Cost-effectiveness of solvent/detergent-treated fresh-frozen plasma.

BACKGROUND AND OBJECTIVES: Although transfusion-transmitted infections are rare, non-infectious complications occur relatively frequently. Solvent/detergent-treated fresh-frozen plasma (SD-FFP) has been shown to reduce the frequency of both types of complication, although previous economic evaluations failed to consider non-infective events and subsequently underestimated the benefits of SD-FFP. MATERIALS AND METHODS: A time-series analytical model was used to estimate the incremental cost/life year saved for SD-FFP compared with untreated FFP, having controlled for post-transfusion mortality and patient age. Various infective and non-infective transfusion-related complications were considered. RESULTS: The discounted cost/life year saved for SD-FFP use in the UK was pound sterling 22,728 [95% confidence interval (95% CI): pound sterling 22,604-22,853] for neonates and pound sterling 98,465 (95% CI: pound sterling 97,924-99,005) for patients aged 70. The cost-effectiveness ratio was below pound sterling 50,000/life year saved for patients < or = 48 years of age, and below pound sterling 30,000/life year saved for those < or = 21 years of age. In transfusion recipients with no significant morbidity, the cost-effectiveness ratio was pound sterling 12,335 for neonates and pound sterling 61,692 for 70-year olds. The most important driver of cost-effectiveness was transfusion-related acute lung injury (TRALI), on account of its relatively high incidence and mortality rate. CONCLUSIONS: Previous analyses greatly underestimated the cost-effectiveness of SD-FFP. Inclusion of non-infectious complications suggests that SD-FFP is cost-effective in patients < or = 48 years of age and in older patients with good clinical prognosis, which may justify the wider use of this technology.

Effectiveness of a high school smoking cessation program.

OBJECTIVE: To evaluate the impact of a school-based smoking cessation program targeting adolescents interested in quitting. DESIGN: Randomized clinical trial over one school year. SETTING: Large public high school. PARTICIPANTS: Students interested in quitting smoking. INTERVENTION: Seventy-four students were randomized to receive either: 1) a 6-week, 8-session, classroom-based, smoking cessation curriculum designed for adolescents (n = 35) or 2) an informational pamphlet on how to quit smoking with promise of the classroom curriculum in 3 months (n = 39). OUTCOME MEASURES: Change in smoking behavior measured by: 1) self-reported smoking cessation and exhaled carbon monoxide <6 parts per million (smoke-free); 2) self-reported quit attempts; and 3) change in cigarettes per day (cpd) at the end of the 6-week curriculum and then 4, 10, and 20 weeks later. Saliva cotinine was also measured at these points to validate these outcome measures. Analysis. Intention-to-treat. RESULTS: Participants in the classroom group attended an average of 4.4 sessions. At the end of the curriculum, the classroom group was significantly more likely to be smoke-free (59% vs 17%), to have tried to quit smoking (82% vs 54%), and to reduce mean cpd (7.0 vs 1.0). Four weeks later, these differences persisted: smoke-free (52% vs 20%), quit attempt (85% vs 60%), and reduction in mean cpd (6.6 vs 1.6). Changes in saliva cotinine were consistent with reported outcome measures; those who were smoke-free had a significant reduction in saliva cotinine at the end of the intervention, and at 4 weeks. At 10 and 20 weeks after the curriculum, 41% and 31%, respectively, of the classroom group remained smoke-free. Once participants in the pamphlet group underwent the classroom intervention (average attendance of 2.2 sessions) their cessation rates were similar to the initial group: 31% at the end of the curriculum and 27% 10 weeks later. CONCLUSION: A school-based curriculum for adolescent smoking cessation is more effective than an informational pamphlet alone and reduces cigarette use by adolescents. More research is needed to test the reproducibility, sustainability, and generalizability of this curriculum to offer more smoking cessation options to teenagers.

Screening for iron deficiency anemia by dietary history in a high-risk population.

BACKGROUND: Iron deficiency anemia (IDA) in young children is important to identify because of its adverse effects on behavior and development. Because of costs and inconvenience associated with blood test screening and the decline in prevalence of IDA, the Institute of Medicine and the Centers for Disease Control and Prevention recommend that blood test screening for IDA be targeted to children first identified by dietary and health history. OBJECTIVE: To evaluate a parent-completed dietary and health history as the first stage of 2-stage screening for IDA. DESIGN AND METHODS: A cross-sectional study was conducted in inner-city clinics in children 9 to 30 months old having routine anemia screening as part of a scheduled visit. Parents completed a questionnaire and children had venous blood sampling for complete blood count and ferritin. Anemia was defined as Hb <11.0 g/dL. Iron deficiency (ID) was defined as ferritin <10 microg/L or mean corpuscular volume <70 fL and red cell distribution width >14.5%. Children were categorized into 1 of 4 groups: iron-sufficient, not anemic (ISNA); iron-sufficient, anemic (ISA); iron-deficient, not anemic (IDNA); and iron-deficient anemic (IDA). The questionnaire consisted of 15 dietary items in domains of infant diet, intake of solid food, intake of beverages, and participation in the Special Supplemental Nutrition Program for Women, Infants, and Children together with 14 historical items in domains of birth history, recent illness, chronic medical conditions, history of anemia, and maternal history. Analysis was performed on individual items, domains, and combinations of selected items. RESULTS: In the 282 study subjects, the prevalence of anemia (35%), IDNA (7%), and IDA (8%) did not vary significantly by age. Among individual historical and dietary questions, maternal history of anemia and drinking >2 glasses of juice per day identified the highest proportion of children with IDA: 50% sensitivity (95% confidence interval [CI]: 16,81) and 77% sensitivity (95% CI: 54,89), respectively. However, specificities for these questions were 60% (95% CI: 55,65) and 22% (95% CI: 17,27), respectively. Domains of questions with the highest sensitivity for IDA were beverage intake (91%; 95% CI: 68,99) and intake of solid food (91%; 95% CI: 68,99). However, specificities of the domains were only 14% (95% CI: 10,18) and 29% (95% CI: 24,35), respectively. The dietary items used by Boutry and Needlman were 95% (95% CI: 77, 99) sensitive but only 15% (95% CI: 11,19) specific for IDA. The recommendations of the Centers for Disease Control and Prevention for health and dietary screening were 73% (95% CI: 56,92) sensitive and 29% (95% CI: 24,35) specific for IDA. The individual questions, domains of questions, and interdomain groups of questions had similar sensitivity and specificity for anemia and ID (IDA + IDNA). CONCLUSION: In this high-risk population, neither individual nor combinations of parental answers to dietary and health questions were able to predict IDA, anemia, or ID well enough to serve as a first-stage screening test.

Relationship between primary care practices in medical school admission and the matriculation of underrepresented-minority and female applicants.

PURPOSE: To determine whether primary care-oriented (generalist) admission practices at U.S. medical schools address physician workforce diversity issues by resulting in the admission of more members of underrepresented-minority populations or more women. METHOD: The authors performed cross-sectional, secondary analyses of databases from the Association of American Medical Colleges (AAMC). The independent variables were four generalist admission practices: generalist admission committee chair, greater representation of generalists on admission committee, offering preferential admission to likely generalists, and having a premedical recruitment activity targeting likely generalists. The control variable was public/private school ownership. The dependent variables were the mean ages of the matriculating classes and the proportions of students at each school who were African American, (total) underrepresented minorities, women, and married. RESULTS: Ninety-five percent of medical schools completed the AAMC's Survey of Generalist Physician Initiatives in either 1993 and 1994; 94% of matriculants replied to the AAMC's 1994 Matriculating Student Questionnaire. In multivariable analyses, no admission practice was associated with percentages of African Americans, total underrepresented minorities, or women. CONCLUSIONS: Schools with primary care-oriented admission practices did not admit greater percentages of underrepresented-minority students or women. Additional efforts may be required to attract and admit minority and female applicants.

Evaluation of Hawaii's Healthy Start Program.

Hawaii's Healthy Start Program (HSP) is designed to prevent child abuse and neglect and to promote child health and development in newborns of families at risk for poor child outcomes. The program operates statewide in Hawaii and has inspired national and international adaptations, including Healthy Families America. This article describes HSP, its ongoing evaluation study, and evaluation findings at the end of two of a planned three years of family program participation and follow-up. After two years of service provision to families, HSP was successful in linking families with pediatric medical care, improving maternal parenting efficacy, decreasing maternal parenting stress, promoting the use of nonviolent discipline, and decreasing injuries resulting from partner violence in the home. No overall positive program impact emerged after two years of service in terms of the adequacy of well-child health care; maternal life skills, mental health, social support, or substance use; child development; the child's home learning environment or parent-child interaction; pediatric health care use for illness or injury; or child maltreatment (according to maternal reports and child protective services reports). However, there were agency-specific positive program effects on several outcomes, including parent-child interaction, child development, maternal confidence in adult relationships, and partner violence. Significant differences were found in program implementation between the three administering agencies included in the evaluation. These differences had implications for family participation and involvement levels and, possibly, for outcomes achieved. The authors conclude that home visiting programs and evaluations should monitor program implementation for faithfulness to the program model, and should employ comparison groups to determine program impact.

Is oral albuterol effective for acute cough in non-asthmatic children?

Fifty-nine non-asthmatic children with acute cough were randomized to receive oral albuterol or placebo for 7 d. There was a similar, rapid rate of resolution of acute cough for the two groups, but more shaking or trembling in those treated with albuterol (5/30 vs 0/29; p = 0.05). In ambulatory children with acute cough who have no history of asthma and a normal chest examination, oral albuterol does not reduce the frequency or duration of cough.

Ipratropium bromide added to asthma treatment in the pediatric emergency department.

OBJECTIVE: To determine if the addition of ipratropium bromide to the emergency department (ED) treatment of childhood asthma reduces time to discharge, number of nebulizer treatments before discharge, and the rate of hospitalization. METHODS: Patients >12 months of age were eligible if they were to be treated according to a standardized ED protocol for acute asthma with nebulized albuterol (2.5 mg/dose if weight <30 kg, otherwise 5 mg/dose) and oral prednisone or prednisolone (2 mg/kg up to 80 mg). Subjects were randomized to receive either ipratropium (250 microg/dose) or normal saline (1 mL/dose) with each of the first three nebulized albuterol doses. Further treatment after the first hour was determined by physicians blinded to subject group assignment. Records were reviewed to determine the length of time to discharge home from the ED, number of doses of albuterol given before discharge, and the number of patients admitted to the hospital. RESULTS: Four hundred twenty-seven patients were randomized to ipratropium or control groups; these groups were similar in all baseline measures. Among patients discharged from the ED, ipratropium group subjects had 13% shorter treatment time (mean, 185 minutes, vs control, 213 minutes) and fewer total albuterol doses (median, three, vs control, four). Admission rates did not differ significantly (18%, vs control, 22%). CONCLUSIONS: The addition of three doses of ipratropium to an ED treatment protocol for acute asthma was associated with reductions in duration and amount of treatment before discharge.

Use of social services by pregnant Medicaid eligible women in Baltimore.

OBJECTIVES: To use linked health and social service databases to determine differences in the use of social services by pregnant women in different managed care systems. METHODS: Comparison of service use by women enrolled in a fee-for-service primary care case management program (Maryland Access to Care or MAC), in a capitated health maintenance organization (HMO), or not assigned to managed care using six state databases. Participants included 5181 women receiving Medical Assistance (MA) and delivering in Baltimore City in 1993. Outcome measures were receipt of WIC, AFDC, and Food Stamps. RESULTS: The overall proportions of women receiving WIC, AFDC, and Food Stamps at delivery were 52.7%, 89.2%, and 62.7%, respectively. Women enrolled in an HMO at delivery were less likely to be receiving WIC (adjusted odds ratios, 0.8, 95% CI, 0.69 to 0.93), AFDC (OR, 0.20; CI, 0.03 to 0.43 for women with prior children and OR 0.13; CI, 0.09 to 0.20 for women without prior children), and Food Stamps (OR 0.77; CI, 0.59 to 0.95 for women with prior children and OR, 0.49; CI, 0.35 to 0.67 for women without prior children) than their MAC counterparts. Women not assigned to managed care also generally were less likely than their MAC counterparts to receive WIC (OR 0.55; CI, 0.46, 0.66), AFDC (OR 1.07; CI 0.83, 1.30 for women with prior children and OR 0.24; CI 0.18, 0.34 for women without prior children), and Food Stamps (OR 0.31; CI 0.08, 0.55 for women with prior children and OR 0.31; CI 0.23, 0.41 for women without prior children). CONCLUSIONS: Although many low-income pregnant women qualify for select social services, receipt of WIC and Food Stamps was low. Increasing efforts are needed by managed care systems and public health agencies to ensure delivery of appropriate services for women.

Associations between primary care-oriented practices in medical school admission and the practice intentions of matriculants.

PURPOSE: To assess associations of primary-care-oriented medical school admission practices with matriculants practice intentions. METHOD: The authors performed cross-sectional, secondary analyses of databases from the Association of American Medical Colleges (AAMC). The independent variables were four medical school admission practices. The control variable was school ownership (public vs private). The dependent variables were the proportions of matriculants at each school interested in generalism, rural practice, and locating in a socioeconomically deprived area. RESULTS: One hundred and twenty medical schools (95%) completed the AAMC's Survey of Generalist Physician Initiatives in either 1993 or 1994; 94% of matriculants replied to the AAMC's 1994 Matriculating Student Questionnaire. Twenty-five percent of the schools had admission committee chairs who were generalists, half had over 25% generalists on their admission committees, 64% gave admission preference to students likely to become generalists, and 33% reported premedical recruitment efforts that targeted applicants likely to become generalists. In multivariable analyses, premedical recruitment efforts and public school ownership (all p < .01) were associated with greater interest of matriculants in both generalism and rural practice. CONCLUSIONS: Public medical schools and schools with premedical recruitment activities targeting future generalists admitted greater proportions of students interested in primary care and rural practice.

Modelling different approaches to the management of upper gastrointestinal disease.

A treatment algorithm for the management of upper gastrointestinal (UGI) disease in general practice has been developed by an international group of general practitioners [the International Gastro Primary Care Group (IGPCG)]. When the algorithm was evaluated to consider the overall cost per patient, it was shown to offer savings over current practice in the UK. Adjustments to the algorithm have been proposed, usually on the basis of variations in the place and timing of Helicobacter pylori testing and eradication, with or without endoscopy. This paper evaluates the current cost of UGI disease in the UK, the base IGPCG algorithm and the 5 major alternative scenarios. The original IGPCG algorithm was the least costly option of all those considered, with additional H. pylori testing for all patients with suspected ulcer being the second least expensive option. Routine endoscopies for all patients or for all patients aged more than 45 years were the most expensive scenarios and would require a 16- or 13-fold increase, respectively, in the provision of endoscopy services in the UK. The use of routine endoscopy for all patients aged more than 45 years who were presenting with UGI symptoms for the first time was a mid-priced option, but would still require a 5-fold increase in the provision of endoscopy services. The modelling process highlights the fact that early stratification of patients into diagnostic and treatment groups, on the basis of history and symptom cluster, is a less costly approach than that of early routine endoscopy or H. pylori testing. If H. pylori testing is to be used routinely, then the least costly way is to apply the method to those patients who have symptoms that are more indicative of ulcer disease. All the scenarios considered resulted in lower drug costs than current average UK drug costs per patient per year, and in fewer prescriptions and general practitioner surgery visits per patient. There are several ways in which the management of UGI disease in the UK could be improved with regard to costs and resource utilisation, some of which are presented here. This process emphasises the value of modelling techniques to investigate the consequences of different patient management scenarios.

The father's role during infancy. Factors that influence maternal expectations.

OBJECTIVE: To describe factors that influence maternal expectations of the father's role during infancy. RESEARCH DESIGN: Cross-sectional survey. SETTING: Postpartum obstetric ward of an inner-city teaching hospital. SUBJECTS: Mothers who were residents in the inner-city communities that surround the hospital and who were recently delivered of a newborn. SELECTION PROCEDURE: Consecutive sampling from March to May 1992. MEASUREMENTS: Through structured maternal interviews, the father's expected role was measured in terms of accessibility, engagement in child care tasks, and decision-making responsibility. Influences included demographics, the mother's desire for the father's involvement, and her perceptions of his motivation, prenatal support, and ability to parent. RESULTS: Of 226 eligible mothers, 197 (87%) were interviewed. Expectations varied widely. Concerning accessibility, 48% and 18% of the mothers expected to see the father daily and less than weekly, respectively. Concerning engagement, 81% of the mothers expected some paternal involvement; the average mother assumed that the father would participate in one third of child care tasks. Concerning decision-making responsibility, 34% of the mothers expected to share all decisions; 30% expected to share none. In all areas, expectations were positively associated with the mother's desires, the strength of the parents' relationship, and the mother's perceptions of the father's motivation and ability to parent and the father's prenatal involvement (all, P < .001). Expected accessibility and engagement were greater for fathers who worked; expected engagement and decision-making responsibility were greater for fathers without children from other relationships (all, P < .03). CONCLUSIONS: The maternal desire for the father's participation, the strength of the parents' relationship, the mother's perception of the father as a parent, and the father's prenatal involvement are all consistently associated with the maternal expectations of the father's role. The demographic characteristics of either parent are not as strongly or consistently associated with the maternal expectations.

The influence of medroxyprogesterone on the duration of breast-feeding in mothers in an urban community.

OBJECTIVE: To assess the effect of medroxyprogesterone acetate on lactation when it is given immediately post partum. DESIGN: Prospective cohort study with follow-up through 16 weeks post partum. SETTING: Urban teaching hospital in Baltimore, Md. PARTICIPANTS: Consecutive sample (N = 95) of mothers who were delivered of healthy, term newborns, had home telephones, received either medroxyprogesterone or nonhormonal contraception at discharge, and were currently breast-feeding their newborns. MAIN OUTCOME MEASURES: Lactation (duration and frequency) and timing of first introduction of formula were measured by weekly telephone interviews. RESULTS: Maternal characteristics included the mean +/- SD maternal age (24 +/- 5 years), race (90% African American), history of pregnancy (63% multiparous), marital status or relationship (50% married or living with partner), and medical assistance (81% of the recipients received aid). Women who were receiving medroxyprogesterone (n = 43) were older (P < .05) and were more likely to be married (P < .05) compared with those who were receiving nonhormonal contraception (n = 52). No other factors that were likely to influence lactation were significantly different. Groups did not differ in the baseline-planned duration of lactation. Follow-up data were obtained on 90 women (96%). The groups were comparable in the duration of lactation (medroxyprogesterone: 98%, 74%, 55%, 47%, and 42% were breast-feeding at least once per day at 1, 4, 8, 12, and 16 weeks, respectively [median, 10.14 weeks], vs nonhormonal contraception: 86%, 70%, 47%, 36%, and 30%, respectively [median, 6.57 weeks] [P = .19]). The percentage of subjects who were exclusively breast-feeding at these times and the timing of formula introduction also did not differ by group. CONCLUSION: Medroxyprogesterone, when given to mothers in an urban community immediately after delivery, has no detrimental effect on the duration of lactation, frequency of lactation, and timing of introduction of formula within the first 16 weeks post partum.

Randomised study of cognitive effects of iron supplementation in non-anaemic iron-deficient adolescent girls.

BACKGROUND: Up to 25% of adolescent girls in the USA are iron deficient. This double-blind, placebo-controlled clinical trial assessed the effects of iron supplementation on cognitive function in adolescent girls with non-anaemic iron deficiency. METHODS: 716 girls who enrolled at four Baltimore high schools were screened for non-anaemic iron deficiency (serum ferritin < or = 12 micrograms/L with normal haemoglobin). 98 (13.7%) girls had non-anaemic iron deficiency of whom 81 were enrolled in the trial. Participants were randomly assigned oral ferrous sulphate (650 mg twice daily) or placebo for 8 weeks. The effect of iron treatment was assessed by questionnaires and haematological and cognitive tests, which were done before treatment started and repeated after the intervention. We used four tests of attention and memory to measure cognitive functioning. Intention-to-treat and per-protocol analyses were done. FINDINGS: Of the 81 enrolled girls with non-anaemic iron deficiency, 78 (96%) completed the study (39 in each group). Five girls (three control, two treatment) developed anaemia during the intervention and were excluded from the analyses. Thus, 73 girls were included in the per-protocol analysis. Ethnic distribution, mean age, serum ferritin concentrations, haemoglobin concentrations, and cognitive test scores of the groups did not differ significantly at baseline. Postintervention haematological measures of iron status were significantly improved in the treatment group (serum ferritin 27.3 vs 12.1 micrograms/L, p < 0.001). Regression analysis showed that girls who received iron performed better on a test of verbal learning and memory than girls in the control group (p < 0.02). INTERPRETATION: In this urban population of non-anaemic iron-deficient adolescent girls, iron supplementation improved verbal learning and memory.

Evidence for selective health maintenance organization enrollment among children and adolescents covered by Medicaid.

OBJECTIVE: To determine whether children and adolescents are selectively enrolled in health maintenance organizations (HMOs) based on age, gender, diagnosis, or prior utilization. DESIGN: Case-control study. New HMO enrollees were compared with a control population of non-HMO enrollees. SETTING: Medicaid claims data and HMO participation records for the Medicaid and Aid to Families of Dependent Children sector in Baltimore, Md. RESULTS: Controlling for age, significant differences in prior health care utilization as measured by Medicaid expenditures and hospital days were noted. Children enrolling in HMOs had significantly lower prior utilization than children from the control population as measured by dollar expenditures and hospital days. Young children enrolling in HMOs were only half as likely to have prior claims for asthma. Conversely, adolescents enrolling in HMOs had significantly higher prior utilization than adolescents from the control population. The difference among adolescents was due to a higher birth rate among new HMO enrollees in that age bracket. CONCLUSIONS: Voluntary HMO enrollment of children covered by Medicaid and Aid to Families of Dependent Children sector was subject to selection biases that may be economically favorable to the HMOs and may undermine the cost-containment goals of prepaid health care for Medicaid participants. Voluntary capitated systems where fee-for-service remains a significant alternative must monitor for these selection biases that are not allowed for in the adjustments to capitation rates.

Oral prednisone as a risk factor for infections in children with asthma.

OBJECTIVE: To determine whether the frequency of acute infections in children with asthma is associated with the number of doses of prednisone received for asthma attacks. DESIGN: A cohort study. SETTING: Primary care clinic and emergency department of an inner-city teaching hospital from March 31, 1992, to May 31, 1993. PATIENTS: Convenience sample of clinic enrollees aged 2 to 14 years who had made two or more outpatient visits for acute asthma in the preceding year. Eighty-six children were enrolled. Seventy-eight (91%) completed the study. MAIN OUTCOME MEASURES: The independent variable was cumulative prednisone dose received during the study period. Outcome variables were episodes of acute infections. RESULTS: The mean (+/-SD) number of doses of prednisone (2 mg/kg to a maximum of 60 mg) received was 9.5 +/- 11.8 doses (range, 0 to 57 doses). Ninety-four episodes of acute infection occurred in 50 children. No difference was observed in the mean number of doses of prednisone received by those with the infection compared with those without the infection. No correlation was observed between the number of doses of prednisone received and the number of episodes of each infection. CONCLUSIONS: The administration of prednisone as short courses for acute asthma is not associated with an increase in the number of episodes of common acute infections.

Depressive symptoms, stress, and social support in pregnant and postpartum adolescents.

OBJECTIVE: To assess prospectively the incidence and course of depressive symptoms among pregnant and postpartum adolescents and explore the roles of stress and social support as influencing factors. METHODS: Pregnant teenagers attending a comprehensive adolescent pregnancy and parenting program were enrolled during their third trimester of pregnancy and followed up through 4 months post partum. Depressive symptoms and social support were measured with validated, self-administered instruments during the third trimester and at 2 and 4 months post partum. Stress was measured during the prenatal and postpartum periods. RESULTS: Study participants (N=125) were predominantly black (93%), and wee aged 12 to 18 years. Completed assessments were obtained from 114 subjects at 2 months post partum and 108 at 4 months. Forty-two percent had significant depressive symptoms in the third trimester, with 36% and 32% having scores that indicated depression at 2 and 4 months post partum. Stress levels increased significantly from the third trimester to the postpartum period (P < .01) and were positively associated with depressive symptoms. Receiving social support from the adolescent's mother or the infant's father, especially in the postpartum period, was significantly associated with lower rates of depression. Reporting conflict with the infant's father was strongly associated with increased rates of depressive symptoms. CONCLUSIONS: Results indicate that depressive symptoms are common among pregnant teenagers and postpartum adolescents. Stress and social support appear to be important mediators. Identifying those teenagers with high stress and conflict and low levels of support will help identify those who are at particular risk for depressive symptoms.

Association between postpartum substance use and depressive symptoms, stress, and social support in adolescent mothers.

OBJECTIVE: Substance use by pregnant teenagers is an important public health problem, but published data on alcohol and illicit drug use by parenting teenagers are virtually nonexistent. This study determined the prevalence of alcohol and drug use in adolescent mothers in the first 4 months postpartum and explored associated psychosocial characteristics. METHODS: Teenagers attending a comprehensive adolescent pregnancy and parenting program were enrolled consecutively during a routine third trimester prenatal visit. Alcohol use since delivery was determined by self-report at 4 months postpartum using an instrument developed for the 1984 Survey of Drug Abuse Among Maryland Adolescents. Illicit drug use was measured with anonymous quantitative urine drug screens at 2 and 4 months postpartum. Depressive symptoms, stress, and social support were assessed at 2 and 4 months postpartum using validated, self-administered instruments. Differences in demographic characteristics, peer group influences, and psychosocial variables between substance users and nonusers were evaluated. RESULTS: Participants (125/129 eligible) were predominantly African-American, mean age 16.3 years. Completed assessments were obtained from 110 at 2 months and 105 at 4 months postpartum. Forty-two percent screened positive for illicit drugs at a postpartum visit or reported using alcohol since delivering their baby and were classified as substance users. Thirty-one percent of subjects reported alcohol use since delivery. Marijuana was the most prevalent illicit drug (14%), followed by opiates (5%), and cocaine (4%). When substance users were compared with nonusers, 44% versus 24% scored depressed (P = .02), 62% versus 43% had high stress (P = .04), and 62% versus 44% reported a high need for social support (P = .07). Results of logistic regression, after controlling for age, indicated that illicit substance and/or alcohol use was 3.3 times greater for those who were depressed, 2.8 times greater if they reported friends' using illicit drugs, and 6.7 times greater if the adolescent reported smoking cigarettes since delivery. CONCLUSIONS: This study indicates that alcohol and drug use are common among this sample of postpartum teenage mothers and that depression, stress, high support need, and peer group drug use are associated factors. Although this study cannot determine whether depression and stress precede or result from use of substances, attention to these factors appears warranted in the care of adolescent mothers.

Outcomes of adolescents using levonorgestrel implants vs oral contraceptives or other contraceptive methods.

OBJECTIVE: To compare outcomes among adolescents who use levonorgestrel implants, oral contraceptives, or other methods of birth control. DESIGN: Prospective, longitudinal study of 166 females who were followed up for 6 months. Fifty-four used implants, 64 used oral contraceptives, and 48 used condoms alone or with spermicide, or no contraceptive. Outcomes were measured by patient interview and medical chart review. SETTING: Inner-city, hospital-based adolescent and teenaged mother and baby clinic between April 1, 1992, and May 31, 1993. PARTICIPANTS: Sexually active 12- to 18-year-old females at least 1 year postmenarche who had no contraindications to use of hormonal contraceptives. MAIN OUTCOME MEASURES: Sexual activity, pregnancy rates, condom use, incidence of sexually transmitted disease, patient satisfaction continuation rates, and side effects. RESULTS: Despite similar reports of sexual activity, one subject who used the implant (2%) vs 13 subjects who used oral contraceptives (20%), and eight subjects who used other methods (17%) became pregnant (chi 2, P < .50). Condom use did not differ among groups (chi 2, P > .60). Overall, 30% of subjects contracted a new sexually transmitted disease; rates did not differ by method (chi 2, P = .92). Implant users were more likely than oral contraceptive users to continue their method (87% vs 50%; chi 2, P < .001) despite similar satisfaction scores (one-way analysis of variance, P = .52). Implant users were more likely to experience irregular menses, mood swings, acne, and hair loss (chi 2, P < .05). CONCLUSIONS: In this population, the levonorgestrel implant is an effective method of pregnancy prevention and is associated with high satisfaction and continuation rates at 6 months. Implant users are not at greater risk than others for sexually transmitted disease. Health care providers should continue to stress the use of barrier methods to all sexually active adolescents.