Anorexia nervosa, conduct disorder, and the juvenile justice system: a case of applying traditional treatment modalities in a non-traditional setting.

BACKGROUND: Anorexia Nervosa is highly comorbid with depressive, anxiety, and obsessive-compulsive spectrum disorders. However, it has not previously been reported as comorbid with antisocial personality traits, except when substance use disorder is also identified. We present an unusual case of a patient with resistant anorexia nervosa and comorbid conduct disorder. This case was also unique in that the juvenile justice system was involved during treatment. CASE PRESENTATION: A 13-year-old female was admitted to our pediatric hospital for the treatment of anorexia nervosa. She had a history of violent behaviors toward family members, often jeopardizing her care. During hospitalization, she physically attacked a physician on her care team shortly before she transitioned to an eating disorders treatment program. She was diagnosed with conduct disorder, and following discharge, she attacked her father in a premeditated act. This led to her entry into the juvenile justice system. While under the custody of the juvenile justice system, she was readmitted to our hospital for further treatment of anorexia nervosa. Our treatment strategy included psychotropics, positive reinforcement, close interdisciplinary coordination among the various hospital teams, and the juvenile justice system. Following discharge from her second hospitalization back to the juvenile detention system, our patient maintained a healthy weight and appeared to show improvements in the cognitive distortions related to her eating disorder. CONCLUSIONS: To our knowledge, this is the first reported successful treatment of an individual with resistant anorexia nervosa and conduct disorder. It was likely a combination of weight gain, psychotropic medications, and the structured milieu provided by the juvenile justice system that led to the effective treatment of our patient. This case illustrates that a non-traditional healthcare setting can be an asset to treatment through persistence and close collaboration across institutions.

Cannabinoids and the Adolescent Patient: A Pragmatic Guide for Pediatric Practitioners.

Primary care and emergency medicine practitioners frequently care for adolescents with acute or chronic effects of cannabinoids. Cannabinoid epidemiology and pharmacology are changing as new laws and regulations, new products, and new means of delivery are rapidly developed. A grasp of basic cannabinoid terminology, which is also constantly shifting, helps clinicians obtain histories and discuss diagnoses, treatments, and outcomes with their patients. The ability to identify and treat cannabinoid-associated illnesses such as cannabinoid hyperemesis syndrome, withdrawal syndrome, and acute intoxication with synthetic cannabinoids can reduce morbidity. Research on neurodevelopmental, cognitive, and psychological effects of adolescent cannabinoid use helps clinicians to have informed conversations with their patients, while providing anticipatory guidance. This article is designed with busy clinicians in mind and highlights the practical information necessary to provide care to their adolescent patients. [Pediatr Ann. 2021;50(2):e57-e64.

Sexually Transmitted Infections: Prevention, Diagnosis, and Treatment in Primary Care.

Most adolescents are cared for by general pediatricians, family practitioners, and mid-level providers. As a result, primary care practitioners need to be prepared to answer questions from adolescent patients and their parents about sexually transmitted infections (STIs), to practice good preventive medicine through screening and vaccination, and to provide treatment of STIs when needed. Although the topic of STIs is broad, there are common scenarios that arise in adolescent care. This review takes a pragmatic look at some of the most routine topics in adolescent health care regarding STIs, including the provision of confidential care, discussions with adolescent patients and their parents about human papillomavirus vaccination, the diagnosis and treatment of urethritis and cervicitis, and STI screening recommendations. [Pediatr Ann. 2019;48(9):e370-e375.].

Shipboard Global Health Engagement Missions: Essential Lessons for Military Healthcare Personnel.

INTRODUCTION: Global health engagement missions are conducted to improve and protect the health of populations worldwide. Recognizing the strong link between health and security, the Armed Forces have increased the number of global health engagement missions over the last decade to support force health protection, medical readiness, enhance interoperability, improve host nation capacity building, combat global health threats (i.e., emerging infectious diseases), support humanitarian assistance and disaster relief efforts, as well as build trust and deepen professional medical relationships worldwide. These missions additionally support the US Global Health Security Agenda, US National Security Strategy, US National Defense Strategy and National Military Strategy.Although global health engagement missions are conducted by armed forces with numerous military units and geographical locations, military healthcare personnel assigned to US Naval hospital ships also perform a wide range of these missions. These missions comprise some of the largest global health engagement missions conducted, encompassing hundreds of subject matter expert exchanges, community health exchanges, medical symposiums, and side-by-side partnered healthcare in countries around the world. Military healthcare personnel who have completed past missions possess valuable knowledge related to ship-based global health engagement missions. Capturing and transferring this knowledge to future deployed personnel is important for future successful missions, but has remained a significant challenge. The purpose of this study was to capture and examine first-person accounts of experiential learning among active duty physicians, nurses, and hospital corpsmen who had participated in recent hospital ship-based global heath engagement missions. MATERIALS AND METHODS: We used the interpretive, ethnographic method of interviewing and data analysis described by Benner. Interviews elicited detailed, narrative examples of experiences from military health care personnel who had participated in previous global health engagement missions aboard hospital ships (N = 141). Our approach to gaining meaning from these narratives was guided by three central strategies: (1) identify paradigm cases, (2) identify themes within and across participant narratives of meaningful patterns, and (3) identify exemplars to represent common patterns of meaning and common situations. Additionally, we collected demographic information. RESULTS: Our findings provide firsthand descriptions of five essential elements to prepare military healthcare personnel for shipboard global health engagement missions. These essential elements are mission clarity, preparedness, experiential knowledge, lessons learned, and flexibility/adaptability. CONCLUSIONS: Widespread dissemination of the lessons learned from military global health engagement missions is crucial to shaping forces that operate effectively in a rapidly changing global environment. Sharing lessons learned increases efficiency, adaptability, and agility, while decreasing variance in processes and the need to relearn mission-specific lessons.

Diagnosis disclosure to adolescents living with HIV in rural Kenya improves antiretroviral therapy adherence and immunologic outcomes: A retrospective cohort study.

BACKGROUND & AIMS: Emphasis on adolescent HIV has increased worldwide as antiretroviral treatment has greatly extended life expectancies of HIV-positive children. Few evidence-based guidelines exist on the optimal time to disclose to an adolescent living with HIV (ALHIV); little is known about the medical effects of disclosure. This study looked to determine whether disclosure is associated with improved medical outcomes in ALHIV. Prior work has tended to be qualitative, cross-sectional, and with an emphasis on psychosocial outcomes. This paper addresses the adolescent cohort retrospectively (longitudinally), building upon what is already known about disclosure. METHODS: Retrospective, longitudinal clinical record reviews of ALHIV seen at Kericho District Hospital between April 2004 and November 2012 were performed. Patient demographics and clinical outcomes were systematically extracted. The student's t-test was used to calculate changes in mean CD4 count, antiretroviral therapy (ART), and cotrimoxazole adherence pre- vs. post-disclosure. Linear regression modelling assessed for trends in those clinical outcomes associated with age of disclosure. RESULTS: Ninety-six ALHIV (54 female, 42 male) were included; most (73%) entered care through the outpatient department. Nearly half were cared for by parents, and 20% experienced a change in their primary caregiver. The mean time in the study was 2.47 years; mean number of visits 10.97 per patient over the mean time in the study. Mean disclosure age was 12.34 years. An increase in mean ART adherence percentage was found with disclosure (0.802 vs. 0.917; p = 0.0015). Younger disclosure age was associated with significantly higher mean CD4 counts over the course of the study (p = 0.001), and a nonsignificant trend toward a higher mean ART adherence percentage (p = 0.055). CONCLUSION: ART adherence and improved immunologic status are both associated with disclosure of HIV infection to adolescent patients. Disclosure of an HIV diagnosis to an adolescent is an important means to improve HIV care.