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There are no prior cases in the literature that report immunoglobulins dropping secondary to oxcarbazepine use in an adolescent patient.This patient was an adolescent female taking buspirone, mirtazapine, and oxcarbazepine for mood stabilization. She was admitted to an inpatient disordered eating program for malnutrition. During her malnutrition evaluation, the patient was found to have low serum IgA, low IgM, and low-normal IgG. A slow wean of oxcarbazepine was initiated, and all immunoglobulins showed an increasing trend after stopping oxcarbazepine.Gabapentin was an added medication during hospitalization but is not known to affect immunoglobulins. Malnutrition is the only other significant factor that changed during the patient's hospital stay. With malnutrition alone, immunoglobulins are normal and IgA could be increased; this essentially rules out malnutrition and disordered eating as the cause of this patient's hypogammaglobulinemia, implicating oxcarbazepine as the cause.Chronic oxcarbazepine use was the most likely cause of the hypogammaglobulinemia seen in this patient; this is not currently a reported side effect of oxcarbazepine. This case highlights the importance of judicious use of all medications given the risk of even rare potential side effects.

For malnourished patients with end stage renal disease (ESRD) on hemodialysis (HD), refeeding is complex; true weight (dry weight) gain must be accounted for as it accrues to safely dialyze. This case describes the challenge of following true weight to appropriately adjust treatment for a patient with ESRD on HD requiring inpatient refeeding. A 17-year-old female presented to an adolescent clinic after referral from her nephrologist for malnutrition and disordered eating. Her weight was 38.3 kg and height was 155.2 cm (76.2% of mean estimated body mass index, MEBMI). Her history was remarkable for a diagnosis of ESRD. The patient was admitted to the inpatient disordered eating program. The patient continued HD three times a week and was followed by nephrology. The team noted that the patient’s dry weight for dialysis had not yet been adjusted, leading to increasingly aggressive dialysis. The nephrology team addressed the need for reassessments of dry weight by utilizing the “crit line” method. Frequent assessment allowed the nephrology team to account for intensive renourishment of the patient. After a 64 day hospital stay, the patient achieved 88.1% of MEBMI, calculated using her most up to date dry weight. Among patients with malnutrition and ESRD requiring HD, it is imperative to determine a patient’s dry weight at the beginning of refeeding so the treatment plan can be adjusted according to the dynamic, true weight of the patient. This case illustrates the importance of interdisciplinary teamwork when managing a patient with malnutrition and ESRD on HD.

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) people often struggle to find quality medical and mental health care. It is important that mental health providers have a general knowledge of the specific needs of the LGBTQ+ population. This article describes how to establish a safe environment for LGBTQ+ patients, as well as how to address their specific mental health and medical needs. Knowledge of these needs can decrease overall morbidity and mortality, thus improving outcomes for this population. [ Psychiatr Ann. 2019;49(10):426–435.]

Gastric perforation in patients with anorexia nervosa is a rare entity associated with high morbidity and mortality [Norris in Int J Eat Disord 49:216-237, 2016]. In cases reported in the literature, the perforation was often preceded by a binge episode, and the subsequent clinical presentation was rapid and acutely deteriorating with a fatality rate as high as 80% [Norris in Int J Eat Disord 49:216-237, 2016, Pitre in J Med Case Rep 15:61, 2021]. We present a case of gastric perforation in the context of restrictive anorexia nervosa unique both for the absence of a premorbid binge episode as well as delayed clinical manifestations of medical distress, leading to abdominal compartment syndrome.Level IV Evidence obtained from multiple time series analysis such as case studies.

Few studies have examined menstrual differences between patients with anorexia nervosa (AN) versus avoidant/restrictive food intake disorder (ARFID). After observing that many patients with ARFID maintain regular menses despite weight loss, we sought to characterize these menstrual differences in the context of specific eating behaviors.Patients with AN or ARFID in a disordered eating database at the University of Oklahoma Health Sciences Center were included. Bivariate analyses explored group differences in demographics, age, percentage of median body mass index for age (%mBMI), time since last menstrual period (LMP), and reported eating behaviors, including whether self-reported diet history included "junk food" consumption in the past 24 hours. Regression analysis examined whether diagnosis and variables that were associated with diagnosis significantly predicted time since LMP.The analyses included 89 participants diagnosed with AN or ARFID (AN: n = 70; ARFID: n = 19). The AN group had higher %mBMI for age than the ARFID group (83.4% vs 76.4%, respectively, P = .004) and was less likely to have reported consuming junk food the day prior (36.8% vs 76.5%, respectively, P = .003). Time since LMP was longer for those with AN versus ARFID (174 vs 13 days, respectively, P.0001). A 2-predictor model with diagnosis and junk food explained a significant proportion of variance in time since LMP (P = .012).This paper may be the first to describe menstrual differences among individuals with AN and ARFID in the context of eating behaviors. In addition to diagnosis, having no self-reported junk food consumption in the past 24 hours was significantly associated with longer time since LMP. Studies that include specific measures of food intake and hormonal responses to food quality are warranted to further explore the etiology of menstrual differences among patients with AN and ARFID.

Emetophobia is defined as the specific fear of vomiting and avoidance behaviors related to vomiting situations; the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, specifies this condition as a Specific Phobia: Other type: Vomiting (SPOV). Our case report describes an adolescent presenting with medical complications, specifically notable dehydration, due to new onset Specific Phobia: Other type: Vomiting after experiencing a bout of viral gastroenteritis. In this patient’s case, her severe anxiety served as the root cause for a significant decrease in her quality of life for a year and was not identified by healthcare providers until after an extensive medical workup had taken place. Treatment involved alleviating her dehydration with slow introduction of foods with high water content into her diet and addressing her anxiety with hydroxyzine as a short-term intervention and a selective serotonin reuptake inhibitor for long-term management. This treatment plan allowed for our patient’s symptoms to resolve over the course of a few months and she was able to return to her usual activities of daily living. With discussing emetophobia, this case highlights a topic that is not largely discussed in the literature surrounding adolescent health.

For malnourished patients with end stage renal disease (ESRD) on hemodialysis (HD), refeeding is complex; true weight (dry weight) gain must be accounted for as it accrues to safely dialyze.This case describes the challenge of following true weight to appropriately adjust treatment for a patient with ESRD on HD requiring inpatient refeeding.A 17-year-old female presented to an adolescent clinic after referral from her nephrologist for malnutrition and disordered eating. Her weight was 38.3 kg and height was 155.2 cm (76.2% of mean estimated body mass index, MEBMI). Her history was remarkable for a diagnosis of ESRD. The patient was admitted to the inpatient disordered eating program. The patient continued HD three times a week and was followed by nephrology. The team noted that the patient's dry weight for dialysis had not yet been adjusted, leading to increasingly aggressive dialysis. The nephrology team addressed the need for reassessments of dry weight by utilizing the "crit line" method.Frequent assessment allowed the nephrology team to account for intensive renourishment of the patient. After a 64 day hospital stay, the patient achieved 88.1% of MEBMI, calculated using her most up to date dry weight.Among patients with malnutrition and ESRD requiring HD, it is imperative to determine a patient's dry weight at the beginning of refeeding so the treatment plan can be adjusted according to the dynamic, true weight of the patient. This case illustrates the importance of interdisciplinary teamwork when managing a patient with malnutrition and ESRD on HD.

Concerns exist that e-cigarette use may introduce adolescents to drugs. This study explores trends and associations of inhaled tobacco use with drug use. We performed a secondary data analysis on the National Youth Risk Behavior Survey examining the inhaled tobacco and drug use patterns among US teens. Adjusted odds ratios were calculated using bivariate and multivariate analyses between inhaled tobacco use with other drug use, adjusting for age, race/ethnicity, and gender. When adjusting for gender, age, and race/ethnicity, teens who use only e-cigarettes had a higher odds than peers who do not use any inhaled tobacco products to have ever tried marijuana or alcohol, currently use marijuana or alcohol, have lifetime drug use, and misused prescription medications. Drug risk behavior appears stratified with type of inhaled tobacco used, with generally exclusive e-cigarette use linked to lowest risk and conventional and e-cigarette use associated with highest risk of drug use.

Background Cervicitis is most commonly caused by sexually transmitted infections. “Normal vaginal flora” are rarely responsible for inflammation of the cervix. Case We describe a 22-year-old female patient with chronic cervicitis who had negative test results for bacterial and viral pathogens most commonly responsible for cervicitis. After 21 months of symptoms and multiple courses of empiric antibiotics addressing the most common causes of cervicitis, a course of antibiotics targeting group B streptococcus found on a genital culture resolved the patient's illness. Summary and Conclusion Bacteria considered to be “normal vaginal flora” in a nonpregnant young female adult should be considered as a potential pathogen when test results for more routine pathogens associated with cervicitis are negative.

Rates of cancers attributable to human papillomavirus (HPV) are rising. A safe and extremely effective vaccine is available to prevent many of these cancers. Studies have shown that health care providers' recommendation to immunize is the most important factor in parents' decision. Parents of all adolescent boys and girls should receive a strong and unequivocal recommendation to vaccinate their child against HPV at the 11- or 12-year-old well child visit. Ideally, adolescents complete their HPV vaccine series by their 13th birthday, leading to greater immune response and protection before most adolescents are exposed to sexually transmitted HPV.

Purpose In November, 2014, the State of Oklahoma enacted legislation potentially eliminating the provision of conditional confidential pediatric care. A consent form for treatment specific to adolescent confidential care was developed in response. This study examines parent/guardian response to the consent form. Methods The consent to treatment form describes the clinical and developmental benefits of conditional confidential treatment of adolescent minors and asks parent/guardians to waive the right to: (1) access confidential portions of the medical record, (2) be present for the physical exam, (3) be present for risk behavior discussions, and (4) consent for hormonal contraception, if indicated. Results Of 269parent/guardian respondents to the consent form, over 95% waived their rights for each of the four provisions. Conclusions When provided with information on the rationale for provision of conditional confidential care, a diverse group of parent/guardians in a conservative state overwhelmingly agree to this standard of care.

Adolescents were first specifically targeted for school-located vaccination (SLV) in the 1990s when hepatitis B catch-up vaccination was recommended for all adolescents. SLV affords the opportunity to access adolescents at a time when their activities have developmental import and the patients have the capacity to decline repeatedly missing school and extracurricular events to get vaccinated. As noted above, SLV has been primarily reserved for brief catch-up interventions among youth, with routine vaccination recommendations quickly defaulting to the primary care provider. Now in 2016, with relatively disappointing adolescent immunization rates for the routinely recommended human papillomavirus (HPV) vaccine, the SLV option is one that could potentially help increase vaccination rates for a particularly effective, life-saving, 3-dose vaccination series. This article will serve as a brief review of the successful use of SLV in other countries, lessons learned when SLV was employed to immunize adolescents against hepatitis B in the United States in the late 1990s and early 2000s, and the current hopes and challenges for the future of adolescent SLV programming in the United States. Overall, the shift to the use of SLV to administer routinely recommend vaccine for adolescents will require careful planning to implement known strategies for accessing youth and in addition to new strategies designed to assure appropriate reimbursement for cost-effect SLV services. While not the best option for all adolescents, SLV provides an important opportunity to immunize youth with limited access to healthcare services in the community at large.

The purpose of this cross-sectional survey study is to explore transgender teens’ and their parents’ interest in and preferences regarding support groups in an effort to optimally serve the entire family’s needs. The aims of the study were to: (1) describe transgender teens interest level and preferences regarding support groups; (2) describe parents of transgender teens interest level and preferences regarding support groups; and (3) compare responses based on demographics including teens versus parent, natal sex, and gender identity. De-identified surveys were collected from a convenience sample of transgender patients (N = 26), ages 13-18 years, and their parents (N = 20). Overall level of interest in support groups was 7.20/10 for youth and 7.95/10 for parents where 0 is not interested and 10 is very interested. Both groups endorsed benefits of a support group, including help with managing school issues, learning about local resources for transgender teens, and providing peer support. Both groups indicated “no time” as the most common potential barrier to attendance. Both groups expressed moderate interest in support groups, with minor differences between youths and parents noted in preferred support group structure. Further examination is warranted to determine optimal support group characteristics aimed specifically at parents and, separately, for youth. Additional support services might complement groups for a more comprehensive approach to support resources for this community.

This is a unique case of a patient with trichotillomania, depression, and anxiety for 2 years, serving as coping strategies for underlying gender dysphoria. To our knowledge, a case of a patient presenting with this unique constellation of comorbid conditions has not previously been reported. This case stresses the importance of providers obtaining a full social history consistently and repeatedly while providing a nonjudgmental environment for patients to disclose sensitive and potentially fluid information related to gender identity and sexuality.

This case series includes innovative information regarding the relationship between Avoidant/Restrictive Food Intake Disorder and the recently formulated diagnosis of Internet Gaming Disorder. The series illustrates two clinical cases in which both disorders were simultaneously recognized during diagnosis and treatment. Both disorders were utilized by patients as maladaptive coping strategies in efforts to avoid emotional distress and are potential risk factors that interfere with physical and mental health functioning. This case series highlights the unique relationship between these disorders and the compounding contribution of these two risk factors to poor physical and mental health outcomes, which is a unique contribution to the eating disorder literature. Level IV Evidence obtained from multiple time series with or without the intervention, such as case studies.

To determine variables associated with parental trust in a school-located immunization program (SLIP) and the effect of trust-building interventions on trust and participation in SLIPs.Parents among eight schools randomized to a trust-building intervention or a control condition (four schools each) completed a five-item trust survey before SLIP implementation both in year 1 (fall 2012) and in year 2 (fall 2013). Mean trust scores were calculated. Associations between baseline demographic and experiential variables and mean trust scores were analyzed. Mean trust scores in intervention and control schools were compared before SLIP in years 1 and 2, and SLIP participation rates were noted.From year 1, 1,608 parent surveys were analyzed. Baseline mean trust score across schools was 3.59 of 5 (5 = highest trust). In a multiple linear regression model, annual household income, survey language version, participation in a previous SLIP, child's health insurance status, and perceived vaccine importance were significantly associated with parental trust in SLIPs (R(2)= .06, p.001). There was no difference in mean trust scores between intervention and control schools (p = .8). In year 2, 844 surveys were analyzed, and a modest difference was observed between intervention and control schools (mean trust score = 3.66 and 3.57, respectively, p = .07). SLIP participation rates appeared higher in intervention (7.7%) versus control schools (4.3%) in year 1.Baseline trust in SLIPs among a low-income, largely Hispanic group of parents in Texas was moderately high. Factors associated with trust included demographic and experiential variables, and interventions aimed at increasing parents' perception of vaccine importance and participation in SLIPs may be effective in increasing parental trust in SLIPs.

Background Patients’ underlying medical conditions might affect the presentation and progression of an eating disorder. Case We describe a patient with an undiagnosed, rare, genetic skeletal dysplasia with effects on body mass index that likely led to body image distortion and delayed the diagnosis of an eating disorder. Summary and Conclusion It is critical to fully assess disordered eating in the context of each patient's clinical status.

SummaryBackground Medical students are often given non-standardised midpoint feedback and final evaluation on their history and physical examination documentation, despite this written communication being one of the most important aspects of patient care. This study aims to assess the effect of using a standardised feedback tool on overall student documentation performance. Methods A standardised written evaluation form, called the history and physical examination write-up assessment (HAPA) form, was previously developed and published in The Clinical Teacher in 2011. This form evaluates the documentation of student communication, data collection and clinical reasoning, and was used to provide midpoint documentation feedback to one group of medical students, whereas a second group received non-standardised midpoint feedback on documentation. Final written history and physical examination documentation from both groups was then evaluated using the standardised tool to assess the effect of receiving more formalised midpoint documentation feedback using the HAPA form. Results The group receiving standardised midpoint feedback using the HAPA form performed significantly better on the final evaluations of their documentation, especially when examining communication and data collection documentation. Performance in clinical reasoning documentation did not demonstrate a significant change between the two groups. Medical students are often given non-standardised midpoint feedback and final evaluation Conclusions The use of a standardised evaluation tool, such as the HAPA form, may be associated with improved student documentation. This form provides educators with an effective tool to use when providing feedback and final evaluation of medical student documentation.

BACKGROUND: Little is known about duration of protection after the infant primary series of hepatitis B (HB) vaccine in settings of low HB endemicity. This study sought to determine the proportion of adolescents immunized as infants who had protective titers of antibody to hepatitis B surface antigen (anti-HBs) before and after a challenge dose of vaccine. METHODS: US-born 16- through 19-year-olds who received a recombinant HB vaccine 3-dose series initiated within 7 days of birth (group 1) or at ≥4 weeks of age (group 2) and completed by 12 months of age were enrolled. Participants had serologic testing before and 2 weeks after randomization to receive a challenge dose of 10 µg or 20 µg of Engerix-B. Baseline and postchallenge levels of anti-HBs were compared by group, challenge dosage, and demographic and behavioral characteristics. RESULTS: At baseline, 24% had protective anti-HBs levels of ≥10 IU/mL; 92% achieved protective levels after challenge dose. Although group 1 had a lower proportion of seroprotection at baseline, group and challenge dosage were not associated with postchallenge proportion of seroprotection. Being in group 2, higher test dosage, higher baseline geometric mean titer, and nonwhite race were associated with significantly higher geometric mean titer after challenge dose. CONCLUSIONS: More than 90% of study participants immunized against HB as infants exhibited a seroprotective response to a challenge dose of vaccine. Duration of protection from the primary infant HB vaccine series extended through the adolescent years in the setting of low HB endemicity.

Males comprise a minority of patients with eating disorders (ED). However, men who have sex with men, males with gender identity disorder, and transsexual (TS) males are at increased risk for ED. Little has been published about the unique treatment needs of TS patients with ED. A 19-year-old male-to-female TS patient presented with restrictive eating, purging, and weight loss. History revealed that her ED ideation and behaviors were strongly intertwined with her gender identity. She was admitted and during her hospitalization both her ED and TS status were addressed medically. Physicians treating patients with ED should be aware of patients' gender identities and the ways in which gender identity may impact management and recovery. When appropriate, providers should consider addressing medical treatment toward gender transition concurrently with treatment for ED to facilitate medical stabilization and weight restoration in the manner most consistent with the patient's identified gender.

Vaccines currently recommended for adolescents by the Advisory Committee on Immunization Practices have the potential to improve the health of youth by preventing conditions such as: tetanus, pertussis, meningococcal disease, influenza, and genital warts, as well as later adult outcomes such as cervical and other human papillomavirus-related cancers. Adolescent vaccine coverage lags behind that for younger age groups. A requirement to obtain parental consent for vaccination can present a significant barrier to improving adolescent vaccine uptake across all health care settings in which adolescents access care. The ability of minors to consent to vaccination can influence whether adolescents receive indicated vaccines during adolescent health care visits when parents are absent and when adolescents are seen for confidential services. State laws govern consent for the delivery of health care to minors. All states have some laws that allow minors to consent to health care based either on their status or on the services they are seeking. Some of these laws would allow them to consent to vaccination. It is the Position of the Society for Adolescent Health and Medicine that, within ethical and legal guidelines, it will be important to develop strategies that maximize opportunities for minors to receive vaccinations when parents are not physically present, including opportunities for them to give their own consent.

The perspectives of parents of private middle school students regarding the use of school-located immunization programs (SLIPs) are unknown. Parents of private middle school students in a large, urban setting were surveyed ( N = 1,210) regarding their willingness to use SLIPs. Analyses included frequencies and chi-square analyses. Data from prior work with public school parents were included for comparison. Of the 1,210 questionnaires, 219 were returned; only 19% of respondents reported they were willing to use a SLIP, compared to 41% of public middle school parents. However, 54% of private school parents were willing to consider using SLIPs for influenza vaccine, and 6% would use SLIPs for human papillomavirus vaccine. Hispanic (Mexican) ethnicity ( p = .014) was associated with greater willingness to utilize SLIPs. Private middle school parents, in this sample, are relatively unwilling to utilize SLIPs compared to public school parents. These data should be considered when implementing SLIPs in the future.

Previous research has implied that while parents may be willing to have their adolescents receive some recommended vaccines via school-located vaccination program (SLVP), they were less likely to agree to the HPV vaccine being administered via SLVP. During an SLVP in a large urban area, 86% of those participating in the program received an HPV vaccine.

Patients with eating disorders are at risk for electrolyte imbalances that can lead to life-threatening complications. Timely recognition and evaluation of electrolyte abnormalities, including hypokalemia, are essential. In this case report, we describe an uncommon etiology of hypokalemia in a patient with disordered eating.

Purpose To describe both parent and student perspectives on the importance of various programmatic factors when deciding to participate in a school-located immunizations program (SLIP) for influenza vaccine. Methods Questionnaires were distributed to middle- and high-school students and their parents; the document assessed demographic data, influenza vaccination history, and the importance of various factors in their decision to participate in a potential SLIP for influenza vaccine. Factor analysis created six primary factors of importance related to programming: (1) safety/trust; (2) outbreaks (representing imminent threat of disease, an environmental factor associated with program timing); (3) issues of site implementation; (4) public health benefits; (5) record-keeping; (6) medical/emotional support. Results Participants included 621 students and 579 parents; 566 student/parent dyads were included. Most respondents were female, felt it is important to be immunized against the flu, and received the influenza vaccine in the past. Fewer than 50% had received the intranasal vaccine. More parents (67%) than students (46%) expressed a general willingness to consent to utilizing a SLIP. The programmatic factors associated with public health were second only to safety/trust factors as the most important to parents and students when considering participation in a SLIP. Demographic variables were found to be associated with the importance ratings of program factors associated with participation in a SLIP. Conclusions When considering possible participation in SLIPs, parents and students consider programmatic factors associated with safety/trust and public health benefits to be of the greatest importance. Further study will be needed to develop effective and culturally sensitive messaging that targets and emphasizes these factors to potentially increase participation in SLIPS.

Objective : To implement a curriculum using simulation and skills training to augment a Pediatric Emergency Medicine (PEM) rotation within a pediatric clerkship. Background : PEM faculty are often challenged with a high learner to teacher ratio in a chaotic clinical setting. This challenge was heightened when our pediatric clerkship’s traditional 1-week PEM rotation (consisting of 4 students completing four 8-hour ED shifts/week) expanded to 8 students every 2 weeks. We sought to meet this challenge by integrating simulation-based education into the rotation. Methods : Clerkship students from March to June 2012 completed our traditional rotation. Students between July and October 2012 completed the new PEM-SIM curriculum with 19 hours ED shifts/week and 16 hours/week of simulation/skills training. Pre/post-tests evaluated 1) medical management/procedural comfort (five-point Likert scale); and 2) PEM knowledge (15 multiple-choice questions). Results : One hundred and nine students completed the study (48 traditional, 61 PEM-SIM). Improvement in comfort was significantly higher for the PEM-SIM group than the traditional group for 6 of 8 (75%) medical management items ( p