Heads above parapets

Putting one’s head above the parapet is a term synonymous with ‘guts’: risking exposure, opprobrium and exclusion it is particularly germane in the scientific world when the middle of the road approach (‘more research is needed’) is safer. Each of these pieces took guts and as a result, each is stronger and more informative.

Global child health

Financial emancipation

Rojiroti (literally ‘daily bread’), is a form of microfinance that involves the formation of women’s self-help groups in which each individual donates small weekly sums to a pool to enable the provision of loans to group members the size of which increase over time. Ojha tests Rojiroti in a poor, rural setting in in Bihar, India on child nutritional status. Villages were randomised to receive Rojiroti at the outset or after 18 months. The primary analysis, comparing the mean weight for height Z score (WHZ) of children under 5 years in the intervention vs control villages was undertaken on 2064 children. The mean WHZ was significantly higher for intervention vs controls children and fewer of these children were wasted, but, Rojiroti only appeared to protect against deterioration rather than improve nutritional status. It is known that microfinance reduces IPV and, therefore conceivable that there are other, less tangible outcomes in terms of family well-being as a result of participation. See page 229.

Traditions in nephrology

Liquid gold, indeed

Kaufman estimates the relative cost effectiveness of urine collection methods. In an Australian emergency room, a comparison was made between non-invasive (urine bag, clean catch, 5 min voiding stimulation for clean catch) and invasive (catheterisation and suprapubic aspirate (SPA)) collection methods in children aged 0–24 months. For initial collection attempts, catheterisation provided best value per successful collection at GBP £26 (euro 30.5, USD 33.8) then (in increasing order of cost) SPA, voiding stimulation, clean catch and urine bag, a jaw dropping GDP £93 (euro 109, USD 121). For definitive collection, catheterisation again was most cost effective, the time occupying a hospital bed being the most significant determinant of cost. Add to this the potential implications for follow-up and unnecessary imaging on the basis of the false positive results which plague bag samples and, my inference is we should all simply (re) learn to catheterise. See page 253.

Oncology: time to diagnosis

In the first of two papers, Hayden examines outcomes by first symptom to diagnosis interval (SI) in children with central nervous system germ cell tumours referred to oncology centres. Median SI was 3 months and prolonged SI (>6 months) seen in (33%), this group having greater metastatic disease at diagnosis and central endocrinopathy. See page 241.

In the second, Murray describes the discussions during (in consultation with the UK Children’s Cancer and Leukaemia Group) and concensus of a Delphi process on practical referral criteria to augment the most recent (2015) National Institute for Clinical Excellence (NICE) document for suspected cancer after. The resulting 21 scenarios outline presentations requiring prompt primary care referral. Many will be familiar and intuitive, many are non-specific, but a couple are worth reflection: hesitancy before prescribing oral steroids without chest X-ray in a child with new onset ‘wheeze’ and a ‘story’ not typical of asthma and constipation in a previously well child. In the first, the mediastinal mass will shrink temporarily and in the second a diversionary placebo effect might distract from a more detailed work up… the final common pathway being a delay in imaging, histology and treatment. See page 247.

A difficult conversation

Though it’s simpler to blame the obesity epidemic on lifestyle malaise, Ferguson’s elegant observations from a general outpatient service shows that despite the BMI being recorded at each visit, in only 1 of every 7 families of obese children was there an open discussion. Interviews with colleagues suggested a reluctance to engage in this on the grounds of the potential effect on the doctor/parent/patient relationship, time constraints, and a belief the family were already aware. Contrary to fatalistic beliefs there are multiple effective interventions and, though individual effect sizes are small, are we not doing families a disservice by unnecessarily tiptoeing around an area with which we feel uncomfortable? Fortune tends to favour the brave. See page 310.