Utilization of electronic communication (E-mail) with patients at university and college health centers.

PURPOSE: To examine the utilization and potential uses and problems of electronic communication with patients. METHODS: University and college health centers were surveyed about the type of utilization and policies of electronic communication with patients. The survey group consisted of 99 health centers predominantly serving students representing small-, medium-, and large-sized public and private colleges and universities. Eighty-nine health centers completed the survey. RESULTS: Of the responding health centers, 63.6% use some form of electronic communication with patients. Twenty-seven percent of the health centers give out some form of medical advice via E-mail or the Internet; 14.7% give out some laboratory results via E-mail; 3.4% make appointments via E-mail; and 63.6% give out administrative advice by E-mail. While there was consistent concern expressed about confidentiality and security, only five health centers had a policy about electronic communication. Uses were most common in nonclinical areas but did include health education, Web sites, medical advice, laboratory results, appointment-making or confirmation, and contacting hard-to-reach patients including those studying abroad. CONCLUSIONS: While electronic communication with patients was common, provision of direct medical advice was less common. Issues receiving little attention include determining the types of electronic communication that is acceptable to staff and students, determining the level of security of their current information system, educating staff about confidentiality and security issues, and establishing a comprehensive policy regarding electronic communication with patients.

Breast disease in adolescents and young women.

Breast lesions, including mastalgia; benign proliferative changes; and benign masses, including fibroadenomas, are common in adolescents and young adult women. Breast cancer is rare in women less than 20 years old and uncommon in women less than 30 years old. Discrete masses in women less than 30 years old that do not feel suspicious on examination can be observed for 1 or 2 months. If they persist, than an FNA can differentiate those that are benign and can be observed versus those that need either an excisional biopsy or definitive surgery. Mammography has little role in the diagnosis of women less than 30 years old except in those individuals with highly suspicious lesions on examination.

Effect of low urine specific gravity on pregnancy testing.

Urine pregnancy tests performed at a large urban university student health center were examined for specific gravity to determine whether a low urine specific gravity, compared with a serum specimen, could alter the result of a urine pregnancy test. At the same time, a serum pregnancy test was performed on those samples with negative results and a specific gravity of less than 1.015. During the study period, 410 urine specimens were evaluated. Eighty of the women with a specific gravity under 1.015 had negative urine pregnancy tests with a concomitant serum specimen. The authors concluded that current sensitive immunoassay tests for human chorionic gonadotropin (HCG) are highly sensitive and that low specific gravity does not appear to alter this sensitivity.

Contraception in women with special medical needs.

Over 10% of women of reproductive age have experienced a serious chronic physical disorder. Reproductive health issues including contraception are frequently ignored in these individuals. Clinicians should have available current knowledge regarding interactions between contraception and these conditions.

PIP: Over 10% of US women have experienced a serious chronic physical disorder or disease by the age of 18 years. Nonetheless, health professionals frequently are unprepared to counsel women with special medical problems about sexuality issues, including the potential adverse effects of pregnancy and contraception on underlying disease. This article, based on a comprehensive review of the clinical literature, summarizes significant contraception-related considerations in women with specific medical conditions. Special emphasis is awarded to cardiovascular and neurologic diseases. In women with cardiac disease, both the cardiovascular sequelae of pregnancy should the contraceptive fail and the potential adverse circulatory effects of various contraceptive methods must be considered. In women with neurologic disease, a method must be selected that will not interact with anticonvulsants or immunosuppressive medications. Also reviewed are indicated and contraindicated contraceptive methods for women with pulmonary, gastrointestinal, endocrine, hematologic, renal, and rheumatologic disease; HIV/AIDS; cancer; and psychiatric morbidity. Tables review World Health Organization medical eligibility criteria for use of the major contraceptive methods, medications that potentially reduce or enhance the efficacy of oral contraceptives (OCs), and drugs whose efficacy may be affected by concomitant OC use.

Uterine myomas in adolescents: case reports and a review of the literature.

Uterine myomas are less common in adolescents than in adults. However, they should be considered in adolescent females who present with pelvic mass, abdominal pain, or abnormal uterine bleeding. The diagnosis is based on pelvic examination and ultrasound. Management is observation for small lesions and surgery for larger masses with myomectomy the choice for preservation of fertility. Medical treatments are currently under investigation as adjuncts to surgery. Ten cases of uterine myomas in adolescent and young-adult women between the ages of 13 and 21 are discussed. The clinical presentation and management is compared with the adult population.

Comparison between vaginal swab and endocervical swab during pelvic examination.

PURPOSE: While wet mounts and potassium hydroxide (KOH) preparations are frequently used to help diagnose vaginitis and cervicitis, the sample site varies. This study was conducted to evaluate whether the specimen site (vaginal pool versus endocervical specimen) affects diagnostic sensitivity. METHODS: The study involved 116 consecutive adolescent females presenting to a medical clinic serving high-risk youth. During the pelvic examination, specimens were obtained from the endocervix and the vagina (posterior fornix and sidewall) and placed in separate tubes of normal saline. Each specimen was examined for trichomonads, white blood cells, pseudohyphae, clue cells, and amine odor using 10% potassium hydroxide. RESULTS: The sensitivity was highest for the vaginal specimen in detecting the presence of trichomonads (100% versus 50%), pseudohyphae (76% versus 65%), and clue cells (95% versus 50%). For those with symptomatic candida vaginitis (n = 12), there was no difference in sensitivity (83%) between the two methods for detecting pseudohyphae. Nineteen of the adolescents had a diagnosis of cervicitis (chlamydia by DFA, gonorrhea by culture, and trichomonas by wet mount). If > 5 white blood cells/high powered field (WBC/HPF) was used as a criterion for the presence of a cervicitis, the vaginal sample had a sensitivity of 79% (15/19) and a specificity of 67%, while the endocervical sample had a 74% sensitivity (14/19) and a 57% specificity. CONCLUSIONS: A wet mount obtained from either the vaginal pool or endocervix is not highly specific for diagnosing a vaginitis or cervicitis. However, obtaining a specimen for wet mount and KOH swab from the vaginal pool is more sensitive for detecting trichomonads, pseudohyphae, or clue cells than an endocervical swab.

Prevalence and longitudinal study of breast masses in adolescents.

This study examined the prevalence and outcome of breast masses in adolescent females and compared these teens to those without breast masses. A longitudinal study of adolescents with breast masses was conducted from October 1984 through January 1990. The prevalence of discrete breast masses in the 13-month study period was 13/400 (3.25%) among new female patients. The mean length and width of the masses were 2.8 and 1.9 cm; 86% had a solitary mass. Of 61 diagnosed with breast masses, 39 were followed for up to 40 months (mean, 7 months). Teens with a mass were older (16.8 versus 15.1 years, p < 0.001) and had a greater chance of a family history of breast disease (26% versus 10.5%, p < 0.05) than those without a breast mass. Of 39 teens returning for at least one follow-up visit, 10 had a clinical diagnosis of "fibrocystic changes." Of these, the lesions resolved in six. Of the 29 teens with a discrete mass on examination, 7 underwent surgery and were found to have fibroadenomas. Nine of the 29 teens had masses which resolved over 1-12 months, six teens had masses which remained unchanged over 3-40 months, while four had masses which became smaller, and two had masses which became larger. One teen with mastitis improved. Eighteen underwent ultrasonographic examination at the breast. Of the 12 teens found to have a solid mass on ultrasound, none had a mass that resolved on follow-up examination.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of cytobrush with Cervex-Brush for endocervical cytologic sampling.

This study was designed to compare the quality of the Papanicolaou (Pap) smear and side effects associated with the Ayres spatula/cytobrush combination and the Cervex-Brush. We evaluated 165 Pap smears, of which 84 (51%) were cytobrush/spatula specimens, and 81 (49%) were from Cervex-Brush specimens. The cytobrush/Ayres spatula combination and the Cervex-Brush alone were equally successful in detecting squamous cells, however, the cytobrush/Ayres spatula combination was significantly better in picking up endocervical cells than the Cervex-Brush (p less than 0.01). There were no significant differences between the two techniques in degree of bleeding and pain in adolescents. The combination of the cytobrush and spatula appears to be superior to the Cervex-Brush alone in producing adequate Pap smears.

Adolescent health care in a large multispecialty prepaid group practice. Who provides it and how well are they doing?

Adolescents are at risk for pregnancy, sexually transmitted diseases, suicide, homicide, accidents, and substance abuse. Adolescent medicine involves an overlap of many skills needed to provide routine medical care, as well as care for those conditions that require psychosocial assessment. We report the results of a mail survey covering care of this age group by practitioners of pediatrics, internal medicine, obstetrics and gynecology, family practice, and adolescent medicine in a large, multispecialty, prepaid group practice. The mail survey covered 10 areas of adolescent care. Adolescent medicine physicians expressed the highest level of perceived knowledge and competence in these areas, with family practitioners ranked second. More than 50% of internists and pediatricians felt only fair to poor competence for a variety of adolescent conditions, whereas a third of internists and pediatricians reported that they liked to care for adolescents. Physicians in all 4 of the primary care specialties reported a need for a teen health center for both consultation and education. These results are similar to those reported for pediatricians and primary care physicians in private practice and for residents in internal medicine.

Hypercholesterolemia in adolescents: effectiveness of screening strategies based on selected risk factors.

This study evaluates the efficacy of the American Academy of Pediatrics' current recommendations for identifying hypercholesterolemia in teenagers. These guidelines advocate a screening strategy that is targeted only at high-risk individuals. Detailed information regarding risk factors for hypercholesterolemia was obtained from 1001 adolescents or their parents at three urban teen clinics during routine health assessments. In addition, serum cholesterol was measured in all adolescents. The population under study was 38.2% Hispanic, 33.5% white, 15.4% black, and 11.3% Asian, with a mean age of 15.6 years (range: 12 through 21 years); 52% were female. Based on the cholesterol values, the study population was divided into two groups: (1) normal cholesterol level, less than 200 mg/dL (n = 937, mean cholesterol value = 157 mg/dL) and (2) elevated cholesterol level, greater than or equal to 200 mg/dL (n = 64, mean cholesterol value = 228 mg/dL, range = 200 through 366 mg/dL). Application of the 1985 American Academy of Pediatrics criteria for selected screening identified 30 of 64 individuals with hypercholesterolemia (sensitivity = 47%). Criteria similar to 1988 recommendations identified 40 of 64 teenagers (sensitivity = 62%). A combination of 1985 and 1988 criteria yielded a sensitivity of 44 of 64, or 69%. The specificity of these criteria was 74%, 60%, and 53%, respectively. Despite the utilization of the 1985, 1988, or a combination of both American Academy of Pediatrics criteria for hypercholesterolemia screening, this study demonstrates that many adolescents with abnormal cholesterol levels would not be identified.(ABSTRACT TRUNCATED AT 250 WORDS)

Menstrual problems in adolescents.

Menarche is a significant event in the course of puberty. Although the age of menarche varies among adolescents, it occurs in most adolescents at an SMR of 4. With the onset of ovulatory cycles, local prostaglandins are released, often causing dysmenorrhea. This usually responds to PSIs. Abnormal uterine bleeding usually is the result of anovulatory cycles. However, complications of pregnancy, systemic illnesses, and local pathology must be considered. Significant bleeding usually responds to hormonal therapy. Amenorrhea may result from abnormalities affecting the hypothalamus, pituitary, or ovaries. The evaluation should be done in a logical, orderly fashion. In addition, pregnancy must always be considered first in the differential diagnosis.

Life-threatening desmoid tumor.

An 18-year-old girl presented with severe chest pain and shortness of breath. She was found to have a large desmoid tumor filling the right chest cavity. The etiology of the desmoid tumor is unknown but is thought to be associated with an underlying genetic defect and local trauma. These tumors may be estrogen sensitive and are more frequent in females of reproductive age. The case demonstrates the difficulty in treating these tumors effectively.

Comparison of cytobrush with cotton swab for endocervical cytologic sampling.

This study was designed to compare the Ayres spatula/cytobrush combination with the Ayres spatula/cotton swab combination as to the quality of the Pap smear in adolescent females. We evaluated 111 Pap smears, of which 60 (54%) were from cotton applicators/spatula combination and 51 (46%) were from cytobrush/spatula combination. Seventy-nine percent of the specimens with the cytobrush showed good cellular yield, compared to only 50% of the specimens obtained with a cotton applicator (p less than 0.05). The adequate specimen rate for endocervical cell content was 68% for the cytobrush versus 56% for the cotton applicator (p = not significant). The adequacy rate was less for trainees than for attending physicians, but the difference was less marked for those using the cytobrush. The cytobrush does have some impact on improving adequacy rates for Pap smears. However, this study was unable to determine whether this is a cost-effective addition to the Ayres spatula or cotton swab. The problem of inadequate Pap smears deserves more scrutiny among various health care systems.

Abdominal and flank pain as presenting symptoms of schwannoma.

Spinal cord tumors have been reported to cause abdominal, flank, and back pain. This case report describes an extensive evaluation of an adolescent male presenting with flank, abdominal, and back pain leading to the diagnosis of a schwannoma. The case underscores the need to consider spinal cord tumors in the differential diagnosis of abdominal and/or flank pain.

Prior training and recommendations for future training of clinical research faculty members.

A survey was conducted of the first authors of half of the research papers published in 18 leading peer-reviewed medical journals over a six-month period in 1986. The first authors of every other article (that is, alternate articles) published during this period were sent a questionnaire that assessed their previous research training and their recommendations for training of clinical research faculty members. Of the 772 physicians sent the questionnaire, 482 responded. Of these, 57% had had some research training in medical school, 52% had received such training during residency, and 87% had received it during their fellowships. Fifty-six percent had taken a formal statistics course, 31.4% had taken some computer training, and 87% had received research supervision in a nonstructured format (that is, no formal course work). Introductory biostatistics was the only formal course in any of the seven subject areas listed in the questionnaire that more than one-third of the respondents had taken, yet at least two-thirds recommended that researchers take formal courses in all of the seven areas listed. The investigators recommend for medical students and postgraduate trainees a graduated experience of research training and exposure that includes formal courses.

Detection of Chlamydia trachomatis. A study of the direct immunofluorescence technique and a review diagnostic limitations.

Because of the high prevalence of Chlamydia trachomatis in adolescent females and the high cost of chlamydia cultures, we evaluated the use of the direct fluorescein conjugated monoclonal antibody test (DFA) in diagnosing C. trachomatis in adolescent females. Chlamydia trachomatis was found in 37 (20.1%) of 184 cultures. The sensitivity of the direct smear as compared with the culture was 89% and the specificity was 99%. The results of recent studies of the DFA and chlamydiazyme tests are reviewed as well as the problems in comparing techniques.