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Martin Ward Platt
The last week of July has seen some very sad news. Our great friend, senior editor, and inspirational colleague, Martin Ward Platt, has died after a long illness. Martin, who was also interim Editor in Chief in 2017, had the rare gift of being able to lift any conversation and to light up a room in every sense, his clinical and academic intellect invariably getting to the nub of an issue whether on the NICU, at Public Health England or in editorial discussion. We will miss this enormously as well as his worldly wisdom. What we will miss most, though, is Martin as a person and his generosity of spirit: he is truly irreplaceable.
Global health: WHO guidance on paediatric mortality review
Although substantial progress in global mortality rates was made in the Millennium Development Goal (2000–2015) era, many child deaths still occur due to, largely preventable factors in terms of quality of care and adverse social and environmental circumstances. Mortality reviews, a routine in many countries for some years provide lessons that can guide quality improvement and policy. These processes were introduced in the US in the 1970s and are a statutory requirement in many high-income countries. In South Africa, Papua New Guinea and Solomon Islands, and a small number of other low/middle-income countries, mortality auditing has been used to initiate improvements in paediatric hospital care, but, until now has not been routine. There have been a few restraints—time, the sheer volume of child deaths and fear of blame, and the lack of infrastructure to use the information, have all contributed to inertia, at least until now. The WHO has seized the initiative in its publication of guidance on mortality audit (https://www.who.int/maternal_child_adolescent/documents/improving-quality-paediatric-care/en/) detailing the essence of the review process, the provision of an accurate account and the discussion of means of avoiding a future similar death In addition, it helps bereaved families know that their child’s life mattered and that their death is being taken seriously. Duke and colleagues describe the spokes inherent to the guidance and the hopes for its widespread implementation. One could argue that this should form an SDG of its own as without this process, it is unlikely that the child health related SDG targets will be realised. See page 831.
Lessons from conflict
Lynne Jones’ absorbing reflection on her time working in war zones is poignant on many levels. Two of her lessons are particularly so, both counterintuitively reminding us that what happens outside can pale into insignificance by comparison to that which happens in the home. To cite one example: ‘the best years of her life were during the most intense phases of the siege… while the worst were before and after the war. The explanation: her father had been away fighting during the war, apart from one brief period of leave, freeing her mother from persistent emotional and physical abuse. Only when her parents divorced did things begin to improve again’. Another study of displaced children in Afghanistan showed that family violence was a key predictor of mental health outcomes even in the context of long-term militarised conflict. This is a facet of global (ill) health in one of its most pervasive forms: and we see it every day, whether in a camp in Syria or an affluent provincial clinic in Western Europe. See page 833.
Few areas are as fraught, subject to as much subtle medical-parental misunderstanding and controversial as organ donation after death. There has though been a change in attitude and a refreshingly evolution in openness in the debate in recent years and Bratton and Zollinger’s editorial on Darlington’s qualitative study with bereaved parents and intensive care staff shows where progress has and has not been made. Medical teams supported organ and tissue donation but acknowledged the additional complications that this involved for the families. The key point alluded to by both pieces is that this option should become part of a routine in meeting parents’ needs. Extrapolating this, when donation is not raised, parents might question the value of their child’s organs and, as they argue, the discussion should be an integral part of end of life discussions irrespective of eligibility. These excellent papers are augmented by a podcast interview on the subject by Rachel Agbeko with the authors (https://soundcloud.com/bmjpodcasts/organ-donation-that-difficult-conversation) in which nuances from the studies are explored more fully. See pages 823 and 837.
Drugs and therapeutics: adherence vacation; plus ca change?
In an intriguing secondary analysis of the Adelaide metformin trial (which primarily sought to assess vascular health in insulin dependent diabetics with and without adjunctive insulin) Legget and colleagues addressed adherence to treatment of allocation in a group of Australian children and adolescents. They used the well-established MEMS electronic monitoring system and (residual) tablet counts as markers. Adherence even within the confines of a trial to fall steadily after randomization by a median of 5.5% between 3 and 6 months, 5.5% between 6 and 12 months and 9.6% across the whole period. Intriguingly, there was a marked weekend and holiday effect: these non-school days predictive of reduced adherence (aOR 0.74; 95% CI 0.69 to 0.80; P<0.001) even after adjustment for age, gender, HbA1C, SES and allocation group. These periods are known for a fall in physical activity too and, given that they comprise 25% of the year, there is a window here for intervention. The question, though, given that these are ‘days off’ when diurnal patterns are completely different, is what form this might take… thoughts which make this editor’s choice for the month. See page 890.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
Patient consent for publication Not required.
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