I find the response to Assistant Professor Samlaska to be a bit
limited.
Firstly, in the study by Wenner, they point out at the end of the
paper that unbeknownst to them the clear duct tape they used had a
different glue on it than regular duct tape. In fact, it had an acrylic
based glue. Furthermore, the control group treatment used moleskin - this
also has an acrylic based glue. So, when Wenner et al found no...
I find the response to Assistant Professor Samlaska to be a bit
limited.
Firstly, in the study by Wenner, they point out at the end of the
paper that unbeknownst to them the clear duct tape they used had a
different glue on it than regular duct tape. In fact, it had an acrylic
based glue. Furthermore, the control group treatment used moleskin - this
also has an acrylic based glue. So, when Wenner et al found no difference
between the effectiveness of treatments in the 2 groups, each of which has
used a patch adhered with acrylic-based glue. In other words, both groups
had largely the same treatment. It seems hardly surprising that they found
no difference in efficacy of treatment versus non-treatment groups.
Further I note the meta analyses done by Gibbs et al in 2006 and Kwok
in 2012 also failed to acknowledge this limitation.
Your comment that the families would not know the difference between
acrylic based or rubber based adhesive may be true but that only speaks to
a potential placebo effect, which given the other significant flaw in the
study, seems moot.
I have updated the wikipedia entry on duct tape occlusion therapy.
feel free to contribute to it. I have not referred to your study since it
is not freely available without subscription.
We thank Zylbersztejn, et al for their constructive letter and for
their support for the Countdown initiative. Their data suggests that high
rates of preterm birth and thresholds for reporting preterm birth [1] in
the UK were one of the most likely explanations for the disparities seen
between the UK and European countries such as Sweden, and we agree this is
likely (as outlined in our recent Lancet paper [2]. We agree en...
We thank Zylbersztejn, et al for their constructive letter and for
their support for the Countdown initiative. Their data suggests that high
rates of preterm birth and thresholds for reporting preterm birth [1] in
the UK were one of the most likely explanations for the disparities seen
between the UK and European countries such as Sweden, and we agree this is
likely (as outlined in our recent Lancet paper [2]. We agree entirely that
it is important to know where to target policy, and their data moves us on
considerably in determining priorities. This is precisely the sort of
approach needed on the Countdown technical committee and we look forward
to further collaboration.
Ingrid Wolfe, Angela Donkin, Michael Marmot, Alison Macfarlane,
Hilary Cass, Russell Viner
Many thanks for the recent letter regarding a rapid assay technique
for testing fecal calprotectin1. This would indeed be useful in the
clinical setting if it allows the transmission of accurate and rapid fecal
calprotectin levels to treating clinicians. As discussed in the original
archimedes report, the difficulties surrounding the need for an adequate
cut-off remain the main barrier to the use of fecal calprotectin a...
Many thanks for the recent letter regarding a rapid assay technique
for testing fecal calprotectin1. This would indeed be useful in the
clinical setting if it allows the transmission of accurate and rapid fecal
calprotectin levels to treating clinicians. As discussed in the original
archimedes report, the difficulties surrounding the need for an adequate
cut-off remain the main barrier to the use of fecal calprotectin as a
diagnostic adjunct in necrotising enterocolitis2.
JFB Houston
1. Bin-Nun A, Booms C, Sabag N, Mevorach R, Algur N, Hammerman C.
Rapid
fecal calprotectin (FC) analysis: point of care testing for diagnosing
early necrotizing enterocolitis. Am J Perinatol. 2015;32:337-42.
2. Houston JFB, Morgan JE. Question 2: Can faecal
calprotectin be used as an effective diagnostic aid for necrotising
enterocolitis in neonates? Arch Dis Child. 2015;100:1003-6
We read with interest the article by Patti et al(1) and agree with
their conclusion that a history of normal voiding does not exclude a
diagnosis of posterior urethral valve (PUV). This has also been
demonstrated in other case series and reports.(2,3) The article by Patti
et al demonstrates a beautiful example of bilateral vesico-ureteric reflux
(VUR) on micturating cystourogram. We however raise...
We read with interest the article by Patti et al(1) and agree with
their conclusion that a history of normal voiding does not exclude a
diagnosis of posterior urethral valve (PUV). This has also been
demonstrated in other case series and reports.(2,3) The article by Patti
et al demonstrates a beautiful example of bilateral vesico-ureteric reflux
(VUR) on micturating cystourogram. We however raise the question of
whether the filling defect highlighted actually represents PUV (also
referred to as a congenitally obstructing posterior urethral membrane).
The classic narrowing of PUV is more distal in the urinary tract with
dilatation proximal to the filling defect. It is difficult to explain the
cystoscopy findings though leaflets of the normal anatomical structure,
plicae colliculi, can be visualised on cystoscopy and their role in
bladder outlet obstruction is debated. Bladder abnormalities are found in
a significant number of patients with VUR(4) and perhaps in this case of
reflux the urethra wasn't to blame at all.
References
1)Patti G, Naviglio S, Pennesi M, et al. Normal voiding does not
exclude posterior urethral valves. Arch Dis Child 2013;98:634
2)Bomalaski MD, Anema JG, Coplen DE, Koo HP, Rozanski T, Bloom DA.
Delayed presentation of posterior urethral valves: a not so benign
condition. J Urol. 1999 Dec;162(6):2130-2
3)Kanaroglou N, Braga LH, Massaro P, Lau K, Demaria J. Lower
abdominal mass in a 16-year old adolescent: an unusual presentation of
posterior urethral valves. Can Urol Assoc J. 2011 Feb;5(1):E1-3. doi:
10.5489/cuaj.10045.
4)Carpenter MA, Hoberman A, Mattoo TK, Mathews R, Keren R, Chesney
RW, Moxey-Mims M, Greenfield SP; RIVUR Trial Investigators. The RIVUR
Trial: Profile and Baseline Clinical Associations of Children With
Vesicoureteral Reflux. Pediatrics. 2013 Jul;132(1):e34-45. doi:
10.1542/peds.2012-2301. Epub 2013 Jun 10.
Monika Bajaj and Amaka Offiah are to be commended for their
thoughtful and helpful review of the benefits and risks of skeletal
imaging in cases of suspected child abuse.(1) The diagnosis of child
abuse is a complex process which requires an evidence-informed approach
combining clinical acumen with collaborative multi-agency working.
Skeletal imaging, including CT scans, provide a valuable tool for the
clinician, but,...
Monika Bajaj and Amaka Offiah are to be commended for their
thoughtful and helpful review of the benefits and risks of skeletal
imaging in cases of suspected child abuse.(1) The diagnosis of child
abuse is a complex process which requires an evidence-informed approach
combining clinical acumen with collaborative multi-agency working.
Skeletal imaging, including CT scans, provide a valuable tool for the
clinician, but, as Bajaj and Offiah point out, is not without its risks.
The clinician must take a lead in informing the parents and other
professionals of the potential benefits of imaging, the inherent risks,
and the statutory responsibilities under which we work.
The concept of informed consent in such situations is problematic.
What reasonable parent will subject their child to a potentially harmful
procedure to rule out abuse which they 'know' has not happened?
Conversely, what reasonable parent, having abused their child, will
consent to a test which may help to prove that abuse? Parents must be
informed of the small but real risks associated with skeletal imaging and
that these need to be balanced against the clinical imperative to identify
or exclude injury and the statutory duty to investigate cases of possible
harm. Where parents do not give their consent to such imaging, the case
needs to be discussed with the multi-disciplinary team, and a decision
made as to whether to work with the increased uncertainty inherent in not
having a skeletal survey or CT scan, or whether to seek a court order to
obtain such investigations outwith parental consent.
Such decisions need to be made in the light of the known short- and
long-term harms caused by child abuse. These include a small risk of
fatality from severe physical abuse, and the much more prevalent ongoing
harm suffered by children living in contexts of ongoing physical or
emotional abuse and neglect. The risk of fatality, while clearly
significant, should not be overstated. Our current analysis of Serious
Case Reviews in England from 2009-14 suggests an average of 28-33 deaths
per year directly caused by child abuse (Sidebotham, unpublished data).
In their article, Bajaj and Offiah state that 'Data from Child Death
Reviews has identified "deliberately inflicted injury, abuse or neglect"
as the single largest category of childhood deaths with modifiable factors
in England.'(2) In fact, these data show that this is the category with
the highest proportion of deaths considered modifiable (65% compared to
20% overall). However, of the 784 child deaths for which child death
overview panels considered there to be modifiable factors present, only 28
(3.6%) were due to deliberately inflicted injury, abuse or neglect. This
compares to 185 sudden unexpected and unexplained deaths (24% of all
deaths with modifiable factors present); 178 deaths from perinatal or
neonatal events (23%); and 145 (18%) from trauma and other external
factors. Far from being the 'single largest category of childhood deaths
with modifiable factors', deaths from child abuse make up a very small
proportion of those child deaths which we, as a society, may be able to
prevent.
References
1. Bajaj M, Offiah AC. Imaging in suspected child abuse: necessity or
radiation hazard? Arch Dis Child. 2015;100(12):1163-8.
2. Department for Education. Child death reviews: year ending 31st March
2012. London: Department for Education, 2013.
The ADC Archivist recently reported that Freedman et al had revealed
that "old-fashioned clinical examination" missed about 20% of cases of
significant dehydration in children.[1] Their assessment of this work was
not surprising because the meta-analysis in the Journal of Pediatrics
carries the headline message that even the "most accurate, noninvasive"
methods could only "identify dehydration suboptimally", and it was a...
The ADC Archivist recently reported that Freedman et al had revealed
that "old-fashioned clinical examination" missed about 20% of cases of
significant dehydration in children.[1] Their assessment of this work was
not surprising because the meta-analysis in the Journal of Pediatrics
carries the headline message that even the "most accurate, noninvasive"
methods could only "identify dehydration suboptimally", and it was a high
quality analysis which only included studies that had accurately
quantified the degree of dehydration by serial weighings.[2] However,
Freedman et al's conclusions are misleading because they only selected
papers for analysis that had evaluated a rapid triaging tool, and none
which had undertaken standard full clinical examinations.
The four papers that qualified for Freedman et al's statistical
reanalysis had used the 'Clinical Dehydration' and 'Gorelick' scores to
detect dehydration secondary to gastroenteritis. The individual components
of these tests were not mentioned in their meta-analysis paper, but either
can be performed quickly on a fully-clothed infant in less than a minute.
They rely on scoring (a) the child's general appearance (seeking signs of
thirst, restlessness, lethargy and irritability, drowsiness, limpness,
cold, sweatiness, or coma), (b) whether the eyes look sunken, (c) if the
tongue feel moist, and (d) if tears are reduced or absent, all on simple
scales. They do not include any of the following components of routine
clinical examinations: capillary refill time, pulse rate and volume,
respiratory pattern, peripheral coolness, or skin turgor. As such, these
authors are not entitled to list their triage-type scoring as being the
"most accurate, noninvasive" clinical tests for dehydration. By presenting
their data as they did, Freedman et al may have produced a false-
impression among paediatricians about the sensitivity of full, careful
clinical examinations for evaluating fluid-balance status, and by
reviewing it as they did the ADC Archivist may have inadvertantly
perpetuated this confusion.
References
1. Archivist. Assessing dehydration. Archives of Diesease in
Childhood 2015;100:999.
2. Freedman SB, Vandermeer B, Milne A, Hartling L. Diagnosing clinically
significant dehydration in children with acute gastroenteritis using
noninvasive methods: a meta-analysis. Journal of Pediatrics 2015;166:908-
16.
I find the response to Assistant Professor Samlaska to be a bit limited.
Firstly, in the study by Wenner, they point out at the end of the paper that unbeknownst to them the clear duct tape they used had a different glue on it than regular duct tape. In fact, it had an acrylic based glue. Furthermore, the control group treatment used moleskin - this also has an acrylic based glue. So, when Wenner et al found no...
We thank Zylbersztejn, et al for their constructive letter and for their support for the Countdown initiative. Their data suggests that high rates of preterm birth and thresholds for reporting preterm birth [1] in the UK were one of the most likely explanations for the disparities seen between the UK and European countries such as Sweden, and we agree this is likely (as outlined in our recent Lancet paper [2]. We agree en...
Many thanks for the recent letter regarding a rapid assay technique for testing fecal calprotectin1. This would indeed be useful in the clinical setting if it allows the transmission of accurate and rapid fecal calprotectin levels to treating clinicians. As discussed in the original archimedes report, the difficulties surrounding the need for an adequate cut-off remain the main barrier to the use of fecal calprotectin a...
Dear Editor,
We read with interest the article by Patti et al(1) and agree with their conclusion that a history of normal voiding does not exclude a diagnosis of posterior urethral valve (PUV). This has also been demonstrated in other case series and reports.(2,3) The article by Patti et al demonstrates a beautiful example of bilateral vesico-ureteric reflux (VUR) on micturating cystourogram. We however raise...
Monika Bajaj and Amaka Offiah are to be commended for their thoughtful and helpful review of the benefits and risks of skeletal imaging in cases of suspected child abuse.(1) The diagnosis of child abuse is a complex process which requires an evidence-informed approach combining clinical acumen with collaborative multi-agency working. Skeletal imaging, including CT scans, provide a valuable tool for the clinician, but,...
The ADC Archivist recently reported that Freedman et al had revealed that "old-fashioned clinical examination" missed about 20% of cases of significant dehydration in children.[1] Their assessment of this work was not surprising because the meta-analysis in the Journal of Pediatrics carries the headline message that even the "most accurate, noninvasive" methods could only "identify dehydration suboptimally", and it was a...
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