UT Southwestern Medical School
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Browsing UT Southwestern Medical School by Subject "Adolescent"
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Item Baseline Assessment of Adolescent Reproductive and Sexual Health in Yantaló, San Martin, Peru(2016-04-01) Murarka, Shivani; Johnson, AndreaBACKGROUND: The term “adolescent fertility rate” refers to the number of births per 1000 in girls ages 15-19. In July 2013, the adolescent fertility rate in rural Yantaló, Peru, was nearly 10%, almost double the national rate of 5.2% in 2012 (World Bank). Adolescent pregnancy remains a major contributor to maternal and child mortality and to the cycle of ill-health and poverty world-wide (WHO). In Yantaló, many young mothers are forced to terminate their schooling in order to care for their children, giving them fewer opportunities for financial independence in a society with a strong machismo culture. OBJECTIVE: To gain a better understanding of the adolescent sexual and reproductive health education and practice in Yantaló and the potential interventions that could be made to decrease the adolescent fertility rate. METHODS: This study involved numerous methods of data collection that were then evaluated and presented to the local community. We started by conducting oral interviews with 19 local authorities, who played different roles in the community, to gain a deeper understanding of the issues surrounding adolescent sexual and reproductive health in the region. We then conducted 218 written surveys with high school students ages 11-19 to investigate their baseline reproductive health knowledge, religious values, family life, and their preferences regarding avenues of receiving sexual health information and sexual health classes. We also evaluated the proposed national curriculum on sexual health. All of this data was then used to create suggestions regarding interventions to improve the adolescent fertility rate in Yantaló, and this information was presented to local authorities. RESULTS: Analysis of the study revealed that there were many components that contributed to the high adolescent fertility rate in Yantaló and many potential areas for intervention were made apparent. Data from oral interviews pointed to a strong machismo culture, rampant misconceptions regarding sexual health and contraceptive methods, insufficient outreach programs, and a general lack of coordination between local entities as reasons for the high number of adolescent pregnancies. The surveys of the adolescents revealed that they lacked basic reproductive health knowledge but were eager to learn more, especially from local clinicians and their mothers and fathers, despite admitting having difficulty communicating openly about sexual health with their parents. Although the proposed national curriculum was analyzed, the school in Yantaló admitted that it only followed the guidelines loosely, which made it an ineffective tool to evaluate sexual health education in the region. CONCLUSION: Yantaló is similar to many other rural communities in South and Central America in that it has a strong traditional, machismo culture that influences much of the adolescent sexual health practices. Like much of Peru, Yantaló also has access to trained healthcare providers and free contraceptive care, but misconceptions and a lack of education regarding sexual health limits access. This research emphasized the importance collaboration within the community to utilize the existing infrastructure of the village to increase education of adolescents and encourage communication between providers, parents, and adolescents to improve adolescent sexual health and reduce the burden of unwanted teenage pregnancy. This practice could be easily translatable to numerous other communities that struggle with the same inefficiencies.Item Health Related Quality of Life of Transgender Adolescents Undergoing Hormonal Transition or Elective Pubertal Delay(2018-04-03) Moore, Antoinette Marie; Gimpel, Nora; Lau, May; McGregor, TamaraBACKGROUND: Research concerning the health and well-being of gender non-conforming and transgender adolescents following pubertal suppression and cross-sex hormone administration has grown dramatically in recent years, providing further evidence supporting a gender-affirming approach to this vulnerable population. Improvement in psychological functioning has been demonstrated in both transgender male and transgender female adolescents following these mentioned medical interventions. Further research is necessary to demonstrate whether a gender-affirming medical approach improves health-related quality of life, which includes not only psychological functioning but physical and social functioning as well. The gender-affirming medical approach also relies heavily on self-reported observations from adolescents, which has come under scrutiny by critics who believe adolescents are incapable of making semi-permanent and permanent gender affirming medical decisions. More research is needed to compare adolescent observations of their quality of life to the observations of their parents/guardians as an index of reliability of reported behaviors and feelings. This will further inform how medical and mental health professionals weigh adolescent and guardian reports in the ongoing debate regarding the appropriate age for cross-sex hormonal transition in gender non-conforming and transgender adolescents. OBJECTIVE: Following medical intervention (pubertal suppression and later cross-sex hormone initiation), adolescents will report a significant increase in their health-related quality of life from their self-reported baseline prior to intervention. METHODS: Adolescents experiencing gender dysphoria were recruited to participate in this study beginning at their intake into GENECIS, a center located in Dallas, Texas, specializing in interdisciplinary gender affirming care of this population. At intake, adolescents agreeable to participate in this study included 108 trans-males (natal female, gender identity male) and 71 trans-females (natal male, gender identity female) as well as their caregivers. All were administered the PedsQL, a validated instrument that quantifies perceived general self-reported and parent-reported quality of life in several core domains. This tool, first developed to assess baseline risk, health status, and outcomes of pediatric cancer patients has since been validated in multiple chronic health conditions. The PedsQL was administered again to adolescents and parents which at one-year follow up, which at the time included 71 adolescents and 90 parents. Paired t-test was performed on baseline and one year follow up PedsQL scores for this group, comparing the gender affirming care model to the gender affirming care model plus medical intervention (cross-sex hormones or pubertal delay, n=56). The PedsQL Family Impact tool was also administered to parents of transgender adolescents at initial intake and one year follow up (n=94). This tool assists in analyzing the health related quality of life of the parents and family when considering the stresses caused by raising a transgender adolescent. RESULTS: The initial assessment provided results regarding baseline QL of transgender adolescents. Out of 179 adolescents, 160 identified as White, 5 African American, 1 American Indian/Alaskan Native, 4 Asian, and 9 Unknown. Ethnically, 15 identifed as Hispanic or Latino, with 164 identifying as Non-Hispanic or Latino. Domain means for all adolescents were as follows, with a score of 100 as a perfect score: Physical functioning 77.98, Emotional functioning 56.92, Social functioning 70.81, School functioning 63.88, Psychosocial health summary score 64.12, and Total Score 68.95. Trans males (n=108) had the following domain means: Physical functioning 74.26, Emotional functioning 53.01, Social functioning 68.01, School functioning 60.46, Psychosocial health 60.89, Total score 65.53. Trans females (n=71) had the following domain means: Physical functioning 83.65, Emotional functioning 62.87, Social functioning 75.07, School functioning 69.08, Psychosocial health 69.03, Total score 74.15. Patients who completed both an initial PedsQL assessment and one year reassessment (n=71) provided data for a Paired T Test (95% CI) with the following results: Physical functioning Initial 80.76, Year 1 78.97, p=.304; Emotional functioning Initial 55.58, Year 1 64.03 p=.004*; Social functioning initial 72.04, Year 1 77.82, p=.006*; School functioning Initial 65.07, Year 1 67.68 p=.396; Psychosocial 64.62, Year 1 70.49, p=.004*; Total score Initial 70.25, Year 1 73.41, p=.065. Of this paired data, Trans Males (n=45) demonstrated the following results: Physical functioning Initial 76.42, Year 1 76.40, p=.99; Emotional functioning Initial 52.67, Year 1 61.02 p=.01*; Social functioning Initial 70.78, Year 1 75.00, p=.12; School functioning Initial 63.44, Year 1 63.56 p=.97; Psychosocial Initial 62.89, Year 1 67.18, p=.06; Total score Initial 67.58, Year 1 70.36, p=.16. Trans Females (n=26) demonstrated the following results: Physical functioning Initial 88.27, Year 1 83.42, p=.17; Emotional functioning Initial 60.62, Year 1 69.23 p=.14; Social functioning Initial 74.23, Year 1 82.69, p=.01*; School functioning Initial 67.88, Year 1 74.81 p=.17; Psychosocial Initial 67.62, Year 1 76.23, p=.03*; Total score Initial 74.88, Year 1 78.69, p=.24. Patients who completed both an initial PedsQL assessment, began cross-sex hormones or elective pubertal delay following initial assessment, and completed a one year reassessment (n=56) provided data for a Paired T Test (95% CI) with the following results: Physical functioning Initial 78.56, Year 1 79.84, p=.53; Emotional functioning Initial 55.27, Year 1 66.71 p=.0004*; Social functioning Initial 69.46, Year 1 77.21, p=.003*; School functioning Initial 63.39, Year 1 70.55 p=.024*; Psychosocial Initial 63.18, Year 1 71.39, p=.0001*; Total score Initial 68.55, Year 1 74.30, p=.002*. Of this paired data, Trans Males (n=38) demonstrated the following results: Physical functioning Initial 73.92, Year 1 77.29, p=.17; Emotional functioning Initial 50.53, Year 1 64.50 p=.00003*; Social functioning Initial 69.34, Year 1 76.29, p=.04*; School functioning Initial 62.11, Year 1 68.55 p=.09; Psychosocial Initial 61.34, Year 1 69.76, p=.0009*; Total score Initial 65.71, Year 1 72.39, p=.002*. Trans Females (n=18) demonstrated the following results: Physical functioning Initial 88.39, Year 1 85.22, p=.38; Emotional functioning Initial 65.28, Year 1 71.39 p=.39; Social functioning initial 69.72, Year 1 79.17, p=.02*; School functioning Initial 66.11, Year 1 75.00 p=.12; Psychosocial Initial 67.06, Year 1 74.83, p=.06; Total score Initial 74.57, Year 1 78.33, p=.26. Parents who also completed an initial PedsQL assessment (parent proxy) and a one year reassessment (n=90) provided data for a Paired T Test (95% CI) with the following results: Physical functioning Initial 78.74, Year 1 81.47 p=.179; Emotional functioning Initial 59.33, Year 1 62.81 p=.08; Social functioning initial 71.23, Year 1 76.78, p=.02*; School functioning Initial 69.18, Year 1 72.36 p=.28; Psychosocial Initial 66.84, Year 1 71.02, p=.03*; Total score Initial 70.96, Year 1 74.59, p=04*. Regarding scores on the PedsQL Family Impact assessment, a Paired T Test (n=94) had the following results: Physical functioning Initial 77.95, Year 1 79.61 p=.49; Emotional functioning Initial 65.59, Year 1 71.01 p=.02*; Social functioning initial 75.31, Year 1 80.18, p=.07; Cognitive Functioning Initial 78.78, Year 1 80.43 p=.44; Communication Health Summary Initial 63.57, Year 1 68.44, p=.047*; Worry Initial 49.34, Year 1 58.55 p=.001*; Daily Activities Initial 74.76, Year 1 80.73, p=.09; Family Relationships Initial 69.73, Year 1 73.56, p= .001*; Parent HRQL Summary Score Initial 74.63, Year 1 77.82, p= .001*; Family Functioning Summary 71.68, Year 1 76.31, p=.178; Total Score Initial 69.70, Year 1 74.70, p=.12. CONCLUSION: By focusing on functionality as demonstrated by the PedsQL, this research has demonstrated that transgender adolescents achieve a significant improvement across multiple QOL domains via medical care rooted in a gender-affirming approach, but adolescents achieved the greatest gains in QOL scores when medical therapy in the form of cross-sex hormones or pubertal suppression was introduced. Trans males had greater improvements in QOL scoring, possibly explained the larger sample size of trans males in the GENECIS clinic, the faster onset of desired side effects of testosterone administration versus estrogen, and the larger percentage of trans males on cross-sex hormones in versus pubertal blockers alone. The similarities in how adolescents reported their quality of life compared to the reported observations of their guardian suggest parents of adolescents at GENECIS can accurately estimate the impact gender dysphoria has on their child's life, and adolescent self-reporting is as accurate to parental proxy. This potentially has great importance in regard to informed decision making, particularly age at which cross-sex hormones are administered. The PedsQL Family Impact instrument provided strong data suggesting that not only do adolescents benefit from receiving care from a gender affirming center (as demonstrated by the PedsQL tool) but that the family unit and the parent also achieve an improved quality of life. Based on these findings, we conclude that this early research on QOL in transgender adolescents continues to support administration of cross-sex hormones and pubertal blockade and consider lowering the age of transition below sixteen years of age as improvement in QOL of the adolescent and family unit is demonstrable and desirable.Item Late Effects of Hypothalamic Radiation Exposure in Pediatric Brain Tumor Survivors(2015-03-31) Wu, Susan Y.; Bowers, Daniel C.; Vega, Gloria L.; Gargan, LynnBACKGROUND: Brain tumors are the second most common childhood malignancy and overall survival rates exceed 70%. Pediatric brain tumor survivors treated with hypothalamic radiation are at increased risk for developing components of metabolic syndrome, characterized by central obesity and two of the following: elevated triglycerides, low HDL, elevated blood pressure, or fasting hyperglycemia. These patients may also be at risk for developing decreased bone density, which is associated with pathologic fractures. OBJECTIVE: Our aim is to compare the prevalence of metabolic syndrome or concomitant cardiometabolic risk, bone density, and body composition among pediatric brain tumor survivors treated with and without hypothalamic radiation. METHODS: This study evaluated 146 survivors of childhood brain tumors (70 radiated, 76 non-radiated) between 5-20 years old (mean: 12.3 years, SD: 4.1 years, average survival time: 6 years). Patients underwent fasting lab assays (lipid panel, insulin, glucose, leptin, and adiponectin), anthropometric measurements (height, weight, and waist circumference), and Dual-energy X-ray Absorptiometry (DXA) scan. Insulin resistance was identified using the homeostasis model assessment of insulin resistance (HOMA-IR). Metabolic syndrome was diagnosed according to the International Diabetes Foundation criteria in children 10 years and older; children between 5-10 years of age who met 3 of 5 risk factors were classified as having concomitant cardiometabolic risk. RESULTS: Metabolic syndrome or concomitant cardiometabolic risk was more common in patients who received hypothalamic-pituitary axis (HPA) radiation (7/38, 18.4%) than those who did not (4/76, 5.3%) (p = 0.04). Patients who received HPA radiation were more likely to have elevated triglyceride levels (p = 0.02), low HDL levels (p = 0.04), and lower IGF-1 z-scores (p < 0.001). On DXA scan, patients exposed to HPA radiation had lower Bone Mineral Content (BMC) and Bone Mineral Density (BMD) z-scores (-1.3 vs. -0.3, p = 0.003 and -1.4 vs. -0.2, p < 0.001 respectively) and lower Fat Free Mass Index z-scores (-1.4 vs. -0.1, p = 0.001) despite no significant difference in BMI (21.7 vs. 22.2, p = 0.7) or percent body fat (35.5% vs. 32.8%, p = 0.11). There was no significant difference in leptin/kg fat and adiponectin/kg fat between patients who received HPA radiation and those who did not (p = 0.55 and p = 0.98 respectively). Patients with elevated HOMA-IR had elevated leptin levels (p = 0.001), lower adiponectin levels (p = 0.04), and elevated leptin:adiponectin ratios (p = 0.001). CONCLUSION: These results suggest that exposure to hypothalamic radiation may have significant subclinical consequences that include components of metabolic syndrome, decreased bone density, and altered body composition. These results highlight the need for stringent follow-up surveillance of these patients and suggest that screening for dyslipidemia may be a sensitive way to detect patients at risk for developing metabolic syndrome.Item Prediction by Insomnia to Treatment Outcomes in an Adolescent Suicide Management Program(2019-03-15) Lau, Jenny Wong; Emslie, Graham; Stewart, Sunita M.; Kennard, Beth D.BACKGROUND: Insomnia is the symptom most strongly associated with suicide-related thoughts and behaviors in adolescents and young adults with diverse diagnoses, even after adjusting for psychiatric conditions like depression (Goldstein, 2008). However, there is little empirical evidence that demonstrates prospectively that sleep problems are in fact a risk factor for suicide attempts (Franklin et al. 2017). OBJECTIVE: This study examines the previously unexplored relationship between insomnia and suicidal relapse in youth enrolled in an outpatient suicide prevention program. METHODS: Data were obtained from clinical records of adolescents ages 12-17 enrolled in the Suicide Prevention and Resilience at Children's Intensive Outpatient program (SPARC IOP) from January 1, 2014 through March 1, 2016 (n = 206). Patients completed measures of depressive symptoms, insomnia, and suicide risk at entry and exit. The association between insomnia, exit suicide risk, and 6-month attempts was tested with multiple regression analyses. RESULTS: Patients were mainly female (79.1%; n = 163) with a primary diagnosis of depression (89.8%; n = 185). Depression, suicide risk, and insomnia scores decreased overall. Entry insomnia was associated with exit suicide risk (CHRT) after controlling for entry risk, age, sex, time in the program, and number of previous attempts. Patients with insomnia did not show a different rate of treatment response (β = 0.257, p > .10). Entry insomnia was also associated with suicide attempts within 6 months after exiting the program when controlling for age, sex, and previous attempts. When entry and exit risk were added to the model, the association between entry insomnia and attempts within 6 months lost significance while the association between exit risk and attempts at 6 months became significant. Thus, patients with higher insomnia scores at entry had higher suicide risk scores at exit, which increased the likelihood of a suicide attempt 6 months after the program. CONCLUSION: These findings suggest that insomnia is a distal variable in the pathway to risk for suicide attempts after discharge. Entry insomnia is associated with exit risk, which has a more proximal relationship with 6-month attempts. Direct management of insomnia symptoms could reduce suicide risk at program exit, which could then reduce the probability of a suicide attempt in the 6 months following discharge. These studies could ultimately lead to new therapeutic approaches for reducing suicide attempts by treating insomnia symptoms.Item Uses of Hypnosis in Pediatric Anesthesia and Pediatric Headaches: A Literature Review(2017-12-29) Zimmern, Vincent; Mihalic, Angela; Ambardekar, Aditee; Remster, EricBACKGROUND: Managing pain and anxiety is a significant challenge for pediatricians. Infants, children, and teenagers - especially those with severe needle phobia -- can experience significant degrees of stress and anxiety prior to and after surgery, and during vaccinations or venipunctures. Headaches and migraines - another significant source of pain and anxiety for children and adolescents - can be difficult to treat with conventional pharmaceutical approaches. Hypnotherapy, or the use of hypnosis to achieve a therapeutic outcome, has a long history of providing some degree of somatic analgesia and anxiolysis. OBJECTIVE: The objective of this study is to critically review the literature dealing with hypnosis as a therapeutic tool in pediatric anesthesia and pediatric headaches. METHODS: A large database of medical and psychological publications (PubMed) was searched for studies in which hypnosis was used either for pediatric anesthesia/analgesia or for pediatric headaches. Those studies were then manually curated for their pertinence to hypnosis and pediatrics. They were subsequently classified according to the level of evidence that they provide in favor of hypnosis as a treatment modality. RESULTS: At this time, there is a relatively strong literature arguing in favor of hypnosis for peri-procedural pain relief and anxiolysis. There is limited evidence, however, to suggest that hypnosis can or should be used in scenarios that normally require general anesthesia. While there is increasing evidence to suggest a role for hypnosis in the management of recurrent headaches in children, there is as yet little substantial evidence to suggest a role in migraine headaches, despite one promising study. CONCLUSION: Given the increased popularity of complementary and alternative medicine (CAM), hypnotherapy is likely to be increasingly incorporated into the repertoire of tools for managing pain, anxiety, and headaches, perhaps in combination with relaxation, mindfulness, and biofeedback approaches. Additional studies of hypnosis, in specific clinical settings such as immobilization for radiotherapy, ophthalmologic procedures, and migraine headaches are needed. A more standardized approach to hypnotic induction by the hypnosis community would allow for more rigorous studies and trials.