Identifying Foods That Optimize Intake of Key Micronutrients During Pregnancy

BACKGROUND

Most pregnant women in the United States are at risk of inadequate intake of vitamin A, vitamin D, folic acid, calcium, iron, and omega-3 fatty acids from foods alone. Very few United States dietary supplements provide sufficient doses of all 6 nutrients without inducing excess intake.

OBJECTIVE

We aimed to identify energy-efficient foods that provide sufficient doses of these nutrients and could be consumed in lieu of dietary supplements to achieve the recommended intake in pregnancy.

METHODS

In a previous analysis of 2,450 pregnant women, we calculated the range of additional intake needed to shift 90% of participants to intake above the estimated average requirement and keep 90% below the tolerable upper level for these 6 nutrients. Here, we identified foods and beverages from the 2019 to 2020 Food and Nutrient Database for Dietary Studies that provide target levels of these nutrients without exceeding the additional energy intake recommended for pregnancy beginning in the second trimester (340 kilocalories).

RESULTS

We identified 2358 candidate foods meeting the target intake range for at least one nutrient. No candidate foods provided target amounts of all 6 nutrients. Seaweed (raw or cooked without fat) provided sufficient vitamin A, folate, calcium, iron, and omega-3s (5 of 6 nutrients) but would require an intake of >5 cups/d. Twenty-one other foods/beverages (mainly fish, vegetables, and beverages) provided target amounts of 4 of the 6 nutrients. Few foods met targets for vitamin D (n = 54) or iron (n = 93).

CONCLUSIONS

Results highlight the difficulty in meeting nutritional requirements from diet alone and imply that dietary supplements are likely necessary to meet vitamin D and iron targets in pregnancy, as well as omega-3 fatty acid targets for individuals who do not consume fish products. Other foods could be added in limited amounts to help meet intake targets without exceeding caloric recommendations or nutrient safety limits.

Development of a Peer-Based Intervention Educating Teenagers about Long-Acting Reversible Contraception (LARC)

OBJECTIVE

Despite a decrease in teenage pregnancy rates in the U.S. in the past decades, teen pregnancy continues to be a considerable health issue. In this paper, we outline the development of our novel peer-based intervention, appropriately named Get It?, that aims to increase awareness of and self-efficacy to use long-active reversible contraceptives (LARCs) among teenagers.

METHODS

Peer narrative videos were created from audio-recording semi-structured, one-on-one interviews with teenage LARC users. Focus groups of young women 19 years old and younger were conducted to choose the most audience-appropriate videos to be included in the final intervention. Using a thematic content analysis approach, transcripts of the audio-recorded focus groups were reviewed and manually coded.

RESULTS

The final layout of Get It? included 4 videos that were chosen by participants of the focus groups, as well as supplemental activities that included a basic description of the LARC devices, the ability to anonymously post personal stories about LARC that can be shared with others, and the opportunity to email the primary investigator questions about LARC. Thematic analysis of the focus group discussions revealed when it came to narrative videos, participants desired: (1) an authentic narrator, (2) more information on the narrator, (3) narrators displaying ample emotions.

CONCLUSION

Peer narratives play a vital role in influencing a teenager's perspective on their health status, therefore understanding what constitutes reliable narration from an online format was critical in the development of a peer-based electronic intervention that informs teenagers of the most effective contraceptive available to them.

Social determinants of health and their relationships to reproductive outcomes

The medical community has begun to focus on factors that impact not only health but also wellness for both mainstream and disadvantaged communities. Public health initiatives have evaluated nonmedical factors to determine whether they have a broader influence on physical health than traditional medicine, especially in reproductive care. These factors, referred to as social determinants of health (SDOH), affect a variety of medical conditions, have an impact on medical strategies, and suggest that traditional medicine may be more limited than commonly thought. The purpose of this article, therefore, is threefold: First, it will offer a general review of selected components of current SDOH that act as nonmedical factors in health and behavioral wellness. Second, it will present specific SODH and their impact on contraceptive and prenatal care. Finally, it will highlight SODH policies that either enhance or impede the ability of health systems to deliver innovative reproductive services to underserved populations.

Psychological factors that may influence use of long-acting reversible contraceptives (LARC): A qualitative study

Although long-acting reversible contraceptives (LARC) remain the most effective method of contraception for teenagers, most adolescents continue to use less reliable methods. The purpose of this study was to investigate possible psychological factors that may lead to this low uptake rate by studying the LARC decisionmaking process among teenagers. In-depth, semistructured, open-ended interviews of sexually active teenagers who had LARC devices placed prior to 18 years of age were conducted. Four key themes emerged from the interviews: (a) the influences of peers (friends and family members) on LARC decision-making; (b) the lack of awareness about obtaining LARC devices; (c) the fear of weight gain as a driving force during contraceptive and LARC decision-making; and (d) the disproportional anxiety about pain from LARC insertion. The results suggest that a paradigm shift in contraceptive counseling is necessary in order to tackle these psychological barriers to teenage LARC use.

Adolescents Accessing School-Based versus Family Planning Clinics: Chlamydia and Gonorrhea Testing and Treatment Outcomes

Simple Summary

Sexually Transmitted Infections, such as gonorrhea and chlamydia, are common in school-aged youths. These infections can cause significant health problems if not identified and treated early. Current estimates of how widespread these infections are among students receiving healthcare in schools, the role school-based clinics may have in gonorrhea and chlamydia testing and treatment, and information on how the COVID-19 pandemic affected testing and treatment, are lacking. This study was conducted in an urban metropolitan area in the United States, and included 2439 patients aged 13–17 years over a 2-year period. The patients were seen at four school-based and five family planning clinics. We found that 35% of those tested in school-based clinics were positive for chlamydia, and 10% were positive for gonorrhea. The rates of these infections were higher than previous reports from school settings (both pre-COVID-19 and the during COVID-19 pandemic). School-based clinics were able to treat patients with gonorrhea and chlamydia much faster (average ~6 days) than the family planning clinics (average ~18 days). This study shows us the critical role that school-based clinics play in the testing and treatment for gonorrhea and chlamydia infections, and the value of strengthening the services these clinics provide.

Abstract

The prevalence and treatment of chlamydia (CT) and gonorrhea (GC) at school-based clinics (SBCs) requires revisiting. To assess whether clinic type influences CT/GC testing and treatment for minors (individuals 13–17 years of age), our study compared four SBCs with five family planning clinics (FPCs) in the Houston, Harris County metropolitan area of Texas, USA for: (1) the prevalence of CT/GC infection (pre-COVID-19 and during COVID-19); (2) treatment rates at the last positive diagnosis; and (3) the time, in days, from testing-to-diagnosis and testing-to-treatment. Between January 2019 and December 2020, 2439 unique patients (1579 at SBCs, 860 at FPCs) were seen. Of the 1924 tests obtained, 39.2% and 15.9% were positive for CT and GC, respectively. The prevalence of CT and GC at SBCs was similar prior to COVID-19 vs. during the COVID-19 pandemic. SBCs were able to provide treatment significantly faster after diagnosis (mean, 6.07 days; 95% CI, 3.22–8.90; 94.7% were within 30 days) than FPCs (mean, 17.60 days; 95% CI, 10.15–25.12; 84.7% were within 30 days) (p = 0.0257). This comparison within our large clinic system, with consistent clinical management protocols, suggests that SBC care may be critical to ensuring optimal sexually transmitted infection management in minors.

Commentary: Making the case for linking behavioral health strategies to enhance work as a social determinant for youth

This commentary addresses the importance of work as a social determinant of health and the role that behavioral health interventions play in its successful execution. Data on the influence of nonmedical factors on wellness of vulnerable populations is reviewed as well as the need to facilitate acquisition of meaningful employment for post-high school graduates, referred to as opportunity youth. It also discusses the role of behavioral health professionals to proactively manage mental health concerns that negatively influence the employment process. Moreover, it suggests that behavioral health professionals can potentially predict work acquisition success based on participant risks and barriers to employment. Such analyses can affect decisions regarding program participant selection and the assessment of program/staff resources required for a successful pathway to job acquisition. Such insights can provide useful guideposts on how to apply this social determinant theory to effectively integrate this unutilized workforce into productive jobs.

Pregnant Adolescents As Perpetrators and Victims of Intimate Partner Violence

The role of pregnant adolescents as perpetrators of intimate partner violence (IPV) is not well understood. Socioecological factors associated with IPV (physical assault and injury, and psychological aggression) perpetrated by pregnant adolescents and the association between IPV and attitudes toward the use of physical punishment to discipline children were examined among 246 pregnant adolescents. Pregnant adolescents were more likely to report perpetrating both physical assault (24%) and psychological aggression (52.7%) than being the recipient (12.2% and 38.6%, respectively) and having been physically injured (7%) than inflicting injury (4.1%). Risk factors for perpetrating physical assault included prior assault by partner, being African American, exposure to community violence, being in trouble with the police, and multiple lifetime drug use. IPV perpetrators had more favorable attitudes toward the use of physical punishment. Interventions should address IPV and parenting attitudes in young couples to maximize the health and safety of both mother and unborn child.

Comparative safety profile of chloral hydrate versus other sedatives for procedural sedation in hospitalized infants

BACKGROUND

Given the limited available evidence on chloral hydrate safety in neonatal populations and the discrepancy in chloral hydrate acceptance between the US and other countries, we sought to clarify the safety profile of chloral hydrate compared to other sedatives in hospitalized infants.

METHODS

We included all infants <120 days of life who underwent a minor procedure and were administered chloral hydrate, clonidine, clonazepam, dexmedetomidine, diazepam, ketamine, lorazepam, midazolam, propofol, or pentobarbital on the day of the procedure. We characterized the distribution of infant characteristics and evaluated the relationship between drug administration and any adverse event. We performed propensity score matching, regression adjustment (RA), and inverse probability weighting (IPW) to ensure comparison of similar infants and to account for confounding by indication and residual bias. Results were assessed for robustness to analytical technique by reanalyzing the main outcomes with multivariate logistic regression, a doubly robust IPW with RA model, and a doubly robust augmented IPW model with bias-correction.

RESULTS

Of 650 infants, 497 (76%) received chloral hydrate, 79 (12%) received midazolam, 54 (8%) received lorazepam, and 15 (2%) received pentobarbital. Adverse events occurred in 41 (6%) infants. Using propensity score matching, chloral hydrate was associated with a decreased risk of an adverse event compared to other sedatives, risk difference (95% confidence interval) of -12.79 (-18.61, -6.98), p <  0.001. All other statistical methods resulted in similar findings.

CONCLUSION

Administration of chloral hydrate to hospitalized infants undergoing minor procedures is associated with a lower risk for adverse events compared to other sedatives.

Enhancing Parent Consent for School-Based Primary and Reproductive Health Care Among Vulnerable Youth

This quality-improvement initiative evaluated procedures to increase parental consent for students, 13 to 18+ years old, to access a school-based health clinic that provides primary and reproductive health care in a Hispanic immigrant neighborhood in the U.S. Southwest. Six consent-retrieval procedures were sequentially implemented. Procedures included school registration, competition, hand delivery, PTO meetings, self-consent, and mail. Age, grade, and number of completed consents were calculated and compared. The percentage of students with completed consents increased from 35% to 72%. Lessons learned include increasing the number of completed consents is difficult; however, it is important to increase students' access to health-care services.

Intranasal midazolam and fentanyl for procedural sedation and analgesia in infants in the neonatal intensive care unit

BACKGROUND

The intranasal route is a minimally invasive method for rapidly delivering midazolam and fentanyl to provide short-term analgesia and sedation in infants. However, intranasal use of midazolam and fentanyl is not labeled for infants and safety data are sparse. The objective of this study is to evaluate the safety of intranasal midazolam and intranasal fentanyl in infants admitted to the Neonatal Intensive Care Unit (NICU).

METHODS

We retrospectively identified all infants receiving intranasal midazolam or fentanyl in the NICU from 2009 to 2015. We recorded indication for use and vital signs and determined the proportion of infants experiencing the following adverse events: death within 24 hours, hypotension, bradycardia, worsening respiratory status, and chest wall rigidity. Vital signs 4 hours before and after each dose were compared using the Wilcoxon signed-rank test.

RESULTS

We identified 17 infants (gestational ages 23- 41 weeks) receiving 25 intranasal doses. None of the infants died or developed hypotension, bradycardia, or chest wall rigidity. Intranasal delivery was most commonly used for sedation during magnetic resonance imaging studies. Other indications include analgesia or sedation for retinopathy of prematurity surgery, intubation, and peripherally inserted central catheter placement. One infant receiving intranasal midazolam experienced worsening respiratory status. Vital signs before and after dosing were not significantly different.

CONCLUSIONS

Intranasal midazolam and fentanyl use in term and preterm infants appeared safe and well-tolerated in this small cohort of infants. Larger, prospective studies evaluating the safety and efficacy of intranasal midazolam and fentanyl use in infants are warranted.

The association of lipophilic phospholipids with native bovine casein micelles in skim milk: Effect of lactation stage and casein micelle size

A known biological role of casein micelles is to transport calcium from mother to young and provide amino acids for growth and development. Previous reports demonstrated that modified casein micelles can be used to transport and deliver hydrophobic probes. In this study, the distribution of lipid-soluble phospholipids, including sphingomyelins (SM) and phosphatidylcholines (PC), was quantified in whole raw milk, skim raw milk, and casein micelles of various sizes during early, mid, and late lactation stages. Low-pressure size exclusion chromatography was used to separate casein micelles by size, followed by hydrophobic extraction and liquid chromatography-mass spectrometry for the quantification of PC and SM. Results showed that the SM d18:1/23:0, d18:1/22:0, d18:1/16:0, d16:1/22:0, d16:1/23:0, and d18:1/24:0 and the PC 16:0/18:1, 18:0/18:2, and 16:0/16:0 were dominating candidates appearing in maximum concentration in whole raw milk obtained from late lactation, with 21 to 50% of total SM and 16 to 35% of total PC appearing in skim milk. Of the total SM and PC found in skim milk, 35 to 46% of SM and 22 to 29% of PC were associated with the casein micelle fraction. The highest concentrations of SM d18:1/22:0 (341 ± 17 µg/g of casein protein) and PC 16:0/18:1 (180 ± 20 µg/g of casein protein) were found to be associated with the largest casein micelles (diameter = 149 nm) isolated in milk from late lactation, followed by a decrease in concentration as the casein micelle size decreased.

Comprehensive Assessment of Health Needs of Young Minority Males Attending a Family Planning Clinic

The objective of this study was to assess the overall health, including sexual and reproductive health (SRH) knowledge and needs, sexual behaviors, and testicular health practices among young minority males. Anonymous questionnaires were administered to 18- to 25-year-old males receiving services at health clinics in a large southwestern U.S. city. The survey was completed by 258 males with a mean age of 20.8 years. Most young males (67.1%) identified as African American, and 32.9% as Hispanic. Results suggest study participants lack SRH knowledge related to pregnancy and condom effectiveness, and engage in risky sexual behavior including not using birth control at their last sexual encounter. Although 21.6% of participants had a sexually transmitted infection (STI) in the past year, approximately 80% perceived their STI/HIV risk as very low or low. Respondents had low engagement and lack of knowledge of testicular health practices. The majority of respondents (71.1%) reported having been in a physical fight one or more times and 18.1% reported being victims of intimate partner violence. These data support a need for comprehensive health services for minority young males.

A case of infant delirium in the neonatal intensive care unit

Infant delirium is an under-recognized clinical entity in neonatal intensive care, and earlier identification and treatment could minimize morbidities associated with this condition. We describe a case of a 6-month-old former 32 weeks gestation infant undergoing a prolonged mechanical ventilation course diagnosed with delirium related to the combination of his underlying illness and the use of multiple sedative and analgesic medications. Initiation of the atypical antipsychotic risperidone allowed for weaning from continuous infusions of benzodiazepines and opiods, and lower dosages of bolus-dosed sedation and analgesics. The patient experienced no adverse side effects from use of this neuroleptic.

Associations of Family Support, Resiliency, and Depression Symptoms among Indigent Teens Attending a Family Planning Clinic

The goal of this study was to examine the effect of resiliency and family support on depression symptoms among 110 indigent adolescents attending a family planning clinic in a large urban city in southwestern USA. Findings suggested that several of the resiliency domains, on the Individual Protective Factors Index, as well as family support measured by the Family Support Scale, were associated with depression symptoms. Scores on the self-concept and positive outlook dimensions of the Personal Competence domain, the confidence and assertiveness dimensions of the Social Competence domain, and family support correlated with depression symptoms. The findings also suggested that 16.4% of the teens in this clinic would be classified as clinically depressed and as needing further evaluation. It seems reasonable to conclude that resilient adolescents may possess characteristics, beliefs, and supports which enable them to cope with life stressors more effectively and avoid depressive symptoms than those who are not as resilient. Given the prevalence and extent of depression among adolescents, it is important to develop interventions to foster attachment and enhance individual protective factors in primary prevention programs as such interventions may ameliorate the effects of high-risk environments.

Integrating Routine HIV Testing into Family Planning Clinics That Treat Adolescents and Young Adults

OBJECTIVE

Adolescents and young adults remain at high risk for new HIV infections and for unknowingly transmitting the virus to others. Yet, they have demonstrated low rates of testing due to barriers such as stigma and difficulty accessing testing services. Few existing programs have successfully integrated family planning and HIV care services to improve testing and diagnosis rates among young adults and adolescents, particularly those of minority groups. This study describes the process of implementing HIV services into family planning clinics and how to train staff in routine, opt-out testing.

METHODS

This study used HIV screening data from 10 family planning clinics serving adolescents and young adults in Houston, Texas. A total of 34,299 patients were tested for HIV during a 48-month study period, from January 2010 through December 2014.

RESULTS

Patients tested included minors <18 years of age (25.5%), males (22.8%), and individuals who had missed opportunities for HIV testing at other health-care settings. From the opt-in period (2006-2007) to the routine, opt-out period (2008-2010), the yearly average number of tests administered more than doubled; the yearly average increased again by 50% from the routine, opt-out period to the routine, rapid period (2011-2014). Eighty-eight (0.3%) patients were diagnosed with HIV, a higher seropositivity rate than CDC's recommended threshold of 0.1% for settings where routine screening is warranted.

CONCLUSION

Routine, opt-out HIV testing integrated into family planning clinics increased rates of testing acceptance, receipt of test results, and HIV-positive diagnoses among adolescents and young adults.

Choice of Postpartum Contraception: Factors Predisposing Pregnant Adolescents to Choose Less Effective Methods Over Long-Acting Reversible Contraception

PURPOSE

The purposes were to determine contraceptive methods pregnant adolescents intend to use postpartum and to understand factors that predispose intention to use less effective birth control than long-acting reversible contraception (LARC).

METHODS

Participants were 247 pregnant minority adolescents in a prenatal program. Intention was assessed by asking "Which of the following methods of preventing pregnancy do you intend to use after you deliver?" Multinomial logistic regression analysis was used to determine factors associated with intent to use nonhormonal (NH) contraception (male/female condoms, abstinence, withdrawal and no method) or short-/medium-acting hormonal (SMH) contraception (birth control pill, patch, vaginal ring, injectable medroxyprogesterone acetate) compared with LARC (implant and intrauterine device) postpartum.

RESULTS

Twenty-three percent intended to use LARC, 53% an SMH method, and 24% an NH method. Participants who intended to use NH or SMH contraceptive methods over LARC were significantly more likely to believe that LARC is not effective at preventing pregnancy, to report that they do not make decisions to help reach their goals and that partners are not important when making contraceptive decisions. Other important factors were having a mother who was aged >19 years at first birth and had not graduated from high school, not having experienced a prior pregnancy or talked with parents about birth control options, and the perception of having limited financial resources.

CONCLUSIONS

Distinct profiles of factors associated with intending to use NH or SMH contraceptive methods over LARC postpartum were identified and may inform future interventions to promote the use of LARC to prevent repeat pregnancy.

A Socioecological Framework to Assessing Depression Among Pregnant Teens

To examine individual, interpersonal, family, and community correlates associated with moderate-to-severe depressive symptoms among pregnant adolescents. A total of 249 primarily African American and Hispanic pregnant adolescents ages 15-18 years were recruited into either an intervention group utilizing Centering Pregnancy prenatal care and case management, or to a comparison group receiving case management only. Moderate-to-severe depressive symptoms were defined as a score ≥16 on the Center for Epidemiologic Studies Depression Scale (CES-D). Intervention and comparison groups did not significantly differ on demographic characteristics or depression scores at baseline. A total of 115 (46.1 %) participants met criteria for moderate-to-severe depressive symptoms at entry into the program. Pregnant adolescents who were moderately-to-severely depressed were more likely to be African American, to have reported limited contact with the father of the baby, and to have experienced prior verbal, physical or sexual abuse. Depressed adolescents also experienced high levels of family criticism, low levels of general support, and exposure to community violence. A significant number of pregnant adolescents were affected by depression and other challenges that could affect their health. Comprehensive interventions addressing these challenges and incorporating partners and families are needed.

Changes in the Use of Contraception at First Intercourse: A Comparison of the National Survey of Family Growth 1995 and 2006-2010 Databases

STUDY OBJECTIVE

To determine trends in characteristics associated with contraceptive use at coitarche from 1995 to 2006-2010.

METHODS

The National Survey of Family Growth (NSFG) 1995 and 2006-2010 databases were used to abstract variables of interest. Generalized linear models (GLM) were applied to examine the association between the use of contraceptive methods at coitarche and variables abstracted for each database.

RESULTS

Of the 9599 women from the 1995 database included in this study, 3885 (40%) used contraception at coitarche in comparison to 4860 (82%) out of 5931 women assessed in 2006-2010. For both time periods, Hispanic women were significantly less likely to use contraception at coitarche when compared to White women. In the 1995 database, only women from families with incomes >$50,000 were more likely to use contraception at coitarche, while women from families with income > $20,000 were more likely to use contraception at coitarche in 2006-2010. There were some differences noted in the association between age at coitarche and contraception use at coitarche, but in general, women who had a higher age at coitarche were more likely to use contraception. For both time periods, women were more likely to use contraception at coitarche if they used barrier methods as their first form of contraception or if they obtained their first contraceptive method from a spouse, partner, or friend.

CONCLUSIONS

Our results suggest that access to contraception may be associated with use of a contraceptive method at coitarche. Innovative measures need to be investigated so that this young population has increased access to more reliable methods before their first sexual experience.

Reproductive health professionals' adoption of emerging technologies for health promotion

The purpose of this study was to assess reproductive health professionals' familiarity with and use of various electronic technologies to support health promotion. The study also examined the relationship between demographic characteristics and attitudes and beliefs of the effectiveness of new technologies and perceived barriers for usage. A total of 165 reproductive health professionals at two conferences related to reproductive health in the United States completed the study survey. Personal and organizational factors affected the adoption of electronic technologies for health promotion. This included lack of knowledge, skills, and confidence as well as privacy concerns. The results of the study also suggested that being from an older generation was associated with having lower levels of knowledge, skills, and confidence in using new media. These findings highlight the importance of creating learning opportunities on the use of new technology for health promotion as well as addressing specific perceived barriers among reproductive health professionals in order to promote the adoption of these technologies.

Impact of a palliative care program on end-of-life care in a neonatal intensive care unit

OBJECTIVE

Evaluate changes in end-of-life care following initiation of a palliative care program in a neonatal intensive care unit.

STUDY DESIGN

Retrospective study comparing infant deaths before and after implementation of a Palliative Care Program comprised of medication guidelines, an individualized order set, a nursing care plan and staff education.

RESULT

Eighty-two infants died before (Era 1) and 68 infants died after implementation of the program (Era 2). Morphine use was similar (88% vs 81%; P =0.17), whereas benzodiazepines use increased in Era 2 (26% vs 43%; P=0.03). Withdrawal of life support (73% vs 63%; P=0.17) and do-not-resuscitate orders (46% vs 53%; P=0.42) were similar. Do-not-resuscitate orders and family meetings were more frequent among Era 2 infants with activated palliative care orders (n=21) compared with infants without activated orders (n=47).

CONCLUSION

End-of-life family meetings and benzodiazepine use increased following implementation of our program, likely reflecting adherence to guidelines and improved communication.

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.