Unusual Cause of Pediatric Vaginal Bleeding: Infantile Capillary Hemangioma of the Cervix.

BACKGROUND: The differential diagnosis for pediatric prepubertal vaginal bleeding is wide. Rare etiologies include vascular malformations and tumors, such as infantile hemangiomas (IHs), which validate the usefulness of exam under anesthesia, vaginoscopy, and tissue diagnosis. CASE: We report a case of an IH in a 6-year-old girl causing vaginal bleeding requiring transfusion. Vaginoscopy revealed a cervical IH of less than 1 cm. Expectant management and oral propranolol were successful management options. SUMMARY AND CONCLUSION: Rare, even small soft tissue tumors such as IH can lead to impressive blood loss via vaginal bleeding. Accurate tissue diagnosis and a multidisciplinary approach are essential to planning safe, effective treatment, and follow-up.

Exposure factors of Victoria's active motorcycle fleet related to serious injury crash risk.

OBJECTIVE: The purpose of this study was to describe the nature and extent of current powered 2-wheeler (PTW) risk exposures in order to support future efforts to improve safety for this mode of transport. METHODS: A cross-sectional analysis of the control arm of a population-based case-control study was conducted. The control sample was selected from 204 sites on public roads within 150 km of the city of Melbourne that were locations of recent serious injury motorcycle crashes. Traffic observations and measurements at each site were sampled for a mean of 2 h on the same type of day (weekday, Saturday, or Sunday) and within 1 h of the crash time. Photographs of passing riders during this observation period recorded data relating to characteristics of PTWs, age of riders, travel speed of PTWs and all vehicles, time gaps between vehicles, visibility, and protective clothing use. RESULTS: Motorcycles and scooters represented 0.6% of all traffic (compared with 4% of all vehicle registrations). Riders were significantly more likely to have larger time gaps in front and behind when compared to other vehicles. The average travel speed of motorcycles was not significantly different than the traffic, but a significantly greater proportion were exceeding the speed limit when compared to other vehicles (6 vs. 3%, respectively). The age of registered owners of passing motorcycles was 42 years. Over half of riders were wearing dark clothing with no fluorescent or reflective surfaces. One third of motorcyclists had maximum coverage of motorcycle-specific protective clothing. CONCLUSIONS: A very low prevalence of motorcyclists combined with relatively higher rates of larger time gaps to other vehicles around motorcycles may help explain their overrepresentation in injury crashes where another vehicle fails to give way. An increased risk of injury in the event of a crash exists for a small but greater proportion of motorcyclists (compared to other vehicle types) who were exceeding the speed limit. An apparent shift toward older age of the active rider population may be reducing injury crash risk relative to exposure time. There is significant scope to improve the physical conspicuity of motorcyclists and the frequency of motorcycle specific protective clothing use. These results can be used to inform policy development and monitor progress of current and future road safety initiatives.

Physical abuse in pregnancy.

Screening interviews to determine the extent of physical abuse were conducted for 742 women seen in the University of Virginia obstetric clinics. Eighty-one women (10.9%) reported that they had experienced abuse at some point in the past. These women were more likely to be divorced or separated, indigent, and less educated than were the non-abused control patients. They were more likely to have had emotional problems, and 20% had attempted suicide. Twenty-nine of the 81 women reported abuse during the current pregnancy, with 21% reporting increased abuse and 36% noting decreased abuse during pregnancy. Women living with an abusive partner did not experience a greater frequency of adverse pregnancy outcomes than did those who had left abusive relationships. An awareness of the extent of the problem and direct questioning will result in an increased identification of women who are at risk for physical abuse during pregnancy.

Genital human papillomavirus infection in adolescents.

Genital HPV infections are much more prevalent than previously believed. The most common clinical manifestation of HPV--the subclinical papillomavirus infection, or SPI--is missed on routine examination. No single diagnostic test is adequate in the assessment of HPV infections, and the more recent studies involving newer nucleic acid technologies have brought about a better understanding of the behavior of HPV. There are different oncogenic potentials regarding specific HPV DNA types. Other possible cofactors include age at diagnosis, method of contraception, and use of tobacco.

Bulimia, anorexia nervosa, and diabetes. Deadly combinations.

Bulimia, anorexia nervosa, and diabetes often coexist, and eating disorders among diabetics frequently go unrecognized. This combination of conditions can have life-threatening effects. Consequently, diagnosis and the medical and psychological management of these patients is of critical importance. The authors outline the complex interactions among the biologic, psychological, and social factors involved in these disorders.

Disseminated herpes simplex in pregnancy: two cases and a review.

Documented disseminated infection with herpes simplex virus has been reported only five times in pregnancy. All cases have been severe and demonstrated common clinical features, including hepatitis and adenopathy. These reports are reviewed and two new cases added. Dissemination is undoubtedly more common, and commonly less dramatic in presentation then previously suspected. Hepatocellular dysfunction and generalized adenopathy should be clues to dissemination. Dissemination has occurred only in the second half of pregnancy, and even with infected amniotic fluid, has not always resulted in an infected infant. Transplacental maternal IGG has been documented, but is not protective, though newer antiviral drugs do show therapeutic potential. The clinician should be aware of the possibility of dissemination in any patient with oral or genital herpes and generalized signs or symptoms of disease.

Compliance and oral contraceptives: a review.

Compliance difficulties are more common among oral contraceptive (OC) users than generally appreciated by clinicians, in part because unintended pregnancy is a relatively infrequent consequence and in part because more common manifestations such as spotting and bleeding may not be recognized as resulting from poor compliance. While improving compliance is a shared responsibility of patients, clinicians, and manufacturers, the clinician is the focal point for these efforts. Counseling must be individualized, which requires knowledge of factors that predict compliance and an understanding of the patient's decision-making process as it relates to medications. Most OC compliance research has focused on adolescents, where predictors of poor compliance include multiple sex partners, low evaluation of personal health, degree of concern about pregnancy, and previous abortion. Good compliance has been linked with patient satisfaction with the clinician, the absence of certain side effects, establishing a regular daily routine to take OCs, and reading information distributed with OC packaging.

PIP: The findings of decades of research on user compliance of drug treatment regimens can be reduced to a simple statement that a third of users always comply, a third never complies, and a third sometimes complies. The efficacy of oral contraceptives (OC), however, relies on compliance even though poor compliance has no immediate or uniform consequences. Research on OC compliance has focused on adolescents because of their high pregnancy rates and their high reliance on OCs. Young women frequently use OCs in a sporadic fashion. While most adolescents are as compliant as older women, only 26% of those aged 14 and younger take their OC daily as compared to 40% of all other age groups. Attempts have been made to identify factors predicting noncompliance using 1) the individualistic model, which measures a number of factors using statistical techniques; 2) the health belief model which postulates that health-seeking behavior depends upon perception of health risk, and 3) the patient-provider model which highlights the importance of communication techniques. Factors which have been found to influence OC use are the occurrence of side effects, the routine followed, and failure to read and/or understand the packaging information. Little is known about the influence of patient-provider interactions, and only a few strategies to improve compliance have been studied. To improve compliance, health care providers should properly counsel women on their choice of method, side effects, OC misinformation and beneficial effects, correct use, missed pill instructions, and how to get additional information. Proper follow-up techniques should also be used. OC users can improve compliance by following a regular routine, carefully reading packaging information, knowing what to do if an OC is missed, and identifying a back-up method. Manufacturers should encourage research into compliance predictors and factors, incorporate findings into tools to help clinicians identify those at risk, use packaging that encourages compliance, and develop standardized and comprehensible written materials.

Experience with side effects and health risks associated with Norplant implant use in adolescents.

Levonorgestrel implants (Norplant) have been recommended as a contraceptive method for teenage women. Our experience suggests that the use of Norplant implants in adolescents is associated with bleeding irregularities and modest weight gain. There is no effect on condom use or STD acquisition. Despite the bleeding irregularities, we documented high continuation rates, suggesting that with appropriate pre-insertion counseling, Norplant implants can be a successful contraceptive method for adolescent women.

PIP: An analysis of the experiences of 72 US adolescents (mean age, 15.5 years) suggests that Norplant implants are an appropriate contraceptive method for this population. All study participants had the implants inserted at a hospital-based adolescent clinic at least 1 year before chart review. The continuation rate was 97% at 12 months and 86% at 24 months. At insertion, 60 adolescents (83%) reported regular menstrual periods. At the various follow-up intervals (e.g., 3, 6, and 12 months), 12-18% had regular periods, 12-16% were amenorrheic, and the remainder had bleeding that was irregular in length and/or interval. Mean weight gains of 3, 4.5, and 5.8 pounds were recorded at 3, 6, and 12 months, respectively; however, there was no consistent trend and a substantial number of young women lost weight during the study period. Finally, there was no clear trend of increase or decrease after Norplant insertion in either condom use or rates of infection with sexually transmitted diseases (STDs). Pre-insertion counseling for adolescent Norplant acceptors should include preparation for menstrual irregularities and encouragement of condom use to prevent STD acquisition.

Contraceptive use and attitudes among U.S. women.

PIP: More than half of the 6.3 million pregnancies which occur annually in the US are unintended. Approximately 50% of the unintended pregnancies which occurred in 1987 were among women not using birth control, while the other 50% occurred among women who were using some form of birth control when they became pregnant and most likely suffered method- or user-related contraceptive failure. The incidence and outcomes of unintended pregnancies vary with women's age. Oral contraceptives are the most popular of reversible birth control methods among US women, with nearly 30% of American couples choosing the pill as their method of reversible contraception. 25% chose tubal sterilization and 11% vasectomy. A 1992 survey found 25% of contraceptive users to use condoms, 8% withdrawal, and 1% the subdermal hormonal implant. As for method satisfaction, 94% of OC users are content with their method compared to only 17% and 57% who are satisfied using rhythm and withdrawal, respectively. The following factors affect women's choice of a contraceptive method: childbearing plans and age, women's perceptions of birth control methods, past experience with contraception, physician's influence, religious factors, education, access and cost factors, and health concerns. Future trends in contraception will likely be shaped by the changing demographics of the US population and increased awareness of sexually transmitted diseases along with the continuation of the AIDS pandemic.^ieng

Self-reported health concerns and sexual behaviors in adolescents with cervical dysplasia. A pilot study.

A group of 46 women attending an adolescent dysplasia clinic were surveyed regarding the reported impact of cervical dysplasia on sexual beliefs and behaviors. The adolescents reported being concerned about their future health and having changed their sexual practices. There were no clear relationships between demographic variables or sexual attitudes and changes. The adolescents' self-reports of their behavior were not consistent; those adolescents who reported safer sex practices did not have lower rates of sexually transmitted diseases postbiopsy. The results of this study indicate the important but complex impact of sexually transmitted disease on adolescents and suggests that this impact on adolescents may be different from that on adults.

Medical students' gynecologic examination skills. Evaluation by gynecology teaching associates.

In the past it was assumed that medical students would be able to perform an adequate pelvic examination by the end of the third-year clinical clerkship. At the University of Virginia, students completing the clinical clerkship were evaluated by trained gynecology teaching associates (GTAs), acting as patients and chaperones, who systematically evaluated students' examination and interpersonal skills using both an objective scale including 86 specific items and two 12-point subjective rating scales. Interrater reliability was demonstrated, as was the correlation between the subjective scores and objective ratings. Thirty-two percent of the students were evaluated as having either inadequate or marginal examination skills, and 29% were rated as having interpersonal skills that fell into the same unsatisfactory category. GTAs can be used as evaluators of skills in a competency-based clerkship.

Complications of cervical cryotherapy in adolescents.

Cervical dysplasia and human papillomavirus (HPV) infections in sexually active adolescents appear to be increasing. Cervical cryotherapy offers the advantages of inexpensive outpatient therapy that is well tolerated without anesthesia. Previous series have focused on women beyond adolescence and have concluded that the risks and complications are rare. Sixty-seven adolescents underwent cervical cryotherapy for cervical intraepithelial neoplasia (CIN) or HPV infection. Pelvic inflammatory disease developed in 9% within one month of treatment. Two patients developed cervical stenosis and hematometra. Cervical cultures performed prior to cryotherapy were documented to be negative, but the interval from negative cultures to treatment exceeded four weeks in 54% of the patients because of problems with patient compliance with appointments. The risk of infectious complication in our adolescent population prompted a recommendation for aggressive preventive measures, including documentation of recent negative cultures for Neisseria gonorrhoeae and Chlamydia. The use of prophylactic antibiotics should be investigated for adolescents undergoing cervical cryotherapy.

Adolescent girls' understanding of Papanicolaou smear results.

STUDY OBJECTIVE: Human papillomavirus (HPV) urogenital infections are common in sexually active adolescents. Previous research has indicated that adolescent girls do not reliably report histories of HPV infection. This study examined whether asking an adolescent girl if she had ever had an abnormal Papanicolaou (PAP) smear was a good screening question for evidence of HPV urogenital infection. DESIGN: The responses to the question about abnormal PAP smears, were compared with their charts for documented abnormal PAP smear, HPV infection, and sexually transmitted infection. SETTING: An urban, hospital-based adolescent clinic. PARTICIPANTS: Fifty adolescent girls (mean age, 14.8 years). MAIN OUTCOME MEASURES: Degree of agreement (kappa statistic). RESULTS: Using a kappa statistic, reported history of an abnormal PAP smear had "fair" agreement with documented dysplasia on PAP smear and "moderate" agreement with documented HPV infection (i.e., either condyloma on PAP smear or genital warts noted on examination). This reported history of an abnormal PAP smear agreed better with documented HPV infection than with documented dysplasia on PAP smear. CONCLUSIONS: There appears to be considerable confusion among adolescent girls regarding their PAP smear results. Care providers need to be sensitive to this when they are collecting historical information and when they are diagnosing HPV infection or an abnormal PAP smear.

Adolescents' knowledge of human papillomavirus and cervical dysplasia.

STUDY OBJECTIVE: This study examined adolescents' knowledge of human papillomavirus (HPV) and cervical dysplasia (CD). Factors associated with knowledge and self-reported change in health-related behaviors were identified. DESIGN: Interviews were conducted at an average of 2.5 years following the diagnosis of HPV/CD. Medical charts were reviewed. SETTING: The study was conducted at a university-based adolescent dysplasia clinic. PARTICIPANTS: Fifty females, ages 15-23 participated in the study: 88% African-American, 12% Caucasian. RESULTS: On average, participants responded correctly to 86% of the questions regarding HPV/CD. However, the following key points were routinely missed: 52% did not know cigarette smoking increased the risk for cervical cancer; 42% believed that HPV/CD was always symptomatic; and 22% did not know condoms decreased the transmission of HPV. According to participants, their health care provider explained the diagnosis and treatment of HPV/CD using words they understood "some" or "most of the time." Higher academic skills significantly correlated with greater knowledge of HPV/CD. Forty-one percent of participants with a smoking history reportedly increased their smoking since the diagnosis, and only 40% used condoms "most of the time." However, 90% had maintained or increased their frequency of Pap tests. CONCLUSIONS: Adolescent girls had knowledge of most factors related to HPV/CD, but many did not understand the risks of cigarette smoking and failure to use condoms. To improve understanding and compliance, health care providers should tailor educational strategies to the functional level of adolescents.

Family involvement in the gynecologic care of adolescents.

The purpose of this paper is to address the issues of family involvement in gynecologic care for adolescent girls. This is accomplished by reviewing pertinent literature and its implication for health-care delivery. Specific aspects of adolescent development including changes in cognitive development and relationships are reviewed. In addition, the implications of communication between parent and adolescent, degree of parental monitoring, and the type of parenting style are discussed. Using this information as a background, recommendations for family involvement in gynecologic care are given. Methods for handling appointments are addressed; including the structure and content of the appointment and also the follow-up appointment, especially for high-risk families. Issues of confidentiality for both adolescent and parent are discussed. This information should aid clinicians in supporting those features of families that promote positive growth in adolescent girls.

Promoting women's health via the World Wide Web.

Women, as a segment of society at risk for chronic illnesses and complications from normal life events, such as pregnancy and menopause, are seeking information to improve their health status. One tool on the World Wide Web provided by a team of Ohio health care providers, including nurses, physicians, pharmacists, and dietitians, is the Ask an Expert feature of NetWellness. Designed as a consumer health information resource, NetWellness (www.netwellness.org) also is a valuable tool to health care professionals.

A moment-based technique for the automatic spatial alignment of plantar pressure data.

Plantar pressure measurements have many potential clinical applications in the field of orthopaedics. However, the only current routine clinical application of pedobarography is for the identification of high pressure zones in diabetic patients with neuropathy who are at risk from foot ulceration. For pedobarography to become a routine clinical tool in orthopaedics, a thorough knowledge of normal plantar pressure distributions would be required. To date, no large scale studies to define population norms have been conducted, probably because of the high cost associated with analysing large quantities of plantar pressure data. Plantar pressure distributions display a high step-to-step variation and, therefore, it is necessary to conduct multiple trials. Comparison between these trials is difficult, somewhat subjective, and slow, because it must be conducted manually. The present authors have developed a technique to align automatically the spatial components of a series of datasets. The technique then allows predefined parameters to be automatically extracted from the data, hence greatly reducing analysis time. The authors believe that not only does the technique make large scale studies economically viable but that it could also form the basis for expert systems for the diagnosis of foot pathologies and the prescription of orthoses.

The yielding of tensioned fine wires in the Ilizarov frame.

The Ilizarov frame uses tensioned fine wires to support bone fragments. The objective of this study was to determine whether these wires deformed plastically under functional load bearing and to determine the significance of such deformation on the long-term performance of frames used for treating lower limb conditions. The mechanical characteristics of the wires were determined by means of destructive tensile tests and used in the construction of a series of finite element models replicating typical frame configurations. Each model was then subjected to a single load cycle representing a single step and the residual displacement (i.e. plastic deformation) was determined. In each case a residual displacement of between 0.26 and 0.42 mm was observed giving a corresponding reduction in wire tension of between 8.3 and 32.8 per cent. These reductions in wire tension reduce the frame's overall stiffness and so compromise its ability to inhibit high-amplitude axial and shear motions at the fracture site which are deleterious to the healing outcome.

A process evaluation of condom availability in the Seattle, Washington public schools.

In 1993, Seattle began making condoms available in all of its 15 high schools. As part of an evaluation of this program, 16 focus groups with students from 13 high schools were conducted to explore students' perceptions of the school environment, program effectiveness, and suggestions for program improvement. The study also included data from a student survey conducted in 10 high schools. The focus group results revealed that students support school condom availability but have concerns about privacy when obtaining condoms. Students prefer obtaining condoms from baskets in private areas of school-based clinics to obtaining them from vending machines. Students do not believe that having condoms available has affected sexual activity or condom use among students. Recommendations for improving school condom availability include access to free condoms in private locations.

PIP: In 1993, the Seattle, Washington Public School District made condoms available in its 10 mainstream and 5 alternative high schools, offered supportive classroom instruction and peer education activities, and provided for an outside evaluation of this policy. This paper presents the results of the process evaluation of students' perceptions of the program. Data were gathered from 16 focus groups involving 130 students conducted in May and October of 1995 and from a spring 1995 survey of 7830 students at the 10 mainstream schools. It was found that 48% of the sexually active students used condoms from the schools. The other sexually active students either did not use condoms or bought them from stores. Those who used school condoms preferred the free ones available in the health centers to the shrink-wrapped ones from the vending machines. Males and females were equally likely to obtain school condoms, and sophomores and juniors used the program more than freshmen and seniors. Condoms were used to protect from pregnancy and from disease, but half of the sexually active students failed to use a condom during their most recent sexual encounter. Students supported school condom availability, but parents were not as favorable. Most students believed that condom availability did not encourage sexual activity but that sexual activity was the norm in their school. School condom availability was considered to have a positive effect on condom use and to have made condoms more commonplace. Recommendations to improve school condom availability include making the condoms available in private location, improving the packaging of vending machine condoms, increasing awareness of condom availability, and improving sexuality education.

Acute and long-term consequences of adolescents who choose abortions.

PIP: An estimated 40% of US females now 14 years of age can be expected to experience pregnancy by age 19 years, and the majority of these pregnancies will be unintended. In 1981, there were 1,343,200 pregnancies among US females under 20 years of age and 448,570 abortions in this same age group. The abortion ratio is highest for adolescents under 15 years of age (1379 abortions/1000 live births), while the abortion rate is highest for 18-19 year olds (61.8/1000). When compared to adult women, adolescents obtain abortions at a later gestational age--a factor that increases both the psychological and medical risks of the procedure. Adolescents are also more likely than adults to base their decision regarding the pregnancy on the opinions of significant others. Comparative studies have shown teenagers who continue a pregnancy to have underdeveloped conceptualizations of the future, high levels of anxiety, and an external locus of control. Adolescents at greatest risk of psychological sequelae of abortion are those with pre-existing mental illness, strong religious beliefs, limited coping skills, a narrow support network, and abortion at later gestational stages. If the teenager feels pressured by her family to terminate the pregnancy, she is also at high risk for adverse psychological sequelae and a repeat pregnancy soon after abortion. Thus, counselors should maintain a neutral position while helping teens to examine the positive and negative aspects of their options. In terms of medical effects, teenagers have been shown to have the lowest risk of all age groups for abortion-related mortality. However, because of the later gestational age at which adolescents seek abortion, there is a higher risk of complications such as endometritis. Emphasis should be placed on expediting the abortion decision making process among adolescents to reduce delays and the potential risks.^ieng