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AN IMPORTANT READ!
Child abuse—and more specifically Munchausen syndrome by proxy (now renamed fabricated and induced illness)—has been the focus of a great deal of attention in both the scientific and popular press. Margaret Talbot, a staff writer and Senior Fellow at a Washington D.C. think-tank, recently wrote a long and provocative piece in the New Yorker (August 9 and 16, 2004 issue). Entitled “The bad mother – Munchausen syndrome by proxy is a rare, bizarre disorder – why are so many women being accused of it?” the article provides a unique perspective of this troubling entity. Beginning with a report by Professor Meadow in the Lancet in 1977, she explores its origins, refers to the work of Professor Southall, extensively reviews the psychiatric literature, and uses a specific case in Ottawa to highlight many of the complex issues surrounding the “syndrome”.
COMMUNICATION WITH PATIENTS
In April, 2004 the NHS announced that letters from consultants to GPs should be copied to parents of young children. As a matter of courtesy, it would be helpful to know whether these letters should be addressed to the GP or to the parent. Bartle and colleagues surveyed 70 families. Virtually all indicated that they wanted copies of correspondence between the GP and consultant. About 40% thought the letter should be addressed to the GP and 35% to the family. This study highlights a number of important contemporary healthcare issues—should all patients keep a copy of their medical record, how can we enhance communication between doctors and between physicians and their patients, and finally, how will E-health—that is, computerised order entry, electronic medical records, email communication, and the Internet, change medicine. Email communication between patient and physician remains controversial.1,2 The results of numerous surveys have been consistent—patients endorse it, but physicians are reluctant to use it, citing concerns about confidentiality, cost, safety, and time. In many regards, the issues raised about email communication are similar to those raised when the telephone was introduced into medicine in the first part of the last century. Two recent “content analyses” of email exchanges between patient and provider, including one done in paediatrics, found that the vast majority of “conversations” were about issues related to health.3,4 This is in sharp contrast to telephone communication, where the majority of calls are for administrative issues; for example, the completion of forms or prescription refills. It is hard to imagine that in a consumer oriented healthcare system, communication by email will not prevail. I recall my own frustration when I called my GP for the results of my cholesterol level and was put on hold for about 10 minutes, all of the time thinking ‘can’t he just email me the results’.
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FLUTICASONE: A CAUTIONARY TALE
In yet another reminder about the potential adverse effects of corticosteroids, researchers from Bangkok found that nine out of 18 children who had received approximately 500 μg of fluticasone daily for between 5 and 16 weeks had evidence of adrenal suppression. George Russell recently reminded us that inhaled cortical steroids (ICS) are safe at normal doses, but that adrenal suppression and other side effects are more common as doses increase.5 Searching for the lowest possible dose of ICS that is effective—particularly for the treatment of children with persistent asthma—remains critical.
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CAESAREAN SECTION AND THE DEVELOPMENT OF ATOPY
There are many possible explanations for the increase in atopy over the past 2–3 decades, including the so called hygiene hypothesis, changes in infant nutrition and diet, and exposure to allergens in the environment. In a prospective cohort study from Germany, investigators explored the risk of gastrointestinal symptoms, atopic dermatitis, and sensitisation to nutritional allergens in a group of infants who were born by caesarian section. The infants were at high risk for atopy (family history of allergy, all infants breastfed for 4 months) and were followed from birth to 1 year of age. In the cohort, 147 of 865 (17%) were born by caesarean section. Caesarean section conveyed a significant risk of sensitisation at 12 months of age to both cows’ milk allergens and any of five nutritional allergens. No relationship with colicky abdominal pain, diarrhoea, or atopic dermatitis was found. The authors discuss the biological plausibility of these results. They are provocative—particularly since the rate of caesarean section has risen steadily in most developed countries over the past two decades.
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AN APOLOGY
I deeply regret the illustration that accompanied the article by Ellaway and colleagues in the September 2004 issue of ADC—it was inappropriate. We have added numerous safeguards to ensure that this does not happen again. We have commissioned illustrations because when done well they can be both entertaining and insightful. Some have argued that they do not belong in a scientific publication, but we will continue to experiment with them.
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