Health issues in adolescents' Internet use - benefits and risks.

The Internet has turned during the past decade into a major information resource in various domains of life and a communication venue among adolescents who seek health information via the net. The increasing availability of computers in homes, as well as wireless Internet access, means that adolescents today can go online anywhere, at any time. The media are not the leading cause of any major health problem, but they do contribute significantly to a variety of adolescent health problems, including aggressive behavior, sexual activity, drug use, obesity, sleep disorders, eating disorders, depression, suicide and self harm. This paper focuses on 3 major health issues in adolescents' Internet use: Body image and eating behaviors; sexuality and reproductive health behaviors; and self harm and suicidal behavior. This paper also demonstrates Internet venues where reliable health information is provided to young people by health professionals. Health professionals need to recognize the hazards of adolescents Internet use, and to address potential Internet abuse when encountering adolescents in clinical settings.

Legal and ethical issues in adolescents' health care.

This review examines confidentiality, consent to health care and research involving adolescents in regard to legal and ethical aspects. Adolescents are more likely to seek health care if their provider assures confidentiality, but in providing confidential care a balance should be considered between the needs of the adolescent patient, parents, and provider. The vast majority of countries set the legal age at 18, but from the age of 14 years adolescents' capability for medical decision-making may be considered already similar to adult capacity. Instead of chronological age of consent, permission for consent must take into consideration the adolescent's capacity for understanding the medical treatment or the research in which the adolescent is requested to be involved. At all circumstances adolescent's assent for both medical treatment and research is always mandatory. Involving adolescents in research should be based on a careful assessment of risks and benefits together with understanding of the developing capabilities of the adolescent.

Sexuality in young people with physical disabilities: theory and practice.

Sexuality and sexual function are important to persons with disabilities just as they are to their able-bodied counterparts, but knowledge about sexual and reproductive health (SRH) among persons with disabilities is frequently inadequate. Adolescents and young adults with physical disabilities are less active socially, and have difficulties in developing intimate relationships. Thus, despite greater needs for SRH education and service delivery than persons without disabilities, dedicated services regarding sexuality and physical disabilities are scantly reported. Together with a literature survey on sexuality and disability in adolescents, a unique comprehensive SRH service for young people with physical disabilities is described in this review. Despite being interdisciplinary, the utilization of the service was limited due to difficulties in transportation to the clinic and in finding escort for aid in accessibility to public transportation. Health authorities should provide the resources for the development of accessible comprehensive multidisciplinary SRH services dedicated to young people with disabilities, and thus fulfill the United Nations General Assembly declaration on the rights of persons with disabilities.

Minding the gap: training in adolescent medicine when formal training programmes are not available.

There is a growing need for healthcare professionals to extend their knowledge in adolescent health care. Formal training curricula in adolescent medicine have been developed in only the United States, Canada and Australia. The Israeli experience in building an infrastructure that allows physicians to train in adolescent medicine is described. It includes the development of hospital-based and community-based multidisciplinary adolescent health services, a 3-year diploma course in adolescent medicine and a simulated patient-based programme regarding communication with adolescents. In the course of one decade an infrastructure has been developed to create a cadre of physicians who are able to operate adolescent clinics and to teach adolescent medicine. Consequently a formal fellowship training programme in adolescent medicine has been recently approved by the Scientific Council of the Israel Medical Association. This model can be applied in countries where formal training programmes in adolescent health care are not yet available.

Simulated-patient-based programs for teaching communication with adolescents: the link between guidelines and practice.

Adolescents frequently tend not to share personal issues with their health care providers, thus communication with the adolescent patient and frequently also with his or her parents requires unique skills on behalf of the physician. Guidelines for obtaining information regarding adolescents' risk behaviors and other psychosocial issues that have been developed, do not provide the necessary tools for optimal communication with adolescents. Communication skills are best obtained in role-play models where either colleagues or actors simulate the patients' roles. Simulation-based medical education offers a safe and "mistake forgiving" environment that enables consideration of the trainees' needs, without the use of real patients that is associated with traditional bedside teaching. Training programs to improve physicians' communication skills with adolescents have been developed at the Israel Center for Medical Simulation (MSR). Between 2003 and 2007, 470 physicians were trained at MSR in 40 one-day courses. These courses dealt with common adolescent health issues that require unique communication skills on behalf of the clinician, utilizing the simulated-patient-based programs. At each training day up to 12 physicians were exposed to 8 typical adolescent health related scenarios simulated by professional actors in rooms equipped with video facilities and one-way mirrors. Following the encounters with the simulated patients, the different scenarios were discussed in debriefing group sessions with experienced facilitators utilizing the encounters' video recording. Feedbacks from participants in the programs were excellent, emphasizing the need to include simulation-based programs in physicians' training curricula.

[Criteria for hospitalization of adolescents with anorexia nervosa according to postmodernistic approach].

The increased incidence of eating disorders in the Western world raises the demand for discussion regarding recommendations for hospitalization of adolescents with these disorders. The American Psychiatric Association has established criteria for hospitalization that include physiological, psychological and social components. The societal and professional discussion regarding adolescent hospitalization is frequently based on obvious assumptions and accepted discourses, such as the hierarchical pattern in the medical model, the control perception, knowledge ownership, freedom of choice, etc. These issues challenge the discussion on the hospitalization of adolescents with eating disorders. Eating disorders involve dimensions of control, boundaries, and psychological space, which are the essence of the difference between therapy in hospital or in the community. Personality and personal patterns, as well as associated psychopathology, family structure and other factors influence these dimensions and the ability of teenagers to be helped by the professional frameworks approached by them. This manuscript raises questions in relation to issues regarding hospitalization based on conflicts unique to eating disorders.

Sleep patterns in children and adolescents with functional recurrent abdominal pain: objective versus subjective assessment.

AIM: To document objective sleep patterns of children and adolescents with functional recurrent abdominal pain (RAP), and to compare them with subjective sleep assessments and sleep patterns of healthy controls. METHODS: Subjective sleep reports and sleep habit assessments were obtained from 25 adolescents with functional RAP and from 15 age- and gender-matched healthy volunteers, and were compared with continuous movement monitoring using the Actigraph for 7 consecutive days. RESULTS: Abdominal pain before falling asleep was a unanimous complaint in the RAP group, with 29% reporting awakening from sleep by the pain. Only 25% of RAP patients assessed their sleep quality as good, compared with 87% of the control group. Objective sleep patterns measurements of the RAP patients were similar to those of the control group as well as to measurements observed in a large population of school-aged children and adolescents. CONCLUSION: This study of a small group of children and adolescents with functional RAP provides objective evidence that their sleep patterns do not differ from those of normal peers, despite their subjective complaints.

Pitfalls in communication with adolescents.

During adolescence much of the relevant information can be obtained from the youngster, thus direct communication with the adolescent patient becomes essential. This review presentation includes principles of communication methods with adolescents, emphasizing the need for a development oriented approach. The main part of the discussion regards pitfalls in communication that frequently occur during encounters of physicians with adolescents. The pitfalls are divided into two groups: 1) Pitfalls related to the patient, such as over-protective parents, uncooperative or shy patients, shy patients, oppositional and aggressive adolescents, and repulsive patients. 2) Solutions for overcoming these pitfalls are suggested.

Training physicians in communication skills with adolescents using teenage actors as simulated patients.

Role-play exercises with simulated patients may serve the purpose of training professionals to develop appropriate communication skills with adolescents. Authentic adolescent responses toward the physicians may be achieved by actors who themselves are in their teenage years. We describe our experience in continuing medical education programmes for primary care physicians aimed at improving their skills in communicating with adolescents, using simulation methodology with teenage actors. Eight 16-17-year-old actors from the drama department of a high school for the arts were trained to simulate 20 cases with characteristic adolescent medical problems, as well as confidentiality issues and home and school problems. The actors performed in front of large groups of 20-30 paediatricians, family practitioners, or gynaecologists in continuing medical education. Diagnostic issues as well as therapeutic and management approaches were discussed, while the actors provided feedback to the trainees about their understanding and their feeling regarding the issues raised during the exercises. Normally, smaller learning groups are more suitable for such training purposes; nevertheless the participants could appreciate learning the principles of careful listening, a non-judgmental approach and assuring confidentiality. A collaboration of medical schools and postgraduate programmes with high schools which have drama departments may be fruitful in the teaching of adolescent medicine with special emphasis on communication skills with teenagers.

Attitudes and practices of Israeli physicians toward adolescent health care: a national survey.

PURPOSE: To assess practices and attitudes of Israeli physicians with regard to adolescent health. METHODS: Questionnaires were sent to a sample of 1050 Israeli physicians specializing in pediatrics (P) family practice (FP), and internal medicine (IM). They were requested to report their experience, perceived skills, and desire for further training regarding 16 adolescent health items grouped under four topics: medical, sexuality, risk behavior, and psychosocial problems. A scoring system was applied to assess their report. Attitudes toward confidentiality in the same topics were also surveyed. RESULTS: Questionnaires were received from 306 (29%) physicians, of whom 42% were P, 35% were FP, and 29% were IM. The majority (96%) of respondents included adolescents in their practice, and adolescents comprised 33%, 17%, and 11% of the registered patient population of the P, FP, and IM, respectively. The mean scores for practice, perceived skills, and desire for further training were generally low. Analysis of variance revealed significant differences among the three physicians groups in all surveyed topics, resulting from the low scores of the IM group. A diversity regarding confidentiality was noted, in that younger FP were most willing to keep health issues confidential. CONCLUSIONS: Physicians in Israel have limited experience and perceive themselves to be underskilled in dealing with adolescent health issues. Training programs in adolescent health need to be developed to meet the needs of physicians in Israel.

The role of the capnography head-up tilt test in the diagnosis of syncope in children and adolescents.

OBJECTIVES: To evaluate the role of the capnography head-up tilt test (CHUTT) in the diagnosis of syncope in pediatric patients. METHODS: The CHUTT is a head-up tilt test with concomitant capnometry. Hyperventilation on CHUTT was diagnosed when the patient's end-tidal carbon dioxide pressure (ETPCO2) was

The clinical significance of rigors in febrile children.

UNLABELLED: The objective of the study was to evaluate the significance of rigor as a predictor of bacterial infection in hospitalized febrile infants and children. One hundred febrile children with rigor were studied and compared to 334 febrile matched controls without rigor. All underwent clinical evaluation and appropriate laboratory investigations. The patients were then divided into "bacterial" and "non bacterial" infection groups, as defined in the text. It was demonstrated that 66% of the patients with rigor belonged to the bacterial infection group versus 50% in the non-rigor group (P < 0.005). There was a significantly greater yield of positive blood cultures in the patients with rigor (P < 0.04), especially those over the age of 1 year (P < 0.015). The only laboratory examination of potential value as a predictor of bacterial infection in children with rigor was the band count. An absolute band count of more than 1500/mm was significantly more frequent in the rigor group (P < 0.003), and the combination of a rigor and band count of more than 1500 increased the relative risk for a bacterial infection by a factor of 1.35. These data demonstrate that rigor in hospitalized febrile infants or children significantly increase the likelihood of bacterial infection. CONCLUSION: Although the absence of rigors in febrile children does not exclude bacterial aetiology, their presence significantly increase the probability of an infection requiring appropriate workup and a reader institution of antibiotic therapy.

The capnography-tilt test for the diagnosis of hyperventilation syncope.

We describe the capnography tilt test (CTT) for the diagnosis of hyperventilation syncope. The CTT is a 10-min supine, 30-min head-up tilt test with simultaneous monitoring of end-tidal PCO2 (ETPCO2). Hyperventilation (HV) was defined as ETPCO2 < or = 25 mmHg. Hyperventilation syncope (HV syncope) was defined as loss of consciousness with ETPCO2 < or = 25 mmHg and no significant drop in blood pressure. Four groups of patients had the CTT: group I (n = 14), patients presenting with syncope who during a prior tilt test had lost consciousness without concomitant fall in blood pressure; group II (n = 50), syncope, primary evaluation, no prior tilt test done; group III (n = 20), generalized anxiety disorder, no syncope; group IV (n = 80), arterial hypertension, no syncope. Hyperventilation was found in 11/14 patients in group I, 5/50 in group II, 7/20 in group III, and none in group IV; HV syncope was diagnosed in seven patients, all in group I. None of the parameters measured in the evaluation, including ETPCO2, predicted HV syncope on tilting. The mechanisms of resting HV and HV during tilt are not well understood. We confirm the existence of HV syncope. The tilt test should probably be used to screen patients presenting with syncope, with the CTT reserved for patients who lose consciousness during the tilt test without an associated fall in blood pressure, as HV is not always clinically obvious.

The adolescent parturient: a study of an Israeli population.

The aim of this study was to describe the frequency and characteristics of adolescent deliveries and to identify issues that might require intervention, in Haifa District, which is the third largest in Israel. The specific objectives were to assess the prevalence of 15-19-year-old parturients in the district, to characterize the younger (15-17-year) age group for demographics and educational status as well as for pregnancy and delivery progress, to describe the newborn babies of these mothers, and to compare the Jewish and Arabic subpopulations within the younger group for these parameters.

PIP: The frequency and characteristics of adolescent deliveries in Israel were investigated through a review of the records of 195 young women 15-17 years of age who gave birth during 1984-88 at the 3 main hospitals in Haifa district. The mean number of annual deliveries by teenagers 15-19 years of age in this district was 321, corresponding to a fertility rate of 19 live births/1000 female adolescents. 57.7% of the 15-17 year old mothers were Jewish and 38.6% were Moslem. At delivery, only 11% were attending school and two-thirds were married. All the husbands/partners were older than 19 years. 76% of the pregnancies did not have any accompanying health problems and 87% were full-term births. The birth weight distribution was similar to that recorded for infants of non-adolescent women. There were 3 deaths: 2 stillbirths and 1 death of a premature infant. The relatively favorable pregnancy outcomes in this cohort in part reflect the availability of free prenatal care in Israel and its utilization by 97% of the population, regardless of educational level. The promotion of school attendance for Israeli girls who have dropped out of school is recommended to reduce pregnancy in this age group.

A school-linked health service for adolescents in Jerusalem.

This paper describes the Adolescent Health Service (AHS) and its multidisciplinary, school-linked, community-based adolescent health clinic located in a western neighborhood of Jerusalem. Files of the first 134 adolescents who completed or discontinued treatment in the clinic during the first two years of operation were reviewed for demographic data, referral source, number of visits, health concerns and clinical impressions. The clinic population included Jewish Jerusalem residents, ages 12-18, 75% of whom were female. Most referrals came from schools. The average number of visits per patient was five (range 1-20). The most frequent presenting concerns as well as the most frequent clinical impressions were in the psychosocial and nutritional domains. Concordance between presenting concern and clinical impression was 61% (k = 0.47). Health problems of Israeli high school students attending the clinic mainly were psychosocial and nutritional. The school-linked health service applied a comprehensive approach to the biopsychosocial needs of adolescents, not addressed at other health services.

PIP: In Jerusalem, Israel, a community-based comprehensive adolescent health center was established in 1989 to promote health among the students of 11 secondary and high schools; to provide multidisciplinary health care within a community-based, school-linked clinic; to serve as a professional training facility; and to establish a research database. The service is accessible during after-school hours, confidential, and free to adolescent residents of Jerusalem. To evaluate the service, data from the first 134 adolescents treated during the first 2 years of service were analyzed to determine demographic parameters, referral sources, presenting symptoms (nutritional, psychosocial, sexuality, somatic, or health maintenance), diagnoses, number of patient visits, management approach, duration of follow-up, and termination of contact. It was found that 75% of the patients were girls, and 75% were 14-17 years old. Referrals came from school professionals (60%), parents (11%), primary care physicians (4%), and the adolescents themselves (25%). The patients averaged 5 visits, with 35% being seen only once and 15% more than 10 times. The most frequent presenting complaints were psychosocial and nutritional problems (sexuality was named by only 4.5% of the patients), and concordance between presenting concern and clinical impression was only 61% (with most discordance among those who presented for health maintenance). Most of the youth who attended were from middle- and upper-class families despite the clinic location in a low-to-middle class neighborhood. It was concluded that the clinic had not yet had a major impact on access to health services for most of the teenagers in the city but that it provided a unique service with a multidisciplinary approach that has served as a model for adolescent "non-acute" health care in Israel. The clinic's high drop-out rate was attributed to ambivalent care-seeking behavior and accessibility of primary health care (which, however, fails to address many of the problems addressed by the adolescent clinic).

Medical complications in male adolescents with anorexia nervosa.

PURPOSE: Medical information on male anorectics is scant. We present data on 10 males with anorexia nervosa, who were treated at our Eating Disorders Center during a twelve-year period. METHODS: Retrospective chart review. RESULTS: All patients were malnourished weighing 80% or less of their ideal body weight with a mean B.M.I. of 13.5 +/- 2.0. Height below the 50th percentile was evident in 80% of the patients, and was below the 10th percentile in 30% of the patients. Structural brain changes on brain computerized tomography scans were noted in seven out of nine patients and more than 50% had mild anemia relative to the Tanner stage. Other findings included a mean presenting heart rate of 68.3 +/- 17: four out of ten patients had presenting heart rates of 80 or greater and of these, three had serious medical problems and were severely malnourished. Two patients had cardiac complications and one had a life-threatening electrolyte disturbance. CONCLUSION: Despite the small number of patients, the proportion of male adolescent anorectics with medical abnormalities seems high, and may be due to difficulties in establishing the diagnosis and delay in seeking medical attention. Patients who had heart rates of 80 or greater were perhaps sicker and further along in their development of congestive heart failure, thus explaining their initial relative tachycardia. We suggest a higher index of suspicion for congestive heart failure and closer medical monitoring when a malnourished adolescent with anorexia nervosa presents with relatively elevated heart rates.

Indirect calorimetry in the nutritional management of eating disorders.

The caloric prescription, a key component of the nutritional therapy of anorexia nervosa (AN) and bulimia nervosa (BN), may be empirically prescribed, or based on predicted resting energy expenditure (REE), yet adaptive changes in the metabolic rate may render both methods unreliable. Indirect calorimetry measurement of fasting REE was obtained in 32 patients with AN (n = 21) or BN (n = 11). Predicted REE was calculated according to the Harris-Benedict equation, and empiric caloric prescriptions were made by experienced physicians. In the AN group, mean measured REE was significantly lower than predicted REE (p = .00). The empiric caloric prescription was, as intended, significantly higher than the measured REE, but the two methods correlated significantly (r = .53, p < .05). The predicted REE overestimated caloric needs but was also highly correlated with measured REE (r = .69, p < .001). By regression analysis, measured REE could be calculated from predicted REE as follows: measured REE (Kcal/day) = (1.84 x Harris-Benedict predicted REE) - 1,435. In the BN group, mean measured REE was not significantly different from the empiric caloric prescription (p = .09) but was significantly lower than the Harris-Benedict predicted REE (p = .022). Neither correlated with measured REE in BN. Therefore, in BN indirect calorimetry is the only reliable method for determining caloric needs. In AN indirect calorimetry remains the preferred method, but when not available, we recommend the above equation to determine resting energy requirements.