We are very pleased to see the comment from Dr Burke regarding the
ethical and social considerations of Next Generation Sequencing, in
response to our review.
As we noted in our original article, the field is very complex, with
a major issue being the interpretation of sequencing data, such that
without follow up investigations many variants cannot be confidently
assigned as either beni...
We are very pleased to see the comment from Dr Burke regarding the
ethical and social considerations of Next Generation Sequencing, in
response to our review.
As we noted in our original article, the field is very complex, with
a major issue being the interpretation of sequencing data, such that
without follow up investigations many variants cannot be confidently
assigned as either benign or pathogenic. Given that this is the case,
reporting on such variants is premature.
It is also true that further research is urgently needed to determine
the potential benefits or harm of wide scale sequencing in children.
However, until we have clearer information on what variants can be
considered pathogenic, in addition to clear irrefutable evidence that
genetic testing in children is beneficial and not harmful, we would
continue to recommend that children be entitled to an open future and
allowed to choose testing for themselves at the appropriate age.
Most patients presenting to a paediatric department for acute care
will be weighed as part of the nursing assessment especially because
weights are important for drug and fluid prescriptions.
Junior doctors however generally fail to take the next step in this
opportunistic contact to plot these weights. Unless clinically indicated
e.g. as part of body surface area for drug prescriptions, the height is
often not measured,...
Most patients presenting to a paediatric department for acute care
will be weighed as part of the nursing assessment especially because
weights are important for drug and fluid prescriptions.
Junior doctors however generally fail to take the next step in this
opportunistic contact to plot these weights. Unless clinically indicated
e.g. as part of body surface area for drug prescriptions, the height is
often not measured, nor is head circumference routinely measured.
Indeed, this is a reflection of less than best practice and needs to be
highlighted as part of junior doctor induction.
I read with interest the article published by Archer et al on
Multisource Feedback of paediatric registrars. This article is very
encouraging for trainees like me and also answers doubts about the
validity and reliability of such work place based assessments.
One of the main conclusions of the authors is that self selection of
assessors by trainees should end. But this raises questions about the
validity of an...
I read with interest the article published by Archer et al on
Multisource Feedback of paediatric registrars. This article is very
encouraging for trainees like me and also answers doubts about the
validity and reliability of such work place based assessments.
One of the main conclusions of the authors is that self selection of
assessors by trainees should end. But this raises questions about the
validity of an assessment which as reported by the authors is based on the
length of working relationship, and trainees would be the best judge of
choosing assessors with whom they have had a reasonable length of working
relationship in terms of number of shifts worked. But as the authors
report that unregulated self selection of assessors can lead to selection
bias. A possible solution could be that the trainee provides a list of
assessors and their supervisor then invites certain number of assessors
selected randomly to provide feedback.
Another point to be considered in the same context of length of
working relationship is the timing of the MSF sessions. If trainees are
changing posts every six months which is still possible in the current
training pattern it might be useful to have these sessions towards the
later part of the post rather than in the middle as they currently are
done.
One of the other questions raised by the authors is the seniority of
the assessors which I feel is partly corrected by the current system of
MSF which suggests that trainees should choose a certain number of
consultants including their supervisor and certain number of nursing
colleagues as well.
The interesting and well-conducted study of Potijk et al reminds us
once again (though we probably don't need reminders) of the important
difference between statistically versus clinically significant differences
in research studies. The authors report that moderately preterm-born
children had significantly worse scores on all subscales of the CBCL than
did term born children; inspection of the P values in Table 2 shows t...
The interesting and well-conducted study of Potijk et al reminds us
once again (though we probably don't need reminders) of the important
difference between statistically versus clinically significant differences
in research studies. The authors report that moderately preterm-born
children had significantly worse scores on all subscales of the CBCL than
did term born children; inspection of the P values in Table 2 shows that,
statistically, this is quite correct. What is not discussed in the paper,
however, is the clinical significance of these differences. A commonly
used metric for evaluating the clinical significance of observed
differences is Cohen's effect size coefficient 'd'. This 'd' is the ratio
of the mean difference in scores between two groups to the standard
deviation in scores of the groups. Most of the differences shown in Table
2 have a 'd' value of 0.2 or less, which by convention would be considered
at the lower end of a small effect size. None of this takes away from the
finding that there were differences between the groups, but it is
important for readers (and authors) to consider the clinical significance
of differences. The use of large study samples can make differences that
are small and even trivial clinically, appear quite impressive
statistically.
Allen et al (1) are to be congratulated in reporting the first
attempt to quantify the efficacy and impact of Child Death Overview Panels
(CDOP) in the UK. They note that Paediatricians contributing to the
workings of the panel are of the view that the panels function well with
71% of responders agreeing or agreeing strongly that they offer good
value. However, the nature of the study may have involved significant bias
as...
Allen et al (1) are to be congratulated in reporting the first
attempt to quantify the efficacy and impact of Child Death Overview Panels
(CDOP) in the UK. They note that Paediatricians contributing to the
workings of the panel are of the view that the panels function well with
71% of responders agreeing or agreeing strongly that they offer good
value. However, the nature of the study may have involved significant bias
as participating Paediatricians were asked to consider a number of
variables where responses were subjective and, because those involved in
the survey are members of CDOP panels, there may have been an
inappropriately positive view of the impact and importance of the process.
Strikingly, only 27% of respondents in the survey identified the
prevention of future child deaths as the most important function of the
process.
The authors acknowledge that a lack of aggregated National data
compromise efficacy of the panels and cite sources indicating that the
cost of introducing the panels across the UK is of the order of ?53
million. As past (IKM) and current (LOC) members of the CDOP panel we
would agree that any value associated with the process remains unclear.
The lack of objective or measurable outcomes hampers any assessment
and it might be argued that the CDOP process could only be seen to work
and offer value for the considerable investment, if a reduction in
childhood mortality could be demonstrated. Our experience, which dates
from the inception of the CDOP process, is that very many hours are spent
reviewing cases where there are very good medical reasons accounting for
the vast majority of deaths. Few deaths are identified as having been
predominantly due to modifiable factors and a large proportion of the
modifiable factors that are identified are already the subject of major
public health campaigns; for example, co-sleeping and smoking in
pregnancy. Further, we have been concerned that the processes of Coronial
review through Inquest and Serious Case Review overlap very significantly
with the CDOP process - an unnecessary duplication of effort.
We would agree that the lack of aggregated National or Regional data
render any analysis of childhood deaths almost impossible. An individual
CDOP cannot know whether there is an excess mortality due to any
particular cause. This effectively precludes the institution of actions to
remedy service failings at a local level. Attempts to address this are in
progress. For example, in Greater Manchester, the Chairs of a number of
CDOPs have met to explore whether regional aggregation of data might
assist in identifying trends and areas of good or poor service provision.
Because the numbers of childhood deaths by cause are relatively small even
this approach is a poor substitute for National data.
It may be that the paediatricians involved find the experience of
reviewing child deaths rewarding and there will be some learning from
detailed review of cases. However, these benefits fall someway short of
providing justification of the expense of the process. We urgently need
aggregated data to allow comparison of death rates from specific
conditions. Only then will we know whether the primary aim of the process
can be achieved. Until this data is available the value of the CDOP
process cannot be quantified. We live in a time of huge financial
constraint in the NHS; it is our duty to extract the maximum benefit from
every pound spent in the healthcare economy.
Reference
1. Allen L, Lenton S, Fraser J and Sidebotham P. Improving the
practice of child death overview panels: a paediatric perspective. Arch
Dis Child. 2014;99:193-196
Poor weight gain over the first 6-8 weeks is known to be a risk
factor in its own right for developmental delay, which can be demonstrated
not only at school age but, as shown by McDougall et al as early as 4
months.1
McDougall et al suggest that the Child Health Surveillance check at 6
-8 weeks provides the opportunity to identify infants with early weight
faltering; and that future research could ascertain whet...
Poor weight gain over the first 6-8 weeks is known to be a risk
factor in its own right for developmental delay, which can be demonstrated
not only at school age but, as shown by McDougall et al as early as 4
months.1
McDougall et al suggest that the Child Health Surveillance check at 6
-8 weeks provides the opportunity to identify infants with early weight
faltering; and that future research could ascertain whether intervention,
presumably to increase weight gain, would improve later outcomes for
infants. However the first 6-8 weeks are the vulnerable period,
interventions are needed during and not after the completion of this time.
It has already been shown that interventions can be used to encourage
weight gain in both breast and formula fed infants during this early
“window” of opportunity.2 3
UK Health Visitors (and midwives) carry calibrated electronic
weighing scales and see mothers frequently during this important time. If
infants are weighed weekly, then there is the opportunity to detect and
promptly remedy weight faltering thereby reducing the risk of
developmental delay. Also since the effect on later intellectual
development has been shown to be approximately linear over the whole range
of weight velocities, there is the opportunity to help all babies.4
The proposal to omit the first 2 weeks from the WHO2006 breastfed
weight charts (for UK use),5 thereby also removing birth weight from the
chart so that birth centile cannot be identified, may unfortunately limit
the implementation of a cheap worthwhile public health intervention.
Yours sincerely
Dr C A Walshaw
References
1 McDougall P., Drewett R.F., Hungin P, Wright C.M. The detection of
early weight
faltering at the 6-8 week check and its association with family
factors, feeding and
Our long experience in the use of electronic reporting supports and
extends the findings reported by Lynn et al (1). The Australian Paediatric
Surveillance Unit (APSU) has used electronic reporting since 1997 to
collect important information on up to 16 rare childhood diseases
simultaneously, including rare genetic, metabolic, traumatic,
communicable, vaccine-preventable and mental conditions (2). The
paediatricians and...
Our long experience in the use of electronic reporting supports and
extends the findings reported by Lynn et al (1). The Australian Paediatric
Surveillance Unit (APSU) has used electronic reporting since 1997 to
collect important information on up to 16 rare childhood diseases
simultaneously, including rare genetic, metabolic, traumatic,
communicable, vaccine-preventable and mental conditions (2). The
paediatricians and paediatric sub-specialists who contribute to the APSU
currently comprise 92% of Fellows in Paediatrics listed with the Royal
Australasian College of Physicians (3).
Since the introduction of electronic reporting, the proportion of
clinicians who receive and respond to monthly APSU report cards via e-mail
has increased steadily from 11% of 918 clinicians in 1997 (2) to 82% of
1329 clinicians in 2010. The overall report card response rate has
remained at or above 90% annually since 1994 (2).
In addition, in the recent evaluation of the APSU which included a
survey of clinicians who report to the APSU, 67% of 818 respondents also
reported willingness to provide detailed demographic and clinical data via
a secure website if one was available (4). The APSU is currently
developing such a web-based system. Importantly, electronic notification
and data collection allows rapid response to outbreaks or importation of
diseases by quickly issuing alerts on new or emerging conditions. In
response to reports of influenza-related child deaths in 2007, APSU was
able to rapidly initiate weekly surveillance for severe complications of
seasonal influenza (5). The implementation of this system proved
invaluable for the rapid collection of detailed data on severe
complications of influenza during the H1N1 2009 pandemic.
Our experiences and the recent experience of Lynn and colleagues
demonstrate that clinicians are willing participants in active disease
surveillance which uses electronic reporting.
References
1. Lynn RM, Riding K, McIntosh N. The use of electronic reporting to
aid surveillance of ADRs in children: a proof of concept study. Arch Dis
Child 2010;95:262-265.
2. Srikanthan S, Zurynski Y, Elliott E. Australian Paediatric
Surveillance Unit: Celebrating 15 years of surveillance. 1993-2007. APSU
2008.
3. He S, Zurynski YA, Elliott EJ. Evaluation of a national resource
to identify and study rare diseases: The Australian Paediatric
Surveillance Unit. J Paediatr Child Health 2009;45:498-504.
4. He S, Zurynski YA, Elliott EJ. What do paediatricians think of the
Australian Paediatric Surveillance Unit? J Paediatr Child Health 2010;
doi: 10.1111/j.1440-1754.2010.01755
5. Zurynski YA, Lester-Smith D, Festa MS, Kesson AM, Booy R, Elliott
EJ. Enhanced surveillance for serious complications of influenza in
children: role of the Australian Paediatric Surveillance Unit. Commun Dis
Intell 2008;32:71-76.
I would like to draw the authors' attention to an eligible systematic
review which was not included in their critical overview. Our systematic
review of homeopathy for ADHD has been published in the Cochrane Library
for some years and is indexed on Medline:
Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005648.
Homeopathy for attention deficit/hyperactivity disorder or hyperkinetic
disorder.
I would like to draw the authors' attention to an eligible systematic
review which was not included in their critical overview. Our systematic
review of homeopathy for ADHD has been published in the Cochrane Library
for some years and is indexed on Medline:
Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005648.
Homeopathy for attention deficit/hyperactivity disorder or hyperkinetic
disorder.
This is important because it raises questions about the sensitivity
of the searches, and in this case of this particular review, emphasises
the importance of observational and theoretical work prior to conducting
expensive RCTs that may not be able to answer clinically relevant
questions.
We read with interest your article demonstrating surprisingly low
levels of culture-confirmed invasive bacterial infections in children.[1]
Whilst we agree better strategies are needed for separating low risk,
febrile children from those with invasive-infections, we believe there is
another significant factor contributing to their apparent low rates.
Large studies demonstrate that blood-culture volumes are frequ...
We read with interest your article demonstrating surprisingly low
levels of culture-confirmed invasive bacterial infections in children.[1]
Whilst we agree better strategies are needed for separating low risk,
febrile children from those with invasive-infections, we believe there is
another significant factor contributing to their apparent low rates.
Large studies demonstrate that blood-culture volumes are frequently
inadequate in children.[2] It is well documented that the most significant
factor in yielding an organism from culture is the volume of blood
sampled.[3, 4] Insufficient volumes lead to large numbers of false-
negatives, and it is estimated that 50% of cultures taken from children
are of inadequate volume.[2]
We audited blood-culture volumes locally, analysing 66 patient
samples (target volumes from previous studies [2]). We documented an
overall compliance of 33%. Significantly this included 0% compliance in
the >10yr age-group (N=11). Similar volumes were taken from 14 year-
olds as 1 month-olds (Mean 1.92ml vs 1.00ml respectively), despite the
>10-fold difference in circulating volume and haemodilutionary effect
on bacterial concentrations. From our intervention we learned this was
largely due to a lack of education of how much blood was necessary from
different sized children. Better education is clearly needed.
Your article mentions standard practice taking "at least 1 - 2ml
blood"[1], however for at least the >6000 tests performed in the 5-15
year-olds, 1-2ml of blood would be insufficient to produce a reliable
result. Recent recommendations even suggest for children >36kg, an
adult regime of cultures should be performed (40-60ml).[5]
Even taking into account "modern technologies [making] blood volumes
less problematic"[1] our audit shows many clinicians remain unaware how
much blood it is necessary to take. Considering that children remain
difficult to venesect due to their small veins and poor compliance, the
positive yield of blood-cultures is certain to underestimate the true
number of invasive-infections in children.
References
1. Le Doare K, Nichols A-L, Payne H, et al. Very low rates of culture
-confirmed invasive bacterial infections in a prospective 3-year
population-based surveillance in Southwest London. Arch Dis Child
Published Online First: February 19th 2014. doi:10.1136/archdischild-2013-
305565
2. Connell TG, Rele M, Cowley D, Buttery JP, Curtis N, How reliable
is a negative blood culture result? Volume of blood submitted for culture
in routine practice in a children's hospital, Pediatrics. 2007;119(5):891.
3. Mermel LA, Maki DG, Detection of bacteremia in adults:
consequences of culturing an inadequate volume of blood, Ann Intern Med.
1993;119(4):270.
4. Ilstrup DM, Washington JA 2nd.The importance of volume of blood
cultured in the detection of bacteremia and fungemia. Diagn Microbiol
Infect Dis. 1983;1(2):107
5. Ellen Jo Baron et al, A guide to utilization of the microbiology
laboratory for diagnosis of infectious diseases: 2013 recommendations by
the Infectious Diseases Society of America (IDSA) and the American Society
for Microbiology, Clinical Infectious Diseases, 2013 Aug; 57 (4) : e22-
e121.
Dear Sir,
Some days ago we received a letter from colleagues in London asking us to
comment on the article of Simeone and coll. reporting a lack of
relationship between chronic constipation (CC) and cow’s milk allergy
(CMA), recently published in ADC (1). Our English Colleagues referred that
they had observed “dramatic cases” of chronic constipation unresponsive to
laxative treatment which fully resolved on CM-free diet a...
Dear Sir,
Some days ago we received a letter from colleagues in London asking us to
comment on the article of Simeone and coll. reporting a lack of
relationship between chronic constipation (CC) and cow’s milk allergy
(CMA), recently published in ADC (1). Our English Colleagues referred that
they had observed “dramatic cases” of chronic constipation unresponsive to
laxative treatment which fully resolved on CM-free diet and as this is
also our experience in many cases (2-5) they asked to “defend this truth”.
However, we think that the study of Simeone and coll. is very different
from our previous studies on CC and CMA. In their article (1) they
investigated for an association between CC and atopic disease and to do
this performed a series of IgE-mediated assays. It is, in part, not
surprising that they did not find a more frequent association of atopy
(positive assays and clinical history) in CC patients than in controls, as
it is well known that the immunologic mechanisms of the majority of
gastrointestinal manifestations of food allergy are not based on IgE-
mediated mechanisms (6) and we ourselves have not found a higher frequency
of positive IgE-based assays in patients with CC due to CMA. Thus, a lack
of association between atopy or IgE-mediated assays and CC was to have
been expected and does not mean that CC cannot be due to CMA. The only
aspect of the Simeone study which could be compared with our and others’
previous studies (7-10), is that they placed eleven CC patients
unresponsive to laxative treatment on CM-free diet. They found that none
of these eleven patients improved on CM-free diet. On the basis of this
very small patient sample they concluded that “the refractory constipation
is not associated with CMA in the general paediatric population”. This
could also be true in the general population, although we do have doubts
about this, but more than eleven patients must be evaluated before a firm
conclusion can be reached.
What is certain is that in a tertiary gastroenterology clinic with
experience in the food allergy-intolerance field – as ours is - the
frequency of CC unresponsive to laxative treatments and due to food
allergy is higher than one third of cases. Probably this high frequency is
biased by the pre-selection of the patients referred to our clinic, but
whatever the real frequency of the relationship between CC and food
allergy may be, many prestigious research groups from England (7), the USA
(10), Finland (11) and other centres world-wide (8,9) have reported
results identical to ours and firmly confirmed that CC can be a
manifestation of food allergy. Furthermore, the CC-CMA association has
also been included in a review published in Gastroenterology (12).
Finally, we recently suggested the possibility that the patients could be
suffering from multiple food allergy and not simply from CM
hypersensitivity. In fact, bowel movements normalised in some patients
unresponsive to CM-free diet when they were placed on a more restricted
oligoantigenic diet (5).
Do paediatricians who first visit a child consider the hypothesis of CMA-
related constipation? We believe they do, but this does not mean that a CM
-free diet should be prescribed for every patient with CC. The first
treatment approach must be a regular diet (water, fibre, etc) and
laxatives. However, if the patient does not improve and especially when
he/she has a previous history or a family history of CMA, the probability
of a CMA diagnosis increases. In these cases a consultation with a
specialist should be suggested and, after further evaluation, an
elimination diet could be prescribed. We do not know how many
paediatricians - or paediatric gastroenterologists - in the world use this
approach, but we think there are too few. Despite the clear evidence,
there are still many paediatricians who do not accept that CMA can be a
cause of CC. The Naples Gastroenterology School is a medical teaching
school which we have learned a great deal from and its members contribute
to form opinions and guidelines in paediatric gastroenterology.
Unfortunately, their experience with CC conflicts with the evidence in the
literature about the relationship between CC and CMA and this certainly
hinders the possibility of a correct treatment for patients with CC due to
CMA. Our role can be to add further data to help better understand the
problem and to offer further evidence of this relationship.
Yours faithfully,
REFERENCES
1) Simeone D, Miele E, Boccia G, Marino A, Troncone R, Staiano A.
Prevalence of atopy in children with chronic constipation. Arch Dis Child
2008;93;1044-1047
2) Iacono G, Carroccio A, Cavataio F, Montalto G, Cantarero MD,
NotarbartoloA. Chronic constipation as a symptom of cow milk allergy. J
Pediatr 1995; 126: 34–9.
3) Iacono G, Cavataio F, Montalto G, et al. Intolerance of cow’s milk and
chronic constipation in children. N Engl J Med 1998; 338: 1100–4.
4) Carroccio A, Scalici C, Maresi M, et al. Chronic constipation and food
intolerance: a model of proctitis causing constipation. Scand J
Gastroenterol 2005; 40: 33–42
5) Iacono G, Bonventre S, Scalici C, et al. Food intolerance and chronic
constipation: manometry and histology study. Eur J Gastroenterol Hepatol
2006; 18: 143–50.
6) Sampson H, Sicherer SH, Birnbaim AH. American Gastroenterological
Association Medical Position Statement: guidelines for the evaluation of
food allergies. Gastroenterology 2001; 120: 1023–5.
7) Shah N, Lindley K, Milla P. Cow’s milk and chronic constipation in
children. N Engl J Med 1999; 340: 891–2.
8) Daher S, Sole` D, de Morais MB. Cow’s milk and chronic constipation in
children. N Engl J Med 1999; 340: 891.
9) Daher S, Tahan S, Sole` D, et al. Cow’s milk protein intolerance and
chronic constipation in children. Pediatr Allergy Immunol 2001; 12:
339–43.
10) Vanderhoof JA, Perry D, Hanner TL, Young RJ. Allergic constipation:
association with infantile milk allergy. Clin Pediatr 2001; 40: 399–402
11) Turunen S, Karttunen TJ, Kokkonen J. Lymphoid nodular hyperplasia and
cow’s milk hypersensitivity in children with chronic constipation. J
Pediatr 2004; 145: 606–11.
12) Bischoff S, Crowe SE. Gastrointestinal food allergy: new insights into
pathophysiology and clinical perspectives. Gastroenterology 2005; 128:
1089–113
To the Editor,
We are very pleased to see the comment from Dr Burke regarding the ethical and social considerations of Next Generation Sequencing, in response to our review.
As we noted in our original article, the field is very complex, with a major issue being the interpretation of sequencing data, such that without follow up investigations many variants cannot be confidently assigned as either beni...
Most patients presenting to a paediatric department for acute care will be weighed as part of the nursing assessment especially because weights are important for drug and fluid prescriptions. Junior doctors however generally fail to take the next step in this opportunistic contact to plot these weights. Unless clinically indicated e.g. as part of body surface area for drug prescriptions, the height is often not measured,...
I read with interest the article published by Archer et al on Multisource Feedback of paediatric registrars. This article is very encouraging for trainees like me and also answers doubts about the validity and reliability of such work place based assessments.
One of the main conclusions of the authors is that self selection of assessors by trainees should end. But this raises questions about the validity of an...
The interesting and well-conducted study of Potijk et al reminds us once again (though we probably don't need reminders) of the important difference between statistically versus clinically significant differences in research studies. The authors report that moderately preterm-born children had significantly worse scores on all subscales of the CBCL than did term born children; inspection of the P values in Table 2 shows t...
Allen et al (1) are to be congratulated in reporting the first attempt to quantify the efficacy and impact of Child Death Overview Panels (CDOP) in the UK. They note that Paediatricians contributing to the workings of the panel are of the view that the panels function well with 71% of responders agreeing or agreeing strongly that they offer good value. However, the nature of the study may have involved significant bias as...
Poor weight gain over the first 6-8 weeks is known to be a risk factor in its own right for developmental delay, which can be demonstrated not only at school age but, as shown by McDougall et al as early as 4 months.1
McDougall et al suggest that the Child Health Surveillance check at 6 -8 weeks provides the opportunity to identify infants with early weight faltering; and that future research could ascertain whet...
Our long experience in the use of electronic reporting supports and extends the findings reported by Lynn et al (1). The Australian Paediatric Surveillance Unit (APSU) has used electronic reporting since 1997 to collect important information on up to 16 rare childhood diseases simultaneously, including rare genetic, metabolic, traumatic, communicable, vaccine-preventable and mental conditions (2). The paediatricians and...
Dear Editors,
I would like to draw the authors' attention to an eligible systematic review which was not included in their critical overview. Our systematic review of homeopathy for ADHD has been published in the Cochrane Library for some years and is indexed on Medline: Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005648. Homeopathy for attention deficit/hyperactivity disorder or hyperkinetic disorder.
...
We read with interest your article demonstrating surprisingly low levels of culture-confirmed invasive bacterial infections in children.[1] Whilst we agree better strategies are needed for separating low risk, febrile children from those with invasive-infections, we believe there is another significant factor contributing to their apparent low rates.
Large studies demonstrate that blood-culture volumes are frequ...
Dear Sir, Some days ago we received a letter from colleagues in London asking us to comment on the article of Simeone and coll. reporting a lack of relationship between chronic constipation (CC) and cow’s milk allergy (CMA), recently published in ADC (1). Our English Colleagues referred that they had observed “dramatic cases” of chronic constipation unresponsive to laxative treatment which fully resolved on CM-free diet a...
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