Effect of transfer from a pediatric to adult cystic fibrosis center on clinical status and hospital attendance.

AIM: Transfer from pediatric to adult services could lead to clinical deterioration, few studies have examined this. We sought to examine the clinical impact of a structured individualized transition and transfer process in patients with cystic fibrosis (CF). METHODS: Medical records of all patients with CF in Western Australia who transferred from a pediatric center (Princess Margaret Hospital for Children) to an adult CF center (Sir Charles Gairdner Hospital) between 2008 and 2012 were reviewed. Data were extracted for 2 years before and after transfer. The number of CF outpatient visits, inpatient days, and home intravenous antibiotic therapy (HIVT) days were recorded at yearly intervals before and after transfer. Sputum culture results at transfer were collected. All respiratory function and anthropometric data over the 4 years were extracted. RESULTS: Forty-two patients with CF were transferred between 2008 and 2012. The mean age at transfer was 18.9 years (range 17-22). Compared to 1-year pre-transfer, the frequency of outpatient visits at 1- and 2-year post-transfer increased. After transfer, there was no change in BMI, HIVT days, or inpatient days, and no acceleration in the expected decline in FEV1. CONCLUSION: This study found that transfer from a pediatric to an adult CF center using a structured, individualized transition and transfer process was not associated with accelerated clinical deterioration.

Complexities of conducting research in adolescent refugees resettling in Australia.

Adolescent refugees resettling in Australia are a vulnerable and marginalised population. Dedicated research to help better understand their health-care needs remains scarce. There are multiple complexities which may deter health professionals from conducting research with this population. Health-care system barriers, such as lack of adolescent- and refugee-specific health-care services, complicate comprehensive data collection. Limited investigator knowledge pertaining to culturally appropriate research in a population with limited English proficiency or a history of trauma can have an impact on adolescent participation and retention in research studies. Additional ethical and legal issues relating to adolescent consent and confidentiality, which include suicidality and physical or sexual abuse, can arise during research and cause potential harm to adolescents if not managed appropriately. This article highlights current knowledge and understanding relating to these issues along with recommendations to address barriers and safeguard adolescents, with the aim of promoting high-quality research that will benefit resettling adolescent refugees.

Epidemiology of paediatric chronic fatigue syndrome in Australia.

OBJECTIVE: To estimate the paediatrician-diagnosed incidence of chronic fatigue syndrome (CFS) in Australia, and describe demographic and clinical features, as well as approaches to diagnosis and management. METHODS: The Australian Paediatric Surveillance Unit facilitates monthly national surveillance of uncommon conditions seen by paediatricians. Data from young people aged <18 years diagnosed with CFS were collected. Incidence was estimated based on new cases reported from April 2015 to April 2016. RESULTS: A total of 164 cases of newly diagnosed CFS in young people aged 4-17 years were identified for inclusion. The estimated national incidence for children aged 4-9 years was 0.25 per 100 000 per annum. In children aged 10-17 years, the estimated incidence of paediatrician-diagnosed cases for Victoria (17.48 per 100 000) was substantially greater than other Australian states (range 1.31-5.51 per 100 000). Most cases were female and Caucasian, most commonly presenting after an infectious illness with symptoms gradual in onset. The majority were diagnosed at least 13 months after symptom onset. Symptoms, associations, investigations and management strategies were highly variable. CONCLUSIONS: Current findings suggest that, consistent with other countries, the Australian incidence of CFS in children aged <10 years is very low. In contrast, the national incidence of CFS in older children and adolescents (aged 10-17 years) is more unclear, with marked variability between geographical regions apparent. This may be due to variation in service accessibility and clinician understanding of CFS. Accordingly, national initiatives to improve equity of care for children with CFS may be required.

Medical needs of adolescent refugees resettling in Western Australia.

OBJECTIVE: To investigate the medical needs and socioeconomic determinants of health among adolescent refugees resettling in Western Australia. DESIGN: Comprehensive medical and socioeconomic health data of resettling adolescent refugees aged 12 years and above attending a Refugee Health Service over a 1-year period were analysed. RESULTS: Medical records of 122 adolescents, median (range) age of 14 (12-17) years, were reviewed. Socioeconomic vulnerabilities included dependence on government financial support (50%), housing issues (27%) and child protection service involvement (11%). Medical concerns included non-communicable disorders (85%), infectious diseases (81%), nutrition/growth (71%) and physical symptoms of non-organic origin (43%). One quarter (27%) of female adolescents had sexual/reproductive health issues. A median (range) of 5 (2-12) health concerns were identified for each adolescent with 49% requiring referral to subspecialty services. CONCLUSION: Resettling adolescent refugees are socioeconomically vulnerable with a range of medical issues that frequently require additional subspecialty health referrals.

Bullying and mental health amongst Australian children and young people with cystic fibrosis.

Currently, there is little research investigating how schools can support the mental health and social development of young people with cystic fibrosis (CF), given their heightened risk of mental illness. Few studies have examined the relationship between bullying and mental health in populations of children with CF. This study describes the peer bullying experiences of young people with CF, and examines associations between school bullying and the psychological well-being of these young people. A sequential mixed-methods approach was used to collect data from 26 young people with CF (10-16 years of age). These data were compared with large samples of healthy children. Following an online survey, 11 young people, through online focus groups, expanded on the survey findings, describing their experiences within the school environment. Young people with CF reported lower involvement in bullying victimization and perpetration relative to the comparison population. For older adolescents with CF, victimization was associated with less connectedness to school and less peer support, and more school loneliness, anxiety, and depression. Young people with CF reported they generally liked the school environment, and were happy with their friendships, whereas some older adolescents reported that bullying evoked anxiety and mood problems. Reported bullying was primarily verbal and targeted characteristics of their CF, including their coughing, noninvolvement in certain activities because of shortness of breath, use of medication, and being underweight (for boys only). The findings provide some recommendations for interventions to promote mental health and school engagement among young people with CF. (PsycINFO Database Record

Identification of health risk behaviours among adolescent refugees resettling in Western Australia.

OBJECTIVE: Adolescent refugees encounter traumatic stressors and are at risk of developing psychosocial health problems; limited research data exist internationally. This study aims to identify health risk behaviours among adolescent refugees resettling in Western Australia and assess the feasibility of using a standardised adolescent health questionnaire for this purpose. DESIGN: Refugees aged 12 years and above attending a tertiary Refugee Health Service (RHS) were recruited over 12 months. Sociodemographic data were collected. Psychosocial assessments based on the 'Home, Education/Eating, Activities, Drugs, Sexuality, Suicide/mental health' (HEADSS) framework were undertaken utilising interpreters where required. Health concerns identified were managed through the RHS. RESULTS: A total of 122 adolescents (20 ethnicities) participated; 65% required interpreters. Median age (range) was 14 (12-17) years. Most (80%) had nuclear family separation. Almost half (49%) had a deceased/missing family member. A third (37%) had lived in refugee camps and 20% had experienced closed detention. The median time (range) since arrival in Australia was 11 (2-86) months. Every adolescent had at least one health concern identified during the psychosocial assessment. Frequency of health concerns identified in each domain were 87% for home, 66% for education, 23% for eating, 93% for activities, 5% for drugs, 88% for sexuality and 61% for suicide/mental health. Most adolescents (75%) required intervention, consisting of counselling for health risk behaviours and/or referral to health or community services. CONCLUSION: It is feasible to use a standardised adolescent health questionnaire to identify health risk behaviours among a cohort of ethnically diverse adolescent refugees. Use of the questionnaire identified a large burden of psychosocial health issues requiring multidisciplinary intervention.

Opportunistic adolescent health assessment in the child protection unit.

AIM: Adolescent health assessments are recommended to identify health-risk behaviours. Adolescents who experience maltreatment are more likely to engage in such behaviours. This study (i) describes the frequency of health-risk behaviours amongst adolescents attending a hospital-based child protection unit (CPU) and (ii) determines whether use of a health assessment questionnaire increases the identification of these behaviours. METHODS: A retrospective audit was performed of case notes of adolescents (aged ≥ 12 years) presenting to the CPU over 5 years (2007-2011). Data regarding health-risk behaviours were extracted. In 2012, following the introduction of a standardised HEADSS-based four-page questionnaire, health-risk data were collected prospectively over 18 months. The proportion of subjects reporting health-risk behaviours, before and after questionnaire introduction, was analysed. RESULTS: Two hundred fifty-eight subjects, median age 13 (range 12-18) years, 78% female, were included in the pre-questionnaire period; and 85 subjects, median age 14 (range 12-17) years, 86% female, were included following introduction of the questionnaire. Questionnaire use was associated with an increase in the frequency of health-risk behaviours identified in the following domains: Education (odds ratio 4.48 [confidence interval 2.56-7.96] P < 0.001), Activities (16.18 [6.70-42.74] P < 0.001), Drugs/alcohol (4.00 [2.23-7.16] P < 0.001) and Suicidality (8.27 [4.59-14.92] P < 0.001). Participants reported higher rates of health-risk behaviours than the national population. CONCLUSION: Adolescents attending a hospital-based CPU report high rates of health-risk behaviours. A standardised questionnaire results in increased identification of such behaviours.

Health of adolescent refugees resettling in high-income countries.

Adolescent refugees are a vulnerable population with complex healthcare needs that are distinct from younger and older age groups. Physical health problems are common in this cohort with communicable diseases being the focus of attention followed by an emphasis on nutritional deficiencies and other chronic disorders. Adolescent refugees have also often experienced multiple traumatic stressors and are at a heightened risk of developing mental health problems. Navigating these problems at the time of pubertal development adds further challenges and can exacerbate or lead to the emergence of health risk behaviours. Educational difficulties and acculturation issues further compound these issues. Adolescents who have had experiences in detention or are unaccompanied by parents are particularly at risk. Despite a constantly growing number of adolescent refugees resettling in high-income countries, knowledge regarding their specific healthcare needs is limited. Research data are largely extrapolated from studies conducted within paediatric and adult cohorts. Holistic management of the medical and psychological issues faced by this group is challenging and requires an awareness of the socioeconomic factors that can have an impact on effective healthcare delivery. Legal and ethical issues can further complicate their management and addressing these in a culturally appropriate manner is essential. Early identification and management of the healthcare issues faced by adolescent refugees resettling in high-income countries are key to improving long-term health outcomes and future healthcare burden. This review article aims to increase knowledge and awareness of these issues among paediatricians and other health professionals.

Adolescent and young adult medicine in Australia and New Zealand: towards specialist accreditation.

In Australia and New Zealand, a critical mass of academic and clinical leadership in Adolescent Medicine has helped advance models of clinical services, drive investments in teaching and training, and strengthen research capacity over the past 30 years. There is growing recognition of the importance of influencing the training of adult physicians as well as paediatricians. The Royal Australasian College of Physicians (RACP) is responsible for overseeing all aspects of specialist physician training across the two countries. Following advocacy from adolescent physicians, the RACP is advancing a three-tier strategy to build greater specialist capacity and sustain leadership in adolescent and young adult medicine (AYAM). The first tier of the strategy supports universal training in adolescent and young adult health and medicine for all basic trainees in paediatric and adult medicine through an online training resource. The second and third tiers support advanced training in AYAM for specialist practice, based on an advanced training curriculum that has been approved by the RACP. The second tier is dual training; advanced trainees can undertake 2 years training in AYAM and 2 years training in another area of specialist practice. The third tier consists of 3 years of advanced training in AYAM. The RACP is currently seeking formal recognition from the Australian Government to have AYAM accredited, a process that will be subsequently undertaken in New Zealand. The RACP is expectant that the accreditation of specialist AYAM physicians will promote sustained academic and clinical leadership in AYAM to the benefit of future generations of young Australasians.

How is paediatric chronic fatigue syndrome/myalgic encephalomyelitis diagnosed and managed by paediatricians? An Australian Paediatric Research Network Study.

AIM: The diagnosis and management of paediatric chronic fatigue syndrome/myalgic encepnalomyelitis (CFS/ME) represent ongoing challenges for paediatricians. A better understanding of current approaches at a national level is important in informing where research and education could improve treatment outcomes. We aimed to examine current diagnosis and management practices for CFS/ME by Australian paediatricians. METHOD: An online survey was sent to members of the Australian Paediatric Research Network. The primary outcomes of interest included diagnostic criteria used, medical investigations and management practices in paediatric CFS/ME. RESULTS: One hundred seventy-eight (41%) of 430 eligible paediatricians responded, with 70 of the 178 (39%) reporting that they diagnose and manage CFS/ME as part of their practice. Medical investigations used for diagnosis were variable. Conditions that more than half of the paediatricians reported as commonly co-occurring (i.e. present in >50% of cases) included somatisation disorders, anxiety, depression and fibromyalgia. There was wide variation in behavioural and pharmacological management strategies but most paediatricians commonly engaged a school teacher, physiotherapist and/or psychologist as part of their management. CONCLUSION: The diagnostic and management practices of paediatricians for CFS/ME within Australia vary widely. This likely reflects a paucity of paediatric-specific guidelines, together with limited evidence to guide best practice and limited training in this area. There is a need for guidance and education for the diagnosis and management of paediatric CFS/ME in Australia.

Management of urinary tract infection in a tertiary children's hospital before and after publication of the NICE guidelines.

INTRODUCTION: The UK National Institute for Health and Clinical Excellence (NICE) introduced guidelines for the diagnosis, treatment and management of urinary tract infection (UTI) in children and adolescents in August 2007. AIM: The primary aim was to determine whether publication of NICE guidelines was associated with a change in the use of diagnostic imaging investigations in patients with a documented first UTI in a tertiary children's hospital. Secondary aims were to describe the epidemiology, microbiology, prescription of prophylactic antibiotics and follow-up for these children, and the incidence of structural renal tract abnormalities, vesicoureteric reflux and renal uptake defects identified. METHODS: Retrospective review of the case notes of patients presenting to Princess Margaret Hospital, Perth, Western Australia with a first UTI over a 4-year period (August 2005-2009). Details of demographics, radiological investigations, microbiology and follow-up were obtained. Data for subjects presenting before and after 31 August 2007 were compared. RESULTS: Data from 659 subjects, median age 6 (range 0-186) months were analysed. Compared with the pre-NICE period, there was no change in the proportion of patients undergoing renal USS in the 2 years following publication of the guidelines. There was a decrease in the proportion undergoing MCUG (p<0.0001) and receiving antibiotic prophylaxis (p<0.0001) and an increase in the proportion undergoing DMSA (p<0.001). CONCLUSIONS: Practice changed following publication of the NICE guidelines. While the reduction in MCUG requests and prescription of antibiotic prophylaxis is in line with NICE guidelines, the increase in DMSA requests is contrary to the recommendations.

Real medicine.

A substantial part of a paediatrician's work increasingly involves caring for children and young people with mental health, developmental, emotional and behavioural problems. Over time, recognition of these aspects has redefined and broadened the notion of what classically constitutes 'Paediatrics.' This paper discusses the ways in which paediatricians and psychiatrists can support each other in this work. It highlights the role of supervision and specifically advocates for the expansion of consultation/liaison psychiatry services.

Opportunistic adolescent health screening of surgical inpatients.

PURPOSE: Opportunistic health screening has long been promoted by advocates of adolescent health. However, there are few objective data documenting the outcomes in an inpatient setting. METHODS: The authors performed opportunistic health screening on 114 surgical inpatients, median age 14 (range 10-18) years, admitted to a general adolescent ward in a tertiary children's hospital. A four-page paper document with a formatted list of questions, based on the Home, Education, Activities, Drugs, Sexual Health, Suicide framework, was developed to standardise screening and documentation. RESULTS: Areas of concern requiring intervention were identified in 34 (30%) patients. Specific interventions included referrals to the Adolescent Medicine clinic (n=6), Hospital School Services (n=7) and Psychological Medicine (n=7). CONCLUSIONS: Consideration should be given to offer adolescent health screening to all surgical inpatients. Further research should involve the participation of young people and should focus on the outcomes, feasibility, acceptability and resource implications of such screening.

Developing and running an adolescent inpatient ward.

Advocates of adolescent health have long argued for the development of dedicated inpatient units. In the UK, many recently built children's hospitals have included adolescent wards, with further wards actively planned for new builds. In Australia, adolescent wards have been established in all but one of the major children's hospitals and will be a feature of all three new children's hospitals currently being built (in Melbourne, Brisbane and Perth). Despite growing interest in the development of adolescent inpatient facilities, and evidence that they improve quality, there is little in the recent literature to guide those tasked with setting up or running such units. Those who currently operate such wards thus have the regular task of fielding enquiries from colleagues about developing and operating hospital-based services for young people. The aim of this article is therefore to describe our experiences of developing and working on adolescent wards in Australia and the UK, focusing on the ward design, case-mix, staffing requirements and ward philosophy and discussing the benefits and potential disadvantages of a dedicated adolescent ward.

Development of the bronchial epithelial reticular basement membrane: relationship to epithelial height and age.

BACKGROUND: The bronchial epithelium and underlying reticular basement membrane (RBM) have a close spatial and functional inter-relationship and are considered an epithelial-mesenchymal trophic unit (EMTU). An understanding of RBM development is critical to understanding the extent and time of appearance of its abnormal thickening that is characteristic of asthma. METHODS: RBM thickness and epithelial height were determined in histological sections of cartilaginous bronchi obtained postmortem from 47 preterm babies and infants (median age 40 weeks gestation (22 weeks gestation-8 months)), 40 children (2 years (1 month-17 years)) and 23 adults (44 (17-90) years) who had died from non-respiratory causes, and had no history of asthma. RESULTS: The RBM was visible by light microscopy at 30 weeks gestation. RBM thickness increased in successive age groups in childhood; in infants (r=0.63, p<0.001) and in children between 1 month and 17 years (r=0.82, p<0.001). After 18 years, RBM thickness decreased with increasing age (r=-0.42, p<0.05). Epithelial height showed a similar relationship with age, a positive relationship from preterm to 17 years (r=0.50, p<0.001) and a negative relationship in adulthood (r=-0.84, p<0.0001). There was a direct relationship between epithelial height and RBM thickness (r=0.6, p<0.001). CONCLUSIONS: The RBM in these subjects was microscopically identifiable by 30 weeks gestation. It thickened during childhood and adolescence. In adults, there was either no relationship with age, or a slow reduction in thickness in older age. Developmental changes of RBM thickness were accompanied by similar changes in epithelial height, supporting the close relationship between RBM and epithelium within the EMTU.

Adolescent and young adult health in a children's hospital: Everybody's business.

BACKGROUND: To guide the development of adolescent health training and the planning of future services, accurate data describing health service use by adolescents and young adults are needed. AIM: To describe admission rates for adolescents (12-17 years) and young adults (age 18 years and over) attending a specialist children's hospital over an 8-year period. Specific objectives were to describe the (i) proportion of adolescents and young adults admitted under different specialties; (ii) age range, with emphasis on those 18 years and over; and (iii) proportion of patients admitted to the general adolescent ward. METHODS: Data on adolescent and young adult admissions to Princess Margaret Hospital (PMH) were collected prospectively from July 2000 to June 2008. RESULTS: Adolescents and young adults accounted for one fifth (range 18-22%) of all admissions to PMH. Over the 8-year period, the number of adolescent and young adult admissions increased from 3935 (54% males) to 4967 (56% males) per year. The proportion admitted to the general adolescent ward ranged from 22% to 36%. The three specialties admitting the most adolescents and young adults were General Surgery (11-13%), Orthopaedics (11-13%) and Oncology/Haematology (10-14%). The age range was: 12-14 years (57-67%); 15-17 (30-39%); 18+ (2-5%). At least 15 patients aged 20 or over were admitted each year, mostly for Dental or Plastic Surgery. CONCLUSIONS: Adolescent and young adult health is part of the core business of paediatrics. This should be reflected in the planning of future paediatric services. All trainees require some basic training, regardless of heir specialty area.

Early detection of airway wall remodeling and eosinophilic inflammation in preschool wheezers.

RATIONALE: It is unclear when the pathologic features of asthma first appear. We hypothesized that eosinophilic airway inflammation and epithelial reticular basement membrane (RBM) thickening, absent in wheezy infants, would be present in preschool children with severe, recurrent wheeze. OBJECTIVES: To compare RBM thickness and inflammation in endobronchial biopsies (EBs) from wheezy preschool children and age-matched control subjects. METHODS: EBs were obtained from wheezy preschool children (aged 3 mo to 5 yr), undergoing a clinically indicated fiberoptic bronchoscopy. Subjects undergoing fiberoptic bronchoscopy to investigate stridor acted as nonasthmatic controls. RBM thickness was measured and the density of subepithelial, immunologically distinct inflammatory cells was determined and expressed as a volume fraction (%). EBs from 16 children (median age, 29 [7-57] mo) with wheeze confirmed by video questionnaire (confirmed wheezers [CWs]), 14 with reported wheeze (reported wheezers [RWs]) (median age, 17 [8-58] mo), and 10 control subjects (median age, 19 [5-42] mo) were assessed. MEASUREMENTS AND MAIN RESULTS: RBM thickness in the three groups was as follows: CWs: median, 4.6 (range, 2.9-8.0) microm; RWs: median, 3.5 (2.1-5.4) microm; control subjects: median, 3.8 (2.5-4.7) microm. RBM was significantly thicker in CWs than in control subjects (P < 0.05). Eosinophil density was as follows: CWs: median, 1.07% (range, 0.0-3.52%); RWs: median, 0.72% (0.0-2.04%); control subjects: median, 0.0% (0.0-1.05%). Eosinophilic inflammation was significantly greater in CWs compared with control subjects (P < 0.05). There were no between-group differences for any other inflammatory cell phenotype. CONCLUSIONS: The characteristic pathologic features of asthma in adults and school-aged children develop in preschool children with confirmed wheeze between the ages of 1 and 3 years, a time when intervention may modify the natural history of asthma.