Changes to medication abortion clinical practices in response to the COVID-19 pandemic.

OBJECTIVES: To document medication abortion clinical practice changes adopted by providers in response to the COVID-19 pandemic. STUDY DESIGN: Longitudinal descriptive study, comprised of three online surveys conducted between April to December, 2020. We recruited sites from email lists of national abortion and family planning organizations. RESULTS: Seventy-four sites opted to participate. We analyzed 55/74 sites (74%) that provided medication abortion and completed all three surveys. The total number of abortion encounters reported by the sites remained consistent throughout the study period, though medication abortion encounters increased while first-trimester aspiration abortion encounters decreased. In response to the COVID-19 pandemic, sites reduced the number of in-person visits associated with medication abortion and confirmation of successful termination. In February 2020, considered prepandemic, 39/55 sites (71%) required 2 or more patient visits for a medication abortion. By April 2020, 19/55 sites (35%) reported reducing the total number of in-person visits associated with a medication abortion. As of October 2020, 37 sites indicated newly adopting a practice of offering medication abortion follow-up with no in-person visits. CONCLUSIONS: Sites quickly adopted protocols incorporating practices that are well-supported in the literature, including forgoing Rh-testing and pre-abortion ultrasound in some circumstances and relying on patient report of symptoms or home pregnancy tests to confirm successful completion of medication abortion. Importantly, these practices reduce face-to-face interactions and the opportunity for virus transmission. Sustaining these changes even after the public health crisis is over may increase patient access to abortion, and these impacts should be evaluated in future research. IMPLICATIONS STATEMENT: Medication abortion serves a critical function in maintaining access to abortion when there are limitations to in-person clinic visits. Sites throughout the country successfully and quickly adopted protocols that reduced visits associated with the abortion, reducing in-person screenings, relying on telehealth, and implementing remote follow-up.

A pilot randomized controlled trial of omega-3 fatty acid supplementation for the treatment of anxiety in adolescents with anorexia nervosa.

OBJECTIVE: To evaluate the effectiveness and tolerability of omega-3 polyunsaturated fatty acid (PUFA) supplementation for treatment of trait anxiety among adolescent females with restrictive anorexia nervosa (AN). METHOD: A pilot double-blind, placebo-controlled randomized trial of adolescent females with AN (N = 24) entering Partial Hospitalization Program (PHP) from January 2015 to February 2016. Participants were randomized to four daily PUFA (2,120 mg eicosapentaenoic acid/600 mg docosohexaenoic acid) or placebo capsules for 12 weeks. A 9-item questionnaire of side effect frequency assessed medication tolerability. The Beck Anxiety Inventory-Trait measured anxiety at baseline, 6, and 12 weeks. Linear mixed models evaluated associations between randomization group and study outcomes. Twenty-two and 18 participants completed 6 and 12 weeks of data collection, respectively. RESULTS: Medication side effect scores were low and were not significantly different between randomization groups at Week 6 (p = .20) or 12 (p = .41). Mean trait anxiety score significantly (p < .01) decreased from baseline to 12 weeks in both groups, and the rate of change over the course of time did not differ between omega-3 PUFA and placebo groups (p = .55). CONCLUSION: Omega-3 PUFA supplementation was well tolerated in adolescent females with AN. Although power to detect differences was limited, we found no evidence that omega-3 PUFA benefited anxiety beyond nutritional restoration.

A Retrospective Chart Review of Contraceptive Use among Adolescents with Opioid Use Disorder.

STUDY OBJECTIVE: To describe contraceptive use among female adolescents initiating outpatient treatment for opioid use disorder. DESIGN: Retrospective chart review. SETTING: Outpatient clinic providing medication-assisted treatment for substance use disorders to adolescents and young adults. PARTICIPANTS: Nonpregnant female adolescents who presented for treatment from January 1, 2013 to January 31, 2016 (N = 123). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Prescription contraceptive use at baseline and initiation of a new method within 90 days. RESULTS: Of 123 female adolescents who presented for treatment of opioid use disorder, 113 (91.9%) reported sexual activity and 80 (65.0%) were not using prescription contraception at intake. Previous pregnancy was reported by 43 (35.0%) and 20 (16.3%) were positive for a sexually transmitted infection. Contraceptive counseling was not documented for 73 (59.3%) patients. Among patients with no prescription contraception at baseline, 56 of 80 (70.0%) initiated a method within the study window. Significant predictors (odds ratio [OR]; 95% confidence interval) of contraceptive initiation included previous pregnancy (8.6; 1.39-52.99), education of less than a high school diploma/general equivalency diploma (7.4; 1.63-33.41), and return for follow-up visit (9.8; 2.18-43.69). CONCLUSION: Young women who presented for opioid use disorder treatment were at high risk of adverse reproductive health outcomes. Most were sexually active and not using prescription contraception. Findings underscore the need for contraceptive counseling in this patient population. Optimally, these services would be provided in conjunction with substance use treatment. Improved contraceptive counseling documentation will allow evaluation of effective contraceptive counseling strategies for adolescents with opioid use disorders and might serve to inform future interventions.

Severe Sepsis and Acute Myocardial Dysfunction in an Adolescent with Chlamydia Trachomatis Pelvic Inflammatory Disease: A Case Report.

BACKGROUND: Although generally asymptomatic, severe Chlamydia trachomatis (C. trachomatis) infections have been documented. C. trachomatis has been associated with myocarditis as well as sepsis. CASE: A 19-year-old girl with type 1 diabetes mellitus developed sudden-onset mental status change and shock after resolution of diabetic ketoacidosis. Abdominal and pelvic imaging showed uterine and adnexal inflammation, and pelvic examination confirmed a diagnosis of pelvic inflammatory disease. The patient was intubated, required vasopressor support, and developed severe biventricular myocardial dysfunction. Infectious myocarditis workup was negative. Nucleic acid amplification testing from vaginal discharge was positive for C. trachomatis and Trichomonas vaginalis and negative for Neisseria gonorrhoeae. SUMMARY AND CONCLUSION: C. trachomatis should be considered in the workup of septic shock, particularly in populations at high risk for sexually transmitted infections.

Statewide opioid prescriptions and the prevalence of adolescent opioid misuse in Ohio.

BACKGROUND: Little is known about the relationship between opioid prescribing practices and the prevalence of adolescent opioid misuse. OBJECTIVE: To examine the relationships between both opioid prescriptions filled by adolescents and adults and adolescents seeking treatment for opioid misuse in Ohio. METHODS: Analyses of large statewide databases from 2008 to 2012, including all 88 counties in Ohio. The Ohio Board of Pharmacy provided data regarding prescription opioids filled by adolescents (12-20 years, N = 50,030,820 doses) and adults (>20 years, N = 3,811,288,395 doses) by county of residence. The Ohio Department of Mental Health and Drug Addiction Services provided annual treatment admissions for adolescent opioid misuse by county of residence (N = 6446). RESULTS: Adults filled prescriptions for nearly 100 oral opioid doses per capita annually, while adolescents filled prescriptions for approximately 7 oral opioid doses per capita annually. In Bayesian Poisson modeling examining the effect of annual adult per capita dose on adolescent treatment admissions, adjusted for annual adolescent per capita dose and year, an increase of one in the annual adult per capita opioid dose resulted in an increase of 1.3% (RR = 1.013, 95% HPD CI = [1.008, 1.017]) in the rate of adolescent treatment admissions. This association corresponds to a 99.99% chance that the adolescent treatment rate increases when the annual per capita adult dose is increased by one unit. CONCLUSION: The amount of opioids filled by adults in Ohio, although relatively stable from 2008 to 2012, is approximately 13 times that filled by adolescents and is significantly associated with adolescents seeking treatment for opioid misuse. Efforts to decrease adolescent opioid misuse should also focus on reducing adult opioid prescriptions.

Healthcare Barriers and Utilization Among Adolescents and Young Adults Accessing Services for Homeless and Runaway Youth.

Homeless and runaway youth are at disproportionate risk for adverse health outcomes. Many barriers to accessing healthcare have been documented; however, the relative impact of discrete barriers on homeless youth healthcare utilization behavior is not firmly established. We administered a survey examining reported barriers and healthcare utilization among adolescents and young adults accessing services at three community centers for homeless and runaway youth. Of 180 respondents, 57 % were male, 80 % non-White, and 21 % identified as a sexual minority. Stepwise logistic regression models, controlling for age and study site, explored associations between barriers and 3 healthcare utilization outcomes (doctor visit in past 12 months; regular care provider; frequent emergency department (ED) visits). The most commonly reported barriers were "don't have a ride" (27.2 %), "no insurance" (23.3 %), and "costs too much" (22.8 %). All fear-based barriers (e.g., "I don't trust the doctors") were reported by <5 % of surveyed youth. Significant predictors of having seen a doctor in the past 12 months included sexual minority status (OR 2.8, p = 0.04) and possession of health insurance (OR 4.9, p < 0.001). Female sex (OR 5.2, p < 0.001) and reported external barriers other than health insurance (OR 0.2, p < 0.001) were associated with having a regular care provider. Fear-based concerns were associated (OR 3.8, p = 0.02) with frequent ED visits, as was being insured (OR 2.2, p = 0.03). These results underscore the need to clearly define healthcare outcomes when investigating barriers to care among homeless and runaway youth as the impact of discrete barriers varies depending on outcome of focus.

Bone Mineral Density and Weight Changes in Adolescents Randomized to 3 Doses of Depot Medroxyprogesterone Acetate.

STUDY OBJECTIVE: To assess the association between medroxyprogesterone acetate exposure and bone mineral density (BMD) loss and weight change in adolescents. DESIGN: Forty-eight-week prospective, randomized trial conducted May 2012-April 2014. SETTING: Recruitment occurred in the general community and outpatient clinics in central Ohio. PARTICIPANTS: Self-referred sample of 34 female adolescents aged 12-21 years initiating depot medroxyprogesterone acetate (DMPA). INTERVENTIONS: Randomization to 1 of 3 DMPA doses (150, 104, or 75 mg) given intramuscularly every 12 weeks for 48 weeks. MAIN OUTCOME MEASURES: Absolute and percent change in BMD from 0-48 weeks at the L1-L4 lumbar spine, total hip, and femoral neck; absolute and percent change in weight at 48 weeks. RESULTS: DMPA dose was associated with medroxyprogesterone acetate exposure as evidenced by a direct relationship (P < .001) between dose group and area under the concentration time curve. At 48 weeks, no significant BMD decreases were seen in the 75 mg dose group. The 104 and 150 mg dose groups experienced significant (P < .01) decreases in L1-L4 lumbar spine BMD (3.1% and 4.0%, respectively). The 150 mg group also had significant (P < .05) decreases in total hip (3.0%) and femoral neck (4.0%) BMD. No group differences in weight change were observed. No pregnancies occurred in any DMPA dose group. CONCLUSIONS: Our data provide evidence of a dose-response relationship between DMPA and BMD loss. Intramuscular DMPA doses less than 150 mg can decrease risk of BMD loss in adolescents. The risk/benefit ratio of lower-dose DMPA should be further investigated in larger and more diverse adolescent populations.

Delayed Ego Strength Development in Opioid Dependent Adolescents and Young Adults.

Objective. To evaluate ego strengths, in the context of Erikson's framework, among adolescents and young adults diagnosed with opioid dependence as compared to non-drug using youth. Methods. Opioid dependent (n = 51) and non-drug using control (n = 31) youth completed the self-administered Psychosocial Inventory of Ego Strengths (PIES). The PIES assesses development in the framework of Erikson's ego strength stages. Multivariate linear regression modeling assessed the independent association of the primary covariate (opioid dependent versus control) as well as potential confounding variables (e.g., psychiatric comorbidities, intelligence) with total PIES score. Results. Mean total PIES score was significantly lower in opioid dependent youth (231.65 ± 30.39 opioid dependent versus 270.67 ± 30.06 control; p < 0.01). Evaluation of the PIES subscores found significant (p < 0.05) delays in all ego strength areas (hope, will, purpose, competence, fidelity, love, care, and wisdom). When adjusting for potential confounders, opioid dependence remained a significant (p < 0.001) independent predictor of total PIES score. Conclusion. Adolescents with opioid dependence demonstrated significant delays in ego strength development. A treatment approach acknowledging this delay may be needed in the counseling and treatment of adolescents with opioid dependence.

Serum adipocytokines and adipose weight gain: a pilot study in adolescent females initiating depot medroxyprogesterone acetate.

OBJECTIVE: To evaluate whether serum adipocytokine concentrations, controlling for baseline adiposity, are predictive of adipose weight gain in adolescents initiating depot medroxyprogesterone acetate (DMPA). METHODS: Percent body fat was measured at baseline and 6 months. Baseline serum adipocytokine concentrations were quantified. RESULTS: Mean percent body fat was 31.6% (±7.6) at baseline and 33.5% (±7.6) at 6 months. In multivariable linear regression modeling (adjusted for baseline percent body fat), Hispanic ethnicity and baseline serum adiponectin concentration were inversely associated (p≤.05) with absolute change in percent body fat at 6 months. CONCLUSIONS: Serum adiponectin concentration may be useful for assessing risk of DMPA-associated adipose gains.

Dietary Intake and Weight Gain Among Adolescents on Depot Medroxyprogesterone Acetate.

STUDY OBJECTIVE: To examine the relationship between dietary intake and weight gain among adolescent females initiating depot medroxyprogesterone acetate (DMPA). DESIGN: Prospective observational study. SETTING: Two urban Adolescent Medicine clinics. PARTICIPANTS: 45 postmenarchal females, age 12 to 21, enrolled after self-selecting to initiate DMPA. INTERVENTION: Participants received 150 mg DMPA intramuscularly every 12 weeks. Height, weight, and 24-hour dietary recall were collected at baseline, 3, 6, and 12 months. MAIN OUTCOME MEASURE: Body mass index (BMI) over time calculated as weight (kg)/height (m(2)). Associations between dietary variables and BMI were evaluated with repeated measures analysis of variance modeling. RESULTS: Mean chronological and gynecologic ages were 16.2 ± 1.5 and 4.2 ± 1.8 years, respectively. Mean BMI increased from 23.7 ± 5.3 to 25.3 ± 5.7 over 12 months. Average dietary intake included: 1781.4 ± 554.1 total kilocalories, 228.5 g ± 69.8 carbohydrates, 71.0 g ± 27.3 fat, and 61.0 g ± 20.2 protein. These diet measures were not associated with BMI over time. Dietary fiber, magnesium, and linoleic acid were inversely associated with increased BMI over time (P < .05) CONCLUSION: We found no evidence that general measures of diet (energy, carbohydrates, fat, and protein), as assessed by 24-hour recall, were predictive of weight gain on DMPA. Several nutrients abundant in foods that benefit overall health were inversely associated with increased BMI over time, suggesting that diet quality, rather than quantity, is a more important predictor of DMPA-associated weight gain.

A pilot study of depot medroxyprogesterone acetate pharmacokinetics and weight gain in adolescent females.

OBJECTIVE: To explore the relationship between medroxyprogesterone acetate (MPA) pharmacokinetic (PK) parameter estimates and weight gain. STUDY DESIGN: Prospective study of adolescents (N=40; age 12-21 years) initiating DMPA. PK parameters were calculated: maximum MPA concentration (Cmax, ng/mL), time to Cmax (Tmax, days) and elimination rate constant (ng/mL/day). Optimal PK cut points were determined for predicting body mass index (BMI) increase ≥10%. RESULTS: Cmax <2.88 ng/mL and elimination rate constant <0.021 ng/mL/day were associated (p<.05) with BMI increase ≥10%. Elimination rate constant was most predictive of weight gain. CONCLUSIONS: PK evaluation may help identify adolescents at risk of excessive DMPA-associated weight gain.