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Although many community ob/gyns are prescribing OC's for adolescents with anorexia, bulimia, and other eating disorders, there's limited evidence that they work for that indication. Moreover, for patients with some eating disorders, OCs will mask the natural return of menses. [ABSTRACT FROM AUTHOR]

BACKGROUND: Chemotherapy and radiation therapy result in increased free radical formation and depletion of tissue antioxidants. It is not known whether parenteral nutrition (PN) administered during bone marrow transplantation (BMT) supports systemic antioxidant status. OBJECTIVE: The aims of the study were to determine 1) whether high-dose chemotherapy decreases concentrations of major circulating antioxidants in patients undergoing BMT and 2) whether administration of standard PN maintains systemic antioxidant concentrations compared with PN containing micronutrients and minimal lipids alone. DESIGN: Twenty-four BMT patients were randomly assigned to receive either standard PN containing conventional amounts of dextrose, amino acids, micronutrients, and lipid (120 kJ/d) or a solution containing only micronutrients (identical to those in standard PN) and a small amount of lipid (12 kJ/d). Plasma antioxidant status was measured before conditioning therapy and serially at days 1, 3, 7, 10, and 14 after BMT. RESULTS: Plasma glutathione (GSH) and alpha- and gamma-tocopherol concentrations decreased and the GSH redox state became more oxidized after conditioning chemotherapy. Plasma cysteine concentrations were unchanged, whereas cystine concentrations increased. Plasma vitamin C and zinc concentrations and GSH peroxidase activity increased over time. Plasma alpha-tocopherol concentrations were lower in patients given standard PN. There were no differences in other plasma antioxidants between groups. CONCLUSIONS: A significant decline in GSH-glutathione disulfide, cysteine-cystine, and vitamin E status occurs after chemotherapy and BMT. Standard PN does not improve antioxidant status compared with administration of micronutrients alone. Further evaluation of PN formulations to support patients undergoing high-dose chemotherapy and BMT are needed. Copyright © 2000 American Society for Clinical Nutrition [ABSTRACT FROM AUTHOR]

Eating disorders may result in medical complications that affect every body system with both acute and chronic consequences. Although some medical complications may require acute medical hospitalization to manage, other complications, such as low bone mineral density, may not present until malnutrition has become chronic. It is critical for team members to be aware of the early clinical signs of malnutrition and disordered eating behaviors, as well as longer-term complications that may affect their patients. When identifying eating disorder concerns, appropriate colleagues from the medical, nutrition, and psychiatric fields can be engaged in order to collaborate on stabilizing and improving the health of patients., Competing Interests: Dr. Lemly reports being Supervising Physician with Equip Health. Dr. Carlson reports no financial relationships with commercial interests., (Copyright © 2024 by the American Psychiatric Association.)

Introduction: Although the female athlete triad (Triad) has been associated with increased risk of bone-stress injuries (BSIs), limited research among collegiate athletes has addressed the associations between the Triad and non-BSI injuries., Objective: To elucidate the relationship between Triad and both BSI and non-BSI in female athletes., Design: Retrospective cohort study., Setting: Primary and tertiary care student athlete clinic., Participants: National Collegiate Athletic Association Division I female athletes at a single institution., Intervention: Participants completed a pre-participation questionnaire and dual-energy x-ray absorptiometry, which was used to generate a Triad cumulative risk assessment score (Triad score). The number of overuse musculoskeletal injuries that occurred while the athletes were still competing collegiately were identified through chart review., Main Outcome Measure: BSI and non-BSI were treated as count variables. The association between BSI, non-BSI, and Triad score was measured using Poisson regression to calculate rate ratios., Results: Of 239 athletes, 43% of athletes (n = 103) sustained at least one injury. Of those, 40% (n = 95) sustained at least one non-BSI and 10% (n = 24) sustained at least one BSI over an average follow-up 2.5 years. After accounting for sport type (non-lean, runner, other endurance sport, or other lean advantage sport) and baseline age, we found that every additional Triad score risk point was associated with a significant 17% increase in the rate of BSI (rate ratio [RR] 1.17, 95% confidence interval [CI] 1.03-1.33; p = .016). However, Triad score was unrelated to non-BSI (1.00, 95% CI 0.91-1.11; p = .99). Compared with athletes in non-lean sports (n = 108), athletes in other lean advantage sports (n = 30) had an increased rate of non-BSI (RR: 2.09, p = .004) whereas distance runners (n = 46) had increased rates of BSI (RR: 7.65, p < .001) and non-BSI (RR: 2.25, p < .001)., Conclusions: Higher Triad score is associated with an increased risk of BSI but not non-BSI in collegiate athletes., (© 2024 American Academy of Physical Medicine and Rehabilitation.)

Purpose: The 21st Century Cures Act Final Rule mandates increased transparency and accessibility of the Electronic Health Record (EHR). This mandate has exacerbated tensions in adolescent healthcare between transparency and confidentiality. This study evaluates clinicians' perspectives on how well the EHR maintains confidentiality for adolescents in the post-Cures Act era., Methods: A web-based survey was distributed via the national listserv of the Society for Adolescent Health and Medicine in March-April 2022. English-speaking members practicing in the Unites States who used an EHR to document clinical visits with minors were eligible. The survey included questions about EHR training, features, and approach to information sharing with adolescent patients and proxies., Results: Participants included 97 respondents from 32 states. Most participants were physicians (98%) and identified themselves as attending (89%). Several EHR vendors were represented, although the majority used Epic (76%). As has been seen in prior studies, there remains significant variability in approaches to patient portal access for adolescent patients and their adult proxies. Respondents report that training around adolescent-specific privacy issues remains infrequent and is perceived as inadequate. Adolescent providers, despite feeling confident in navigating the EHR generally, continue to report low rates of confidence in how well their EHR may protect adolescent privacy., Discussion: Clinicians have persistent concerns about adolescent confidentiality postimplementation of the 21st Century Cures Act. Sharing sufficient information while protecting adolescent confidentiality might require standardization by EHR vendors to improve granularity of proxy information sharing. Healthcare institutions must also commit to training providers on management of adolescent confidentiality., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Extensive literature exists on bone health in females with an eating disorder, yet few have studied males. Our study assessed clinician confidence and current practices for assessing bone health in patients with an eating disorder. We also aimed to identify any differences in practice based on patient sex. Our 31-item survey, distributed to adolescent clinicians in the United States via the Society for Adolescent Health and Medicine (SAHM) listserv, assessed clinician confidence and practices for assessing bone mineral density in both male and female adolescents with an eating disorder. Findings showed that clinicians (n = 104) were less confident in assessing bone mineral density in males compared to females (p < .001), yet there was no significant difference in rates of obtaining a DXA (p = .390). Although clinicians are less confident assessing bone health in males with an eating disorder than females, this does not appear to result in screening differences.

Background: The 21st Century Cures Act mandates the immediate, electronic release of health information to patients. However, in the case of adolescents, special consideration is required to ensure that confidentiality is maintained. The detection of confidential content in clinical notes may support operational efforts to preserve adolescent confidentiality while implementing information sharing., Objectives: This study aimed to determine if a natural language processing (NLP) algorithm can identify confidential content in adolescent clinical progress notes., Methods: A total of 1,200 outpatient adolescent progress notes written between 2016 and 2019 were manually annotated to identify confidential content. Labeled sentences from this corpus were featurized and used to train a two-part logistic regression model, which provides both sentence-level and note-level probability estimates that a given text contains confidential content. This model was prospectively validated on a set of 240 progress notes written in May 2022. It was subsequently deployed in a pilot intervention to augment an ongoing operational effort to identify confidential content in progress notes. Note-level probability estimates were used to triage notes for review and sentence-level probability estimates were used to highlight high-risk portions of those notes to aid the manual reviewer., Results: The prevalence of notes containing confidential content was 21% (255/1,200) and 22% (53/240) in the train/test and validation cohorts, respectively. The ensemble logistic regression model achieved an area under the receiver operating characteristic of 90 and 88% in the test and validation cohorts, respectively. Its use in a pilot intervention identified outlier documentation practices and demonstrated efficiency gains over completely manual note review., Conclusion: An NLP algorithm can identify confidential content in progress notes with high accuracy. Its human-in-the-loop deployment in clinical operations augmented an ongoing operational effort to identify confidential content in adolescent progress notes. These findings suggest NLP may be used to support efforts to preserve adolescent confidentiality in the wake of the information blocking mandate., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: The 21st Century Cures Act information blocking final rule mandated the immediate and electronic release of health care data in 2020. There is anecdotal concern that a significant amount of information is documented in notes that would breach adolescent confidentiality if released electronically to a guardian., Objectives: The purpose of this study was to quantify the prevalence of confidential information, based on California laws, within progress notes for adolescent patients that would be released electronically and assess differences in prevalence across patient demographics., Methods: This is a single-center retrospective chart review of outpatient progress notes written between January 1, 2016, and December 31, 2019, at a large suburban academic pediatric network. Notes were labeled into one of three confidential domains by five expert reviewers trained on a rubric defining confidential information for adolescents derived from California state law. Participants included a random sampling of eligible patients aged 12 to 17 years old at the time of note creation. Secondary analysis included prevalence of confidentiality across age, gender, language spoken, and patient race., Results: Of 1,200 manually reviewed notes, 255 notes (21.3%) (95% confidence interval: 19-24%) contained confidential information. There was a similar distribution among gender and age and a majority of English speaking (83.9%) and white or Caucasian patients (41.2%) in the cohort. Confidential information was more likely to be found in notes for females ( p  < 0.05) as well as for English-speaking patients ( p  < 0.05). Older patients had a higher probability of notes containing confidential information ( p  < 0.05)., Conclusion: This study demonstrates that there is a significant risk to breach adolescent confidentiality if historical progress notes are released electronically to proxies without further review or redaction. With increased sharing of health care data, there is a need to protect the privacy of the adolescents and prevent potential breaches of confidentiality., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: For caregivers of adolescents and young adults with severe cognitive deficits, or "diminished capacity," access to the medical record can be critical. However, this can be a challenge when utilizing the electronic health record (EHR) as information is often restricted in order to protect adolescent confidentiality. Having enhanced access for these proxies would be expected to improve engagement with the health system for the families of these medically complex adolescents and young adults., Objectives: To describe a process for granting full EHR access to proxies of adolescents with diminished capacity and young adults who are legally conserved while respecting regulations supporting adolescent confidentiality., Methods: The first step in this initiative was to define the "diminished capacity" access class for both adolescents and young adults. Once defined, workflows utilizing best practice alerts were developed to support clinicians in providing the appropriate documentation. In addition, processes were developed to minimize the possibility of erroneously activating the diminished capacity access class for any given patient. To enhance activation, a support tool was developed to identify patients who might meet the criteria for diminished capacity proxy access. Finally, outreach and educations were developed for providers and clinics to make them aware of this initiative., Results: Since activating this workflow, proxies of 138 adolescents and young adults have been granted the diminished capacity proxy access class. Approximately 54% are between 12 and 17 years with 46% 18 years and older. Proxies for both age groups have engaged with portal functionality at higher rates when compared to institutional rates of use by proxies of the general pediatric population., Conclusion: With this quality improvement initiative, we were able to enhance EHR access and engagement of families of some of the most complex adolescent and young adult patients without inadvertently compromising adolescent confidentiality., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Bone stress injuries (BSIs) are common in athletes. Risk factors for BSI may differ by skeletal anatomy and relative contribution of trabecular-rich and cortical-rich bone., Hypothesis: We hypothesized that Female Athlete Triad (Triad) risk factors would be more strongly associated with BSIs sustained at trabecular-rich versus cortical-rich skeletal sites., Study Design: Cohort study; Level of evidence, 2., Methods: The study population comprised 321 female National Collegiate Athletic Association Division I athletes participating in 16 sports from 2008 to 2014. Triad risk factors and a Triad cumulative risk score were assessed using responses to preparticipation examination and dual energy x-ray absorptiometry to measure lumbar spine and whole-body bone mineral density (BMD). Sports-related BSIs were diagnosed by a physician and confirmed radiologically. Athletes were grouped into those sustaining a subsequent trabecular-rich BSI, a subsequent cortical-rich BSI, and those without a BSI. Data were analyzed with multinomial logistic regression adjusted for participation in cross-country running versus other sports., Results: A total of 19 participants sustained a cortical-rich BSI (6%) and 10 sustained a trabecular-rich BSI (3%) over the course of collegiate sports participation. The Triad cumulative risk score was significantly related to both trabecular-rich and cortical-rich BSI. However, lower BMD and weight were associated with significantly greater risk for trabecular-rich than cortical-rich BSIs. For every value lower than 1 SD, the odds ratios (95% CIs) for trabecular-rich versus cortical-rich BSI were 3.08 (1.25-7.56) for spine BMD; 2.38 (1.22-4.64) for whole-body BMD; and 5.26 (1.48-18.70) for weight. Taller height was a significantly better predictor of cortical-rich than trabecular-rich BSI., Conclusion: The Triad cumulative risk score was significantly associated with both trabecular-rich and cortical-rich BSI, but Triad-related risk factors appeared more strongly related to trabecular-rich BSI. In particular, low BMD and low weight were associated with significantly higher increases in the risk of trabecular-rich BSI than cortical-rich BSI. These findings suggest Triad risk factors are more common in athletes sustaining BSI in trabecular-rich than cortical-rich locations., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: A.S.T. has received research support from DJO and Uniform Health Services. M.F. has received consulting fees from Ipsen Bioscience and honoraria from Fidia Pharma. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Purpose: This study sought to examine associations between meat-restricted diets and disordered eating cognitions and behaviors in a large sample of university students and assess the relationships between motivations for choosing a vegetarian or semi-vegetarian diet and eating patterns., Methods: University students (n = 1585; 60%F, 40%M, mean age 20.9) completed an online survey; students were categorized into vegetarians, semi-vegetarians, and non-vegetarians. Vegetarians and semi-vegetarians were sub-categorized into groups: those who cited weight or health among their reasons for adopting the diet and those who reported other reasons (e.g., religion). Outcomes were Eating Disorder Examination Questionnaire (EDE-Q) scores and rates of disordered eating behaviors., Results: Vegetarians comprised 8.6% (32M, 104F) and semi-vegetarians comprised 3.2% (6M, 45F) of the sample; 25% of vegetarians (n = 34) and 65% of semi-vegetarians (n = 33) chose the diet for weight or health-related reasons. Semi-vegetarians scored the highest on measures of eating disorder cognitions and were the most likely to report engaging in disordered eating behaviors, with vegetarians at intermediate risk and non-vegetarians the least likely to report disordered cognitions or behaviors. Semi-vegetarians adopting the diet for reasons of weight or health were at especially high risk compared to other semi-vegetarians, while no associations were found between motivations for adopting a vegetarian diet and disordered eating patterns., Conclusion: Semi-vegetarians, especially those adopting the diet for reasons of weight or health, are more likely to exhibit disordered eating cognitions and behaviors compared to vegetarians and non-vegetarians., Level of Evidence: Level III, cohort study., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Objectives: Reproductive health is an important issue in the care of adolescents and young adults (AYA). Unfortunately, many AYAs, particularly those with chronic medical conditions, may not regularly access primary care to address these issues. This study evaluates the impact of an inpatient reproductive health consult service on reproductive health care., Methods: A reproductive health-focused screening consult service was initiated in June 2017 at an academic teaching hospital. Patients aged 15 to 26 admitted to pediatric ward teams were eligible for screening. A retrospective chart review was conducted from December 2016 to June 2019 to determine the effect of the consult service on the primary outcome, documentation of a psychosocial assessment, and reproductive health concerns., Results: Nine hundred twenty-nine encounters were analyzed (345 preintervention and 584 during intervention), representing 675 patients. The proportion of encounters with a documented psychosocial assessment increased from 14.8% to 41.3% during the intervention (P < .001); a reproductive health screening consult was responsible for 37.3% (109 of 292) of the documented assessments. There were high self-reported rates of sexual activity (38%), substance use (47%), and mood concerns (48%) among hospitalized AYA; all behaviors were documented at statistically significant increased frequencies (P < .001) during the intervention compared with preintervention., Conclusions: Initiation of an inpatient reproductive health screening consult service led to increased documentation of psychosocial assessments, including increased documentation of sexual health history and other risk factors. With improved screening of reproductive and psychosocial needs, targeted interventions can meet underrecognized needs among hospitalized AYA., (Copyright © 2022 by the American Academy of Pediatrics.)

Purpose: Managing confidential adolescent health information in patient portals presents unique challenges. Adolescent patients and guardians electronically access medical records and communicate with providers via portals. In confidential matters like sexual health, ensuring confidentiality is crucial. A key aspect of confidential portals is ensuring that the account is registered to and utilized by the intended user. Inappropriately registered or guardian-accessed adolescent portal accounts may lead to confidentiality breaches., Methods: We used a quality improvement framework to develop screening methodologies to flag guardian-accessible accounts. Accounts of patients aged 12-17 were flagged via manual review of account emails and natural language processing of portal messages. We implemented a reconciliation program to correct affected accounts' registered email. Clinics were notified about sign-up errors and educated on sign-up workflow. An electronic alert was created to check the adolescent's email prior to account activation., Results: After initial screening, 2,307 of 3,701 (62%) adolescent accounts were flagged as registered with a guardian's email. Those accounts were notified to resolve their logins. After five notifications over 8 weeks, 266 of 2,307 accounts (12%) were corrected; the remaining 2,041 (88%) were deactivated., Conclusions: The finding that 62% of adolescent portal accounts were used/accessed by guardians has significant confidentiality implications. In the context of the Cures Act Final Rule and increased information sharing, our institution's experience with ensuring appropriate access to adolescent portal accounts is necessary, timely, and relevant. This study highlights ways to improve patient portal confidentiality and prompts institutions caring for adolescents to review their systems and processes., (Copyright © 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Although extensive literature exists on hypothalamic-pituitary-gonadal (HPG) axis suppression in females with an eating disorder, there are few studies in males. Our study aimed to determine clinician practices for the assessment of HPG axis suppression and to identify differences in practice based on the sex of the patient., Method: Our 31-item survey queried clinicians about confidence level and practices for assessing HPG suppression in male compared to female patients., Results: Findings showed that clinicians (n = 104) were less likely to evaluate HPG suppression in males compared to females, including assessment of sexual maturity rating (p < .050), screening of decreased libido compared to amenorrhea (p < .001) and lab assessment (luteinizing hormone and follicular-stimulating hormone: p < .001; estradiol/testosterone: p < .010; TSH: p < .050). Participants also felt less confident evaluating male patients (p < .001) and requested better screening tools for males (p < .001)., Discussion: Our data suggest that clinician practices differ based on patient sex and that clinicians request tools for HPG suppression assessment in males. This is the first study examining specific practices and comfort levels of clinicians when assessing HPG axis suppression. Findings suggest that more guidance on the management of male patients may be needed to standardize care and to prevent short and long-term sequela of malnutrition., (© 2021 Wiley Periodicals LLC.)

Ergogenic supplements to improve athletic performance are commonly used among college athletes, but little is known about their association with eating disorder symptoms. The objective of this study was to examine associations between ergogenic supplement use and disordered eating attitudes and behaviors among university students, and to compare differences by sex. Undergraduate students from 10 top-ranked National College Athletics Association (NCAA) Division I colleges completed an online survey on supplement use, athletic activities, and eating attitudes and behaviors. Among 1633 university students, males (38.9%) reported higher rates of current supplement use than females (15.2%) ( p < .001). In linear regression models adjusting for athletic status and body mass index, current supplement use was associated with higher Eating Disorders Examination-Questionnaire (EDE-Q) Global, Shape Concern, and Restraint scores in both males and females. Supplement use was associated with driven/compelled exercise (OR 2.00, 95% CI 1.33-2.99) in males and diuretic (OR 6.39, 95% CI 2.02-20.22) and diet pill use (OR 3.07, 95% CI 1.79-5.27) in females. Results suggest ergogenic supplement use is common in undergraduates and associated with disordered eating attitudes and behaviors. Clinicians should screen for disordered eating behaviors particularly in young adults who use ergogenic supplements.

Introduction: Determinants of bone health and injury are important to identify in athletes. Bone mineral density (BMD) is commonly measured in athletes with Female Athlete Triad (Triad) risk factors; the trabecular bone score (TBS) has been proposed to predict fracture risk independent of BMD. Evaluation of TBS and spine BMD in relation bone stress injury (BSI) risk has not been studied in female collegiate athletes., Objective: We hypothesized that spine BMD and TBS would each independently predict BSI and that the combined measures would improve injury prediction in female collegiate athletes. We also hypothesized that each measure would be correlated with Triad risk factors., Design: Retrospective cohort., Setting: Academic Institution., Methods: Dual energy x-ray absorptiometry (DXA) of the lumbar spine was used to calculate BMD and TBS values. Chart review was used to identify BSI that occurred after the DXA measurement and to obtain Triad risk factors. We used logistic regression to examine the ability of TBS and BMD alone or in combination to predict prospective BSI., Results: Within 321 athletes, 29 (9.0%) sustained a BSI after DXA. BMD and TBS were highly correlated (Pearson correlation r = 0.62, P < .0001). Spine BMD and TBS had similar ability to predict BSI; the C-statistic and 95% confidence intervals were 0.69 (0.58 to 0.81) for spine BMD versus 0.68 (0.57 to 0.79) for TBS. No improvement in discrimination was observed with combined BMD + TBS (C-statistic 0.70, 0.59 to 0.81). Both TBS and BMD predicted trabecular-rich BSI (defined as pelvis, femoral neck, and calcaneus) better than cortical-rich BSI. Both measures had similar correlations with Triad risk factors., Conclusion: Lower BMD and TBS values are associated with elevated risk for BSI and similar correlation to Triad risk factors. TBS does not improve prediction of BSI. Collectively, our findings suggest that BMD may be a sufficient measure of skeletal integrity from DXA in female collegiate athletes., (© 2020 American Academy of Physical Medicine and Rehabilitation.)

Purpose: The Female Athlete Triad (Triad) is common in female athletes. The Triad is caused by low-energy availability (EA), which is often difficult to measure and has been postulated to be associated with low-iron status. Here, we explore whether markers of low-iron status may be associated with indicators of low EA including Triad risk factors., Methods: A total of 239 female National Collegiate Athletic Association Division I athletes completed preparticipation examinations that included Triad risk factors, medication/supplement use, diagnosis of anemia, and elected to complete dual-energy x-ray absorptiometry scan to measure bone mineral density. The association of markers of low iron (defined as self-report of iron supplementation and/or history of anemia) with each component of the Triad risk assessment score was assessed by stratifying low-iron status across different levels of Triad risk category. Differences across iron status groups were assessed using Fisher exact testing., Results: Every component of the Triad risk assessment score excluding delayed menarche was associated with low-iron status. The proportion of women who reported low iron was 11.5% in the low-risk EA group compared with 50% in the moderate-risk and 66.7% in the high-risk EA groups (P = 0.02); respectively. These numbers were 11.6%, 25.0%, and 66.7% (P = 0.02) for body mass index; 9.7%, 16.7%, and 25.0% (P < 0.05) for oligomenorrhea; 10.3%, 45.5%, and 50.0% (P < 0.01) for bone mineral density; and 10.4%, 20.8%, and 30.8% (P = 0.03) for history of stress reaction or fracture. Lean/endurance athletes were more likely to have low-iron status than other athletes (15.5% vs 3.4%, P = 0.02)., Conclusions: Markers for low-iron status were associated with Triad risk factors. Our study suggests that female athletes with a history of anemia or iron supplementation may require further screening for low EA., (Copyright © 2021 by the American College of Sports Medicine.)

Purpose: Research concerning eating disorders among adolescent and young adult male athletes is limited compared with female counterparts, but increasing evidence indicates that they may be at unique risk for unhealthy exercise and eating behavior. The current study aimed to characterize unhealthy exercise and eating behavior according to competitive athlete status, as well as per sport type., Method: Collegiate male athletes (N = 611), each affiliated with one of the 10 National College Athletics Association (NCAA) Division I schools in the United States, completed an online survey, reporting on eating and extreme weight control behaviors, and reasons for exercise., Results: Competitive athletes endorsed increased driven exercise and exercising when sick. Baseball players, cyclists, and wrestlers emerged as the sports with the most players reporting elevated Eating Disorder Examination-Questionnaire scores in a clinical range, and basketball players reported the highest rates of binge eating. overall, baseball players, cyclists, rowers, and wrestlers appeared to demonstrate the greatest vulnerability for unhealthy eating and exercise behavior., Conclusion: Findings revealed differences between competitive and non-competitive male athletes. Among competitive athletes, results identified unique risk for unhealthy eating and exercise behavior across a variety of sport categories and support continued examination of these attitudes and behaviors in a nuanced manner., Level Ii: Evidence obtained from well-designed controlled trials without randomization.

Introduction: The study objectives were to estimate plasma flunixin (FLU) pharmacokinetic parameters and milk depletion profiles for FLU and its metabolite (5-hydroxy flunixin; 5-OH) after subcutaneous (SC) and intravenous (IV) administration of single and multiple flunixin meglumine (FM) doses to non-lactating (nulliparous and pregnant does) and lactating dairy goats. Analytical methods (ELISA and UPLC-MS/MS) for quantifying plasma FLU concentrations were compared. The final objective was to use regulatory (FDA and EMA) methods to estimate milk withdrawal intervals following extra-label drug use in goats. Methods: FM was administered IV and SC to commercial dairy goats at 1.1 mg/kg for single and multiple doses. Plasma and milk samples were analyzed for FLU and 5-OH via UPLC-MS/MS. Plasma samples were also analyzed for FLU concentrations via ELISA. Using statistical approaches recommended by regulatory agencies, milk withdrawal intervals were estimated following FM extra-label use. Results: Following IV administration of a single FM dose, clearances were 127, 199, and 365 ml/kg/h for non-lactating (NL) pregnant does, NL nulliparous does, and lactating dairy does, respectively. Following multiple SC doses, clearance/ F was 199 ml/kg/h for lactating does. After IV administration of a single FM dose, terminal elimination half-lives were 4.08, 2.87, and 3.77 h for NL pregnant does, NL nulliparous does, and lactating dairy does, respectively. After multiple SC doses, the terminal elimination half-life was 3.03 h for lactating dairy does. No significant differences were noted for samples analyzed by UPLC-MS/MS or ELISA. Milk withdrawal intervals ranged from 36 to 60 h depending on the regulatory statistical method and dosage regimen. Conclusions: Subcutaneous administration of FM to goats results in similar plasma pharmacokinetic parameters as IV administration. ELISA analysis is an alternative method to UPLC-MS/MS for quantifying FLU concentrations in caprine plasma samples. Following FM extra-label administration to dairy goats, clinicians could consider 36-60 h milk withdrawal intervals., (Copyright © 2020 Smith, Marmulak, Angelos, Lin, Rowe, Carlson, Shelver, Lee and Tell.)

Purpose: Electronic health records (EHRs) have led to more transparency and improvements in patient safety, yet electronic access to personal health information can pose significant threats to maintaining confidentiality for adolescents. To date, no studies have explored clinicians' perspectives on EHR functionality and institutional policies related to confidentiality and health information sharing for adolescents aged <18 years., Methods: A Web-based survey was sent out via the national listserv of the Society for Adolescent Health and Medicine. All English-speaking members practicing in the U.S. were eligible to participate. The survey included questions about demographics, EHR functionality, information sharing, and attitudes about confidentiality within the EHR., Results: Participants included 212 clinicians who consented to the survey and used an EHR to document clinical visits with minors. Most participants were physicians and nurse practitioners (96.5%), and 60.0% had been on their institution's EHR for >5 years. Positive findings included high levels of experience and comfort using the EHR and awareness of confidential features within their EHR. However, providers reported lack of training related to confidentiality within the EHR, low confidence in their EHR's ability to maintain confidentiality, and variation in approaches to portal access for adolescents and their adult proxies., Conclusions: Despite high comfort levels and robust EHR functionality at many institutions, significant concerns about adolescent confidentiality remain. Varying institutional approaches to protecting confidentiality underscores the need for a standardized and comprehensive framework to enable providers and institutions to take better care of adolescents in the age of EHRs., (Copyright © 2019 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Objective: To identify the effect of duration of weight-bearing exercise and team sports participation on bone mineral density (BMD) and body composition among adolescents with anorexia nervosa (AN)., Method: We retrospectively reviewed electronic medical records of all patients 9-20 years old with a DSM-5 diagnosis of AN evaluated by the Stanford Eating Disorders Program (1997-2011) who underwent dual-energy X-ray absorptiometry., Results: A total of 188 adolescents with AN were included (178 females and 10 males). Using multivariate linear regression, duration of weight-bearing exercise (B = 0.15, p = 0.005) and participation in team sports (B = 0.53, p = 0.001) were associated with higher BMD at the hip and team sports (B = 0.39, p = 0.006) were associated with higher whole body BMC, controlling for covariates. Participation in team sports (B = - 1.06, p = 0.007) was associated with greater deficits in FMI Z-score. LBMI Z-score was positively associated with duration of weight-bearing exercise (B = 0.10, p = 0.018) and may explain the relationship between exercise and bone outcomes., Conclusion: Duration of weight-bearing exercise and team sports participation may be protective of BMD at the hip and whole body BMC, while participation in team sports was associated with greater FMI deficits among adolescents with AN., Level of Evidence: Level V, descriptive retrospective study.

Objective: To compare bone mineral density (BMD) and body composition among adolescents: (a) with atypical anorexia nervosa (AAN) versus anorexia nervosa (AN) and (b) those with and without a prior history of overweight., Method: Electronic medical records of patients 9-20 years with AN or AAN who underwent dual-energy x-ray absorptiometry scans were retrospectively reviewed and analyzed., Results: A total of 286 adolescents with AN or AAN were included. In linear regression models, AAN was associated with greater Z-scores in whole body bone mineral content (BMC, B = 0.88, p < 0.001), lumbar spine BMD (B = 0.79, p = 0.002), femoral neck BMD (B = 0.670, p = 0.009); fat mass index (B = 1.33, p = 0.003), and lean body mass index (LBMI, B = 1.10, p < 0.001) compared to AN, adjusting for age, sex, and duration of illness. A prior overweight history was associated with greater Z-scores in whole body BMC; lumbar spine BMD, total hip BMD, femoral neck BMD, and LBMI., Discussion: Adolescents with AAN had higher BMD Z-scores than adolescents with AN; adolescents with a prior overweight history had greater BMD Z-scores than adolescents without a prior overweight history. These findings may inform clinical guidelines for the medical management of AAN., (© 2019 Wiley Periodicals, Inc.)

Purpose: Athletes in weight-bearing sports may benefit from higher bone mineral density (BMD). However, some athletes are at risk for impaired BMD with female athlete triad (Triad). The purpose of this study is to understand the influence of sports participation and Triad on BMD. We hypothesize that athletes in high-impact and multidirectional loading sports will have highest BMD, whereas nonimpact and low-impact sports will have lowest BMD. Triad risk factors are expected to reduce BMD values independent of sports participation., Methods: Two hundred thirty-nine female athletes participating in 16 collegiate sports completed dual-energy x-ray absorptiometry (DXA) scans to measure BMD z-scores of the lumbar spine (LS) and total body (TB). Height and weight were measured to calculate body mass index (BMI). Triad risk assessment variables were obtained from preparticipation examination. Mean BMD z-scores were compared between sports and by sport category (high-impact, multidirectional, low-impact, and nonimpact). Multivariable regression analyses were performed to identify differences of BMD z-scores accounting for Triad and body size/composition., Results: Athlete populations with lowest average BMD z-scores included synchronized swimming (LS, -0.34; TB, 0.21) swimming/diving (LS, 0.34; TB, -0.06), crew/rowing (LS, 0.27; TB, 0.62), and cross-country (LS, 0.29; TB, 0.91). Highest values were in gymnastics (LS, 1.96; TB, 1.37), volleyball (LS, 1.90; TB, 1.74), basketball (LS, 1.73; TB, 1.99), and softball (LS, 1.68; TB, 1.78). All Triad risk factors were associated with lower BMD z-scores in univariable analyses; only low BMI and oligomenorrhea/amenorrhea were associated in multivariable analyses (all P < 0.05). Accounting for Triad risk factors and body size/composition, high-impact sports were associated with higher LS and TB BMD z-scores and nonimpact sports with lower LS and TB BMD z-scores compared to low-impact sport (all P < 0.05)., Conclusions: Both sport type and Triad risk factors influence BMD. Athletes in low-impact and nonimpact sports and athletes with low BMI and oligomenorrhea/amenorrhea are at highest risk for reduced BMD.

Objectives: To assess pediatric providers' attitudes and barriers to initiating a contraceptive method in the inpatient setting., Methods: Pediatric attending physicians and trainees from 5 academic institutions were surveyed about contraceptive prescribing practices, attitudes, and potential barriers to initiating contraception in the inpatient setting., Results: In 2016, 271 pediatric providers (34.0% were attending physicians, 18.1% fellows, and 47.9% residents) completed the survey; the response rate was 19.2%. Most participants practiced in both inpatient and outpatient settings (95.7% and 85.0%, respectively). More providers felt confident screening for sexual activity among young adults as compared with adolescents (71.9% vs 65.6%). The same was true for discussing contraceptive options (44.0% vs 38.8%, respectively). Inpatient providers reported seeing adolescents and young adults privately, discussing confidentiality, and asking about sex less than half of the time. More than 80% of providers agreed that it would be appropriate to initiate a contraceptive method for inpatients; 35.8% had done so, and 85.2% indicated that having additional consultation would increase initiation of a contraceptive method in the hospital (88.1% felt similarly for long-active reversible contraception methods). General barriers to initiating contraception included insufficient training, insufficient exposure to adolescents and young adults to maintain skills, and lack of time. Barriers specific to the inpatient setting included concerns about follow-up, confidentiality, and interference with the treatment plan., Conclusions: Initiation of a contraceptive method in the inpatient setting is acceptable to providers. In our findings, it is suggested that strategies are needed to enhance provision of these services by addressing confidentiality concerns and educating providers., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Resistant starches are non-digestible starches that are fermented in the colon by microbiota. These carbohydrates are prebiotic and can be beneficial to consumer health. Many types of resistant starch exist with varying physical properties that may result in differences in fermentability. The objective of this research project was to compare potential prebiotic effects and fermentability of four novel resistant starches using an in vitro fermentation system and measuring changes in total gas production, pH, and formation of SCFAs (short chain fatty acids). Fecal donations were collected from seven healthy volunteers. Four novel resistant starches, modified potato starch (MPS), modified tapioca starch (MTS), and modified maize starches (MMS-1 and MMS-2), were analyzed and compared to polydextrose and short chain fructooligosaccharides (FOS) as controls. After twenty-four hours of fermentation, MPS and MTS responded similarly in gas production (74 mL; 70.6 mL respectively), pH (5.93; 5.93 respectively), and SCFA production (Acetate: 115; 124, Propionate: 21; 26, Butyrate: 29; 31 μmol/mL respectively). While MMS-1 had similar gas production and individual SCFA production, the pH was significantly higher (6.06). The fermentation of MMS-2 produced the least amount of gas (22 mL), with a higher pH (6.34), and lower acetate production (78.4 μmol/mL). All analyzed compounds were fermentable and promoted the formation of beneficial SCFAs., Competing Interests: M.L.S. is an employee of Ingredion Incorporated. J.L.S., J.M.E. and J.L.C. declare no conflict of interest.

Prebiotic dietary fibers act as carbon sources for primary and secondary fermentation pathways in the colon, and support digestive health in many ways. Fructooligosaccharides, inulin, and galactooligosaccharides are universally agreed-upon prebiotics. The objective of this paper is to summarize the 8 most prominent health benefits of prebiotic dietary fibers that are due to their fermentability by colonic microbiota, as well as summarize the 8 categories of prebiotic dietary fibers that support these health benefits. Although not all categories exhibit similar effects in human studies, all of these categories promote digestive health due to their fermentability. Scientific and regulatory definitions of prebiotics differ greatly, although health benefits of these compounds are uniformly agreed upon to be due to their fermentability by gut microbiota. Scientific evidence suggests that 8 categories of compounds all exhibit health benefits related to their metabolism by colonic taxa.

Prebiotic dietary fiber supplements are commonly consumed to help meet fiber recommendations and improve gastrointestinal health by stimulating beneficial bacteria and the production of short-chain fatty acids (SCFAs), molecules beneficial to host health. The objective of this research project was to compare potential prebiotic effects and fermentability of five commonly consumed fibers using an in vitro fermentation system measuring changes in fecal microbiota, total gas production and formation of common SCFAs. Fecal donations were collected from three healthy volunteers. Materials analyzed included: pure beta-glucan, Oatwell (commercially available oat-bran containing 22% oat β-glucan), xylooligosaccharides (XOS), WholeFiber (dried chicory root containing inulin, pectin, and hemi/celluloses), and pure inulin. Oatwell had the highest production of propionate at 12 h (4.76 μmol/mL) compared to inulin, WholeFiber and XOS samples ( p < 0.03). Oatwell's effect was similar to those of the pure beta-glucan samples, both samples promoted the highest mean propionate production at 24 h. XOS resulted in a significant increase in the genus Bifidobacterium after 24 h of fermentation (0 h:0.67 OTUs (operational taxonomic unit); 24 h:5.22 OTUs; p = 0.038). Inulin and WholeFiber increased the beneficial genus Collinsella , consistent with findings in clinical studies. All analyzed compounds were fermentable and promoted the formation of beneficial SCFAs., Competing Interests: The authors declare no conflict of interest. The funding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results.

Objective: To characterize exercise behaviors among adolescents with anorexia nervosa (AN), atypical AN, or bulimia nervosa (BN), and determine associations between exercise and medical risk., Study Design: Cross-sectional electronic medical records of all patients evaluated by the Eating Disorder Program at Stanford between January 1997 and February 2011 were retrospectively reviewed., Results: 1,083 subjects (961 females, 122 males; mean age 15.6) met eligibility criteria. Most patients (89.7%) reported exercise (mean 7.0 h per week over mean 5.4 days per week) prior to presentation. Running (49.9%), calisthenics (40.7%), walking (23.4%), soccer (20.9%), and swimming (18.2%) were the most common exercises; a majority (60.6%) reported team sport participation. Males were less likely to report team exercise (p = .005). Bradycardia (heart rate <50) at presentation was associated with team sport participation (adjusted odds ratio [AOR] 1.66, 95% confidence interval [CI] 1.02-2.72) and hours of exercise per week (AOR 1.05, 95% CI 1.02-1.09), controlling for diagnosis, sex, age, duration of illness, rate of weight loss, and percent median body mass index (%mBMI)., Discussion: Adolescents with AN, atypical AN, and BN reported high levels of exercise. Females reported more team sport participation. Greater exercise frequency and team sport participation were associated with bradycardia. Further studies assessing the relationship between exercise and bradycardia may help inform the medical management of adolescents with these eating disorders who are more physically active., (© 2017 Wiley Periodicals, Inc.)

Purpose: To compare deficits in fat mass (FM) and lean body mass (LM) among male and female adolescents with anorexia nervosa (AN) and to identify other covariates associated with body composition., Methods: We retrospectively reviewed electronic medical records of all subjects aged 9-20 years with a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis of AN and dual-energy x-ray absorptiometry scans after initial evaluation at Stanford between March 1997 and February 2011. From the dual-energy x-ray absorptiometry scans, LM and FM results were converted to age-, height-, sex-, and race-specific Z-scores for age using the National Health and Nutrition Examination Survey reference data., Results: A total of 16 boys and 119 girls with AN met eligibility criteria. The FM Z-score in girls with AN (-3.24 ± 1.50) was significantly lower than that in boys with AN (-2.41 ± .96) in unadjusted models (p = .007). LM was reduced in both girls and boys with AN, but there was no significant sex difference in LM Z-scores. In multivariate models, lower percentage median body mass index was significantly associated with lower FM Z-scores (β = .08, p < .0001) and lower LM Z-score (β = .03, p = .0002), whereas lower whole body bone mineral content Z-score was significantly associated with lower LM Z-score (β = .21, p = .0006)., Conclusions: FM deficits in girls were significantly greater than those in boys with AN in unadjusted models; however, the degree of malnutrition appeared to be the primary factor accounting for this difference. There were no significant sex differences in FM or LM in adjusted models., (Copyright © 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to compare sex differences in bone deficits among adolescents with anorexia nervosa (AN) and to identify other correlates of bone health., Method: Electronic medical records of all patients 9-20 years of age with a DSM-5 diagnosis of AN who were evaluated by the eating disorders program at Stanford with dual-energy X-ray absorptiometry (DXA) between March 1997 and February 2011 were retrospectively reviewed. Whole body bone mineral content Z-scores and bone mineral density (BMD) Z-scores at multiple sites were recorded using the Bone Mineral Density in Childhood Study (BMDCS) reference data., Results: A total of 25 males and 253 females with AN were included, with median age 15 years (interquartile range [IQR] 14-17) and median duration of illness 9 months (IQR 5-13). Using linear regression analyses, no significant sex differences in bone deficits were found at the lumbar spine, total hip, femoral neck, or whole body when controlling for age, %mBMI, and duration of illness. Lower %mBMI was significantly associated with bone deficits at all sites in adjusted models., Discussion: This is the first study to evaluate sex differences in bone health among adolescents with AN, using novel DSM-5 criteria for AN and robust BMDCS reference data. We find no significant sex differences in bone deficits among adolescents with AN except for a higher proportion of females with femoral neck BMD Z-scores <-1. Degree of malnutrition was correlated with bone deficits at all sites. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:352-358)., (© 2016 Wiley Periodicals, Inc.)

Purpose: The purpose of this study was to determine whether a history of overweight, weight suppression, and weight gain during treatment have an effect on return of menses (ROM) in adolescents with eating disorders (EDs)., Methods: Retrospective chart review of female adolescents presenting to an ED program from January 2007 to June 2009., Results: One hundred sixty-three participants (mean age, 16.6 ± 2.1 years) met eligibility criteria. The mean median body mass index percent at ROM for those previously overweight was 106.1 ± 11.7 versus 94.2 ± 8.9 for those not previously overweight (p < .001). Both groups needed to gain weight for ROM. Greater weight suppression (odds ratio, 0.90; 95% confidence interval, 0.84-0.98; p = .013) was associated with lower likelihood of ROM, and greater weight gain during treatment (odds ratio, 1.20; 95% confidence interval, 1.07-1.36; p = .002) was associated with higher likelihood of ROM in those not previously overweight., Conclusions: Previously overweight amenorrheic patients with EDs needed to be at a higher median body mass index percent for ROM compared to those who were not previously overweight., (Copyright © 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The female athlete triad (referred to as the triad) contributes to adverse health outcomes, including bone stress injuries (BSIs), in female athletes. Guidelines were published in 2014 for clinical management of athletes affected by the triad., Purpose: This study aimed to (1) classify athletes from a collegiate population of 16 sports into low-, moderate-, and high-risk categories using the Female Athlete Triad Cumulative Risk Assessment score and (2) evaluate the predictive value of the risk categories for subsequent BSIs., Study Design: Cohort study; Level of evidence, 3., Methods: A total of 323 athletes completed both electronic preparticipation physical examination and dual-energy x-ray absorptiometry scans. Of these, 239 athletes with known oligomenorrhea/amenorrhea status were assigned to a low-, moderate-, or high-risk category. Chart review was used to identify athletes who sustained a subsequent BSI during collegiate sports participation; the injury required a physician diagnosis and imaging confirmation., Results: Of 239 athletes, 61 (25.5%) were classified into moderate-risk and 9 (3.8%) into high-risk categories. Sports with the highest proportion of athletes assigned to the moderate- and high-risk categories included gymnastics (56.3%), lacrosse (50%), cross-country (48.9%), swimming/diving (42.9%), sailing (33%), and volleyball (33%). Twenty-five athletes (10.5%) assigned to risk categories sustained ≥1 BSI. Cross-country runners contributed the majority of BSIs (16; 64%). After adjusting for age and participation in cross-country, we found that moderate-risk athletes were twice as likely as low-risk athletes to sustain a BSI (risk ratio [RR], 2.6; 95% confidence interval [95% CI], 1.3-5.5) and high-risk athletes were nearly 4 times as likely (RR, 3.8; 95% CI, 1.8-8.0). When examining the 6 individual components of the triad risk assessment score, both the oligomenorrhea/amenorrhea score ( P = .0069) and the prior stress fracture/reaction score ( P = .0315) were identified as independent predictors for subsequent BSIs (after adjusting for cross-country participation and age)., Conclusion: Using published guidelines, 29% of female collegiate athletes in this study were classified into moderate- or high-risk categories using the Female Athlete Triad Cumulative Risk Assessment Score. Moderate- and high-risk athletes were more likely to subsequently sustain a BSI; most BSIs were sustained by cross-country runners.

Purpose: Psychopharmacologic medications are often prescribed to patients with restrictive eating disorders (EDs), and little is known about the frequency of use in adolescents. We examined the use of psychopharmacologic medications in adolescents referred for treatment of restrictive ED, potential factors associated with their use, and reported psychiatric comorbidities., Methods: Retrospective data from the initial and 1-year visits were collected for patients referred for evaluation of restrictive ED at 12 adolescent-based ED programs during 2010 (Group 1), including diagnosis, demographic information, body mass index, prior treatment modalities, and psychopharmacologic medications. Additional data regarding patients' comorbid psychiatric conditions and classes of psychopharmacologic medications were obtained from six sites (Group 2)., Results: Overall, 635 patients met inclusion criteria and 359 had 1-year follow-up (Group 1). At intake, 20.4% of Group 1 was taking psychopharmacologic medication and 58.7% at 1 year (p ≤ .0001). White, non-Hispanic race (p = .020), and prior higher level of care (p < .0001) were positively associated with medication use at 1 year. Among Group 2 (n = 256), serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors use was most common, and 62.6% had a reported psychiatric comorbidity. Presence of any psychiatric comorbidity was highly associated with medication use; odds ratio, 10.0 (5.6, 18.0)., Conclusions: Adolescents with restrictive ED treated at referral centers have high rates of reported psychopharmacologic medication use and psychiatric comorbidity. As more than half of this referral population were reported to be taking medication, continued investigation is warranted to ensure the desired outcomes of the medications are being met., (Copyright © 2015 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Maintaining low body weight for the sake of performance and aesthetic purposes is a common feature among young girls and women who exercise on a regular basis, including elite, college and high-school athletes, members of fitness centres, and recreational exercisers. High energy expenditure without adequate compensation in energy intake leads to an energy deficiency, which may ultimately affect reproductive function and bone health. The combination of low energy availability, menstrual disturbances and low bone mineral density is referred to as the 'female athlete triad'. Not all athletes seek medical assistance in response to the absence of menstruation for 3 or more months as some believe that long-term amenorrhoea is not harmful. Indeed, many women may not seek medical attention until they sustain a stress fracture. This review investigates current issues, controversies and strategies in the clinical management of bone health concerns related to the female athlete triad. Current recommendations focus on either increasing energy intake or decreasing energy expenditure, as this approach remains the most efficient strategy to prevent further bone health complications. However, convincing the athlete to increase energy availability can be extremely challenging. Oral contraceptive therapy seems to be a common strategy chosen by many physicians to address bone health issues in young women with amenorrhoea, although there is little evidence that this strategy improves bone mineral density in this population. Assessment of bone health itself is difficult due to the limitations of dual-energy X-ray absorptiometry (DXA) to estimate bone strength. Understanding how bone strength is affected by low energy availability, weight gain and resumption of menses requires further investigations using 3-dimensional bone imaging techniques in order to improve the clinical management of the female athlete triad.

The relative risk of changes in metabolic parameters during treatment with atypical antipsychotics has not been fully investigated. Baseline-to-endpoint mean and anytime-categorical changes in metabolic parameters were evaluated in Lilly active comparator-controlled clinical trials. Olanzapine-treated patients gained significantly more baseline-to-endpoint weight versus risperidone- (3.3 kg [N = 713; median exposure [ME, days] = 68] versus 1.8 kg [N = 697; ME = 65], p < 0.001), ziprasidone-(2.8 kg [N = 463; ME = 168] versus -1.3 kg [N = 443; ME = 89], p < 0.001), and aripiprazole-treated patients (3.7 kg [N = 273; ME = 104] versus 0.5 kg [N = 275; ME = 187], p < 0.001). Significantly more olanzapine-treated patients gained ≥ 7% of their baseline weight versus risperidone-(30.6% [N = 713; ME = 169] versus 20.2% [N = 697; ME = 140], p < 0.001), ziprasidone-(30.0% [N = 463; ME = 147] versus 6.5% [N = 443; ME = 165], p < 0.001), and aripiprazole-treated patients (40.3% [N = 273; ME = 170] versus 16.4% [N = 275; ME = 154], p < 0.001). Olanzapine-treated patients had significantly greater baseline-to-endpoint changes in fasting triglycerides compared with ziprasidone- (0.24 mmol/L [N = 365; ME = 168] versus -0.24 mmol/L [N = 316; ME = 140], p < 0.001) and aripiprazole-treated patients (0.28 mmol/L [N = 215; ME = 195] versus -0.19 mmol/L [N = 210; ME = 194], p < 0.001). Olanzapine-treated patients had significantly greater baseline-to-endpoint changes in fasting glucose than ziprasidone-(0.25 mmol/L [N = 379; ME = 168] versus -0.04 mmol/L [N = 333; ME = 133], p = 0.016) and aripiprazole-treated patients (0.27 mmol/L [N = 227; ME = 195] versus 0.04 mmol/L [N = 220; ME = 194], p = 0.048). The study concluded that there are changes with varying frequencies and magnitude in some metabolic parameters in patients treated with olanzapine compared with other atypical antipsychotics.

Six nonlactating and six lactating adult female goats received a single subcutaneous injection of ceftiofur crystalline free acid (CCFA) at a dosage of 6.6 mg/kg. Blood samples were collected from the jugular vein before and at multiple time points after CCFA administration. Milk samples were collected twice daily. Concentrations of ceftiofur and desfuroylceftiofur-related metabolites were measured using high-performance liquid chromatography. Data were analyzed using compartmental and noncompartmental approaches. The pharmacokinetics of CCFA in the domestic goat was best described by a one compartment model. Mean (±SD) pharmacokinetic parameters were as follows for the nonlactating goats: area under the concentration time curve(0-∞) (159 h·μg/mL ± 19), maximum observed serum concentration (2.3 μg/mL ± 1.1), time of maximal observed serum concentration (26.7 h ± 16.5) and terminal elimination half life (36.9 h; harmonic). For the lactating goats, the pharmacokinetic parameters were as follows: area under the concentration time curve(0-∞) (156 h·μg/mL ± 14), maximum observed serum concentration (1.5 μg/mL ± 0.4), time of maximal observed serum concentration (46 h ± 15.9) and terminal elimination half life (37.3 h; harmonic). Ceftiofur and desfuroylceftiofur-related metabolites were only detectable in one milk sample at 36 h following treatment. There were no significant differences in the pharmacokinetic parameter between the nonlactating and lactating goats., (© 2010 Blackwell Publishing Ltd.)

Progesterone (P4)-impregnated intravaginal controlled internal drug-releasing devices (CIDRs) have been used worldwide for estrus synchronization in ruminants. CIDRs serve to place all treated animals in the luteal phase of the estrous cycle. The objectives of this study were to compare P4 concentrations in milk from normal reproductively cycling, CIDR-treated, and pregnant goats. CIDRs were placed in treatment goats on day 0 and removed on day 19. Milk was collected daily from day 0 to day 21 from control and CIDR-treated goats and for 5 consecutive days between 40 and 60 days of gestation from pregnant does. Milk P4 was plotted against time (in days) for each individual, and the area under the curve (AUC) was calculated as an estimate of total milk P4. The AUC(day 0-21) for control and CIDR-treated goats were 29.5 ± 11.9 and 33.7 ± 6.6 d·ng/mL, respectively (P = 0.77). The highest single-day and highest 5-day average P4 values for each animal were also compared among groups. Single-day peak P4 levels were 4.8 ± 1.5, 4.0 ± 1.0, and 6.0 ± 0.4 ng/mL for control, CIDR-treated, and pregnant goats (P = 0.42). The highest 5-day average P4 concentrations were 3.6 ± 1.3, 2.9 ± 1.8, and 4.2 ± 0.3 for control, CIDR-treated, and pregnant goats (P = 0.56). The results of this study show that intravaginal P4 CIDR devices inserted for 19 days in healthy goats resulted in milk P4 levels similar to or less than those endogenously produced during diestrus or pregnancy., (© 2010 Blackwell Publishing Ltd.)

Objective: Agitation is a medical emergency with increased risk for poor outcome. Successful treatment often requires intramuscular (IM) psychotropics. Safety data from the first 21 months of olanzapine IM, approved in the United States for the treatment of agitation associated with schizophrenia and bipolar disorder, are presented., Method: A Lilly-maintained safety database was searched for all spontaneous adverse events (AEs) reported in temporal association with olanzapine IM treatment., Results: The estimated worldwide patient exposure to olanzapine IM from January 1, 2004, through September 30, 2005, was 539,000; 160 cases containing AEs were reported from patients with schizophrenia (30%), bipolar disorder (21%), unspecified psychosis (10%), dementia (8%), and depression (5%). Many reported concomitant treatment with benzodiazepines (39%) or other antipsychotics (54%). The most frequently reported events involved the following organ systems: central nervous (21%), cardiac (12%), respiratory (6%), vascular (6%), and psychiatric (5%). Eighty-three cases were considered serious, including 29 fatalities. In these fatalities, concomitant benzodiazepines or other antipsychotics were reported in 66% and 76% of cases, respectively. The most frequently reported events in the fatal cases involved the following organ systems: cardiovascular (41%), respiratory (21%), general (17%), and central nervous (10%). The majority of fatal cases (76%) included comorbid conditions and potentially clinically significant risk factors for AEs., Conclusions: Clinicians should use care when treating agitated patients, especially when they present with concurrent medical conditions and are treated with multiple medications, which may increase the risk of poor or even fatal outcomes. Clinicians should use caution when using olanzapine IM and parenteral benzodiazepines simultaneously., (Copyright 2010 Physicians Postgraduate Press, Inc.)

Objective: To describe the safety of olanzapine treatment in adolescents (aged 13-17 years) with schizophrenia or bipolar I disorder, and to compare these data with those of olanzapine-treated adults., Data Sources and Study Selection: Placebo-controlled database, adolescents: acute phase of 2 double-blind, placebo-controlled trials (3-6 weeks; olanzapine, N = 179, mean age = 15.5 years; placebo, N = 89, mean age = 15.7 years); overall adolescent olanzapine exposure database, adolescents: 4 trials (e.g., the 2 aforementioned studies, each with a 26-week open-label extension phase, and 2 open-label, 4.5- and 24-week trials; N = 454, mean age = 15.9 years); and adult database: 84 clinical trials of up to 32 weeks., Data Synthesis: The mean daily dosage of olanzapine was 10.6 mg/day (exposure = 48,946 patient days). In the overall adolescent olanzapine exposure database, the most common adverse events included increased weight (31.7%), somnolence (19.8%), and increased appetite (17.4%). In up to 32 weeks of treatment, when compared with adults, adolescents from the overall adolescent olanzapine exposure database gained statistically significantly more weight (7.4 kg vs. 3.2 kg, p < .001); statistically significantly more adolescents gained > or = 7% of their baseline weight (65.1% vs. 35.6%, p < .001). Adolescents experienced statistically significant within-group baseline-to-endpoint changes in fasting glucose (p < .001), total cholesterol (p = .002), triglycerides (p = .007), and alanine aminotransferase (p < .001). Two patients from the overall adolescent olanzapine exposure database (0.4%) attempted suicide; 13 (2.9%) had suicidal ideation. In the placebo-controlled database, adolescents had statistically significant baseline-to-endpoint increases in prolactin (11.4 micrograms/L, p < .001); 47.4% had high prolactin levels., Conclusions: The types of adverse events in olanzapine-treated adolescents appear to be similar to those of adults. The magnitude and incidence of weight and prolactin changes were greater in adolescents., Trial Registration: clinicaltrials.gov Identifiers: NCT00051298, NCT00050206, and NCT00113594., (Copyright 2009 Physicians Postgraduate Press, Inc.)

Menstrual irregularity is a common occurrence during adolescence, especially within the first 2-3 years after menarche. Prolonged amenorrhea, however, is not normal and can be associated with significant medical morbidity, which differs depending on whether the adolescent is estrogen-deficient or estrogen-replete. Estrogen-deficient amenorrhea is associated with reduced bone mineral density and increased fracture risk, while estrogen-replete amenorrhea can lead to dysfunctional uterine bleeding in the short term and predispose to endometrial carcinoma in the long term. In both situations, appropriate intervention can reduce morbidity. Old paradigms of whom to evaluate for amenorrhea have been challenged by recent research that provides a better understanding of the normal menstrual cycle and its variability. Hypothalamic amenorrhea is the most prevalent cause of amenorrhea in the adolescent age group, followed by polycystic ovary syndrome. In anorexia nervosa, exercise-induced amenorrhea, and amenorrhea associated with chronic illness, an energy deficit results in suppression of hypothalamic secretion of GnRH, mediated in part by leptin. Administration of recombinant leptin to women with hypothalamic amenorrhea has been shown to restore LH pulsatility and ovulatory menstrual cycles. The use of recombinant leptin may improve our understanding of the pathophysiology of hypothalamic amenorrhea in adolescents and may also have therapeutic possibilities.

This study sought to describe clinician practices for the management of amenorrhea in the adolescent and young adult athlete. Clinicians adhered to certain guidelines but did not have a uniform "standard of care" for amenorrheic athletes. Almost 80% of clinicians reported insufficient guidelines for the management of this population.

Objective: Olanzapine and other antipsychotics are not approved by the U.S. Food and Drug Administration to treat behavioral disturbances associated with dementia, but they are often prescribed to these patients. Although antipsychotics may be efficacious in this population, elderly patients with dementia may be particularly vulnerable to adverse events. This article reviews the safety of olanzapine in elderly patients with dementia., Data Sources: Data from 6 studies comparing olanzapine to placebo, risperidone, or conventional antipsychotics in elderly patients with dementia were analyzed for mortality, cerebrovascular adverse events (CVAEs), and other adverse events. These trials represent all Lilly olanzapine-comparator trials in this population. The data included integration of 5 double-blind, placebo-controlled studies (olanzapine, N = 1184; placebo, N = 478; median age = 79 years; 1 study also compared olanzapine with risperidone, N = 196) and an open-label study comparing olanzapine (N = 150) with conventional antipsychotics (N = 143)., Data Synthesis: Incidence of mortality was significantly higher in olanzapine- (3.5%) than in placebo-treated patients (1.5%; p = .024). There were no significant differences in the crude incidence of mortality between olanzapine- (2.9%) and risperidone- (2.0%) or olanzapine- (14.8%) and conventional antipsychotic-treated patients (16.1%; p = .871). Risk factors associated with mortality in olanzapine-treated patients included age >/= 80, concurrent benzodiazepine use, treatment-emergent sedation, or treatment-emergent pulmonary conditions. Incidence of CVAEs was approximately 3 times higher in olanzapine- (1.3%) than in placebo-treated patients (0.4%). There were no significant differences in the incidence of CVAEs between olanzapine- (2.5%) and risperidone- (2.0%; p = 1.0) or olanzapine- (3.4%) and conventional antipsychotic-treated patients (4.3%; p = .765)., Conclusion: These findings should be considered if prescribers elect to treat behavioral disturbances associated with dementia in the elderly with olanzapine or other antipsychotics.

The study sought to describe service utilization patterns of homeless youth based on their life cycle stage. Ninety-nine percent of participants accessed services. Medical service utilization was highest among youth who were attempting to leave the street. Drug-related service utilization was lowest among youth most entrenched in street life.

Oxidative stress is a component of diseases and degenerative processes associated with aging. However, no means are available to assess causative oxidative events separately from decline in function of protective antioxidant systems. Previous studies show that ongoing oxidative processes maintain plasma cysteine/cystine redox at a value that is more oxidized than the antioxidant glutathione/glutathione disulfide (GSH/GSSG) system, suggesting that redox analysis of these plasma thiols could allow separate evaluation of an increase in oxidative events from a decline in antioxidant function. The present study uses measurement of cysteine/cystine and GSH/GSSG redox in plasma of 122 healthy individuals aged 19-85 years to determine whether thiol-disulfide redox changes occur with age. The results show a linear oxidation of cysteine/cystine redox state with age at a rate of 0.16 mV/year over the entire age span. In contrast, GSH/GSSG redox was not oxidized prior to 45 years and subsequently was oxidized at a nearly linear rate of 0.7 mV/year. These data suggest that there is a continuous, linear increase in oxidative events throughout adult life but that the capacity of the GSH antioxidant system is maintained until 45 years and then declines rapidly. The data further suggest that redox states of cysteine/cystine and GSH/GSSG provide an approach to clinically distinguish between increased causative oxidative events and decreased GSH antioxidant function. In principle, such analyses can be used to assess efficacy of intervention strategies against oxidative stress prior to or early after onset of clinical symptoms in aging and age-related disease.

Thiol and disulfide forms of glutathione (GSH) and cysteine (Cys) were measured in plasma from 24 healthy individuals aged 25-35 and redox potential values (E(h)) for thiol/disulfide couples were calculated using the Nernst equation. Although the concentration of GSH (2.8 +/- 0.9 microM) was much greater than that of GSSG (0.14 +/- 0.04 microM), the redox potential of the GSSG/2GSH pool (-137 +/- 9 mV) was considerably more oxidized than values for tissues and cultured cells (-185 to -258 mV). This indicates that a rapid oxidation of GSH occurs upon release into plasma. The difference in values between individuals was remarkably small, suggesting that the rates of reduction and oxidation in the plasma are closely balanced to maintain this redox potential. The redox potential for the Cys and cystine (CySS) pool (-80 +/- 9 mV) was 57 mV more oxidized, showing that the GSSG/2GSH and the CySS/2Cys pools are not in redox equilibrium in the plasma. Potentials for thiol/disulfide couples involving CysGly were intermediate between the values for these couples. Regression analyses showed that the redox potentials for the different thiol/disulfide couples within individuals were correlated, with the E(h) for CySS-mono-Gly/(Cys. CysGly) providing the best correlation with other low molecular weight pools as well as protein disulfides of GSH, CysGly and Cys. These results suggest that E(h) values for GSSG/2GSH and CySS-mono-Gly/(Cys. CysGly) may provide useful means to quantitatively express the oxidant/antioxidant balance in clinical and epidemiologic studies.