammar studies as well as social sciences showed a significant improvement where grades for mathematics did not show any significant change (p=0.054). The most important factor that improves school performance is the financial status of the family. In Group 1 demonstrated grade improvements following sports activities only in social sciences, whereas Group 2 athletes showed such an improvement for all the disciplines (p<0.05). Conclusions Licensed athletes' school success during the junior high school period showed a significant increase after sports in this study. The most important factors that affected the academic performance were the socioeconomic status of the family.

A comparison of bone mineral density in adolescent swimmers, pentathletes and figure skaters

Gümüş E, Akgül S, Kanbur N, Derman O. A comparison of bone mineral density in adolescent swimmers, pentathletes and figure skaters. Turk J Pediatr 2019; 61: 831-838. Physical activity accounts for up to 17% of the variance in bone mineral density (BMD). Specifically, weight bearing exercises are of critical importance in increasing BMD. The aim of the present study was to evaluate the influence of three different sports with different mechanical loading properties on BMD of young athletes. This was an observational retrospective cohort study. All available medical records of adolescent athletes who have been followed at the Division of Adolescent Medicine at Hacettepe University were reviewed. Bone mineral content (BMC) and BMD of lumbar spine (L1-L4) and left femoral region were compared between young athletes participating in swimming (n=50), pentathlon (n=18), and figure skating (n=7). Femur total and lumbar spine (L1-L4) BMC values of figure skaters (29.1±8.1 g and 51.5±19.0 g, respectively) were found to be higher than swimmers (21.5±6.6 g and 36.1±11.7 g, respectively) and pentathletes (21.6±6.2 g and 41.7±19.4 g, respectively). However, there were no significant differences between any of the groups in lumbar spine and left proximal femur measurements. Regarding BMD, figure skaters (1.1±0.2 g/cm2) had significantly higher femur total BMD values than pentathletes (0.9±0.1 g/cm2) and swimmers (0.9±0.1 g/cm2, p < 0.05). The type of sport has an impact on BMD. Weight bearing and high impact loading activities seem to be associated with a better bone density in a region specific manner. Recommendation of high impact loading exercises may be considered to improve bone health in young athletes especially participating in low impact and non-weight bearing sports.

Mental health of Syrian refugee adolescents: how far have we come?

Akgül S, Hüsnü Ş, Derman O, Özmert E, Bideci A, Hasanoğlu E. Mental health of Syrian refugee adolescents: how far have we come? Turk J Pediatr 2019; 61: 839-845. Among the consequences of war, its impact on the mental health of children and adolescents is one of the most significant. A previous study from our team evaluated the psychiatric symptoms of Syrian refugee adolescents living in one of Turkey`s Temporary Accommodation Centers (TACs) in 2016. Findings suggested that mental health had been compromised in these teens. Since then many measures have been taken to address this problem. The aim of the current study was to re-assess the mental health status of adolescents living in the same center. A total of 76 adolescents (35 female, 41 male) aged between 12-18 years (14.2 ± 0.83 years) received the Brief Symptom Inventory (BSI) which assessed their anxiety, depression, negative self-concept, somatization and hostility levels in addition to a Global Severity Index (GSI). Results > 1.0 indicated psychopathological symptoms. All BSI sub-scores decreased from 2016 to 2019 showing significant improvement in psychopathological symptoms. The most significant change was in the GSI score which decreased from 2.15 to 0.8. For the 2019 participants a significant correlation was found between years of stay at the camp and the depression subscale. Evaluation to assess gender differences found that adolescent girls reported significantly higher scores than males in anxiety, depression, somatization and the global severity index. This study has shown that interventions designed to tackle post-traumatic stress symptomology may have been effective in improving the mental health status of these teens and can provide a roadmap for tackling existing issues in vulnerable conditions. Additionally, females are under higher risk for psychopathology so gender targeted interventions may specifically be necessary to deal with such issues.

Vitamin D deficiency in adolescent pregnancy and obstetric outcomes

OBJECTIVE

The aim of this study was to evaluate the rates of vitamin D deficiency in adolescent pregnants and its influence on the obstetric outcomes.

MATERIALS AND METHODS

A total of 300 singleton pregnant women aged between 14 and 20 years, were divided into three groups according to their gestational weeks (100 pregnant adolescents from each trimester). Randomly selected 300 singleton pregnant women older than 20 years of age with the similar gestational ages were designed as the control group at the same time period. We divided serum 25(OH)D levels into three categories deficiency, inadequacy and adequate levels according to the Endocrine Society guidelines. Serum 25(OH)D levels were also evaluated according to age, seasons and gestational periods. Adverse obstetric outcomes were recorded.

RESULTS

Overall, 86% of the subjects were found to have deficient 25(OH)D levels (<20 ng/ml). The levels indicated an inadequate state in 72 subjects (12%) and only 12 (2%) women had adequate 25 (OH) D levels. Among adult pregnant women the rates of deficient, inadequate and adequate levels were 88.3%, 11%, and 0.7% respectively. Among adolescent pregnant women these rates were 83.7%, 13%, and 3.3% respectively. The lowest 25(OH)D levels occurred during the winter while the highest levels were detected during the summer in both groups. Calcidiol, 25(OH)D, was a significant predictor for preterm delivery (AUC = 0,909; p < 0,001) and also for SGA (AUC = 0,915; p < 0,001). Maternal age was another significant predictor for SGA (AUC = 0,787; p < 0,001) and preterm delivery (AUC = 0,785; p < 0,001).

CONCLUSION

We found a high incidence of 25(OH)D deficiency in Turkish pregnant women. Adolescent age and low 25(OH)D levels are significant risk factors for PTD and SGA. Effective prophylaxis programs for vitamin D deficieny and/or fortification of foods with vitamin D are essential in pregnant women especially in the winter season.

Nutritional Status of Syrian Refugees in Early Adolescence Living in Turkey

This study evaluated the nutritional status of Syrian refugees in the early adolescent period living in different vulnerable settings. Nutritional assessment of Syrian refugee adolescents is often neglected but essential for a healthy physical, pubertal and mental development. Growth parameters of Syrian refugee adolescents going to a public school in an urban area and in a temporary protection center (TPC) were recorded along with the Turkish adolescents. Stunting percentages were similar between the groups (p = 0.811). While the proportion of children with a BMI over 85th percentile were significantly higher among Syrian adolescents living in TPC, Turkish children have the highest percentage of underweight (p = 0.01). Both food insecurity and unhealthy weight gain continue to be major concerns for refugee adolescents after their resettlement to a host country. The findings suggest that nutritional assessment and intervention at early adolescence is critical for Syrian refugees depending on their living conditions.

Effects of vitamin D and estrogen receptor polymorphisms on bone mineral density in adolescents with anorexia nervosa

Background Anorexia nervosa (AN) is a serious eating disorder that is associated with decreased bone mineral density (BMD) and greater lifetime risk for fractures. The aim of this study was to determine the correlation between BMD and genetic polymorphisms in AN. Methods This case-control study analyzed vitamin D receptor (VDR) (VDRBsml, VDRFokl) and estrogen receptor (ESR) (ESR1Xbal, ESR1Pvull) polymorphisms in 45 adolescents diagnosed with AN and 46 age-matched healthy controls. BMD values of the AN group were classified as low or normal, and polymorphisms were compared between cases and controls. The effects of body mass index (BMI), duration of disease and amenorrhea on BMD were also evaluated. Results In girls with AN, a positive effect of the bb genotype of VDRBsmI polymorphism on femur Z-scores (p = 0.103) and of the Ff genotype of VDRFokI polymorphism on vertebra Z-scores (p = 0.097) was observed. In boys with AN, a positive effect of the Ff genotype of VDRFokI polymorphism on vertebra BMD (g/cm2) was detected (p = 0.061). No association was detected between ESR polymorphisms. An inverse relationship was observed between BMD and duration of illness and amenorrhea. A direct relationship was detected between BMD and BMI. Conclusions Specific VDR gene polymorphism genotypes may have positive effects on BMD in patients with AN. Additionally, the lack of association between ESR gene polymorphisms on BMD could be attributed to the low estrogen status of the patient.

Bisphenol A and phthalate levels in adolescents with polycystic ovary syndrome

Endocrine disruptors have been proposed in the etiology of polycystic ovary syndrome (PCOS) as they have the potency to interfere with hormone-sensitivity systems. The aim of this study was to evaluate the levels of bisphenol A (BPA) and phtalates in adolescents with PCOS. Sixty-two girls with PCOS and 33 controls, age 12-18 years were enrolled in the study. The diagnosis of PCOS was made using modified Rotterdam criteria. Urinary BPA levels were measured using high-performance liquid chromatography. Di-(2-ethylhexyl)-phthalate (DEHP), the most commonly used phthalate and mono-(2-ethylhexyl)-phthalate (MEHP), its main metabolite were measured by using high-performance liquid chromatography. Adolescents with PCOS had markedly increased BPA levels (15.89 μg/g creatine ± 1.16) when compared with the control group (7.30 μg/g creatine ± 1.38) (p = .016). In adolescents with PCOS, BPA was significantly correlated with polycystic morphology on ultrasound but not with obesity androgen levels, or other metabolic parameters. Patients with PCOS (DEHP: 0.40 ppm ± 0.24, MEHP: 0.13 ppm ± 0.23) and controls (DEHP: 0.49 ppm ± 0.27, MEHP: 0.14 ppm ± 0.3) had similar serum phtalate concentrations (p = .7 and p = .3, respectively). Exposure to specific endocrine disruptors such as BPA could modify neuroendocrine, reproductive, and metabolic regulation favoring PCOS development in adolescents.

Can having a sibling with type 1 diabetes cause disordered eating behaviors?

Background Adolescents with type 1 diabetes mellitus (T1DM) are at an increased risk of eating disturbances. The aim of this study was to evaluate whether the risk of a disordered eating behavior (DEB) also applies to the well sibling sharing the same environment. Methods Well siblings were included if they were 10-18 years old, had a sibling with a T1DM diagnosis for at least 6 months and lived with the sibling during the illness. The control group was comprised of healthy participants recruited from the outpatient clinic with no family history of T1DM. Participants completed a four-part questionnaire concerning their eating behaviors that was developed by the study team. This survey aimed to evaluate the dietary habits and eating patterns. All participants completed the Eating Attitudes Test-26 (EAT-26) and a 24-h food dietary recall. Any participant with a high EAT-26 score or that seemed to be at risk according to the questionnaire was re-evaluated. Results Eight cases (33.3%) in the well sibling group had either a total and/or subgroup pathological score. Three of them were found to have DEB and one case was diagnosed with anorexia nervosa (AN). In the control group, five cases (17.2%) had either a total and/or subgroup pathological score. Three of these cases were found to have DEB, no cases were diagnosed with an eating disorder. There were no statistically significant differences in the EAT-26 scores between the groups. Conclusions Although a direct relationship was not observed, the probability of having a pathologic EAT-26 score was higher in the group with a sibling with T1DM.

Do Different Diagnostic Criteria Impact Polycystic Ovary Syndrome Diagnosis for Adolescents?

STUDY OBJECTIVE

Although early diagnosis of polycystic ovary syndrome (PCOS) in adolescents might allow for earlier treatment and prevention of chronic disorders, incorrect or premature diagnosis carries risks of unnecessary treatment and psychological distress. There is no consensus concerning which diagnostic criteria to use for adolescents and current criteria vary. The objective of this study was to determine whether using different diagnostic criteria will affect PCOS diagnosis in adolescents.

DESIGN, SETTING, AND PARTICIPANTS

Fifty-two patients aged 13-18 years with at least 2 of the following criteria were included in the study: (1) oligomenorrhea or amenorrhea; (2) Clinical or biochemical hyperandrogenism; and (3) polycystic ovaries on ultrasonography. Patients were then categorized according to the 6 different criteria for PCOS. National Institutes of Health, Rotterdam criteria, Androgen Excess Society, Amsterdam criteria, Endocrine Society criteria, and the Pediatric Endocrine Society criteria. The characteristics of adolescents who were diagnosed with PCOS were also evaluated.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Forty-one patients out of 52 (78.8%) received diagnosis with National Institutes of Health and Endocrine Society criteria, all with Rotterdam criteria, 45/52 (86.5%) with Androgen Excess Society criteria, 36/52 (69.2%) with Amsterdam criteria and 34/52 (65.4%) with the Pediatric Endocrine Society criteria.

RESULTS AND CONCLUSION

This study shows that the choice of guideline used does have a great effect on whether an adolescent received the PCOS diagnosis or not. For physicians using the broader criteria, care should be taken to ensure the patient does not receive diagnosis because of the physiological changes seen during puberty, which might mimic PCOS. For those using stricter criteria, close monitoring of patients who do not receive diagnosis is necessary to prevent chronic complications.

Bone mineral density comparison of adolescents with constitutional thinness and anorexia nervosa

BACKGROUND

The negative impact of anorexia nervosa (AN) on bone health is well defined. However, there are very few studies evaluating the effect of constitutional thinness on bone health, especially in the adolescent period and in the male gender. The aim of this study is to compare the bone mineral density (BMD) measurements of adolescents with AN and with constitutional thinness.

METHODS

Between April 2013 and March 2014, 40 adolescents with AN and 36 adolescents with constitutional thinness participated in the study. The femoral neck and lumbar spine BMD were measured by dual energy X-ray absorptiometry (DXA).

RESULTS

Mean lumbar z and BMD scores of adolescents with constitutional thinness were significantly lower than in adolescents with AN, whereas the mean femoral z and BMD scores were not significantly different. When males were compared separately, lumbar z and BMD values of the constitutionally thin group were found to be significantly lower than in the AN group. This difference was not significant for females.

CONCLUSIONS

The difference between the male and female results of our study suggested two hypotheses. The significantly lower BMD values in constitutionally thin boys are attributed to their longer duration of low body mass index (BMI). Although the duration of low BMI is also longer for constitutionally thin girls, similar BMD values of AN and constitutionally thin female groups are attributed to the additional negative impact of estrogen deficiency on the bone health of girls with AN.

Low zinc levels may contribute to gynecomastia in puberty

This study aimed to determine whether there were any differences in trace element levels between adolescent boys with gynecomastia and control boys and to determine the correlations between the levels of trace elements and body mass index (BMI) and sex hormones. The pubertal gynecomastia group comprised of 41 patients (mean age=13.2 ±0.9 years), who were admitted to Hacettepe University İhsan Doğramacı Children's Hospital in Ankara. Control group comprised of 21 healthy male children. Analyses of trace element levels were performed atomic absorption spectrometry. The mean zinc level of control group was 101.33±16.87μg/dL and the mean zinc level of gynecomastia group was 81.36±17,43μg/dL (20% lower in gynecomastia patients, p=0.0001). However, the mean copper and manganese levels of gynecomastia patients were not statistically different than the control group. There were significant positive correlations between plasma zinc and total testosterone levels in gynecomastia group (r=0.592; p<0.05). There was a significant negative correlation between plasma zinc levels and BMI (r=-0.311; p<0.05). These results indicate that zinc deficiency might be one of the underlying factors of gynecomastia, the importance of which needs to be further elucidated.

Is white matter affected in adolescents with anorexia nervosa? A study using magnetization transfer imaging

The aim of the study was to assess potential changes in structural integrity of the brain in adolescent patients with Anorexia Nervosa (AN) using the magnetization transfer imaging technique and re-evaluating after nutritional rehabilitation was accomplished. Magnetization transfer ratio (MTR) was used for the detection and quantification of histological changes to the white matter of 9 adolescents diagnosed with AN at diagnosis and after weight gain. Using the MTR technique 6 regions were measured: the pons, left cerebellar hemisphere, amygdala, thalamus, corona radiata and white matter adjacent to the left dorsolateral prefrontal cortex. Scans from the patients with AN were also compared with scans from an age-matched subset of 9 healthy controls. Compared with control subjects, the MTR of participants with AN was no different either at the early stages of diagnosis (p=0.62) or after weight recovery (p=0.81). Similarly, comparison of MTR between patients with AN at diagnoses compared with MTR after weight recovery yielded no statistically significant difference (P=0.33). We conclude that MTR was not able to detect any neuropathological alterations in adolescent patients with AN at either diagnosis or after nutritional recovery and the achievement of weight gain.

Pubertal gynecomastia: years of progress - the Hacettepe experience

Gynecomastia is defined as an enlargement of the male breast. Although it is commonly seen during puberty, it is often overlooked by many physicians. As adolescent medicine specialists, we believe there is a gap in the literature concerning both the etiology and maybe more importantly the care of these adolescents. Thus, we have been dedicated to conducting research on this topic. The aim of this review article was to evaluate the studies concerning pubertal gynecomastia that took place at the Division of Adolescent Medicine, Hacettepe University, published between the years 2003 and 2016. The review covers in detail both the short- and long-term effectivity and safety of tamoxifen used for the treatment of pubertal gynecomastia. As the exact basis for the pathogenesis of gynecomastia remains unknown, we also evaluate three studies that aimed to answer this question. We additionally review a study that aimed to assess the psychological distress and effect on body image that gynecomastia may have on the adolescent male. An important contribution this review article adds to the literature is as a conclusion to all the studies performed, we present the 'Hacettepe indications for tamoxifen treatment for pubertal gynecomastia'. These indications will aid physicians when considering treating these patients.

The understanding of risk factors for eating disorders in male adolescents

OBJECTIVE

The study aimed to describe the medical, psychiatric, and cultural features of adolescent males with an eating disorder (ED).

MATERIALS AND METHODS

This retrospective evaluation took place at Hacettepe University, İhsan Doğramacı Children's Hospital, Ankara, Turkey, and covered a 4-year period between 2010 and 2013. Sixty adolescents were diagnosed with an ED during this period, 47 (78.3%) were females and 13 were males (21.7%) male. All 13 male patients who met full criteria for an ED according to the DSM criteria were included. Medical and psychiatric records of male patients treated for an ED were re-evaluated.

RESULTS

The most striking finding of the study was that the female to male ratio became 3.6:1, with the increasing number of male adolescents with an ED. In our study, medical findings and complications of males with ED were similar to those seen in females. However, the most predominant gender difference was the co occurrence of a comorbid physical or mental illness.

CONCLUSION

It is imperative to raise awareness of EDs in males. Although the medical findings of the study suggest that male and female adolescents with EDs are clinically similar to each other, the understanding of certain gender-specific risk factors shown in our study, such as a medical illness and/or obesity and co-morbid psychiatric diagnosis, are essential in raising suspicion. Further studies that especially evaluate cultural and social factors that affect parenting styles for boys are important in addessing possible risk factors for the development of EDs in males within different societies.

Evaluation of Serum Vitamin D Levels in Adolescents with Pubertal Gynecomastia

BACKGROUND

Since vitamin D has an inhibitory function on ductal morphogenesis of the pubertal mammary gland, it may have a role in the development of gynecomastia. The aim of this study was to determine the effect of vitamin D deficiency on the development of pubertal gynecomastia.

METHODS

Serum 25-hydroxyvitamin D (25D) levels in 50 adolescents with pubertal gynecomastia and 54 healthy controls between the ages of 11 and 17 years were compared.

RESULTS

Mean 25D level was 14.03 ± 6.38 (5.0-32.5) ng/ml in the pubertal gynecomastia group and 15.19 ± 6.49 (5.0-33.2) ng/ml in the control group (p = 0.361). According to the vitamin D status classification of the American Academy of Pediatrics, 66% of the pubertal gynecomastia group was found to be deficient and 14% were insufficient. In the control group these values were 53.7% and 29.6%, respectively (p = 0.158).

CONCLUSION

From our results we hypothesize that, rather than low serum levels of 25D, a dysregulation of the vitamin D signal pathway, vitamin D metabolism or vitamin D storage within the mammary tissue might be the contributing factors to the development of gynecomastia.

A different training model for adolescent medicine: a PhD program in Turkey, where adolescent medicine is not currently a sub-specialty at this stage

Adolescent medicine is currently not a certified subspecialty by the Ministry of Health in Turkey. Until recently, no subspecialty education was available for pediatricians interested in pursuing a career in this field. To compensate for the lack of training opportunities in the field, to meet the needs of adolescents and to increase research and strengthen scientific knowledge in the area of adolescent medicine, a doctoral program was established in 2004 by the Division of Adolescent Medicine under the Institute of Child Health at Hacettepe University in Ankara. This paper discusses the opportunities provided by the program, describing the pros and cons of such a course and what the program aims to achieve. This unique program provides pediatricians with extended postgraduate, subspecialty education in adolescent health care. We believe that the adolescent medicine PhD program at Hacettepe University could be a model for educating health care professionals in this field in other countries where there are not established fellowship programs.

Increased P-wave dispersion a risk for atrial fibrillation in adolescents with anorexia nervosa

Studies have shown that a prolonged P-wave dispersion is a risk factor for the development of atrial fibrillation. The aim of this study was to evaluate P-wave dispersion in adolescents with anorexia nervosa at diagnosis. We evaluated electrocardiographic findings, particularly the P-wave dispersion, at initial assessment in 47 adolescents with anorexia nervosa. Comparison of P-wave dispersion between adolescents with anorexia nervosa and controls showed a statistically significant higher P-wave dispersion in patients with anorexia nervosa (72 ± 16.3 msec) when compared to the control group (43.8 ± 9.5 msec). Percent of body weight lost, lower body mass index, and higher weight loss rate in the patients with anorexia nervosa had no effect on P-wave dispersion. Due to the fact that anorexia nervosa has a high mortality rate we believe that cardiac pathologies such as atrial fibrillation must also be considered in the medical evaluation.

The effect of tamoxifen on pubertal bone development in adolescents with pubertal gynecomastia

During puberty, estrogen has a biphasic effect on epiphyses; at low levels, it leads to an increase in height and bone mass, whereas at high levels, it leads to closure of the epiphysis. Tamoxifen is a selective estrogen receptor modulator that has been used in the treatment of pubertal gynecomastia. Although it has not been approved for this indication, studies have shown it to be both successful and safe. In males, the peak of pubertal bone development occurs during Tanner stage 3-4, which is also when pubertal gynecomastia reaches its highest prevalence. Thus tamoxifen treatment could potentially effect pubertal bone development. The aim of this study was to assess the effects of tamoxifen on bone mineral density (BMD) and skeletal maturation when used for pubertal gynecomastia. We evaluated 20 boys with pubertal gynecomastia receiving tamoxifen for at least 4 months. BMD was measured with dual-energy X-ray absorptiometry. Z-score and absolute BMD (g/cm(2)) was determined at baseline and 2 months after completing tamoxifen treatment. Bone age and height was evaluated before treatment and again one year later. Using absolute BMD (g/cm(2)), the mean difference from baseline was significant between the two groups both at spine (p=0.002) and femur (p=0.001), but not with the Z-score. This result was attributed to the expected increase during puberty according to sex and age. No significant effect on skeletal maturation was found (p=1.112). We conclude that when pubertal bone development is concerned, tamoxifen is safe for the treatment of pubertal gynecomastia as neither bone mineralization nor growth potential was affected.

Type of setting for the inpatient adolescent with an eating disorder: Are specialized inpatient clinics a must or will the pediatric ward do?

There are a range of different services for treating adolescent eating disorders (ED) but there is no clinical consensus and a paucity of research indicating which type of treatment setting is the best. Although it would be ideal to have a specialized ward for these patients what happens when this is not possible? The aim of this study was to evaluate patients with ED hospitalized on a general pediatric ward. A retrospective chart review for 37 patients hospitalized for an ED and followed by a team consisting of an adolescent medicine specialist, a child and adolescent psychiatrist and a dietician on a pediatric ward were re-evaluated. Twenty-four (64.9%) patients were diagnosed with anorexia nervosa (AN) restricting type, 8 (21.6%) with anorexia nervosa binging purging type, 3 (8.1%) with bulimia nervosa (BN) and 2 (5.4%) with eating disorder otherwise not specified. The mean age at admission was 14.79 ± 1.75 years and 7 (20%) were males. A majority were hospitalized due to medical instability. Mean period of time from admittance to medical stabilization was 6.04 ± 4.79 days. The mean period of admittance was 26.4 ± 11.9 days for AN and 23.7 ± 15.03 days for BN patients. The mean calorie intake of the AN group was 607 ± 333 kcal and 2,358 ± 605 kcal at hospitalization and discharge, respectively. Hypophosphatemia occurred in 2 patients during refeeding. Mean total weight gained during the whole hospitalization period was 3,950 ± 3,524grs. This study shows that although not ideal, EDs can successfully be followed on general pediatric wards and could have implications at centers with no specialized wards.

The effect of swimming and type of stroke on bone metabolism in competitive adolescent swimmers: a pilot study

BACKGROUND/AIM

Physical activity plays a key role in increasing and preserving bone mineral density (BMD). Effects on bone development associated with various nonweight-bearing sporting activities, such as swimming, are controversial. Different strokes used in swimming may also present as another factor. The aim of this study was to evaluate the effect of swimming and type of stroke on BMD in competitive adolescent athletes.

MATERIALS AND METHODS

Seventy-nine swimmers between the ages of 10 and 21 years participated in this study. BMD was measured with dual-energy X-ray absorptiometry at the lumbar vertebrae and left proximal femur. Daily calorie intake and calcium consumption, and measurements of calcium, phosphorus, alkaline phosphates, 25-hydroxyvitamin D (25(OH) D), and osteocalcin were evaluated.

RESULTS

Preliminary results revealed that the type of stroke had no effect on BMD (P = 0.79). Additionally competitive swimmers did not have augmented bone mineral accretion, and in 13.9% of athletes low BMD was confirmed. Sixty percent of swimmers had either deficient or insufficient 25(OH) D levels and a low mean calorie (P = 0.542) and calcium (P = 0.038) intake was observed.

CONCLUSION

This was the first study to evaluate the effect of swimming stroke on BMD. Although no effect was statistically shown, further studies with a larger series may determine this effect.

Final diagnosis of children and adolescents with musculoskeletal complaints

BACKGROUND

Musculoskeletal complaints (MSCs) are one of the leading causes of outpatient admissions. However, analytical and epidemiological data are limited. The aim of this study is to identify the etiology of MSCs (excluding acute traumatic conditions) in children and adolescents, and to identify clues for the differential diagnosis.

METHODS

Children and adolescents presenting with musculoskeletal pain, swelling or limitation of movement were enrolled in a prospective design. Demographic, clinical and laboratory features were recorded.

RESULTS

Four hundred and twenty-two children (48.2% female) with a mean age of 7.90±3.95 years were enrolled. Etiology was identified in 97.2% of the cases: non-inflammatory and mechanical conditions (NIMC; 42.2%), rheumatic diseases (RD; 31%), infection-related disorders (IRD; 21.6%) and malignancy (M; 2.4%). NIMC was characterized by longer duration of complaints, a higher rate of non-articular complaints, a lower rate of joint involvement and limping and lower levels of leukocytes, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The prevalence of RD was higher in the age group of >12 years; younger age was associated with higher prevalence of IRD. Small-joint involvement was highest in the RD group. Median ESR in RD and M groups was higher; compared to the other groups; the frequency of patients with ESR ≥ 60 mm/hr was higher in the M group; compared to the RD group. In the RD group familial Mediterranean fever (9.7%), juvenile idiopathic arthritis (8.3%) and Henoch-Schönlein purpura (5.7%) were the leading causes of MSCs.

CONCLUSIONS

RD accounted for one-third of the etiologies for MSCs. Age, duration of complaints, pattern of joint involvement and acute phase reactants are practical tools that may guide the pediatrician for diagnosis.

The effect of gynecomastia on body image perception and gender roles in adolescents

The aim of our study was to evaluate the effect of gynecomastia on body image perception and gender roles in adolescents. Forty-seven adolescents with gynecomastia and 63 healthy adolescents were enrolled in the study. The Body Image Perception Scale (BIPS) and the Bem Gender Role Inventory (BGRI) were administered to the study group after the first evaluation and also one month later. The percentage of adolescents with a BIPS score lower than the median was higher in the study group than in the control group, although there was no significant difference. Additionally, considering the single item "my breasts," it was observed that body image perception disturbance existed mostly, if not entirely, in relation to this body part. After detailed information regarding gynecomastia was given during the first clinical session, the BIPS score improved at the one-month follow-up, emphasizing the importance of informing and educating patients regarding this condition. BGRI results showed that gender roles of patients with gynecomastia are not influenced in the feminine direction.

Fasting during Ramadan: a religious factor as a possible trigger or exacerbator for eating disorders in adolescents

Culture-based contributors play a role in eating disorders (EDs). Here, we present one such factor that may play a role in triggering ED's in adolescents: Fasting during the holy period of Ramadan. Ramadan is the Islamic month of fasting, in which participating Muslims refrain from eating, drinking, and smoking, which starts from dawn lasting until sunset. For the past 2 years, we have noticed an increase in patients with disordered eating patterns that have applied to Hacettepe University, Division of Adolescent Medicine during or shortly after Ramadan. We document six of these patients, three of which were diagnosed with an ED and three that did not meet full criteria. We argue that the possible effects of a drastic change in ones diet such as that which occurs during Ramadan, play an important role in triggering ED's in adolescents with a predisposition or may exacerbate an eating pathology.

A case of anorexia nervosa with multiple medical complications

Anorexia nervosa (AN) is a potentially life-threatening eating disorder characterized by an intense fear of gaining weight and a distorted body image. Although AN is a psychiatric illness, it is also very important from a pediatric perspective, as it can cause major medical complications in every organ system in the growing and developing body. The medical complications of anorexia nervosa may endanger the patient in several ways, and the severity of medical complications may be underestimated. Pediatricians should be aware of the possibility of medical complications in adolescent patients who have an eating disorder and understand that, if not managed correctly, such complications may be fatal. This case report describes the vast number of medical complications that can be observed in an adolescent due to an eating disorder.