Relationship between long-acting reversible contraception and acne in a cohort of adolescents and young adults

BACKGROUND

The use of progestin-only long-acting reversible contraception (LARC) may be a risk factor for acne. Few studies have focused primarily on the effects of hormonal LARC on the development or exacerbation of acne in adolescents and young adults. We sought to understand the incidence and management of acne following hormonal LARC insertion in this adolescent/young adult population.

METHODS

A secondary data analysis was conducted of prospectively collected quality improvement (QI) data from the Adolescent Medicine LARC Collaborative. Subjects were evaluated by clinicians in adolescent medicine clinics at participating study sites, and acne severity was documented using a standardized recording instrument and scale. Descriptive statistics were reported as frequencies and percentages for categorical variables or mean and standard deviation (SD) for continuous variables. We compared demographic and clinical characteristics by those who had worsening acne, accounting for site inter-correlation using Cochran-Mantel-Haenszel chi-square tests for categorical variables and linear generalized estimating equation (GEE) regression for continuous variables.

RESULTS

Of 1319 subjects who completed LARC insertion, 28.5% (376/1319) experienced worsening acne following use of progestin-only LARC. Acne was a contributing factor to LARC removal in only 3% (40/1319), and the sole reason for removal in 0.4% (5/1319) of all subjects. As this was a secondary analysis of prospectively collected QI data, limitations of this study include incomplete or inaccurate documentation of acne severity. Moreover, LARC insertions without follow-up/removal visits or with only follow-up/removal within 8 weeks of insertion were excluded from our study, which may also bias results.

CONCLUSIONS

Adolescents and young adults seeking progestin-only LARC should be counseled about the potential for developing acne or experiencing a worsening of existing acne during LARC use. However, acne was not a common reason for LARC discontinuation.

Opioid dependence among pregnant and post-partum incarcerated individuals: A review of the literature

BACKGROUND

Pregnant and post-partum women with opioid dependence are an extremely vulnerable population within correctional facilities. A significant number of maternal inmates, however, still lack adequate provision of medications for opioid use disorder (OUD) and are subsequently forced into withdrawal. Currently, there exist no comprehensive reviews on the scope of literature regarding the management of this population. We aimed to provide a review on the research surrounding these women.

DESIGN

A systematic search of PubMed Central was conducted to identify studies evaluating OUD among pregnant and post-partum incarcerated women. Citations from only the last 20 years were included to ensure both relevance and scope of information.

RESULTS

The topics that emerged from this review included medications for OUD (MOUD) administration vs detoxification practices, treatment upon incarceration and upon release, and maternal and fetal outcomes. Across all articles, current care management of this population appeared inadequate. We further compiled all author recommendations and perspectives into a framework that can inform potential improvements in care coordination.

CONCLUSIONS

This review identifies significant gaps in current management-particularly regarding administration of MOUDs-and emphasizes the need for standardization of addiction-related and perinatal healthcare. We also highlight gaps in the literature and potential areas for future research.

Quantifying Procedure-level Prophylaxis Misutilization in Pediatric Surgery: Implications for the Prioritization of Antimicrobial Stewardship Efforts

OBJECTIVE

To quantify procedure-level inappropriate antimicrobial prophylaxis utilization as a strategy to identify high-priority targets for stewardship efforts in pediatric surgery.

BACKGROUND

Little data exist to guide the prioritization of antibiotic stewardship efforts as they relate to prophylaxis utilization in pediatric surgery.

METHODS

This was a retrospective cohort analysis of children undergoing elective surgical procedures at 52 children's hospitals from October 2015 to December 2019 using the Pediatric Health Information System database. Procedure-level compliance with consensus guidelines for prophylaxis utilization was assessed for indication, antimicrobial spectrum, and duration. The relative contribution of each procedure to the overall burden of noncompliant cases was calculated to establish a prioritization framework for stewardship efforts.

RESULTS

A total of 56,845 cases were included with an overall inappropriate utilization rate of 56%. The most common reason for noncompliance was unindicated utilization (43%), followed by prolonged duration (32%) and use of excessively broad-spectrum agents (25%). Procedures with the greatest relative contribution to noncompliant cases included cholecystectomy and repair of inguinal and umbilical hernias for unindicated utilization (63.2% of all cases); small bowel resections, gastrostomy, and colorectal procedures for use of excessively broad-spectrum agents (70.1%) and pectus excavatum repair and procedures involving the small and large bowel for prolonged duration (57.6%). More than half of all noncompliant cases were associated with 5 procedures (cholecystectomy, small bowel procedures, inguinal hernia repair, gastrostomy, and pectus excavatum).

CONCLUSIONS

Cholecystectomy, inguinal hernia repair, and procedures involving the small and large bowel should be considered high-priority targets for antimicrobial stewardship efforts in pediatric surgery.

Trends in the use of surgical antibiotic prophylaxis in general pediatric surgery: Are we missing the mark for both stewardship and infection prevention?

BACKGROUND

The purpose of this study was to assess compliance with antimicrobial spectrum guidelines in the use of surgical antibiotic prophylaxis (SAP) in pediatric surgery.

METHODS

A retrospective cohort study of children undergoing elective clean-contaminated and clean surgical procedures with foreign body implantation using the Pediatric Health Information System database (10/2015-6/2018) was performed. Compliance rates with consensus guidelines surrounding appropriate spectrum of SAP coverage were calculated for each procedure. Undertreatment was defined as the use of SAP with inappropriately narrow coverage (or omission altogether), while overtreatment was defined as inappropriately broad coverage.

RESULTS

Eight procedure groups including a total of 15,708 patients were included. Overall, 44% of cases received inappropriate prophylaxis, of which 58% were considered undertreatment and 42% overtreatment. Procedures with the highest rates of overtreatment included small bowel procedures (77%), colorectal procedures (29%), and hepatobiliary procedures (20%), while the highest rates of undertreatment were associated with placement of tunneled central venous catheters and ports (43%), hepatobiliary procedures (24%), and colorectal procedures (20%).

CONCLUSION

Noncompliance with the recommended spectrum of coverage for surgical antibiotic prophylaxis is common in pediatric surgery, with both over and undertreatment being common themes. Improved compliance is needed to optimize both antibiotic stewardship and infection prevention.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

Impact of standardized protocols for cytomegalovirus disease prevention in pediatric solid organ transplant recipients

End-organ disease caused by CMV is a significant cause of morbidity and mortality in pediatric SOT recipients. Pediatric transplant centers have adopted various approaches for CMV disease prevention in this patient population. We observed significant practice variation in CMV testing, prophylaxis, and surveillance across SOT groups in our center. To address this, we implemented evidence-based standardized protocols and measured outcomes pre- and post-implementation of these protocols. We performed retrospective chart review for SOT recipients from 2009 to 2014 at Boston Children's Hospital. Using descriptive statistics, we measured practice improvement in provision of appropriate prophylaxis, occurrence of neutropenia and associated complications, and occurrence of CMV DNAemia and CMV disease pre- and post-intervention. The pre- and post-intervention periods included 141 and 109 patients, respectively. With the exception of kidney transplant recipients, provision of appropriate valganciclovir prophylaxis improved across SOT groups post-intervention (P < .01). Occurrence of >1 episode of neutropenia was greater in the preintervention period (30% vs 10%, P < .001). In both periods, neutropenia was associated with few episodes of invasive infections. The occurrence of CMV disease did not differ and was overall low. However, due to routine surveillance a significantly greater number of asymptomatic CMV DNAemia episodes were identified and treated in the post-intervention period. Implementation of standardized prevention protocols helped to improve the provision of appropriate prophylaxis to patients at risk for CMV acquisition, increased the diagnosis and treatment of asymptomatic CMV DNAemia, and decreased episodes of recurrent neutropenia in patients receiving prophylaxis.

280. The Impact of a Revised Neutropenic Fever Guideline on Vancomycin-Resistant Enterococcus Rates in Pediatric Oncology Patients

Background

Data on the impact of empiric febrile neutropenia (FN) guidelines on resistant bacteria in pediatric oncology patients are limited. We implemented a risk-stratified guideline for empiric FN antibiotics, limiting vancomycin use to high-risk patients for 48 hours if cultures were negative. Our aim was to assess the impact of this intervention on rates of vancomycin-resistant Enterococcus (VRE) and vancomycin use.

Methods

We conducted a retrospective, quasi-experimental study of oncology patients ≤ 18 years with FN admitted from 2010 to 2014. Microbiologic data and inpatient antibiotic use were obtained by chart review. Risk strata incorporated diagnosis, chemotherapy phase, Down syndrome, septic shock, and typhlitis. The primary outcome was VRE incidence; all VRE isolates were included but active surveillance was only performed in intensive care units (ICUs) in both periods. We compared VRE incidence and antibiotic days of therapy (DOT) before and after the intervention using interrupted time-series analysis with segmented Poisson regression with auto-correlation.

Results

We identified 183 patients with 765 admissions and 382 FN episodes pre-intervention, and 185 patients with 830 admissions and 385 FN episodes post-intervention. The proportion of high-risk patients was 51% pre vs. 45% post (P = 0.06). Median length of stay for FN admissions was 7 days (IQR: 4–22) preintervention and 5 days (IQR: 3–15) postintervention (P ≤ 0.01). Median duration of empiric vancomycin decreased from 5 days (IQR: 3–9) pre- to 3 days (IQR: 3–4) postintervention (P ≤ 0.01). Empiric vancomycin DOT/1,000 FN days decreased from 287 preintervention to 199 postintervention (P ≤ 0.01). Incidence of VRE/1,000 patient-days decreased significantly from 1.71 preintervention to 0.45 postintervention (IRR=0.26, 95% CI 0.09–0.80; P = 0.02). The proportion of VRE isolates representing colonization did not differ significantly pre- and postintervention (50% vs. 67%).

Conclusion

Implementation of an FN guideline limiting vancomycin exposure was associated with decreased incidence of VRE among pediatric oncology patients. Antimicrobial stewardship interventions are feasible in immunocompromised patients and can impact antibiotic resistance.

Disclosures

All authors: No reported disclosures.

Outcomes from an orientation model to reduce attrition in paediatric weight management

We aimed to reduce attrition of newly referred patients in a paediatric weight management programme by implementing an orientation to address families' expectations and screen for and support behavioural and mental health problems and psychosocial stressors at programme outset. Orientation impact was monitored with run charts with percentages of scheduled encounters completed. Long-term impact was assessed by comparing patients in the initial 6 months of the orientation to a baseline group of referred patients during the same 6-month time interval in the prior year (Pre-Orientation Group). The outcome measure was programme attrition within 15 months. Groups were compared using Kaplan-Meier survival analysis and Cox proportional hazards regression modelling. Patients in the Orientation Group had a 23% increased odds of attrition compared to patients in the Pre-Orientation group (adjusted Hazard ratio, aHR 1.23; 95% confidence interval, CI: 1.01, 1.51) and shorter median duration of follow-up (2.0 vs. 2.9 months, P = 0.004). An increase in body mass index z-score of 1 unit resulted in a nearly fivefold increased odds of attrition (aHR 5.24; 95% CI: 2.95, 9.3). An orientation for new patients did not reduce attrition within 15 months. We suggest that ongoing retention strategies should be embedded into the treatment phase of the programme.

Exposure to violence in childhood is associated with higher body mass index in adolescence

To determine whether different types of childhood adversity are associated with body mass index (BMI) in adolescence, we studied 147 adolescents aged 13-17 years, 41% of whom reported exposure to at least one adversity (maltreatment, abuse, peer victimization, or witness to community or domestic violence). We examined associations between adversity type and age- and sex-specific BMI z-scores using linear regression and overweight and obese status using logistic regression. We adjusted for potential socio-demographic, behavioral, and psychological confounders and tested for effect modification by gender. Adolescents with a history of sexual abuse, emotional abuse, or peer victimization did not have significantly different BMI z-scores than those without exposure (p>0.05 for all comparisons). BMI z-scores were higher in adolescents who had experienced physical abuse (β=0.50, 95% CI 0.12-0.91) or witnessed domestic violence (β=0.85, 95% CI 0.30-1.40). Participants who witnessed domestic violence had almost 6 times the odds of being overweight or obese (95% CI: 1.09-30.7), even after adjustment for potential confounders. No gender-by-adversity interactions were found. Exposure to violence in childhood is associated with higher adolescent BMI. This finding highlights the importance of screening for violence in pediatric practice and providing obesity prevention counseling for youth.

School social capital and body mass index in the National Longitudinal Study of Adolescent Health

BACKGROUND

Social capital in neighborhoods and workplaces positively affects health. Less is known about the influence of school social capital on student health outcomes, in particular weight status. We sought to examine the association between individual- and school-level social capital and student body mass index (BMI).

METHODS

Analyzing data from the National Longitudinal Study of Adolescent Health, a nationally representative sample of adolescents in grades 7-12 (N = 13,428), we used principal components analysis to define 3 school social capital factors: "connectedness" (feel part of/close to people/safe in school), "treatment" (get along with teachers/students, teachers treat students fairly), and "parental involvement" (school administrator reported percent family/parent self-reported participation in Parent Teacher Organization, average daily school attendance). We examined the associations between individual- and school-level social capital and individual BMI using multilevel modeling techniques.

RESULTS

In girls, both feeling connected to one's school (β = -0.06, p < .05) and attending schools with overall high connectedness (b = -0.43, p < .01) were associated with lower BMIs. In boys only attending a school with high "treatment" was inversely associated with BMI (b = -0.61, p < .01), adjusting for individual and school demographics.

CONCLUSIONS

Although further studies are needed, our findings suggest enhancing school social capital as a novel approach to addressing student obesity.

Child maltreatment and blood pressure in young adulthood

Adverse childhood experiences are associated with hypertension in older adults. This study assessed whether an association between child maltreatment and blood pressure is detectable in young adults and whether any association differs by sex or is modified by genetic polymorphisms known to be involved in stress sensitivity. We examined these patterns in a sample of 12,420 young adults ages 24-32 years who participated in Wave IV of the National Longitudinal Study of Adolescent Health. Participants retrospectively reported history of physical, emotional, or sexual abuse before age 18 years. Participants with a systolic blood pressure (SBP) ≥140 mmHg or a diastolic blood pressure (DBP) ≥90 mmHg were classified as hypertensive. We used sex-stratified linear and logistic regression models to assess associations between each type of childhood maltreatment and SBP, DBP, and hypertension. We created interaction terms to assess for effect modification of any relationship between maltreatment and blood pressure by sex or SLC64A genotype. Fifteen percent of females and 31.5% of males were hypertensive. Frequent physical abuse in childhood was reported by 5%, frequent emotional abuse by 12%, and any sexual abuse by 5%. No association was observed between abuse history and blood pressure in either males or females, nor was effect modification present by SLC64A genotype. Child maltreatment exposure was not associated with blood pressure or hypertension in young adults in this study. Future studies should investigate additional critical windows for the effect of child maltreatment on cardiovascular health.

Diagnosing dysglycemia in adolescents with polycystic ovary syndrome

PURPOSE

Screening for impaired glucose tolerance (IGT) is recommended for adolescents with polycystic ovary syndrome (PCOS) with oral glucose tolerance test (OGTT). Whether glycated hemoglobin (HbA1c) can be used for screening in this patient population is unknown. We sought to determine the utility of HbA1c and 2-hour OGTT for diagnosing dysglycemia in adolescents with PCOS.

METHODS

This was a retrospective cohort study of 68 adolescents with PCOS seen in the Boston Children's Hospital Division of Adolescent Medicine between 2008 and 2011 and not known to have diabetes. Prevalence of dysglycemia (impaired fasting glucose, IGT, increased risk for diabetes, or diabetes mellitus as diagnosed by fasting plasma glucose, 2-hour OGTT, and/or HbA1c) and sensitivity and specificity of HbA1c for diagnosing dysglycemia compared with OGTT were assessed.

RESULTS

Twenty-four participants had abnormal glucose testing, including one participant (1.5%) who met criteria for diabetes mellitus and 23 participants (34%) who met criteria for impaired fasting glucose/IGT/prediabetes. More patients were identified as having dysglycemia by HbA1c than OGTT. Compared with OGTT, HbA1c had a sensitivity of 60% and a specificity of 69% for diagnosing dysglycemia.

CONCLUSIONS

In adolescents with PCOS, HbA1c had moderate sensitivity and specificity for detecting dysglycemia compared with OGTT. Clinicians should be aware that both tests have benefits and limitations, and the optimal test for follow-up requires further study.