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Arthritis as the presenting feature of acute lymphoblastic leukaemia
The presentation of leukaemia is not always typical and this can potentially lead to diagnostic delay. Brix and colleagues report their experience of joint involvement at presentation in a retrospective cohort (286 patients, 21 years). 53/286 presented with localised joint pain half of which had objective signs of arthritis, most commonly an oligoarthritis. Initial impressions at presentation were of a reactive arthritis (19), osteomyelitis (9) and juvenile idiopathic arthritis (8). Children with joint involvement had, in general, fewer objective signs of haematological disease (cytopenia absent in 24% v 8%, no organomegally in 44% versus 29%). The difficulty is should everyone who presents with joint pathology be investigated for leukaemia. This is discussed in the accompanying editorial—Are you missing leukaemia? It is important to remember that if this issue is looked at in a different way children who present with joint pathology rarely have leukaemia and so the decisions regarding how intensively to investigate remain a clinical decision based on specific features and the risk benefit of testing being done. See pages 821 and 811
Long term effects of bullying
Bullying is the systematic abuse of power defined as aggressive behaviour or intentional harm done by peers that is carried out repeatedly and involves an imbalance of power either actual or perceived between the victim and the bully. One in three children report having been bullied at some point in their lives and 10–14% experience chronic bullying lasting for more than 6 months. Of note cyber bullying is a relatively small proportion of the total with up to 90% of cyber bullying victims also being victims of traditional face to face bullying. Dieter Wolke and colleagues discuss the long term impact. Bullying is not a 'normal right of passage'. Bullying can be direct or indirect—indirect is characterised by social exclusion for example 'you can't play with us' or 'you are not invited'. Bullying is a major risk factor for poor physical and mental health and reduced adaptation to adult roles including forming lasting relationships, integrating into work and being economically independent. In the UK over 16,000 young people aged 11–15 are estimated to be absent from school with bullying as the main reason; with bullying a factor in a much higher proportion of school absence. We mostly don't discuss bullying in the clinic but should as it represents a significant risk factor for future physical and mental well being and is a safe guarding issue particularly when factors such as impact on education are considered. This is an important paper for paediatricians to read and consider in their practice. There is a useful bullying screener in the paper which is straightforward to implement. See page 879
Cognitive faction in adolescents with chronic fatigue
Depression, anxiety and sleep problems are common in children with chronic fatigue syndrome (CFS). Sulheim and colleagues compare cognitive function in adolescents with CF (120, average age 15.4, range 112–18) with healthy controls (39, average age 15.2, range 12–18). All completed a neurocognitive test battery; parents completed the Behavioural Rating Inventory of Executive Function. Adolescents with CF had clinically significant impairment of processing times, working memory, cognitive inhibition response time and verbal learning. Everyday executive functions were significantly worse than controls. These changes were not explained by symptoms of depression, anxiety traits or sleep disturbance and require consideration in the assessment of cases particularly when school absence is a prominent feature. See page 838
Who's afraid of fever?
If the child has a temperature of 38°C strip the child down and ask the duty doctor to write up some paracetamol… if the child has a temperature of 39°C ask for Ibuprofen as well as paracetamol… So what is the evidence? In a leading article this month Richardson and colleagues discuss these issues—Is fever dangerous in itself? Is it a marker of disease severity? Is it beneficial to bring the fever down? Is it the right thing to do? Does physical cooling help? Are the drugs used safe and effective? It is interesting to reflect on the fact that there is a lack of evidence for antipyretics being of use for anything other than reducing the body temperature and to acknowledge the fact that this effect is not necessarily of benefit to the child. The authors cite the NICE guidance, broadly similar to the AAP guidance which encourages a cautious and stepwise approach to bringing the fever down. See page 818
Emergency admissions; contribution of recurrent admissions, contribution of chronic conditions
Rates of emergency admissions have been increasing year-on-year in children and young people (CYP). It is widely felt that at least a proportion of the admissions are potentially avoidable. Wijlaars and colleagues explore the contribution of recurrent admissions/admissions for children with chronic conditions to better understand the emergency admissions and thereby strategies to reduce them. The data is of considerable interest and relevance to health care planning. In 2009 there were 869, 885 children who had at least one emergency admission. 32% of these index cases were readmitted within 2 years, 26% within 30 days of discharge. The total number of readmissions generated from the original cohort were 939, 710 of which 64% were emergency admissions. Recurrent emergency admissions accounted for 41% of all emergency admissions during the two year cohort and 66% of inpatient days. 76% of the recurrent admissions (41% of the index admissions) were in children with chronic conditions. The important questions to ask if you do want to reduce emergency admissions are which groups do you target and what alternative services are required. The authors make the important point that any attempt to reduce admissions could potentially undermine necessary inpatient care for children with chronic conditions. See page 845