Role of metabolic CO2 production in ventilatory response to steady-state exercise.

We examined the role of metabolic CO2 production in the hyperpnea of muscular exercise by comparing the response of alveolar ventilation to moderate levels of exercise with the response to venous infusion of CO2 at rest. Studies were performed in four awake sheep that were trained to run on a treadmill. The sheep had been cannulated for veno-venous extracorporeal perfusion so that CO2 could be infused into the peripheral venous blood through membrane lungs in the perfusion circuit. The sheep breathed room air through an endo-tracheal tube inserted through a tracheostomy, and samples of expired gas were collected for measurement of the rates of CO2 production and O2 consumption. All measurements were made in the steady state. In each of the four sheep, the relationship between alveolar ventilation and the rate of CO2 production could be described by a single linear function (r greater than 0.99; P less than 0.001), regardless of whether CO2 production was increased by exercise, venous CO2 infusion, or combinations of both procedures. This relationship applied for values of CO2 production up to 350% of control. In contrast, no unique relationship was found between the rate of alveolar ventilation and either the rate of O2 consumption, cardiac output, or mixed venous blood gas pressures. The findings indicate that the hyperpnea of mild to moderate steady-state exercise can be attributed to the associated increase in the rate of CO2 production. Therefore, there is no need to invoke obligatory nonmetabolic stimuli to account for the ventilatory response to steady-state exercise.

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.

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.

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.

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.

Pseudomonas aeruginosa empyema in an adult with cystic fibrosis.

Pseudomonas aeruginosa is frequently grown from the sputum of adults with cystic fibrosis-related bronchiectasis. A rare case of pseudomonal empyema is reported in this clinical setting. Early diagnosis permitted successful treatment with closed needle aspiration and intravenous antibiotics.

Changes in airway resistance during sleep onset.

Ventilation is lower during sleep than wakefulness. An increase in airway resistance has been proposed as the critical factor. As the change in ventilation has been shown to occur abruptly at transitions between alpha and theta electroencephalogram activity, it was of interest to determine whether the increase in airway resistance between wakefulness and sleep also occurs at these transitions. Three young healthy male subjects were run for an average of 15 sleep onsets in each of three conditions. The three conditions were 1) an esophageal balloon was put in place to allow the measurement of airway resistance, 2) in addition to an esophageal balloon the nose was occluded, and 3) there was no esophageal balloon and the nose was not occluded. Ventilation and airway resistance were measured during sleep onset and analyzed as a function of arousal state. In those conditions of the experiment in which airway resistance was affected by state, the changes, like those in ventilation, occurred at transitions between alpha and theta electroencephalogram activity. However, in the three subjects studied, the magnitude of ventilatory changes at alpha-theta transitions and the extent to which changes in ventilation were associated with changes in airway resistance differed between subjects. It was concluded that although inspiratory airway resistance is a major component affecting the state-related changes in ventilation at sleep onset, the degree of its contribution may vary over individuals.

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.

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.

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.

Pediatric asthma deaths in Victoria: the mild are at risk.

Previous reviews of pediatric asthma mortality have mostly been from hospital-based clinic populations and suggest that only those with severe asthma are most at risk. This report summarizes an investigation, by interviewer-administered questionnaire, into the circumstances surrounding the death in all patients aged 20 years or less who died from asthma in the State of Victoria over a 3 year period from May 1, 1986. During this period, 51 deaths due to asthma were reported. Thirty-three percent of these were judged to have a history of trivial or mild asthma, and 32% had no previous hospital admission for asthma. However, 36% were judged to have had severe asthma, 43% were taking regular inhaled beclomethasone or sodium cromoglycate, and 10% were taking regular oral steroids. Twenty-two percent had a previous admission to an ICU. Death occurred outside hospital in 40 (78%) subjects. In the final attack 63% had sudden onset and collapse within minutes, 12% were found dead, and 25% had acute progression of an established attack. The investigators assessed 39% of the deaths to have had potentially preventable elements. The preventable factors included: inadequate assessment or therapy of prior asthma (68%), poor compliance with therapy (53%), and delay in seeking help (47%). The majority of subjects in this survey could not be classified as "high risk." Therefore, clinicians should ensure that all young patients with asthma are aware of optimal maintenance management, can recognize deteriorating asthma, and follow a clear individualized crisis plan.

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.

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.

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.

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.

Atrial natriuretic factor during hypoxia and mild exercise.

The effect of hypoxia on plasma atrial natriuretic factor (ANF), plasma renin activity (PRA), and plasma aldosterone concentration (PAC) was evaluated during 2 h of treadmill exercise at 2 km/h, 0 grade at sea level. Six male subjects exercised on 2 separate days during normoxia (21% O2) and hypoxia (13.3 +/- 0.3% O2). No significant changes in ANF or PRA occurred during either normoxic or hypoxic exercise. However, PAC fell significantly during normoxic exercise (17.5 +/- 3.6 vs. 12.7 +/- 2.6 ng/dl, p less than 0.05) but not during hypoxic exercise. Serum potassium concentration fell during hypoxic exercise (5.0 +/- 0.1 vs. 4.4 +/- 0.1 mmol/l, p less than 0.05) along with bicarbonate (27.8 +/- 0.7 vs. 25.8 +/- 0.6 mmol/l, p less than 0.01). Between normoxic and hypoxic studies there was a significantly higher heart rate during hypoxic exercise (78 +/- 5 vs. 90 +/- 6 b/min, p less than 0.01). The major conclusion of this study is that hypoxia resulting in arterial oxygen saturations of 81 +/- 0.7% does not affect plasma atrial natriuretic factor levels during mild exercise in normal male subjects.

Factors in childhood as predictors of asthma in adult life.

OBJECTIVE: To determine which factors measured in childhood predict asthma in adult life. DESIGN: Prospective study over 25 years of a birth cohort initially studied at the age of 7. SETTING: Tasmania, Australia. SUBJECTS: 1494 men and women surveyed in 1991-3 when aged 29 to 32 (75% of a random stratified sample from the 1968 Tasmanian asthma survey of children born in 1961 and at school in Tasmania). MAIN OUTCOME MEASURES: Self reported asthma or wheezy breathing in the previous 12 months (current asthma). RESULTS: Of the subjects with asthma or wheezy breathing by the age of 7, as reported by their parents 25.6% (190/741) reported current asthma as an adult compared with 10.8% (81/753) of subjects without parent reported childhood asthma (P < 0.001). Factors measured at the age of 7 that independently predicted current asthma as an adult were being female (odds ratio 1.57; 95% confidence interval 1.19 to 2.08); having a history of eczema (1.45; 1.04 to 2.03); having a low mild forced expiratory flow rate (interquartile odds ratio 1.40; 1.15 to 1.71); having a mother or father with a history of asthma (1.74 (1.23 to 2.47) and 1.68 (1.18 to 2.38) respectively); and having childhood asthma (1.59; 1.10 to 2.29) and, if so, having the first attack after the age of 2 (1.66; 1.17 to 2.36) or having had more than 10 attacks (1.70; 1.17 to 2.48). CONCLUSION: Children with asthma reported by their parents in 1968 were more likely than not to be free of symptoms as adults. The subjects who had more severe asthma (especially if it developed after the age of 2 and was associated with reduced expiratory flow), were female, or had parents who had asthma were at an increased risk of having asthma as an adult. These findings have implications for the treatment and prognosis of childhood asthma, targeting preventive and educational strategies and understanding the onset of asthma in adult life.

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.

Is it asthma?

A patient assessment with history, physical examination and simple tests of air flow limitation will usually allow the primary care physician to make the correct diagnosis and to commence treatment. Nevertheless, the diagnosis of asthma is not always easy and the author discusses approaches to adults if the diagnosis of asthma is uncertain.