Telehealth: experience of the first 120 consultations delivered from a new refugee telehealth clinic.

BACKGROUND: In 2011, the Australian Government introduced Medicare item numbers for telehealth consultations. This is a rapidly expanding method of healthcare provision. AIMS: We assessed the demographic and disease profile of refugee patients attending a new telehealth clinic, and calculated the patient travel avoided. We examined technical challenges and assessed the performance of two videoconferencing solutions using different bandwidth and latencies. METHODS: We audited the first 120 patients attending the telehealth clinic. During consultations, the patient was with the general practitioner (GP) and linked by internet videoconference using VIDYO, GoToMeeting or Skype, to the specialist at a tertiary referral hospital. Travel avoided was calculated and technical problems were assessed by the participating specialist. Bandwidth and latency variations were examined within a university broadband testing facility. RESULTS: The two most frequently managed conditions were hepatitis C and latent tuberculosis. Twenty-nine different GP were included and 42 consultations required an interpreter. Nearly 500 km of travel and 127 kg of CO(2) production was avoided per consultation. Technical issues were faced in 25% of consultations, most frequently sound problems and connections dropping out. A bandwidth of at least 512 kbps and latency of no more than 300 ms was necessary to conduct an adequate multipoint videoconference. CONCLUSIONS: Telehealth using videoconferencing adds a new component to care of refugee and immigrant patients settling in regional areas. Telehealth will be improved by changes to improve simplicity and standardisation of videoconferencing, but requires ongoing Medicare funding to allow sufficient administrative support.

Longitudinal analysis of lung function growth in healthy children and adolescents.

Lung function and height in 242 8-yr-old and 299 12-yr-old children without known or suspected predisposition to lung disease were measured annually over 6 and 8 yr, respectively. Growth of forced expiratory volume in 1 s (FEV1), vital capacity, and expiratory flow after expiring 50% of vital capacity were statistically modeled by age and height by use of a multivariate normal model for longitudinal data. This method has the flexibility to fit an appropriate (not necessarily linear) mathematical description of average lung function while concurrently modeling the covariance between measures on the same individual. Differences in lung function growth between girls and boys, pre- and post-puberty, showed that girls had a steadier though less pronounced increase in lung function with height. In boys, before puberty there was deficit in lung volume relative to height (not evident in girls), which was compensated for by rapid growth after puberty. The standard error of FEV1 predictions based on current height and age were more than halved when measurements of FEV1, age, and height taken 1 yr before were incorporated. We found evidence for dysanaptic growth in childhood. Fitted models have application to early detection of departures from healthy lung function.

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.

Childhood asthma following hospitalization with acute viral bronchiolitis in infancy.

A prospective follow-up of 48 infants hospitalized with respiratory syncytial virus bronchiolitis in the first year of life revealed that 44 of these infants had symptoms suggestive of asthma in the 5 years following their initial illness (cumulative prevalence 92%). Symptoms became less frequent and less troublesome during the follow-up period. Thirty-five of these children visited the laboratory for clinical examination, pulmonary function testing, and histamine challenge. Twenty-five children were believed to have clinical evidence of asthma at the time of the laboratory visit (point prevalence 71%). Five children were unable to perform pulmonary function tests; 25 of the remaining 30 (67%) had a positive histamine challenge test. No relationship could be demonstrated between a clinical diagnosis of asthma, a family history of atopy, and the results of histamine challenge testing. These results question the relationship between the results of bronchial provocation tests and clinical asthma in this age group.

Diurnal variation of peak expiratory flow rate in asthmatic children.

A diurnal variation in peak expiratory flow rate (PEFR) has been described in normal and asthmatic adults. This variation has been apparent in data reported from children, but the rhythm has not been characterized. Sixty-eight asthmatic children recorded PEFR three times a day for 4 weeks at home. Data were analyzed using paired t-tests, cosinor analysis, and spectral analysis. Fifty subjects (73.5%) had significant diurnal variations in PEFR on paired t-tests. Mean amplitude, derived from cosinor analysis, was 22.6% (SD = 13.2%) of mean PEFR. The trough of the PEFR rhythm occurred at 0345 hours for the group. Spectral analysis confirmed that the major component of the variation in PEFR was due to a rhythm with a period of 24 hours. The amplitude of the diurnal variation was not related to the subjects' age, sex, or medications taken but was inversely related to mean lung function (expressed as percentage predicted).

Lung function values from a longitudinal study of healthy children and adolescents.

From a cohort of 543 healthy children and adolescents, subjects were studied annually to obtain longitudinal data so that precise predictive values for lung volumes and flows from ages 8 to 19 years could be obtained. Strict guidelines for subject selection and pulmonary function testing were used. These data are presented in a readily usable form as equations, graphs, and tables.

Inherent variability of pulmonary function tests in infants with bronchiolitis.

During the last decade, many new methods of assessing pulmonary function in infants have been introduced. However, considerable controversy has arisen when these different techniques are used to assess the efficacy of various inhaled medications. The currently employed measures of pulmonary function have been reported to have coefficients of variation of less than 10%. However, these figures refer to repeated measurements made in individual babies over a short period of time, with the infant in a constant position. They may not be applicable to studies on the effects of drugs when a significant time interval elapses between measurements, particularly if the infant is repositioned during this time. In the present study, we found that the variability of measurements of thoracic gas volume (TGV), passive respiratory mechanics, and forced expiration approximately doubled if the infant was taken out of the plethysmograph, or repositioned within the plethysmograph, between sets of measurements. The between-test coefficients of variation ranged from 4.8% to 18.9% for TGV, 7.8% to 23.5% for respiratory system resistance, from 5.0% to 24.1% for respiratory system compliance, and from 10.8% to 36.1% for maximal flow at functional residual capacity. These results demonstrate that the commonly employed infant pulmonary function tests have wide variability in infants with acute wheezing illnesses. Before studying the efficacy of therapeutic interventions in such infants, it is necessary to establish the individual variability of the tests in the infants under the conditions of the study. Failure to do so may result in erroneous conclusions and recommendations.

Tracking of lung function in healthy children and adolescents.

Two hundred twenty-six healthy school children, with a mean age of 8.8 years; 62 girls mean age 8.8, 48 boys mean age 12.6 and 51 girls mean age 12.6 years at the start, were enrolled in a longitudinal study of lung function and tested annually for 5 years. All were free of respiratory symptoms, and none smoked more than five cigarettes per week during the 5 years. Static and dynamic lung volumes (other than residual volume), maximum expiratory and inspiratory flows, and maximum mouth pressures "track," that is, individuals remain at a constant deviation from the sample mean over time. The data indicate that these measurements of lung function in healthy individuals grow in constant proportion relative to other healthy children and adolescents.

Changes in lung, airway, and chest wall function in boys and girls between 8 and 12 yr.

Maximum expiratory flows, maximum inspiratory and expiratory pressures, and lung volumes were measured in 248 8-yr-old and 215 12-yr-old healthy school children. Eight-year-old girls had smaller total lung capacity but higher volume-corrected expiratory flows than boys. Maximum expiratory flow and total lung capacity increased more in girls than in boys between 8 and 12 yr. Girls had a greater increase in residual volume (0.23 liter for girls, 0.16 liter for boys) as well as lower maximum expiratory and inspiratory pressures (P less than 0.001). Girls have smaller lung volumes than boys, so one would expect smaller airways in girls, but girls generate greater flows, indicating that their airways are possibly wider than those of boys. There is also evidence of unequal growth of the airways and air spaces between 8 and 12 yr. Chest wall development appears less in girls than boys and the difference becomes more marked at 12 yr.

Maximal respiratory pressures in children.

Maximal inspiratory ( PImax ) and expiratory ( PEmax ) pressures were measured 7 separate times during 1 month in 40 children (13 males and 27 females, 101 to 208 months of age). After an initial period of learning, the Pimax for 20 repeated efforts was 11.1 +/- 2.4 kPa and the PEmax was 14.0 +/- 3.6 kPa. Mean values for the 20 efforts were 83% of PImax and 84% of PEmax . Individual coefficient of variation was 10% for PImax and 11% for PEmax . Postpubertal boys had higher pressures than did girls, primarily related to their greater muscle area. Pressures correlated with upper arm muscle area in both sexes and with age and height in boys. The PEmax was lower in these children than in previously reported normal adults, probably because of less muscle development. The PImax was similar to adult values, suggesting that a factor in addition to muscle strength influences inspiratory pressures in children.

Computer administration of a school-based adolescent health survey.

OBJECTIVE: To examine the utility of notebook computers in the collection of data in large scale surveys. METHODOLOGY: A notebook computer administered survey of health in adolescents was conducted in 1992 using a multi-instrument questionnaire. Students in school years 7, 9 and 11 in private and government schools in Melbourne and rural Victoria participated. RESULTS: Parental consent was obtained with an 83% response rate. Each student answered questions directly onto the computer taking an average of 68 min to complete the highly branched confidential but not anonymous questionnaire. Students were presented with on average 33% of the 897 possible questions. Over 90% of students reported enjoying using the computer. Those who reported answering the questions honestly all the time ranged from 68 to 85%, increasing with grade level. CONCLUSIONS: The use of computers in survey research provides many advantages in data collection including exposure only to relevant questions and the opportunity of asking sensitive questions.

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

OBJECTIVES: This study aimed to examine the associations between the frequency and severity of self-reported acne and age, gender, puberty and psychiatric symptoms in Victorian adolescents. METHODOLOGY: A sample of secondary schoolchildren in Victoria, Australia were surveyed using a computerized questionnaire. Developmental and psycho-social factors associated with acne were recorded and analysed using logistic regression. RESULTS: The Victorian Adolescent Health Survey (1992) recorded the frequency and severity of self-reported acne in 2491 students. Frequency of acne increased with age and pubertal development. For females commencement of menstruation was associated with increased frequency of acne. Asian born male students were less likely to report acne than Australian born males. Acne severity was coded into mild (students reporting acne sometimes on back or face) and moderate (students reporting acne often on face or back). Students reporting moderate acne were more likely to report a high level of psychiatric symptoms and were in the later stages of puberty. CONCLUSIONS: This study confirms an association between the frequency and severity of self-reported acne and stage of pubertal development. It showed also that students reporting moderate acne were more likely to report psychiatric symptoms of depression and anxiety.

Instability in smoking patterns among school leavers in Victoria, Australia.

OBJECTIVE: To describe patterns of smoking in a cohort of young adults over the first 15 months after leaving school. DESIGN: A four-wave, longitudinal survey design was used to gather data. Final-year students from 93 schools completed the recruitment questionnaire at an average age of 17 years. Follow-up questionnaires were posted to their home addresses three months, nine months and 15 months after the end of school. SETTING: Victoria, Australia. PARTICIPANTS: A cohort of 1903 respondents who completed and returned all four questionnaires. MAIN OUTCOME MEASURES: Self-labelled smoking status ("heavy smoker", "light smoker", "occasional smoker", "ex-smoker", and "non-smoker"), daily cigarette consumption, and maximum daily cigarette consumption. RESULTS: At school, 72% of the sample were "non-smokers", 5% "ex-smokers", 11% "occasional", 8% "light", and 5% "heavy smokers". At 15 months after school, these proportions had shifted to 64%, 8%, 11%, 9%, and 7%, respectively. Over the study, "light smokers" and "heavy smokers" substantially increased their daily consumption; "occasional" and "ex-smokers" did not. There was relatively high stability in self-labelled smoking status at one wave and the next. However, over the four waves, 38% of the sample changed their self-labelled smoking status, and 41% of these had been "non-smokers" at school. A reduced second-order Markov chain model was found to fit this four-wave behavioural sequence. Detailed description of smoking status changes revealed greater progression to higher levels of smoking than transition to lower levels. CONCLUSIONS: There is considerable flux in smoking patterns among young adults after leaving school, suggesting an opportunity to intervene with smoking prevention programmes at this stage of development.

Relation of armspan to height and the prediction of lung function.

Height and armspan were measured in healthy 8-18 year old boys and girls to assess the appropriate correction factor to be applied when height cannot be measured easily. No correction factor was found necessary, height being directly estimated from armspan.

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

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

Adolescent dieting: healthy weight control or borderline eating disorder?

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

Adolescent suicidal behaviours: a population-based study of risk.

BACKGROUND: Reports of adolescent suicidal behaviour have generally derived from clinical settings but population-based studies are likely to provide a clearer epidemiological view. METHODS: Non-fatal suicidal behaviours were studied in 1699 Australian 15- to 16-year-old secondary school students at 44 schools in the state of Victoria, Australia. Self-reported episodes of self-harm were characterized using items from the Beck Suicide Intent Scale. RESULTS: The 12 month weighted prevalence estimate for deliberate self-harm was 5.1%. The commonest forms were self-laceration (1.7%), self-poisoning (1.5%) and deliberate recklessness (1.8%). Self-poisoning and self-laceration were commoner in girls. The prevalence of 'true suicide attempts' was 0.2%. Most self-harmers did not perceive death as likely, plan self-harming episodes at length or inform others of the episodes. Psychiatric morbidity had the strongest association with self-harm, an association which held for all subtypes. Antisocial behaviour and substance abuse were associated with self-harm in girls but not boys. Sexual activity was independently associated with self-harm in both genders. CONCLUSIONS: Deliberate self-harm was common but the great majority of episodes were not 'true suicide attempts'. It is, therefore, possible that attributable mortality and morbidity may be greater in self-harmers without definite suicidal intent.