Karen Soren

Mental Health Issues in Adolescents and Young Adults With Type 1 Diabetes: Prevalence and Impact on Glycemic Control

Mental health comorbidities can negatively affect disease management in adolescents with chronic illnesses. This study sought to determine the prevalence and impact of mental health issues in a population of adolescents and young adults with type 1 diabetes. A cross-sectional study of 150 patients aged 11 to 25 years with type 1 diabetes from an urban, academic diabetes center was conducted. Participants completed 3 validated mental health disorder screening instruments: Beck’s Depression Inventory, the Screen for Child Anxiety Related Emotional Disorders-41 anxiety screen, and the Eating Disorder Screen for Primary Care. More than a third screened positive: 11.3% for depression, 21.3% for anxiety, and 20.7% for disordered eating (14.7% had ≥2 positive screens). Patients with a positive screen had twice the odds of having poor glycemic control as those without, as measured by HgbA1c. This study supports screening for mental health issues in adolescents and young adults with type 1 diabetes.

Adolescent Understanding and Acceptance of the HPV Vaccination in an Underserved Population in New York City.

Background. HPV vaccination may prevent thousands of cases of cervical cancer. We aimed to evaluate the understanding and acceptance of the HPV vaccine among adolescents. Methods. A questionnaire was distributed to adolescents at health clinics affiliated with a large urban hospital system to determine knowledge pertaining to sexually transmitted diseases and acceptance of the HPV vaccine. Results. 223 adolescents completed the survey. 28% were male, and 70% were female. The mean age for respondents was 16 years old. Adolescents who had received the HPV vaccine were more likely to be female and to have heard of cervical cancer and Pap testing. Of the 143 adolescents who had not yet been vaccinated, only 4% believed that they were at risk of HPV infection and 52% were willing to be vaccinated. Conclusions. Surveyed adolescents demonstrated a marginal willingness to receive the HPV vaccine and a lack of awareness of personal risk for acquiring HPV.

HPV vaccination: are we initiating too late?

BACKGROUND Human papillomavirus (HPV) vaccination is recommended in early adolescence. While limited data suggest that patients frequently delay initiation of the three-dose series, age-based variability in initiation of HPV vaccination and its clinical relevance are not well described. Thus, this study aims to characterize HPV vaccination delay among adolescent and young adult females. METHODS This retrospective cohort study examined age at HPV vaccination initiation and missed opportunities for receipt of the first vaccine dose (HPV1) among 11-26 year-old females (n=22,900) receiving care at 16 urban academically-affiliated ambulatory care clinics between 2007 and 2011. Predictors of timely vaccination and post-licensure trends in age at HPV1 receipt were assessed using multivariable logistic regression and a generalized linear mixed model, respectively. Chlamydia trachomatis and Papanicolaou screening before HPV vaccination initiation, as markers of prior sexual experience and associated morbidity, were examined in a subcohort of subjects (n=15,049). RESULTS The proportion of 11-12 year-olds who initiated HPV vaccination increased over time (44.4% [2007] vs. 74.5% [2011], p<0.01). Initiation rates also improved among 13-26 year-olds. Thus, the mean age at HPV1 receipt remained unchanged between 2007 and 2011 (16.0 ± 2.7 vs. 15.9 ± 4.0 years, p=0.45). Spanish language was a positive predictor (AOR 1.62, 95% CI 1.05-2.48) of HPV vaccination initiation among 11-12 year-olds in 2011. The majority (70.8-76.4%) of unvaccinated subjects experienced missed vaccination opportunities. Of the subcohort, 36.9% underwent Chlamydia screening before HPV1 receipt (19.1% with ≥ 1 positive result). Of those with prior Papanicolaou screening (16.6%), 32.1% had ≥ 1 abnormal result. CONCLUSIONS These low-income, minority females frequently delayed initiation of HPV vaccination. Many had evidence of prior sexual experience and associated morbidity, placing them at risk of HPV-related complications. Promoting timely HPV vaccination and reducing missed vaccination opportunities are crucial.

Evaluation of household contacts of children with positive tuberculin skin tests

BACKGROUND Associate investigation, defined as screening the contacts of children with positive tuberculin skin tests (TST) and normal chest radiographs, has been recommended to improve case finding for active tuberculosis (TB). The success of this strategy has not been adequately studied in either adults or children. METHODS A 2-year prospective study was conducted wherein 187 children and adolescents with infection caused by Mycobacterium tuberculosis (positive TST and normal chest radiograph) were referred to a TB Screening Clinic. An associate investigation was performed among their 659 household contacts who were interviewed to assess risk factors for TB and screened with TSTs and with chest radiographs when appropriate. RESULTS No cases of active TB were detected, but 32% of household contacts had TSTs > or = 10 mm and were candidates for preventive therapy. Logistic regression analysis revealed that household contacts with Calmette-Guérin bacillus immunization and foreign birth were 2.26 and 3.92 times more likely (P < 0.001 and 0.002, respectively) to be tuberculin-positive. Univariate analysis of the 187 households revealed that the following risk factors present in a household member were associated with detecting a household contact with a positive TST: Calmette-Guérin bacillus immunization (P = 0.001), foreign birth (P = 0.017) and a history of having hosted foreign visitors (P = 0.032). CONCLUSION In this Hispanic immigrant population, primarily from the Dominican Republic, screening household contacts of children with positive TSTs did not identify new cases of active TB. However, this strategy did identify household contacts who were eligible for preventive therapy.

Human Papillomavirus Vaccination and Cervical Cytology Outcomes Among Urban Low-Income Minority Females

IMPORTANCE The quadrivalent human papillomavirus (HPV) vaccine was licensed for use in 9- through 26-year-old females in 2006. Postlicensure studies in Australia, Denmark, and Canada have demonstrated vaccine effectiveness against abnormal cervical cytology results. However, there are limited data describing postlicensure effectiveness in the United States, particularly among minority females at higher risk for HPV infection and cervical cancer. OBJECTIVE To examine the effect of HPV vaccination on abnormal cervical cytology results among minority females. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study conducted between January 2007 and January 2014 at 16 academically affiliated community clinics serving a low-income minority population. Included in this study was a population-based sample of 16 266 females aged 11 through 20 years as of January 1, 2007, who received care at a participating clinic on or after that date. EXPOSURE Human papillomavirus vaccination, stratified by the number of doses. MAIN OUTCOMES AND MEASURES Cervical cytology abnormality following either HPV vaccination or, if unvaccinated, the first missed opportunity for HPV vaccination after January 1, 2007. Abnormalities were defined as atypical glandular cells, atypical squamous cells of undetermined significance, atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion, low-grade squamous intraepithelial lesions, or high-grade squamous intraepithelial lesions. RESULTS There were 4127 female patients who initiated quadrivalent HPV vaccination or had their first missed HPV vaccination opportunity from 11 through 20 years of age and underwent subsequent cervical cytology screening. The patients were primarily Spanish speaking (n = 2297; 58.3%) and publicly insured (n = 3801; 92.1%). The detection rate for an abnormal cervical cytology result during the observation period was lower among vaccinated (≥1 dose) (79.1 per 1000 person-years) vs unvaccinated (125.7 per 1000 person-years) females. The risk for an abnormal cervical cytology result was lower among vaccinated vs unvaccinated females (hazard ratio [HR], 0.64; 95% CI, 0.57-0.73), particularly if the 3-dose series was completed (HR, 0.48; 95% CI, 0.41-0.56) or if the vaccine was administered from 11 through 14 years of age (≥1 dose: HR, 0.36; 95% CI, 0.16-0.79; 3 doses: HR, 0.27; 95% CI, 0.12-0.63). This protective effect remained after adjusting for demographics, clinic type, abnormal baseline cervical cytology result, and baseline Chlamydia screening (as proxy for sexual experience). CONCLUSIONS AND RELEVANCE This study demonstrated the HPV vaccine is effective in a real-world setting of high-risk patients with variable HPV vaccination patterns.

A 6-Year Experience with Pap Smears in an Urban Adolescent Practice: The Scope and Burden of Abnormalities

STUDY OBJECTIVE To determine the prevalence of cervical dysplasia and adherence to recommendations for referral/follow-up in a group of adolescent girls undergoing routine reproductive health care in a primary care setting. DESIGN Retrospective review of all screening Papanicolaou (Pap) smears performed between 12/99 and 12/05. SETTING An urban academic adolescent medicine practice in New York City. PARTICIPANTS 824 sexually active adolescent girls. MAIN OUTCOMES Cytology and cervical biopsy results and adherence to follow-up and colposcopy recommendations. RESULTS Among 824 adolescents ages 12-21 years (mean = 17) who underwent 1 to 6 screening Paps, 81% (n = 666) had normal Pap smears only and 19% (n = 158) had at least one abnormal Pap. Of the 1214 screening Pap smears reviewed, only one was suggestive of a high grade lesion, 85 (7%) revealed atypical squamous cells of undetermined significance (ASCUS), 81 (6.6%) showed low-grade squamous intraepithelial lesions (LGSIL), and the rest were normal. Fifteen percent of patients (n = 123) were referred for at least one colposcopy; only 72% (n = 88) complied. Biopsy identified 5 high-grade lesions; 3 patients required cervical Loop Electrosurgical Excision Procedures: Despite appropriate referrals and access to services, 32% of patients with ASCUS and 28% of patients with LGSIL lacked evidence of either follow-up Pap or colposcopy by the time of last review. CONCLUSIONS High-grade lesions were rare in our sample, supporting new guidelines for less colposcopy in this age group. Although many adolescents were followed within primary care, achieving appropriate follow-up for those with cervical dysplasia was challenging and often unsuccessful.

Long-Acting Reversible Contraception and Condom Use: We Need a Better Message

The age-old argument has reared its head again—does giving adolescents access to effective birth control motivate them to engage in more or riskier sex? This time the question pertains to adolescents who are choosing long-acting reversible contraception (LARC), specifically intrauterine devices and implants; are these adolescents less likely to use condoms than users of other contraceptive methods? Many health care professionals who care for adolescents believe that LARC methods are ideally suited to adolescents, given their high efficacy and ease of use. There is good reason to think that more effective contraception will help reduce unintended pregnancy. Almost half of unintended pregnancies occur in the context of contraceptive misuse, rather than nonuse, makingthelessuser-dependentLARCmethodsappealing.1 However, as more adolescents elect to use LARC and national organizations like the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists support LARC as first-line contraception for adolescents,2,3 a theoretical concern has arisen: once adolescents have intrauterine devices or contraceptive implants, will they stop using condoms? This question is the focus of the investigation by Steiner et al4 in this issue of JAMA Pediatrics. Using the well-known Youth Risk Behavior Survey data set, the authors explore the question of whether LARC users differ in their use of condoms compared with users of other contraceptive methods, namely combined hormonal methods (the birth control pill, the transdermal patch, and the intravaginal ring) and the depot medroxyprogesterone acetate injection, or “the shot.” Steiner and colleagues found that condom use is lower among LARC users than among those using oral contraceptive pills. The authors point out that these data correspond to national data, specifically the 2006-2008 National Survey of Family Growth. Despite the important conclusions of the study, this research question begs for a prospective study. To examine whether condom use is affected by initiation of LARC, it is not enough to look at cross-sectional data that suggest an association between birth control method use and condom use. It is highly likely, as the authors discuss, that LARC users differ in their condom use precisely for the same reasons that they elect to use LARC. Coitally dependent methods like condoms require an organizational and planning ability similar to that which is needed to take birth control pills effectively. Young women who struggle to remember to take a daily birth control pill may be more likely to also struggle with regular condom use, perhaps making a long-acting method more appealing to them. Using the current cross-sectional data set, we cannot tease out directionality of cause and effect. It is interesting to note that condom use among LARC users did not significantly differ from that of those who use the shot, patch, or ring. Additionally, while the authors controlled for demographic differences between the groups of contraceptive users, it is likely that LARC users, a small minority of contraceptive-using adolescents, may differ from users of moderately effective methods in significant ways that are difficult to capture. Only a randomized trial could truly answer this question. Another important consideration is whether LARC users are in fact a higher-risk group of adolescents. It is unfortunate that we do not have information about condom use practices prior to LARC initiation among female adolescents in this study. However, the authors found that participants who reported using long-acting methods had greater odds of reporting 2 or more sexual partners in the last 3 months and 4 or more lifetime partners, suggesting that these adolescents appear to be engaging in higher-risk sexual behavior and are therefore at greater risk for acquiring sexually transmitted infections (STIs). Yet, it is very likely that health care professionals are preferentially recommending LARC to these young high-risk adolescents. It would be interesting to know about the relationship context in which these adolescents were engaging in sex, to better assess their risk potential, and to have data about whether LARC users in this study were subject to a greater burden of STIs. The premise that underlies the hypothesis that teenagers who choose LARC use condoms less than their counterparts is that adolescents—and perhaps women in general—use condoms as a backup for their less effective forms of birth control, a so-called belt and suspenders approach. However, this hypothesis deserves scrutiny. We know from studies assessing condom use motivation that adolescents are motivated to use condoms when they do not trust their partner, do not know their partner well, or have previously had an STI.5,6 It would be interesting to have data from a prospective cohort that looks at shifting condom intention with initiation of LARC compared with other methods. The findings of this study support the need for better public health interventions. With nearly half of new STIs occurring among 15to 24-year-olds,7 we cannot afford to forget about condom use. However, with pregnancy failure rates for Related article page 428 Opinion

Adolescent Chlamydia Infection Treatment, Expedited Partner Therapy, and Testing for Reinfection

Chlamydia trachomatis (CT) is the most prevalent bacterial sexually transmitted infection in the United States with rates highest among 15to 24-year-olds. Because of the burden of disease, reproductive complications, and frequent lack of symptoms, the Centers for Disease Control and Prevention recommends yearly CT screening for all sexually active females and high-risk males ≤25 years old. Prompt treatment of infected individuals and all partners is recommended to prevent spread of infection and reduce reproductive complications. Ideal treatment for CT infection is direct-observed medication administration and referral for evaluation, testing, and treatment of sex partner(s). If partner(s) of the infected individual might not seek treatment, then expedited partner therapy (EPT) is recommended with either antibiotic prescriptions or partner-delivered medications. To prevent prolonged undetected infection, tests of reinfection (TOR) are recommended ideally between 3 and 6 months but can be done up to 12 months after treatment regardless of whether sexual partner(s) were treated. The time frame of retesting is important; a retest <21 days after treatment may be falsely positive due to residual nonviable organisms in the genital tract, and retests after 12 months are considered routine screening. Limited data exist regarding EPT and TOR for CT in adolescents. One report from 2005 identified gaps in care related to CT treatment, counseling, partner management, and retesting in adolescents. Our study aimed to describe the comprehensive management of adolescents infected with chlamydia, specifically with respect to timeliness of treatment, partner therapy, and retesting.

Screening for Depression in Urban Latino Adolescents

Purpose. Investigations were conducted on whether screening for adolescent depression was feasible and acceptable to patients in low-income, urban, predominantly Latino clinics. Further investigations were undertaken for provider acceptance of such screening. Methods. Adolescents aged between 13 and 20 years presenting to 3 pediatric and adolescent primary care practices affiliated with an academic medical center in New York City were screened for depressive symptoms using the Columbia Depression Scale. Providers were surveyed pre- and postimplementation of the screening regarding their attitudes and practices. Results. The vast majority (92%) of those approached accepted the screening. Twelve percent of those screened were referred for mental health treatment. Providers reported satisfaction with the screening tool and a desire to continue to use it. Screening was limited to 24% of eligible participants, and only 10% of screens were at sick visits. Conclusions. The Columbia Depression Scale seems acceptable to adolescent providers and patients in the mostly Latino study population. It may prove to be a helpful tool in evaluating adolescents presenting to primary care for depression. Further study will be required in other Spanish-speaking and minority populations. New methods will also be required to reach a greater proportion of patients, particularly those presenting for sick visits.

Cervical cytology screening among low-income, minority adolescents in New York City following the 2009 ACOG guidelines

OBJECTIVES In December 2009, the American College of Obstetricians and Gynecologists recommended that cervical cancer screening begin at age 21 for young women. In this study, we examine receipt of first lifetime Papanicolaou (Pap) test and predictors of over-screening among adolescents within a large urban ambulatory care network. METHODS We compared the proportion of first lifetime Pap test of adolescents aged 13-20years between June 2007 - November 2009 (n=7700) and December 2009-June 2012 (n=9637) using electronic health records. We employed multivariable regression models to identify demographic and health care factors associated with receiving a first lifetime Pap test at age <21years in the post-guideline period (over-screening). RESULTS The proportion of Pap tests declined from 19.3% to 4.2% (p<0.001) between the two periods. Multivariable logistic regression results showed receiving care from gynecologic/obstetric/family planning clinics compared to pediatric clinics, having more clinic encounters, and older age were associated with over-screening in the post-guideline period. CONCLUSIONS We found that guideline adherence differed by clinic type, insurance status, and health care encounters. In the quickly evolving field of cervical cancer control, it is important to monitor practice trends as they relate to shifts in population-based guidelines, especially in high-risk populations.