[Diagnostic workup and therapy of acute venous diseases]. / Diagnostik und Therapie akuter venöser Erkrankungen.

Acute venous diseases, especially deep leg and pelvic vein thrombosis, present an angiological emergency and can lead to acute life-threatening events such as pulmonary embolism. Long-term consequences may be postthrombotic syndromes. In addition to stroke and myocardial infarction, deep leg and pelvic vein thrombosis are one of the most common cardiovascular diseases. Early diagnosis and rapid initiation of therapy are important.

Eating disorders and health insurance.

Eating disorders are being diagnosed and managed by an increasing number of pediatricians and practitioners of adolescent medicine. These physicians are increasingly discovering the power and importance of their patients' health insurance status in the management of these conditions because the lack of appropriate insurance may often pose obstacles and barriers to care. This article provides an analysis of this situation through brief case presentations followed by a discussion and recommendations.

An epidemiological view of adolescent health in Latin America.

PIP: Only recently has attention been given to the condition and needs of adolescents in Latin America. Many assume that the low mortality rate among adolescents is an indication of their more than adequate health status. In reality, however, data on the health status of Latin American teens in lacking and those data which are available have been poorly synthesized and employed. In an effort to redress this oversight, the authors review and synthesize existing data on the subject from UNESCO, the World Bank, PAHO, the ILO, and other international organizations. From sections on the demography of adolescents, education, employment, economic and social conditions, mortality, morbidity, risk behaviors, and reproductive health, the authors find that adolescents in Latin America suffer traditional infectious illnesses and nutritional deficiencies; are increasingly exposed to alcohol, tobacco and drugs; and are experiencing new morbidities from violence, self-destructive behaviors, injuries, and addictions. While the level of educational attainment had increased for these youths and illiteracy has decreased across the board, poverty pervades much of the region and constrains the ability of adolescents to secure and maintain a decent quality of life. Health professionals and the general public need to dismiss the myth that adolescents in Latin America are overwhelmingly healthy and move proactively to provide them with the attention and services they so desperately need.^ieng

Substance abuse and syphilis in urban adolescents: a new risk factor for an old disease.

The incidence of syphilis is increasing. To identify the epidemiologic characteristics of adolescents with syphilis in an urban adolescent clinic, we performed a retrospective review and case-control study of 59 patients with syphilis and 111 sex-matched controls seen at our institution between 1985 and 1988. Only 24% of cases occurred in males, in contrast with 61% in a 1977-1981 study. Almost one-half (46%) of cases occurred in asymptomatic individuals, and only 24% were diagnosed at the initial visit. Patients with syphilis were more likely to have a history of substance abuse (odds ratio, 4.94; 95% confidence interval, 1.83, 13.3). This study suggests that the epidemiology of syphilis in adolescents may be changing. The high percentage of asymptomatic syphilis cases underscores the need for a high index of suspicion, particularly in sexually active adolescents who abuse drugs.

Ethical and legal issues in adolescent pregnancy.

A review of the health consequences of adolescent pregnancy indicates that pregnancy in adolescents has a higher mortality rate than that of legal abortions. The rights of minors to give consent to medical care is expressed in the mature minor doctrine and has been extended, with some limitations, to the abortion decision. Efforts to persuade adolescent patients that they should involve their parents in their medical care may be very beneficial; however, when this cannot be achieved, the adolescent should receive confidential medical care, with the adult professional assuming a protective role.

Clinical spectrum of anorexia nervosa in children.

A retrospective review of 21 patients ages 12 years and younger (age of onset range 7 to 12 years) with anorexia nervosa showed diagnostic delay in the youngest ones, high incidence of family psychiatric history, a remarkable severity of illness, and positive response to intensive treatment. Additional findings included significant comorbidity, a distinct subgroup with personality disorder and another with features of the "vulnerable child syndrome." This broad clinical spectrum of anorexia nervosa in children may explain the great variability in outcome. The development of anorexia nervosa in children relates to a complex combination of etiological and trigger factors. Precipitants identified in this study were physical maturation, entry into junior high, loss, or some combination thereof.

Eating disorders and reflex sympathetic dystrophy syndrome: is there a common pathway?

The comorbidity of eating disorders and reflex sympathetic dystrophy syndrome in the same patients raises the possibility of a common pathway for both conditions. Reflex sympathetic dystrophy syndrome may be manifesting itself in those individuals who have sympathetic overdrive. Microtrauma, often induced by compulsive exercise, and depression may be contributory factors. It is recommended that: patients with eating disorders who develop pain in an extremity should be investigated for possible reflex sympathetic dystrophy syndrome; patients with reflex sympathetic dystrophy syndrome should be discouraged from dieting, and eating disorders should be suspected if they begin to lose weight or are already malnourished.

Anorexia nervosa in black adolescents.

Anorexia nervosa has been considered rare or nonexistent among blacks. A report of the presentation and clinical course of this disorder in two black female adolescents illustrates a serious medical psychiatric problem that may be increasingly detected among predisposed teenagers of the black middle and professional classes. Unrecognized and incorrectly treated, the disease may run a fatal course in 20 percent of the cases. Differential diagnosis, etiology, and treatment of the condition are reviewed.

Physician--adolescent patient relationship. The ethical dimension.

Adolescents are very different from each other, but they all have a developmental process in common: they are going through their second period of individuation and they are developing value systems. Doctors get in touch with their adolescent patients on many different levels and with varying degrees of intensity, but they too have something in common: an obligation to their patient. Although the nature of this obligation is open to debate, the fact is that any interpersonal experience contains a moral element virtually by definition: there is an ethical dimension to the physician-adolescent patient relationship. The nature of the doctor's obligation to the adolescent is defined as aiding the patient to achieve growth. The physician can do this through appropriate use of value clarification and often through personal example.

Diagnosis of adolescent pregnancy--1965 vs 1980.

The study compares changes in the accuracy of the diagnosis of pregnancy in adolescents between 1965 and 1980. We compared 44 records of adolescents evaluated in 1965 to those of 44 who were evaluated 15 years later in 1980. The following data were examined: (1) reason for consultation, (2) amount of time prior to making the correct diagnosis, and (3) the most common diagnostic errors. The results showed that (1) the initial diagnosis was correct only 75 per cent of the time in 1965 and 86 per cent in 1980, (2) both in 1965 and 1980 most patients initially consulted for "vague complaints," (3) in 1965 and 1980 the most common diagnostic errors were "gastrointestinal disorder" and "functional symptoms," and (4) pregnancy was diagnosed earlier in 1980 than in 1965. Improvement in diagnostic accuracy should be possible if clinicians screen for pregnancy in adolescent girls consulting for vague symptoms such as nausea, weight gain, urticaria, and somnolence.

Psychiatric manifestations of systemic lupus erythematosus in children and adolescents. A review.

The purpose of this article is to review the psychiatric conditions associated with systemic lupus erythematosus (SLE) in children and adolescents. Emphasis is placed on clinical presentation and the differential diagnosis between organic psychiatric disorder, toxic psychiatric disorder, and functional psychological symptoms.

Ethical and legal issues relating to abortion in adolescence.

PIP: At least 1 million teenagers in the United States get pregnant every year; 350,000 teenagers choose to terminate their pregnancies by abortion. Doctors who examine teenagers usually find that their patients come in fairly late, and some teenagers may carry their pregnancy to term while others request abortions as late as the 2nd trimester. Abortion as well as full-term pregnancy are procedures that carry extreme mental stress. Many teenagers that go through with either procedure suffer mental breakdowns. Adolescents' stages of moral development can be classified into a 3 major categories: preconventional; conventional; or postconventional. Preconventional behavior may consist of worry about the reactions of individuals holding power over the adolescent's life; conventional behavior may consist of the adolescent conforming, as well as maintaining societal rules; and postconventional behavior may consist of the wishes of the adolescent outweighing societal expectations in their decision-making. The legal aspects concerning adolescents seeking abortions are governed by the "mature minor doctrine". Some abortions can be performed on adolescents without parental support; however, recent court decisions have provided certain measures for "immature minors." Recent debates on ethical and moral issues have been on the autonomy of the adolescent to make decisions on their own and the rights of the fetus versus the mother. Counseling is available for adolescents unsure of what decisions to make the unable to get support from their families.^ieng

Psychosocial aspects of chronic illness in adolescence.

Success in the survival of children with significant medical conditions has resulted in a dramatic increase in the prevalence of adolescents with chronic illness. Unfortunately, the traditional biomedical approach does not prepare practitioners for the complexities of managing chronic illness, because numerous psychosocial factors are involved. This article will address the need for integrating psychosocial issues into the assessment and treatment of the chronically ill adolescent. Assessment of the teen should incorporate an understanding of the developmental stages of adolescence, a review of how these developmental tasks are being accomplished, a discernment of individual characteristics, and knowledge of the family and community to which they belong. Management should take into account the phases of illness (acute, chronic or terminal) and encourage empowerment of the adolescent and family in decision making. A team approach that is community-based, comprehensive, and culturally appropriate is ideal.

Abortion in adolescence: the ethical dimension.

The purpose of this essay is to present a bioethical approach to the abortion dilemma in adolescence. It is addressed to health workers involved in the medical care of adolescents and to those involved in adolescent counseling. The introduction presents an overview of the subject in the U.S.A., its medical significance (obstetric, gynecologic, psychologic) as well as some anthropological historico-legal data relating to adolescent abortion. This is followed by a practical description of ethical theory. The main body of the presentation consists of a review of the most important contributions of bioethical thought as they relate to abortion. Adolescent abortion in particular is addressed in the context of issues such as autonomy, rights and responsibility. This includes a description of moral development in adolescence and an analysis of moral aspects of treatment of adolescents. Some personal comments and propositions are made, with the aim of generating further contributions.

Adolescent marijuana use: screening and ethics.

Adolescent marijuana use is an issue of concern to the entire community. The emergence of technology that can identify marijuana use poses questions relating to public health issues such as justification and extension of screening. This article discusses the moral issues relating to surveillance of adolescent marijuana use and postulates a justification for clinical screening.

Adolescent marijuana use: the role of the physician.

Adolescent marijuana use is an issue of concern to the community at large. Physicians now have the technology to identify marijuana use and thus are in a unique position to deal with the issue. This article addresses the moral issues related to screening and surveillance of adolescent marijuana use and postulates the justification for active physician intervention.

Chronic illness in adolescents: a sociological perspective.

This article relates chronic illness in adolescents to a sociological model of deviance. This is an area of controversy: the views of Freidson, Lorber and Robinson are presented as being representative of the dispute. Four situations are discussed in which the issues of prognosis, responsibility and stigma elicit societal response. The usefulness of a sociological model consists in making vague societal perception and rules explicit. The concept of the chronically ill adolescent as deviant is descriptive and devoid of value judgment. Only through such rigorous assessment is it possible to gain a realistic understanding of the societal role in the life of the chronically ill adolescent.

Adolescent medicine: the development of a new specialty.

The purpose of this article is to review the developments that contributed to the appearance of Adolescent Medicine. A historical account is followed by the application of two related sociological concepts: a) Rosen's hypothesis of changes in the attitudes of the medical profession to specialization and b) the process of segmenting theory as developed by Butcher and Strauss. The article concludes with a discussion of the implication of those theories for the future of the new specialty.