Michael I. Cohen

Great transitions preparing adolescents for a new century: A commentary on the health component of the concluding report of the Carnegie Council on adolescent development.

Carnegie Corporation of New York is a philanthropic foundation created by Andrew Carnegie in 1911 to promote the advancement and diffusion of knowledge and understanding. In June 1986 it established the Carnegie Council on Adolescent Development to place the challenges of the adolescent years higher on the nations agenda. An operating program of the foundation the Council elected to build on the work of many organizations and individuals to stimulate sustained public attention to the risks and opportunities of the adolescent years and generate public and private support for measures that would facilitate the critical transition to adulthood. Composed of national leaders in education law science health religion business the media youth-serving agencies and government the Council worked within the best tradition of multidisciplinary and interprofessional cooperation. Through task forces and working groups meetings and seminars commissioned reports sponsored studies and the support for publication of a half-dozen major books as well as other activities the Council sought to identify authoritative information about the nature and scope of adolescent problems. It stimulated public discussion that resulted in well-informed action to foster constructive roles for families schools health agencies community organizations and the media in developing competent healthy adolescents. (excerpt)

Special considerations for the health care of adolescents with chronic illnesses.

While issues of independence, sexuality, and identity are important for all adolescents, they become of particular concern for chronically ill teenagers because of the interaction of rapid developmental change in these areas with the stresses of chronic illness. Unlike adults with chronic diseases who often need to be rehabilitated so that they can function independently again and resume their sexual lives, adolescents need to be habilitated; they have no prior experience to draw on. Chronically ill children can be sheltered and protected from many stresses by their families, but as they move into the adolescent years, they must be allowed to gradually take over responsibility for their actions. This takes practice, and some mistakes are inevitable. In addition, teenagers with chronic illnesses deserve assistance to help them maximize their strengths and develop a positive self-identity. Health professionals have a significant role to play in encouraging independence, preventing adverse consequences of sexual behavior, and enhancing the self-image of their chronically ill adolescent patients.

The History of Adolescent Medicine

The field of adolescent medicine is unique as a subspecialty in that the practice of providing care to teenagers has always been viewed historically as a responsibility of generalists. Scientific advances in subspecialty fields such as endocrinology, gynecology, gastroenterology, infectious disease, and sports medicine were incorporated with considerable success into the general practices of not only pediatricians but also internists and family practitioners. However, societal changes in the past century began to shape the way health professionals thought about adolescents and their families and significantly influenced the practice of providing health care to adolescents. The most notable change, however, was the shift from the traditional role of providing anticipatory guidance to parents toward a reduction of risk-taking behaviors aimed directly at the adolescent. The subspecialty of adolescent medicine thus emerged as an amalgam of researchers, clinicians, and educators, who, through a variety of settings, hoped to advance science, moderate public and social policy, improve health care, and stimulate health promotion to this special population of patients.

The drug-using adolescent as a pediatric patient

The adolescent who uses drugs for pleasure or social reasons differs from the adult in the type of drug used, in the route of administration, and in the resulting medical complications. A group of 1,429 ambulatory and hospitalized adolescent patients, selected in part because of suspected delinquency, used heroin more often than other drugs. Hepatitis was the most frequent complication. Other complications of drug use included secondary amenorrhea, renal failure, eosinophilia, glycosuria, elevated serum alkaline phosphatase levels, and false positive serologic tests.

Cervical cytology: The need for routine screeningin the sexually active adolescent

Pelvic examinations, including a Papanicolaou smear of the uterine cervix, were performed on 403 asymptomatic, sexually active adolescent girls aged from 12 to 16 years who were in a youth detention center in New York City. The smears were negative for precancerous abnormalities in 389 girls, but 168 of these had evidence of inflammation or nonspecific atypia. In the remaining 14 smears there was cytologic evidence of early precancerous changes (low-grade cervical intraepithelial neoplasia). The prevalence rate for early neoplastic changes was 35/1,000, far higher than previously reported. Further evaluation of three of these girls, by colposcopy and biopsy, revealed precancerous epithelial abnormalities of varying degrees of severity in two of them. Since all patients screened were sexually active and were asyptomatic, no clinical feature distinguished the 389 with negative cytology from the 14 with intraepithelial neoplasia. Five of the patients with precancerous cellular abnormalities had histories of sexual activity of less than two years. The data suggest that cervical cytologic screening should be incorporated into the routine examination of sexually active female adolescents.

Asymptomatic gonorrhea: Prevalence in apopulation of urban adolescents

During a 12-month period, 2,672 sexually active youths, 12 to 16 years of age, had genital bacteriologic cultures for Neisseria gonorrhoeae. Anterior urethral cultures were obtained from 2,098 males of whom 2,064 had no symptoms or signs of genitourinary disease. Forty cultures (1.9%) were positive for gonorrhea. Of 574 females, 374 were asymptomatic and 26 (7.0%) had positive gonorrhea cultures from the cervix. Since adolescent boys are more likely to be sexual adventurers, the 1.9% carrier rate represents an important reservoir of gonorrhea and equal in importance to that found in the asymptomatic adolescent girl.

25-hydroxycholecalciferol in the management of rickets associated with extrahepatic biliary atresia

In children with extrahepatic biliary atresia, impaired hydroxylation and defective intestinal absorption of cholecalciferol may lead to a deficiency of vitamin D and rickets. The data presented herein demonstrate that in such patients serum levels of vitamin D measured as 25-hydroxycalciferol are reduced. A moderate therapeutic oral dose of 25-hydroxycholecalciferol, by circumventing the hepatic conversion of cholecalciferol to 25-hydroxycholecalciferol, will replete vitamin D stores and maintain the serum concentration of 25-hydroxycalciferol required to prevent or heal rickets in these patients.

Liver disease in the drug-using adolescent

Evaluation of 7,272 presumably well adolescent users of heroin, sedatives and airplane glue revealed abnormalities in liver function in 37 per cent. Elevation of the concentration of serum glutamic pyruvic transaminase was the most common abnormality, while elevation of serum bilirubin levels was recorded in less than 10 per cent. These abnormalities were prevalent in the patients who used heroin and sedatives. Inhalation of airplane glue was not associated with abnormalities in liver function tests. The substances commontly abused by our patients did not appear toxic when tested in an in vitro system designed to evaluate acute hepatotoxicity. The long-term prognosis of chronic persistent hepatitis in teen-agers who abuse drugs is still unknown.

The use of medium-chain triglycerides in the management of biliary atresia

This study demonstrates reduction in fecal fat losses, improvement in bowel patterns,or enhanced growth in 11 children with biliary atresia who were offered medium-chain triglyceride (MCT) diets. In 3 children the start of the MCT diet allowed for catch-up growth, and initiation of this formula during very early infancy in 3 other patients permitted a normal growth pattern. Careful clinical and laboratory appraisal of these patients failed to demonstrate any untoward effects.

Gamma Glutamyl Transpeptidase : Measurement and Development in Guinea Pig Small Intestine

Extract: A modification of a previous method for the assay of γ glutamyl transpeptidase (GGTP) was developed. Substrate solubility difficulties alluded to by other investigators were avoided by employing heating and solubilization of the chromogenic substrate γ glutamyl-β-naphthylamide in a medium of carbonate 0.05 M and Tris buffer 0.1 M at pH 9.5. The kinetics and conditions for such an assay are described. Whole intestinal homogenates of adult male guinea pigs were used as the source of the enzyme.The developmental pattern of this enzyme was determined in fetuses at 55 and 63 days of gestation and at varying times from 1 to 90 days of age. A total of 69 animals was assayed. The general pattern was that of high specific activity during prenatal life, with a rapid decline during the neonatal period (3–24 days of age) and a slight increase after 55 days of age.Other guinea pig organs were studied. Liver and kidney were found to contain enzyme activity greater than that of the intestine. Subcellular fractionation of intestinal mucosa using ultracentrifugation revealed a twenty-fold enrichment of activity in jejunal brush border membrane, compared with whole jejunal homogenates when expressed as specific enzyme activity per mg of protein. The stability characteristics of GGTP disclosed no loss of specific activity when stored at −28° for 50 days.This simple enzyme assay, stability of the enzyme when frozen, subcellular distribution in the intestinal brush border membrane, and an unusual developmental pattern made this enzyme a useful adjunct to the study of intestinal protein metabolism.Speculation: The unique ability of GGTP to hydrolyze γ glutamic acid-peptide bonds and the location of the enzyme in the intestinal brush border suggest a role for this enzyme in the metabolism of an unusual group of physiologically important peptides such as glutathione, folic acid, and gluten-gliadin. The significance of these γ-bonded compounds may now be approached in order to investigate the role of this enzyme in gluten enteropathy and related disorders.