Effectiveness of Virtual Reality Interventions for Adolescent Patients in Hospital Settings: Systematic Review.

BACKGROUND: Given the high level of interest and increasing familiarity with virtual reality among adolescents, there is great potential to use virtual reality to address adolescents' unique health care delivery needs while in hospital. While there have been reviews on the use of virtual reality for specific health conditions and procedures, none to date have reviewed the full scope of virtual reality hospital interventions for adolescents who are often combined with children as a homogenous group, despite the fact that adolescents experience virtual environments different from children. OBJECTIVE: The aim of this review was to systematically identify available evidence regarding the use of virtual reality interventions for adolescent patients in hospital settings to evaluate effectiveness, suitability, and safety and identify opportunities for future research. METHODS: PubMed, PsycINFO, Medline, and Scopus databases were searched using keywords and phrases. Retrieved abstracts (n=1525) were double screened, yielding 276 articles for full-text screening. Of these, 8 articles met inclusion criteria. Data were extracted to a standardized coding sheet, and a narrative synthesis was performed due to the heterogeneity of the studies. RESULTS: Four RCTs and 4 single-case reports were identified for inclusion, all of which aimed to reduce pain or anxiety. The scenarios targeted were burn pain, venipuncture, chemotherapy, preoperative anxiety, and palliative care. Three out of 4 RCTs found significant reductions in pain or anxiety outcomes measures when using virtual reality compared to standard care or other distraction techniques; however, only 1 study combined self-reported experiences of pain or anxiety with any physiological measures. Single-case reports relied primarily upon qualitative feedback, with patients reporting reduced pain or anxiety and a preference for virtual reality to no virtual reality. CONCLUSIONS: Virtual reality can provide a safe and engaging way to reduce pain and anxiety in adolescents while in hospital, particularly when virtual reality software is highly immersive and specifically designed for therapeutic purposes. As VR becomes more accessible and affordable for use in hospitals, larger and more diverse studies that capitalize on adolescents' interest in and aptitude for virtual reality, and on the full range of capabilities of this emerging technology, are needed to build on these promising results. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42020198760; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020198760.

A double-blind randomized controlled trial of oxytocin nasal spray in Prader Willi syndrome.

Individuals with Prader-Willi syndrome (PWS) have a significant reduction in the number of oxytocin-producing neurons (42%) in the hypothalamic paraventricular nucleus. A number of animal studies and observations of humans show that lesions in this region can produce PWS-like symptoms. Given the evidence for potential oxytocin deficiency, we tested the effects of a course of intranasal oxytocin on PWS symptoms. Thirty individuals with PWS aged 12-30 years participated in an 18-week randomized double-blind placebo-controlled crossover trial. Participants received 8 weeks of oxytocin and 8 weeks of placebo with a minimum 2-week washout period. The first 11 participants received the following oxytocin doses: 24 IU (twice daily) B.I.D for participants 16 years and over and 18 IU B.I.D for participants 13-15 years. The dose was increased for the remaining 18 participants to 40 IU B.I.D for participants 16 years and over and 32 IU B.I.D for 13-15 years. Measures used to assess changes were standardized well-accepted measures, including the Developmental Behavior Checklist-Monitor, Parent, Teacher, and Adult; The Yale-Brown Obsessive Compulsive Scale; The Dykens Hyperphagia questionnaire; Reading The Mind in the Eyes Test; Epworth Sleepiness Scale and the Movie Stills. Oxytocin had little impact on any measure. The only significant difference found between the baseline, oxytocin, and placebo measures was an increase in temper outbursts (P = 0.023) with higher dose oxytocin. The lack of effect of oxytocin nasal spray may reflect the importance of endogenous release of oxytocin in response to exogenous oxytocin.

Adolescent and young adult medicine is a special and specific area of medical practice.

Adolescent and young adult medicine is a concept that has gained traction in the last decade or so. The medical literature has come primarily from oncology. Advances in neuroscience that document continuing brain development into the third decade, and research that shows risk behaviours associated with adolescence both remain and may increase in the third decade, have been two of the drivers in the conversation around linking these two age groups together as a medical practice group. A third driver of importance is transition care in chronic illness, where older adolescents and young adults continue to have difficulties making effective linkages with adult care. The case for specific training in adolescent and young adult medicine, including the developmental concepts behind it, the benefits of the delineation and the particular challenges in the Australian health-care system, are discussed. On balance, there is a strong case for managing the health issues of adolescents and young adults together. This scenario does not fit easily with the age demarcations that are in place in acute care facilities. However, this is less the case in community services and can work in focused private practice. Such a situation suggests that both paediatric and adult physicians might be interested in adolescent and young adult medicine training and practice.

Adolescent chronic fatigue syndrome and somatoform disorders: a prospective clinical study.

AIM: To examine and compare the presenting characteristics and the change in the physical and psychosocial functioning of adolescents with chronic fatigue syndrome (CFS) or somatoform disorders who have received an adaptable multidisciplinary intervention over a 12-month period. METHODS: Fifty adolescents presenting to the Complex Adolescent Clinic at The Children's Hospital at Westmead, Sydney, Australia were assessed. Their physical and psychosocial functioning was rated by the adolescents and their parents using the Child Health Questionnaire. Participants were assessed at baseline, 4 months and 12 months after initiating treatment. Analyses examined whether diagnosis and/or illness precipitants were related to treatment outcome. RESULTS: Adolescents with both CFS and somatoform disorders demonstrated improvement in physical and psychosocial functioning over the first 4 months of treatment, sustained at 12-month follow-up. A diagnosis of CFS was associated with poorer physical functioning over time and a trend towards a longer illness time course compared with somatoform disorder. Adjustment for a physical precipitant reduced the association between diagnosis and physical functioning. Those who had a physical precipitant to their illness had significantly poorer physical functioning over time than those who did not, regardless of diagnostic category. Diagnosis and physical precipitant were not associated with psychosocial functioning. CONCLUSIONS: Improvement in adolescent physical and psychosocial functioning over time suggests that a multidisciplinary treatment model may be effective for varied complex medico-psychosocial presentations, irrespective of diagnosis and illness precipitant. Illness precipitant may have a greater influence on treatment outcome than diagnostic category.

The health diagnoses of homeless adolescents: a systematic review of the literature.

BACKGROUND: Homelessness during adolescence impacts negatively upon young people's physical and mental wellbeing. To be effective, programs aimed at addressing the health needs of this population must include knowledge of both the presenting and underlying acute and chronic conditions that characterise this high risk group of youth. METHODS: We undertook a systematic review of the international literature for studies that used validated instruments and techniques to diagnose prevalence rates of physical and mental health disorders in homeless adolescents. RESULTS: Twenty-one studies fulfilled the selection criteria. Of these, nine studies examined mental health diagnoses including depression, post-traumatic stress disorder, anxiety and substance abuse disorders. With one exception, the remaining twelve studies all related to sexually transmitted infections. CONCLUSION: Homeless adolescents are diagnosed with widely varying rates of mental health disorders and high rates of sexually transmitted infection. Other likely chronic and acute physical conditions appear to be neglected in the published research.

Sustaining dignity? food insecurity in homeless young people in urban Australia.

ISSUE ADDRESSED: Food insecurity is recognised as an increasing problem in disadvantaged and marginalised groups. The aim of this study was to investigate issues associated with food insecurity and nutrition in young people experiencing, or at risk of, homelessness in metropolitan Australia. METHODS: Eight focus group discussions were conducted with 48 young people (aged between 15 and 25 years) in specialist homelessness services in central and south-western Sydney. RESULTS: Participants described daily experiences of food insecurity, persistent hunger and poverty. Structural barriers to food security and nutrition were identified and included poverty and reduced physical access to fresh foods. Participants also described a desire to save time, for convenience and to be socially connected. Despite the hardships and the chaos of youth homelessness, the groups were defined by their strength of character, resilience and hope for the future. CONCLUSION: Homeless young people within central and south-western Sydney report varying degrees of food insecurity, despite being supported by specialist youth homelessness services. SO WHAT? A collaborative, multistrategic approach with youth participation is required to further enhance the capacity of youth services to improve food security, food access and the availability of nutritious foods for homeless young people. A greater focus on advocacy and policy action is also required to bring food security and nutrition to the forefront of national efforts to improve the health and welfare of disadvantaged groups.

Adolescence and young adulthood: an untapped window of opportunity for obesity prevention.

Adolescence and young adulthood (AYA) are formative life stages, second only to the first 1000 days. Yet young people have historically been 'forgotten' in our health system. Major health risk factors, like adolescent obesity, have largely been left untreated, resulting in significant chronic disease burdens and health costs later in life. In Australia, strategies to address obesity have primarily been implemented disjointedly by different jurisdictions of government, which has meant that obesity responses across the country have been piecemeal. Current state-based interventions show modest effects on improving weight-related behaviours. Major fiscal and regulatory measures have yet to be implemented despite demonstrable public health benefits and public support. The new National obesity strategy 2022-2032, which recognises the importance of engaging with youth, is a welcomed approach to coordinating obesity prevention Australia-wide. The challenge remains to ensure that meaningful AYA engagement is followed through with future interventions. The digitalisation of society poses future health challenges for AYA because of the likelihood of greater physical inactivity and ease of access to junk foods.

Hypoglycemia in cystic fibrosis during an extended oral glucose tolerance test.

BACKGROUND: Hypoglycemia in cystic fibrosis (CF), in the absence of glucose-lowering therapies, has long been identified as an important issue in the management of CF. There is currently still no unifying hypothesis for its etiology. AIM: The aims of this study were to perform a 3-h oral glucose tolerance test (OGTT) in participants with CF and (1) document glucose, insulin, glucagon, glucagon-like-peptide-1 (GLP-1), and glucose-dependent insulinotropic peptide (GIP) release patterns within varying glucose tolerance groups during the OGTT; (2) determine the prevalence of hypoglycemic during the OGTT; and (3) define any association between hypoglycemia and patterns of insulin, glucagon, GLP-1, and GIP release. METHODS: Eligible participants attending an adult CF clinic completed a 3-h OGTT. Hypoglycemia on OGTT was defined as mild (glucose 3.4-3.9 mmol/L), moderate (glucose 3.1-3.3 mmol/L), and severe (glucose ≤ 3 mmol/L). Hormones were measured at fasting, 30, 60, 120, and 180 min. RESULTS: Twenty-four participants completed the study, of which 7 had normal glucose tolerance, 12 had abnormal glucose tolerance, and 5 had cystic fibrosis related diabetes (CFRD). All participants had a delayed insulin response compared with normative data. All glucose tolerance groups showed appropriate and similar suppression of fasting glucagon. Four participants (17%) had mild hypoglycemic, three (13%) had moderate hypoglycemic, and eight (33%) had severe hypoglycemic. No participant with CFRD demonstrated hypoglycemic. Of the 19 participants without CFRD, 15 (79%) experienced hypoglycemic. Participants with hypoglycemic had greater peak glucose and insulin responses than those that did not have hypoglycemic, and this approached significance (p = .0625 for glucose and p = .0862 for insulin). No significant mean differences between GLP-1 and GIP release were found. There was no relationship between hypoglycemic and modulator therapy. CONCLUSION: Postprandial hypoglycemic was unmasked by the extension of an OGTT to 3 h. Delayed and abnormal insulin release, and ineffective counter-regulatory action of glucagon may have a role in its etiology.

Dietary intake in cystic fibrosis and its role in glucose metabolism.

BACKGROUND: Dietary intervention in cystic fibrosis (CF) has historically focused on high-energy diets to address malnutrition, with little attention on diet quality. With increased survival, CF complications such as impaired glucose tolerance (IGT) and cystic fibrosis related diabetes (CFRD) have increased in prevalence. In the absence of consensus on the management of IGT, the role of dietary intake, specifically carbohydrate quality, requires consideration. AIMS: The aims of this study were to: 1) determine nutritional quality of dietary intake at an adult CF clinic and compare this to the Australian Dietary Guidelines 2) explore relationships between dietary intake, including glycaemic index (GI) and glycaemic load (GL), and glucose response variables using continuous glucose monitoring (CGM). METHODS: Adults attending a Sydney hospital were recruited to undergo CGM for five-seven days and record dietary intake using a food record over the CGM period. The relationship between variables of dietary intake, including GI and GL and variables of glycaemic response, including mean amplitude of glycaemic excursions (MAGE), percentage of time in hyperglycaemic and euglycaemic range, were determined. RESULTS: Eighteen participants completed the study with 87 full days of dietary and CGM data. Dietary intake was higher than recommendations in the Australian Dietary Guidelines in relation to grains and protein foods and only slightly higher in saturated fat. Bivariate correlations showed dietary GI was significantly positively associated with percentage of time in hyperglycaemic range. Dietary GL was significantly associated with SD, MAGE and percentage of time in euglycaemic range on CGM. Results remained significant when controlled for energy intake in partial correlation analyses. CONCLUSIONS: This study suggests GI and GL may be important dietary factors influencing glucose metabolism in CF. Further studies exploring low GI or GL diets as a dietary intervention in CF are the next step.

Association between Obesity and Omega-3 Status in Healthy Young Women.

Omega-3 polyunsaturated fatty acids (n-3 PUFAs) are essential for healthy development and protect against metabolic disease. However, individuals with obesity may be pre-disposed to experiencing lower n-3 PUFA status than normal-weight individuals. This cross-sectional study examined the relationship between the omega-3 index (O3I), body mass index (BMI) and dietary intake in healthy young women (n = 300; age = 18-35 y), a group not previously focused on. Intake was adjusted for energy using the residuals method, and associations were explored using independent t-tests and Pearson's correlations. Participants with obesity were found to have significantly lower O3I than normal-weight participants (p < 0.0001); however, no significant differences were observed in mean n-3 PUFA intakes. Even so, energy-adjusted intakes of n-3 PUFAs, with the exception of alpha-linolenic acid, were significantly correlated with O3I. This study demonstrates that O3I is influenced by both BMI and diet in young women; however the relationship between these two variables may be complex. Current intakes of n-3 PUFA observed in young women may not be effective in achieving target O3I levels in those with obesity, and further research is needed to find effective ways of improving n-3 PUFA status in a group already at increased risk of metabolic disease.

Hypoglycaemia in cystic fibrosis: An analysis of a single centre adult cystic fibrosis clinic.

BACKGROUND: Hypoglycaemia in cystic fibrosis (CF) is known to occur during oral glucose tolerance tests (OGTT) and continuous glucose monitoring, however demographic, clinical and mechanistic data are limited. The aims of this study were to review patient electronic medical records (EMR) in order to 1) describe patient characteristics of a university teaching hospital CF clinic, 2) determine the prevalence of hypoglycaemia on OGTT and explore associations with demographic and clinical characteristics, and 3) explore patient reported symptoms suggestive of hypoglycaemia documented in the EMR. METHODS: Adults who attended the RPA CF clinic between January 2009 to April 2016 were included in the study. The prevalence of hypoglycaemia on OGTT was determined and clinical and demographic data were compared to age, sex and glucose tolerance matched controls. Reported symptoms suggestive of hypoglycaemia documented in EMR were qualitatively explored. RESULTS: Hypoglycaemia on OGTT was prevalent in 25 (3 fasting and 22 reactive) of 169 patients who had an OGTT. They were heavier, less likely to have pancreatic insufficiency and had a lower insulin response at 2-h. Another 14 patients reported symptoms suggestive of hypoglycaemia in their EMR. No patient appropriately suppressed insulin at 2-h on OGTT. CONCLUSIONS: This study identified two potentially different presentations of hypoglycaemia occur in different clinic sub-populations. Knowledge gaps in the aetiology and triggers of hypoglycaemia remain.

Association between Haem and Non-Haem Iron Intake and Serum Ferritin in Healthy Young Women.

Iron is an essential micronutrient for human health and inadequate intake may result in iron deficiency (ID) or iron deficiency anaemia (IDA). Unlike other recent studies investigating iron status in young women, this cross-sectional study analysed dietary intake and biochemical data from healthy young (18-35 years) women (n = 299) to determine the association between both haem iron (HI) and non-haem iron (NHI) intakes and serum ferritin (SF). Dietary restraint and possible inflammation secondary to obesity were also measured and accounted for, and energy intake was adjusted for using the residuals method. Independent samples t-tests and chi-squared tests were performed, and factors found to be significantly different between iron replete (IR) and ID/IDA participants were analysed using general linear modelling. ID/IDA participants consumed significantly lower total energy than iron replete (IR) (p = 0.003). Lower energy intake was also associated with higher levels of dietary restraint (p = 0.001). Both HI and NHI were positively associated with SF with HI was found to be a stronger predictor (ß = 0.128, p = 0.009) than NHI (ß = 0.037, p = 0.028). The study demonstrates that intake of both HI and NHI, as well as adequate dietary energy, are associated with normal iron status levels in young women, and that restrained eaters may be at greater risk of low iron status.

Adolescent overweight and obesity--how best to manage in the general practice setting.

BACKGROUND: The prevalence of overweight and obesity continues to increase in adolescents. Community level management is necessary as specialist services are limited. OBJECTIVE: This article outlines a management plan for the overweight adolescent in general practice, using a chronic care approach and follows the National Health and Medical Research Council Clinical practice guidelines for the management of overweight and obesity in children and adolescents. DISCUSSION: Overweight and obesity will not resolve spontaneously at puberty, and active intervention is required both to improve current health and wellbeing and to reduce the risks of premature morbidity and mortality in adult life. Modest, cumulative changes to lifestyle together with modest weight loss goals to reduce the risk of weight rebound are important. Any intervention has to take account of the rapid cognitive and behavioural changes of adolescence.

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.

Hypertriglyceridemic waist as a screening tool for CVD risk in indigenous Australian women.

Research has demonstrated that the simultaneous determination of waist circumference and fasting plasma triglyceride (TG) concentrations can identify men characterized by a metabolic triad of unconventional risk variables: increased levels of fasting insulin, apolipoprotein (apo) B, and a predominance of small, dense, low density lipoprotein (LDL) particles. The aim of this study was to assess the efficacy of using "hypertriglyceridemic waist" to identify individuals at high risk of CVD in a sample of indigenous Australian women, for whom 2 of the 3 non-traditional risk factors were measured (apo B and insulin). Subjects (N=80) were divided into subgroups on the basis of waist girth and TG levels. The TG/HDL ratio increased in women with both elevated waist (above 95 cm) and TG levels (above 2.0 mmol/L), who were also characterized by lower HDL and elevated LDL concentrations. Although there was no trend toward an increase in apo B with increasing waist girth and TG levels, apo B concentration was highest among subgroups with elevated waist and TG levels. Fasting insulin levels were higher with increasing waist girth, but not with increasing TG levels. Utilizing hypertriglyceridemic waist as a marker of high plasma insulin and apo B can be an important factor in assessing cardiovascular risk in indigenous Australian women, despite an unexpected apo B distribution.

Low glycaemic index dietary interventions in youth with cystic fibrosis: a systematic review and discussion of the clinical implications.

A systematic review was conducted to assess what is known about the effect of low glycaemic index (GI) diets on glycaemic control, weight and quality of life in youth with cystic fibrosis (CF). Eligibility criteria were systematic reviews, randomised and non-randomised trials of low GI dietary interventions in CF. Outcomes examined were glycaemic control, quality of life, anthropometry and respiratory function. Reference lists were manually searched and experts in the field were consulted. Four studies met the eligibility criteria; two were excluded because they did not include data on any of the outcomes. The remaining two were studies that examined GI secondary to any other intervention: one used GI as a factor in enteral feeds and the other incorporated low GI dietary education into its treatment methodology. There is insufficient evidence to recommend use of low GI diets in CF. Since there is evidence to support use of low GI diets in type 1, type 2 and gestational diabetes, low GI diets should be tested as an intervention for CF. The potential risks and benefits of a low GI diet in CF are discussed.

Obesity and nutrition in adolescents.

Adolescence is a period of life that encompasses rapid physical growth and dramatic psychosocial change. Over the centuries, humans have evolved an energy balance system that is biased toward fat storage. Obesity has become the most prevalent nutritional concern in adolescents, and clearly it has a complex etiology that includes both genetic and lifestyle aspects. The greatest impact of overweight and obesity in adolescents is the appearance of related physical and psychosocial comorbidity and the tracking of these into adulthood. Thus, there is a strong imperative to treat adolescent overweight and obesity before lifestyles become entrenched and significant comorbidity intervenes. Anorexia nervosa, at the opposite end of the weight spectrum, exhibits many older evolutionary traits that attempt to protect against undernutrition. Iron and vitamin D deficiencies are common in adolescents, both of which have important nutritional aspects.

Childhood obesity in Australia remains a widespread health concern that warrants population-wide prevention programs.

Recent reports have suggested that the problem of childhood and adolescent obesity has been exaggerated in Australia, and that community-wide obesity prevention initiatives are not warranted; we argue that this is not an accurate reflection of the situation. Available data indicate that obesity affects 6%-8% of Australian schoolchildren, and that the proportion has continued to increase in recent years. Childhood and adolescent obesity is associated with a wide range of immediate health concerns, as well as increasing the risk of disease in adulthood. Some weight-related health problems are also found in overweight children. A range of strategies, including whole-of-community obesity prevention programs, will be required to tackle this problem. Concerns about disordered eating in children and adolescents should not preclude appropriate action on childhood obesity.