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New vaccines are being targeted to help protect the adolescent population from disease. The Society for Adolescent Medicine strongly urges compliance with adolescent vaccination recommendations provided by the Advisory Committee on Immunization Practices. These vaccines will significantly impact the health and well-being of the adolescent population. To enhance vaccination compliance and access to prevention health care and promotion, the Society supports linking vaccination to the three distinct comprehensive preventive health care visits already recommended by multiple organizations during early, middle, and late adolescence. In addition, multiple provider strategies should be used to increase vaccination rates among adolescents.

On a broad range of indicators pertaining to risk taking and access to care, young adults fare worse than younger adolescents or older adults. Vulnerable groups, such as those facing chronic illness and those with unstable living arrangements, fare especially poorly as they transition to adulthood. Fortunately, a confluence of factors, particularly the changing nature of the transition to adulthood in modern society, has led to renewed interest in this critical period of the life cycle. Health science research is increasingly focused on issues faced by young adults, and public health policies designed specifically to address the health and well-being of young adults--notably the Patient Protection and Affordable Care Act in the United States--are now being implemented. Successful efforts at improving the health and well-being of adolescents should be mirrored in efforts to support young adults. A new report based on a broad range of United States national datasets lays out the challenges that must be addressed in these efforts.

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

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

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

Background. Pretravel medication and vaccination recommendations and receipt were compared between primary care providers (PCPs) without special training and clinical pharmacists specializing in pretravel health. Methods. A retrospective chart review of patients seen for pretravel health services in a pharmacist-run travel clinic (PTC) compared to PCPs at a University Student Health Center. Vaccine/medication recommendations were assessed for consistency with national/international guidelines. Medical/pharmacy records were queried to determine the receipt of medications/vaccinations. Results. The PTC recommended antibiotics for travelers' diarrhea were given more often when indicated (96% vs 50%, p < 0.0001), and patients seen in the PTC received their medications more often (75% vs 63%, p = 0.04). PCPs prescribed more antibiotics for travelers' diarrhea that were inconsistent with guidelines (not ordered when indicated 49% vs 6%, p < 0.0001 and ordered when not indicated 21% vs 3%, p < 0.0001). The PTC prescribed antimalarials more often when indicated (98% vs 81%, p < 0.0001), while PCPs prescribed more antimalarials that were inconsistent with guidelines (not ordered when indicated 15% vs 1%, p < 0.0001 and ordered when not indicated 19% vs 2%, p < 0.0001). The PTC ordered more vaccines per patient when indicated (mean = 2.77 vs 2.31, p = 0.0012). PTC patients were more likely to receive vaccines when ordered (mean = 2.38 vs 1.95, p = 0.0039). PCPs recommended more vaccines per patient that were inconsistent with guidelines (not ordered when indicated: mean = 0.78 vs 0.12, p < 0.0001, ordered when not indicated: mean 0.18 vs 0.025, p < 0.0001). Conclusions. A pharmacist-run pretravel health clinic can provide consistent evidence-based care and improve patient compliance compared to PCPs without special training. Pretravel health is a dynamic and specialized field that requires adequate time, resources, and expertise to deliver the best possible care.

see more p 325, 344, 347 Physicians must go beyond the medical model About 2 million adolescents (6% of persons aged 10-18 years) in the United States have a chronic health condition that results in limitation of daily activities or disability.1,2 The most common of these conditions are asthma and other chronic respiratory tract diseases, musculoskeletal disorders, and heart disease.3 Mental health problems, such as depression, are a leading cause of disability in this age group, as are speech, hearing, and visual impairments. Many of these teens face complex physical and emotional challenges during adolescence and in the difficult transition into adulthood.1 Adolescence includes a period of accelerated physical growth, the development of secondary sexual characteristics, and acceleration in cognitive and psychosocial development. As a result, the management of teens with a chronic illness must go beyond the strictly medical; it should include addressing issues such as development, family and social support, substance use, and reproductive health. The developmental processes involved in adolescence have a complex and bi-directional interaction with chronic illness such that a chronic disease can alter development and vice versa. For example, some chronic diseases, such as cystic fibrosis or diabetes mellitus, can impair pubertal development. On the other hand, puberty itself can affect the course of a chronic disease. For example, normal puberty is associated with insulin resistance; therefore, blood glucose control can be difficult during pubertal years in teens with diabetes.4,5 Family relationships and psychosocial issues can play a key role in the emotional health of teens with a chronic illness. In such teens, family connectedness has a greater influence on their well-being than the actual disease itself.6 The psychosocial factors associated with worse emotional health in these teens include male gender, psychiatric illness and/or criminality in a parent, and low socioeconomic status.7,8 Aspects of the disease that affect emotional well-being include its duration, the visibility of the disease, the way in which it limits mobility, and the patients' expected survival.9 Protective factors include a positive temperament, above-average intelligence, social competence, a supportive relationship with at least one parent, family closeness, and adequate rule setting by parents. Alcohol and recreational drug use can contribute to morbidity in teens with chronic illness and may interact adversely with prescribed medications. Although the rates of substance use are lower in teens who have a chronic illness than in those who do not, risky behaviors do occur.10,11 Health care providers often neglect the reproductive health of chronically ill teens; yet, many studies indicate that such teens are sexually active and interested in knowing about contraception, their fertility, and the genetics of their disease.10,12,13 In the United States, almost half of adolescents aged 15 through 17 years have been sexually active,14 and these rates of sexual activity are probably similar for chronically ill teens.10,12,13 The specific contraceptive needs of teens with chronic illness are well documented.15 Whereas some chronic conditions are associated with impaired fertility from the disease itself (eg, male adolescents with cystic fibrosis) or from the treatment (eg, survivors of certain childhood cancers),16 most chronic illnesses do not impair libido or fertility. Therefore, advice on effective contraception is extremely important. Although care must be taken in prescribing hormonal contraception to teenaged girls with a medical illness, most contraceptive methods are safer than pregnancy itself. Such teens should also be counseled about the necessity of carefully planning pregnancies to minimize teratogenicity from medications and treatments. All teens with chronic illness who are sexually active should be advised on how to protect themselves from sexually transmitted infections. A broad, holistic approach is therefore needed in caring for chronically ill teens. There are a number of ways in which primary care physicians can adopt such an approach. First, they can pay attention to the difficulties that teens face in adhering to medical therapies, and they should try to identify reasons for these difficulties, decrease the complexity of treatment regimens, enlist parental support, and refer to specialists and counselors as needed. Second, they can educate the teen and family about the nature and course of the disease and involve the family in providing support to the teen and in treatment decisions. Because teens are often familiar with using computer technology and the Internet, web-based educational materials and resources can be helpful. Third, a multidisciplinary team that provides continuity of care can help deal with the complex issues that teens face over time. Fourth, disease or peer support groups can be helpful. Finally, a smooth transition from child-centered to adult-oriented health care systems is a critical component of the care of older teens. Sadly, most adolescents with chronic disease make their way into the adult health system in an unplanned, uncoordinated manner. Further research is needed on the elements of a successful transitional program.

This study evaluates the efficacy of the American Academy of Pediatrics' current recommendations for identifying hypercholesterolemia in teenagers. These guidelines advocate a screening strategy that is targeted only at high-risk individuals. Detailed information regarding risk factors for hypercholesterolemia was obtained from 1001 adolescents or their parents at three urban teen clinics during routine health assessments. In addition, serum cholesterol was measured in all adolescents. The population under study was 38.2% Hispanic, 33.5% white, 15.4% black, and 11.3% Asian, with a mean age of 15.6 years (range: 12 through 21 years); 52% were female. Based on the cholesterol values, the study population was divided into two groups: (1) normal cholesterol level

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

Influenza is a serious health problem worldwide and is associated with an average of 226,000 hospitalizations each year in the United States.1 The principal method for prevention of influenza-related deaths and complications is vaccination of persons at high risk. The Advisory Committee on Immunization Practices (ACIP) recommends vaccination of health care workers (HCWs) because they care for persons at high risk for influenza-related complications.1 Despite these recommendations, vaccination rates among HCWs are only approximately 40%.1 Fear of vaccine adverse effects and inconvenience are among the reasons HCWs choose not to be vaccinated.2,3 ACIP defines HCWs as physicians, nurses, and other personnel in hospital and outpatient care settings; employees of nursing homes and chronic care facilities who have direct contact with patients and persons who provide care to persons at high risk.1 Student HCWs are also frequently in direct contact with patients at high risk for complications associated with influenza because of their program curriculum. Previous studies, primarily focused on nursing and medical students, determined

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

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

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

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

Conclusions: Despite readily available contraceptive resources and high educational levels unintended pregnancies as a result of inadequate contraception is a significant issue among university students. The large proportions of International students and Asian-American women in the sample compared to the demographics of the university (15.1% International 16.8% Asian- American) suggest that pregnancy education programs should examine these groups closely. Despite existing education programs readily available contraceptives and free condoms on campus 35.6% of the women in the sample still reported using no method of contraception at the time of risk. The pregnancies among the 51.3% of the women using condoms suggest less than ideal condom use among this university population. The low use of oral contraceptive pills among this population despite easy access and availability also suggests the need for further educational programs about hormonal contraceptives and a further examination of reasons for the lack of use of oral contraceptives in this particular population. Lastly the high percent of unintended pregnancies and high percent of women either undecided or choosing termination emphasizes the need for pregnancy counseling to assist young women in coping and resolving their difficult situations. (excerpt)

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

The prevalence rate of Chlamydia trachomatis in the vagina of prepubertal sexually abused children was examined. Additionally, the culture technique was compared to direct immunofluorescence assay (DFA) for diagnosing chlamydial infections in the vaginas of prepubertal children. The study group included 50 consecutive prepubertal girls examined for sexual abuse in an urban pediatric hospital's emergency room. Vaginal swabs were obtained for culture and direct immunofluorescence assay of C trachomatis and for gonorrhea culture. of these, 8/47 (17%) of the Chlamydia cultures, 4/43 (9.3%) of the direct immunofluorescence assay specimens, and 0/49 gonorrhea cultures were positive for Chlamydia. All patients with positive findings by direct immunofluorescence assay also had positive chlamydial cultures. Of the four other patients with positive cultures for Chlamydia, two had negative findings by direct immunofluorescence assay and two had inconclusive results reported. Twenty-nine patients had a syphilis serologic study performed, and all had negative results. There was no significant difference between the Chlamydia-positive and -negative groups with regards to age, race, nature of the abuse, frequency of abuse, and symptoms or findings on physical examination. Although not statistically significant, children with cultures positive for C trachomatis reported rectal penetration five times and vaginal penetration twice as often as those children with C trachomatis-negative results. This study demonstrates a significant prevalence of vaginal chlamydial infections in sexually abused children. Vaginal cultures for C trachomatis should be included in the medical evaluation of sexually abused girls. The culture technique was superior to the direct immunofluorescence assay in this group of patients.

This study examined the prevalence of Chlamydia trachomatis infections of the urethra in asymptomatic teenage males in a juvenile detention setting. Gonorrhea cultures, chlamydia smears using the direct immunofluorescent antibody (DFA) technique, and 15–20 ml of a first-catch urine (FCU) sample were obtained. Of the 227 adolescent males screened, 205 had experienced sexual intercourse. Twenty-seven (13.2%) of the sexually active adolescents had positive DFA smears for C. trachomatis . Three (1.5%) had positive Neisseria gonorrhoeae cultures. A urine leukocyte count of greater than 10 per high-power field gave a 91% specificity but only a 26% sensitivity for a positive DFA. The high prevalence of chlamydia in this population and the relative low cost of the DFA screen for chlamydia make this a useful procedure for discovering unsuspected disease, particularly in a high-risk population. The FCU screen for leukocytec was of limited value in identifying asymptomatic infection.

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

The 1978 Task Force Report on pediatric education encouraged increased participation by pediatricians in the health care of adolescents. A survey of pediatricians in the Los Angeles County area was conducted to assess the pediatrician's self-evaluation regarding the medical and psychosocial problems of the adolescent, the problems of the sexually active teenager, and the pelvic examination. A questionnaire was used to assess competence, level of comfort, ability to counsel, prior training, and the importance and relevance of these areas to pediatricians' practice. Areas of least and greatest competence were examined. Our results support the conclusion of the 1978 Task Force Report on pediatric education that there is inadequate training in adolescent health care issues. This appears to be especially true for issues relating to the sexually active teen and the pelvic examination.

This study reports the effect of hypnotherapy in an asthmatic. The patient had moderately severe asthma with frequent attacks despite multiple medications. He received four weekly hypnosis sessions, and was then followed bimonthly for a year. The patient's course was followed by subjective daily scoring of wheezing severity, daily recording of peak expiratory flow rate by a Wright minispirometer, and once a month recording of his Forced Vital Capacity (FVC), Forced Expiratory Volume in one second/Forced Vital Capacity (FEV 1 /FVC), and Maximal Midexpiratory Flow Rate (MMRF). The severity rating showed improvement at one year when the start of therapy was compared to pretherapy ( P 1 /FVC and MMFR before and after therapy. School attendance and academic performance improved during the year of therapy. Hypnotherapy may be a helpful adjunct in asthma therapy during adolescence.

This study evaluates the effect of physician dress and other variables (i.e., sex of physician and patient, age, and type and site of visit) on patient-physician rapport. Three hundred eighty-six teens filled out a questionnaire, at the end of an office visit, which evaluated their attitudes regarding their physician and their preference for physician dress. The physicians alternated between very informal, informal, formal-white coat, and formal-suit/dress styles. Dress style made no statistical difference in patients' attitudes toward their physician. When asked what they preferred their doctor to wear 43% responded "makes no difference," 26% said "white coat," 14% said "pants and shirt," 10% said "jeans and shirt," and 4% said "suit and tie." Female patients were significantly more comfortable (3.6 versus 3.3, p less than 0.01) with female physicians. Male patients did not show a preference for a same-sex physician.

In an attempt to increase physician efficiency by lowering the "no show" rate of adolescents in a teenage health center, the possible variables related to broken appointments were explored. A new triage system was implemented. While most of the variables studied did not differ between the "show" and "no show" adolescents, there were significant differences based on the chief complaint. Those teenagers seen for well adolescent care had a 55% "no show" rate, those with noncosmetic problems had a 37% "no show" rate, and those with cosmetic complaints had a zero "no show" rate. With the implementation of a new triage system which required parent/adolescent involvement, the "no show" rate fell by 50%, thus dramatically decreasing the waiting time for initial appointment and improving the utilization of physician and nurse time.

This article examines contraception in adolescents with hematologic, oncologic, dermatologic, and psychiatric disorders, connective tissue diseases, and renal disease and transplants. Teens with iron-deficiency anemia or heavy menstrual flow who need contraception could benefit from oral contraceptives. The IUD is contraindicated for these teens. The IUD is also contraindicated in females with hemorrhagic disease, and hormonal contraceptives are a more appropriate choice for these females. Teens with sickle cell hemoglobinpathies should not use the IUD. Safe use of oral contraceptives (OCs) is questionnable for these teens. The best choice would be barrier methods. Concerns regarding contraception in teens with tumors are mainly 2-fold: effects of pregnancy or contraception on the tumor, and effects of the tumor or tumor therapy on pregnancy and fertility. Therapy including drugs and radiation can have profound effects on the fetus and future fertility. There seems to be no indication that pregnancy has adverse effects on nonhormonal-dependent tumors common in young adults. Malignant melanoma has a strong positive relationship with the use of OCs. OCs have been reported to be helpful in some chronic skin disorders. OCs may not be appropriate for teens who are taking antidepressants or who have a history of depression, although there are contradictory reports in the literature on the effect of the pill on depression. It is helpful for contraceptive services for mentally ill women to be provided by specially trained individuals who are able to obtain informed consent, while taking into account the specific needs of the psychiatrically impaired individual. There are special concerns in prescribing contraception to the mentally retarded teen. Combinations OCs should probably be avoided in adolescents with systemic lupus erythematosus. Because teens with severe chronic renal failure or those on hemodialysis are usually infertile, contraception is less of an issue than for other teens. A barrier method woudl be the msot appropriate method for such teens if they need contraception.

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

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

This study evaluated the effects of an adolescent medicine rotation on the attitudes and skills in the care of adolescents of third-year pediatric residents and medical students. Competence, comfort, and prior training in four areas were assessed by a self-evaluation questionnaire. Ratings were made at the start of the year, prerotation, and post a four- to six-week rotation. Residents not taking the rotation were rated at the beginning and end of the year. In addition, pelvic-examination skills were assessed by the clinic nurse and by the patients during the first and last week of the rotation. There were no significant changes in those not taking the rotation. In those residents taking the rotation, there was no change from beginning of year to prerotation, but there were significant changes after the rotation. Only those residents taking the rotation indicated an increase in liking adolescents. Pelvic examination skills were rated significantly higher during the last week of the rotation by the nurse and patients. A one-year follow-up study continued to show significantly higher scores in those residents taking the rotation. An adolescent medicine elective may significantly improve medical students' and residents' self-assessed levels of competence, comfort, and training in adolescent health care and pelvic examination skills.

This study determined the prevalence rates of Chlamydia trachomatis infection in the oropharynx of adolescents with and without pharyngitis. One hundred teenagers with and without symptoms of pharyngitis were cultured for C. trachomatis. Swabs were taken from the oropharynx and tonsillar areas for direct fluorescent antibody assay and cell culture. Of the 100 adolescents enrolled in the study 55% had a history of pharyngitis and 45% had no pharyngeal symptoms; 29% were male and 71% were female. The mean age was 15.5 years. Forty-two percent had a history of sexual intercourse, and 11.5% described a history of oral-genital sex. Only one 14-year-old female with a 2-week history of a sore throat had a positive culture. Her direct fluorescent antibody assay was inconclusive and the throat culture for Group A Streptococcus was negative. She had no history of sexual activity. The overall prevalence rate in the 100 adolescents was 1% with a 1.8% prevalence in the symptomatic group and 0 in the asymptomatic group. Of the symptomatic adolescents 39 had cultures for Group A Streptococcus and 8 (20.5%) were positive. The results of this study suggest that C. trachomatis is a rare inhabitant of the oropharynx in adolescents and is not a common cause of pharyngitis.

This study analyzed weight gain as a side effect of oral contraceptive use in teens and young adults. A retrospective chart review from 1978 to 1983 was conducted at two family planning clinics. Weight gain over 12 months was compared between females starting oral contraceptive pills and a control group using an IUD or a barrier method. One-hundred thirty-eight charts were included in the oral contraceptive group and 35 in the control group. There was no significant difference between the oral contraceptive group and control group in initial weight and weight after one year of use. Distribution of weight was also similar. There were no significant blood pressure changes. In the oral contraceptive group only five (3.7%) users listed weight gain as a side effect. The results suggest that for many young women who use oral contraceptive pills there is no greater risk of weight gain than for other sexually active young females.

Several factors potentially involved in the menstrual dysfunction of some females with cystic fibrosis were analyzed by a retrospective chart review. The mean age of menarche for the cystic fibrosis patients was 14.4 years, compared to 12.9 years for American females (p less than 0.001). At last evaluation, comparison of the mean figures for amenorrheic patients and for menarchal cystic fibrosis patients reveals statistically significant differences in the age of diagnosis, weight-height index, weight, height, percent of body fat, weight percentile, and height percentile. The highest correlative was weight (r = 0.59). Of our cystic fibrosis patients who were menarchal, 95% had a weight greater than 82 pounds, whereas 75% of those who were amenorrheic weighed less than 82 pounds. Menstrual irregularities, sexual activity, and contraceptive use among these patients also is discussed.Several factors potentially involved in the menstrual dysfunction of some females with cystic fibrosis were analyzed by a retrospective chart review. The mean age of menarche for the cystic fibrosis patients was 14.4 years, compared to 12.9 years for American females (P0.001). At last evaluation, comparison of the mean figures for amenorrheic patients and for menarchal cystic fibrosis patients reveals statistically significant differences in the age of diagnosis, weight-height index, weight, height, percent of body fat, weight percentile, and height percentile. The highest correlative was weight (r=0.59). Of our cystic fibrosis patients who were menarchal, 95% had weight greater than 82 pounds, whereas 75% of those who were amenorrheic weighed less than 82 pounds. Menstrual irregularities, sexual activity, and contraceptive use among these patients is also discussed.

Summary. This study evaluated the effects of an adolescent medicine rotation on paediatric residents' pelvic examination skills. Measurements were: (1) self-evaluations pre- and postrotation; (2) nurse's evaluations of pelvic examination performance during the first and last week of the rotation; and (3) patients' evaluations. The self-evaluation was also given at the start and at the end of the year to residents not taking the rotation. Twenty-four third-year residents were evaluated during the year. Eighteen subjects taking the rotation showed significant improvement post-rotation in the areas of competence, comfort, evaluation of training and importance to career, while the six residents not taking the rotation showed no change. The nurse's evaluation of the pelvic examination showed increases in comfort level, skill, awareness of adolescents' feelings, and ability to explain and reassure. Patient ratings were high at the beginning of the rotation and showed no significant change post-rotation. An adolescent medicine rotation significantly improved pelvic examination skills as assessed by self-ratings and a nurse's evaluation. A rotation in adolescent medicine can play a crucial role in developing gynaecological skills in paediatric residents.

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

In Reply.— We thank Dr Hammerschlag for her thoughtful comments. We wholeheartedly agree with her about the use of cultures in the setting of suspected sexual abuse. As other studies have indicated, the sensitivity and specificity of the direct fluorescent antibody test are too low in a population with low prevalence rates such as a population with suspected child abuse. We also agree with Dr Hammerschlag about the possibility of perinatal infection in a young child.

A case of coincident acute appendicitis and hemorrhagic corpus luteal cyst is presented. The difficulty of differentiating acute appendicits from gynecological problems is discussed. In addition, prior simultaneous occurrences of other abdominal emergencies with acute appendicitis are reviewed.

To the Editor.— The article by Dunn et al 1 entitled "Patient and House Officer Attitudes on Physician Attire and Etiquette" was interesting in that there are few studies that have examined the impact of physician dress style. However, this survey examined only the preferences of patients and did not examine the subsequent effect of dress style on patient-physician rapport. This question has been examined, at least in an adolescent population, in a study we conducted recently. 2 In our study, physicians randomly dressed in four dress styles from jeans to suit and tie. At the end of the interview, patients were asked to fill out a confidential questionnaire on their comfort level with their physician and also their preferences about the dress of their physician. Regardless of the dress style of the physician, the patients evaluated their physicians equally. In this study, 43% of the respondents stated that dress