Impact of Telemedicine on Access to Care for Rural Transgender and Gender-Diverse Youth.

OBJECTIVE: To explore the impact of telemedicine on access to gender-affirming care for rural transgender and gender diverse youth. STUDY DESIGN: A retrospective analysis of data drawn from the electronic medical records of a clinic that provides approximately 10 000 adolescent and young adult visits per year and serves patients seeking gender health care. The no-show rate was examined as a proxy for access to care due to anticipated challenges with recruiting a representative sample of a historically marginalized population. Logistic regression with generalized estimating equations was conducted to model the association between the odds of a no-show visit and covariates of interest. RESULTS: Telemedicine visits, rural home address, gender health visits, longer travel time, and being younger than 18 years old were associated with lower odds of a no-show in univariate models (n = 17 928 visits). In the adjusted model, the OR of no-shows for gender health visits was 0.56 (95% CI 0.42-0.74), adjusting for rurality, telemedicine, age (< or >18 years), and travel time to the clinic. CONCLUSIONS: In this study, telemedicine was associated with reduced no-shows overall, and especially for rural, transgender and gender diverse youth, and patients who hold both identities. Although the no-show rate does not fully capture barriers to access, these findings provide insight into how this vulnerable population may benefit from expanded access to telemedicine for rural individuals whose communities may lack providers with the skills to serve this population.

Puberty and menarche in young females with cerebral palsy and intellectual disability: a qualitative study of caregivers' experiences.

AIM: To explore experiences of parents of young females with cerebral palsy (CP) and intellectual disability at the onset of puberty. METHOD: This was a phenomenological qualitative study. We conducted phone interviews of parents of young females with CP and intellectual disability who had been seen in the CP center at a freestanding children's hospital within the prior 2 years. Inclusion criteria were English-speaking parents of young females who had combined diagnoses of CP and intellectual disability. Interviews were coded and analyzed by the research team facilitated by Dedoose software. RESULTS: Nine interviews were conducted with parents of daughters aged 14 to 24 years. All daughters used wheelchairs for mobility and augmentative technology for communication. Despite homogeneity in functional ability, there was marked variation in parental perception of the significance of puberty for their daughters. Families often learned about reproductive health from informal social networks. Although families acknowledged the need for sexual abuse screening, there was little consensus about how to do it, and most denied that their own daughter could ever be abused. INTERPRETATION: Parents of young females with CP and intellectual disability have diverse reproductive health beliefs that health care providers must explore in order to provide appropriate recommendations for management of puberty. WHAT THIS PAPER ADDS: Parents of young females with cerebral palsy (CP) and intellectual disability have diverse reproductive health beliefs. Approaches to menstrual management in this population must be individualized. Families discounted the likelihood of abuse, despite acknowledging their daughters' risk.

What to do when she's bleeding through: the recognition, evaluation, and management of abnormal uterine bleeding in adolescents.

PURPOSE OF REVIEW: This article reviews the current understanding and management of abnormal uterine bleeding (AUB) in adolescents. The readers will learn a practical approach to the evaluation and treatment of mild-to-severe uterine bleeding. RECENT FINDINGS: In 2011, a new classification system was proposed to standardize the terminology used to describe AUB. This system is based on the pattern and etiology of bleeding and has been adopted by other organizations. The term dysfunctional uterine bleeding has been replaced by AUB. The negative effect of AUB on adolescents' quality of life is now well established. The levonorgestrel-releasing intrauterine system is considered a first-line treatment for heavy menstrual bleeding and should be considered, especially in those adolescents who may also need contraception. SUMMARY: AUB is a common adolescent complaint that can vary from mild to life-threatening if not recognized and treated promptly. This article reviews the appropriate assessment and management of AUB and proposes a practical algorithm that can be used in an office or hospital setting.

Managing menstruation for medically complex paediatric patients.

Physicians who care for children and adolescents need evidence-based information about how to manage menses for medically complicated patients. The use of many hormonal medications for menstrual management is considered 'off-label' because many of these medications have indications only for contraception. A growing body of evidence supports the use of particular medications or strategies for a wide variety of medical conditions, but this information has been slow to reach all paediatric patients, perhaps in part because of the off-label nature of prescribing. Specialists skilled in hormone management are in short supply and often not immediately available for consultation, and they may also be inexperienced prescribing for medically complex paediatric patients. Misconceptions about the necessity of menstruation or concerns regarding use of contraceptives in young patients may also limit the use of medically indicated off-label hormonal regimens. This review will outline current patient-centred strategies to inform physicians' choices about when and how to intervene medically to improve quality of life for medically complex girls with problematic periods-whether by making periods more predictable, preventing ovulation, reducing pain or eliminating menses altogether.

Teen pregnancy prevention on a LARC: an update on long-acting reversible contraception for the primary care provider.

PURPOSE OF REVIEW: This update will highlight recent research and recommendations on long-acting reversible contraception (LARC) in the teen population, in order to make primary care providers more comfortable counseling on these methods in the medical home. LARC methods, which include intrauterine devices (IUDs) and subdermal hormonal implants, are used by only a small minority of sexually active teens, despite their endorsement by professional organizations as effective and well tolerated birth control options in this population. RECENT FINDINGS: Recent studies show a lack of knowledge about LARC methods among young women, as well as persistent misconceptions among providers regarding who is eligible for LARC use. Existing trials of small numbers of adolescents generally show enthusiasm for its use among teens who are educated about LARC, high satisfaction rates among users of subdermal implants and IUDs, as well as varying pregnancy and continuation rates. SUMMARY: The existing research on LARC shows promise for these methods in the teen population. However, larger trials are needed to establish accurate data on satisfaction, continuation, and failure rates, as well as to explore other barriers to use. Medical home providers should stay informed of research on LARC in order to improve contraceptive counseling to young women.

Morpho-phonemic analysis boosts word reading for adult struggling readers.

A randomized control trial compared the effects of two kinds of vocabulary instruction on component reading skills of adult struggling readers. Participants seeking alternative high school diplomas received 8 h of scripted tutoring to learn forty academic vocabulary words embedded within a civics curriculum. They were matched for language background and reading levels, then randomly assigned to either morpho-phonemic analysis teaching word origins, morpheme and syllable structures, or traditional whole word study teaching multiple sentence contexts, meaningful connections, and spellings. Both groups made comparable gains in learning the target words, but the morpho-phonemic group showed greater gains in reading unfamiliar words on standardized tests of word reading, including word attack and word recognition. Findings support theories of word learning and literacy that promote explicit instruction in word analysis to increase poor readers' linguistic awareness by revealing connections between morphological, phonological, and orthographic structures within words.

Total Direct Medical Expenses and Characteristics of Privately Insured Adolescents Who Incur High Costs.

IMPORTANCE: Accountable care payment models aim to reduce total direct medical expenses for high-cost patients through improved quality of care and preventive health services. Little is known about health care expenditures of privately insured adolescents, especially those who incur high costs. OBJECTIVES: To assess health care expenditures for high-cost adolescents and to describe the patient characteristics associated with high medical costs. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort analysis was conducted of data from January 1 to December 31, 2012, of 13,103 privately insured adolescents aged 13 to 21 years (mean [SD] age, 16.3 [2.4] years; 6764 [51.6%] males) at 82 independent pediatric primary care practices in Massachusetts. Analysis was conducted from April 1, 2014, to April 1, 2015. MAIN OUTCOMES AND MEASURES: We compared demographic (age, sex, median income by zip code) and clinical (obesity, behavioral health problem, complex chronic condition) characteristics between high-cost (top 1%) and non-high-cost adolescents. We assigned high-cost adolescents to clinical categories using software from the Agency for Healthcare Research and Quality to describe clinically relevant patterns of spending. RESULTS: Total direct medical expenses were $41.2 million for the entire cohort and a median $1167 per patient. A total of 132 (1.0%) patients with the highest costs accounted for 23.6% of expenses of the cohort, with a median $52,577 per patient. Mental health disorders were the most common diagnosis in high-cost patients; 78 (59.1%) of these patients had at least 1 behavioral health diagnosis. Pharmacy costs accounted for 28.4% of total direct medical expenses of high-cost patients; primary care accounted for 1.0%. Characteristics associated with being a high-cost patient included having 1 complex chronic condition (relative risk [RR], 6.5; 95% CI, 4.7-9.0), having 2 or more complex chronic conditions (RR, 23.5; 95% CI, 14.2-39.1), having any behavioral health diagnosis (RR, 3.6; 95% CI, 2.6-5.1), and obesity (RR, 2.0; 95% CI, 1.3-3.0). CONCLUSIONS AND RELEVANCE: Total direct medical expenses for privately insured high-cost adolescents are associated with medical complexity, mental health conditions, and obesity. Cost reduction strategies in similar populations should be tailored to these cost drivers.

Salivary progesterone levels before menarche: a prospective study of adolescent girls.

OBJECTIVE: Our objective was to determine the frequency of ovulatory salivary progesterone levels before menarche in healthy girls. DESIGN: We recruited a prospective cohort of midpubertal, premenarcheal girls. Participants collected weekly saliva samples until first menses or for 12 months. Menstrual cycles were considered to have ovulatory salivary progesterone levels if values were greater than 0.100 ng/ml (0.318 nmol/liter) 0-14 d before menarche. SETTINGS: Participants collected saliva samples weekly at home and attended monthly clinic visits. PATIENTS: Patients included 63 premenarcheal females, age 9-15 yr, with body mass index higher than the fifth percentile for age and Tanner stage III or greater for both pubic hair and breast development. MAIN OUTCOME MEASURES: Frequency of ovulatory levels of salivary progesterone before menarche was assessed. RESULTS: Fifty-five girls completed the study, and 43 experienced menarche. Of the 42 girls who reached menarche and provided a sample within 14 d of menarche, five (12%) had ovulatory progesterone levels. The mean anovulatory salivary progesterone level was 0.041 ng/ml (0.130 nmol/liter; range, 0.012-0.078 ng/ml, 0.038-0.248 nmol/liter), and the mean ovulatory level was 0.194 ng/ml (0.617 nmol/liter; range, 0.125-0.343 ng/ml, 0.398-1.09 nmol/liter). The levels of estrogen, testosterone, and 17-hydroxyprogesterone were higher and the mean BMI was lower in those with ovulatory progesterone levels vs. those with anovulatory levels. CONCLUSION: A significant proportion of girls displayed ovulatory levels of progesterone before menarche. More research is needed to clarify the hormonal events that occur in the perimenarcheal time period.

Predicting sexual initiation in a prospective cohort study of adolescents.

OBJECTIVE: To determine whether a new scale measuring beliefs about postponing sexual initiation (PSI) predicts sexual initiation and whether the association between PSI and sexual initiation is mediated by intention to initiate sexual intercourse. DESIGN: Prospective cohort study. SETTING: The Growing Up Today Study, a longitudinal cohort study of adolescents. PARTICIPANTS: A total of 11,448 adolescents aged 12 to 17 years who reported in 1999 that they had never had sexual intercourse. MAIN EXPOSURE: Beliefs and attitudes about PSI measured in 1999 (12-item scale, Cronbach alpha = 0.86). Higher PSI scale scores indicated stronger beliefs about postponing sex. OUTCOME MEASURE: Sexual intercourse reported on the 2000 survey. RESULTS: The mean (SD) age of participants was 14.3 (1.5) years, and 94.4% were white. Of the participants, 7.5% of boys and 10.1% of girls initiated sexual intercourse between 1999 and 2000. The PSI scale score was inversely associated with intention to initiate sex and with sexual initiation in boys and girls (P < .001 for both). Intention to initiate sex was positively associated with sexual initiation (P < .001). In multivariate models, PSI scale scores were inversely associated with sexual intercourse initiation in boys (odds ratio, 0.90 for a 1-U increase in PSI scale score; 95% confidence interval, 0.87-0.93; P < .001) and girls (odds ratio, 0.91; 95% confidence interval, 0.89-0.93; P < .001). The strength of the association decreased when intention to initiate sexual intercourse was added to both models. CONCLUSION: A new scale measuring beliefs and attitudes about PSI predicted sexual intercourse initiation in the next year, and intention to initiate sex mediated this association.