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Recent eLetters

Displaying 1-8 letters out of 1353 published

  1. Management of chronic hepatitis B infection - will NICE guidance lead to over investigation?

    We were pleased to read Dr Davison's review of the two recently published guidelines for managing chronic Hepatitis B infection in children [1]. We have recently audited our practice against both of these guidelines. As Dr Davison points out; "The level of Alanine transaminase (ALT) at which treatment should be considered highlights a fundamental difference between the guidelines". NICE suggests that ALT in males above 30 IU/L and in females above 19 IU/L is considered abnormal [2]. The ESPGHAN guidelines suggest a threshold of more than 1.5 times the upper limit of normal (or more than 60 IU/L) [3]. In our cohort of 12 children with chronic hepatitis B, all the children had an abnormal ALT using NICE guidance, but only 7 had abnormal ALT by ESPHGAN criteria, of which only 4 remain abnormal 6 months later. The number of children in our audit is small, but suggests that using the NICE criteria for abnormal ALT could lead to over investigation for children with chronic hepatitis B. NICE guidance extrapolated adult ALT values to children. We agree that "further research is needed to review the appropriateness of these values in children and young people when making decisions to start treatment".

    References

    1. Davison S. Management of chronic hepatitis B infection. Arch Dis Child. 2014 May 8. doi: 10.1136/archdischild-2013-304925. [Epub ahead of print]

    2. National Institute for Health and Care Excellence (NICE). Diagnosis and management of chronic hepatitis B in children, young people and adults, 2013. guidance.org.uk/cg165.

    3. Sokal EM, Paganelli M, Wirth S, et al. Management of chronic hepatitis B in childhood: ESPGHAN clinical practice guidelines: consensus of an expert panel on behalf of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition. J Hepatol 2013;59:814-29.

    Conflict of Interest:

    Dr Davison comes to do a Hepatitis clinic with me once a year.

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  2. How to make a microbiologist go pale

    There are a few ways in which we can induce funny turns in our microbiology colleagues. One of the easiest is to say, within their earshot: "We'll stop the antibiotics if the cultures are negative". Blood cultures are a terrible gold standard. If they're positive, for a plausible organism, then they're useful - they allow you to refine antimicrobial therapy, and make decisions about duration etc. But negative cultures? My practice was strongly influenced by McWilliam and Riordan's review of CRP. http://ep.bmj.com/content/95/2/55.full In short, if you have two CRPs, more than 18 hours apart, and both 10 or lower, you can be pretty sure that you're not dealing with serious bacterial sepsis. The exception to this is the child who looked genuinely dreadful when they came in. We use the following hierarchy: - the clinical status of the child - paired CRP - cultures at 48 hours The sepsis 6 principles (http://survivesepsis.org/the-sepsis-six/) will undoubtedly improve our management of the child with true sepsis - but they will also promote over treatment, unless we're really good at stopping antibiotics too.

    Conflict of Interest:

    I'm an editor at ADC, with responsibility for the Education and Practice edition

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  3. Vitamin D supplementation - The North Tyneside Experience

    The Department of Health (DoH) recommends universal vitamin D supplementation for non-formula-dependent children aged 6 months to 5 years [1]. Following the report by Jamieson et al. [2], we share similar data from North Tyneside, showing that few children are being supplemented with vitamin D and that parental awareness of current recommendations is poor.

    We distributed questionnaires to consecutive parents and carers of children aged 6 months to 5 years, presenting acutely to the Children's Assessment Unit at North Tyneside General Hospital earlier this year. We defined children at high-risk of vitamin D deficiency as those receiving less than 500 ml formula milk per day. The hospital serves a predominantly White British population at risk of vitamin D deficiency owing to the negative impact of reduced sunlight exposure in the higher latitudes of Northeast England.

    The median age of the surveyed population was 27 months. Overall 10.5% (4/38) took Vitamin D supplements or 15.4% (4/26) in the high risk group. Only 18.5% (7/38) of carers were aware of current DoH recommendations with regard to vitamin D supplementation.

    In view of the resurgence of vitamin D deficiency and its paediatric manifestations [3-4], we support the suggestion that a health promotion campaign to raise public awareness of DoH recommendations on supplementation is indicated and argue for universal vitamin distribution for children from birth to 5 years in primary care.

    REFERENCES

    1.National Institutes of health. July 2014.<http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional />

    2.Jamieson K, Braha N, Gritz A, et al. Vitamin D deficiency: are we preventing the preventable? Arch Dis Child 2014;99(5):486-7.

    3.Ladhani S, Srinivasan L, Buchanan C, et al. Presentation of Vitamin D deficiency. Arch Dis Child 2004;89(8):781-4.

    4.Pearce SH, Cheetham TD. Diagnosis and management of vitamin D deficiency. BMJ 2010;340:b5664.

    Conflict of Interest:

    None declared

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  4. Is litigation an indispensable form of protection against error

    I read with great interest, Dr Rosenbloom's recent article. He discusses how difficult issues are raised involving blame when a medical error is discovered but the process may offer families restitution and compensation. 'Parental responsibility' is a term used to describe the legal duty that a parent has to their child (1). Parents act, therefore, as surrogate decision makers on the basis of what they believe to be in the child's best interests. This responsibility includes making decisions to pursue litigation that may have an effect on their child's future and weighing up the harms and benefits of pursuing litigation.

    Existing regulations and legislation are designed to afford protection to children receiving medical care. However, in today's climate, litigation can be viewed as an indispensable form of protection or compensation against medical carelessness or error. Almost every hospital and clinician have full insurance coverage which are skyrocketing annually. Yet, there is no evidence that medical litigation has resulted in improved healthcare.(2) Studdert et al found that claims which found no evidence of medical error were often denied compensation but substantial expenditures go toward litigation over errors and payment of them. The overhead costs of medical litigation is spiralling (3).

    Wood states that 'the law confuses error with negligence and error should not be the basis for litigation'(4). Litigation based on error is therefore counter-productive to improving quality of care. Surely, the ultimate aim of our healthcare system is to enhance safety and quality, not reduce insurance premiums

    1.Children's Act 1989, section 3(1). 2. Morris JA Jr, Carrillo Y, Jenkins JM, Smith PW, Bledsoe S, Pichert J, White A. Surgical adverse events, risk management, and malpractice outcome: morbidity and mortality review is not enough. Ann Surg. 2003 Jun;237(6):844-51 3. Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med 2006;354:2024-33. 4. Wood C.The misplace of litigation in medical practice. Aust N Z J Obstet Gynaecol. 1998 Nov;38(4):365-76.

    Conflict of Interest:

    None declared

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  5. Anxiety disorders in children with tics

    We read with great interest the recent review article by Creswell, Waite and Cooper on 'Assessment and management of anxiety disorders in children and adolescents'. The article brought to the forefront the importance of accurately identifying and treating anxiety disorders during development, with an encouraging discussion of new treatment strategies and delivery approaches to increase access to psychological therapies for children with anxiety disorders. We are keen to add to these discussions by raising awareness of the common co-occurrence and interaction between anxiety symptomatology and tics for children with Tourette syndrome or other chronic tic disorders (CTD). Psychiatric diagnoses are commonly reported for children with CTD , with approximately 50% of children meeting criteria for at least one anxiety disorder.[1] Obsessive compulsive disorder (OCD), social phobia and generalised anxiety disorder are most commonly reported, though separation anxiety may also co- occur.[1] Interestingly, for children with CTD, behavioural difficulties (e.g. Attention Deficit Hyperactivity Disorder) are most commonly reported during the primary school years whilst anxiety disorders are more prevalent during the teenage years, thus a reduction in externalising behaviours are associated with an increase in internalising behaviours.[2] Findings from our own clinical population support this trajectory and indicate that for children with CTD quality of life is more closely related to anxiety symptomatology than tic severity.[3] In addition, in our clinical experience, the effective management of anxiety disorders with evidence based cognitive-behavioural strategies (as advocated by Creswell and colleagues) often results in improved in tic control and reduced interference from tics on day to day life. Thus, there is a complex interaction between anxiety and tics during development. This highlights the need for the careful evaluation of anxiety disorders in children with CTD to ensure that their broader mental health needs are not overlooked, as for many children often it is not the tics that need managing but the co-morbid psychiatric conditions.

    References:

    1. Specht, M. W., Woods, D. W., Piacentini, J., Scahill, L., Wilhelm, S., Peterson, A. L., ... & Walkup, J. T. Clinical characteristics of children and adolescents with a primary tic disorder. Journal of Developmental and Physical Disabilities 2011;23(1):15-31.

    2. Rizzo, R., Gulisano, M., Cal?, P. V., & Curatolo, P. (2012). Long term clinical course of Tourette syndrome. Brain and Development 2012;34(8):667-673.

    3. Woods, M., Robinson, S., Brennan, H, Bunton, P., & Hedderly, T. A Comparison of Clinician and Self-Report Measures of Tics, Co-morbid Difficulties and Quality of Life [abstract p48]. European Society Study of Tourette Syndrome, 25-26 April 2014, Pitie-Salpetriere Hospital, Paris

    Conflict of Interest:

    None declared

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  6. Re: Epidemiology of Paediatric Firearm Injuries

    We appreciate the response from Murch(1) and colleagues as it highlights the dramatic difference in firearm injury rates between the United Kingdom and the United States. Great Britain's firearm regulation is among the strictest in the world while there is significant state to state variability in the United States (2, 3). A study by Fleegler (3), et al. demonstrated that greater statewide firearm regulations are associated with a lower rate of firearm fatalities within the state both for suicides and homicides, which may partially account for the differences in rates between the countries.

    Other factors that may contribute to the differing rates between the two countries include the differences in firearm availability and ownership. It has been shown that large cities with more federal firearms licensees (individuals or stores licensed by the federal government to sell firearms) have higher rats of gun homicide (4). Additionally, a recent study demonstrated that countries with higher numbers of guns per capita had higher rates of firearm-related deaths(5).

    These studies along with our own (6) support the notion that the United States has far to go in terms of improving firearm regulations and safety. By looking to other countries, we can learn which legislative models and injury prevention strategies have been most successful in reducing firearm-related injuries worldwide.

    1. Murch H, Heatman B, Naughton A, Sibert JR. Epidemiology of paediatric firearm injuries. Arch Dis Child. 2014; doi: 10.1136/archdischild-2014-306861 [published Online First: 2014/06/22].

    2. Firearms-Control Legislation and Policy: Great Britain. Washington, D.C.: The Law Library of Congress.

    3. Fleegler EW, Lee LK, Monuteaux MC, Hemenway D, Mannix R. Firearm legislation and firearm-related fatalities in the United States. JAMA Intern Med. 2013;173:732-40 doi: 10.1001/jamainternmed.2013.1286 [published Online First: 2013/03/08].

    4. Wiebe DJ, Krafty RT, Koper CS, Nance ML, Elliott MR, Branas CC. Homicide and geographic access to gun dealers in the United States. BMC Public Health. 2009;9:199 doi: 10.1186/1471-2458-9-199 [published Online First: 2009/06/25].

    5. Bangalore S, Messerli FH. Gun ownership and firearm-related deaths. Am J Med. 2013;126:873-6 Online.

    6. Srinivasan S, Mannix R, Lee LK. Epidemiology of paediatric firearm injuries in the USA, 2001-2010. Arch Dis Child. 2014;99:331-5 doi: 10.1136/archdischild-2013-304642 [published Online First: 2013/12/18].

    Conflict of Interest:

    None declared

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  7. At the threshold

    The question asks would a rapid PCR test on blood alter management in a febrile infant by way of discontinuing antibiotic therapy if found to be negative.

    The multiplex PCR offered would not alter management in a "hot, grumpy, 2 month old" even if it offered 100% certainty that the infant did not have bacteraemia. Bacteraemia implies bacterial infection directly in the blood and is only one of a number of potential sources of bacterial infection in this clinical scenario. Limiting multiplex PCR tests to blood would not eliminate the need for CSF, urine and chest-xray analysis in identifying the source of the pyrexia. The question fails to acknowledge the fact that an infant may have a serious bacterial infection in the absence of bacteraemia. In fact, traditional methods of bacterial blood culture are often negative despite positive urine/CSF culture, or infective changes on a chest xray/ultrasound.

    Therefore, in reality, antibiotics would continue irrespective of the accuracy and "evidence" associated with the multiplex PCR test described in your article. It would simply be another tool for rapidly assessing a sick infected infant.

    Conflict of Interest:

    None declared

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  8. Malawi trial is included

    The second paragraph of this brief note is entirely incorrect, as the trial from Malawi is indeed included in the BMJ meta-analysis. It is included as reference #34 and mentioned explicitly by name in Tables 1 and 2 and Figures 2 and 3. That trial in fact provided approximately 2/3 of the participants included in the meta-analysis.

    Conflict of Interest:

    None declared

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