Lawrence S. Neinstein

Detection of Chlamydia trachomatis: A study of the direct immunofluorescence technique and a review of diagnostic limitations

Because of the high prevalence of Chlamydia trachomatis in adolescent females and the high cost of chlamydia cultures, we evaluated the use of the direct fluorescein conjugated monoclonal antibody test (DFA) in diagnosing C. trachomatis in adolescent females. Chlamydia trachomatis was found in 37 (20.1%) of 184 cultures. The sensitivity of the direct smear as compared with the culture was 89% and the specificity was 99%. The results of recent studies of the DFA and chlamydiazyme tests are reviewed as well as the problems in comparing techniques.

Menstrual dysfunction in cystic fibrosis

Several factors potentially involved in the menstrual dysfunction of some females with cystic fibrosis were analyzed by a retrospective chart review. The mean age of menarche for the cystic fibrosis patients was 14.4 years, compared to 12.9 years for American females (p less than 0.001). At last evaluation, comparison of the mean figures for amenorrheic patients and for menarchal cystic fibrosis patients reveals statistically significant differences in the age of diagnosis, weight-height index, weight, height, percent of body fat, weight percentile, and height percentile. The highest correlative was weight (r = 0.59). Of our cystic fibrosis patients who were menarchal, 95% had a weight greater than 82 pounds, whereas 75% of those who were amenorrheic weighed less than 82 pounds. Menstrual irregularities, sexual activity, and contraceptive use among these patients also is discussed.

Asymptomatic Chlamydia trachomatis infections in teenage males

This study examined the prevalence of Chlamydia trachomatis infections of the urethra in asymptomatic teenage males in a juvenile detention setting. Gonorrhea cultures, chlamydia smears using the direct immunofluorescent antibody (DFA) technique, and 15-20 ml of a first-catch urine (FCU) sample were obtained. Of the 227 adolescent males screened, 205 had experienced sexual intercourse. Twenty-seven (13.2%) of the sexually active adolescents had positive DFA smears for C. trachomatis. Three (1.5%) had positive Neisseria gonorrhoeae cultures. A urine leukocyte count of greater than 10 per high-power field gave a 91% specificity but only a 26% sensitivity for a positive DFA. The high prevalence of chlamydia in this population and the relative low cost of the DFA screen for chlamydia make this a useful procedure for discovering unsuspected disease, particularly in a high-risk population. The FCU screen for leukocytes was of limited value in identifying asymptomatic infection.

Young adults remain worse off than adolescents.

On a broad range of indicators pertaining to risk taking and access to care, young adults fare worse than younger adolescents or older adults. Vulnerable groups, such as those facing chronic illness and those with unstable living arrangements, fare especially poorly as they transition to adulthood. Fortunately, a confluence of factors, particularly the changing nature of the transition to adulthood in modern society, has led to renewed interest in this critical period of the life cycle. Health science research is increasingly focused on issues faced by young adults, and public health policies designed specifically to address the health and well-being of young adults--notably the Patient Protection and Affordable Care Act in the United States--are now being implemented. Successful efforts at improving the health and well-being of adolescents should be mirrored in efforts to support young adults. A new report based on a broad range of United States national datasets lays out the challenges that must be addressed in these efforts.

Utilization of electronic communication (E-mail) with patients at university and college health centers

PURPOSE To examine the utilization and potential uses and problems of electronic communication with patients. METHODS University and college health centers were surveyed about the type of utilization and policies of electronic communication with patients. The survey group consisted of 99 health centers predominantly serving students representing small-, medium-, and large-sized public and private colleges and universities. Eighty-nine health centers completed the survey. RESULTS Of the responding health centers, 63.6% use some form of electronic communication with patients. Twenty-seven percent of the health centers give out some form of medical advice via E-mail or the Internet; 14.7% give out some laboratory results via E-mail; 3.4% make appointments via E-mail; and 63.6% give out administrative advice by E-mail. While there was consistent concern expressed about confidentiality and security, only five health centers had a policy about electronic communication. Uses were most common in nonclinical areas but did include health education, Web sites, medical advice, laboratory results, appointment-making or confirmation, and contacting hard-to-reach patients including those studying abroad. CONCLUSIONS While electronic communication with patients was common, provision of direct medical advice was less common. Issues receiving little attention include determining the types of electronic communication that is acceptable to staff and students, determining the level of security of their current information system, educating staff about confidentiality and security issues, and establishing a comprehensive policy regarding electronic communication with patients.

Menstrual Problems in Adolescents

Menarche is a significant event in the course of puberty. Although the age of menarche varies among adolescents, it occurs in most adolescents at an SMR of 4. With the onset of ovulatory cycles, local prostaglandins are released, often causing dysmenorrhea. This usually responds to PSIs. Abnormal uterine bleeding usually is the result of anovulatory cycles. However, complications of pregnancy, systemic illnesses, and local pathology must be considered. Significant bleeding usually responds to hormonal therapy. Amenorrhea may result from abnormalities affecting the hypothalamus, pituitary, or ovaries. The evaluation should be done in a logical, orderly fashion. In addition, pregnancy must always be considered first in the differential diagnosis.

Weight gain in adolescent and young adult oral contraceptive users

This study analyzed weight gain as a side effect of oral contraceptive use in teens and young adults. A retrospective chart review from 1978 to 1983 was conducted at two family planning clinics. Weight gain over 12 months was compared between females starting oral contraceptive pills and a control group using an IUD or a barrier method. One-hundred thirty-eight charts were included in the oral contraceptive group and 35 in the control group. There was no significant difference between the oral contraceptive group and control group in initial weight and weight after one year of use. Distribution of weight was also similar. There were no significant blood pressure changes. In the oral contraceptive group only five (3.7%) users listed weight gain as a side effect. The results suggest that for many young women who use oral contraceptive pills there is no greater risk of weight gain than for other sexually active young females.

Comparison of cytobrush with cotton swab for endocervical cytologic sampling.

This study was designed to compare the Ayres spatula/cytobrush combination with the Ayres spatula/cotton swab combination as to the quality of the Pap smear in adolescent females. We evaluated 111 Pap smears, of which 60 (54%) were from cotton applicators/spatula combination and 51 (46%) were from cytobrush/spatula combination. Seventy-nine percent of the specimens with the cytobrush showed good cellular yield, compared to only 50% of the specimens obtained with a cotton applicator (p less than 0.05). The adequate specimen rate for endocervical cell content was 68% for the cytobrush versus 56% for the cotton applicator (p = not significant). The adequacy rate was less for trainees than for attending physicians, but the difference was less marked for those using the cytobrush. The cytobrush does have some impact on improving adequacy rates for Pap smears. However, this study was unable to determine whether this is a cost-effective addition to the Ayres spatula or cotton swab. The problem of inadequate Pap smears deserves more scrutiny among various health care systems.

Contraceptive use in the chronically ill adolescent female. part II.

This article examines contraception in adolescents with hematologic, oncologic, dermatologic, and psychiatric disorders, connective tissue diseases, and renal disease and transplants. Teens with iron-deficiency anemia or heavy menstrual flow who need contraception could benefit from oral contraceptives. The IUD is contraindicated for these teens. The IUD is also contraindicated in females with hemorrhagic disease, and hormonal contraceptives are a more appropriate choice for these females. Teens with sickle cell hemoglobinpathies should not use the IUD. Safe use of oral contraceptives (OCs) is questionnable for these teens. The best choice would be barrier methods. Concerns regarding contraception in teens with tumors are mainly 2-fold: effects of pregnancy or contraception on the tumor, and effects of the tumor or tumor therapy on pregnancy and fertility. Therapy including drugs and radiation can have profound effects on the fetus and future fertility. There seems to be no indication that pregnancy has adverse effects on nonhormonal-dependent tumors common in young adults. Malignant melanoma has a strong positive relationship with the use of OCs. OCs have been reported to be helpful in some chronic skin disorders. OCs may not be appropriate for teens who are taking antidepressants or who have a history of depression, although there are contradictory reports in the literature on the effect of the pill on depression. It is helpful for contraceptive services for mentally ill women to be provided by specially trained individuals who are able to obtain informed consent, while taking into account the specific needs of the psychiatrically impaired individual. There are special concerns in prescribing contraception to the mentally retarded teen. Combinations OCs should probably be avoided in adolescents with systemic lupus erythematosus. Because teens with severe chronic renal failure or those on hemodialysis are usually infertile, contraception is less of an issue than for other teens. A barrier method woudl be the msot appropriate method for such teens if they need contraception.

A review of Society for Adolescent Medicine abstracts and Journal of Adolescent Health Care articles

Adolescent medicine research has dramatically increased over the past 20 years. The object of this study was to assess the status of design in adolescent health care research. All abstracts of presentations at the 1978-1985 Society for Adolescent Medicine (SAM) Meetings are included as well as all articles from the Journal of Adolescent Health Care (JAHC) from 1980 through September of 1985. The abstracts were analyzed for basic design, subject, sample size, study site, number of authors, and type of statistical analysis. A descriptive design comprised 32.8% of the SAM abstracts and 62.9% of the JAHC articles. An observational design comprised 57.8% of the SAM abstracts and 35.5% of the JAHC articles. An experimental design comprised 9.3% of the SAM abstracts and 1.6% of the JAHC articles. Of the 203 abstracts, 46% involved medical and 45.6% psychosocial topics. The JAHC articles were also fairly equally divided. Descriptive studies have decreased from 1978 to 1985 whereas observational studies have increased. The medium sample size of SAM abstracts increased from 1978 (83) to 1985 (100). Statistical methods were only analyzed for JAHC articles. Sixty-one percent used either no methods or used descriptive statistics only. The major statistical tests used were contingency tables, t-tests, analyses of variance, and Pearson correlations. Adolescent medicine research from these two sources usually involves descriptive and observational designs. The few clinical trials conducted involved small sample sizes. An increase in experimental and collaborative projects is needed.