Aim: The role of granulocyte-specific S100A12, a marker for inflammatory disorders, in newborn lung disease is unknown. We compared postnatal blood S100A12 concentrations against respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD).Methods: Blood samples from 92 newborns were collected on admission, 12 h, day 1, day 3-4 and day 7, and analysed for S100A12. IL-8 and IL-6 were assayed in 52 infants.Results: Infants with RDS were significantly more premature (median 27 vs. 34 weeks), more likely to receive antenatal corticosteroids (84% vs. 26%) and have lower neutrophil counts (median 2.4 vs. 3.8 x 10(9)/L) at admission. S100A12 levels peaked during the first day and were significantly lower in preterm infants with RDS compared to those without (median 250 vs. 616 ng/mL at 12 h, 281 vs. 828 ng/mL day 1, respectively). S100A12 levels were low among the 35 very preterm infants (24-29 week gestation) regardless of the presence of BPD (285 vs. 288 ng/mL on day 1). In comparison, IL-8 and IL-6 levels were not different between groups.Conclusion: Plasma S100A12 is low in infants with RDS, possibly because of gestationally related differences in neutrophil response or to the effects of antenatal corticosteroids. It is therefore not a useful marker of BPD development.

Back ground. Airway narrowing after hypertonic saline challenge (HSC) is postulated to be mediated by bronchoconstrictors and inflammatory mediators, Objective. To study the mechanism of this challenge by using exhaled breath condensate (EBC). Methods. Fifty-six subjects (9 to 72 years of age) performed an HSC, with EBC collection and exhaled nitric oxide (FENO) measurements before and after the challenge. Bronchial hyper-reactivity (BHR) was defined if forced expiratory volume in 1 second (FEV1) decreased by 10% compared with baseline (PD10). EBC volume was recorded and was analyzed for mucin, histamine. nitrite/nitrate, and pH. Results. Those with BHR had a significant rise in EBC volume/5-minute collection period after challenge (286.3 +/- 25.6 mu l vs 402.2 +/- 31.3 mu l, p =0.0002), while BHR(-) Subjects did not show this change (387.6 +/- 29.7 mu l vs 364.1 +/- 30.1 mu l, p =0.55). FENO showed a significant decrease in both BHR(+) and BHR(-) groups after challenge (p =< 0.0001). In BHR(+) subjects histamine increased significantly (1.3 +/- 0.1 mu M vs 1.5 +/- 0.1 mu M, p =0.006) compared with baseline. while EBC pH and mucin increased significantly after HSC in both groups. EBC nitrite did not change in either group. Conclusion. EBC analysis Suggests that HSC causes an increase in pH and mucin in both groups, but EBC volume and histamine only increased in the BHR(+) group. This suggests that mast cells are activated and fluid flux is associated With the positive response, while mucin release is independent of BHR in HSC.

RATIONALE:In children, intermittent asthma is the most common pattern and is responsible for the majority of exacerbations. Montelukast has a rapid onset of action and may be effective if used intermittently.OBJECTIVES:To determine whether a short course of montelukast in children with intermittent asthma would modify the severity of an asthma episode.METHODS:Children, aged 2-14 years with intermittent asthma participated in this multicenter, randomized, double-blind, placebo-controlled clinical trial over a 12-month period. Treatment with montelukast or placebo was initiated by parents at the onset of each upper respiratory tract infection or asthma symptoms and continued for a minimum of 7 days or until symptoms had resolved for 48 hours.MEASUREMENTS AND MAIN RESULTS:A total of 220 children were randomized, 107 to montelukast and 113 to placebo. There were 681 treated episodes (345 montelukast, 336 placebo) provided by 202 patients. The montelukast group had 163 unscheduled health care resource utilizations for asthma compared with 228 in the placebo group (odds ratio, 0.65; 95% confidence interval, 0.47-0.89). There was a nonsignificant reduction in specialist attendances and hospitalizations, duration of episode, and beta-agonist and prednisolone use. Symptoms were reduced by 14% and nights awakened by 8.6% (p = 0.043), and days off from school or childcare by 37% and parent time off from work by 33% (p < 0.0001 for both).CONCLUSIONS:A short course of montelukast, introduced at the first signs of an asthma episode, results in a modest reduction in acute health care resource utilization, symptoms, time off from school, and parental time off from work in children with intermittent asthma.

A previous position paper provided a national policy on asthma management for schools. This updated paper takes into account new medications and devices, changes in approaches to management, national guidelines for cleaning of asthma first aid kits in schools and the National Asthma Friendly Schools Program. School teachers and ancillary staff need to be aware both of asthma symptoms and the general principles of asthma management.

Background: Combining exhaled breath condensate (EBC) and exhaled nitric oxide (eNO) may be a useful, non-invasive method to assess airway inflammation in pediatric asthma. This cross-sectional study evaluated the relationship of both EBC nitrite/nitrate (NOx) and EBC pH with asthma control and eNO in asthmatic, normal, and atopic children.Methods: A total of 92 children were recruited, comprising 62 with asthma, 14 with atopy only, and 16 who were normal and non-atopic. All completed a questionnaire for asthma symptoms and control. Variables measured were spirometry, EBC NOx, pH, and eNO.Results: EBC NOx in those with asthma (mean 8.4 mu M, Cl 7.5-9.4) was significantly elevated when compared with normal (4.8 mu M, Cl 3.4-6.2, P= 0.0007) and atopic children (6.5 mu M, Cl 4.0-9.1, P=0.02). The mean level of eNO was significantly higher in those with asthma (43.7 ppb, Cl 34.7-51.1, P< 0.001) and atopy (24 ppb, Cl 16.7-31.2, P< 0.05) when compared with normal children (11.5 ppb, Cl 6.7-16.2). There was a significantly lower pH in those with asthma and a FEV1, < 80% predicted (P= 0.03), but no significant overall differences in EBC pH between the three groups of children. There was a significant correlation between eNO and EBC NOx in the group as a whole, but not between eNO and EBC pH.Conclusions: Mean EBC NOx levels differ between children with asthma, atopy, and those who are normal, but it is not interchangeable with eNO. EBC pH may be an additional marker of asthma control.

Clara cell secretory protein (CC10) is an important anti-inflammatory mediator in the adult lung, but its role in newborn pulmonary protection is uncertain. We examined the early postnatal behavior of CC10 in newborn serum and tracheal fluid and hypothesized that CC10 production is positively influenced by gestation. Blood from 165 infants from the first, third/fourth, and seventh days of life (gestational ages: 23–29 wk, 30–36 wk, >36 wk) and tracheal fluid (TF) from the first day of life from 32 ventilated infants were analyzed for CC10. Surfactant proteins A (SPA) and B (SPB) were also analyzed from the blood of a subgroup of infants. Serum CC10 on day 1 was highest in term infants (69.4 ng/mL), followed by moderately preterm (55.8 ng/mL), and then extremely preterm infants (median 42.1 ng/mL). Term infants also had higher tracheal fluid CC10 than preterm infants. (20.152 ng/mL versus 882 ng/mL). Mechanical ventilation increased serum CC10 only in moderately preterm infants, and only on d 1 [68.4 ng/mL versus 42.1 ng/mL (nonventilated moderately preterm infants)]. Serum CC10 decreased progressively by the end of the first week in all infants, in contrast to SPA and SPB, which increased. Our results show that CC10 is detectable in the blood of newborn infants and that a production surge occurs at birth. This surge is more pronounced in term infants and may confer them with superior extrauterine pulmonary protection compared with preterm infants.

ISSUES ADDRESSED:The aim of this study was to identify the strengths and weaknesses of asthma management in child care services in the Hunter region and to develop, implement and evaluate a health education program to address the deficiencies.METHODS:A questionnaire was sent to the 190 child care services in the Hunter region in 1997 to assess their asthma management practices. Results of the survey were used to develop a two-hour training workshop for child care staff in the management of asthma. District-based workshops were conducted for 535 child care staff (representing 140 services) over two years. Participants completed pre- and post-workshop knowledge and confidence questionnaires. The survey was repeated in 2000.RESULTS:The baseline survey identified potential for substantial improvement in the management of asthma in child care services and in the training of staff. Training workshops significantly improved asthma knowledge and confidence in managing asthma (p<0.0001). The follow-up survey showed that an additional 50% (p<0.0001) of all child care services had implemented recommended asthma management practices.CONCLUSION:The program was effective in achieving vast improvements in the knowledge and confidence that child care staff require to manage asthma and has led to the broad dissemination and adoption of the appropriate policies and procedures for the management of asthma in child care services.

Although children in Australia generally have good health, some alarming indicators of poor health and wellbeing exist, which are related to major socioeconomic discrepancies. The pathways connecting socioeconomic disadvantage to child health outcomes are complex and poorly understood. Reducing social disadvantage requires strategies beyond the health arena, involving political, moral, cultural and economic initiatives. Developing “social capital” — cohesion in communities, a sense of belonging and involvement in community affairs — may be a key strategy in improving health indicators. Overseas studies of early intervention and home visiting programs in early childhood have shown improvements in child health and development outcomes. Similar programs have been introduced in Australia and face considerable challenges in their widespread roll-out and evaluation. Health professionals need to develop practical ways to interact with community programs and thus improve social capital.

The objective of this study was to investigate the feasibility of using home telecare for monitoring cystic fibrosis (CF). Five adolescents were asked to use a home telecare system during a routine hospital visit over one week. Frequency of use was measured from computer logs. Unacceptable measurements were identified by visual inspection. User impressions of home telecare and appropriateness of the system for managing CF was determined from observations of user interaction, survey and qualitative analysis. Patients used the system to record lung function measurements without any supervision and indicated that the system was easy to learn and use. The role of home telecare in supporting collaborative self-management appeared to be well understood. Home telecare was seen as a supplement to standard care that would provide a link to the hospital between clinic visits. Participants indicated that feedback provided by the system and ongoing clinical support would determine long-term use and compliance with the monitoring protocol. Clinicians reported the usefulness of home telecare in maintaining a longitudinal record of their patient's health that would supplement verbal description of symptoms and reduce time to treatment by increasing patient self-awareness of health status. Home telecare may be a feasible intervention for monitoring CF. Feedback provided by the system must be presented in a format that is familiar and easily understood by users. Further system refinement and evaluation is required to determine patient compliance with their customized monitoring protocol prior to assessing impact on clinical outcomes.

Medical Journal of AustraliaVolume 182, Issue 5 p. 249-249 Letter Severe childhood pneumonitis caused by the Queensland strain of community-acquired methicillin-resistant Staphylococcus aureus Bradley T Martin, Corresponding Author Bradley T Martin Respiratory Fellow (currently bradleym@chw.edu.au Department of Respiratory Medicine, Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145)Correspondence: bradleym@chw.edu.auSearch for more papers by this authorPamela Palasanthiran, Pamela Palasanthiran Infectious Diseases Specialist Department of Respiratory Medicine, Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145)Search for more papers by this authorIain B Gosbell, Iain B Gosbell Infectious Diseases Fellow Department of Respiratory Medicine, Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145)Search for more papers by this authorThelma Barbagiannakos, Thelma Barbagiannakos Director Sydney Children's Hospital, Sydney, NSWSearch for more papers by this authorEmma J Best, Emma J Best Hospital Scientist SWAPS Staphylococcal Reference Facility, South Western Area Pathology Service, Sydney, NSWSearch for more papers by this authorRichard L Henry, Richard L Henry Head of School of Women's and Children's Health and Senior Associate Dean Faculty of Medicine, University of New South Wales, Sydney, NSW.Search for more papers by this author Bradley T Martin, Corresponding Author Bradley T Martin Respiratory Fellow (currently bradleym@chw.edu.au Department of Respiratory Medicine, Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145)Correspondence: bradleym@chw.edu.auSearch for more papers by this authorPamela Palasanthiran, Pamela Palasanthiran Infectious Diseases Specialist Department of Respiratory Medicine, Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145)Search for more papers by this authorIain B Gosbell, Iain B Gosbell Infectious Diseases Fellow Department of Respiratory Medicine, Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145)Search for more papers by this authorThelma Barbagiannakos, Thelma Barbagiannakos Director Sydney Children's Hospital, Sydney, NSWSearch for more papers by this authorEmma J Best, Emma J Best Hospital Scientist SWAPS Staphylococcal Reference Facility, South Western Area Pathology Service, Sydney, NSWSearch for more papers by this authorRichard L Henry, Richard L Henry Head of School of Women's and Children's Health and Senior Associate Dean Faculty of Medicine, University of New South Wales, Sydney, NSW.Search for more papers by this author First published: 07 March 2005 https://doi.org/10.5694/j.1326-5377.2005.tb06678.xCitations: 4Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume182, Issue5March 2005Pages 249-249 RelatedInformation

This book is described by the publishers as a follow-up to Muriel Morley's Cleft palate and speech. As more than a decade has passed since that book's last edition this review of advances in management fills the gap. Although the editors are from the UK, the 15 contributors are from North America and Scandinavia and from this country. The scope of the book is wider than the title suggests: there are chapters on embryology, anatomical and physiological considerations, and growth and development, and P Fogh Anderson contributes a succinct chapter on 'Incidence and what is known ofaetiology'. From Edinburgh the second editor and Muriel Campbell, Nursing Officer at the Royal Hospital for Sick Children, contribute a splendidly down-to-earth chapter on the 'Management of the neonate' full of useful practical details, and for the DIY inclined there is an appendix for the construction of a modified Burston nursing frame for babies with the Pierre Robin syndrome. The surgical chapters are comprehensive, critical, and lucid. The still controversial role of orthodontic treatment is fully and fairly discussed (T D Foster). So is hearing loss, the almost inevitable middle-ear effusions, and the evidence (or rather lack of evidence) about the efficacy of treatment by myringotomy and grommets (Ruth Lencione). There is a mass ofinformation about the speech and language aspects of cleft palate but some of it is uncritically presented and opinion is not always supported by facts. Here the somewhat turgid style, sometimes verging towards jargon, makes hard reading. Each chapter is supported by up-to-date references. The drawings are clear and helpful, the numerous photographs uniformly excellent. The common goal of treatment of the child with a cleft palate, writes D R Millard, is that he should 'look well, eat well, and speak well'. This is a valuable, up-to-date, comprehensive guide to that journey.

Recently published reports suggest that the combination of aminoglycosides with ceftazidime may increase the risk of renal disease in cystic fibrosis. We describe a case of unusually severe acute tubular necrosis occurring in an adolescent with cystic fibrosis receiving i.v. gentamicin plus ceftazidime and discuss the possible mechanisms.

An admission to an intensive care unit (ICU) with asthma is a marker of asthma severity and may be a precursor of asthma death. The aim of this study was to investigate risk factors for acute severe asthma needing an ICU admission. We hypothesized that children admitted to the ICU represent a severe phenotype with identifiable premorbid clinical features. The study was case-control in design. One hundred and forty-one children were studied. Seventy children admitted to the ICU and 71 children admitted to the general medical ward served as cases and controls, respectively. Children were aged between 1-16 years. They underwent skin prick allergy testing, and had a nasopharyngeal aspirate and serology performed to screen for respiratory pathogens. Their parents completed an asthma and allergy symptom questionnaire and the Newcastle Asthma Knowledge Questionnaire (NAKQ). On univariate analysis, an admission to the ICU was more likely in children with 1) "frequent episodic" or "persistent" background asthma; 2) three or more previous admissions for asthma; 3) one or more asthma admissions in the previous 12 months; 4) three or more presentations to the Emergency Department (ED) in the preceding 12 months; 5) three or more positive responses on skin prick allergy testing; 6) an elevated IgE level; 7) oxygen saturation on presentation < or =91%; 8) longer duration of asthma; 9) lower level of maternal education; 10) an admission during autumn; 11) three or more siblings; and 12) being prescribed antibiotics. Risk factors that remained significant on multivariate analysis were three or more presentations to the ED in the preceding 12 months (P=0.003), an elevated IgE level (P=0.01), oxygen saturation on presentation < or =91% (P=0.003), and longer asthma duration (P=0.02). ICU patients took longer to see a doctor and to commence oral steroids. No differences were found between cases and controls in the proportion taking preventer therapy (58% vs. 52%), provided with a written asthma action plan (32% vs. 25%), or in whom spirometry or peak flow was measured (28% vs. 42%). However, rates were low in both groups. Parental asthma knowledge was generally poor. This study identified risk factors for an ICU admission in children with asthma. A potentially preventable risk factor is a history of multiple ED presentations in the past year. Specialist referral of children with multiple ED presentations may improve asthma control and reduce the risk of an ICU admission. Background asthma management remains suboptimal in children needing hospitalization.

19th June 2004 Dear Editor, We report a case of prenatal diagnosis of a congenital cystic adenomatoid malformation (CCAM), which was assumed to have regressed completely postnatally, however, it resulted in the child presenting with an infection of her lesion later. A 2.5-year-old girl with mild global developmental delay presented with a 3-day history of fever, lethargy, cough and sore throat. A chest radiograph revealed right middle and lower lobe opacities. Pneumonia was diagnosed and she was treated with intravenous antibiotics for 4 days and then discharged on oral antibiotics. Two weeks post discharge, she re-presented with persistent fevers. The history was obtained that her 34-year-old mother had an antenatal diagnosis at 19 weeks gestation of a right fetal intrathoracic mass. Subsequent scans at 30 and 32 weeks gestation did not demonstrate the chest mass. The infant was born at full term via a normal vaginal delivery with a birth weight of 3.5 kg. A chest radiograph at birth was normal and she was discharged home. During her second admission with pneumonia, a computed tomography (CT) scan of her chest showed a large multiloculated cystic mass in the right lower lobe with air fluid levels, consistent with an infected CCAM. She underwent a CT-guided drainage of the lung abscess and insertion of a right intercostal catheter on day 3 of her admission and then underwent a thoracotomy and right lower lobectomy on day 9. Her postoperative course was uncomplicated. She is now 5 years of age and has been well from the respiratory point of view. Congenital cystic adenomatoid malformation is a rare pulmonary malformation characterized by the overgrowth of the terminal respiratory structures, which form cysts of different sizes that are walled in a polypoid configuration. There is an arrest of normal fetal pulmonary maturation thought to be caused by primary bronchial atresia or failure of normal bronchial segmentation and the subsequent development of dysplastic bronchopulmonary tissue distal to the affected segment1. It has been considered that such a developmental disorder is identical to that seen in congenital polycystic kidney2, and usually occurs around 16−20 weeks of gestation3. Our patient was diagnosed at 19 weeks gestation. Congenital cystic adenomatoid malformation occurs most frequently in newborns, and with almost equal frequency in premature and term infants. 80−85% of all cases are diagnosed in the first 2 years of life4−7, but CCAM has been described in older patients and in adults8. The outcome for infants in whom the chest radiograph is normal after birth is unknown and there is no consensus as to whether further investigation and follow-up are necessary. In this case, the CCAM was thought to have resolved on subsequent antenatal scans and a postnatal chest radiograph and hence, she was not followed-up postnatally until she presented with an infection of her lesion. Fetal CCAMs are known to regress or increase in size9. This patient had a CCAM which was thought to have regressed antenatally and was asymptomatic in the postnatal period. The asymptomatic patients typically have normal chest radiographs postnatally. It is therefore important that such a finding should not lead to the assumption that the CCAM had regressed completely, as demonstrated in our patient. Prenatal sonographic identification of the asymptomatic patient with a known CCAM has posed a management dilemma to the paediatric surgeon. Historically, this population would come to medical attention when and if symptoms related to the pulmonary anomaly arose. No prospective studies have been published, to our knowledge, regarding the observation of these patients to determine the long-term natural history of asymptomatic lesions. Therefore, no established data exist to predict who will become symptomatic in this initially asymptomatic population. Classically, the teaching has been to remove all CCAM lesions because of the risk of secondary infection and the possible development of neoplasia (bronchioloalveolar carcinoma and rhabdomyosarcoma)10−13. Some surgeons say that the possible development of malignancies justifies prompt resection of CCAM shortly after diagnosis, even in asymptomatic patients. The abnormal lung also has abnormal mucociliary clearance, which often causes recurrent pulmonary infection14. This infection risk must be taken into account when deciding whether an asymptomatic patient should be treated. Until prospective studies further evaluate the natural history of the asymptomatic CCAM population, the debate regarding prophylactic resection versus expectant observation will continue. Some surgeons advise life-long follow-up in those patients who had a resection of CCAM in early childhood, as they believe there may be a risk of malignancy even after resection of the CCAM10. Our case highlights that routine chest radiograph in the newborn period is inadequate and that all prenatally detected CCAMs should have a postnatal chest CT scan.

AIM:To gauge the importance and relevance placed by general practitioners on components of the National Asthma Campaign's 'Six step' Asthma Management Plan for childhood asthma.METHOD:A cross sectional postal survey of a national randomised sample of 824 GPs.RESULTS:Each component was considered to be 'quite' or 'very' important by at least 70% of respondents. All 11 components were rated to be either 'quite' or 'very' important by 44%, and 91% of respondents considered eight or more of the components to be 'quite' or 'very' important. Two characteristics were consistently associated with the rating of importance: gender, (women GPs generally showing higher ratings), and reported frequency of use of the Asthma Management Plan (frequent users rate importance more frequently).CONCLUSION:There were high levels of endorsement of the Asthma Management Plan for children with asthma.

Mirthful emotions such as laughter and excitement are unrecognized but perhaps important triggers of asthma. Our study aimed to explore the prevalence, mechanisms, and associations of mirth-triggered asthma (MTA) in children. Our MTA prevalence questionnaire was given to 285 children who presented to the Emergency Department of Sydney Children's Hospital (SCH) with an acute episode of asthma. Our MTA profile questionnaire study was a cross-sectional study of 541 children with asthma. The parents completed a questionnaire regarding their child's asthma. In our laughter diary study, diary cards were given to the parents of 21 children with asthma. The diary required details regarding the mirthful stimulus, symptoms of asthma, and recording of peak expiratory flow (PEF) measurements. Of the selected cohort, 31.9% had mirth-triggered asthma. In the cross-sectional study, mirth-triggered asthma was more common: with increasing age (P = 0.02); in those who in the last 3 months had taken more doses of salbutamol (P = 0.005), and who had more wheeze, nocturnal symptoms, and early morning symptoms (P < 0.0005); and in those who reported exercise-induced asthma (P < 0.0005). Laughter was more commonly reported as a trigger than excitement; cough was the most prominent symptom; and symptoms mostly occurred within 2 min of the mirthful stimulus. In the laughter diary study, 59 of 130 recorded events described symptoms of asthma. Mirth while watching a film led to PEF of 73% of baseline, compared with 81% for mirth with exertional play, and 95% for mirth with nonexertional play (P = 0.01). Mirth-triggered asthma is common, and is an indicator of suboptimal asthma control.

OBJECTIVE:To determine the effect of a peer led programme for asthma education on quality of life and related morbidity in adolescents with asthma.DESIGN:Cluster randomised controlled trial.SETTING:Six high schools in rural Australia.PARTICIPANTS:272 students with recent wheeze, recruited from a cohort of 1515 students from two school years (mean age 12.5 and 15.5 years); 251 (92.3%) completed the study.INTERVENTION:A structured education programme for peers comprising three steps (the "Triple A Program").MAIN OUTCOME MEASURES:Quality of life, school absenteeism, asthma attacks, and lung function.RESULTS:When adjusted for year and sex, mean total quality of life scores showed significant improvement in the intervention than control group. Clinically important improvement in quality of life (>0.5 units) occurred in 25% of students with asthma in the intervention group compared with 12% in the control group (P=0.01). The number needed to treat was 8 (95% confidence interval 4.5 to 35.7). The effect of the intervention was greatest in students in year 10 and in females. Significant improvements occurred in the activities domain (41% v 28%) and in the emotions domain (39% v 19%) in males in the intervention group. School absenteeism significantly decreased in the intervention group only. Asthma attacks at school increased in the control group only.CONCLUSION:The triple A programme leads to a clinically relevant improvement in quality of life and related morbidity in students with asthma. Wider dissemination of this programme in schools could play an important part in reducing the burden of asthma in adolescents.

The design and evaluation of a Web-based system in which a longitudinal clinical record is used for management of cystic fibrosis, is described. In the home, a low-cost, PC-based spirometry module will be used for the acquisition of lung function measurements using a standard web browser interface. An electronic diary will be used to record symptoms of cough, mucus, activity, appetite, weight, breathing, mood and fever. The patient's clinical record will be maintained on a centralised server. An intelligent software agent on the Web server is activated whenever new patient data is collected remotely from the home. The agent compares historical data with newly acquired data. Using this method, an optimum patient care strategy can be evaluated, with reminders and suggestions for action sent to the doctor and patient by email. A two-stage evaluation will be carried out to assess the effectiveness of home monitoring in cystic fibrosis. In addition to the home diary, qualitative and quantitative measures including the NIH scoring system, the CFQoL questionnaire, interviews and observations will be used in the study. The system will initially be deployed at Sydney Children's Hospital where 15 patients will be recruited from the Cystic Fibrosis Clinic and trained to use the system. The system will then be installed in these patient's homes to determine the clinical utility of a longitudinal clinical record and feasibility of the design for management of cystic fibrosis.