Talk with Tiff: teen's inquiries to a sexual health website

Because of its availability, anonymity, and low cost of access, the Internet is an increasingly common way for adolescents to find information about sensitive issues. Sexual health website question portals are an important way for adolescents to seek personalized information tailored to their individualized needs. Few studies have examined the content within anonymous e-mails sent to these question portals. The purpose of this qualitative evaluation was to analyze thematic content of anonymous e-mails sent through a question portal on a comprehensive sexual health clinic website for an adolescent family planning clinic in a large city in the southwest United States. Between August 2009 and June 2012, the e-mail server received questions from 484 individuals who were seeking sexual health-related information. The authors used a content analysis to identify recurrent themes in the questions submitted. The most common questions regarded the cost of the clinic's services and testing for sexually transmitted diseases. The questions revealed that adolescents lack basic sexual health knowledge and hold many misconceptions. The findings support the usefulness of online question portals as effective venues for teenagers to quickly and anonymously obtain accurate information on sensitive issues.

Access to sexual and reproductive health care services: young men's perspectives

This study aimed to identify health issues that affect young men and the barriers they experience in accessing care. Participants were 48 minority men 18-28 years old, distributed among 9 focus groups. Four main themes emerged in the study. First, the authors identified sexually transmitted infections, mental health problems, and drug use as major health issues. Second, participants identified attitudinal and institutional barriers to accessing care. This included denial; fear; embarrassment; perception that it is not considered manly to seek help; cost; and accessibility. Third, focus group participants felt that services have to be augmented in order to address the specific needs of men. Last, participants suggested strategies to attract men to family planning clinics that are consistent with a youth culture. Focus groups are effective in obtaining input in order to augment services for men.

Fluconazole pharmacokinetics and safety in premature infants

Invasive candidiasis (IC) in the premature infant population is a common infection that results in substantial morbidity and mortality. For these patients, fluconazole is among the first line therapies to treat and prevent IC, and yet few prospective studies investigating its pharmacokinetics (PK) and safety have been performed in this vulnerable population. We review five phase I studies examining the PK of fluconazole in premature infants, which demonstrate markedly differing kinetics compared to adults. Based on these data, a treatment dose of 12 mg/kg/day, with the potential need of a loading dose of 25 mg/kg to achieve rapid steady state concentrations, achieves surrogate pharmacodynamic targets. Additionally, fluconazole appears to be safe to use in this population, with only minimal reversible hepatobiliary effects.

Clinical characteristics and response to prophylactic fluconazole of preterm VLBW neonates with baseline and acquired fungal colonisation in NICU: data from a multicentre RCT

BACKGROUND

Fungal colonisation by Candida spp. affects a high proportion of VLBW neonates in NICU. However, few data are available on the clinical characteristics of colonisation in preterm infants who are colonised at baseline via vertical transmission, compared to preterms who become colonised during their stay in NICU via horizontal transmission.

MATERIAL AND METHODS

We reviewed the database of a multicentre, randomised trial of prophylactic fluconazole in VLBW neonates conducted in 8 Italian NICUs in the years 2004 and 2005 (Manzoni et al., NEJM 2007;356(24):2483-95). Per the protocol, all enrolled infants underwent weekly surveillance cultures from birth till discharge. We investigated the frequency of the two different modalities of Candida colonisation in this population, as well as the clinical and outcome characteristics possibly related to them.

RESULTS

Overall, Candida colonisation affected 54 of 336 infants (16.1%). Baseline (i.e., detected <3(rd) day of life) colonisation affected 16 (4.7%), and acquired 38 (11.4%), of the 54 colonised preterms. Infants with baseline colonisation had significantly higher birth weight (1229 ± 28 g vs. 1047 g ± 29, p = 0.01) and gestational age (30.2 wks ± 2.7 vs. 28.5 wks ± 2.6, p = 0.01), and were significantly more likely to limit progression from colonisation to invasive Candida infection when fluconazole prophylaxis was instituted (21.6% vs. 42.7%, p = 0.009). Isolation of C. parapsilosis was significantly more frequent in infants with acquired colonisation.

CONCLUSIONS

Infants with baseline and acquired colonisation differ for demographics characteristics and for their response to fluconazole prophylaxis. This information may be useful for targeting more accurate management strategies for these two different groups of colonised preterms in NICU.

HIV risk perceptions among adolescents attending family planning clinics: an integrated perspective

Abstract The current study assessed the impact of individual, interpersonal, and contextual factors on HIV risk perception. A total of 426 female adolescents attending family planning clinics took part in this study. The majority, 60.1% were African-American and 39.9% were Hispanic. The results indicated that the majority of participants perceived themselves to be at no or low risk for contracting HIV. Individual, interpersonal as well as contextual factors correlated with HIV risk perception in the study. Adolescents who perceived themselves to be at no or low risk were more likely to be Hispanic, be married and had children. They also felt that they can control situations where they have to refuse sex or insist on condom use, had more frequent communication with sexual partners about condom use and held perceptions that peer norms support condom use. The findings in this study have important implications for risk reduction education for female adolescents. Risk reduction education should strengthen adolescents' personal skills to help them avoid HIV risk despite the various pressures they experience in their life.

Characteristics of patients who die of necrotizing enterocolitis

OBJECTIVE

Necrotizing enterocolitis (NEC) is associated with high morbidity and mortality among infants admitted for intensive care. The factors associated with mortality and catastrophic presentation remain poorly understood. Our objective was to describe the factors associated with mortality in infants with NEC and to quantify the degree to which catastrophic presentation contributes to mortality in infants with NEC. Catastrophic NEC was defined before data analysis as NEC that led to death within 7 days of diagnosis.

STUDY DESIGN

We performed a retrospective review of the Pediatrix's Clinical Data Warehouse (1997 to 2009, n=560,227) to compare the demographic, therapeutic and outcome characteristics of infants who survived NEC vs those who died. Associations were tested by bivariate and multivariate analysis.

RESULT

We compared the 5594 infants diagnosed with NEC and who were discharged home with 1505 infants diagnosed with NEC who died. In multivariate analysis, the factors associated with death (P<0.01 in analysis) were lower estimated gestational age, lower birth weight, treatment with assisted ventilation on the day of diagnosis of NEC, treatment with vasopressors at the time of diagnosis, and Black race. Patients who received only ampicillin and gentamicin on the day of diagnosis were less likely to die. Two-thirds of NEC deaths occurred quickly (<7 days from diagnosis), with a median time of death of one day from time of diagnosis. Infants who died within 7 days of diagnosis had a higher birth weight, more often were on vasopressors and high frequency ventilation at the time of diagnosis compared with patients who died at 7 or more days. Although mortality decreased with increasing gestational age, the proportion of deaths that occurred within 7 days was relatively consistent (65 to 75% of the patients who died) across all gestational ages.

CONCLUSION

Mortality among infants who have NEC remains high and infants who die of NEC commonly (66%) die quickly. Most of the factors associated with mortality are related to immaturity, low birth weight and severity of illness.

Evaluation of a digital microfluidic real-time PCR platform to detect DNA of Candida albicans in blood

Species of Candida frequently cause life-threatening infections in neonates, transplant and intensive care unit (ICU) patients, and others with compromised host defenses. The successful management of systemic candidiasis depends upon early, rapid diagnosis. Blood cultures are the standard diagnostic method, but identification requires days and less than half of the patients are positive. These limitations may be eliminated by using real-time polymerase chain reaction (PCR) to detect Candida DNA in the blood specimens of patients at risk. Here, we optimized a PCR protocol to detect 5-10 yeasts in low volumes of simulated and clinical specimens. We also used a mouse model of systemic candidiasis and determined that candidemia is optimally detectable during the first few days after infection. However, PCR tests are often costly, labor-intensive, and inconvenient for routine use. To address these obstacles, we evaluated the innovative microfluidic real-time PCR platform (Advanced Liquid Logic, Inc.), which has the potential for full automation and rapid turnaround. Eleven and nine of 16 specimens from individual patients with culture-proven candidemia tested positive for C. albicans DNA by conventional and microfluidic real-time PCR, respectively, for a combined sensitivity of 94%. The microfluidic platform offers a significant technical advance in the detection of microbial DNA in clinical specimens.

Safety and pharmacokinetics of multiple-dose anidulafungin in infants and neonates

Candida infections are common and often fatal in infants and neonates. Anidulafungin has excellent activity against Candida species, but the pharmacokinetics (PK) and safety of the drug in infants and neonates are unknown. The object of our study was to determine the PK and safety of anidulafungin in infants and neonates at risk for invasive candidiasis. Intravenous anidulafungin (1.5 mg/kg/day maintenance dose) was administered to 15 infants and neonates over 3 to 5 days. Plasma samples were collected after the first dose and again after the third to fifth doses. The pharmacokinetic parameters of the drug were determined by noncompartmental analysis. Safety was assessed using National Cancer Institute common toxicity criteria. The study showed that drug exposure levels were similar between neonates and infants; the median areas under the concentration-time curve (range) was 75 (30-109) µg·h/ml and 98 (55-278) µg·h/ml (P = 0.12) for neonates and infants, respectively. No drug-related serious adverse events were observed. The study results indicate that neonates and infants receiving 1.5 mg/kg/day have anidulafungin exposure levels similar to those in children receiving similar weight-based dosing and in adult patients receiving 100 mg/day.

Students' experiences and perceived benefits of a sex education curriculum: a qualitative analysis

A qualitative evaluation explored the experiences and perceived benefits of students who participated in an abstinence-plus sex education program at enrollment and conclusion. The sample included 1130 inner-city high school students, 73.7% of whom were Hispanic. Thematic analysis was used to identify main themes in responses made by students to 3 open-ended questions. The most common preparticipation request was for information about sexually transmitted infections. At program conclusion, the most common response theme involved the quality of course delivery. Students indicated that they appreciated the facilitators who allowed open conversations. The implications of these findings to sex education programs are discussed.

Parental communication as a protective factor in increasing condom use among minority adolescents

The purpose of this study was to examine ethnic differences in risk behaviors among adolescents who attended family planning clinics and to evaluate the impact of parental communication regarding sexual topics on adolescent condom use. The sample for this study included 697 black and Hispanic female adolescents ranging in age from 13-22 years. Ethnic differences were found in sexually transmitted infection rates, number of sexual partners, and condom use. Although black adolescents were more likely than Hispanic adolescents to report recent condom use, Black adolescents reported higher rates of sexually transmitted infections and more sexual partners. Black adolescents reported more parental communication about sexual topics than Hispanic adolescents. Parental communication was associated with increased condom use. The results of this study emphasize the importance of parental communication in risk reduction among adolescents. As ethnicity emerged in the study as a significant factor, interventions aimed at increasing parent-adolescent communication will have to be tailored to address the needs of specific ethnic groups.

Ethnicity as a factor in reproductive health care utilization among males attending family planning clinics

Health care utilization of reproductive health care services among males is an emerging issue. This study examined ethnicity as a factor in reproductive health care utilization among 1,606 African American and Hispanic young males attending family planning clinics. Seventy percent were African American and 30% were Hispanic. Across groups, the most received service was treatment for a sexually transmitted infection (STI). African American males were more likely than Hispanic males to have health insurance, report a prior visit to a family planning/STI clinic, and have a history of an STI. Hispanic males had higher rates of employment. The most common source of referral for family planning services for both groups was either a current girlfriend or female friend. Hispanic males were more likely to use family as a referral source than African American males. Differences were also noted in regard to interest in health topics with African American males most interested in STI prevention and getting a job and Hispanic males in services related to working-out/eating well, controlling anger, feeling depressed, and getting along with family. Young males' perceptions of what they consider to be important health care needs should be assessed carefully in order to maintain their interest in returning to the clinics.

Cough in pediatric patients receiving angiotensin-converting enzyme inhibitor therapy or angiotensin receptor blocker therapy in randomized controlled trials

The incidence of cough in children receiving antihypertension therapy with angiotensin-converting enzyme inhibitors (ACEis) or angiotensin receptor blockers (ARBs) is unknown. We analyzed patient-level data from eight randomized trials for the treatment of pediatric hypertension, six of them involving ACEis and two involving ARBs. The incidence of cough in children receiving ACEis (reported cough, 3.2%) was similar to that in children receiving ARBs (reported cough, 1.8%) (P = 0.34). Reports of cough were lower in children than in adults.

Efficacy of a motivational behavioral intervention to promote chlamydia and gonorrhea screening in young women: a randomized controlled trial

BACKGROUND

Seeking screening and treatment for chlamydia (CT) and gonorrhea (GC) by young women is critical to reduction of asymptomatic cervicitis and its complications.

OBJECTIVES

To evaluate the efficacy of a client-centered motivational behavioral intervention (MBI), to promote seeking of sexually tranmitted infection (STI) checkups by young women.

METHODS

Three hundred seventy-six of 770 eligible sexually active, nonpregnant, English-speaking women (mean age 18.5 years) were recruited from an urban reproductive health clinic and randomized to two groups: intervention plus standard care (MBI) or standard care alone (SC). MBI (two sessions plus booster) was based on the Transtheoretical Model of Change and employed motivational interviewing. Outcome measures monitored for 12 months included: client-initiated clinic visits for STI checkups in response to seven high-risk sexual behaviors by self-report (primary), consistent condom use, number of CT and GC episodes, and movement along the stages of change obtained at baseline and 6- and 12-month follow-up assessments (secondary). Analyses included chi-square, logistic regression, and generalized estimating equations.

RESULTS

At baseline, more than 70% endorsed the action stage of change for seeking STI checkups for three of seven high-risk sexual behaviors. No significant differences were noted between the two groups for the primary or secondary outcomes. Across groups, having multiple partners and being pregnant or thinking one might be pregnant were associated with STI checkups.

CONCLUSIONS

This is the first known client-centered clinical trial to promote STI screening. Risk-taking and health-seeking behaviors are complex and interrelated with STI and pregnancy concerns. The intervention may have an effect if it is targeted to women in a less medically connected community-based sample.

Evaluation of "big decisions": an abstinence-plus sexuality curriculum

This study examines the effectiveness of Big Decisions, a sexuality curriculum developed to promote abstinence, as well as condom and contraceptive use, while overcoming school districts' concern about controversy surrounding sex education. The authors used a pre- and post-test survey design to measure changes in attitudes, self-efficacy, and behavioral intentions regarding sex, pregnancy, sexually transmitted diseases, and condom use. The sample for this analysis included 788 inner-city 9th-grade students, the majority of which (78.4%) were Hispanic. Pre- to posttest data comparisons demonstrated improvement in mean scores for each item, with statistically significant changes for 11 of the 12 items measured. The male participants' pretest responses reflected higher risk status than did those of female participants. A large majority (87.8%) of students rated the program as "great" or "good". The results suggest that Big Decisions provides a promising approach to reaching minority students with both abstinence and risk-reduction messages.

Mental health screening in family-planning clinics: a sexual risk-reduction opportunity

This study examined the association between depression, risk behaviors, parental communication, and perceived barriers related to condom use among adolescents attending family-planning clinics. A total of 751 minority women participated in the study. The authors collected data on demographic characteristics, depression, risk behaviors, parental communication about sex-related topics, and perceptions about partner attitudes. Results indicated that 15.2% of adolescents reported depressive symptoms. Depressive symptoms were associated with risk behaviors such as low condom use, substance use, reduced parental communication, and negative perceptions about condom use. These findings suggest that to provide a comprehensive healthcare service to adolescents, the focus of treatment must be expanded beyond the scope of the traditional family planning model. Issues such as depression, risk behaviors, and family communication have to be incorporated in prevention programs to increase the effectiveness of services aimed at risk reduction among adolescents.

Clinical trial design in neonatal pharmacology: effect of center differences, with lessons from the Pediatric Oncology Cooperative Research experience

Survival for premature neonates has improved dramatically over the past 20 years; however, there has been minimal improvement in prematurity-associated morbidities. Morbidity rates and assessment of outcomes vary across neonatology intensive care units (NICUs). Here, we address the reasons underlying these differences, note the impact that this center variation has on trial design and interpretation, and highlight the success of the efforts in pediatric oncology to develop standards of care through the conduct of multicenter clinical trials.

Safety and pharmacokinetics of repeat-dose micafungin in young infants

Given the risk of central nervous system infection, relatively high weight-based echinocandin dosages may be required for the successful treatment of invasive candidiasis and candidemia in young infants. This open-label study assessed the safety and pharmacokinetics (PK) of micafungin in 13 young infants (>48 h and <120 days of life) with suspected candidemia or invasive candidiasis. Infants of body weight > or =1,000 and <1,000 g received 7 and 10 mg/kg/day, respectively, for a minimum of 4-5 days. In the 7-mg/kg/day group, the mean baseline weight and gestational age were 2,101 g and 30 weeks, respectively; in the 10-mg/kg/day group, they were 688 g and 25 weeks, respectively. The median pharmacokinetic values for the 7- and 10-mg/kg/day groups, respectively, were as follows: area under the concentration-time curve from 0 to 24 h (AUC(0-24)), 258.1 and 291.2 microg x h/ml; clearance at steady state adjusted for body weight, 0.45 and 0.57 ml/min/kg; maximum plasma concentration, 23.3 and 24.9 micro g/ml; and volume of distribution at steady state adjusted for body weight, 341.4 and 542.8 ml/kg. No deaths or discontinuations from treatment occurred. These data suggest that micafungin dosages of 7 and 10 mg/kg/day are well tolerated and provide exposure levels that have been shown (in animal models) to be adequate for central nervous system coverage.

Correlates of consistent condom use with main-new and main-old sexual partners

An exploratory study identified correlates of consistent condom use for young women reporting Main-new or Main-old partners in the past 3 months: frequency of vaginal sex (across partner types); perceived likelihood of getting a STI (Main-new); age and STI history (Main-old). To enhance programmatic efficacy in community clinics, these key correlates of condom use for main partner types should be incorporated in STI risk reduction counseling.

Ethnic and Marital Differences in Family Structure, Risk Behaviors, and Service Requests Among Young Minority Fathers

The purpose of this study was to examine ethnic and marital status differences in family structure, risk behaviors and service requests among African American and Hispanic adolescent fathers participating in a community-based fatherhood program. Demographic factors, risk behaviors, and service requests were gathered at program entry. The results indicated that each group demonstrated distinct patterns associated with family structure, sexual risk behaviors, substance use, and criminal behavior. In comparison to African American fathers, Hispanic fathers were younger and were more likely to be married and present at the delivery of their child. African American fathers reported having more children than Hispanic fathers. Disparities in school-related measures were also found, with African American fathers having higher high school graduation rates than Hispanic fathers. The impact of marriage on risk behaviors had mixed results. Services requests were similar for both groups. The finding that different ethnic groups have specific patterns of risk behaviors highlights the importance of considering the ethnic composition of a population when developing future research and interventions.

Young women's perspective of the pros and cons to seeking screening for chlamydia and gonorrhea: an exploratory study

STUDY OBJECTIVE

To identify young women's pros and cons (decisional balance) to seeking chlamydia (CT) and gonorrhea (NGC) screening.

DESIGN

Prospective, cross sectional study

SETTING

Community-based reproductive health clinic

PARTICIPANTS

192 young women (66% African American; mean age 18.9 years).

MAIN OUTCOME MEASURES

Content analysis of responses obtained during a decisional balance exercise (pros and cons) promoting CT and NGC screening was conducted. Thematic categories were developed through a coding process, and each response was assigned to one thematic category. The frequency of pros and cons responses for each category and the frequency of participants endorsing each category were calculated.

RESULTS

Ten thematic categories in relation to pros and cons of seeking CT and NGC screening were: being healthy; awareness of the body; systemic factors around the clinic visit and testing procedures; benefits and aversions around treatment; partner trust issues; confidentiality; prevention of long term adverse effects, protection of the body; concern for others; fear of results/aversion to testing; and logistical barriers. The three most often cited pros were awareness of the body, being healthy and treatment issues; and the three most often cited cons were logistical barriers (time/transportation), fear/aversion to testing, and systemic factors.

CONCLUSIONS

A variety of pros and cons to seeking CT and NGC screening were identified at a community-based clinic. Providers in clinical settings can utilize this information when encouraging patients to seek regular STI screening by elucidating and emphasizing those pros and cons that have the most influence on a young woman's decision-making to seek screening.

Neonatal Candida meningitis: significance of cerebrospinal fluid parameters and blood cultures

OBJECTIVE

The purpose of this study was to examine the frequency of normal cerebrospinal fluid (CSF) parameters in Candida meningitis and the proportion of candidemia associated with Candida meningitis.

STUDY DESIGN

We evaluated the initial lumbar puncture results from infants discharged from 150 Neonatal Intensive Care Units between 1997 and 2004. Candida meningitis was diagnosed by a positive CSF culture or positive Gram stain for yeast. We calculated two-tailed P-values using non-parametric testing, Mann-Whitney, Kruskal-Wallis or Fisher's exact tests where appropriate.

RESULTS

Twenty infants had culture-positive Candida meningitis. Normal CSF parameters were found in 43% (3/7) of the infants with Candida meningitis and only 37% (7/19) of them had positive blood cultures for Candida.

CONCLUSION

Normal CSF parameters do not exclude the diagnosis of neonatal Candida meningitis. The majority of infants in this cohort with Candida meningitis did not have evidence of candidemia at the time of diagnosis.

Caspofungin for the treatment of azole resistant candidemia in a premature infant

Candidemia is common in extremely low birth weight infants and is associated with substantial mortality and morbidity. Treatment options have traditionally been limited to amphotericin B deoxycholate or fluconazole. We present a case of a premature infant with persistent candidemia despite antifungal treatment that responded to therapy with caspofungin, an echinocandin antifungal. The infant's Candida isolate developed resistance to azoles during fluconazole administration and also suffered from severe hypercalcemia during the initiation of caspofungin therapy.