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The Shape of Training: the right people with the right skills in the right place
There is no doubt that medicine has changed considerably in the last 25 years and will continue to do so—the population is ageing, the population with complex health care needs is increasing, treatments are progressively better (and more expensive) and the expectations of patients, quite rightly, increases year on year. Getting the best workforce to deliver health care is challenging and made more complex by the increasing complexity of medicine, reduced junior doctor cover and increasing need for specialisation and for senior cover to be available 24/7. These are issues we all face as clinicians all of the time and have huge implications for undergraduate and postgraduate training of the medical workforce of the future. In this issue Robert Klaber and colleagues discuss the key messages for postgraduate education from the Shape of Training Review chaired by Professor David Greenaway and published in November 2013. It is interesting to work through. The priority is to develop the right workforce to care for children adapting the training (and workforce) to best meet these needs. There are important issues to address—the changing needs of patients, the need to ensure high quality general training, the need for less rigid medical career pathways, the need for enhanced cross discipline training (and working), academic and subspecialisation training and subspecialisation per se are just some. It is important we all engage in the process to ensure we best meet the needs of the children of the future and are able to develop and retain a high calibre, motivated workforce to deliver those needs. See page 119
Hospital Admissions for Unintentional Poisoning
It is refreshing to see a downward trend. Mbeledogu et al report a population based time trend analysis of all unexplained admissions for unintentional poisoning (age <5 years, 2000–2011, England). Rates decreased overall from 179 per 100 000 to 139 per 100 000—this downward trend occurred across ingestion of medicines, organic solvents, corrosive substances, pesticides and alcohol. It is interesting that this has occurred at a time when the overall admission rates to hospital have increased. The relative risk of hospital admission from the most deprived quintile compared with the least deprived centile has reduced from 2.37 (95% CI 2.15 to 2.6) to 1.54 (95% CI 1.4 to 1.7). The potential reasons for these changes are discussed and include legislative change (increase in child resistant containers), public awareness and the impact of targeted public health education programmes. There is clearly still more work to be done to reduce these numbers further. See page 180
Cerebral Sinovenous Thrombosis
Cerebral sinovenous thrombosis (CSVT) is defined as a blood clot in a vein carrying blood to the heart. It is rare: 0.34 to 0.67 per 100 000 children annually with a previously reported mortality of 3 to 12% and high long-term morbidity. Ichord et al report 170 children (60% male, median age 7.2 years) presenting with CSVT over 5 years from 10 countries on behalf of the International Paediatric Stroke Study. Common presenting features included headache, altered consciousness, focal deficits and seizures. Infarction affected 37% and intracranial haemorrhage 31%. Risk factors included chronic disease (50%), acute systemic illness/head and neck disorders (41%), and prothrombotic state 20%. Mortality was 4%. Discharge neurological examination was normal in 48%. Risk of death was greater in children not given anticoagulation (OR 5.2, CI 1 to 28). Outcome was less good in children with a reduced conscious level at presentation and in whom a prothrombotic state was identified. No other risk factors were statistically significant. This large study highlights the heterogeneity of this rare condition and gives valuable information about risk factors, treatment and outcome. The authors discuss the need to standardise the approach, particularly to anticoagulation in the hope that this will enable further research and improve outcome. See page 174
Recent Advances in HIV
Childhood HIV infection and AIDS remain a global challenge. In 2012 approximately 260 000 children under age 15 years were diagnosed with HIV, bringing the number of children estimated to be living with HIV to 3.3 million. Bamford et al review the current status of Paediatric HIV in the UK and Ireland. There have been considerable successes, including the prevention of mother to child transmission. The changing epidemiology is discussed with the reduction in new cases, but better survival effectively means the cohort is ‘growing up’. It is interesting that the emphasis has progressed beyond limiting short-term morbidity and mortality to ensuring optimum health status in adult life. This is discussed in detail, including the importance of transition and potential need for lifelong antiretroviral therapy. The authors emphasise that lessons from this relatively small cohort are increasingly applicable to the global paediatric HIV population. See page 183
Global Child Health
This year will see the WHO Millennium Development Goals become sustainable development goals. This ambitious programme has impacted significantly on global child health although much remains to be done. This issue is accompanied by a supplement—Millennium Development Goals Progress Report—edited by Dr Nick Brown, global child health editor. It is an impressive collection of the perspectives of national and international authorities including progress reports, regional perspectives and potential future developments. I am delighted that HRH The Princess Anne has written the foreword and very grateful to Nick Brown for his hard work and commitment over the past 2 years in producing the supplement and for his accompanying editorial. See page 198
In Education & Practice
Education & Practice was launched in 2004, initially 24 pages four times a year. The intent was to deliver simple, practical and patient focused continuing professional development (CPD) relevant to trainee and career grade paediatricians. It has been a great success and has gone from strength to strength. Now in its 11th year with editions every other month, and an increase in pages from 40 to 56, it includes multiple sections and an excellent team of editors led by Dr Ian Wacogne, ensuring up to date and stimulating content endorsed by the RCPCH for CPD. This month's highlights include a 15-minute consultation, investigation and management of epistaxis; from the interpretations series, how to use the ESR; an excellent update on practical pharmacokinetics; and a guideline review on the management of autism. In the quality improvement section there is an excellent discussion on overcoming barriers to change in order to improve quality of care, plus a challenging problem-solving case, epilogue, dermatophile and picket. All great CPD and fun to read.
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