Background: Youth of color are disproportionately subjected to negative formal and informal label... more Background: Youth of color are disproportionately subjected to negative formal and informal labels by parents, peers, and teachers. This study examined the consequences of such labels on health-protective behaviors, wellbeing, peer networks and school engagement. Methods: In-depth interviews were conducted with 39 adolescents and 20 mothers from a predominantly Latinx and immigrant agricultural community in California. Teams of coders completed iterative rounds of thematic coding to identify and refine key themes. Results:Dichotomous labeling of “good” and “bad” was pervasive. Youth labeled as “bad” experienced limited educational opportunities, exclusion from peers, and community disengagement. Additionally, preservation of “good kid” labels compromised health protective-behaviors including foregoing contraception. Participants pushed back on negative labeling when it was applied to close family or community acquaintances. Discussion: Targeted interventions that foster social belon...
Program Goals Through the Resident Education in Advocacy and Community Health (REACH) program wit... more Program Goals Through the Resident Education in Advocacy and Community Health (REACH) program within the Kaiser Permanente Northern California pediatrics residency, we aimed to create a longitudinal outreach opportunity for residents to provide curriculum-development training and to promote nutritional education by developing a school based gardening program for middle-school students. Evaluation A needs assessment of 278 students showed 90% were minorities and 33% identified as having food insecurity. Responses showed 51% of …
Background Adverse Childhood Experiences (ACEs) are a measure of childhood toxic stress that have... more Background Adverse Childhood Experiences (ACEs) are a measure of childhood toxic stress that have a dosedependent relationship with many adult health outcomes. While ACEs have been validated across diverse populations to measure neglect, abuse, and family dysfunction, they do not specifically assess trauma related to racism/ xenophobia and immigration. 54% of Latinx youth in the United States are immigrants or children of immigrants and a large group with potentially unmeasured trauma. This study looks beyond ACEs to identify adverse and protective factors for healthy development among Latinx youth in an agricultural community through the perspectives of their mothers. Methods Twenty mothers of adolescent participants in A Crecer: the Salinas Teen Health Study (a prospective cohort study of 599 adolescents) completed semi-structured interviews in Spanish. Interviews focused on mothers' perspectives on community resources, parenting strategies, parenting support systems, and their future aspirations for their children. Four coders completed iterative rounds of thematic coding drawing from published ACEs frameworks (original ACEs, community ACEs) and immigrant specific adverse events arising from the data. Results Mothers in this study reported adverse experiences captured within community-level ACEs but also distinct experiences related to intergenerational trauma and immigrant-related adversities. The most cited community-level ACEs were housing instability and community violence. Immigrant related adversities included experiences of systemic racism with loss of resources, political instability limiting structural resources, and language-limited accessibility. These were exacerbated by the loss of family supports due to immigration related family-child separation including deportations and staggered parent-child migration. Having experienced intergenerational trauma and systemic oppression, mothers discussed their strategies for building family unity, instilling resilience in their children, and improving socioeconomic opportunities for their family. Conclusions Latina mothers shared the impacts of immigrant-related experiences on systemic inequities in the United States which are currently missing from the ACEs framework. Immigrant specific adverse events include language-limited accessibility, or family-child separations, and policies impacting structural resources for immigrant families. Mothers highlighted their capacity to build resilience in their children and buffer impacts of systemic racism. Community-tailored interventions can build on this foundation to reduce health disparities and promote health equity in this population.
There is scant research on how Asian American adolescents’ resiliency relates to mental well-bein... more There is scant research on how Asian American adolescents’ resiliency relates to mental well-being in adulthood. The objective of this study was to determine the prospective associations between resiliency factors (individual, family, and school community) in adolescence and mental health outcomes in adulthood, among a national sample of Asian Americans. We analyzed data from 1020 Asian American adolescents who were followed for 14 years in the National Longitudinal Study of Adolescent to Adult Health. Of the resiliency factors, individual self-esteem (Adjusted Odds Ratio [AOR] 0.54, 95% Confidence Interval [CI] 0.37–0.79) and family connectedness (AOR 0.78, 95% CI 0.65–0.93) in adolescence were found to be protective against adult mental health outcomes in logistic regression models adjusting for sociodemographic factors and baseline mental health. Our study identified individual and family resiliency factors which can be leveraged to help Asian American adolescents and families in...
Supplemental Digital Content is available in the text. Children exposed to antibiotics develop co... more Supplemental Digital Content is available in the text. Children exposed to antibiotics develop community-associated Clostridioides difficile infections in the 12 weeks following exposure. This secondary analysis was a retrospective review of children with filled prescriptions for commonly prescribed antibiotics between January 1, 2012, and December 31, 2016. Compared with amoxicillin, incident rates of community-associated Clostridioides difficile infections were highest following clindamycin, cephalosporins, and amoxicillin-clavulanate.
PURPOSE The aim of this study is to identify and evaluate the efficacy of adolescent protective f... more PURPOSE The aim of this study is to identify and evaluate the efficacy of adolescent protective factors against mental health (MH) outcomes in young adulthood of sexual minority identifying youth (SMY). METHODS Using data from the National Longitudinal Study of Adolescent to Adult Health, we identified potential protective factors (e.g., individual factors like self-esteem, family factors like family communication, and community factors like caring teachers) at baseline (1994) when the sample was school-aged for SMY. SMY included those who identified their sexual identity as mostly heterosexual, bisexual, mostly homosexual, or 100% homosexual. MH outcomes (depression, anxiety, or suicidality) were assessed at 14-year follow-up. RESULTS Approximately 14,800 youth completed baseline and follow-up surveys, where 13.5% identified as SMY. Of SMY, 57% had a MH outcome compared to 37% of non-SMY (p < .05). Not all factors were protective for SMY. At the individual level, emotional well-being (adjusted odds ratio [AOR] .56, 95% confidence interval [CI] .41-.78) and self-esteem (AOR .79, 95% CI .66-.95) were found to be protective for MH outcomes in regression models. At the family level, family connectedness (AOR .82, 95% CI .71-.95) was found to be protective. At the community level, school connectedness (AOR .78, 95% CI .66-.92) and caring teachers (AOR .76, 95% CI .58-.99) were found to be protective for SMY. CONCLUSION Factors at the individual, family, and community (e.g., caring teachers) levels appear to be protective against MH outcomes unique to SMY. Developing interventions focused on protective factors have potential to prevent health disparities.
Background. Incidence of Clostridium difficile infection (CDI) in children has been shown to be h... more Background. Incidence of Clostridium difficile infection (CDI) in children has been shown to be highest among those aged 1 to 3 years, with similar clinical presentation, disease severity, and outcomes as older children. In addition, a large proportion of CDI in children are community-associated (CA), but few data exist regarding associated risk factors. We sought to identify CA-CDI risk factors in younger children. Methods. We enrolled children from 8 geographically-diverse U.S. sites during October 2014-February 2016. Case-patients were defined as children aged 12-60 months with a positive C. difficile stool specimen collected as an outpatient or within 3 days of hospitalization, who had no healthcare facility admission in the prior 12 weeks and no history of CDI. Each case-patient was matched to one randomly selected control (child with no prior history of CDI) by site and age group. Caretakers were interviewed about participants' relevant exposures in the 12 weeks prior to case-patient's illness onset date; univariate analysis was performed using exact conditional logistic regression. Results. Of 138 children, 43.5% were female; 69.6% were 12-23 months old. A significantly higher proportion of cases than controls had: an underlying chronic medical condition (33.3% vs 11.9%; P = 0.02); a neonatal intensive care unit (NICU) stay at time of birth (26.9% vs 13.2%; P = 0.04); or recent antibiotic exposure (53.6% vs 20.6%; P = 0.0001). More cases than controls had recent higher-risk outpatient healthcare exposures (emergency department, outpatient procedure and surgical centers, hospital-based outpatient settings, or urgent care) (34.9% vs 19.1%; P = 0.06) or a household member with diarrhea (36.2% vs 20.6%; P = 0.05). No difference was found in the proportion of cases and controls who had a feeding tube (2.9% vs 0%; P = 0.50) or a recent exposure to gastric acid suppressants (6.1% vs 2.9%; P = 0.63). Conclusion. Young children with underlying disease, NICU stay, or recent antibiotic use might be at higher risk for CA-CDI. Improving outpatient antibiotic use, particularly among children with comorbidities, might reduce CA-CDI in this population. Further investigation of other risk factors, including outpatient healthcare and household exposures, is needed. Disclosures. All authors: No reported disclosures.
Journal of the Pediatric Infectious Diseases Society, 2021
Background Third-generation cephalosporin-resistant urinary tract infections (UTIs) often have li... more Background Third-generation cephalosporin-resistant urinary tract infections (UTIs) often have limited oral antibiotic options with some children receiving prolonged parenteral courses. Our objectives were to determine predictors of long parenteral therapy and the association between parenteral therapy duration and UTI relapse in children with third-generation cephalosporin-resistant UTIs. Methods We conducted a multisite retrospective cohort study of children <18 years presenting to acute care at 5 children’s hospitals and a large managed care organization from 2012 to 2017 with a third-generation cephalosporin-resistant UTI from Escherichia coli or Klebsiella spp. Long parenteral therapy was ≥3 days and short/no parenteral therapy was 0–2 days of concordant parenteral antibiotics. Discordant therapy was antibiotics to which the pathogen was non-susceptible. Relapse was a UTI from the same organism within 30 days. Results Of the 482 children included, 81% were female and the med...
To determine the prevalence of disordered eating behaviors (DEBs) and body image dissatisfaction ... more To determine the prevalence of disordered eating behaviors (DEBs) and body image dissatisfaction (BID) according to sexual minority youth (SMY) status and describe healthcare utilization patterns by SMY status. Methods: Retrospective data from 107,528 adolescents, who had a Well Check in Kaiser Permanente Northern California in 2016, were used to compare DEB and BID by SMY status. Multivariate logistic models were used to examine the associations of SMY, birth-assigned sex, age, race/ ethnicity, and body mass index on DEB and BID. The utilization of specialized eating disorder (ED) medical and mental health services and general mental health services was described at one Kaiser Permanente Northern California facility. Results: BID was reported in 20,763 (19.3%) adolescents, DEB in 1,458 (1.7%) adolescents, and 5,363 (5%) adolescents identified as SMY. SMY had higher odds of having DEB and BID than non-SMY, respectively (adjusted odds ratio 2.0 95% confidence interval [1.9e2.2] and adjusted odds ratio 3.8 [3.4e4.2]). Regardless of SMY status, adolescents with older age, female sex, nonwhite race, and elevated body mass index had higher odds of ED risk factors. SMY with ED risk factors had higher ED medical utilization than non-SMY with ED risk factors (4.6% vs. 1.6%). However, SMY status was not associated with utilization of specialized ED mental health services. Conclusions: SMY had increased rates of DEB and BID but had underutilization of specialized ED mental health services. Future targeted efforts to prevent eating disorder-related mortality and morbidity for SMY should include targeted eating disorder screening and referral to specialized ED medical and mental health services.
Background As rates of pediatric community-associated (CA) Clostridium difficile infection (CDI) ... more Background As rates of pediatric community-associated (CA) Clostridium difficile infection (CDI) increase, additional research is needed to address rates of infection following common antibiotics. Methods This study was a retrospective review of the electronic health records of all children with stool specimens sent for C difficile from January first 2012 – December 31st2016 at Kaiser Permanente Northern California. Children with clinical symptoms consistent with CDI, confirmatory laboratory testing, no other identified causes of diarrhea, and community associated disease were defined as cases. Using outpatient and ED antibiotic prescription records for children, incidence rates were calculated for subsequent CA CDI for the most commonly prescribed antibiotics. Results Of 507 primary CDI cases in our cohort, 327 had any antibiotic use 2012–2015. There were 205 primary CDI cases that were preceded by an antibiotic in the previous 1–365 days. Many of these patients had more than 1 ant...
OBJECTIVES: To describe the initial clinical response and care escalation needs for children with... more OBJECTIVES: To describe the initial clinical response and care escalation needs for children with urinary tract infections (UTIs) resistant to third-generation cephalosporins while on discordant antibiotics. METHODS: We performed a retrospective study of children <18 years old presenting to an acute care setting of 5 children’s hospitals and a large managed care organization from 2012 to 2017 with third-generation cephalosporin-resistant UTIs (defined as the growth of ≥50 000 colony-forming units per mL of Escherichia coli or Klebsiella spp. nonsusceptible to ceftriaxone with a positive urinalysis). We included children started on discordant antibiotics who had follow-up when culture susceptibilities resulted. Outcomes were escalation of care (emergency department visit, hospital admission, or ICU transfer while on discordant therapy) and clinical response at follow-up (classified as improved or not improved). RESULTS: Of the 316 children included, 78% were girls and the median a...
Euclidean distance from primary zip code centroids to the institution was 17.5 miles (IQR 7.86-25... more Euclidean distance from primary zip code centroids to the institution was 17.5 miles (IQR 7.86-25.44), and median network travel distance was 20 miles (IQR 11.66 e 32.58). Subjects who traveled an estimated network distance greater than 17.5 miles from their primary residence to the institution were 74% more likely to be lost to follow-up (HR 1.74; p 0.005; 95% CI [1.18-2.57]). Similarly, older subjects were 10% more likely to be lost to follow-up for each one-year increase in age (HR 1.096; p 0.016; 95% CI [1.01-1.18]). In contrast, subjects with a co-morbid psychiatric diagnosis were 49% less likely to be lost to follow-up (HR 0.51; p <0.001; 95% CI [0.36-0.73]), and those with any prior admissions for eating disorder management were 38% less likely (HR 0.62; p 0.014; 95% CI [ 0.43-0.91]). Conclusions: Greater network travel distance and increasing age are associated with loss to follow-up in AYA with eating disorders evaluated at a large children's hospital. History of prior admission and known psychiatric diagnoses were protective against loss to follow-up. To our knowledge, this is the first study to demonstrate an association between network travel distance and loss to follow-up in AYA with eating disorders. Given this along with prior data demonstrating a correlation between distance to care and worsened eating disorder severity at presentation, future studies should consider the impact of distance to care on long-term outcomes. Sources of Support: None 52.
The aim of the study was to estimate the prevalence of sexual minority youth (SMY) within an inte... more The aim of the study was to estimate the prevalence of sexual minority youth (SMY) within an integrated health care system using a standardized questionnaire. Methods: This study assessed SMY status in youth aged 12.5e18 years using a previsit Well Check questionnaire at Kaiser Permanente Northern California facilities in 2016. SMY was defined as selfreported attraction to the same sex or both sexes. Results: A total of 93,817 youth (87.3%) self-reported sexual attraction, and 5% (n ¼ 5,329) of respondents (N ¼ 107,532) identified as SMY: 1.7% were attracted to same sex, and 3.2% were attracted to both sexes. There were youth who responded neither (1.5%) and unsure (2.4%). Females were 2.8 times (95% confidence interval 2.6e2.94) more likely to be SMY than males. SMY status significantly increased with age. Nonwhite youth were significantly less likely to be SMY compared with white youth. Conclusions: This is the first study to examine SMY prevalence in pediatric primary care. Primary care providers can use previsit screening before preventive visits to identify and support sexual minority adolescents, facilitate family acceptance, and promote healthy behaviors with care coordination.
Background: Recurrence of community-associated (CA) Clostridiodes difficile infection (CDI) appro... more Background: Recurrence of community-associated (CA) Clostridiodes difficile infection (CDI) approaches 30%. Studies on risk factors and treatment of choice for pediatric CA-CDI are scarce with variable recommendations. Methods: This was a retrospective cohort study of the electronic health records of children 1-17 years with stool specimens sent for C. difficile at Kaiser Permanente Northern California from January 01, 2012 to December 31, 2016. Children with (1) CA disease, (2) confirmatory C. difficile laboratory testing with no other identified causes of diarrhea and (3) clinical symptoms consistent with CDI were defined as cases. Recurrent CA-CDI was defined using the abovedescribed case criteria and onset of diarrhea within 8 weeks of primary CA-CDI. Results: Of the 7350 children with stool samples sent for C. difficile testing, 408 had primary CA-CDI. Forty-five (11%) experienced a recurrence. Using multivariable logistic regression, inflammatory bowel disease [odds ratio (OR) 7.5; 95% confidence interval (CI): 2.6-21.1] and cancer (OR 6.3; 95% CI: 1.6-24.1) diagnoses were risk factors for recurrent disease. Compared with children of Caucasian race, those with multi/other/unknown race had an OR of 3.03 (95% CI: 1.04-8.82) of recurrence. There was no statistically significant difference in the type or duration of therapy as a predictor for recurrent CA CDI. Six percent of children who received metronidazole were switched to vancomycin due to subjective metronidazole allergy or intolerance or metronidazole treatment failure. Conclusions: Recurrent CA-CDI in children in our population is less common than previously reported. This study supports first-line treatment with the standard, short course metronidazole in most cases of primary CA-CDI.
Background. ESC-R UTIs often have limited oral antibiotic options with some children receiving a ... more Background. ESC-R UTIs often have limited oral antibiotic options with some children receiving a course of intravenous (IV) antibiotics. Our objectives were to determine predictors of long course IV therapy and the association between short-course therapy and UTI relapse. Methods. We conducted a multicenter retrospective cohort study of children <18 years with ESC-R UTIs presenting to an acute care setting of 5 children's hospitals and a large managed care organization from 2012 to 2017. ESC-R UTI was defined as having a urinalysis with positive leukocyte esterase or >5 white cells per high power field and urine culture with ≥50,000 colony-forming units per milliliter of E. coli or Klebsiella spp. nonsusceptible to ceftriaxone. Children with urologic surgery, immunosuppression and nonrenal chronic conditions were excluded. Long course therapy was defined as ≥5 days and short course as 0-4 days of a concordant IV antibiotic (an agent to which the isolate was susceptible). Relapse was defined as UTI with the same organism within 30 days. Limited oral antibiotic options were defined as nonsusceptibility to amoxicillin-clavulanate, ciprofloxacin, and trimethoprim-sulfamethoxazole. Predictors of long course therapy were determined using mixed effects logistic regression with hospital site as a random effect. Since UTI relapse was a rare outcome, we evaluated the association between short-course therapy and UTI relapse using Fisher's exact test. Results. Of 383 children with ESC-R UTIs, 80% were female, median age was 3 years (interquartile range 0.7-7.8), and 24% had a prior UTI. Forty-five children (12%) received long course therapy and 338 (87%) received short-course therapy. Predictors of long course therapy included age <2 months (adjusted odds ratio [AOR] 61.4, 95% confidence interval [CI] 12.5-302), male sex (AOR 3.0, 95% CI 1.2-7.8), and limited oral antibiotic options (AOR 5.3, 95% CI 2.2-12.6). UTI relapse occurred in 1/45 (2%) children treated with long course therapy and in 3/335 (0.9%) treated with short-course therapy (P = 0.40). Conclusion. Long course IV therapy in children with ESC-R UTIs was more likely in infants <2 months, males and those with limited oral antibiotic options. UTI relapse was rare and not associated with short course/no IV therapy. Disclosures. All authors: No reported disclosures.
Background. For new antibiotics to treat Gram-negative infections, one regulatory pathway include... more Background. For new antibiotics to treat Gram-negative infections, one regulatory pathway includes complicated urinary tract infections (cUTI) clinical trials. Although individual clinical trials comply with regulatory guidelines, they may differ substantially in design and execution. Six recent cUTI trials that supported or are likely to support FDA regulatory review were compared to determine variables that impacted patient selection and outcome parameters. Methods. cUTI trials for six new antibiotics developed to treat multi-drug-resistant Gram-negative infections were obtained from publicly disclosed information including FDA documents, publications, or presentations at scientific meetings. Antibiotics included were: ceftolozane-tazobactam (CTL-TAZ), ceftazidime-avibactam (CTZ-AVI), meropenem-vaborbactam (MER-VAB), cefiderocol, plazomicin, and fosfomycin. Comparison variables included: mMITT sample size, age, % female patients, % acute pyelonephritis, % E. coli and other pathogens at baseline, switch to PO antibiotic, and the non-inferiority margin. Other variables as well as the microbiologic eradication, clinical response, and the combined outcomes will be included in the poster. Results.
How would you handle this case? Answer the challenge questions throughout this article CASE Broke... more How would you handle this case? Answer the challenge questions throughout this article CASE Broken down Ms. E, age 20, is a college student who has had major depressive disorder for several years and a genetic bone disease (osteogenesis imperfecta, mixed type III and IV). She presents with depression, anxiety, and suicidal ideation. She reports recent worsening of her depressive symptoms, including anhedonia, excessive sleep, difficulty concentrating, and feeling overwhelmed, hopeless, and worthless. She also describes frequent thoughts of suicide with the plan of putting herself in oncoming traffic, although she has no history of suicide attempts. Previously, her primary care physician prescribed lorazepam, 0.5 mg, as needed for anxiety, and sertraline, 100 mg/d, for depression and anxiety. She experienced only partial improvement in symptoms, however. In addition to depressive symptoms, Ms. E describes manic symptoms lasting for as long as 3 to 5 days, including decreased need for sleep, increased energy, pressured speech, racing thoughts, distractibility, spending excessive money on cosmetics, and risking her safety--given her skeletal disorder--by participating in high-impact stage-combat classes. She denies auditory and visual hallucinations, homicidal ideation, and delusions. The medical history is significant for osteogenesis imperfecta, which has caused 62 fractures and required 16 surgeries. Ms. E is a theater major who, despite her short stature and wheelchair use, reports enjoying her acting career and says she does not feel demoralized by her medical condition. She describes overcoming her physical disabilities with pride and confidence. However, her recent worsening mood symptoms have left her unable to concentrate and feeling overwhelmed with school. Ms. E is voluntarily admitted to an inpatient psychiatric unit with a diagnosis of bipolar I disorder with rapid cycling, most recent episode mixed. Because of her bone fragility, the treatment team considers what would be an appropriate course of drug treatment to control bipolar symptoms while minimizing risk of bone loss. Which medications are associated with decreased bone mineral density? a) citalopram b) haloperidol c) carbamazepine d) paliperidone e) all of the above The potential risk of fracture presented by class of psychotropic medications Class of drug Lowest risk Moderate risk Highest risk Anticonvulsants Lamotrigine Carbamazepine Phenytoin Valproic acid Antidepressants Maprotiline Amitriptyline Citalopram Mirtazapine Desipramine Fluoxetine Tranylcypromine Doxepin Fluvoxamine Nefazodone Imipramine Nortriptyline Paroxetine Trazodone Sertraline Venlafaxine Antipsychotics Aripiprazole lloperidone Haloperidol Asenapine Lurasidone Paliperidone Clozapine Olanzapine Risperidone Quetiapine Typical Ziprasidone antipsychotics (all) Lithium May be protective but evidence is insufficient The authors' observations Osteogenesis imperfecta is a genetic condition caused by mutations in genes implicated in collagen production. As a result, bones are brittle and prone to fracture. Different classes of psychotropics have been shown to increase risk of bone fractures through a variety of mechanisms. Clinicians often must choose appropriate pharmacotherapy for patients at high risk of fracture, including postmenopausal women, older patients, malnourished persons, and those with hormonal deficiencies leading to osteoporosis. …
Journal of Pediatric and Adolescent Gynecology, 2015
To determine the awareness of, access to, and knowledge of the proper use of emergency contracept... more To determine the awareness of, access to, and knowledge of the proper use of emergency contraception pills (ECPs) among uninsured adolescents. Anonymous surveys were used to assess awareness of, knowledge of, and access to ECPs. From 2010 to 2012 at mobile primary care clinic in the San Francisco Bay Area. Patients were uninsured adolescents aged 13 to 25; 40% of the participants were currently or had been homeless in the past year. Ethnicity was 50% Asian, 22% Hispanic, 17% Pacific Islanders, 5.5% white, and 5.5% other/mixed ethnicity. Post survey completion, patients received one-on-one 15-minute dedicated ECP education. Awareness of, knowledge of, and access to ECPs. Of the study population of 439, 30% of the participants were 13-16 years old and 70% were 17-25 years old (mean age 17.8 years); 66% were women. Young women (86%) reported higher rates of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;hearing about emergency contraception&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; than did young men (70%) (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001). Many incorrectly identified or were uncertain if ECPs were an abortion pill (40%) or could be used as regular birth control (40%) or to prevent sexually transmitted infections (19%). Only 40% of women and 43% of men aged 17 and older correctly answered that they could obtain EC over the counter; 72% did not know that males could receive EC for use by their partner; 12% incorrectly selected that infertility was a side effect; 44% were under the false impression that EC had to be taken within 1 day of unprotected sex. Uninsured adolescents have high rates of ECP awareness but low ECP knowledge. These adolescents need more ECP education to alleviate misconceptions and increase practical knowledge, specifically, education about male access, side effects, over-the-counter availability for young men and women, and the 120-hour window of use.
Background: Youth of color are disproportionately subjected to negative formal and informal label... more Background: Youth of color are disproportionately subjected to negative formal and informal labels by parents, peers, and teachers. This study examined the consequences of such labels on health-protective behaviors, wellbeing, peer networks and school engagement. Methods: In-depth interviews were conducted with 39 adolescents and 20 mothers from a predominantly Latinx and immigrant agricultural community in California. Teams of coders completed iterative rounds of thematic coding to identify and refine key themes. Results:Dichotomous labeling of “good” and “bad” was pervasive. Youth labeled as “bad” experienced limited educational opportunities, exclusion from peers, and community disengagement. Additionally, preservation of “good kid” labels compromised health protective-behaviors including foregoing contraception. Participants pushed back on negative labeling when it was applied to close family or community acquaintances. Discussion: Targeted interventions that foster social belon...
Program Goals Through the Resident Education in Advocacy and Community Health (REACH) program wit... more Program Goals Through the Resident Education in Advocacy and Community Health (REACH) program within the Kaiser Permanente Northern California pediatrics residency, we aimed to create a longitudinal outreach opportunity for residents to provide curriculum-development training and to promote nutritional education by developing a school based gardening program for middle-school students. Evaluation A needs assessment of 278 students showed 90% were minorities and 33% identified as having food insecurity. Responses showed 51% of …
Background Adverse Childhood Experiences (ACEs) are a measure of childhood toxic stress that have... more Background Adverse Childhood Experiences (ACEs) are a measure of childhood toxic stress that have a dosedependent relationship with many adult health outcomes. While ACEs have been validated across diverse populations to measure neglect, abuse, and family dysfunction, they do not specifically assess trauma related to racism/ xenophobia and immigration. 54% of Latinx youth in the United States are immigrants or children of immigrants and a large group with potentially unmeasured trauma. This study looks beyond ACEs to identify adverse and protective factors for healthy development among Latinx youth in an agricultural community through the perspectives of their mothers. Methods Twenty mothers of adolescent participants in A Crecer: the Salinas Teen Health Study (a prospective cohort study of 599 adolescents) completed semi-structured interviews in Spanish. Interviews focused on mothers' perspectives on community resources, parenting strategies, parenting support systems, and their future aspirations for their children. Four coders completed iterative rounds of thematic coding drawing from published ACEs frameworks (original ACEs, community ACEs) and immigrant specific adverse events arising from the data. Results Mothers in this study reported adverse experiences captured within community-level ACEs but also distinct experiences related to intergenerational trauma and immigrant-related adversities. The most cited community-level ACEs were housing instability and community violence. Immigrant related adversities included experiences of systemic racism with loss of resources, political instability limiting structural resources, and language-limited accessibility. These were exacerbated by the loss of family supports due to immigration related family-child separation including deportations and staggered parent-child migration. Having experienced intergenerational trauma and systemic oppression, mothers discussed their strategies for building family unity, instilling resilience in their children, and improving socioeconomic opportunities for their family. Conclusions Latina mothers shared the impacts of immigrant-related experiences on systemic inequities in the United States which are currently missing from the ACEs framework. Immigrant specific adverse events include language-limited accessibility, or family-child separations, and policies impacting structural resources for immigrant families. Mothers highlighted their capacity to build resilience in their children and buffer impacts of systemic racism. Community-tailored interventions can build on this foundation to reduce health disparities and promote health equity in this population.
There is scant research on how Asian American adolescents’ resiliency relates to mental well-bein... more There is scant research on how Asian American adolescents’ resiliency relates to mental well-being in adulthood. The objective of this study was to determine the prospective associations between resiliency factors (individual, family, and school community) in adolescence and mental health outcomes in adulthood, among a national sample of Asian Americans. We analyzed data from 1020 Asian American adolescents who were followed for 14 years in the National Longitudinal Study of Adolescent to Adult Health. Of the resiliency factors, individual self-esteem (Adjusted Odds Ratio [AOR] 0.54, 95% Confidence Interval [CI] 0.37–0.79) and family connectedness (AOR 0.78, 95% CI 0.65–0.93) in adolescence were found to be protective against adult mental health outcomes in logistic regression models adjusting for sociodemographic factors and baseline mental health. Our study identified individual and family resiliency factors which can be leveraged to help Asian American adolescents and families in...
Supplemental Digital Content is available in the text. Children exposed to antibiotics develop co... more Supplemental Digital Content is available in the text. Children exposed to antibiotics develop community-associated Clostridioides difficile infections in the 12 weeks following exposure. This secondary analysis was a retrospective review of children with filled prescriptions for commonly prescribed antibiotics between January 1, 2012, and December 31, 2016. Compared with amoxicillin, incident rates of community-associated Clostridioides difficile infections were highest following clindamycin, cephalosporins, and amoxicillin-clavulanate.
PURPOSE The aim of this study is to identify and evaluate the efficacy of adolescent protective f... more PURPOSE The aim of this study is to identify and evaluate the efficacy of adolescent protective factors against mental health (MH) outcomes in young adulthood of sexual minority identifying youth (SMY). METHODS Using data from the National Longitudinal Study of Adolescent to Adult Health, we identified potential protective factors (e.g., individual factors like self-esteem, family factors like family communication, and community factors like caring teachers) at baseline (1994) when the sample was school-aged for SMY. SMY included those who identified their sexual identity as mostly heterosexual, bisexual, mostly homosexual, or 100% homosexual. MH outcomes (depression, anxiety, or suicidality) were assessed at 14-year follow-up. RESULTS Approximately 14,800 youth completed baseline and follow-up surveys, where 13.5% identified as SMY. Of SMY, 57% had a MH outcome compared to 37% of non-SMY (p < .05). Not all factors were protective for SMY. At the individual level, emotional well-being (adjusted odds ratio [AOR] .56, 95% confidence interval [CI] .41-.78) and self-esteem (AOR .79, 95% CI .66-.95) were found to be protective for MH outcomes in regression models. At the family level, family connectedness (AOR .82, 95% CI .71-.95) was found to be protective. At the community level, school connectedness (AOR .78, 95% CI .66-.92) and caring teachers (AOR .76, 95% CI .58-.99) were found to be protective for SMY. CONCLUSION Factors at the individual, family, and community (e.g., caring teachers) levels appear to be protective against MH outcomes unique to SMY. Developing interventions focused on protective factors have potential to prevent health disparities.
Background. Incidence of Clostridium difficile infection (CDI) in children has been shown to be h... more Background. Incidence of Clostridium difficile infection (CDI) in children has been shown to be highest among those aged 1 to 3 years, with similar clinical presentation, disease severity, and outcomes as older children. In addition, a large proportion of CDI in children are community-associated (CA), but few data exist regarding associated risk factors. We sought to identify CA-CDI risk factors in younger children. Methods. We enrolled children from 8 geographically-diverse U.S. sites during October 2014-February 2016. Case-patients were defined as children aged 12-60 months with a positive C. difficile stool specimen collected as an outpatient or within 3 days of hospitalization, who had no healthcare facility admission in the prior 12 weeks and no history of CDI. Each case-patient was matched to one randomly selected control (child with no prior history of CDI) by site and age group. Caretakers were interviewed about participants' relevant exposures in the 12 weeks prior to case-patient's illness onset date; univariate analysis was performed using exact conditional logistic regression. Results. Of 138 children, 43.5% were female; 69.6% were 12-23 months old. A significantly higher proportion of cases than controls had: an underlying chronic medical condition (33.3% vs 11.9%; P = 0.02); a neonatal intensive care unit (NICU) stay at time of birth (26.9% vs 13.2%; P = 0.04); or recent antibiotic exposure (53.6% vs 20.6%; P = 0.0001). More cases than controls had recent higher-risk outpatient healthcare exposures (emergency department, outpatient procedure and surgical centers, hospital-based outpatient settings, or urgent care) (34.9% vs 19.1%; P = 0.06) or a household member with diarrhea (36.2% vs 20.6%; P = 0.05). No difference was found in the proportion of cases and controls who had a feeding tube (2.9% vs 0%; P = 0.50) or a recent exposure to gastric acid suppressants (6.1% vs 2.9%; P = 0.63). Conclusion. Young children with underlying disease, NICU stay, or recent antibiotic use might be at higher risk for CA-CDI. Improving outpatient antibiotic use, particularly among children with comorbidities, might reduce CA-CDI in this population. Further investigation of other risk factors, including outpatient healthcare and household exposures, is needed. Disclosures. All authors: No reported disclosures.
Journal of the Pediatric Infectious Diseases Society, 2021
Background Third-generation cephalosporin-resistant urinary tract infections (UTIs) often have li... more Background Third-generation cephalosporin-resistant urinary tract infections (UTIs) often have limited oral antibiotic options with some children receiving prolonged parenteral courses. Our objectives were to determine predictors of long parenteral therapy and the association between parenteral therapy duration and UTI relapse in children with third-generation cephalosporin-resistant UTIs. Methods We conducted a multisite retrospective cohort study of children <18 years presenting to acute care at 5 children’s hospitals and a large managed care organization from 2012 to 2017 with a third-generation cephalosporin-resistant UTI from Escherichia coli or Klebsiella spp. Long parenteral therapy was ≥3 days and short/no parenteral therapy was 0–2 days of concordant parenteral antibiotics. Discordant therapy was antibiotics to which the pathogen was non-susceptible. Relapse was a UTI from the same organism within 30 days. Results Of the 482 children included, 81% were female and the med...
To determine the prevalence of disordered eating behaviors (DEBs) and body image dissatisfaction ... more To determine the prevalence of disordered eating behaviors (DEBs) and body image dissatisfaction (BID) according to sexual minority youth (SMY) status and describe healthcare utilization patterns by SMY status. Methods: Retrospective data from 107,528 adolescents, who had a Well Check in Kaiser Permanente Northern California in 2016, were used to compare DEB and BID by SMY status. Multivariate logistic models were used to examine the associations of SMY, birth-assigned sex, age, race/ ethnicity, and body mass index on DEB and BID. The utilization of specialized eating disorder (ED) medical and mental health services and general mental health services was described at one Kaiser Permanente Northern California facility. Results: BID was reported in 20,763 (19.3%) adolescents, DEB in 1,458 (1.7%) adolescents, and 5,363 (5%) adolescents identified as SMY. SMY had higher odds of having DEB and BID than non-SMY, respectively (adjusted odds ratio 2.0 95% confidence interval [1.9e2.2] and adjusted odds ratio 3.8 [3.4e4.2]). Regardless of SMY status, adolescents with older age, female sex, nonwhite race, and elevated body mass index had higher odds of ED risk factors. SMY with ED risk factors had higher ED medical utilization than non-SMY with ED risk factors (4.6% vs. 1.6%). However, SMY status was not associated with utilization of specialized ED mental health services. Conclusions: SMY had increased rates of DEB and BID but had underutilization of specialized ED mental health services. Future targeted efforts to prevent eating disorder-related mortality and morbidity for SMY should include targeted eating disorder screening and referral to specialized ED medical and mental health services.
Background As rates of pediatric community-associated (CA) Clostridium difficile infection (CDI) ... more Background As rates of pediatric community-associated (CA) Clostridium difficile infection (CDI) increase, additional research is needed to address rates of infection following common antibiotics. Methods This study was a retrospective review of the electronic health records of all children with stool specimens sent for C difficile from January first 2012 – December 31st2016 at Kaiser Permanente Northern California. Children with clinical symptoms consistent with CDI, confirmatory laboratory testing, no other identified causes of diarrhea, and community associated disease were defined as cases. Using outpatient and ED antibiotic prescription records for children, incidence rates were calculated for subsequent CA CDI for the most commonly prescribed antibiotics. Results Of 507 primary CDI cases in our cohort, 327 had any antibiotic use 2012–2015. There were 205 primary CDI cases that were preceded by an antibiotic in the previous 1–365 days. Many of these patients had more than 1 ant...
OBJECTIVES: To describe the initial clinical response and care escalation needs for children with... more OBJECTIVES: To describe the initial clinical response and care escalation needs for children with urinary tract infections (UTIs) resistant to third-generation cephalosporins while on discordant antibiotics. METHODS: We performed a retrospective study of children <18 years old presenting to an acute care setting of 5 children’s hospitals and a large managed care organization from 2012 to 2017 with third-generation cephalosporin-resistant UTIs (defined as the growth of ≥50 000 colony-forming units per mL of Escherichia coli or Klebsiella spp. nonsusceptible to ceftriaxone with a positive urinalysis). We included children started on discordant antibiotics who had follow-up when culture susceptibilities resulted. Outcomes were escalation of care (emergency department visit, hospital admission, or ICU transfer while on discordant therapy) and clinical response at follow-up (classified as improved or not improved). RESULTS: Of the 316 children included, 78% were girls and the median a...
Euclidean distance from primary zip code centroids to the institution was 17.5 miles (IQR 7.86-25... more Euclidean distance from primary zip code centroids to the institution was 17.5 miles (IQR 7.86-25.44), and median network travel distance was 20 miles (IQR 11.66 e 32.58). Subjects who traveled an estimated network distance greater than 17.5 miles from their primary residence to the institution were 74% more likely to be lost to follow-up (HR 1.74; p 0.005; 95% CI [1.18-2.57]). Similarly, older subjects were 10% more likely to be lost to follow-up for each one-year increase in age (HR 1.096; p 0.016; 95% CI [1.01-1.18]). In contrast, subjects with a co-morbid psychiatric diagnosis were 49% less likely to be lost to follow-up (HR 0.51; p <0.001; 95% CI [0.36-0.73]), and those with any prior admissions for eating disorder management were 38% less likely (HR 0.62; p 0.014; 95% CI [ 0.43-0.91]). Conclusions: Greater network travel distance and increasing age are associated with loss to follow-up in AYA with eating disorders evaluated at a large children's hospital. History of prior admission and known psychiatric diagnoses were protective against loss to follow-up. To our knowledge, this is the first study to demonstrate an association between network travel distance and loss to follow-up in AYA with eating disorders. Given this along with prior data demonstrating a correlation between distance to care and worsened eating disorder severity at presentation, future studies should consider the impact of distance to care on long-term outcomes. Sources of Support: None 52.
The aim of the study was to estimate the prevalence of sexual minority youth (SMY) within an inte... more The aim of the study was to estimate the prevalence of sexual minority youth (SMY) within an integrated health care system using a standardized questionnaire. Methods: This study assessed SMY status in youth aged 12.5e18 years using a previsit Well Check questionnaire at Kaiser Permanente Northern California facilities in 2016. SMY was defined as selfreported attraction to the same sex or both sexes. Results: A total of 93,817 youth (87.3%) self-reported sexual attraction, and 5% (n ¼ 5,329) of respondents (N ¼ 107,532) identified as SMY: 1.7% were attracted to same sex, and 3.2% were attracted to both sexes. There were youth who responded neither (1.5%) and unsure (2.4%). Females were 2.8 times (95% confidence interval 2.6e2.94) more likely to be SMY than males. SMY status significantly increased with age. Nonwhite youth were significantly less likely to be SMY compared with white youth. Conclusions: This is the first study to examine SMY prevalence in pediatric primary care. Primary care providers can use previsit screening before preventive visits to identify and support sexual minority adolescents, facilitate family acceptance, and promote healthy behaviors with care coordination.
Background: Recurrence of community-associated (CA) Clostridiodes difficile infection (CDI) appro... more Background: Recurrence of community-associated (CA) Clostridiodes difficile infection (CDI) approaches 30%. Studies on risk factors and treatment of choice for pediatric CA-CDI are scarce with variable recommendations. Methods: This was a retrospective cohort study of the electronic health records of children 1-17 years with stool specimens sent for C. difficile at Kaiser Permanente Northern California from January 01, 2012 to December 31, 2016. Children with (1) CA disease, (2) confirmatory C. difficile laboratory testing with no other identified causes of diarrhea and (3) clinical symptoms consistent with CDI were defined as cases. Recurrent CA-CDI was defined using the abovedescribed case criteria and onset of diarrhea within 8 weeks of primary CA-CDI. Results: Of the 7350 children with stool samples sent for C. difficile testing, 408 had primary CA-CDI. Forty-five (11%) experienced a recurrence. Using multivariable logistic regression, inflammatory bowel disease [odds ratio (OR) 7.5; 95% confidence interval (CI): 2.6-21.1] and cancer (OR 6.3; 95% CI: 1.6-24.1) diagnoses were risk factors for recurrent disease. Compared with children of Caucasian race, those with multi/other/unknown race had an OR of 3.03 (95% CI: 1.04-8.82) of recurrence. There was no statistically significant difference in the type or duration of therapy as a predictor for recurrent CA CDI. Six percent of children who received metronidazole were switched to vancomycin due to subjective metronidazole allergy or intolerance or metronidazole treatment failure. Conclusions: Recurrent CA-CDI in children in our population is less common than previously reported. This study supports first-line treatment with the standard, short course metronidazole in most cases of primary CA-CDI.
Background. ESC-R UTIs often have limited oral antibiotic options with some children receiving a ... more Background. ESC-R UTIs often have limited oral antibiotic options with some children receiving a course of intravenous (IV) antibiotics. Our objectives were to determine predictors of long course IV therapy and the association between short-course therapy and UTI relapse. Methods. We conducted a multicenter retrospective cohort study of children <18 years with ESC-R UTIs presenting to an acute care setting of 5 children's hospitals and a large managed care organization from 2012 to 2017. ESC-R UTI was defined as having a urinalysis with positive leukocyte esterase or >5 white cells per high power field and urine culture with ≥50,000 colony-forming units per milliliter of E. coli or Klebsiella spp. nonsusceptible to ceftriaxone. Children with urologic surgery, immunosuppression and nonrenal chronic conditions were excluded. Long course therapy was defined as ≥5 days and short course as 0-4 days of a concordant IV antibiotic (an agent to which the isolate was susceptible). Relapse was defined as UTI with the same organism within 30 days. Limited oral antibiotic options were defined as nonsusceptibility to amoxicillin-clavulanate, ciprofloxacin, and trimethoprim-sulfamethoxazole. Predictors of long course therapy were determined using mixed effects logistic regression with hospital site as a random effect. Since UTI relapse was a rare outcome, we evaluated the association between short-course therapy and UTI relapse using Fisher's exact test. Results. Of 383 children with ESC-R UTIs, 80% were female, median age was 3 years (interquartile range 0.7-7.8), and 24% had a prior UTI. Forty-five children (12%) received long course therapy and 338 (87%) received short-course therapy. Predictors of long course therapy included age <2 months (adjusted odds ratio [AOR] 61.4, 95% confidence interval [CI] 12.5-302), male sex (AOR 3.0, 95% CI 1.2-7.8), and limited oral antibiotic options (AOR 5.3, 95% CI 2.2-12.6). UTI relapse occurred in 1/45 (2%) children treated with long course therapy and in 3/335 (0.9%) treated with short-course therapy (P = 0.40). Conclusion. Long course IV therapy in children with ESC-R UTIs was more likely in infants <2 months, males and those with limited oral antibiotic options. UTI relapse was rare and not associated with short course/no IV therapy. Disclosures. All authors: No reported disclosures.
Background. For new antibiotics to treat Gram-negative infections, one regulatory pathway include... more Background. For new antibiotics to treat Gram-negative infections, one regulatory pathway includes complicated urinary tract infections (cUTI) clinical trials. Although individual clinical trials comply with regulatory guidelines, they may differ substantially in design and execution. Six recent cUTI trials that supported or are likely to support FDA regulatory review were compared to determine variables that impacted patient selection and outcome parameters. Methods. cUTI trials for six new antibiotics developed to treat multi-drug-resistant Gram-negative infections were obtained from publicly disclosed information including FDA documents, publications, or presentations at scientific meetings. Antibiotics included were: ceftolozane-tazobactam (CTL-TAZ), ceftazidime-avibactam (CTZ-AVI), meropenem-vaborbactam (MER-VAB), cefiderocol, plazomicin, and fosfomycin. Comparison variables included: mMITT sample size, age, % female patients, % acute pyelonephritis, % E. coli and other pathogens at baseline, switch to PO antibiotic, and the non-inferiority margin. Other variables as well as the microbiologic eradication, clinical response, and the combined outcomes will be included in the poster. Results.
How would you handle this case? Answer the challenge questions throughout this article CASE Broke... more How would you handle this case? Answer the challenge questions throughout this article CASE Broken down Ms. E, age 20, is a college student who has had major depressive disorder for several years and a genetic bone disease (osteogenesis imperfecta, mixed type III and IV). She presents with depression, anxiety, and suicidal ideation. She reports recent worsening of her depressive symptoms, including anhedonia, excessive sleep, difficulty concentrating, and feeling overwhelmed, hopeless, and worthless. She also describes frequent thoughts of suicide with the plan of putting herself in oncoming traffic, although she has no history of suicide attempts. Previously, her primary care physician prescribed lorazepam, 0.5 mg, as needed for anxiety, and sertraline, 100 mg/d, for depression and anxiety. She experienced only partial improvement in symptoms, however. In addition to depressive symptoms, Ms. E describes manic symptoms lasting for as long as 3 to 5 days, including decreased need for sleep, increased energy, pressured speech, racing thoughts, distractibility, spending excessive money on cosmetics, and risking her safety--given her skeletal disorder--by participating in high-impact stage-combat classes. She denies auditory and visual hallucinations, homicidal ideation, and delusions. The medical history is significant for osteogenesis imperfecta, which has caused 62 fractures and required 16 surgeries. Ms. E is a theater major who, despite her short stature and wheelchair use, reports enjoying her acting career and says she does not feel demoralized by her medical condition. She describes overcoming her physical disabilities with pride and confidence. However, her recent worsening mood symptoms have left her unable to concentrate and feeling overwhelmed with school. Ms. E is voluntarily admitted to an inpatient psychiatric unit with a diagnosis of bipolar I disorder with rapid cycling, most recent episode mixed. Because of her bone fragility, the treatment team considers what would be an appropriate course of drug treatment to control bipolar symptoms while minimizing risk of bone loss. Which medications are associated with decreased bone mineral density? a) citalopram b) haloperidol c) carbamazepine d) paliperidone e) all of the above The potential risk of fracture presented by class of psychotropic medications Class of drug Lowest risk Moderate risk Highest risk Anticonvulsants Lamotrigine Carbamazepine Phenytoin Valproic acid Antidepressants Maprotiline Amitriptyline Citalopram Mirtazapine Desipramine Fluoxetine Tranylcypromine Doxepin Fluvoxamine Nefazodone Imipramine Nortriptyline Paroxetine Trazodone Sertraline Venlafaxine Antipsychotics Aripiprazole lloperidone Haloperidol Asenapine Lurasidone Paliperidone Clozapine Olanzapine Risperidone Quetiapine Typical Ziprasidone antipsychotics (all) Lithium May be protective but evidence is insufficient The authors' observations Osteogenesis imperfecta is a genetic condition caused by mutations in genes implicated in collagen production. As a result, bones are brittle and prone to fracture. Different classes of psychotropics have been shown to increase risk of bone fractures through a variety of mechanisms. Clinicians often must choose appropriate pharmacotherapy for patients at high risk of fracture, including postmenopausal women, older patients, malnourished persons, and those with hormonal deficiencies leading to osteoporosis. …
Journal of Pediatric and Adolescent Gynecology, 2015
To determine the awareness of, access to, and knowledge of the proper use of emergency contracept... more To determine the awareness of, access to, and knowledge of the proper use of emergency contraception pills (ECPs) among uninsured adolescents. Anonymous surveys were used to assess awareness of, knowledge of, and access to ECPs. From 2010 to 2012 at mobile primary care clinic in the San Francisco Bay Area. Patients were uninsured adolescents aged 13 to 25; 40% of the participants were currently or had been homeless in the past year. Ethnicity was 50% Asian, 22% Hispanic, 17% Pacific Islanders, 5.5% white, and 5.5% other/mixed ethnicity. Post survey completion, patients received one-on-one 15-minute dedicated ECP education. Awareness of, knowledge of, and access to ECPs. Of the study population of 439, 30% of the participants were 13-16 years old and 70% were 17-25 years old (mean age 17.8 years); 66% were women. Young women (86%) reported higher rates of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;hearing about emergency contraception&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; than did young men (70%) (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001). Many incorrectly identified or were uncertain if ECPs were an abortion pill (40%) or could be used as regular birth control (40%) or to prevent sexually transmitted infections (19%). Only 40% of women and 43% of men aged 17 and older correctly answered that they could obtain EC over the counter; 72% did not know that males could receive EC for use by their partner; 12% incorrectly selected that infertility was a side effect; 44% were under the false impression that EC had to be taken within 1 day of unprotected sex. Uninsured adolescents have high rates of ECP awareness but low ECP knowledge. These adolescents need more ECP education to alleviate misconceptions and increase practical knowledge, specifically, education about male access, side effects, over-the-counter availability for young men and women, and the 120-hour window of use.
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