Andrea E. Bonny

School disconnectedness: identifying adolescents at risk.

Objective. School connectedness, or the feeling of closeness to school personnel and the school environment, decreases the likelihood of health risk behaviors during adolescence. The objective of this study was to identify factors differentiating youth who do and do not feel connected to their schools in an effort to target school-based interventions to those at highest health risk. Methods. The study population consisted of all students attending the 7th through 12th grades of 8 public schools. The students were asked to complete a modified version of the in-school survey designed for the National Longitudinal Study of Adolescent Health (Add Health). The school connectedness score (SCS) was the summation of 5 survey items. Bivariate analyses were used to evaluate the association between SCS and 13 self-reported variables. Stepwise linear regression was conducted to identify the set of factors best predicting connectedness, and logistic regression analysis was performed to identify students with SCS >1 standard deviation below the mean. Results. Of the 3491 students receiving surveys, 1959 (56%) submitted usable surveys. The sample was 47% white and 38% black. Median age was 15. Median grade was 9th. The SCS was normally distributed with a mean of 15.7 and a possible range of 5 to 25. Of the 12 variables associated with connectedness, 7 (gender, race, extracurricular involvement, cigarette use, health status, school nurse visits, and school area) entered the linear regression model. All but gender were significant in the logistic model predicting students with SCS >1 standard deviation below the mean. Conclusions. In our sample, decreasing school connectedness was associated with 4 potentially modifiable factors: declining health status, increasing school nurse visits, cigarette use, and lack of extracurricular involvement. Black race, female gender, and urban schools were also associated with lower SCS. Further work is needed to better understand the link between these variables and school connectedness. If these associations are found in other populations, school health providers could use these markers to target youth in need of assistance.

Serum adipocytokines and adipose weight gain: a pilot study in adolescent females initiating depot medroxyprogesterone acetate.

OBJECTIVE To evaluate whether serum adipocytokine concentrations, controlling for baseline adiposity, are predictive of adipose weight gain in adolescents initiating depot medroxyprogesterone acetate (DMPA). METHODS Percent body fat was measured at baseline and 6 months. Baseline serum adipocytokine concentrations were quantified. RESULTS Mean percent body fat was 31.6% (±7.6) at baseline and 33.5% (±7.6) at 6 months. In multivariable linear regression modeling (adjusted for baseline percent body fat), Hispanic ethnicity and baseline serum adiponectin concentration were inversely associated (p≤.05) with absolute change in percent body fat at 6 months. CONCLUSIONS Serum adiponectin concentration may be useful for assessing risk of DMPA-associated adipose gains.

A pilot study of depot medroxyprogesterone acetate pharmacokinetics and weight gain in adolescent females

OBJECTIVE To explore the relationship between medroxyprogesterone acetate (MPA) pharmacokinetic (PK) parameter estimates and weight gain. STUDY DESIGN Prospective study of adolescents (N=40; age 12-21 years) initiating DMPA. PK parameters were calculated: maximum MPA concentration (Cmax, ng/mL), time to Cmax (Tmax, days) and elimination rate constant (ng/mL/day). Optimal PK cut points were determined for predicting body mass index (BMI) increase ≥10%. RESULTS Cmax <2.88 ng/mL and elimination rate constant <0.021 ng/mL/day were associated (p<.05) with BMI increase ≥10%. Elimination rate constant was most predictive of weight gain. CONCLUSIONS PK evaluation may help identify adolescents at risk of excessive DMPA-associated weight gain.

Twelve-month discontinuation of etonogestrel implant in an outpatient pediatric setting ☆

OBJECTIVE The etonogestrel (ENG) contraceptive implant is the most effective reversible contraceptive method. Uptake remains limited in adolescents, a population at high risk for unintended pregnancy. The objectives of this study were to determine the 12-month discontinuation rate of the ENG implant among adolescents in an outpatient setting and to characterize risk factors for discontinuation. STUDY DESIGN A retrospective chart review identified adolescent females aged 12 to 22years who received the ENG implant in one pediatric institution between January 1, 2011, and April 15, 2014. Patients were categorized into ENG discontinuers (removed prior to 12months) and ENG continuers (continued for ≥12months). Associations between demographic, clinical and postplacement characteristics with ENG discontinuation category were assessed with t tests, χ(2)/Fishers Exact Tests and backwards stepwise logistic regression. RESULTS Of the 750 patients who had an ENG implant inserted, 77 (10.3%) had the device removed prior to 12months of use. The mean length of implant use for those who discontinued was 7.5months. Problematic bleeding was the most commonly cited reason for discontinuation. Older age at time of insertion, history of pregnancy and ≥1 medical visit for implant concerns (not including removal) were independently predictive (p<.01) of method discontinuation. CONCLUSION The vast majority of adolescents continued the ENG implant at 12months, making it an excellent contraceptive choice for adolescents within the outpatient pediatric setting. Greater efforts should be made to increase its use by pediatric providers. IMPLICATIONS The ENG implant is an excellent contraceptive option for adolescents in the outpatient pediatric setting.

Healthcare Barriers and Utilization Among Adolescents and Young Adults Accessing Services for Homeless and Runaway Youth

Homeless and runaway youth are at disproportionate risk for adverse health outcomes. Many barriers to accessing healthcare have been documented; however, the relative impact of discrete barriers on homeless youth healthcare utilization behavior is not firmly established. We administered a survey examining reported barriers and healthcare utilization among adolescents and young adults accessing services at three community centers for homeless and runaway youth. Of 180 respondents, 57 % were male, 80 % non-White, and 21 % identified as a sexual minority. Stepwise logistic regression models, controlling for age and study site, explored associations between barriers and 3 healthcare utilization outcomes (doctor visit in past 12 months; regular care provider; frequent emergency department (ED) visits). The most commonly reported barriers were “don’t have a ride” (27.2 %), “no insurance” (23.3 %), and “costs too much” (22.8 %). All fear-based barriers (e.g., “I don’t trust the doctors”) were reported by <5 % of surveyed youth. Significant predictors of having seen a doctor in the past 12 months included sexual minority status (OR 2.8, p = 0.04) and possession of health insurance (OR 4.9, p < 0.001). Female sex (OR 5.2, p < 0.001) and reported external barriers other than health insurance (OR 0.2, p < 0.001) were associated with having a regular care provider. Fear-based concerns were associated (OR 3.8, p = 0.02) with frequent ED visits, as was being insured (OR 2.2, p = 0.03). These results underscore the need to clearly define healthcare outcomes when investigating barriers to care among homeless and runaway youth as the impact of discrete barriers varies depending on outcome of focus.

Hormonal Contraceptive Agents: A Need for Pediatric-Specific Studies

Adolescents are frequently prescribed hormonal contraceptive agents for both contraceptive and noncontraceptive purposes. Over half of all sexually experienced females aged 15 to 19 have used some form of hormonal contraception: 56% oral contraceptive pills (OCPs), 20% injectable, 14% emergency, 10% patch, and 5% ring.1 Given that 50% of adolescent girls have been sexually active before age 18, ∼1 in 4 adolescent girls will be exposed to hormonal contraceptives by age 18.2 Additionally, teenagers are more likely than adult women to use hormonal contraceptives for purposes other than birth control: 33% of adolescents on OCPs use the method solely for noncontraceptive purposes.3 Hormonal contraceptive agents have many noncontraceptive benefits that are of particular importance during adolescence. They decrease menstrual flow, anemia, painful periods, acne, functional ovarian cysts, as well as other menstrual-related symptoms such as premenstrual syndrome, headaches, and epilepsy. Menstrual irregularity is common among adolescent girls, particularly in the first 2 years after menarche. These irregular periods can lead to prolonged excessive bleeding. In girls with bleeding disorders, sickle cell disease, polycystic ovary syndrome, or developmental delays, menstrual control may be essential to well-being and indicated soon after menarche. The median age at menarche is 12 to 13 years old. Given this median, girls 10 to 12 years of age could be menstruating and have reason to be prescribed hormonal contraceptive agents. Especially few data are available regarding hormonal contraceptive use in girls under the age of 13. Despite their widespread use, the overwhelming majority of hormonal contraceptive agents have not been adequately studied in pediatric populations. Pharmacokinetic … Address correspondence to Andrea E. Bonny, MD, Division of Adolescent Medicine, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205. E-mail: andrea.bonny{at}nationwidechildrens.org

A pilot randomized controlled trial of omega-3 fatty acid supplementation for the treatment of anxiety in adolescents with anorexia nervosa

OBJECTIVE To evaluate the effectiveness and tolerability of omega-3 polyunsaturated fatty acid (PUFA) supplementation for treatment of trait anxiety among adolescent females with restrictive anorexia nervosa (AN). METHOD A pilot double-blind, placebo-controlled randomized trial of adolescent females with AN (N = 24) entering Partial Hospitalization Program (PHP) from January 2015 to February 2016. Participants were randomized to four daily PUFA (2,120 mg eicosapentaenoic acid/600 mg docosohexaenoic acid) or placebo capsules for 12 weeks. A 9-item questionnaire of side effect frequency assessed medication tolerability. The Beck Anxiety Inventory-Trait measured anxiety at baseline, 6, and 12 weeks. Linear mixed models evaluated associations between randomization group and study outcomes. Twenty-two and 18 participants completed 6 and 12 weeks of data collection, respectively. RESULTS Medication side effect scores were low and were not significantly different between randomization groups at Week 6 (p = .20) or 12 (p = .41). Mean trait anxiety score significantly (p < .01) decreased from baseline to 12 weeks in both groups, and the rate of change over the course of time did not differ between omega-3 PUFA and placebo groups (p = .55). CONCLUSION Omega-3 PUFA supplementation was well tolerated in adolescent females with AN. Although power to detect differences was limited, we found no evidence that omega-3 PUFA benefited anxiety beyond nutritional restoration.

Computerized Self-Administered Substance Use Screening in a General Adolescent Clinic:

Adolescent substance use remains a pressing public health concern. Approximately 37% of US high school students have used alcohol in the past year, 23% have used marijuana, and 10% have used any illicit drug other than marijuana. Use of increasingly dangerous drugs (ie, opioids) has also led to a recent increase in adolescent overdose deaths. Despite the magnitude of this problem, it is estimated that less than 10% of adolescents who need treatment for substance use disorders receive it. Primary care providers have a crucial role to play in identifying youth at risk for substance use problems. Although health providers should routinely screen all adolescent patients for substance use, time and practice constraints may limit ability to achieve ideal compliance with recommended screening. Electronic modalities have the potential to improve screening compliance by easing provider burden and appealing to adolescent patients. Adolescents report feeling more comfortable and honest when screened electronically as opposed to on paper or with provider interviews. The CRAFFT (car, relax, alone, forget, friends, trouble) is a brief, developmentally appropriate substance use screening test that has been validated in adolescent populations. Computerized, self-administered screening with the CRAFFT was recently recommended as a valid alternative to clinician-administered screening. The objectives of this brief report were to explore self-administered, computerized CRAFFT screening in a general adolescent clinic population and to identify the proportion of patients screening positive. We sought to compare our findings to those previously reported in other populations in order to further support the usefulness of self-administered screening in identifying atrisk youth.

Severe Sepsis and Acute Myocardial Dysfunction in an Adolescent with Chlamydia Trachomatis Pelvic Inflammatory Disease: A Case Report

BACKGROUND Although generally asymptomatic, severe Chlamydia trachomatis (C. trachomatis) infections have been documented. C. trachomatis has been associated with myocarditis as well as sepsis. CASE A 19-year-old girl with type 1 diabetes mellitus developed sudden-onset mental status change and shock after resolution of diabetic ketoacidosis. Abdominal and pelvic imaging showed uterine and adnexal inflammation, and pelvic examination confirmed a diagnosis of pelvic inflammatory disease. The patient was intubated, required vasopressor support, and developed severe biventricular myocardial dysfunction. Infectious myocarditis workup was negative. Nucleic acid amplification testing from vaginal discharge was positive for C. trachomatis and Trichomonas vaginalis and negative for Neisseria gonorrhoeae. SUMMARY AND CONCLUSION C. trachomatis should be considered in the workup of septic shock, particularly in populations at high risk for sexually transmitted infections.