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Farewell Howard
Howard Bauchner was Editor-in-chief of Archives for 8 years, and his departure should not be allowed to pass without a few words of tribute. Although initially some eyebrows were raised at the appointment of an American paediatrician to edit a British journal, his tenure proved an unqualified success. The circulation and the impact factor have both improved at a time when many journals are struggling, the quantity and quality of what we publish has increased, and many new features, such as Education and Practice and Drug Therapy, have been incorporated.1 His appointment as Editor-in-chief of the Journal of the American Medical Association is a tribute both to his own skills and a credit to our specialty: few paediatricians hold top jobs in medical publishing. I will be occupying the Editor's chair on a temporary basis until a substantive appointment is made. My fellow associate editors will contribute to Atoms on occasion.
When do paediatricians get sued?
In February 2011 we published a paper from France describing the pattern of successful litigation claims in children, accompanied by a commentary from Harvey Marcovitch, former Editor-in-chief of Archives.2 3 Coincidentally, Raine was doing a similar study in the UK, published in this issue. Although the UK paper derives its data from the National Health Service (NHS) litigation authority while the French study came from the records of medical insurance companies, nonetheless the findings are remarkably similar. Parents sue for delays in diagnosis and treatment, and substandard care. Most of the diagnoses involved are as expected (sepsis, meningitis etc) but there is one surprise: anorectal malformation was missed on six occasions. These studies serve as timely reminders of what types of cases can come back to haunt us. See page 838
Where to take your febrile child?
Emergency care for children, particularly out-of-hours, is a contentious area in the UK as the traditional role of the general practitioner (GP) has changed in recent years. Many parents are uncertain where to seek advice, and services available are often fragmented. Working with the Royal College of Paediatrics and Child Health (RCPCH), Maguire and colleagues asked 220 parents of febrile under-5s what they did, and what services they preferred. Most ended up consulting different agencies during the short illness (GP, hospital emergency departments, walk-in centres, NHS Direct etc) when most would have preferred just to see their GP. There were many onward referrals, perhaps unnecessarily increasing workload. This paper confirms my impression that acute care for children in the NHS needs a radical shake-up, doing away with multiple facilities and concentrating services in places that are child-appropriate and where staff are properly trained. Parents would then be less confused. Although this study was done in England, the lessons could apply elsewhere. See page 810
VZIG or Aciclovir?
Many papers end with a call for a randomised controlled trial (RCT) to answer a specific question, but rarely can the need be so obvious as with the question of what post-varicella exposure prophylaxis to give immunocompromised children. This challenge can present to any paediatrician, not just oncologists. The question also arises for immunocompromised children who do not have a malignancy. Bate and colleagues ‘triangulated’ the problem by looking not only at individual oncologists' policies, but also recorded varicella susceptibility rates and varicella-zoster immune globulin (VZIG) usage. Oncologists were divided down the middle between Aciclovir-givers and VZIG-givers. This surely qualifies as ‘equipoise’, the starting justification for an ethical RCT. Considering how diligent the paediatric oncology community have been in doing multi-centre RCTs, it seems surprising that this question has gone unanswered for so long. See page 841
New treatment for haemangiomas
The Drug Therapy section carries a review by Starkey and Shahidullah on the growing use of propranolol to treat infantile haemangiomas. Like many new treatments, its efficacy was discovered by serendipity when a child who happened to have a haemangioma was given propranolol for something else. Several trials are ongoing and there seems little doubt about its effectiveness, but toxicity, particularly hypoglycaemia, remains a concern. Because of this, the authors warn against yielding to pressure from parents to use it to treat lesions for purely cosmetic reasons. See page 890
In this month's F&N
Those interested in the long-term follow-up of preterm neonates will find a wealth of papers: Ratihalli and the Trent group find improving outcomes in extreme preterms over a decade; the EPIPAGE study from France looks at growth, and finds systemic steroids in the neonatal period to be a strong predictor of short stature; Logan et al reassuringly find no association between numerically low blood pressure and poor neurodevelopmental outcomes; and a review by Zeitlin and Ancel guides us on how to interpret all this data.