Concentrations of metals in blood and feathers of nestling ospreys (Pandion haliaetus) in Chesapeake and Delaware Bays.

In 2000, 2001, and 2002, blood and feather samples were collected from 40-45-day-old nestling ospreys (Pandion haliaetus) from Chesapeake Bay and Delaware Bay and River. Concentrations of 18 metals, metalloids, and other elements were determined in these samples by inductively coupled plasma-mass spectroscopy, and Hg concentrations were measured by cold vapor atomic absorption spectroscopy. When compared to concurrent reference areas (South, West, and Rhode Rivers), mean As and Hg concentrations in blood were greater (p < 0.05) in two of three Chesapeake Bay regions of concern (Baltimore Harbor [As: 1.18 vs. 0.548 microg/g dw], Anacostia River [Hg: 0.305 vs. 0.178 microg/g dw], and Elizabeth River [As: 0.876 vs. 0.663 microg/g dw; Hg: 0.260 vs. 0.180 microg/g dw]). Lead was detected more frequently in blood of nestlings from the highly industrialized Elizabeth River compared to the rural reference area. When compared to the concurrent reference area, mean Al, Ba, Hg, Mn, and Pb concentrations in feathers were substantially greater (p < 0.05) in one or more Chesapeake regions of concern (Anacostia River [Al: 206 vs. 62.1 microg/g dw; Ba: 3.31 vs. 0.823 microg/g dw; Mn: 65.4 vs. 22.9 microg/g dw] and Elizabeth River [Al: 165 vs. 63.5 microg/g dw; Hg: 1.24 vs. 0.599 microg/g dw; Pb 1.47 vs. 0.543 microg/g dw]). When compared to the coastal Inland Bays reference area, feathers of nestlings from northern Delaware Bay and River had greater concentrations (p < 0.05) of Ba (1.90 vs. 0.660 microg/g dw), Fe (258 vs. 109 microg/g dw), Mn (18.5 vs. 4.66 microg/g dw), Mo (0.130 vs. 0.040 microg/g dw), Pb (1.96 vs. 0.624 microg/g dw), and V (0.671 vs. 0.325 microg/g dw), presumably due to extensive metal-working and petroleum refinery activities. Concentrations of Hg in nestling feathers from Delaware were frequently greater than in the Chesapeake. The present findings and those of related reproductive studies suggest that concentrations of several heavy metals (e.g., Cd, Hg, Pb) in nestling blood and feathers from Chesapeake and Delaware Bays were below toxicity thresholds and do not seem to be affecting chick survival during the nestling period.

Retrospective ecotoxicological data and current information needs for terrestrial vertebrates residing in coastal habitat of the United States.

The Contaminant Exposure and Effects-Terrestrial Vertebrates (CEE-TV) database was developed to conduct simple searches for ecotoxicological information, examine exposure trends, and identify significant data gaps. The CEE-TV database contains 16,696 data records on free-ranging amphibians, reptiles, birds, and mammals residing in estuarine and coastal habitats of the Atlantic, Gulf, and Pacific coasts, Alaska, Hawaii, and the Great Lakes. Information in the database was derived from over 1800 source documents, representing 483 unique species (about 252,000 individuals), with sample collection dates spanning from 1884 to 2003. The majority of the records contain exposure data (generally contaminant concentrations) on a limited number (n = 209) of chlorinated and brominated compounds, cholinesterase-inhibiting pesticides, economic poisons, metals, and petroleum hydrocarbons, whereas only 9.3% of the records contain biomarker or bioindicator effects data. Temporal examination of exposure data provides evidence of declining concentrations of certain organochlorine pesticides in some avian species (e.g., ospreys, Pandion haliaetus), and an apparent increase in the detection and possibly the incidence of avian die-offs related to cholinesterase-inhibiting pesticides. To identify spatial data gaps, 11,360 database records with specific sampling locations were combined with the boundaries of coastal watersheds, and National Wildlife Refuge and National Park units. Terrestrial vertebrate ecotoxicological data were lacking in 41.9% of 464 coastal watersheds in the continental United States. Recent (1990-2003) terrestrial vertebrate contaminant exposure or effects data were available for only about half of the National Wildlife Refuge and National Park units in the geographic area encompassed by the database. When these data gaps were overlaid on watersheds exhibiting serious water quality problems and/or high vulnerability to pollution, 72 coastal watersheds, and 76 National Wildlife Refuge and 59 National Park units in the continental United States were found to lack recent terrestrial vertebrate ecotoxicology data. Delineation of data gaps in watersheds of concern can help prioritize monitoring in areas with impaired water quality and emphasize the need for comprehensive monitoring to gain a more complete understanding of coastal ecosystem health.

Contaminant exposure and reproductive success of ospreys (Pandion haliaetus) nesting in Chesapeake Bay regions of concern.

The Chesapeake Bay osprey population has more than doubled in size since restrictions were placed on the production and use of DDT and other toxic organochlorine contaminants in the 1970s. Ospreys are now nesting in the most highly polluted portions of the Bay. In 2000 and 2001, contaminant exposure and reproduction were monitored in ospreys nesting in regions of concern, including Baltimore Harbor and the Patapsco River, the Anacostia and middle Potomac rivers, and the Elizabeth River, and a presumed reference site consisting of the South, West, and Rhode rivers. A "sample egg" from each study nest was collected for contaminant analysis, and the fate of eggs remaining in each nest (n = 14-16/site) was monitored at 7- to 10-day intervals from egg incubation through fledging of young. Ospreys fledged young in regions of concern (observed success: 0.88-1.53 fledglings/active nest), although productivity was marginal for sustaining local populations in Baltimore Harbor and the Patapsco River and in the Anacostia and middle Potomac rivers. Concentrations of p,p'-DDE and many other organochlorine pesticides or metabolites, total PCBs, some arylhydrocarbon receptor-active PCB congeners and polybrominated diphenyl ether congeners, and perfluorooctanesulfonate were often greater in sample eggs from regions of concern compared to the reference site. Nonetheless, logistic regression analyses did not provide evidence linking marginal productivity to p,p'-DDE, total PCBs, or arylhydrocarbon receptor-active PCB congener exposure in regions of concern. In view of the moderate concentrations of total PCBs in eggs from the reference site, concerns related to new and emerging toxicants, and the absence of ecotoxicological data for terrestrial vertebrates in many Bay tributaries, a more thorough spatial evaluation of contaminant exposure in ospreys throughout the Chesapeake may be warranted.

Eating disorders in children and adolescents: epidemiology, diagnosis and treatment.

Eating disorders such as anorexia nervosa (AN) and bulimia nervosa (BN) are increasingly prevalent among children and adolescents. Whereas AN has a peak age of onset in early to mid-adolescence, BN typically presents during or after late adolescence. There is a spectrum of eating disorders that can be categorised by the criteria in the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders into AN, BN and 'eating disorder not otherwise specified (ED-NOS)'. The key clinical signs of AN are those of protein calorie malnutrition. In BN, signs of purging are also important. Despite marked physical changes, metabolic decompensation occurs late and when present is an indication for hospital admission. During refeeding, electrolyte disturbances, in particular hypophosphataemia, should be serially monitored. For females with AN, restoration of gonadotropins, oestradiol and resumption of menses is a cardinal indicator of nutritional recovery. Treatment should address the medical, nutritional and psychological needs of children and adolescents with eating disorders. No single professional can be proficient in all spheres. Children and adolescents with eating disorders are best managed by a 'team approach'. Treatment may occur in a variety of inpatient, daypatient or outpatient settings. The aims of medical treatment are to promote bodyweight gain and nutritional recovery. Psychiatric goals address the psychosocial precipitants, treat comorbid mood symptoms and assist the patient to develop alternative coping skills. The crude mortality of AN has decreased to around 6%. For children and adolescents, the morbidity from malnutrition is increased because of the biological changes that are interrupted.

Emergency contraception: pediatricians' knowledge, attitudes, and opinions.

UNLABELLED: Emergency contraception (EC) is the use of a method of contraception after unprotected intercourse to prevent unintended pregnancy. Although first described over 20 years ago, physician awareness of EC has been limited and many feel uncomfortable prescribing it. OBJECTIVE: To assess the knowledge, attitudes, and opinions of practicing pediatricians regarding the use of EC in adolescents. METHODS: An anonymous questionnaire was mailed to all 954 active members of New York Chapter 2, District II of the American Academy of Pediatrics. The questionnaire assessed basic knowledge, attitudes, and opinions regarding EC in adolescents. Data were analyzed by physician age, gender, year completed residency, and practice type. RESULTS: Two hundred thirty-three practicing pediatricians (24.4%) completed the survey. Of the respondents, 23.7% had been asked to prescribe EC to an adolescent and 49% of these cases involved a rape victim. Only 16.7% of pediatricians routinely counsel adolescent patients about the availability of EC, with female pediatricians more likely to do so. Most respondents (72.9%) were unable to identify any of the Food and Drug Administration-approved methods of EC. Only 27.9% correctly identified the timing for its initiation and only 31.6% of respondents felt comfortable prescribing EC. Inexperience with use was cited as the primary reason for not prescribing EC by 70% of respondents. Twelve percent cited moral or religious reasons and 17% were concerned about teratogenic effects. There were no differences in comfort level based on age, gender, or practice type. Twenty-two percent of respondents believed that providing EC encourages adolescent risk-taking behavior and 52.4% would restrict the number of times they would dispense EC to an individual patient. A minority of respondents (17%) believed that adolescents should have EC available at home to use if necessary and only 19.6% believed that EC should be available without a prescription. The vast majority (87.5%) were interested in learning more about EC. CONCLUSIONS: Despite the safety and efficacy of EC, the low rate of use is of concern. Pediatricians are being confronted with the decision to prescribe EC but do not feel comfortable prescribing it because of inadequate training in its use. Practicing pediatricians are aware of their lack of experience and are interested in improving their knowledge base.

Cardiac arrest and delirium: presentations of the refeeding syndrome in severely malnourished adolescents with anorexia nervosa.

AIM: To describe the clinical presentation of the refeeding syndrome and highlight the dangers of performing nutritional rehabilitation too rapidly in a severely malnourished patient. DESIGN: Retrospective case review of adolescents admitted with anorexia nervosa who developed the refeeding syndrome. RESULTS: Between July 1993 and July 1994, 3 of 48 adolescent females developed the refeeding syndrome. While the cardiac complications occurred in the first week of refeeding, the delirium characteristic of this syndrome occurred later and was more variably related to hypophosphatemia. OBSERVATIONS: Refeeding malnourished patients with anorexia nervosa can be associated with hypophosphatemia, cardiac arrhythmia and delirium. Refeeding patients with anorexia nervosa who are < 70% of ideal body weight should proceed with caution, and the caloric prescription should be increased gradually. Supplemental phosphorus should be commenced early and serum levels maintained above 3.0 mg/dL. Cardiac and neurologic events associated with refeeding are most likely to occur within the first weeks, justifying close monitoring of electrolyte and cardiac status.

The metabolic responses to starvation and refeeding in adolescents with anorexia nervosa.

Adaptive changes in metabolism result in decreased energy requirements in AN. A retrospective study of 21 hospitalized female AN patients demonstrated that indirect calorimetry (IC) measurement of resting energy expenditure (REE) was significantly lower than REE calculated by the Harris-Benedict equation (HBE). The HBE was adjusted by multiple-regression analysis to reflect the hypometabolic state of AN, and the adjusted equation was prospectively validated in 37 hospitalized female AN patients. Refeeding requires an understanding of both baseline requirements and metabolic changes that occur during nutritional rehabilitation. In our present study, we prospectively evaluated changes in fasting and postprandial REE in 50 hospitalized female patients meeting DSM-IV criteria for AN. Baseline IC measurements of fasting and postprandial REE were obtained within three days of admission, and every two weeks thereafter. Mean fasting REE increased significantly from 72 (+/-11.7) to 83.2 (+/-12.6) percent of predicted (p < 0.001) during the first two weeks of hospitalization. Likewise, postprandial REE also increased significantly from 17.5 (+/-18.2) to 27.9 (+/-15.9) percent above fasting REE during the same time period (p < 0.01). Significant increases in both REE and postprandial REE persisted in patients requiring longer hospitalizations. Despite the fact that prescribed energy intake and triiodothyronine (T3-RIA) levels increased during refeeding, there was no significant relationship between postprandial REE and energy intake or T3 levels after baseline. We conclude that energy metabolism in AN adapts to semistarvation by a reduction in fasting REE. With refeeding there is a reversal of this adaptive function, demonstrated by an increase in both fasting and postprandial energy expenditure. The increase in postprandial REE is not related to energy intake or thyroid function.

Resumption of menses in anorexia nervosa.

OBJECTIVE: To determine factors associated with resumption of menses (ROM) in adolescents with anorexia nervosa. DESIGN: Cohort study with 2-year follow-up. SETTING: Tertiary care referral center. PATIENTS: Consecutive sample of 100 adolescent girls with anorexia nervosa. INTERVENTIONS: Body weight, percent body fat, and luteinizing hormone, follicle-stimulating hormone, and estradiol levels were measured at baseline and every 3 months until ROM (defined as 2 or more consecutive spontaneous menstrual cycles). Treatment consisted of a combination of medical, nutritional, and psychiatric intervention aimed at weight gain and resolution of psychological conflicts. MAIN OUTCOME MEASURES: Body weight, body composition, and hormonal status at ROM. RESULTS: Menses resumed at a mean (+/-SD) of 9.4 +/- 8.2 months after patients were initially seen and required a weight of 2.05 kg more than the weight at which menses were lost. Mean (+/-SD) percent of standard body weight at ROM was 91.6% +/- 9.1%, and 86% of patients resumed menses within 6 months of achieving this weight. At 1-year follow-up, 47 (68%) of 69 patients had resumed menses and 22 (32%) remained amenorrheic. No significant differences were seen in body weight, body mass index, or percent body fat at follow-up in those who resumed menses by 1 year compared with those who had not. Subjects who remained amenorrheic at 1 year had lower levels of luteinizing hormone (P < .001) and follicle-stimulating hormone (P < .05) at baseline and lower levels of luteinizing hormone (P < .01) and estradiol (P < .001) at follow-up. At follow-up, a serum estradiol level of more than 110 pmol/L (30 pg/mL) was associated with ROM (relative risk, 4.6; 95% confidence interval, 1.9-11.2). CONCLUSIONS: A weight approximately 90% of standard body weight was the average weight at which ROM occurred and is a reasonable treatment goal weight, because 86% of patients who achieved this goal resumed menses within 6 months. Resumption of menses required restoration of hypothalamic-pituitary-ovarian function, which did not depend on the amount of body fat. Serum estradiol levels at follow-up best assess ROM.

Update on adolescent health care in pediatric practice.

PURPOSE: To determine current adolescent health care practices of pediatricians and evaluate whether changes have taken place during the past decade. METHODS: A questionnaire completed by 101 pediatricians in 1985 was abbreviated and adapted by Committee on Youth of Chapter 2, District II of the American Academy of Pediatrics and sent to 1,633 members of the Chapter in June 1993. RESULTS: Forty-three percent of the 436 respondents in 1993 were female, 43% < or = 40 years of age and 53% were in private practice. Most accept new patients > or = 16 years of age (76%), continue to see patients > or = 19 years of age (63%), and interview adolescents without their parents (86%). Although between one-third and two-thirds of respondents report having equipment for gynecologic examinations, most indicate they are "not entirely comfortable" treating adolescent issues and therefore refer to others for management. Between one-quarter and one-half indicate they are "very interested" in learning more about adolescent issues and an additional 40-50% are "somewhat interested." Obstacles to providing adolescent care include: "image as a baby doctor" (65%), fear that parents would object (61%), no separate hours (57%), difficulty in providing confidential care (56%), and difficulty in charging appropriate fees (47%). Females and younger pediatricians are more comfortable with some aspects of gynecologic care and more likely to be satisfied with the adolescent care they are providing. There were few differences between responses in 1993 and 1995. CONCLUSIONS: Few of the pediatricians surveyed provide comprehensive care to adolescent patients. Future policy decisions and medical education must respond to these realities in pediatric practice.

Reversibility of cerebral ventricular enlargement in anorexia nervosa, demonstrated by quantitative magnetic resonance imaging.

OBJECTIVE: To determine the reversibility of the loss of brain parenchyma and ventricular enlargement in patients with anorexia nervosa after refeeding. STUDY DESIGN: Quantitative magnetic resonance imaging was performed on three groups of subjects: (1) 12 female adolescents hospitalized with anorexia nervosa, (2) the same 12 patients after nutritional rehabilitation, a mean of 11.1 months later, and (3) 12 healthy age-matched control subjects. Sixty-four contiguous coronal magnetic resonance images, 3.1 mm thick, were obtained. With a computerized morphometry system, lateral and third ventricular volumes were measured by a single observer unaware of the status of the patient. RESULTS: On admission, patients were malnourished and had lost an average of 11.7 kg (body mass index, 14.3 +/- 2.0 kg/m2). After refeeding, they gained an average of 9.7 kg (body mass index, 17.9 +/- 1.5 kg/m2). Total ventricular volume decreased from 17.1 +/- 5.5 cm3 on admission to 12.4 +/- 3.0 cm3 after refeeding (p < 0.01) and returned to the normal range. The degree of enlargement of the third ventricle was greater than that of the lateral ventricles. There was a significant inverse relationship between body mass index and total ventricular volume (r = -0.63; p < 0.05). CONCLUSION: In patients with anorexia nervosa, cerebral ventricular enlargement correlates with the degree of malnutrition and is reversible with weight gain during long-term follow-up.

Effectiveness of breast self-examination prompts on oral contraceptive packaging.

BACKGROUND: The purpose of this study was to determine if a breast self-examination (BSE) "prompt" on oral contraceptive pill (OCP) packages would improve the frequency and timing of BSE among women who use OCPs. METHODS: Women between 13 and 40 years of age who were initiating, restarting, or continuing use of OCPs completed a baseline survey that assessed health behavior and practices. All received BSE education, and then were randomized to take either OCPs with a BSE prompt or regularly packaged OCPs (without BSE prompt) for three cycles. Three months later, subjects completed a follow-up survey that assessed BSE frequency and timing. A telephone survey of randomly selected subjects conducted 6 months after the baseline survey assessed BSE compliance after discontinuation of the prompt. RESULTS: Of the 907 subjects at baseline, 49.3% performed BSE monthly but only 24.5% performed BSE during the correct time of the menstrual cycle. Among subjects who never performed BSE prior to the study, 40.3% of prompt subjects and 36.4% of the education-only subjects began BSE by the 3-month survey. Among subjects who performed BSE less than once per month at baseline, 50.9% of prompt subjects and 45.5% of education-only subjects increased the frequency of BSEs to a monthly basis by the 3-month survey. More women performed BSE during the correct time of the menstrual cycle at the 3 month follow-up survey (68.1% prompt, 62.2% education only) and 6-month survey (57.4% prompt, 48.9% education only) when compared with the baseline survey (24.7% prompt, 24.1% education only). Ninety-one percent of women in this study expressed a preference for a BSE prompt on OCP packaging. CONCLUSIONS: An increased frequency of BSE was observed when women were exposed to an OCP package prompt, particularly for women who at baseline were already partially compliant with performing monthly BSE. A small but significant improvement was observed for correct BSE timing and this effect continued after the prompt was removed, although at a reduced level. The innovative BSE prompt was overwhelmingly well received by women in this study.

PIP: The inclusion of a breast self-examination (BSE) "prompt" on oral contraceptive (OC) packaging resulted in an increased frequency of this critical breast cancer preventive practice. 907 women 13-40 years old from 7 health care sites in the US were recruited without knowledge of the goals of the study and given a general health promotion pamphlet and a BSE demonstration. 601 of these women were randomly assigned to receive 3 prompt-included OC packets; the remainder received unmarked OCs. The marked OC packets printed a reminder of the ideal time for BSE (7 days after menstrual period) beneath the first row of pills. At baseline, 49.3% of all subjects had performed BSE at least once in the preceding 3 months, while 21.5% had never done so. The interventions were most effective among women who were at least partially compliant with BSE at baseline (50.9% of prompt subjects and 45.5% of education-only subjects increased BSE frequency to monthly), but there was a 40% increase in frequency among women new to this regimen. The percentages of women performing BSE at the proper time of the cycle increased from baseline levels of 24.7% in the prompt group and 24.1% in the education-only group to 68.1% and 62.2%, respectively. These improvements in the frequency and timing of BSE persisted, although at a reduced level, 3 months after completion of the special OC packets. Finally, 91.2% of women who received the prompt indicated they would like this to be a regular feature of their OC packaging and 80.3% said it had reminded them to perform BSE.

Medical complications in male adolescents with anorexia nervosa.

PURPOSE: Medical information on male anorectics is scant. We present data on 10 males with anorexia nervosa, who were treated at our Eating Disorders Center during a twelve-year period. METHODS: Retrospective chart review. RESULTS: All patients were malnourished weighing 80% or less of their ideal body weight with a mean B.M.I. of 13.5 +/- 2.0. Height below the 50th percentile was evident in 80% of the patients, and was below the 10th percentile in 30% of the patients. Structural brain changes on brain computerized tomography scans were noted in seven out of nine patients and more than 50% had mild anemia relative to the Tanner stage. Other findings included a mean presenting heart rate of 68.3 +/- 17: four out of ten patients had presenting heart rates of 80 or greater and of these, three had serious medical problems and were severely malnourished. Two patients had cardiac complications and one had a life-threatening electrolyte disturbance. CONCLUSION: Despite the small number of patients, the proportion of male adolescent anorectics with medical abnormalities seems high, and may be due to difficulties in establishing the diagnosis and delay in seeking medical attention. Patients who had heart rates of 80 or greater were perhaps sicker and further along in their development of congestive heart failure, thus explaining their initial relative tachycardia. We suggest a higher index of suspicion for congestive heart failure and closer medical monitoring when a malnourished adolescent with anorexia nervosa presents with relatively elevated heart rates.