Medical record review of deaths, unexpected intensive care unit admissions, and clinician referrals: detection of adverse events and insight into the system

AIMS AND METHODS

To determine whether a programme of continuous medical record review of deaths, unexpected intensive care unit (ICU) admissions, and admissions referred by medical and nursing staff for specific review, would provide a range of adverse events from which to gain insight into the healthcare system of a large paediatric referral hospital. A quality assurance programme was commenced in 1996.

RESULTS

Over a six year period there were 103 255 admissions; 1612 (1.6%) records were reviewed, from which 325 adverse events were detected. Events were associated with operations, procedures and anaesthesia (56.5%), diagnosis and therapy (24%), drug and fluid management (12.6%), and system issues (7%). Medical records were reviewed from 23 of the 28 clinical units. Review of the records and analysis of the adverse events triggered many system changes.

CONCLUSIONS

The findings suggest that continuous medical record review may be a valuable method for the detection of adverse events and identifying system issues in children's hospitals.

Life events and early onset depression: cause or consequence?

BACKGROUND

Adverse life events prior to episodes of depression are assumed to play a causal role. Earlier studies have, however, not adequately controlled for the potential confounding effects of previous depression.

METHOD

A two-phase study was nested within a six-wave population based cohort study of 1947 adolescents. Interviews at two assessment phases with the CIS-R and CIDI were used to generate ICD-10 diagnoses of depressive disorder. Life events with longer-term contextual threat were reported for the 6 months before first diagnosis and categorized on the basis of participant appraisal as negative and neutral/positive in effects. Previous depressive and anxiety symptoms were measured 6 months earlier.

RESULTS

Pre-existing depressive and anxiety symptoms predicted later events, increasing three-fold the risks for both neutral/positive and negative events in females and increased seven-fold the risk of negative events in males. Life events in turn predicted the onset of depressive disorder independently of previous symptoms. Single negative events held an over five-fold elevated risk and multiple events an almost eight-fold higher risk. Personal threat and loss were associated with disorder in females but not males.

CONCLUSIONS

The findings are consistent with a causal role for life events in early episodes of depression. The association also reflects a reciprocal relationship in which earlier symptoms predict later events, perhaps as a result of an individual's attempts to change unfavourable social circumstances.

Adverse outcomes of alcohol use in adolescents

AIMS

To compare the occurrence of behaviours occurring under the influence of alcohol in 16-17-year-olds and determine associated risk factors for the different behaviours.

DESIGN/SETTING

Cross-sectional survey administered by laptop computers in secondary schools across the state of Victoria, Australia. MEASUREMENT/FINDINGS: The participation rate was 79%. Seventy per cent of participants drank alcohol; 17% of drinkers reported alcohol-related violence (accidents or injuries) and 15% reported problems relating to sex under the influence of alcohol (having sex and later regretting it or having had unsafe sex) in the previous 12 months. Males were more likely to report alcohol-related violence (20% compared to 14% females). Almost one in 10 young people reported having sex while under the influence of alcohol and later regretting it and 10% reported having had unsafe sex. There were no significant gender differences in the reporting rates of alcohol-related sexual risk taking (prop. cum. OR 1.1, 95% CI 0.68-1.9). For alcohol-related injuries, strong independent associations were found with dose of alcohol consumed (prop. cum. OR 2.3, 95% CI 1.3-4.0), frequency of alcohol consumption (prop. cum. OR 2.7, 95% CI 0.94-7.5), antisocial behaviour (prop. cum. OR 2.4, 95% CI 1.4-4.1) and peer drinking (prop. cum. OR 3.3, 95% CI 1.4-8.1). For alcohol-related sexual risk-taking, psychiatric morbidity (prop. cum. OR 4.1, 95% CI 1.9-9.0) and high frequency of alcohol consumption (prop. cum. OR 2.0, 95% CI 0.87-4.6) had strong independent associations.

CONCLUSIONS

Physical injury and high-risk sexual behaviour under the influence of alcohol are common in teenagers. Alcohol-related physical injury appears closely related to patterns of alcohol consumption whereas alcohol-related sexual risk-taking is most closely associated with symptoms of depression and anxiety.

Putting harm reduction into an adolescent context

Drug use is now widespread amongst Australian youth. Substance abuse and dependence are becoming increasingly significant health problems. Approximately 50% of 17-year-old Australians report regular consumption of alcohol and nearly 30% report tobacco smoking. The age of onset of substance use is reported to be decreasing. Between 1993 and 1995 the proportion of heroin users who had used the drug before the age of 16 years increased from 2% to 14%. The debate about youth substance use tends to be polarized between the views of Zero Tolerance and Legalization of drugs. The harm reduction approach spans between these two extremes. Examples of harm reduction strategies, such as education campaigns on safe injecting and needle exchange programs, have been effective in curbing the spread of blood-borne viruses such as HIV amongst intravenous drug using youth. The harm reduction approach, taking social context and developmental stage of the individual into account, may also be applied to adolescents at the less extreme end of the substance use spectrum. It is proposed that the harm reduction framework used in this way enables a rational, relevant and consistent response to contemporary youth substance use, aiming to minimize drug related harm.

Development and validation of the Adolescent Asthma Quality of Life Questionnaire (AAQOL)

Current asthma-specific quality of life questionnaires have major conceptual and methodological deficiencies for use in adolescents. The aim of this study was to develop and validate the "Adolescent Asthma Quality of Life Questionnaire (AAQOL)", specifically developed for adolescents with asthma. One-hundred and eleven adolescents with frequent-episodic or persistent asthma aged 12-17 yrs were recruited from three tertiary paediatric asthma clinics. The standardized multi-step method consisted of: 1) item selection including semistructured interviews (n=14); 2) item reduction and validation (n=66); and 3) assessment of reproducibility (n=31). Item reduction was performed applying the clinical impact method. The 32 item AAQOL covers six domains: symptoms, medication, physical activities, emotion, social interaction and positive effects. There was high internal consistency for the six domains (alpha=0.70-0.90) and for the total score (alpha=0.93). Test-retest reliability was high for all domain scores (r=0.76-0.85) and the total score (r=0.90), indicating high reproducibility of the AAQOL. There was high correlation with the paediatric Asthma Quality of Life Questionnaire (rho=0.81) which focuses primarily on symptoms and emotional well-being. There was weak to moderate correlation with clinical parameters of asthma severity (rho=0.25-0.65). The 32-item Adolescent Asthma Quality of Life Questionnaire is a valid, developmentally age-appropriate and dimensionally comprehensive asthma-specific quality of life measure for use in adolescents.

A CO(2)-Flux Mechanism Operating via pH-Polarity in Hydrilla verticillata Leaves With C(3) and C(4) Photosynthesis

The aquatic angiosperm Hydrilla verticillata lacks Kranz anatomy, but has an inducible, C(4)-based, CO(2) concentrating mechanism (CCM) that concentrates CO(2) in the chloroplasts. Both C(3) and C(4) Hydrilla leaves showed light-dependent pH polarity that was suppressed by high dissolved inorganic carbon (DIC). At low DIC (0.25 mol m(-3)), pH values in the unstirred water layer on the abaxial and adaxial sides of the leaf were 4.2 and10.3, respectively. Abaxial apoplastic acidification served as a CO(2) flux mechanism (CFM), making HCO (3) (-) available for photosynthesis by conversion to CO(2). DIC at 10 mol m(-3) completely suppressed acidification and alkalization. The data, along with previous results, indicated that inhibition was specific to DIC, and not a buffer effect. Acidification and alkalization did not necessarily show 1:1 stoichiometry; their kinetics for the apolar induction phase differed, and alkalization was less inhibited by 2.5 mol m(-3) DIC. At low irradiance (50 mumol photons m(-2) s(-1)), where CCM activity in C(4) leaves is minimized, both leaf types had similar DIC inhibition of pH polarity. However, as irradiance increased, DIC inhibition of C(3) leaves decreased. In C(4) leaves the CFM and CCM seemed to compete for photosynthetic ATP and/or reducing power. The CFM may require less, as at low irradiance it still operated maximally, if [DIC] was low. Iodoacetamide (IA), which inhibits CO(2) fixation in Hydrilla, also suppressed acidification and alkalization, especially in C(4) leaves. IA does not inhibit the C(4) CCM, which suggests that the CFM and CCM can operate independently. It has been hypothesized that irradiance and DIC regulate pH polarity by altering the chloroplastic [DIC], which effects the chloroplast redox state and subsequently redox regulation of a plasma-membrane H(+)-ATPase. The results lend partial support to a down-regulatory role for high chloroplastic [DIC], but do not exclude other sites of DIC action. IA inhibition of pH polarity seems inconsistent with the chloroplast NADPH/NADP(+) ratio being the redox transducer. The possibility that malate and oxaloacetate shuttling plays a role in CFM regulation requires further investigation.

The Gatehouse Project: a systematic approach to mental health promotion in secondary schools

OBJECTIVE

The objective of this paper is to outline the conceptual background and strategy of intervention for a systematic and sustainable approach to mental health promotion in secondary schools.

METHOD

The conceptual origins of the Gatehouse Project are described in terms of the epidemiology of adolescent mental health problems, attachment theory, education reform research and health promotional theory and practice. The elements of health promotional work are described in terms of structural change and priority setting; implementation at multiple levels within the participating schools is described.

RESULTS

The conceptual framework of the Gatehouse Project emphasises healthy attachments with peers and teachers through the promotion of a sense of security and trust, effective communication and a sense of positive self-regard based on participation in varied aspects of school and community life. A school social climate profile is derived from a questionnaire survey of students. An adolescent health team uses this information to set priorities for change within the school. Interventions may focus on the promotion of a positive social climate of the whole school or in the classroom. Curriculum-based health education is also used and based on materials that are relevant to the normal developmental experiences of teenagers. These are integrated into the mainstream curriculum and incorporate a strong component of teacher professional development. Lastly, the intervention promotes linkage between the school and broader community with a particular emphasis on the needs of young people at high risk of school drop-out.

CONCLUSIONS

Educational environments are complex systems undergoing continuous and simultaneous changes. The Gatehouse Project will provide unique information on the relationship between the social environment and the emotional wellbeing of young people. More importantly it outlines a sustainable process for building the capacity of schools to promote the social and emotional development of young people.

The Gatehouse Project: a systematic approach to mental health promotion in secondary schools

OBJECTIVE

The objective of this paper is to outline the conceptual background and strategy of intervention for a systematic and sustainable approach to mental health promotion in secondary schools.

METHOD

The conceptual origins of the Gatehouse Project are described in terms of the epidemiology of adolescent mental health problems, attachment theory, education reform research and health promotional theory and practice. The elements of health promotional work are described in terms of structural change and priority setting; implementation at multiple levels within the participating schools is described.

RESULTS

The conceptual framework of the Gatehouse Project emphasises healthy attachments with peers and teachers through the promotion of a sense of security and trust, effective communication and a sense of positive self-regard based on participation in varied aspects of school and community life. A school social climate profile is derived from a questionnaire survey of students. An adolescent health team uses this information to set priorities for change within the school. Interventions may focus on the promotion of a positive social climate of the whole school or in the classroom. Curriculum-based health education is also used and based on materials that are relevant to the normal developmental experiences of teenagers. These are integrated into the mainstream curriculum and incorporate a strong component of teacher professional development. Lastly, the intervention promotes linkage between the school and broader community with a particular emphasis on the needs of young people at high risk of school drop-out.

CONCLUSIONS

Educational environments are complex systems undergoing continuous and simultaneous changes. The Gatehouse Project will provide unique information on the relationship between the social environment and the emotional wellbeing of young people. More importantly it outlines a sustainable process for building the capacity of schools to promote the social and emotional development of young people.

Randomised controlled trial of an educational strategy to increase school-based adolescent hepatitis B vaccination

OBJECTIVES

This study aimed to evaluate a specifically designed hepatitis B education/promotion curriculum package as part of a successful hepatitis B vaccination delivery system to adolescents.

METHODS

A randomised-controlled trial was used to evaluate the effect of the curriculum package (or intervention) on uptake of vaccine. Schools were randomly selected from the metropolitan region of Melbourne to intervention (66 schools or 7,588 students) or control groups (69 schools or 9,823 students). Class teachers administered the intervention to students over 4 class periods before the vaccination course.

RESULTS

The difference in mean school uptake between intervention and control was small at 1-2% per dose. 95% confidence intervals around the differences were -5% to 2% per dose and not significant. Intervention schools taught an average of 7 items out of 12 from the curriculum package. Immunisation rates increased by 4-10% per dose between low and high implementation schools, but this trend was not significant. Impact evaluation demonstrated significantly greater knowledge of hepatitis B and vaccination among students in the intervention than the control group.

CONCLUSION

Hepatitis B vaccination of pre-adolescents was not increased by the implementation of a curriculum package that successfully increased knowledge and awareness of hepatitis B in a school-based vaccination program. Additional strategies directed at the education of parents, the cooperative role of schools and pro-active providers might also be required to maximise vaccine uptake in this age group.

Effects of an educational intervention for general practitioners in adolescent health care principles: a randomized controlled study

Objective To evaluate the effectiveness of an educational intervention in adolescent health designed for general practitioners, in accordance with evidence-based practice in continuing medical education. Design Randomized, controlled trial with baseline testing and 7- and 13-month follow-ups. Setting The intervention was delivered in local community settings to general practitioners in metropolitan Melbourne, Australia. Participants A total of 108 self-selected general practitioners. Intervention A multifaceted educational program (2.5 hours per week for 6 weeks) in the principles of adolescent health care, followed 6 weeks later by a 2-hour session of case discussion and debriefing. Outcome measures Objective ratings of videotaped consultations with standardized adolescent patients and self-completion questionnaires were used to measure general practitioners' knowledge, skill, and self-perceived competency; satisfaction with the program; and self-reported change in practice. Results 103 of 108 physicians (95%) completed all phases of the intervention and evaluation protocol. The intervention group showed significantly greater improvements than the control group in all outcomes at the 7-month follow-up (all subjects P<0.03), except for the standardized patients' rating of rapport and satisfaction (P=0.12). 104 participants (96%) found the program appropriate and relevant. At the 13-month follow-up, most improvements were sustained, the standardized patients' rating of confidentiality fell slightly, and the objective assessment of competence further improved. 106 physicians (98%) reported a change in practice attributable to the intervention. Conclusions General practitioners were willing to complete continuing medical education in adolescent health and its evaluation. The design of the intervention, using evidence-based educational strategies, proved effective and expeditious in achieving sustainable and large improvements in knowledge, skill, and self-perceived competency.

Evaluation of the effectiveness of an educational intervention for general practitioners in adolescent health care: randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of an educational intervention in adolescent health designed for general practitioners in accordance with evidence based practice in continuing medical education.

DESIGN

Randomised controlled trial with baseline testing and follow up at seven and 13 months.

SETTING

Local communities in metropolitan Melbourne, Australia.

PARTICIPANTS

108 self selected general practitioners.

INTERVENTION

A multifaceted educational programme for 2.5 hours a week over six weeks on the principles of adolescent health care followed six weeks later by a two hour session of case discussion and debriefing.

OUTCOME MEASURES

Objective ratings of consultations with standardised adolescent patients recorded on videotape. Questionnaires completed by the general practitioners were used to measure their knowledge, skill, and self perceived competency, satisfaction with the programme, and self reported change in practice.

RESULTS

103 of 108 (95%) doctors completed all phases of the intervention and evaluation protocol. The intervention group showed significantly greater improvements in all outcomes than the control group at the seven month follow up except for the rapport and satisfaction rating by the standardised patients. 104 (96%) participants found the programme appropriate and relevant. At the 13 month follow up most improvements were sustained, the confidentiality rating by the standardised patients decreased slightly, and the objective assessment of competence further improved. 106 (98%) participants reported a change in practice attributable to the intervention.

CONCLUSIONS

General practitioners were willing to complete continuing medical education in adolescent health care and its evaluation. The design of the intervention using evidence based educational strategies proved an effective and quick way to achieve sustainable and large improvements in knowledge, skill, and self perceived competency.

A computerised screening instrument for adolescent depression: population-based validation and application to a two-phase case-control study

Computer-administered questionnaires have been little explored as a potentially effective and inexpensive alternative to pencil and paper screening tests. A self-administered computerised form of the revised Clinical Interview Schedule (CIS-R) was compared with the Composite International Diagnostic Interview (CIDI) in a two-phase study of 2032 Australian high school students (mean age 15.7 years) drawn from a stratified random sample of 44 schools in the state of Victoria, Australia. Prevalence, sensitivity and specificity were estimated using weighting to compensate for the two-phase sampling. Point prevalence estimates of depression using the CIS-R were 1.8% for males and 5.6% for females--an overall prevalence of 3.2%. Prevalence estimates for depression in the past 6 months using the CIDI were 5.2% for males and 16.9% for females--an overall estimate of 12.1%. The CIS-R had a positive predictive value (PPV) of 0.49 and negative predictive value (NPV) of 0.91 for CIDI depression in the past 6 months. Specificity was very high (0.97) but sensitivity low (0.18), indicating that a majority of those with a CIDI-defined depressive episode in the past 6 months were not recognised at a single screening using the CIS-R. Even so, the CIS-R has proved at least as good as any pencil and paper questionnaire in identifying cases for nested case-control studies of adolescent depression. Further exploration of strategies such as serial screening to enhance sensitivity is warranted.

Young people with spina bifida: transfer from paediatric to adult health care

An expectation of health care for young people with disability is that quality coordinated care continues to be available as they pass from the paediatric to the adult health care system. While individual clinicians provide this service well, the widespread absence of coordinated multidisciplinary care for young people with spina bifida in the adult health care system is a major deficiency. This paper describes the planning and implementation that underpinned the transfer of 10 young people with spina bifida from a paediatric to an adult service. The range of structural, financial and 'cultural' barriers that need to be overcome before patients can be successfully transferred is highlighted; lessons learned from this model may serve to facilitate the development of other transfer services.

Depression, anxiety, and smoking initiation: a prospective study over 3 years

OBJECTIVES

This report considers the extent to which depression and anxiety predict smoking onset in adolescence.

METHODS

A 6-wave cohort design was used to study a sample of 14- and 15-year-old students (n = 2032) drawn from 44 secondary schools in the state of Victoria, Australia. The students were surveyed between 1992 and 1995 with a computerized questionnaire that included a 7-day retrospective diary for tobacco use and a structured psychiatric interview.

RESULTS

Experimental smokers were 29 times more likely than non-smokers to make a transition into daily use in the subsequent 6 months. Depression and anxiety, along with peer smoking, predicted initiation of experimental smoking. Specifically, depression and anxiety accentuated risks associated with peer smoking and predicted experimentation only in the presence of peer smoking.

CONCLUSIONS

The finding that experimental smoking is an overwhelmingly strong predictor of later daily smoking focuses attention on smoking initiation. Depressive and anxiety symptoms are associated with higher risks for initiation through an increased susceptibility to peer smoking influences. Promoting the psychological well-being of adolescents and addressing perceived interpersonal benefits of smoking may play a role in the prevention of adolescent tobacco use.

Changes in growth CO2 result in rapid adjustments of ribulose-1, 5-bisphosphate Carboxylase/Oxygenase small subunit gene expression in expanding and mature leaves of rice

The accumulation of soluble carbohydrates resulting from growth under elevated CO2 may potentially signal the repression of gene activity for the small subunit of ribulose-1,5-bisphosphate carboxylase/oxygenase (rbcS). To test this hypothesis we grew rice (Oryza sativa L.) under ambient (350 &mgr;L L-1) and high (700 &mgr;L L-1) CO2 in outdoor, sunlit, environment-controlled chambers and performed a cross-switching of growth CO2 concentration at the late-vegetative phase. Within 24 h, plants switched to high CO2 showed a 15% and 23% decrease in rbcS mRNA, whereas plants switched to ambient CO2 increased 27% and 11% in expanding and mature leaves, respectively. Ribulose-1,5-bisphosphate carboxylase/oxygenase total activity and protein content 8 d after the switch increased up to 27% and 20%, respectively, in plants switched to ambient CO2, but changed very little in plants switched to high CO2. Plants maintained at high CO2 showed greater carbohydrate pool sizes and lower rbcS transcript levels than plants kept at ambient CO2. However, after switching growth CO2 concentration, there was not a simple correlation between carbohydrate and rbcS transcript levels. We conclude that although carbohydrates may be important in the regulation of rbcS expression, changes in total pool size alone could not predict the rapid changes in expression that we observed.

Quality-of-life assessment in children and adolescents with asthma

Health-related quality of life has become an essential part of health outcome measurement in chronic disorders. However, it is only recently that health professionals have focused on quality-of-life assessment in children and adolescents. Several generic, as well as the asthma-specific quality-of-life instruments specifically designed for use in children and adolescents are reviewed in this article with particular regard to the conceptual and methodological features of the measures and their applicability in clinical studies. The recently published Child Health Questionnaire is a useful generic instrument to comprehensively assess quality of life, in particular when comparing young people with different chronic disorders. The Pediatric Asthma Quality-of-life Questionnaire has shown responsiveness to change over time, but it lacks age-specificity with regard to psychosocial issues and comprehensiveness of quality-of-life assessment. In contrast, the Childhood Asthma Questionnaire provides three different versions for different target ages. However, its generic part is not reflective of the respondent's health status. The other asthma-specific instruments have major conceptual deficiencies when used as a single measure for quality-of-life assessment. In the absence of a single ideal instrument, the use of batteries of quality-of-life instruments is therefore recommended and further research is required to identify the impact that age and developmental status have on quality-of-life assessment.

The course of early smoking: a population-based cohort study over three years

AIMS

To examine the uptake and course of smoking in a representative adolescent cohort.

DESIGN

Six-wave cohort study.

PARTICIPANTS

Secondary school students initially aged 14-15 years at 44 schools in the state of Victoria, Australia.

MEASUREMENTS

Computerized questionnaire including 7-day retrospective recall for tobacco use.

FINDINGS

Prevalence rates for smoking in the past month rose from 25% to 31% and daily smoking 9% to 18% across the 3-year follow-up. Forty-five per cent of the sample smoked at some point but only 18% were daily smokers at the end-point. High rates of short-term cessation were observed for both experimental and daily smokers, but 70% of daily smokers relapsed within 12 months. Occasional smoking at the outset was the strongest predictor of later daily smoking and was also predictive of lower cessation and higher relapse rates. Parental divorce and parental daily smoking were associated with smoking at the outset and parental smoking was strongly predictive of the course of daily smoking. In contrast, prevalence rates of smoking in a subject's school did not significantly predict either smoking initiation or subsequent course. Female daily smokers were half as likely as males to cease smoking, a finding that accounted for gender differences in smoking prevalence in this sample.

CONCLUSIONS

The strength of association between occasional and later daily smoking indicates the importance of primary prevention but the variability in the early course indicates that there should be much scope for promotion of adolescent efforts to quit. Both the diminished likelihood of smoking cessation in young women and parental influences on smoking course deserve further exploration.

Measles-mumps-rubella and hepatitis B vaccination uptake in adolescents: a survey in metropolitan Melbourne

OBJECTIVE

To measure the uptake of preadolescent measles-mumps-rubella (MMR) and adolescent hepatitis B vaccinations and assess the influence of certain demographic factors on the uptake of these vaccines.

DESIGN

Prevalence surveys of uptake rates of preadolescent (school Year 6; age 10-11 years) MMR and adolescent (school Year 9; age 13-14 years) hepatitis B vaccination.

SETTING

City of Darebin, an inner northern metropolitan region of Melbourne, 1996.

SUBJECTS

1160 Year 6 school students (580 boys) and 1102 Year 9 school students (548 boys).

INTERVENTION

School-based vaccination program administered by Darebin Council.

RESULTS

83% of Year 6 students were vaccinated with the MMR vaccine (84.1% of girls and 81.9% of boys). 71.6% of Year 9 students completed the full course of hepatitis B vaccination (68.9% of boys and 74.2% of girls). There was a higher uptake of MMR in non-government primary schools, but no other demographic factors (sex, economic status, non-English-speaking background, parental education, school class size) were associated.

CONCLUSIONS

These uptake rates do not meet National Health and Medical Research Council (NHMRC) recommendations. Further study is required to determine and quantify the factors that affect vaccination uptake in adolescence. Programs may then be developed to improve vaccination uptake.

Regulation and Localization of Key Enzymes during the Induction of Kranz-Less, C4-Type Photosynthesis in Hydrilla verticillata

Kranz-less, C4-type photosynthesis was induced in the submersed monocot Hydrilla verticillata (L.f.) Royle. During a 12-d induction period the CO2 compensation point and O2 inhibition of photosynthesis declined linearly. Phosphoenolpyruvate carboxylase (PEPC) activity increased 16-fold, with the major increase occurring within 3 d. Asparagine and alanine aminotransferases were also induced rapidly. Pyruvate orthophosphate dikinase (PPDK) and NADP-malic enzyme (ME) activities increased 10-fold but slowly over 15 d. Total ribulose-1,5-bisphosphate carboxylase/oxygenase activity did not increase, and its activation declined from 82 to 50%. Western blots for PEPC, PPDK, and NADP-ME indicated that increased protein levels were involved in their induction. The H. verticillata NADP-ME polypeptide was larger (90 kD) than the maize C4 enzyme (62 kD). PEPC and PPDK exhibited up-regulation in the light. Subcellular fractionation of C4-type leaves showed that PEPC was cytosolic, whereas PPDK and NADP-ME were located in the chloroplasts. The O2 inhibition of photosynthesis was doubled when C4-type but not C3-type leaves were exposed to diethyl oxalacetate, a PEPC inhibitor. The data are consistent with a C4-cycle concentrating CO2 in H. verticillata chloroplasts and indicate that Kranz anatomy is not obligatory for C4-type photosynthesis. H. verticillata predates modern terrestrial C4 monocots; therefore, this inducible CO2-concentrating mechanism may represent an ancient form of C4 photosynthesis.

Gas Exchange and C Allocation in Dunaliella salina Cells in Response to the N Source and CO2 Concentration Used for Growth

The halotolerant alga Dunaliella salina was cultured on 10 mM NH4+ or NO3- with air CO2 or 5% (v/v) CO2. Cells grown on NH4+ rather than NO3- were up to 17% larger in volume but had similar division rates. The photosynthetic K0.5 of dissolved inorganic C per cell was reduced, but the light- and CO2-saturated photosynthesis, dark respiration, and light-independent fixation rates were increased. The cells exhibited 2- to 5-fold greater activities of ribulose-1,5-bisphosphate carboxylase/oxygenase, phosphoenolpyruvate carboxylase and carboxykinase, and carbonic anhydrase and more soluble and ribulose-1,5-bisphosphate carboxylase/oxygenase protein. Chlorophyll and [beta]-carotene also increased by 30 to 70%. However, starch and glycerol decreased, indicating that C was reallocated from carbohydrates into protein and pigments by growth on NH4+. Algae cultured on air-CO2 rather than a high CO2 concentration were 44% smaller with 55 to 67% lower cell division rates and thus appeared C-limited, despite the operation of a CO2-concentrating mechanism. Cells cultured on air-CO2 had less protein and starch and 28% more glycerol, but the pigment content was unchanged. In only one growth regime was the cell glycerol concentration sufficient to maintain osmotic equilibrium with the external medium, indicating that an additional osmoticum was required. It appears that the N source, as well as the growth [CO2], substantially modifies photosynthetic and growth characteristics, light-independent C metabolism, and C-allocation patterns of D. salina cells.

Acne in Victorian adolescents: associations with age, gender, puberty and psychiatric symptoms

OBJECTIVES

This study aimed to examine the associations between the frequency and severity of self-reported acne and age, gender, puberty and psychiatric symptoms in Victorian adolescents.

METHODOLOGY

A sample of secondary schoolchildren in Victoria, Australia were surveyed using a computerized questionnaire. Developmental and psycho-social factors associated with acne were recorded and analysed using logistic regression.

RESULTS

The Victorian Adolescent Health Survey (1992) recorded the frequency and severity of self-reported acne in 2491 students. Frequency of acne increased with age and pubertal development. For females commencement of menstruation was associated with increased frequency of acne. Asian born male students were less likely to report acne than Australian born males. Acne severity was coded into mild (students reporting acne sometimes on back or face) and moderate (students reporting acne often on face or back). Students reporting moderate acne were more likely to report a high level of psychiatric symptoms and were in the later stages of puberty.

CONCLUSIONS

This study confirms an association between the frequency and severity of self-reported acne and stage of pubertal development. It showed also that students reporting moderate acne were more likely to report psychiatric symptoms of depression and anxiety.

Adolescent suicidal behaviours: a population-based study of risk

BACKGROUND

Reports of adolescent suicidal behaviour have generally derived from clinical settings but population-based studies are likely to provide a clearer epidemiological view.

METHODS

Non-fatal suicidal behaviours were studied in 1699 Australian 15- to 16-year-old secondary school students at 44 schools in the state of Victoria, Australia. Self-reported episodes of self-harm were characterized using items from the Beck Suicide Intent Scale.

RESULTS

The 12 month weighted prevalence estimate for deliberate self-harm was 5.1%. The commonest forms were self-laceration (1.7%), self-poisoning (1.5%) and deliberate recklessness (1.8%). Self-poisoning and self-laceration were commoner in girls. The prevalence of 'true suicide attempts' was 0.2%. Most self-harmers did not perceive death as likely, plan self-harming episodes at length or inform others of the episodes. Psychiatric morbidity had the strongest association with self-harm, an association which held for all subtypes. Antisocial behaviour and substance abuse were associated with self-harm in girls but not boys. Sexual activity was independently associated with self-harm in both genders.

CONCLUSIONS

Deliberate self-harm was common but the great majority of episodes were not 'true suicide attempts'. It is, therefore, possible that attributable mortality and morbidity may be greater in self-harmers without definite suicidal intent.

Chronic illness in adolescents: transfer or transition to adult services?

It is widely believed that the improved survival of young people with chronic diseases will be associated with the development of appropriate services within the adult healthcare domain. There is, however, little evidence to suggest that this is happening at a rate commensurate with clinical requirements. This paper highlights the multiplicity of barriers that impede the development of transition services to facilitate the transfer of medical care from the paediatric to the adult domain. Different models of transition care are described, and the terms 'transfer' and 'transition' are differentiated. The clinical demand for service development is highlighted, as well as the need for specific research in this area of healthcare delivery.

Caring for the terminally ill adolescent

Terminally ill adolescents, a heterogeneous group, face unique problems in coming to terms with the prospect of death and dying. In parallel, the psychosocial sequelae of a terminal illness in the adolescent, and their effects on the family and health professionals, present unique challenges for management. Using a developmental framework, we examine issues surrounding the care of dying adolescents and present strategies for their management.

Adolescent dieting: healthy weight control or borderline eating disorder?

Dieting in adolescent girls is ubiquitous but its health significance is uncertain. On the one hand it might be seen as promoting healthy weight control and on the other it might be considered as a risk factor for eating disorders. Dieting levels were systematically assessed in a representative group of 2525 Australian teenagers and classified using item response theory. In this group, 38% of girls and 12% of boys were categorised as intermediate dieters; 7% of girls and 1% of boys fell into a group of extreme dieters. Body mass carried a strong positive association with intermediate dieting. Most female dieters, nevertheless, fell within a normal weight range. Psychiatric morbidity was the clearest factor associated with extreme dieting and 62% of extreme dieters reported high levels of depression and anxiety. Extreme dieting might reasonably be viewed as lying on a spectrum with clinical eating disorders. Most dieting is unjustified on the grounds of appropriate weight control and appears to reflect a widespread striving of teenage girls towards body shapes at the lower end of age-adjusted norms.

Childhood asthma and lung function in mid-adult life

The longitudinal lung function data in 286 subjects from a 28 year follow-up of childhood asthma is reported. Airway obstruction in mid-adult life was present mainly in those with moderately severe asthma. Subjects who had been wheeze free for at least 3 years, even if asthma had been persistent in childhood, had normal lung function and no increased bronchial reactivity. Only two subjects, both with persistent asthma from childhood, failed to show an improvement in FEV1 of greater than 10% following inhalation of a beta-adrenergic agonist. Subjects with relatively mild asthma who had not taken inhaled steroids did not appear to be disadvantaged with respect to lung function.

Comparison of oral bambuterol and terbutaline in elderly patients with chronic reversible airflow obstruction

Bambuterol, a carbamate prodrug of terbutaline, is the first once-daily oral beta 2-agonist. The effect/side effect ratio of bambuterol oral solution was compared with terbutaline mixture in elderly patients with chronic reversible obstructive airways disease. The study was of a double-blind, crossover, randomized design and consisted of a 4-7-day run-in period followed by four consecutive treatment periods each of 2 weeks. The treatments were bambuterol solution 20 mg nocte (B20), 10 mg nocte (B10), terbutaline mixture 3 mg t.i.d., (T), and placebo solution (P). Patients measured daily peak expiratory flow rate (PEFR), asthma symptoms, use of inhaled beta 2-agonist, and tremor. Of 84 patients, 66 completed all periods. Mean age was 67 years (60-90), basal FEV1 1.49 L, and reversibility of FEV1 30%. Ninety-four percent of the patients used inhaled/oral steroids in constant dosage. All treatments were significantly more effective than placebo. B20 resulted in higher morning PEFR than T (306 +/- 2.9 L/min vs. 297 +/- 2.9 L/min), while B10 gave equivalent results to T. No differences were seen in the use of inhaled beta 2-agonist. Less shortness of breath was experienced during the night with B20 and during the day with B10 compared with placebo. Both B20 and T produced more tremor than B10 and P. In elderly patients with chronic reversible airways obstruction once-daily bambuterol (10-20 mg) has a better effect/side effect ratio than 3 mg terbutaline thrice daily.

Menarche and the onset of depression and anxiety in Victoria, Australia

STUDY OBJECTIVE

Psychiatric disorder often begins at adolescence. This study aimed to examine the associations between puberty and social circumstances and the adolescent rise in depression and anxiety.

DESIGN

A two stage cluster sampling procedure was used to identify a representative group of Australian secondary school students in years 7 (age 12-13 years), 9 (14-15 years), and 11 (16-17 years) of 45 Victorian schools. The computerised clinical interview schedule (CIS) was used to evaluate psychiatric morbidity.

MAIN RESULTS

A total of 2525 subjects completed the survey - an overall participation rate of 83%. Levels of depression and anxiety increased with the secondary school years and girls had significantly higher rates at each school year level. For boys, the clearest independent associations with depression and anxiety were rising school year level and high parental educational achievement. For girls menarchal status emerged as the strongest predictor. Associations with age and school year level, evident on univariate analysis, did not persist when the recency of menarche was taken into account. After addition of measures of perceived social stress to a multivariate model, a significant association between depression/anxiety and parental divorce disappeared but the association with menarche persisted.

CONCLUSIONS

Menarche marks a transition in the risk of depression and anxiety in girls. The pattern of findings is consistent with a biological mediation of this association.

Computer administration of a school-based adolescent health survey

OBJECTIVE

To examine the utility of notebook computers in the collection of data in large scale surveys.

METHODOLOGY

A notebook computer administered survey of health in adolescents was conducted in 1992 using a multi-instrument questionnaire. Students in school years 7, 9 and 11 in private and government schools in Melbourne and rural Victoria participated.

RESULTS

Parental consent was obtained with an 83% response rate. Each student answered questions directly onto the computer taking an average of 68 min to complete the highly branched confidential but not anonymous questionnaire. Students were presented with on average 33% of the 897 possible questions. Over 90% of students reported enjoying using the computer. Those who reported answering the questions honestly all the time ranged from 68 to 85%, increasing with grade level.

CONCLUSIONS

The use of computers in survey research provides many advantages in data collection including exposure only to relevant questions and the opportunity of asking sensitive questions.

Barriers to effective primary health care for adolescents

OBJECTIVES

To assess general practitioners' (GPs') perceptions of barriers in the health care system that hinder provision of effective adolescent health care; and to assess the training needs of GPs for a future education program in adolescent health issues.

DESIGN

Retrospective questionnaire survey.

METHODS

A 66-item questionnaire was mailed during May and June 1995 to a random stratified sample of 997 rural and urban Victorian GPs. A Practice Assessment Task enabling respondents to fulfil Royal Australian College of General Practitioners' quality assurance requirements was mailed on return of completed questionnaires if requested.

RESULTS

The response rate was 72.4%. After adjusting for stratified sampling, 77% (95% confidence interval [CI], 73%-81%) of respondents favoured individual Medicare cards for adolescents from the age of 16. Thirty-eight per cent (95% CI, 34%-43%) were less willing to charge for longer consultations because they feared Health Insurance Commission (HIC) investigation. Most respondents indicated that their undergraduate training in adolescent mental health issues was inadequate and 64% (95% CI, 61%-68%) found it difficult to obtain advice about complex mental health problems. An interest in continuing medical education in adolescent health issues was expressed by 82% (95% CI, 79%-86%) of respondents.

CONCLUSIONS

Individual Medicare cards should be automatically issued to adolescents from the age of 16 to improve their ability to access health care. Revision of the Medicare rebate system and clarification of HIC's investigative functions may improve GP's effectiveness in adolescent consultations. Undergraduate medical and GP training should include curriculum relevant to adolescent health care.

The association between secondary amenorrhea and common eating disordered weight control practices in an adolescent population

PURPOSE

This study examined the relative importance of low weight, in contrast with other symptoms of eating disorder, as a determinant of amenorrhea.

METHODS

A cross-sectional survey was conducted of students at Year 10 (mean age 15.0 years) attending 43 schools in the state of Victoria. Amenorrhea and symptoms of eating disorder were assessed using the Branched Eating Disorders Test, administered through the medium of a notebook computer.

RESULTS

The survey response rate was 84% (n = 886). A total of 23% (n = 205) reported either fasting or purging in the previous month. Secondary amenorrhea of at least 3 months duration was reported by 4.1% (n = 35). No statistically significant association was found between amenorrhea and body mass index. In contrast, 40% of amenorrheic subjects reported fasting or purging (P = .03), an association most evident in the heaviest subjects.

CONCLUSION

These finding suggests that secondary amenorrhea may develop in normal and above-weight teenagers who engage in eating disordered weight control practices.

The branched eating disorders test: validity in a nonclinical population

OBJECTIVE

To develop an effective measure of the symptoms of eating disorders for use in community surveys.

METHOD

A branched eating disorders instrument for administration by notebook computer was evaluated as a screen in 487 teenage schoolgirls. High scorers and a stratified sample of low scorers were evaluated in a second-stage interview with the Eating Disorders Examination (EDE).

RESULTS

The Branched Eating Disorders Test (BET) proved to have exceptional validity coefficients (sensitivity 100%, specificity 99%, positive predictive value 70%).

DISCUSSION

This pilot validation suggests that the BET largely overcomes the problems of earlier instruments of limited screening utility when applied to community samples.

Is smoking associated with depression and anxiety in teenagers?

OBJECTIVES

An association of smoking with depression and anxiety has been documented in adult smokers. This study examines this association in a representative group of teenage smokers.

METHODS

A two-stage cluster sample of secondary school students in Victoria, Australia, were surveyed by using a computerized questionnaire, which included a 7-day retrospective diary for tobacco use and a structured psychiatric interview.

RESULTS

Subjects reporting high levels of depression and anxiety were twice as likely to be smokers after the potential confounders of year level, sex, alcohol use, and parental smoking were controlled for. Regular smokers were almost twice as likely as occasional smokers to report high levels of depression and anxiety. In a stratified analysis, an association between regular smoking and psychiatric morbidity was found in girls of all ages but for boys only in the youngest group.

CONCLUSIONS

The cross-sectional association is consistent with the use of smoking by teenage girls as self-medication for depression and anxiety. Therefore, future health promotional campaigns might consider strategies that attend to perceived psychological benefits of smoking.

Compliance issues in adolescence: practical strategies

Understanding the process of adolescent development is crucial to engendering good compliance. Successful outcomes can be achieved by approaching adolescents with respect and negotiating with them shared treatment goals. A few simple interventions can help make the issue of compliance in adolescents less problematic.

The prevalence of prodromal features of schizophrenia in adolescence: a preliminary survey

In most cases of schizophrenia the onset of frank psychosis is preceded by a period of prodromal features. This period has been relatively neglected by researchers and is potentially important in promoting early intervention. The prevalence of DSM-III-R schizophrenia prodrome symptoms was assessed as part (n = 657) of a large (n = 2525) questionnaire-based survey of high school students. Individual symptoms were highly prevalent and the prevalence of DSM-III-R prodromes ranged from 10 - 15% to 50%. Despite methodological weaknesses, the data suggest that DSM-III-R prodromal features are extremely prevalent among older adolescents and unlikely to be specific for subsequent schizophrenia. Clinically these features cannot be regarded as sufficient evidence of early schizophrenia and more accurate predictors of incipient schizophrenia need to be defined.

Patterns of common drug use in teenagers

To ascertain current levels of drug use among teenagers and to examine interrelationships in use, a two-stage cluster sample of Victorian secondary school students in years 7 (aged 12 to 13 years), 9 (14 to 15 years) and 11 (16 to 17 years) were surveyed using a questionnaire on computer. Tobacco use and alcohol consumption were evaluated by self-reported frequency of use and seven-day retrospective diaries. Marijuana and coffee consumption were assessed by self-reported frequency of recent use. The questionnaire was completed by 2525, a participation rate of 83 per cent. Tobacco use rose with year, with 24 per cent of young women and 16 per cent of young men in year 11 being regular smokers. Trends across year level for heavier alcohol consumption were also observed, with just under 10 per cent of year 11 students reporting a weekly consumption higher than the current recommended guidelines for adults. Strong interrelationships in drug use were found, with a pattern of association between smoking and drinking consistent with a mutual elevation of risk. Frequent use of tobacco and alcohol had a high risk for associated marijuana use. Coffee consumption carried a significant independent association with regular smoking. Teenage substance use is common and most occurs at low level and frequency. However, for a substantial and increasing minority across the teenage years, high levels of tobacco and alcohol consumption potentially compromise health. Frequent alcohol or tobacco use rather than heavy intermittent consumption is most likely to be associated with concurrent substance use potentially damaging to health.

Adolescent health care: perspectives of Victorian general practitioners

OBJECTIVES

To assess general practitioners' (GPs') views of adolescents as a discrete patient group with specific developmental health care needs; to document GPs' perceived knowledge of and competence in adolescent health care; and to clarify the barriers GPs perceive to effective delivery of such care.

DESIGN

Qualitative research.

METHODS

Stratified sampling generated a sample of 57 GPs from rural and urban divisions of general practice. Focus group discussions and individual interviews were recorded and transcripts were analysed.

RESULTS

Thirty-three GPs (62%) reported that adolescents made up 10% or more of their weekly consultations. Although 10 GPs defined adolescents by developmental criteria, 47 had an incomplete understanding of the developmental aspects of adolescence. Most GPs (43) had some concerns about their knowledge of and competence in delivering adolescent health care and 52 stated that they had had little or no formal training in adolescent health. The participants perceived a range of barriers to effective health care provision, including issues of confidentiality, communication and cost.

CONCLUSIONS

Changes are needed in the Medicare card and rebate systems to ensure improved access to affordable, confidential care for adolescents. Our results also support the incorporation of important adolescent health care issues in undergraduate and postgraduate medical training.

Reproductive health in young women with cystic fibrosis: knowledge, behavior and attitudes

PURPOSE

The improved life-expectancy in cystic fibrosis (CF) results in the fact that the majority of affected young women now survive to face the same reproductive health decisions as other women, in addition to those that specifically relate to CF. The aim of this study was to assess the reproductive health knowledge of women with CF, to investigate the range of their reproductive health problems, and to review their reproductive health attitudes and behaviors.

METHODS

Women aged 18 years and over attending CF services in the state of Victoria, Australia were invited to complete a reproductive health questionnaire. Comparison subjects (n = 76) were enrolled from 2 primary care practices.

RESULTS

Fifty-five women participated (89%), with a median age of 22 years (range 18-50). There was no significant difference in marital status between the two groups and a similar proportion were sexually active, yet women with CF were less likely to use contraception. A majority of women with CF believed that fertility was reduced, and there was poor knowledge of the potentially deleterious effect of pregnancy. A relatively high proportion were planning to become pregnant in the near future. Twenty-two percent had tried to conceive, with a success rate of 67%.

CONCLUSIONS

Women with CF are currently lacking important information about reproductive health that potentially has a major impact on their health and their lives.

The self-image of adolescents with cystic fibrosis

PURPOSE

The changing expectations, therapies and outcomes for young people with cystic fibrosis (CF) necessitate a re-evaluation of the impact of this chronic illness on adolescent development. The aim of this study was to assess the psychological well-being and adjustment of contemporary adolescents with CF.

METHODS

Forty-nine adolescents with CF (24 males, 25 females) aged 14-18 years were enrolled from the Royal Children's Hospital CF Clinic, Melbourne, Australia. The Offer Self-Image Questionnaire was administered to participating subjects whose growth and pubertal developmental and pulmonary function was assessed.

RESULTS

The mean (SD) FEV1% was 82 (21), and mean (SD) National Institute of Health clinical score was 81 (12). There were no significant differences between males and females in pulmonary function or clinical scores, but growth and pubertal development were delayed in both sexes. Females, but not males, with CF were less well-adjusted than their healthy peers. Two-way analysis of variance was performed and showed significant sex differences in sub-scales of the Offer questionnaire numbers I, II, III, VI, VIII, IX, as well as in the total score. Age was significant only for scales II and VIII, and only scale II displayed an interaction between sex and age.

CONCLUSIONS

This study suggests that adjustment and self-esteem are less than ideal in young people with CF, especially females.