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I’ll admit it: I find the ending salvo to a paper to the effect that ‘more studies are urgently required’ oddly enervating. In essence, I think there are four reasons. First, it should be a reader’s prerogative to decide which level of the ecosystem of evidence the paper inhabits. Second, it feels as if the authors are perhaps trying too hard. Thirdly, it has an oddly counterintuitive diminishing effect on one’s confidence in the findings: it’s easy to misconstrue as saying ‘we’re not sure our findings standalone’. Finally, on a (pedantic) semantic point, it often represents a misuse of the term ‘urgency’ itself.
This practice isn’t of course, confined to medicine, and is perhaps simply a reflection of societal trends: the email exclamation mark, the use of bold and capital letters, the anatomical attachment to the mobile and social media site, the raising of voices (ruffling of feathers…) to which we are all, probably, becoming unwittingly inured.
As you will have guessed, I prefer papers to make their point(s) then (quietly) leave the reader to assimilate. In this vein, none of this month’s papers express any urgency, but, all are important, just one of many reasons I enjoyed them. I think you will too.
Limited post mortems
Post mortem rates have fallen over the last few years. Of the order of 50% of parents decline consent, a decision many subsequently regret, having lost the opportunity for information which might have helped them come to terms with their losses. Though non-invasive autopsy (NIA) based on MRI and CT and minimally invasive autopsy (NIA and limited laparoscopic examination) with complementary investigations (microbiology and placental histology) are now well developed, little is known about the perceptions of those most directly involved. Other than parents, these, of course include medical personnel, pathologists and coroners. Sebire and colleagues ( see page 572 ) tackle this gap in an absorbing qualitative study. Though the advantages (and there are many) are well known, the limitations and reservations articulated were as surprising as thought provoking: doubts about the validity of the tests against the gold standard, confidence in microbiology in suspected sepsis and de-skilling of trainee pathologists were all voiced. There seems little doubt that these techniques will become more widely used, so the issue is how can these valid concerns be addressed
The weekend effect
In the UK at least, the prickly issue of the relationship between hospital mortality in adults and time of week of admission has caused not inconsiderable chagrin. As a result, though, of residual confounding and study heterogeneity, the jury is at least partly still on the fence. Less is known about the weekend effect in children and Greenough and colleagues’ ( see page 611 ) systematic review and meta-analysis is, therefore, welcome. Unsurprisingly, they found similar obstacles to those in the adult literature, but, on meta-analysis of the 10 appropriate papers, found no significant weekend effect on mortality. Perhaps mortality as a thankfully, relatively rare event in children, is too crude an outcome be which to define ‘quality’, and their finding that length of stay appears to increase at weekends suggests other measures might be more sensitive barometers.
Intensive care: when to change tack
Paediatric intensive care has advanced so far that children with life limiting conditions (LLCs) are now routinely offered care when in the not-so-distant past they would not have been admitted. Numerically, the greatest numbers are those with cardiac, respiratory, oncological and neurological diagnoses, and an elegant linkage study by Fraser ( see page 540 ) and accompanying editorial by Pearson ( see page 527 ) put these changes into perspective. An overall 58% of PICU admissions and 73% of deaths concern children with LLCs with ORs for death in this group during admission of 1.75 (95 % CI 1.6 to 1.9) and to a 1 year post discharge of 2.6 (95 % CI 2.6 to 2.7). Though the majority of such children survive this year, the papers mount a cogent argument for consideration of palliation in the broadest context for the subgroup for whom intensive care is often merely prolonging the sadly inevitable.
Patterns of injury
Few areas divide opinion and generate emotion in the way that child abuse does, one reason of course being is that the inherent difficulty in diagnosis as events are so rarely witnessed or admitted. One area which has been extensively studied is that relating to the triad of signs, subdural haemorrhage, retinal bleeds and encephalopathy in a non-mobile child and possible non-accidental shaking, though, new evidence, as in any debate is to be welcomed. In 2016, the Swedish Agency for Health and Technology Assessment published a systematic review which challenged this association. Given how divisive the area, the report unsurprisingly generated a strong reaction and Kemp and colleagues ( see page 606 ) provide their response.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.