Krishna K. Upadhya

Effects of polycystic ovary syndrome on health-related quality of life

Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting 5–10% of women of reproductive age. The health risks associated with PCOS include infertility, diabetes, metabolic syndrome and endometrial cancer. In this article, we review the tools used to assess health-related quality of life (HRQL) and the current state of knowledge of the effects of PCOS on HRQL in adult women and adolescent girls. A significant body of evidence consistently demonstrates that PCOS has a negative impact on women’s HRQL. This impact does not necessarily correlate with clinical measures of disease severity. There is evidence that the effect on HRQL may be mediated by obesity, infertility concerns and menstrual dysfunction. Cross-cultural studies suggest that the effect of PCOS on the HRQL of an individual patient may be specific to the perception, values and culture of that patient.

Contraceptive service needs of women with young children presenting for pediatric care

OBJECTIVES The primary objective of this study is to characterize the need for contraceptive services and contraceptive method use among women with young children presenting to child health clinics. A secondary objective is to characterize the factors, including access to care and health needs, that exist in this population and to evaluate their association with contraceptive method use. STUDY DESIGN This is a cross-sectional study of women with children under age 36 months presenting to four child health practices in the Baltimore, Maryland, area. Participating women completed a survey to assess desire for pregnancy, contraceptive method use and related characteristics. RESULTS A total of 238 participants (82%) were in need of contraceptive services (fertile and not desiring pregnancy). Overall, 59 (25%) of women in need were not using a contraceptive method (unmet need) and 79 (33%) were using a highly effective method (implant or intrauterine device). Factors associated with lower odds of unmet need for contraceptive services included attendance at a routine postpartum visit and visiting a healthcare provider to discuss contraception after pregnancy. Approximately half of index pregnancies were unintended and this was the only health factor associated with greater odds of using of a highly effective contraceptive method. CONCLUSIONS Most women presenting with young children for pediatric care indicated that they were not currently trying to become pregnant and reported current methods of pregnancy prevention that ranged from none to highly effective. Women who had not sought postpregnancy contraceptive care were more likely to have unmet need for contraceptive services. IMPLICATIONS Child health clinics may be a novel site for providing contraceptive care to women with children as part of a strategy to reduce unplanned pregnancies.

Contraception for Adolescents

1. Krishna K. Upadhya, MD, MPH* 1. *Division of General Pediatrics and Adolescent Medicine, Johns Hopkins School of Medicine, Baltimore, MD. 1. Low use of highly effective contraception in the United States contributes to a teen pregnancy rate higher than other developed countries. Pediatricians can play an important role in educating adolescents and their parents about contraception. 2. Although intrauterine devices (IUDs) are the most widely used contraceptive method worldwide, use in the United States remains limited. Prompted by proven safety and superior efficacy, the American College of Obstetrics and Gynecology endorses IUDs as a first line contraceptive for all women, regardless of age and parity. 3. The American Academy of Pediatrics and the Society for Adolescent Health and Medicine both support over-the-counter access to emergency contraception (EC) for adolescents despite the fact that most pediatricians in practice do not routinely provide EC counseling. After completing this article, readers should be able to: 1. Identify, in order of effectiveness, the reversible methods of contraception that are approved by the US Food and Drug Administration (FDA) and available to adolescents in the United States. 2. Describe the 4 available methods of long-acting reversible contraceptives, including their duration of action, adverse effects, and contraindications of use. 3. Discuss the use of combined hormonal contraceptives, including effects on menstruation, absolute and relative contraindications to use, common adverse effects, and recent innovations, including progestin types and ultralow-dose pills. 4. Recognize common barriers to the use of effective contraceptives among adolescents. 5. Prescribe hormonal contraceptives and emergency contraceptives to adolescents. This afternoon you have an appointment with a 17-year-old girl who is a long-time patient. She comes to the visit with her mother and reports that she is here to find out about birth control options. She is previously healthy but has a history of dysmenorrhea and has heard …

The status of adolescent medicine: Building a global adolescent workforce

Abstract Remarkable public health achievements to reduce infant and child mortality as well as improve the health and well-being of children worldwide have successfully resulted in increased survival and a growing population of young people aged 10–24 years. Population trends indicate that the current generation of 1.8 billion young people is the largest in history. However, there is a scarcity of dedicated resources available to effectively meet the health needs of adolescents and young adults worldwide. Growing recognition of the pivotal roles young people play in the cultures, societies, and countries in which they live has spurred an expanding global movement to address the needs of this special population. Building an effective global workforce of highly-skilled adolescent health professionals who understand the unique biological, psychological, behavioral, social, and environmental factors that affect the health of adolescents is a critical step in addressing the health needs of the growing cohort of young people. In this review, we aim to: 1) define a global assessment of the health needs for adolescents around the world; 2) describe examples of current training programs and requirements in adolescent medicine; 3) identify existing gaps and barriers to develop an effective adolescent health workforce; and 4) develop a call for targeted actions to build capacity of the adolescent health workforce, broaden culturally relevant research and evidence-based intervention strategies, and reinforce existing interdisciplinary global networks of youth advocates and adolescent health professionals to maximize the opportunities for training, research, and care delivery.

Integrating Pregnancy Prevention Into an HIV Counseling and Testing Program in Pediatric Primary Care

PURPOSE Certified health educator (CHE)-based HIV counseling and testing typically focus on HIV and sexually transmitted infection (STI) prevention only. A quality improvement initiative examined integrating assessment of reproductive life plans, counseling about pregnancy prevention, and contraception referral into a CHE-based HIV testing program. METHODS Between February 2014 and January 2017, in one urban pediatric primary care clinic serving patients aged 0-25, CHEs assessed sexual history, HIV risk, short-term (i.e., the next 6-12 months) pregnancy desire, and current contraception method and satisfaction among patients aged 13-25 who had ever had vaginal sex, using a standardized questionnaire. Data were analyzed using a de-identified administrative dataset that also tracked referrals to initiate contraception and actual method initiation. RESULTS Of 1,211 patients, most (96%) reported no short-term pregnancy or partner pregnancy desire. Use of less effective or no contraception, as well as method dissatisfaction, was common. A high proportion of female patients referred to new methods opted for more effective methods (62%) and initiated these methods (76%); a high proportion of male patients opted for receipt of condoms (67%). Patients reporting short-term pregnancy desire reported higher rates of previous pregnancy and STIs. CONCLUSIONS Program findings highlight the potential benefit of integrating assessment for and counseling about pregnancy prevention in a CHE-based HIV testing program. This can more effectively address the needs of patients with concomitant risks of STI/HIV and unintended pregnancy, and link patients who do not desire pregnancy to more effective methods.

Research and statistics: case-control studies.

1. Krishna Upadhya, MD, MPH* 2. Peter Rowe, MD† 1. *Fellow in Adolescent Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md. 2. †Professor of Pediatrics, Division of General Pediatrics & Adolescent Medicine, Johns Hopkins School of Medicine, Baltimore, Md. A 16-year-old obese girl presents to your office for evaluation of headaches. On physical examination, you document a body mass index (BMI) of 40 kg/m2 and optic disk swelling. After negative results on head imaging, the patient undergoes a lumbar puncture that shows elevated opening pressure of 30 cm H 2 O. You diagnose idiopathic intracranial hypertension (IIH). You know that the patients weight is likely to be a major factor in this illness, but you have been working with her over several years to lose weight without success. To obtain the most up-to-date information on the link between IIH and weight gain, you conduct a literature search. You find a recent article that posed the question: How do BMI and rate of weight gain affect the risk for IIH? (1) This case-control study demonstrated that higher BMI is associated with greater risk for IIH. The authors also found that a 5% to 15% weight gain over 1 year is associated with increased risk for IIH among both obese and nonobese patients. You wonder if you can use this information to help motivate your patient to lose weight. Case-control studies start with a disease and compare affected patients (cases) and unaffected individuals (controls) to evaluate potential risk factors. Like cohort studies, case-control studies are observational, meaning …

Effectiveness of a Pediatric Primary Care Intervention to Increase Maternal Folate Use: Results from a Cluster Randomized Controlled Trial

Objective To assess the impact of provision of folate vitamins and a preconception health intervention on folate use among mothers bringing infants to pediatric primary care. Study design We conducted a cluster randomized trial in mothers presenting with their infants (<12 months) at 4 urban pediatric practices in the Baltimore, Maryland, metropolitan area. There were 45 clinicians randomized into an intervention group (15‐item preconception health screening and counseling and 90‐day multivitamin supply) and control group (preconception health and community resource handouts and 90‐day multivitamin supply). Participating mothers were enrolled in the study group assigned to their childs clinician. Baseline and 6‐month follow‐up interviews were performed. The outcome was daily use of folate, multivitamin, and a prenatal vitamin containing folate. Primary independent variables were time of assessment and mothers study group (intervention or control groups). Covariates investigated were mothers and childs age, race/ethnicity, education, marital status, income, insurance status, previous live births, and intention to have a pregnancy in the next 6 months. Results We enrolled 415 mothers at baseline who were majority African American and low income. Of the 415 enrolled participants, 352 (85%) completed follow‐up interviews. Among all participants, daily vitamin intake increased from baseline to 6‐month follow‐up (33.8% vs 42.6%; P = .016). After adjustment for covariates and clustered design, there was an augmented effect in the intervention vs control group (aOR, 2.04; 95% CI, 1.04‐3.98). Conclusions Offering vitamins and recommending folate intake to mothers within pediatric practice can increase use. Pediatric practice is an important contact point and context for improving maternal folate use. Trial Registration ClinicalTrials.gov NCT02049554.

A System-Level Approach to Improve HIV Screening in an Urban Pediatric Primary Care Setting

Rapid HIV screening in pediatric primary care can be used to improve the screening rate and result receipt in youth, one of the highest-risk populations. BACKGROUND AND OBJECTIVES: Less than 50% of youth living with HIV know their status. The Centers for Disease Control and Prevention and the United States Preventive Services Task Force recommend universal HIV screening in adolescence. Pediatric primary care settings are still lacking in testing youth who are at risk for HIV. Our objective was to determine whether implementing rapid HIV screening improved HIV screening rates and result receipt in 13- to 25-year-old pediatric primary patients. METHODS: From March 2014 to June 2015, a 4-cycle plan-do-study-act quality improvement model was used. A total of 4433 patients aged 13 to 25 years were eligible for HIV screening on the basis of Centers for Disease Control and Prevention criteria. Logistic regression with random effects was used to estimate the odds of HIV screening and screening with a rapid test compared with each previous cycle. Statistical process control charts using standard interpretation rules assessed the effect of patients receiving rapid HIV screening. RESULTS: Baseline HIV screening rate was 29.6%; it increased to 82.7% in cycle 4. The odds of HIV screening increased 31% between cycle 1 and baseline (odds ratio 1.31 [95% confidence interval: 1.01–1.69]) to a 1272% increase between cycle 4 and baseline (odds ratio 12.72 [95% confidence interval: 10.45–15.48]), with most (90.4%) via rapid screening. Rapid screening yielded higher same-day result receipt . Five patients were identified with HIV and immediately linked to on-site care. CONCLUSIONS: Rapid HIV screening and system-level modifications significantly increased screening rates and result receipt, revealing this to be an effective method to deliver HIV services to youth.

Improving LARC Access for Urban Adolescents and Young Adults in the Pediatric Primary Care Setting

The objective of this quality improvement study was to assess the feasibility, acceptability, and impact of integrating long-acting reversible contraceptive (LARC) delivery services into an academic pediatric primary care practice. Adolescent medicine providers in Baltimore, Maryland, were trained in LARC placement with gynecology providers integrated to offer onsite LARC placement and procedural support. Referrals, appointments, and contraceptive method choice/receipt were tabulated. Of 212 individuals referred for LARC consultations, 104 attended appointments. LARC placement at the initial referral increased from year 1 (N = 1) to year 2 (N = 42; P < .01). Adolescent medicine providers placed more LARCs in year 2 (N = 34) than year 1 (N = 0; P < .01). Patients aged 18 to 24 years were less likely to have a LARC placed than those aged 13 to 17 years (unadjusted odds ratio = 0.47 [0.26-0.86]). In conclusion, provider training and service integration of LARC services within a pediatric practice is feasible, acceptable, and increases LARC access and placement.

Why Didn’t You Text Me? Poststudy Trends From the DepoText Trial

Objective. To evaluate the longitudinal impact of a 9-month text message intervention on participant adherence beyond the intervention to highly effective contraceptive methods among urban adolescent and young adult women enrolled in the DepoText randomized control trial (RCT). Study Design. Retrospective longitudinal cohort study of long-term follow-up data from the DepoText RCT. Sixty-seven female participants (aged 13-21 years) using depot medroxyprogesterone acetate (DMPA) were recruited from an urban academic adolescent practice in Baltimore, Maryland. The principal outcome measured was a comparison of contraceptive method choice between the control and intervention groups during the 20 months postintervention. Results. Intervention participants were 3.65 times more likely to continue using DMPA or a more efficacious method at the 20-month postintervention evaluation (odds ratio 3.65, 95% CI 1.26-10.08; P = .015). Conclusion. Participation in the DepoText trial was associated with continued use of DMPA or a more effective contraceptive method almost 20 months after the intervention exposure ended.