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Should Lucina put down her pen on the grounds that “the more you know the worse...”? For that is the face value message of a Florida study of family physicians (Journal of Family Practice1999;48:23–30; abstracted and discussed inEvidence-Based Medicine1999;4:158). Those who were assessed as better educated, both at medical school and subsequently, were significantly more prone to being sued for malpractice. Lucina's meme machine keeps flashing up “confounding factors” and “measurement difficulties”; she does not yet feel able to devote herself wholeheartedly to the pursuit of ignorance.
Both hand, foot, and mouth disease and herpangina are usually ascribed to infection with group A coxsackieviruses. In Taiwan in 1998 over 100 000 people, mostly children, developed one or other of these two conditions (New England Journal of Medicine1999;341: 929–35) and the predominant cause was enterovirus 71. Neurological complications were common (Ibid: 936–42) and pulmonary oedema often followed and was invariably fatal. The strongest predictor of pulmonary oedema was hyperglycaemia (Lancet1999;354:1682–6).
Almost two thirds of respondent adult members of a large Californian health maintenance organisation admitted to at least one of eight categories of childhood adverse experience (Journal of the American Medical Association1999;282:1652–8). There was a direct, quantifiable relationship between the number of adverse childhood experiences and tobacco smoking in adolescence and adult life. The authors make no attempt to relate smoking behaviour to the current life experiences of their respondents.
Do people with mild to moderate learning disability who develop schizophrenia have learning disorder with added schizophrenia or schizophrenia with learning disorder as the first manifestation? Work in Edinburgh (Lancet1999;354:1867–71) has suggested the latter. MRI scans were examined from 20 adults with learning disability, 25 with schizophrenia, 23 with both disorders, and 29 normal controls. Those with both disorders resembled those with schizophrenia and not those with learning disability with regard to brain size and amygdalohippocampal volume.
In iontophoresis of the skin, glucose is carried with cations to the cathode where its concentration can be measured. Tests in the USA (Journal of the American Medical Association1999;282:1839–44) have shown that in adults, an iontophoretic analyser strapped to the forearm was able to give accurate, painless, repeated, automated blood glucose recordings over a period of 15 hours, though there is a lag of about 18 minutes between finger prick blood glucose and the iontophoretic measurements. It does not seem to have been assessed in children.
All health care professionals who see children need to constantly bear in mind the possibility of retinoblastoma as an explanation for ocular abnormalities in young children. Of 100 children with retinoblastoma referred to a supraregional referral centre in London (British Journal of Ophthalmology1999;83: 1320–3), the first symptom was a white pupil in 52, squint in 29, altered appearance of the eye in 10, and decreased visual acuity in nine. Most patients were referred quickly to an ophthalmologist, but for 23 children the time between first consultation with a health professional and seeing an ophthalmologist was more than 8 weeks. In general, this lag time was longer when the first symptom was a squint, or when the first health professional seen was a health visitor. Health visitors were slower than general practitioners to refer children with leucocoria. Delay increased the likelihood of local invasion by the tumour.
Parents in the USA began to ask for secretin injections for their children with autism after media attention focused on the case of a 3 year old who improved dramatically after being given secretin during endoscopy. An estimated 2500 or more children have been given the drug. Now a randomised study of 60 children in North Carolina (New England Journal of Medicine1999,341:1801–6) has produced negative results, but 70% of parents expressed continuing interest in the drug for treatment of their child after the results of the trial were explained to them.
Lucina finds the excesses of medical rivalry difficult to fathom, but she does admit to a certain fascination with a good old fashioned spat. In Arizona, USA, doctors in Phoenix have, apparently, disagreed for many years with those in Tucson about the management of severe poisoning by the nastiest variety of American scorpion (usually, only children develop severe symptoms). In Phoenix they favour giving the antivenom (Annals of Emergency Medicine1999;34:615–19), whereas in Tucson they plump for midazolam infusion (Ibid: 620–5). The two centres can't even agree about the proper name for the offending arachnid. The writer of an editorial (Ibid: 669–70) likens their behaviour to that of rival sets of college football fans and would clearly like to knock their heads together.
Recent increases in the incidence of diabetes in children appear to have been particularly marked in the very young. Data from Finland (Diabetes Care1999;22:1950–5) have shown that children who develop diabetes before the age of 2 years are more likely than older children to have high titres of antibodies to islet cells and insulin, poorly preserved β cell function, and high genetic susceptibility as judged by HLA genotype. Nevertheless, it is concluded that factors other than HLA genotype must be important.
The younger you are the more likely you are to develop thyroid cancer after irradiation. An Anglo-French study (Archives of Internal Medicine 1999;159:2713–19) included 2827 patients who had received external radiotherapy for childhood cancer. After 3 to 45 years (mean 15 years) of follow up, 14 developed thyroid cancer. The findings suggested that the survivors of childhood cancer have an excess risk of thyroid cancer above that related to the dose of radiation given to the thyroid. The standardised incidence ratio for thyroid cancer was 35 for a dose of 0.5 Gy and 73 for a dose of 73 Gy.
In the meningitis belt of sub-Saharan Africa, meningococcal epidemics occur every 8 to 12 years; they may affect up to 1% of the population with a 5 to 10% case fatality and leave up to 15% of survivors with neurological damage. Meningococcal polysaccharide vaccines are effective, but there is controversy about whether they should be given in response to outbreaks (as recommended by the World Health Organization) or as routine vaccination for infants and adults. After an outbreak in northern Ghana in 1997, it was calculated (Lancet2000;355:30–3) that delayed mass immunisation prevented about 23% of cases and 18% of deaths. Following WHO guidelines would have probably prevented some 61% of cases and a policy of routine vaccination would have had the same effect (61% prevention). For the present, WHO policy may be more practical but the development of conjugate vaccines may favour routine immunisation.
At a hospital in Tennessee, USA, six newborn babies developed whooping cough, and erythomycin prophylaxis was recommended for neonates at risk (Lancet1999;354:2101–5). A subsequent survey showed that pyloric stenosis developed in seven of 157 babies given erythomycin, but in none of 125 born in the same hospital at around the same time and not given erythromycin. The incidence of pyloric stenosis in erythomycin treated babies was about ten times the usual incidence in babies born in that hospital. Erythromycin is known to stimulate gastric motilin receptors.
A twin study in Pennsylvania, USA (Journal of the American Medical Association1999;282: 2125-30) showed that concordance for recurrent middle ear effusion was 96% in monozygous and 63% in dizygous twins. It is estimated that almost three quarters of the risk is genetically determined.
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