Post-Trial Sustainability and Scalability of the Benefits of a Medical Home for High-Risk Children with Medical Complexity.

OBJECTIVE: To assess the sustainability of the benefits relative to usual care of a medical home providing comprehensive care for high-risk children with medical complexity (≥2 hospitalizations or ≥1 pediatric intensive care unit [PICU] admission in the year before enrollment) after we made comprehensive care our standard practice and expanded the program. STUDY DESIGN: We conducted pre-post comparisons of the rate of children with serious illness (death, PICU admission, or >7-day hospitalization) and health-system costs observed after program expansion (March 2014-June 2015) to those during the clinical trial (March 2011-August 2013) for each of the trial's treatment groups (usual care, n = 96, and comprehensive care, n = 105; primary analyses), and among all children given comprehensive care (nPost-trial = 233, including trial usual care children who transitioned to comprehensive care post-trial and newly enrolled medically complex children, and nTrial = 105; secondary analyses). We also analyzed the findings for the trial patients as a 2-phase stepped-wedge study. RESULTS: In intent-to-treat analyses, rates of children with serious illness and costs were reduced or unchanged post-trial vs trial for the trial's usual care group (rate ratio [RR], 0.36; 95% CI, 0.20-0.64; cost ratio [CR], 0.68; 95% CI, 0.28-1.68), the trial's comprehensive care group (RR, 0.74; 95% CI, 0.39-1.41; CR, 0.67; 95% CI, 0.51-0.89), and among all children given comprehensive care (RR, 0.97; 95% CI, 0.61-1.52; CR, 0.75; 95% CI, 0.61-0.93). Conservative stepped-wedge analyses identified overall benefits with comprehensive care across both study periods (RR, 0.46; 95% CI, 0.30-0.72; CR, 0.64; 95% CI, 0.43-0.99). CONCLUSIONS: Major benefits of comprehensive care did not diminish with post-trial program expansion.

Azithromycin efficacy in the treatment of Chlamydia trachomatis among detained youth.

We assessed the efficacy of azithromycin among detained adolescents with Chlamydia trachomatis. Infected adolescents took azithromycin and submitted a test of cure. Of the 128 youth, 5 patients experienced treatment failure. We found that azithromycin was 96.1% (95% confidence interval, 91.1%-98.8%) effective in treating chlamydia infections, supporting its continued use.

Scurvy, abnormal MRI, and gelatinous bone marrow in an adolescent with avoidant restrictive food intake disorder.

BACKGROUND: Although medical literature describes pediatric scurvy as "rare", a growing number of case reports suggests otherwise. Patients often undergo costly and unnecessary workup due to unfamiliarity with the presentation of scurvy. This case report further supports the small yet growing literature documenting scurvy and its manifestations in patients with eating disorders. CASE PRESENTATION: A 15-year-old female presented to the emergency department with bilateral knee and ankle swelling and pain in the setting of chronic lower limb rash and BMI of 16.3. For years, she had restricted her diet to carbohydrates. Exam showed perifollicular petechial hemorrhagic rash with corkscrew hairs, knee edema, ankle edema with restricted range of motion, and antalgic gait. She was admitted for severe malnutrition from avoidant restrictive food intake disorder. Her hospital course was complicated by recurrent normocytic anemia and fever. Hematology workup revealed anemia from iron deficiency, vitamin K deficiency, and anemia of chronic disease. Rheumatology workup was negative. MRI findings showed dark T1 and bright T2 signals and were read as consistent with leukemia/lymphoma, chronic multifocal osteomyelitis, or Langerhans cell histiocytosis. However, bone marrow biopsy showed gelatinous transformation secondary to malnutrition. She was treated with vitamin C and a nutrition plan and her symptoms improved. CONCLUSIONS: Although this patient had common manifestations of scurvy, including perifollicular petechial hemorrhagic rash, joint effusions, anemia, and recurrent fevers, she still underwent an extensive workup. Clinicians should be aware that scurvy can present with multiple symptoms that mimic infectious, rheumatic, oncologic and hematological disease. Clinicians should have a high index of suspicion for scurvy in patients with malnutrition and eating disorders.

Trichomonas Vaginalis Infections Among Youth in Detention in the Southeastern United States.

Most juvenile detention facilities do not screen for Trichomonas Vaginalis (TV) despite being the most common parasitic STI. We aimed to assess TV prevalence and risk factors among young women in a large urban juvenile detention center. We evaluated a retrospective cohort from April to December 2016. Youth submitted an intake urine sample for gonorrhea and chlamydia testing; we tested remnant urine for TV. Outcomes included prevalence of TV and risk factors for infection. A total of 1009 samples were collected, 374 from young women ages 13 - 17 years old. Among females, 8% tested positive for TV with co-infection of either gonorrhea, chlamydia or both occurring in 12/29 (41%) patients. Compared to youth without TV females with TV were more likely to be African American (76%) and report symptoms (41%) (p<0.05). In our study population, prevalence of TV was 8%. As nearly half of those with TV were asymptomatic, we recommend routine screening among this population.

A Contraception Quality Improvement Initiative with Detained Young Women: Counseling, Initiation, and Utilization.

STUDY OBJECTIVE: To assess the effect of providing standardized counseling to improve the rates of contraception initiation and utilization among detained young women. This was a quality improvement (QI) project conducted at a large urban juvenile short-term detention center. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: The intervention included educating all staff and care providers, counseling detained young women on various contraceptive options, and offering contraception initiation with oral contraceptive pills or depot medroxyprogesterone acetate injection. Retrospective chart review before February 2012 established baseline contraception initiation and utilization rates. The QI intervention began in February 2012 and continued for 6 months followed by chart review. Outcomes measured included number of patients counseled about contraception, started contraception, and overall contraception utilization. RESULTS: We reviewed 120 and 186 charts before and after intervention, respectively. Compared with baseline data, the intervention group had statistically significant (P < .05) higher proportions of patients counseled (10% [10/120] baseline vs 84% [156/186] intervention) and who started contraception (7% [8/120] baseline vs 52% [97/186] intervention). CONCLUSION: This contraception QI intervention showed significant improvement in the rates of contraception counseling, contraception initiation, and utilization among detained young women. Most of youths' guardians were supportive and approved contraception initiation. This project showed it is feasible for health care providers to include contraception services for all intake assessments at juvenile detention facilities.