Confidential billing accounts for adolescents in private practice.

The purpose of this study was to determine how individual confidential billing accounts for adolescents in private practice would be received, and to assess the impact of these accounts on practice reimbursement. Adolescents wishing to keep confidential any part of the charges for an office visit were offered individual billing accounts. Enrollees agreed to pay whenever and whatever they could. One attempt was made to contact nonpayers at least 3 months after starting their accounts. The mean charge for 40 confidential accounts was $42 (total charges $1489) and all of the charges were for laboratory testing. Participants reimbursed 38% of the total charged ($565/$1489). Confidential accounts were well-received by study participants and may improve access to confidential care.

Clinician agreement on physical findings in child sexual abuse cases.

OBJECTIVE: To measure agreement among experienced clinicians regarding the interpretation of physical findings in child sexual abuse cases and to determine whether knowledge of clinical history affects the interpretation of the physical findings. DESIGN: Experienced clinicians rated colposcopic photographs on a scale of 1 to 5 with 1 being normal and 5 being clear evidence of penetrating injury. To answer an additional study question of whether clinical history affected interpretation, 4 clinicians rated 69 cases in which they were blinded to the patients' histories and 70 cases in which the patients' histories were available. The other 3 clinicians then rated the same cases with the presence or absence of history reversed. SETTING: All clinicians involved perform child sexual abuse examinations at tertiary care centers. PATIENTS: A total of 139 girls with Tanner stage 1 or 2 genitalia who were referred to a general pediatric clinic at an academic medical center for examination of possible sexual abuse. RESULTS: Half of the photographs were interpreted as indicating little or no evidence of abuse. Of those photographic sets that both readers could interpret, 39% were in perfect agreement and 77% disagreed by 1 category or less. Perfect agreement across all possible pairs of readers was 34.5%. Agreement was better when the patient's clinical history was unknown (29.3% vs 38.9%, P = .005). The kappa, a measure of interrater reliability, indicated poor agreement among clinicians. The combined kappa for the first group of clinicians was 0.22 without knowledge of clinical history and 0.11 with knowledge of clinical history. For the second group of clinicians, the kappa was 0.31 without knowledge of clinical history and 0.15 with knowledge of clinical history. The overall kappa across all 7 clinicians disregarding clinical history was 0.20. Agreement was best for categories 1 (normal, kappa = 0.28) and 5 (clear evidence of a penetrating injury, kappa = 0.39). CONCLUSIONS: Clinicians educated and experienced in assessing child sexual abuse do not agree perfectly on the interpretation of photographs of genital findings in girls with Tanner stage 1 or 2 genitalia. Clinicians agree less when a patient's clinical history is available. Efforts should be directed at standardizing physical findings and avoiding overemphasis on physical findings in child sexual abuse cases.

Are adolescents who report prior sexual abuse at higher risk for pregnancy?

Adolescents who report prior sexual abuse are at increased risk for adolescent pregnancy. This may result from earlier, more frequent, less well-protected sexual activity or from a greater desire to conceive. To determine the relative contribution of these two possible explanations to the reported association between sexual abuse and adolescent pregnancy, we studied the reproductive and sexual histories of 200 sexually active 13-18 year old females in relation to self-reported sexual abuse. Anonymous questionnaires revealed that 40 (20%) of the 200 subjects reported sexual abuse. Analyses revealed no group differences in the median age of first voluntary intercourse, the frequency of sexual intercourse, or the consistency of birth control use. Compared to their nonabused peers, however, teenagers reporting abuse were more likely to be trying to conceive (35% vs. 14% p < .01), to have boyfriends pressuring them to conceive (76% vs. 44% p < .01), and to have fears about infertility (38% vs. 16% p < .01). Our findings suggest that childhood sexual abuse may increase the risk of adolescent pregnancy by fostering the desire to conceive. Further study is needed to determine why a disproportionate number of sexually abused adolescents desire pregnancy. The efficacy of adolescent pregnancy prevention programs may be improved by identifying previously abused adolescents and by designing educational interventions that specifically address their desire to conceive.

PIP: Female adolescents who report prior sexual abuse are at increased risk for adolescent pregnancy. Such pregnancy may result from earlier, more frequent, less well-protected sexual activity or from a greater desire to conceive. The authors studied the reproductive and sexual histories of 200 sexually active 13-18 year old females in relation to self-reported sexual abuse to determine the relative contribution of these two possible explanations to the association between sexual abuse and adolescent pregnancy. 20% of the participants reported being sexually abused. There were, however, no differences found between the groups in the median age of first voluntary intercourse, the frequency of sexual intercourse, or the consistency of birth control use. Compared to their nonabused peers, however, teenagers reporting abuse were more likely to be trying to conceive, to have boyfriends pressuring them to conceive, and to have fears about infertility. These findings therefore suggest that childhood sexual abuse may increase the risk of adolescent pregnancy by fostering the desire to conceive. Further study is needed to determine why a disproportionate number of sexually abused adolescents desire pregnancy.

Parents' knowledge of the purposes and content of preparticipation physical examinations.

OBJECTIVES: To determine whether parents of student athletes plan to use the preparticipation physical examination (PPE) as their student athlete's only annual health evaluation, to identify factors associated with this decision, and to assess their knowledge about the objectives of PPEs and more comprehensive examinations. DESIGN: Survey. SETTING: General community, school-sponsored PPEs. PARTICIPANTS: A convenience sample of parents or guardians of high school student athletes who obtained a school-sponsored, multiple-station format PPE were surveyed by using an anonymous paper-and-pencil questionnaire. Questionnaires were completed by the parents of 381 of 763 student athletes who obtained PPEs (participation rate, 49.9%). RESULTS: Thirty percent of the parents in this sample planned to use the PPE as their student athlete's only contact with a health care provider. Parents whose adolescent's health insurance provided for comprehensive health assessments were more likely than those without this benefit to plan a comprehensive care evaluation (75% vs 60%, respectively) (P = .01 by chi 2 analysis). In addition to addressing problems that might affect sports participation, parents thought that the PPE visit should evaluate medical problems that are unrelated to athletics (34%), perform health screening procedures (22%), assess social or behavioral issues (16%), and provide immunizations (7%). CONCLUSIONS: Many parents plan to use the PPE as their student athlete's only scheduled contact with a health care provider; this decision may be influenced by factors that are related to access to health care and misperceptions with regard to the mission of these specialized examinations. For these adolescents, important medical, social, and behavioral needs may not be met. Consideration should be given to including elements of the PPE in health assessments that are performed by individual clinicians or expanding the scope of large-group, multiple-station format PPEs.

Compliance with return appointments for reproductive health care among adolescent Norplant users.

PURPOSE: Norplant's long duration of action may result in users being less motivated than non-users to return for reproductive health care appointments. This study determined compliance with scheduled return appointments among adolescents using Norplant and those using other methods of contraception. METHODS: We retrospectively reviewed the records of all teenagers (age < or = 18 years) who received Norplant between June 1991 and August 1993, as well as those of a comparison group of adolescents, matched for age and race, using other methods of contraception. Subjects receiving Norplant were given appointments for a two-week and an annual examination. Comparison subjects were given only an appointment for an annual examination. Norplant users not returning within 5 weeks or any subject not presenting within 12 months for an annual examination, were considered non-compliant. RESULTS: Eighty-eight adolescents received Norplant during the study period and the records of 85 were available for review. Only 48 of the 85 Norplant users returned for scheduled two-week check-up, while 18 of 43 subjects who had Norplant at least 12 months were compliant with annual examinations. The compliance rate with annual examinations among the 89 subjects not using Norplant was 38%, not dissimilar from that of the Norplant group. CONCLUSIONS: These data demonstrate that compliance with return appointments for reproductive health care among adolescent Norplant users is poor but not significantly worse than that of non-users of Norplant. Strategies promoting the benefits of return visits need to be improved for adolescents receiving contraception.

PIP: Although the long-term protection from pregnancy conferred by Norplant use makes this a potentially effective method for adolescents, there are concerns that teenagers with implants will not be motivated to return for routine reproductive health examinations. To assess this possibility, compliance with scheduled return clinic appointments among 85 Norplant acceptors aged 18 years and younger and 89 age- and race-matched controls was compared through retrospective review of records at a community-based family planning clinic in North Carolina. Only 14 Norplant acceptors returned to have the insertion site examined within five weeks of insertion; another seven appeared for the initial examination after a reminder was mailed, yielding a 25% compliance rate. In terms of the annual examination, 18 of the 43 subjects who had used Norplant for at least 12 months and 34 of the 89 controls were compliant. There was no significant difference in this compliance rate between cases (41.9%) and users of other methods (38.2%). Among cases, the records showed that appointment compliance after Norplant insertion was not significantly lower than it had been among these women when they were using other methods. Only three Norplant acceptors discontinued the method, indicating a high degree of user satisfaction. Although these findings indicate that Norplant use does not increase the risk of poor compliance with reproductive health care, they indicate a need to convince teenagers of the benefits of such care, especially for the detection of sexually transmitted diseases.

Infant positioning and SIDS. Acceptance of the nonprone position among clinic mothers.

In April 1992, the American Academy of Pediatrics recommended that healthy infants not be placed prone to sleep because of the association between the prone sleeping position and sudden infant death syndrome (SIDS). We determined the awareness and acceptance of this recommendation among 190 mothers attending a community health center pediatric clinic in the first year after the recommendation. Ninety-seven women (51.1%) had heard the recommendation. The compliance with the recommendation among women who had heard it was 63.9% (62 of 97). Fifty-three percent of all the mothers worried that their infant would choke in the supine position. More education is necessary in this population to improve acceptance of this new recommendation and to correct misinformation about the supine position.

Self-perception of infertility among female adolescents.

OBJECTIVE: To determine the prevalence and correlates of the self-perception of infertility among female adolescents. DESIGN: Cross-sectional survey. SETTING: Urban adolescent clinic in a neighborhood health center in Denver, Colo. PARTICIPANTS: Two hundred sexually active, nulliparous, 14- through 18-year-old female adolescents. MEASUREMENTS/MAIN RESULTS: Concerns about fertility were expressed by 43 (21.5%) of the 200 respondents. Logistic regression analysis revealed that the factors most strongly associated with the self-perception of infertility were as follows (odds ratios; 95% confidence interval): a history of discussing infertility with anyone (4.3; 1.8 to 10.4); desire for pregnancy (3.8; 1.4 to 10.3); boyfriend desiring pregnancy (3.0; 1.1 to 8.3); a history of sexually transmitted disease(s) (3.0; 1.2 to 7.1); and having an older boyfriend (2.6; (1.1 to 6.2). Adolescents who doubted their fertility used contraceptives less frequently than other teens (30% vs 55% of the time; P < .01). CONCLUSIONS: The self-perception of infertility is common among sexually active urban female adolescents and may pose another barrier to contraceptive use. Our findings may help clinicians counsel adolescents about contraceptives more effectively.

Newspapers: a source for injury surveillance?

Newspapers have not been extensively evaluated as an injury surveillance source. We compared clippings with medical examiner records for 45 residential fire deaths and 58 drownings of children to assess extent, completeness, and accuracy of newspaper coverage. Newspapers covered 96% of the fire fatalities and 78% of the drownings and contained more information than medical examiner records on several factors, including fire cause and smoke detector presence, pool fences, warning signs, and supervision of children.

Associations between enzyme genotypes and dark respiration in perennial ryegrass, Lolium perenne L.

In this study, we determined whether relationships existed between dark respiration and genotype at five enzyme polymorphisms in perennial ryegrass, Lolium perenne L. Positive correlations were found between Q 10 of dark respiration and genotype at the phosphoglucomutase (PGM) and 6-phosphogluconate dehydrogenase (6PGD) loci. Plants doubly homozygous for the common allele at these loci were found to have Q 10 values 20% higher than those for double heterozygotes. In plants that were heat stressed for five consecutive days, Q 10 was found to be negatively correlated with apparent vigor after stressing. Individuals homozygous for PGM and 6PGD (with higher Q 10 values) exhibited more apparent damage following the stress than heterozygous individuals. Both PGM and 6PGD occupy positions in metabolism with regulatory potential. Although caution must be used in assigning causal relationships, the results suggest that specific forms of these enzymes are directly related to, or are correlated with, the determinants of respiratory efficiency in L. perenne.