Higher calorie diets increase rate of weight gain and shorten hospital stay in hospitalized adolescents with anorexia nervosa.

PURPOSE: Current recommendations for refeeding in anorexia nervosa (AN) are conservative, beginning around 1,200 calories to avoid refeeding syndrome. We previously showed poor weight gain and long hospital stay using this approach and hypothesized that a higher calorie approach would improve outcomes. METHODS: Adolescents hospitalized for malnutrition due to AN were included in this quasi-experimental study comparing lower and higher calories during refeeding. Participants enrolled between 2002 and 2012; higher calories were prescribed starting around 2008. Daily prospective measures included weight, heart rate, temperature, hydration markers and serum phosphorus. Participants received formula only to replace refused food. Percent Median Body Mass Index (%MBMI) was calculated using 50th percentile body mass index for age and sex. Unpaired t-tests compared two groups split at 1,200 calories. RESULTS: Fifty-six adolescents with mean (±SEM) age 16.2 (±.3) years and admit %MBMI 79.2% (±1.5%) were hospitalized for 14.9 (±.9) days. The only significant difference between groups (N = 28 each) at baseline was starting calories (1,764 [±60] vs. 1,093 [±28], p < .001). Participants on higher calories had faster weight gain (.46 [±.04] vs. .26 [±.03] %MBMI/day, p < .001), greater daily calorie advances (122 [±8] vs. 98 [±6], p = .024), shorter hospital stay (11.9 [±1.0] vs. 17.6 [±1.2] days, p < .001), and a greater tendency to receive phosphate supplementation (12 vs. 8 participants, p = .273). CONCLUSIONS: Higher calorie diets produced faster weight gain in hospitalized adolescents with AN as compared with the currently recommended lower calorie diets. No cases of the refeeding syndrome were seen using phosphate supplementation. These findings lend further support to the move toward more aggressive refeeding in AN.

Parental acceptability of contraceptive methods offered to their teen during a confidential health care visit.

PURPOSE: To examine parental acceptability of contraceptive methods offered confidentially to their adolescent daughter. METHODS: A random sample of 261 parents/guardians with a daughter aged 12-17 years completed a telephone survey examining the relationship between parental acceptability of seven contraceptive methods and adolescents' likelihood to have sex, parenting beliefs, parents' sexual health as teens, sexually transmitted infection knowledge, and demographic factors. RESULTS: Acceptability was highest for oral contraceptive pills (59%) and lowest for intrauterine device (18%). Parental acceptance of teens' autonomy was significantly associated with increased acceptability of all methods. Parental knowledge of sexually transmitted infections was poor, and 51% found it acceptable for clinicians to provide their sexually active teen with condoms. CONCLUSIONS: Parents were more accepting of oral contraceptive pills and condoms compared with intrauterine devices and implants. Parental recognition of their teen's autonomy was associated with greater parental acceptability of clinicians providing their adolescent with contraceptives (regardless of the specific type of method being offered).

Understanding the attitudes of Latino parents toward confidential health services for teens.

OBJECTIVES: To explore the knowledge and attitudes that Latino parents have about confidential health services for their teens and to identify factors that may influence those attitudes. METHODS: Latino parents of teens (12-17 years) were randomly selected from a large health maintenance organization and a community-based hospital to participate in 1-hour focus groups. We conducted eight focus groups in the parent's preferred language. Spanish and English transcripts were translated and coded with intercoder reliability >80%. RESULTS: There were 52 participants (30 mothers, 22 fathers). There is a wide range of parental knowledge and attitudes about confidential health services for teens. Parents believed they had the right to know about their teens' health but were uncomfortable discussing sexual topics and thought confidential teen-clinician discussions would be helpful. Factors that influence parental acceptability of confidential health services include parental trust in the clinician; the clinician's interpersonal skills, clinical competencies, and ability to partner with parents and teens; and clinician-teen gender concordance. Most parents preferred teens' access to confidential services than having their teens forego needed care. CONCLUSIONS: This study identifies several underlying issues that may influence Latino youths' access to confidential health services. Implications for clinical application and future research are discussed.

A prospective examination of weight gain in hospitalized adolescents with anorexia nervosa on a recommended refeeding protocol.

PURPOSE: Current refeeding recommendations for adolescents hospitalized with anorexia nervosa (AN) are conservative, starting with low calories and advancing slowly to avoid refeeding syndrome. The purpose of this study was to examine weight change and clinical outcomes in hospitalized adolescents with AN on a recommended refeeding protocol. METHODS: Adolescents aged 13.1-20.5 years were followed during hospitalization for AN. Weight, vital signs, electrolytes, and 24-hour fluid balance were measured daily. Percent median body mass index (%MBMI) was calculated as 50th percentile BMI for age and gender. Calories were prescribed on admission and were increased every other day. RESULTS: Thirty-five subjects with a mean (SD) age of 16.2 (1.9) years participated over 16.7 (6.4) days. Calories increased from 1,205 (289) to 2,668 (387). No subjects had refeeding syndrome; 20% had low serum phosphorus. Percent MBMI increased from 80.1 (11.5) to 84.5 (9.6); overall gain was 2.10 (1.98) kg. However, 83% of subjects initially lost weight. Mean %MBMI did not increase significantly until day 8. Higher calories prescribed at baseline were significantly associated with faster weight gain (p = .003) and shorter hospital stay (p = .030) in multivariate regression models adjusted for %MBMI and lowest heart rate on admission. CONCLUSIONS: Hospitalized adolescents with AN demonstrated initial weight loss and slow weight gain on a recommended refeeding protocol. Higher calorie diets instituted at admission predicted faster weight gain and shorter hospital stay. These findings support the development of more aggressive feeding strategies in adolescents hospitalized with AN. Further research is needed to identify caloric and supplementation regimens to maximize weight gain safely while avoiding refeeding syndrome.

Medical faculty development: a modern-day odyssey.

Academic medical centers (AMCs) are pillars of the community; they provide health care, create jobs, educate biomedical professionals, and engage in research and innovation. To sustain their impact on human health, AMCs must improve the professional satisfaction of their faculty. Here, we describe ways to enhance recruitment, retention, creativity, and productivity of health science faculty.

Screening for asymptomatic Chlamydia infections among sexually active adolescent girls during pediatric urgent care.

OBJECTIVE: To develop and evaluate an intervention to increase Chlamydia trachomatis (CT) screening among sexually active adolescent girls during pediatric urgent care. DESIGN: Ten pediatric clinics were randomly assigned to an intervention (5 clinics) or control group (5 clinics). The proportion of sexually active girls screened for CT was estimated over 18 months (April 2005-September 2006). SETTING: Large health maintenance organization in northern California. PARTICIPANTS: Pediatric clinics providing urgent care services for adolescent girls aged 14 to 18 years. INTERVENTION: In the intervention clinics, a team of providers and clinic staff met monthly to redesign their clinic system to improve CT screening during urgent care. Controls received an informational lecture on CT screening. MAIN OUTCOME MEASURES: Clinic-specific proportions of sexually active adolescent girls screened for CT. RESULTS: The change over time in clinic-specific CT screening rates in urgent care was significantly greater in the intervention group than in the control group (likelihood ratio, chi(2)(1) = 18.7; P < .001). Between baseline and the fifth intervention period, the proportions of girls screened for CT increased by 15.93% in the intervention group and decreased by 2.13% in the comparison clinics. CONCLUSIONS: The intervention significantly improved the proportion of adolescent girls screened for CT during urgent care. Despite this success, substantial barriers to screen for CT in urgent care remain. Innovative strategies to provide basic information about CT, other sexually transmitted infections, and pregnancy are greatly needed since many teens are never seen for preventive care in a given year.

Predictors of one-year attrition in female Marine Corps recruits.

OBJECTIVES: The study seeks to identify demographic and health-related predictors of attrition among female Marine Corps recruits. METHODS: Data are from a longitudinal study of female recruits entering the Marine Corps between June 1999 and June 2000 (N = 2,157). Measures come from tracking data and a self-administered paper-and-pencil questionnaire. RESULTS: During recruit training (RT) 11.2% of recruits were discharged. Among RT graduates 6.6% were discharged during the following year. The cumulative attrition rate was 17.1%. No prior history of regular exercise was the only consistent predictor of discharge. Multivariate analysis also identified unsafe sex, age, race/ethnicity, and recruiting status (for active duty vs. reserve) as significant predictors of cumulative attrition. CONCLUSIONS: One-year attrition among female Marines may be reduced by more extensively screening applicants who report risk-taking behavior. Such screening can exclude applicants who are unlikely to succeed and identify others who may need additional support to complete their tour of duty.

Relationships among sociodemographic markers, behavioral risk, and sexually transmitted infections in U. S. female Marine Corps recruits.

OBJECTIVES: The purpose of this study was to examine the effect of sociodemographic factors and constructs derived from the Information, Motivation, and Behavioral Skills (IMB) model on sexually transmitted infections (STIs) and a composite STI risk score in female Marine Corps recruits. METHODS: Data were collected in 1999 to 2000 through self-administered questionnaires and laboratory-confirmed tests of STIs. Logistic regression analyses were used to assess factors associated with sexual risk and STIs. RESULTS: Recruits with the highest STI risk scores were younger, single, had high STI knowledge, less positive condom attitudes, perceptions of higher STI risk, perceived that sex is more likely and enjoyable under the influence of alcohol, and were heavy alcohol and drug users before recruit training entry. Recruits diagnosed with STIs had higher STI risk scores, had last sexual partners who were non-Caucasian, and resided in rural locations before recruit training entry. CONCLUSIONS: A significant proportion of young women entering the Marine Corps present with STIs and/or recent sexual behavior that put them at risk for acquiring STIs despite high group means for prevention skills. Deficiencies in STI/human immunodeficiency virus knowledge and motivation to reduce risk (denoted by negative attitudes toward condom use and acceptance of the connection between sex and substance use) are possible targets for intervention.

Acquisition of Chlamydia trachomatis by young women during their first year of military service.

OBJECTIVES: To define the acquisition rate of Chlamydia trachomatis among a cohort of young, nonhealth-care seeking, sexually active women with well-defined exposure periods over a 12-month period. GOAL: The long-term goal is to inform public health practitioners and young women of the risk of reinfection with C. trachomatis and the need for frequent active screening to eliminate asymptomatic infections over time. STUDY DESIGN: Young sexually active female Marine Corps recruits (N = 332), serving as "controls" for an intervention to prevent sexually transmitted infections, were screened for C. trachomatis using nucleic acid amplification tests (treated if positive) at entry (T1). They were rescreened and completed self-report behavioral surveys at 4 weeks (T2) and 9 to 12 months (T3) from recruit training. MAIN OUTCOME MEASURE: The rate of C. trachomatis acquisition during a contiguous 12-month period. RESULTS: Based on microbiologic laboratory testing alone, the acquisition rate for C. trachomatis was 3.6% (T2) and 9.9% (T3) yielding a total of 13.0%. The self-reported acquisition rate for the period since graduation from recruit training was 8.1% yielding a total acquisition rate of 19.9%. CONCLUSIONS: The acquisition rate among this cohort of nonhealth-care seeking young women, who have universal health care access is as high or higher than most clinic-based studies, suggesting the need for increased implementation of active screening in primary, urgent, and nonclinic settings.

Body mass index and disordered eating behaviors are associated with weight dissatisfaction in adolescent and young adult female military recruits.

OBJECTIVE: To examine factors associated with weight dissatisfaction, a risk factor for eating disorders, among female Marine recruits. METHODS: A diverse adolescent/young adult sample of 2157 female recruits completed a questionnaire upon entering Marine Corps training. Weight dissatisfaction was the main variable of interest. RESULTS: Body mass index (BMI), disordered eating history, and worry about meeting military "weight" were related highly to weight dissatisfaction. Women with BMIs near the upper limit of the Marine Corps weight standard (23.5 kg/m2) reported the highest rates of weight dissatisfaction. Those who reported vomiting, binging or pill use, or being worried about "making weight" were four and five times, respectively, more likely to report weight dissatisfaction. CONCLUSIONS: New female Marine recruits with higher BMIs, disordered eating histories, and worries about "making weight" are significantly more likely to be weight dissatisfied. Such findings may identify those at risk for developing eating disorders when exposed to strict military weight standards.

Chlamydial screening in urgent care visits: adolescent-reported acceptability associated with adolescent perception of clinician communication.

OBJECTIVE: To examine the association between adolescents' perception of clinician communication and adolescents' reported acceptability of the steps involved in chlamydial screening during urgent care visits. DESIGN: Cross-sectional survey of adolescents after urgent care visits. SETTING: Four pediatric clinics in a health maintenance organization. PARTICIPANTS: Three hundred sixty-five adolescents aged 13 to 18 years. OUTCOME MEASURES: Participants' ratings of the acceptability of talking about sexual health and providing a urine sample for chlamydial testing in an urgent care visit. RESULTS: Most adolescents found sexual health discussions and urine collection for chlamydial screening acceptable in the urgent care setting (84% and 80%, respectively). Acceptability of sexual health discussion was significantly associated with adolescents' perception that the clinician explained confidentiality (adjusted odds ratio [AOR], 2.7; 95% confidence interval [CI], 1.3-5.5), knew "how to talk to teens like me" (AOR, 9.0; 95% CI, 3.5-24.2), and "listened carefully as I explained my concerns" (AOR, 14.3; 95% CI, 4.3-54.9). Acceptability of providing a urine sample for chlamydial testing was associated with the adolescents' perception that the clinician knew "how to talk to teens like me" (AOR, 3.7; 95% CI, 1.5-9.3) and "listened carefully as I explained my concerns" (AOR, 3.6; 95% CI, 1.1-11.5). CONCLUSIONS: Sexual history taking and urine collection are 2 key components of chlamydial screening and were reported as acceptable by the great majority of adolescents in the urgent care setting. Aspects of clinician communication appear to be important target areas for pediatric clinician education in supporting expansion of chlamydial screening to adolescents in urgent care visits.

Forgone health care among U.S. adolescents: associations between risk characteristics and confidentiality concern.

PURPOSE: To examine risk characteristics associated with citing confidentiality concern as a reason for forgone health care, among a sample of U.S. adolescents who reported having forgone health care they believed was necessary in the past year. METHODS: The study used data from Wave I home interviews of the National Longitudinal Study of Adolescent Health. The generalized estimating equations method was used to account for the clustered nature of the data. RESULTS: Prevalence of several risk characteristics was significantly higher among boys and girls who reported confidentiality concern, as compared with those who did not report this concern. Regression analyses for boys (n = 1123), which adjusted for age, race/ethnicity, parental education and insurance type showed that high depressive symptoms, suicidal ideation, and suicide attempt were each associated with increased odds of reporting confidentiality concern as a reason for forgone health care. In multivariate analyses for girls (n = 1315), having ever had sexual intercourse, birth control nonuse at last sex, prior sexually transmitted infection, past-year alcohol use, high and moderate depressive symptoms, suicidal ideation, suicide attempt, and unsatisfactory parental communication were each associated with increased odds of citing confidentiality concern as a reason for forgone care. CONCLUSION: The population of U.S. adolescents who forgo health care due to confidentiality concern is particularly vulnerable and in need of health care services. Adolescents who report health risk behaviors, psychological distress and/or unsatisfactory communication with parents have an increased likelihood of citing confidentiality concern as a reason for forgone health care, as compared with adolescents who do not report these factors. Findings of this study suggest that if restrictions to confidentiality are increased, health care use may decrease among adolescents at high risk of adverse health outcomes.

Sexual behaviors after universal screening of sexually transmitted infections in healthy young women.

OBJECTIVE: To prospectively study the relationship between diagnosis of sexually transmitted infections (STIs) at entry to U.S. Marines recruit training and subsequent sexual behaviors during vacation. METHODS: Of all women entering recruit training (June 1999-June 2000), 2,157 (94%) voluntarily enrolled. At baseline, women received universal screening for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis and treatment and counseling for positive STIs. Recruit training (13 weeks) precluded any social activities. Unrestricted vacation followed (median 10 days). After training resumed (3 weeks), questionnaires and repeat STI screening were administered. Multivariable logistic regression examined STI diagnosis at baseline as a predictor for risky sexual behaviors at vacation and STI-positive diagnosis after vacation. RESULTS: The study was completed by 1,712 (79%) women (median age 18 years); 1,038 reported sexual activity during vacation; 71% used condoms inconsistently; 19% had casual partners. At baseline, 152 (15%) tested STI-positive. Baseline STI diagnosis was unrelated to inconsistent condom use, nonmonogamous partnerships, or multiple partnerships. However, women testing STI-positive at baseline were more likely to test STI-positive after vacation (adjusted odds ratio 3.74, 95% confidence interval 2.10-6.65). Baseline STI diagnosis predicted casual partnerships among women aged 19-21 years (adjusted odds ratio 2.48, 95% confidence interval 1.12-5.50). CONCLUSION: Substantial numbers of women engaged in risky sexual behaviors after universal STI screening and counseling. Compared with STI-negative women, STI-positive women were at increased risk for subsequent STI acquisition regardless of their similar behaviors. As universal STI screening is increasingly implemented, follow-up care will likely be required to further reduce risky behaviors and address network-level factors. LEVEL OF EVIDENCE: II.

Acquisition of sexually transmitted infections in adolescents attending an urban, general HMO teen clinic.

To determine association between acquisition of sexually transmitted infections (STIs) over a nine-month period among sexually experienced adolescents attending an urban, general HMO teen clinic and African American race, use of marijuana more than once or twice a week, and having had relationships with a sexual partner who is more than four years older.

Sociodemographic markers and behavioral correlates of sexually transmitted infections in a nonclinical sample of adolescent and young adult women.

BACKGROUND: We examined sociodemographic markers and 3-month behavioral correlates of sexually transmitted infections (STIs) in a nonclinical cross-section of adolescent and young adult women. METHODS: All women (N=2288) enrolled in recruit training for the US Marine Corps during a 1-year period were asked to voluntarily participate in either a cognitive-behavioral, skills-building intervention to prevent STIs and unintended pregnancies or a nutrition and fitness program. Participants (94.2%) completed a self-administered questionnaire and were screened for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis infection. The present study presents only the baseline data from the larger study. RESULTS: One or more STIs was diagnosed in 14.1% of participants. Results of a logistic-regression model indicated that the presence of an STI at screening was significantly (Por=2 years), frequency of hormonal contraceptive use (never and sometimes), perception that their sex partners had other concurrent sex partners, and the race or ethnicity of their last sex partner (African American and Native American). CONCLUSIONS: The high prevalence of STIs in this nonclinical sample of young women suggests the need for ongoing screening and prevention interventions that target young, healthy, sexually active women.

Examination of the treatment and follow-up care for adolescents who test positive for Chlamydia trachomatis infection.

OBJECTIVE: To document the comprehensive management of Chlamydia trachomatis infections in sexually active 14- to 19-year-old adolescents. DESIGN: A chart review of both paper and electronic records to examine documentation of treatment and follow-up of adolescents who tested positive for C. trachomatis infection. SETTING: Five pediatric clinics of a large northern California health maintenance organization. PARTICIPANTS: Consecutive sample of 122 adolescent girls and boys aged 14 to 19 years who tested positive for C. trachomatis infection beginning May 1, 2001, for 20-month (4 sites) or 4-month (1 site) study periods. MAIN OUTCOME MEASURES: Antibiotic treatment, counseling regarding safer sex, management of patients' partners, screening for other sexually transmitted infections, and retesting for C. trachomatis infection. RESULTS: The median age of participants was 16.9 years. All but 4 teenagers (97%) were treated with appropriate antibiotics. During follow-up, safer-sex counseling was documented for 79% of the patients. Partner management was addressed for 52% of the patients. Only 36% of the patients were tested for other sexually transmitted infections, and 10% received C. trachomatis retesting during the Centers for Disease Control and Prevention-recommended time frame of 3 to 12 months after treatment. Significantly fewer boys than girls received safer-sex counseling (P = .02) and partner management (P = .02). CONCLUSIONS: Most teenagers received appropriate antibiotics, but fewer received other recommended care. The current study highlights important "missed-opportunity" clinical encounters for counseling to address high-risk behaviors, management of partners, detection of other sexually transmitted infections, and retesting for reinfections. Systems to address these gaps in care should be incorporated into the clinical management of adolescents infected with C. trachomatis.

Screening sexually active adolescents for Chlamydia trachomatis: what about the boys?

OBJECTIVES: We sought to determine the effectiveness of a systems-based intervention designed to increase Chlamydia trachomatis (CT) screening among adolescent boys. METHODS: An intervention aimed at increasing CT screening among adolescent girls was extended to adolescent boys (14-18 years). Ten pediatric clinics in a health maintenance organization with an ethnically diverse population were randomized. Experimental clinics participated in a clinical practice improvement intervention; control clinics received traditional information on screening. RESULTS: The intervention significantly increased CT screening at the experimental sites from 0% (baseline) to 60% (18-month posttest); control sites evidenced a change only from 0% to 5%. The overall prevalence of CT was 4%. CONCLUSIONS: Although routine CT screening is currently recommended only for young sexually active women, the present results show that screening interventions can be successful in the case of adolescent boys, among whom CT is a moderate problem.