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Imaging following UTI in children
Over the past five years results from various studies have challenged the assumption that antibiotic prophylaxis can prevent urinary tract infections and ultimately lead to reduction in future rates of end stage renal disease from reflux nephropathy. Although the American Academy of Pediatrics guideline continues to favour imaging, the recent NICE guideline has suggested a much more restrained approach to radiologic testing following UTI in children. In this issue of ADC, a report from Australia details a dramatic decline in micturating cystourethrography, intravenous pyelography, and nuclear medicine isotope scanning in children less than 14 years of age between 1993 and 2008. Only the rates of renal ultrasound remained stable. Interestingly an article soon to be published in NEJM from Australia involving 576 children with UTIs found that children who received antibiotic prophylaxis for a year following the first diagnosis of UTI had significantly less recurrent UTI (36 of 288–13%) than children who received placebo (55 of 288—19%). This likely will revive the debate about the utility of antibiotic prophylaxis following UTI. However, this study, like most, does not focus on the outcome of interest—some measure of long term renal function. See page 927
Do children understand body image?
I remember watching one of my sons play football about 10 years ago. It was a hot day and many of the boys took off their shirts. I was amazed. From my own childhood and coaching days, I remember the gangly look of adolescent boys, without an ounce of fat anywhere on their bodies. Many of the boys I saw that day were “chubby” and some were clearly overweight. This was my first visual awareness of the obesity epidemic. I didn’t need any data, or pronouncements from professional societies or government to know something was fundamentally changing in society. In this issue of the Journal, investigators from the University College London, describe how 399 children, aged 7 to 9 years, assess their own body size. The results are not surprising, but are disturbing, there is a strong tendency for children to underestimate their actually body size, particularly at greater weights.
The obesity epidemic seems so at odds with the fashion and advertising industries, which champion very thin women. Clearly there is a societal mismatch between messages in the media, and the reality of body size. It appears that we have adapted to changes in body size and can no longer accurately assess ourselves. See page 944
Adherence in children with HIV disease
It is estimated that only about 75% of parents fill prescriptions when they leave an emergency department and only a quarter of children receive a full-course of any drug that is prescribed. In some cases this maybe good—clearly over the past two decades the length of treatment for many diseases, particularly those requiring antibiotics, has declined. However, for children with chronic disease, where taking medication daily is critical, we have made little progress in improving adherence. One of my colleagues who cares for children with HIV disease, believes that adherence with treatment represents one of the most important challenges in health care. Khan and colleagues from George Washington University School of Medicine remind us of the difficulty of adherence to medication. In a study involving 140 HIV-infected children, they found that complete adherence with drug treatment over 1 year was reported by only 24% of patients. Only 64% of children achieved undetectable viral loads. Despite modern technological wizardry, few advances have been made to ensure adherence to drug regimens. See page 970
We receive some 300 case reports each year. We publish about 10. What are we looking for—novelty in diagnosis, treatment, or risk—of common problems. Many of the submissions detail unusual findings in rare diseases. Given our readership most of those reports will be rejected. In this issue a group from the Royal Hospital for Sick Children in Glasgow describes five patients who were prescribed a B-blocker and had severe hypoglycaemic episodes. This report is novel, defining an important problem in children with arrhythmias. See page 968
I want to personally thank the 500 or so of you who have responded to the readership survey (as of October 6, 2009). As promised I am reviewing all of the written comments—they will be quite helpful as we plan for the future. I urge you to complete the survey. In the coming months I will summarize the responses in Atoms. Below are some of the more “amusing” comments which I have enjoyed:
“put me on the editorial board”
“that the pages are waterproof as I read it in the bath”
“Be more inclined to accept for publication papers that I have submitted”
“How about a regular ‘Heretics Section’ where a distinguished (or maybe not so distinguished) author puts forth an unorthodox or even heretical view on an important topic…”
Since I read these responses in our hot tub, indeed, water proof pages would be helpful.
This month in E&P
The Centers of Disease Control and Prevention now estimate that 1 in every 100 US children has Autism Spectrum Disorder—a rate that I find astonishing. Professor Anne O’Hare writes a best practice on ASD.
Problem solving in clinical practice, a review of neuroblastoma, and another report from our series on Learning and Teaching also appear.