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Stating the obvious

There’s an aphorism (an ‘old’ one if you’ll excuse the lapse into tautology), in the medical literature world which states that ‘everything, even the obvious, needs to be proved (and published) once’.

It’s a surprisingly good rule of thumb, the authors’ genius being in the appreciation that the ‘obvious’ has never been formally proven. If you take Newton’s observations on gravity as an analogy, the argument gains torque. The corollary, of course, is that much research effort is spent unnecessarily replicating previous work, but that’s another, altogether more complicated story.

The theme linking my choices this month then is that each paper, one way or another, takes an association we assumed to be obvious and finally proves (or disabuses us of) it.

This month’s journal is also the first of a larger Archives, 8 pages longer, and I’d like to think correspondingly broader, as the new sections and international health papers gain momentum. I really hope you enjoy it.

Extremes of stature

Managing extremes of stature has been driven as much by societal expectation as any other factor, Adult heights have increased as a result of enhanced living standards to the point that ‘excess’ height is almost the norm. When it comes to managing tall stature, though, there is an elephant in the room. The overlooked ‘obvious’ is that no one really knows the efficacy of the interventions (medical and surgical) with any degree of precision, as none have been tested in randomised controlled trials, and estimates of effect size based on individual predicted height on small numbers of children. Much as we want to believe that the somatostatin analogues, sex steroids and growth plate stapling help, we lack certainty. In an elegant editorial, which is as philosophical as clinical, Peter Hindmarsh examines, extrapolates and contextualises the findings of Goedegebuure et al’s study on early epiphysisial closure. See pages 207 and 219.

Erratic periods don’t mean erratic ovulation

Isn’t it also ‘obvious’ that when a teenager’s periods become erratic then so does her ovulation? While it is known that ovulation becomes more regular with time from menarche, and is more likely to be regular if periods are also so, no one, remarkably (until now) has studied the patterns between menstrual cycles and objectively measured ovulation before. Pena and her colleagues ( see page 235 ) followed a group of 40 girls fulfilling predefined criteria for irregular periods (less than 21 days or more than 35 days) originally recruited as part of the Western Australian ‘RAINE’ pregnancy cohort. Their cycles were diarised and ovulation ascertained by peaks in (daily collected) early morning urine pregnanediol-3α–glucuronide/creatinine ratio. Of the total, 65% had periodic (1 episode every 2 months) and 82% had at least sporadic ovulation (1/3 months). So why is this of more than academic interest? Because it shows what everyone suspected, that erratic periods do not mean that pregnancy can’t occur, and that contraceptive advice is just as important (arguably more so) for these girls.

Neonatal resuscitation in low and middle income countries

There is no doubt that the Helping Babies Breathe neonatal resuscitation programme for Low and Middle Income Country midwives has saved thousands of lives already. Its beauty is in its simplicity based on basic care in the ‘golden minute’, and airway management using a face mask (FM). What, though, happens when an airway and ventilation can’t be established? The American Heart Association and European Resuscitation Council have already mooted using the laryngeal mask airway (LMA) as a first line (rather than endotracheal intubation) when ventilation is ineffective. In an important randomised controlled trial in Uganda, Pejovic et al ( see page 255 ) tested the technique against standard face mask resuscitation. The participants were midwives attending emergency caesarean sections at a large maternity hospital in Uganda. All had received instruction and demonstration of aptitude in use of the LMA before the trial. All resuscitations were supervised and babies were randomised at delivery to either the FM or LMA. These were to be used only for babies with apnoea or gasping at 1 min of age. If one method failed then a switch was made to the other limb. A total of 50 babies (25 in each arm) were studied. The LMA performed better in all areas: time to spontaneous breathing, total ventilation time and rate of non-response were all lower. None of the LMA arm babies required a change to FM, but 11 of the 25 randomised to FM were switched to the LMA on the basis of inadequate ventilation. This is a small trial, but, the findings compelling, bound to lead to larger studies and potentially a change in practice. Given the huge contribution that early neonatal deaths make to the global burden of disease, this is surely worth exploring.

Asthma and GORD: not quite as we had hoped

I’m going to end with a subject about which we all have an opinion but to which the solution is far from clear: the relationship between gastro-oesophageal reflux and asthma. We all know of the association and of the physiologically plausible physiological pathways to explain the observation including: the accentuation of intrathoracic pressure changes; disturbance of the diaphragmatic sphincter; vagally mediated bronchospasm resulting from irritation of the lower oesophagus and the gastric induced cytokine response. We have been seduced by these for decades, for almost as long as we have been disappointed in our enthusiastic attempts to improve asthma control by treating GORD. Please read de Benedictis’ excellent review of the field ( see page 292 ) in which the obvious, at last, becomes obvious.

Thanks as always for reading, challenging and contributing.


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