Unusual Cause of Pediatric Vaginal Bleeding: Infantile Capillary Hemangioma of the Cervix.

BACKGROUND: The differential diagnosis for pediatric prepubertal vaginal bleeding is wide. Rare etiologies include vascular malformations and tumors, such as infantile hemangiomas (IHs), which validate the usefulness of exam under anesthesia, vaginoscopy, and tissue diagnosis. CASE: We report a case of an IH in a 6-year-old girl causing vaginal bleeding requiring transfusion. Vaginoscopy revealed a cervical IH of less than 1 cm. Expectant management and oral propranolol were successful management options. SUMMARY AND CONCLUSION: Rare, even small soft tissue tumors such as IH can lead to impressive blood loss via vaginal bleeding. Accurate tissue diagnosis and a multidisciplinary approach are essential to planning safe, effective treatment, and follow-up.

Condom use by adolescents.

The use of condoms as part of the prevention of unintended pregnancies and sexually transmitted diseases (STDs) in adolescents is evaluated in this policy statement. Sexual activity and pregnancies decreased slightly among adolescents in the 1990s, reversing trends that were present in the 1970s and 1980s, while condom use among adolescents increased significantly. These trends likely reflect initial success of primary and secondary prevention messages aimed at adolescents. Rates of acquisition of STDs and human immunodeficiency virus (HIV) among adolescents remain unacceptably high, highlighting the need for continued prevention efforts and reflecting the fact that improved condom use can decrease, but never eliminate, the risk of acquisition of STDs and HIV as well as unintended pregnancies. While many condom education and availability programs have been shown to have modest effects on condom use, there is no evidence that these programs contribute to increased sexual activity among adolescents. These trends highlight the progress that has been made and the large amount that still needs to be accomplished.

Care of the adolescent sexual assault victim.

Sexual assault is a broad-based term that encompasses a wide range of sexual victimizations, including rape. Since the American Academy of Pediatrics published its last policy statement on this topic in 1994, additional information and data have emerged about sexual assault and rape in adolescents, the adolescent's perception of sexual assault, and the treatment and management of the adolescent who has been a victim of sexual assault. This new information mandates an updated knowledge base for pediatricians who care for adolescent patients. This statement provides that update, focusing on sexual assault and rape in the adolescent population.

A moment-based technique for the automatic spatial alignment of plantar pressure data.

Plantar pressure measurements have many potential clinical applications in the field of orthopaedics. However, the only current routine clinical application of pedobarography is for the identification of high pressure zones in diabetic patients with neuropathy who are at risk from foot ulceration. For pedobarography to become a routine clinical tool in orthopaedics, a thorough knowledge of normal plantar pressure distributions would be required. To date, no large scale studies to define population norms have been conducted, probably because of the high cost associated with analysing large quantities of plantar pressure data. Plantar pressure distributions display a high step-to-step variation and, therefore, it is necessary to conduct multiple trials. Comparison between these trials is difficult, somewhat subjective, and slow, because it must be conducted manually. The present authors have developed a technique to align automatically the spatial components of a series of datasets. The technique then allows predefined parameters to be automatically extracted from the data, hence greatly reducing analysis time. The authors believe that not only does the technique make large scale studies economically viable but that it could also form the basis for expert systems for the diagnosis of foot pathologies and the prescription of orthoses.

Adolescents' knowledge of human papillomavirus and cervical dysplasia.

STUDY OBJECTIVE: This study examined adolescents' knowledge of human papillomavirus (HPV) and cervical dysplasia (CD). Factors associated with knowledge and self-reported change in health-related behaviors were identified. DESIGN: Interviews were conducted at an average of 2.5 years following the diagnosis of HPV/CD. Medical charts were reviewed. SETTING: The study was conducted at a university-based adolescent dysplasia clinic. PARTICIPANTS: Fifty females, ages 15-23 participated in the study: 88% African-American, 12% Caucasian. RESULTS: On average, participants responded correctly to 86% of the questions regarding HPV/CD. However, the following key points were routinely missed: 52% did not know cigarette smoking increased the risk for cervical cancer; 42% believed that HPV/CD was always symptomatic; and 22% did not know condoms decreased the transmission of HPV. According to participants, their health care provider explained the diagnosis and treatment of HPV/CD using words they understood "some" or "most of the time." Higher academic skills significantly correlated with greater knowledge of HPV/CD. Forty-one percent of participants with a smoking history reportedly increased their smoking since the diagnosis, and only 40% used condoms "most of the time." However, 90% had maintained or increased their frequency of Pap tests. CONCLUSIONS: Adolescent girls had knowledge of most factors related to HPV/CD, but many did not understand the risks of cigarette smoking and failure to use condoms. To improve understanding and compliance, health care providers should tailor educational strategies to the functional level of adolescents.

Promoting women's health via the World Wide Web.

Women, as a segment of society at risk for chronic illnesses and complications from normal life events, such as pregnancy and menopause, are seeking information to improve their health status. One tool on the World Wide Web provided by a team of Ohio health care providers, including nurses, physicians, pharmacists, and dietitians, is the Ask an Expert feature of NetWellness. Designed as a consumer health information resource, NetWellness (www.netwellness.org) also is a valuable tool to health care professionals.

The yielding of tensioned fine wires in the Ilizarov frame.

The Ilizarov frame uses tensioned fine wires to support bone fragments. The objective of this study was to determine whether these wires deformed plastically under functional load bearing and to determine the significance of such deformation on the long-term performance of frames used for treating lower limb conditions. The mechanical characteristics of the wires were determined by means of destructive tensile tests and used in the construction of a series of finite element models replicating typical frame configurations. Each model was then subjected to a single load cycle representing a single step and the residual displacement (i.e. plastic deformation) was determined. In each case a residual displacement of between 0.26 and 0.42 mm was observed giving a corresponding reduction in wire tension of between 8.3 and 32.8 per cent. These reductions in wire tension reduce the frame's overall stiffness and so compromise its ability to inhibit high-amplitude axial and shear motions at the fracture site which are deleterious to the healing outcome.

Adolescent girls' understanding of Papanicolaou smear results.

STUDY OBJECTIVE: Human papillomavirus (HPV) urogenital infections are common in sexually active adolescents. Previous research has indicated that adolescent girls do not reliably report histories of HPV infection. This study examined whether asking an adolescent girl if she had ever had an abnormal Papanicolaou (PAP) smear was a good screening question for evidence of HPV urogenital infection. DESIGN: The responses to the question about abnormal PAP smears, were compared with their charts for documented abnormal PAP smear, HPV infection, and sexually transmitted infection. SETTING: An urban, hospital-based adolescent clinic. PARTICIPANTS: Fifty adolescent girls (mean age, 14.8 years). MAIN OUTCOME MEASURES: Degree of agreement (kappa statistic). RESULTS: Using a kappa statistic, reported history of an abnormal PAP smear had "fair" agreement with documented dysplasia on PAP smear and "moderate" agreement with documented HPV infection (i.e., either condyloma on PAP smear or genital warts noted on examination). This reported history of an abnormal PAP smear agreed better with documented HPV infection than with documented dysplasia on PAP smear. CONCLUSIONS: There appears to be considerable confusion among adolescent girls regarding their PAP smear results. Care providers need to be sensitive to this when they are collecting historical information and when they are diagnosing HPV infection or an abnormal PAP smear.

Experience with side effects and health risks associated with Norplant implant use in adolescents.

Levonorgestrel implants (Norplant) have been recommended as a contraceptive method for teenage women. Our experience suggests that the use of Norplant implants in adolescents is associated with bleeding irregularities and modest weight gain. There is no effect on condom use or STD acquisition. Despite the bleeding irregularities, we documented high continuation rates, suggesting that with appropriate pre-insertion counseling, Norplant implants can be a successful contraceptive method for adolescent women.

PIP: An analysis of the experiences of 72 US adolescents (mean age, 15.5 years) suggests that Norplant implants are an appropriate contraceptive method for this population. All study participants had the implants inserted at a hospital-based adolescent clinic at least 1 year before chart review. The continuation rate was 97% at 12 months and 86% at 24 months. At insertion, 60 adolescents (83%) reported regular menstrual periods. At the various follow-up intervals (e.g., 3, 6, and 12 months), 12-18% had regular periods, 12-16% were amenorrheic, and the remainder had bleeding that was irregular in length and/or interval. Mean weight gains of 3, 4.5, and 5.8 pounds were recorded at 3, 6, and 12 months, respectively; however, there was no consistent trend and a substantial number of young women lost weight during the study period. Finally, there was no clear trend of increase or decrease after Norplant insertion in either condom use or rates of infection with sexually transmitted diseases (STDs). Pre-insertion counseling for adolescent Norplant acceptors should include preparation for menstrual irregularities and encouragement of condom use to prevent STD acquisition.

Compliance and oral contraceptives: a review.

Compliance difficulties are more common among oral contraceptive (OC) users than generally appreciated by clinicians, in part because unintended pregnancy is a relatively infrequent consequence and in part because more common manifestations such as spotting and bleeding may not be recognized as resulting from poor compliance. While improving compliance is a shared responsibility of patients, clinicians, and manufacturers, the clinician is the focal point for these efforts. Counseling must be individualized, which requires knowledge of factors that predict compliance and an understanding of the patient's decision-making process as it relates to medications. Most OC compliance research has focused on adolescents, where predictors of poor compliance include multiple sex partners, low evaluation of personal health, degree of concern about pregnancy, and previous abortion. Good compliance has been linked with patient satisfaction with the clinician, the absence of certain side effects, establishing a regular daily routine to take OCs, and reading information distributed with OC packaging.

PIP: The findings of decades of research on user compliance of drug treatment regimens can be reduced to a simple statement that a third of users always comply, a third never complies, and a third sometimes complies. The efficacy of oral contraceptives (OC), however, relies on compliance even though poor compliance has no immediate or uniform consequences. Research on OC compliance has focused on adolescents because of their high pregnancy rates and their high reliance on OCs. Young women frequently use OCs in a sporadic fashion. While most adolescents are as compliant as older women, only 26% of those aged 14 and younger take their OC daily as compared to 40% of all other age groups. Attempts have been made to identify factors predicting noncompliance using 1) the individualistic model, which measures a number of factors using statistical techniques; 2) the health belief model which postulates that health-seeking behavior depends upon perception of health risk, and 3) the patient-provider model which highlights the importance of communication techniques. Factors which have been found to influence OC use are the occurrence of side effects, the routine followed, and failure to read and/or understand the packaging information. Little is known about the influence of patient-provider interactions, and only a few strategies to improve compliance have been studied. To improve compliance, health care providers should properly counsel women on their choice of method, side effects, OC misinformation and beneficial effects, correct use, missed pill instructions, and how to get additional information. Proper follow-up techniques should also be used. OC users can improve compliance by following a regular routine, carefully reading packaging information, knowing what to do if an OC is missed, and identifying a back-up method. Manufacturers should encourage research into compliance predictors and factors, incorporate findings into tools to help clinicians identify those at risk, use packaging that encourages compliance, and develop standardized and comprehensible written materials.

Ruminal digestion and duodenal nutrient flows in dairy cows consuming grass as pasture, hay, or silage.

The objective of this experiment was to quantitate ruminal digestion and flow of nutrients to the small intestine of Holstein cows grazing grass pasture or fed grass hay or silage. Three dry, nonpregnant Holstein cows fitted with ruminal and duodenal (Y-type) cannulas grazed or were given free choice access to hay or silage during three consecutive 19-d periods. Pasture intake was estimated using chromic oxide; hay and silage intakes were both measured and estimated. Intakes were similar among forages. Ruminal samples had higher VFA and ammonia when cows grazed than when cows were fed hay or silage. Ruminal pH did not differ. Based on duodenal spot sampling, cows on pasture had lower DM flows to the small intestine. Bacterial N flow, as a percentage of total N flow, was higher for cows that grazed. Most flows of AA to the small intestine were similar among forages, but Pro and Phe were lower for grazing cows. Supplementation strategies for cows on pasture should be designed to synchronize protein and carbohydrate in the rumen and to increase the supply of nutrients available in the small intestine.

Family planning in the teen population.

As an increasing percentage of adolescents reach their sexual debut at younger ages, effective contraceptive methods, which will decrease the risks of unintended pregnancies and sexually transmitted diseases (STDs), become even more critical. Contraceptive methods which are less 'compliance-dependent', such as the implantable subdermal levonorgestrel and the injectable depot formulation of medroxyprogesterone acetate, are popular in adolescents but careful counseling before method selection and on-going counseling when side-effects are experienced are necessary and essential. The use of condoms to decrease the risks of STDs will continue to be important for adolescents, and it remains to be seen what impact the long-term methods will have on effective condom use. Adolescents' access to abortions when contraceptive methods fail, or when no method is used, is being challenged with state laws which mandate parental notification or permission. A greater knowledge about the option of emergency contraception could potentially lead to increased use of this method, particularly when the option of medications such as RU486 becomes available. The potential for a reduction in unintended pregnancies in adolescents, and a reduced need for abortions is a welcome prospect.

Oral contraception noncompliance: the extent of the problem.

Compliance has been defined as the extent to which a patient's behavior coincides with the clinical prescription. The lowest expected failure rate of oral contraceptive (OC) use has been suggested to be 0.1%; however, in typical users, the failure rate varies by age, race, and marital status. In some populations in the United States (eg, unmarried black adolescents), the failure rate is 18%; rates that factor in the occurrence of abortions suggest an overall failure rate of 6.2% during the first year of use. If the annual failure rate of 6.2% is assumed, long-term failure rates rapidly approach 25% to 50% (ie, the proportion of users who will experience an unintended pregnancy) over 10 years of use. The gap between the lowest expected failure rate and the failure rates seen in typical users is related in large part to problems of compliance. Compliance with OC use includes both correct daily use and continuing use. Factors that contribute to OC discontinuation include the experience of side effects, fears and misinformation about OC side effects fueled by negative media reports, and intermittent use. There are relatively few data regarding the issue of missed pills and correct use, but studies suggest that adolescents may miss an average of 3 pills a month, and at least 20% to 30% of individuals miss a pill every month. Patients may have difficulty in the transition from one packet of pills to the next, and missed pills that extend the hormone-free interval may contribute to the failure rate.(ABSTRACT TRUNCATED AT 250 WORDS)

The patient's reaction to side effects of oral contraceptives.

Approximately 14 million American women currently use oral contraceptives. This represents only 32% of those at risk for pregnancy. Many studies suggest that bleeding irregularities are a primary reason for discontinuation of oral contraceptives, especially among adolescents. The Triphasic Randomized Clinical Trial study and several others suggest that intermenstrual bleeding may be experienced by at least one third of women taking oral contraceptives at one time or another. The socioeconomic costs of these episodes, realized in calls and visits to physicians, as well as pill discontinuation, pregnancy, and perhaps abortion, carry their own unique set of risks. Absence of withdrawal bleeding, or amenorrhea, is another concern because, to the woman, it signals pregnancy. Roughly two thirds of patients who have amenorrhea while taking oral contraceptives will consult a physician. Physicians should select oral contraceptives with the lowest doses of hormones and fewest side effects such as breakthrough bleeding or amenorrhea, which are major obstacles to compliance.

Acute and long-term consequences of adolescents who choose abortions.

PIP: An estimated 40% of US females now 14 years of age can be expected to experience pregnancy by age 19 years, and the majority of these pregnancies will be unintended. In 1981, there were 1,343,200 pregnancies among US females under 20 years of age and 448,570 abortions in this same age group. The abortion ratio is highest for adolescents under 15 years of age (1379 abortions/1000 live births), while the abortion rate is highest for 18-19 year olds (61.8/1000). When compared to adult women, adolescents obtain abortions at a later gestational age--a factor that increases both the psychological and medical risks of the procedure. Adolescents are also more likely than adults to base their decision regarding the pregnancy on the opinions of significant others. Comparative studies have shown teenagers who continue a pregnancy to have underdeveloped conceptualizations of the future, high levels of anxiety, and an external locus of control. Adolescents at greatest risk of psychological sequelae of abortion are those with pre-existing mental illness, strong religious beliefs, limited coping skills, a narrow support network, and abortion at later gestational stages. If the teenager feels pressured by her family to terminate the pregnancy, she is also at high risk for adverse psychological sequelae and a repeat pregnancy soon after abortion. Thus, counselors should maintain a neutral position while helping teens to examine the positive and negative aspects of their options. In terms of medical effects, teenagers have been shown to have the lowest risk of all age groups for abortion-related mortality. However, because of the later gestational age at which adolescents seek abortion, there is a higher risk of complications such as endometritis. Emphasis should be placed on expediting the abortion decision making process among adolescents to reduce delays and the potential risks.^ieng

Medical students' gynecologic examination skills. Evaluation by gynecology teaching associates.

In the past it was assumed that medical students would be able to perform an adequate pelvic examination by the end of the third-year clinical clerkship. At the University of Virginia, students completing the clinical clerkship were evaluated by trained gynecology teaching associates (GTAs), acting as patients and chaperones, who systematically evaluated students' examination and interpersonal skills using both an objective scale including 86 specific items and two 12-point subjective rating scales. Interrater reliability was demonstrated, as was the correlation between the subjective scores and objective ratings. Thirty-two percent of the students were evaluated as having either inadequate or marginal examination skills, and 29% were rated as having interpersonal skills that fell into the same unsatisfactory category. GTAs can be used as evaluators of skills in a competency-based clerkship.

Physical abuse in pregnancy.

Screening interviews to determine the extent of physical abuse were conducted for 742 women seen in the University of Virginia obstetric clinics. Eighty-one women (10.9%) reported that they had experienced abuse at some point in the past. These women were more likely to be divorced or separated, indigent, and less educated than were the non-abused control patients. They were more likely to have had emotional problems, and 20% had attempted suicide. Twenty-nine of the 81 women reported abuse during the current pregnancy, with 21% reporting increased abuse and 36% noting decreased abuse during pregnancy. Women living with an abusive partner did not experience a greater frequency of adverse pregnancy outcomes than did those who had left abusive relationships. An awareness of the extent of the problem and direct questioning will result in an increased identification of women who are at risk for physical abuse during pregnancy.