Professor Emeritus, Pediatrics - Adolescent Medicine
DIRECTOR, CENTER FOR ADVANCED STUDY IN THE BEHAVIORAL SCIENCE, STANFORD UNIVERSITY (2013 - Present)
Research focus is on the health problems of adolescent women, with particular emphasis on the interaction of psychosocial phenomena with biologic features of the second decade of life. The effects of eating disorders on reproductive physiology, bone density and growth is one example of this interest. Pregnancy prevention and medication compliance in adolescents are other research interests.
This study examined the prevalence, demographic variables and adverse outcomes associated with non-adherence to post-transplant care in adolescent liver transplant recipients. We conducted a retrospective chart review of 111 adolescent patients (age 12-21 yr) greater than six months post-transplantation and defined non-adherence as not taking the immunosuppressive(s) or not attending any clinic visit in 2005. Fifty subjects (45.0%) were non-adherent and 61 (55.0%) were adherent. Twenty percent of the subjects did not attend clinic and 10.9% did not complete laboratory tests. Non-adherence was significantly associated with fewer completed laboratory tests (p < 0.0001), single parent status (p < 0.0186), and older age and greater years post-transplantation by both univariate and multivariate analyses (p < 0.008, p < 0.0141 and p < 0.0012, p < 0.0174, respectively). Non-adherence to medication was significantly associated with a rejection episode in 31 patients (p < 0.0069) but not in the subgroup of seven patients who stopped their immunosuppression completely. Non-adherence to post-transplant care is a prevalent problem in adolescents particularly of an older age and greater years post-transplantation. Rejection was a significant consequence of medication non-adherence except in a subgroup with presumed graft tolerance who discontinued their immunosuppression. These results emphasize the need for strict monitoring of adherence to post-transplant care to improve long-term survival and quality of life in adolescent transplant patients.
View details for DOI 10.1111/j.1399-3046.2007.00809.x
View details for Web of Science ID 000253637400013
View details for PubMedID 18307668
Pro-eating disorder Web sites are communities of individuals who engage in disordered eating and use the Internet to discuss their activities. Pro-recovery sites, which are less numerous, express a recovery-oriented perspective. This pilot study investigated the awareness and usage of pro-eating disorder Web sites among adolescents with eating disorders and their parents and explored associations with health and quality of life.This was a cross-sectional study of 698 families of patients (aged 10-22 years) diagnosed with an eating disorder at Stanford between 1997 and 2004. Anonymous surveys were mailed and offered in clinic. Survey content included questions about disease severity, health outcomes, Web site usage, and parental knowledge of eating disorder Web site usage.Surveys were returned by 182 individuals: 76 patients and 106 parents. Parents frequently (52.8%) were aware of pro-eating disorder sites, but an equal number did not know whether their child visited these sites, and only 27.6% had discussed them with their child. Most (62.5%) parents, however, did not know about pro-recovery sites. Forty-one percent of patients visited pro-recovery sites, 35.5% visited pro-eating disorder sites, 25.0% visited both, and 48.7% visited neither. While visiting pro-eating disorder sites, 96.0% reported learning new weight loss or purging techniques. However, 46.4% of pro-recovery site visitors also learned new techniques. Pro-eating disorder site users did not differ from nonusers in health outcomes but reported spending less time on school or schoolwork and had a longer duration of illness. Users of both pro-eating disorder and pro-recovery sites were hospitalized more than users of neither site.Pro-eating disorder site usage was prevalent among adolescents with eating disorders, yet parents had little knowledge of this. Although use of these sites was not associated with other health outcomes, usage may have a negative impact on quality of life and result in adolescents' learning about and adopting disordered eating behaviors.
View details for DOI 10.1542/peds.2006-1133
View details for Web of Science ID 000242478900056
View details for PubMedID 17142493
Few studies have examined the prevalence, demographic variables and adverse consequences associated with non-adherence to immunosuppressive therapy in the adolescent liver transplant population. Our hypothesis is that a significant proportion of adolescent liver transplant recipients exhibit non-adherence to medical regimens and that certain demographic and medical condition-related characteristics can be identified as potential predictors of non-adherent behavior. Furthermore, non-adherence leads to a greater incidence of morbidity and mortality in this population as compared with the adherent subset of adolescent patients. We reviewed the charts of 97 patients from 1987 to 2002 who by December of 2002 had survived at least 1 yr post-transplant and were followed by the Pediatric Liver Transplant Service at any point during their adolescent period (ages of 12-21). Non-adherence was defined as documentation of a report of non-adherence by a patient, parent or healthcare provider that was recorded in the patient's legal medical record. Descriptive statistics were used to determine the prevalence, demographic variables and adverse outcomes associated with non-adherence to immunosuppressive therapy. Categorical variables were analyzed using the chi-square test or the Fisher exact probability test. The unpaired Student's t-test was used to analyze the continuous variable of age at transplant. Using the inclusion criteria, a total of 97 patients represented the study sample of whom 37 subjects (38.1%) were defined as non-adherent and 60 (61.8%) were adherent. Non-adherent subjects were more likely to be female, older (>18 yr) and from a single-parent household. There was no significant difference in immunosuppressive regimen between non-adherent and adherent patients. Non-adherence was significantly (p<0.025) associated with lower socioeconomic status (SES), older age at transplant (p<0.005, 95% CI: -5.5 to -.99, Student's t-test) and episodes of late acute rejection (p<.001). Non-adherence was also significantly associated with re-transplantation and death secondary to chronic rejection by the Fisher exact test (p<0.006 and p<0.05, respectively). Non-adherence to immunosuppressive therapy is a prevalent problem that is correlated with certain demographic and medical condition-related risk factors and more frequent adverse consequences in the adolescent liver transplant population. The greater incidence of late acute rejection, death and re-transplantation owing to chronic rejection in non-adherent patients suggests that non-adherence is significantly associated with an increased risk of morbidity and mortality. Further investigation to identify patients at greatest risk for non-adherence is necessary to design the most effective intervention to increase patient survival and well being.
View details for DOI 10.1111/j.1399-3046.2005.00451.x
View details for Web of Science ID 000237096700007
View details for PubMedID 16677353
We assessed the relationship between outcomes at one year and a variety of possible predictors among a group of adolescents who were hospitalized for medical complications associated with adolescent onset AN. We reviewed the 12 month outcomes of 41 adolescent patients admitted for medical complications associated with AN to our center. Data on initial percent ideal body weight, length of initial hospitalization, and percent ideal body weight at discharge from first admission were collected. Our primary outcome measure was percent ideal body weight obtained 12 months after initial discharge. Using multiple linear regression to predict percent ideal body weight achieved at 12 months postdischarge, we found that only percent of ideal body weight at discharge predicted better outcomes. Response to initial hospitalization in terms of weight gain, rather than admission weight or length of initial hospital stay, predict better outcomes at 12 months. These results suggest the need for further study of predictors of response to intensive hospital treatment in order to improve initial response rates and ultimately to better outcomes postdischarge.
View details for PubMedID 16864282
To examine the importance of chronologic age versus pubertal status in predicting adolescent girls' depressive symptoms in different ethnic groups.A national probability sample was used to obtain a representative cohort of 3216 adolescents, 5th through 8th grades. Subjects completed a questionnaire, which included a modified version of the Children's Depression Inventory (CDI) and an assessment of timing of menarche.Among Caucasians, post-menarcheal adolescent girls had higher depression scores than did same-aged pre-menarcheal girls. Boys and pre-menarcheal girls had similar depression scores in most age groups. Among African-Americans and Hispanics, there were no menarche-associated differences in depressive symptoms.In early adolescence pubertal status is a better predictor of depressive symptoms than chronological age in Caucasian, but not African-American or Hispanic girls.
View details for Web of Science ID 000081723700008
View details for PubMedID 10447041
Risk factors for the initiation of cigarette smoking were examined in 2 consecutive cohorts of teenagers (N = 1,901). Students in Cohort 1 were followed over 4 years from 9th to 12th grade; those in Cohort 2 were followed over 3 years from 9th to 11th grade. Among girls with no history of smoking at baseline, those with more friends who smoked at baseline (p < .001) and those with higher sociability scores (p < .05) were significantly more likely to have tried smoking over the study interval. Among boys with no history of smoking at baseline, those with more friends who smoked at baseline (p < .05) and those with higher depression symptoms scores (p < .01) were significantly more likely to have tried smoking over the study interval. The data suggest that future research is needed to examine potential gender differences that may have implications for the next generation of smoking-prevention programs.
View details for Web of Science ID A1997YJ46300011
View details for PubMedID 9420362
This study prospectively evaluated the relationship between early puberty and the onset of internalizing symptoms and disorders in adolescent girls.The sample was drawn from 1,463 sixth-, seventh-, and eighth-grade girls who participated in a longitudinal school-based study of growth and development. Pubertal stage was determined by self-assessment of Tanner stage. Psychiatric assessments included self-report instruments and structured diagnostic interviews. Survival methods were utilized for data analysis.Girls with onset of internalizing symptoms were on average 5 months earlier in pubertal development than those who were asymptomatic (p < .001). In addition, girls with earlier maturation (earliest quartile) were more likely to develop internalizing symptoms than were nonearly matures (hazard ratio = 1.8, confidence interval = 1.2, 2.7). In a subsample of girls followed into high school, early-maturing girls were at marginally higher risk (p < .10) for developing internalizing disorders by the study's end. The highest risk for internalizing disorders was for those girls with both early puberty and prior internalizing symptoms (odds ratio = 3.3).Early puberty increases the risk of internalizing symptoms and perhaps internalizing disorders in adolescent girls.
View details for Web of Science ID A1997WD92900017
View details for PubMedID 9031579
To compare prevalences and correlates of body dissatisfaction among white, Hispanic, and Asian girls.A total of 939 6th and 7th grade girls (mean age 12.4 years) attending four middle schools in northern California completed self-administered assessments of age, ethnicity, desired body shape, parent education levels, mother's and father's body shapes, pubertal stage, and body dissatisfaction. Body dissatisfaction was assessed with the Body Dissatisfaction scale of the Eating Disorder Inventory. Height, weight, triceps skinfold thickness, and waist and hip circumferences were measured by trained examiners.Hispanic girls reported significantly greater body dissatisfaction than white girls, with Asian girls in-between. After adjustment for body mass index (weight/height), normal and overweight white, Hispanic, and Asian girls reported similar levels of body dissatisfaction. However, among the leanest 25% of girls, Hispanics and Asians reported significantly more body dissatisfaction than white girls. Body mass index was the strongest independent predictor of increased body dissatisfaction in all three ethnic groups. Shorter height among white girls and taller height among Asian girls also made significant independent contributions. Parent education level, a measure of socioeconomic status, was not significantly associated with body dissatisfaction.Body dissatisfaction is not limited to white girls in middle and upper socioeconomic strata. These findings suggest Hispanic and Asian girls may be at greater risk for adopting eating disorder behaviors than previously recognized.
View details for Web of Science ID A1996VY33400005
View details for PubMedID 8969369
View details for PubMedID 7624276
Community-based prospective studies are needed to shed light on mechanisms that may influence development of eating disorders and identify variables that could serve as potential targets for prevention efforts. In this paper we examine level of weight preoccupation and other variables prospectively associated with age of onset of eating disorder symptoms over a 3-year interval in a community sample (N = 939) of young adolescent girls. 3.6% (32/887) experienced onset of symptoms over the interval. Only one factor, a measure of Weight Concerns, was significantly associated with onset (p < .001). Girls scoring in the highest quartile on the measure of Weight Concerns had the shortest survival time (12% incidence by age 14.5) and those scoring in the lowest quartile had the highest survival time (2% incidence by age 14.5; p < .001). This finding is consistent with both theoretical and clinical perspectives and represents one of the first prospective demonstrations of a linkage between weight and body shape concerns and later onset of eating disorder symptoms. An understanding of the independent variables that predispose girls to development of symptoms is a useful step towards the establishment of a rational basis for the choice of a prevention intervention target.
View details for PubMedID 7833956
Much has been written about the care of the hopelessly ill adult, but there is little guidance for pediatric health care professionals in the management of children who are critically or terminally ill.Through a 3-day meeting in Tarrytown, NY, attended by a group of pediatricians and others directly involved in these issues, a principled approach was developed for the treatment of, and health care decision-making for, children who are gravely ill.The group agreed that the needs and interests of the child must be the central focus of any treatment plan and that the child should be involved to as great extent possible, consistent with developmental maturity, in the decision-making process. Quality of future life should be viewed as being relevant in all decisions. Parents are believed to be the natural guardians of children and ought to have great latitude in making decisions for them. However, parental discretion is not absolute and professionals must maintain an independent obligation to protect the child's interests.Decision-making should be collaborative among patient, parents, and professionals. When conflict arises, consultation and ethics committees may assist in resolution. When cure or restoration of function is no longer possible, or reasonable, promotion of comfort becomes the primary goal of management. Optimal use of pain medication and compassionate concern for the physical, psychological, and spiritual well-being of the child and family should be the primary focus of the professionals caring for the dying child.
View details for Web of Science ID A1994PK84000004
View details for PubMedID 7936849
Nine hundred thirty-nine 6th and 7th grade girls participated in the baseline phase of a prospective study designed to examine a set of potential risk factors for the development of eating disorders. Of the 939,839 girls (89%) completed the bulimia nervosa section of the Structured Clinical Interview for DSM-III-R disorders. One girl received the diagnosis of bulimia nervosa, another 35 were classified as a symptomatic group. Using analysis of covariance (ANCOVA), controlling for age and stage of sexual maturation, symptomatic and asymptomatic groups were compared on the following measures: Eating Disorders Inventory (EDI), BMI, triceps skinfold thickness, waist-to-hip ratio, depression symptoms (CES-D and DSRS), Restraint Scale, and a measure of family adaptability and cohesion (FACES). Symptomatic girls were more developmentally mature, significantly heavier, reported greater fear of weight gain, experienced greater dysphoria, indicated increased body dissatisfaction, and reported greater feelings of inadequacy and personal worthlessness. Their status on these dimensions may indicate potential vulnerability to eating disorders and, ultimately, suggest the choice of targets for intervention. Our future goal is to conduct the prospective analyses needed to confirm the hypothesized linkages.
View details for Web of Science ID A1994NG59800005
View details for PubMedID 8032350
This is the first long-term, controlled study evaluating the effectiveness of a prevention curriculum designed to modify the eating attitudes and unhealthful weight regulation practices of young adolescent girls. Nine hundred sixty-seven sixth and seventh-grade girls were randomized to experimental healthy weight regulation curriculum or no-treatment control classes. A prevention intervention was developed around three principal components: (1) Instruction on the harmful effects of unhealthful weight regulation; (2) promotion of healthful weight regulation through the practice of sound nutrition and dietary principles and regular aerobic physical activity; (3) development of coping skills for resisting the diverse sociocultural influences that appear linked to the current popular obsessions with thinness and dieting. The intervention failed to achieve the hoped-for impact. We did observe a significant increase in knowledge among girls receiving the intervention and among high-risk students only, there was a small albeit statistically significant effect on body mass index. These findings question the wisdom of providing a curriculum directed at all young adolescents, most of whom are not at risk to develop an eating disorder. Rather than targeting the entire population, a healthy weight curriculum designed to modify the eating attitudes and unhealthful weight regulation practices of young adolescent girls might better focus on "at risk" students.
View details for Web of Science ID A1993KZ50300004
View details for PubMedID 8490639
Although the incidence of first panic attacks appears to peak during adolescence, little is known about which features of adolescence contribute to the risk of a first panic episode. The purpose of this study was to compare the relative importance of age and pubertal stage in explaining the occurrence of panic attacks in adolescents.From a school-based sample of sixth- and seventh-grade girls, 754 subjects completed both a structured clinical interview determining history of one or more panic episodes and a self-assessment of Tanner stages of pubertal development. A multiple logistic regression analysis was performed with panic attack history as the dependent variable and pubertal stage, age, and their interaction as the independent variables.A history of one or more four-symptom panic attacks was found in 5.3% of the girls (N = 40). After age was controlled for, pubertal stage was significantly related to panic attack history. At each age, higher rates of panic attacks were found in the more physically mature girls.Pubertal stage, after adjustment for the effects of age, appears to predict panic attack occurrence in young adolescent girls. Understanding the link between puberty and panic may offer clues regarding the onset and etiology of panic attacks.
View details for Web of Science ID A1992JK72200019
View details for PubMedID 1503139
IGFBP-3 concentrations rise in the second decade of life. To test the hypothesis that the stage of pubertal development, independent of chronological age, was associated with these increases we measured serum IGFBP-3 concentrations by radioimmunoassay in 324 sixth and seventh grade girls (12.3 +/- 0.7 years) at the beginning of a multisite school-based health curriculum. The mean (+/- SD) serum IGFBP-3 among the 242 girls with complete data was 4.0 +/- 0.7 mg/l. Pubertal stage was significantly associated with IGFBP-3 (p less than 0.0001, ANOVA). Mean concentrations rose from 3.5 +/- 0.7 mg/l among those with the earliest pubertal stages to 4.2 +/- 0.7 mg/l among the mature girls. IGF-I and IGFBP-3 concentrations were significantly correlated (Spearman's r = 0.43, p less than 0.0001). After controlling for the association between pubertal development and IGFBP-3 concentrations, only the waist/hip ratio, among the various measures of body composition, was significantly associated with IGFBP-3 concentration (Spearman's r = -0.23, p = 0.0002). Likewise, none of the measures of nutrition: intake of total calories, protein, fat and carbohydrate; serum iron; red cell mean corpuscular volume; or cholesterol; were significantly associated with IGFBP-3 concentrations. There was, however, a small, but significant association between IGFBP-3 concentrations and both serum transferrin and blood hemoglobin concentrations. Pubertal stage has a significant impact on IGFBP-3 concentrations and those attempting to utilize IGFBP-3 concentrations during adolescence should be cognizant of the subject's pubertal stage.
View details for Web of Science ID A1992HZ93000001
View details for PubMedID 1377853
To examine the association between stage of sexual maturation and eating disorder symptoms in a community-based sample of adolescent girls.All sixth- and seventh-grade girls (N = 971) enrolled in four northern California middle schools. MAIN VARIABLES EXAMINED: Pubertal development measured using self-reported Tanner stage and body mass index (kg/m2). The section of the Structured Clinical Interview for DSM-III-R Disorders (SCID) discussing bulimia nervosa was used to evaluate symptoms of bulimia nervosa.Girls manifesting eating disorder symptoms, while not significantly older than their peers without such symptoms, were more developmentally advanced as determined with Tanner self-staging. The odds ratio for the association between sexual maturity and symptoms was 1.8 (95% confidence interval, 1.2 to 2.8); ie, at each age, an increase in sexual maturity of a single point was associated with a 1.8-fold increase in the odds of presenting symptoms. The odds ratio for the association between body mass index (adjusted for sexual maturity) and symptoms was 1.02 (95% confidence interval, 1.0 to 1.05). There was no independent effect of age or of the interaction between age and the sexual maturity index.These results suggest that (1) puberty may be a risk factor for the development of eating disorders, and (2) prevention efforts might best be directed at prepubertal and peripubertal adolescents.
View details for Web of Science ID A1992HG92400016
View details for PubMedID 1543180
Large variations in nutritional intake have profound effects on the GH-insulin-like growth factor-I (IGF-I) axis in children and adults, but the effect of normal variations in nutrition on IGF-I concentrations is largely unstudied, particularly during puberty. We measured serum IGF-I concentrations in 325 sixth and seventh grade girls (12.4 +/- 0.7 yr) at the beginning of a multisite school-based health curriculum. The mean serum IGF-I level among the 243 girls with complete data was 573 +/- 244 micrograms/L. Pubertal stage was significantly associated with IGF-I (P less than 0.0001, by analysis of variance). Mean concentrations rose from 427 +/- 198 micrograms/L among those at the earliest pubertal stages to 639 +/- 219 micrograms/L among the mature girls. After adjusting for the association with the stage of pubertal development, serum IGF-I was not significantly associated with measures of body composition (body mass index, triceps skin fold thickness, waist/hip ratio, height, and weight). Additionally, IGF-I concentrations were not associated with nutritional intake (total calories, total protein, total fat, and total carbohydrate) or such measures of nutrition as serum iron, hemoglobin, red cell mean corpuscular volume, white cell count, and cholesterol. IGF-I concentrations, however, were significantly correlated with transferrin concentrations, another possible index of nutritional status (r = 0.29; P less than 0.0001). IGF-I is not a clinically useful index of nutritional status among normal pubertal girls.
View details for Web of Science ID A1991GF68400035
View details for PubMedID 1890162
Chlamydia pneumoniae has recently been identified as a cause of lower respiratory tract infections. From March 1987 to March 1988, 259 university students-151 students with lower respiratory tract infections and 108 controls-from the University of California, Berkeley, were studied to determine the incidence and pattern of C pneumoniae lower respiratory tract infections. Serologic evidence of a recent C pneumoniae infection was found in less than 2%, and the organism was not isolated from any of the subjects. Despite the paucity of evidence of a recent infection, 47.5% of this university population showed serologic evidence of a previous C pneumoniae infection. The lower incidence of C pneumoniae infection in our population, when compared with previous reports, suggests that there may be geographic and temporal differences or fluctuations among populations.
View details for Web of Science ID A1991GA96400002
View details for PubMedID 1926842
Variation in the waist/hip ratio (WHR) may be related to changes in hormonal secretion associated with pubertal maturation. We therefore studied the effects of race, pubertal development, and body fatness on WHR during adolescence in a multiethnic population. A total of 688 white, Asian, and Hispanic female adolescents (mean (+/- SD) 12.4 +/- 0.7 years), participating in the evaluation of a multisite school-based health education program, were included in these analyses. Self-assessed stage of puberty and measurements of height, weight, waist circumference, and hip circumference were obtained from each participant. The WHR and age-adjusted body mass index were calculated. Analysis of covariance demonstrated that puberty significantly affects hip circumference and WHR but not waist circumference among female adolescents. Age and fatness, as reflected by age-adjusted body mass index, contributed significantly to both circumferences and to the WHR. There was a significant effect of ethnicity on hip circumference but not on waist circumference or the WHR. These results confirm that pubertal stage exerts a significant effect on the hip circumference and WHR in female adolescents, even after the effects of fatness and age are controlled. Studies of body fat distribution during late childhood and adolescence should include assessments of pubertal maturation.
View details for Web of Science ID A1991FQ10800029
View details for PubMedID 2040937
Comparing mothers' reports of early feeding practices in 18 mothers of anorexics and 25 mothers of normal children by means of a questionnaire, we found that the mothers of anorexics introduced solids earlier and used Schedule rather than Demand feedings more frequently. The mothers of anorexics did not treat patients and control siblings differentially. Our study suggests that differences in early feeding and in infant temperament may be operative in the pathogenesis of anorexia nervosa.
View details for Web of Science ID A1991EZ76300001
View details for PubMedID 2007340
Osteopenia is a frequent complication of anorexia nervosa (AN). To determine whether the deficit in bone mineral changes during the course of this illness, we studied 15 adolescent patients prospectively for 12-16 months using dual photon absorptiometry of the spine and whole body. At follow-up, mean weight, height, and body mass index (BMI) had increased significantly, although 6 girls had further weight loss or minimal gain (less than 1.2 kg). Spontaneous menses occurred in 2 girls, and 3 others were given estrogen replacement. Bone mineral density of the lumbar spine did not change significantly (mean +/- SD, 0.836 +/- 0.137 vs. 0.855 +/- 0.096 g/cm2), while whole body bone mineral density increased (0.710 +/- 0.118 vs. 0.773 +/- 0.105; P less than 0.05). Despite gains in bone mineral, 8 patients had osteopenia of the spine and/or whole body. Changes in weight, height, and BMI were significant predictors of change in bone mineral density. Increased bone mass occurred with weight gain before return of menses; conversely, weight loss was associated with further decreases in bone density. In 1 patient who failed to gain weight, estrogen therapy resulted in increased spinal, but not whole body, bone mineral. We also studied a second group of 9 women who had recovered from AN during adolescence. All 9 had normal whole body bone mineral for age, but 3 had osteopenia of the lumbar spine. We conclude that osteopenia in adolescents with AN reflects bone loss, perhaps combined with decreased bone accretion. Weight rehabilitation results in increased bone mineral before the return of menses. Estrogen may have an independent effect on bone mass. The persistence of osteopenia after recovery indicates that deficits in bone mineral acquired during adolescence may not be completely reversible.
View details for Web of Science ID A1991FA52300012
View details for PubMedID 1997514
View details for PubMedID 2006128
Osteoporosis develops in women with chronic anorexia nervosa. To determine whether bone mass is reduced in younger patients as well, bone density was studied in a group of adolescent patients with anorexia nervosa. With single- and dual-photon absorptiometry, a comparison was made of bone mineral density of midradius, lumbar spine, and whole body in 18 girls (12 to 20 years of age) with anorexia nervosa and 25 healthy control subjects of comparable age. Patients had significantly lower lumbar vertebral bone density than did control subjects (0.830 +/- 0.140 vs 1.054 +/- 0.139 g/cm2) and significantly lower whole body bone mass (0.700 +/- 0.130 vs 0.955 +/- 0.130 g/cm2). Midradius bone density was not significantly reduced. Of 18 patients, 12 had bone density greater than 2 standard deviations less than normal values for age. The diagnosis of anorexia nervosa had been made less than 1 year earlier for half of these girls. Body mass index correlated significantly with bone mass in girls who were not anorexic (P less than .05, .005, and .0001 for lumbar, radius, and whole body, respectively). Bone mineral correlated significantly with body mass index in patients with anorexia nervosa as well. In addition, age at onset and duration of anorexia nervosa, but not calcium intake, activity level, or duration of amenorrhea correlated significantly with bone mineral density. It was concluded that important deficits of bone mass occur as a frequent and often early complication of anorexia nervosa in adolescence. Whole body is considerably more sensitive than midradius bone density as a measure of cortical bone loss in this illness.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1990DW64600018
View details for PubMedID 2388792
Anorexia nervosa is notoriously difficult to treat, but little is known regarding the relationship of compliance to treatment outcome. We investigated in 41 adolescents who fulfilled DSM-III-R criteria for anorexia nervosa, the relationship between the completion of a standard psychosocial treatment program, subtypes of anorexia nervosa, and outcome as determined by standardized measurements. These adolescents were observed for an average of 32.4 months. Overall, 29 patients (70%) improved considerably, but 10 (24%) were symptomatic, and 2 (5%) remained in poor condition. There were no deaths. Of the 41 patients, 14 (34%) completed our entire treatment program, 15 (37%) received major treatment and failed in the outpatient follow-up phase only, 7 (17%) dropped out of inpatient treatment before its completion, and 5 (12%) refused treatment in our system altogether. Of all the dropouts, 10 received no further treatment. One patient was admitted to hospital elsewhere but again dropped out in the outpatient phase of that program. Seven patients (17%) received further outpatient treatment only, and 9 (22%) received inpatient and outpatient care and seemingly completed their treatment. Treatment completion significantly affected the measures of global clinical functioning and specific psychopathologic features, but only for those patients who completed the initial program. Bulimic patients did considerably worse on follow-up and were less likely to complete treatment. Patients with restricted anorexia nervosa were more likely to complete treatment than those with a bulimic subtype (P = .03). Differential compliance rates in the two subtypes confound the effects of treatment completion and need to be controlled for in future studies. Depression was not associated with noncompliance but, if present, was associated with poor outcome on follow-up and abated in only a third of those in whom it was initially present.
View details for Web of Science ID A1990DU82600001
View details for PubMedID 2219868
The knowledge and concerns regarding acquired immunodeficiency syndrome (AIDS) and their relationship to certain behaviors among adolescents with hemophilia, a pediatric risk group with human immunodeficiency virus (HIV) antibody positivity rate as high as 70% to 90%, are described. Information was obtained from 26 patients, 13 to 19 years of age, through the use of a confidential self-administered questionnaire and a semistructured interview. In general, subjects demonstrated a high level of factual knowledge regarding the cause, natural history, transmission, and prevention of AIDS. Despite this, participants frequently behaved in ways that were potentially harmful to themselves and others. Specifically, although aware of the importance of using condoms, sexually active adolescents with hemophilia were not practicing safe sex. Restriction in the use of heat-treated clotting factor because of concerns about AIDS was also frequently reported. Professionals providing AIDS education and counseling for these individuals need to be cognizant of the concerns and social skills of this population; they should focus not only on factual information but also on the social and situational pressures confronting these teenagers, which may be more immediate determinants of their behavior and well-being. As AIDS continues to spread into the general population, these findings have relevance to AIDS education and health policy efforts aimed at all adolescents.
View details for Web of Science ID A1989T087000008
View details for PubMedID 2783626
We encountered seven female adolescents with the Fitz-Hugh-Curtis syndrome and no signs or symptoms of salpingitis. Six of the patients had cervical cultures positive for Chlamydia trachomatis. The Fitz-Hugh-Curtis syndrome should be included in the differential diagnosis of right-sided abdominal pain in the sexually active female adolescent to avoid unnecessary diagnostic procedures and to reduce the prevalence of chlamydial infection and its complications.
View details for Web of Science ID A1988P928200031
View details for PubMedID 3414633
Anorexia nervosa and bulimia are occurring with increased frequency among adolescents and preadolescents. To determine the range and severity of medical complications encountered in younger anorectic and bulimic patients, we reviewed the medical records of 65 adolescents and preadolescents, aged 10 to 20 years, who were observed in the Eating Disorders Clinic of the Children's Hospital at Stanford. Significant medical instability was present in the majority of our patients. A total of 55% of anorectic patients and 22% of bulimic patients required hospitalization for medical reasons during the study period. Cardiovascular abnormalities were frequent, including bradycardia, prolonged corrected QT intervals, dysrhythmias, and marked orthostatic pulse and BP instability. Hypothermia, with temperatures less than 35.5 degrees C, was common. Renal abnormalities included pyuria, hematuria, and proteinuria. Electrolyte derangements occurred in patients who vomited or purged. Hypokalemia was most common, but hypocalcemia, hypomagnesemia, and hypophosphatemia were also noted. The majority of our pediatric patients with eating disorders had evidence of physiologic derangement requiring medical intervention. The need for adolescents and preadolescents with eating disorders to receive ongoing medical monitoring in concert with psychiatric treatment and the need for therapists and medical practitioners to become familiar with the potential medical sequelae of eating disorders are underscored by our data.
View details for Web of Science ID A1988N207600002
View details for PubMedID 3162764
A case of asymptomatic pneumomediastinum in a 14-year-old girl with anorexia nervosa and self-induced emesis is reported to emphasize the atypical aspects of this case and the importance of differentiating benign from potentially life-threatening sources of mediastinal air. Individuals who engage in purging behavior are not only at increased risk for both alveolar (primary pneumomediastinum) and esophageal perforation (Boerhaave syndrome) but may also obscure or delay the diagnosis by denying symptoms and/or previous emesis. Because esophageal perforation is serious, the presence of free mediastinal air in a patient with a known or suspected history of emesis should provoke prompt radiographic evaluation of the upper gastrointestinal tract.
View details for Web of Science ID A1988L542300022
View details for PubMedID 3336579
This preliminary study was undertaken to explore the hypothesis that socioeconomic and racial, as well as medical, factors influence the physician's decision about obtaining a sexual history from an adolescent female. Sixty consecutive medical records of adolescent-age emergency room patients with acute abdominal pain were classified according to ethnic group and socioeconomic status and searched for evidence that a sexual history had been taken. The study revealed a much higher number of recorded sexual histories among blacks and Hispanics. Although the absence of such a history seemed to have little relationship to diagnostic accuracy, a sensitive selectivity in exposing acutely ill teenagers to possible embarrassing questions appeared to be reserved for white, middle-class teenagers.
View details for Web of Science ID A1988L199200007
View details for PubMedID 3335471
Adolescents with anorexia nervosa were evaluated for clinical and biochemical evidence of zinc deficiency. To assess whether these patients would benefit from zinc supplementation, a double-blind, randomized, controlled trial was conducted. The mean zinc intake of the anorexic group calculated on the basis of three-day dietary records was 7.7 +/- 5.2 mg/day, which is significantly below the recommended daily allowance of 15 mg for adolescents (p less than 0.001). The mean urinary zinc excretion in the anorexic group was 257.1 +/- 212.7 micrograms/24 hours compared to 749.9 +/- 897.8 micrograms/24 hours in the control group (p less than 0.005). This result suggests that the zinc status of anorexia nervosa patients may be compromised due to an inadequate zinc intake. Zinc supplementation (50 mg elemental zinc/day) was followed by a decrease in the level of depression and anxiety as assessed by the Zung Depression Scale (p less than 0.05) and the State-Trait Anxiety Inventory (p less than 0.05), respectively. Our data suggest that individuals with anorexia nervosa may be at risk for zinc deficiency and may respond favorably after zinc supplementation.
View details for Web of Science ID A1987J656200002
View details for PubMedID 3312133
We examined menstrual function in two groups of patients meeting the DSM III criteria for anorexia nervosa who differed only in their physical activity. Sixteen athletes with anorexia nervosa were compared with eight sedentary patients who had anorexia nervosa. Athletic patients with anorexia were found to have lower gonadotropin levels, a longer period of amenorrhea both before significant weight loss and after weight rehabilitation, and a higher weight at the time of resumption of menses than patients with anorexia who were sedentary. However, both groups were markedly undernourished, had amenorrhea before significant weight loss and after weight rehabilitation, and had lower gonadotropin levels than normal subjects. These data suggest that the increased physical activity often seen in patients with anorexia nervosa worsens, but does not cause, menstrual dysfunction.
View details for Web of Science ID A1986D124100033
View details for PubMedID 3088243