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‘The world is so unpredictable. Things happen suddenly, unexpectedly… We want to feel we are in control of our own existence. In some ways we are, in some ways we’re not. We are ruled by the forces of chance and coincidence’. The words of the American author, Paul Auster and particularly relevant during a week in which the rate of new (Covid-19) coronavirus infections, literally weeks after first detection in December 2019, has accelerated to pandemic levels.
Though, through different lenses, each of this month’s papers looks at (un)predictability
Self-harm in primary care
Self-harm strongly predicts later suicide, up to 80% of those committing suicide having had a primary or secondary care mental health contact in the year before death. Self-harm data is therefore crucial to suicide prevention efforts. Approximately twice as many people who self-harm seek help in primary care than access secondary care. John examines individual-level linked data across general practice, emergency departments (EDs), outpatients and hospital admissions to examine contacts across settings and time by sex for self-harm in individuals aged 10–24 years old in Wales, UK between 2003 and 2015.
Self-harm incidence was highest in primary care but remained stable over time. Incidence of ED attendance, however, increased over time (IRR=1.3; 95% CI 1.2 to 1.5) as did hospital admissions (IRR=1.4; 95% CI 1.1 to 1.6) the highest rates being in the 15–19 years age group. Most, reassuringly, appeared to have been offered mental health specialty follow-up but, what are the messages for prediction, primary care and primary prevention? See page 347
Global child health
The greatest burden of low birth weight (and related mortality) falls on low and middle income countries. A common practical issue in these settings is identifying these at risk children due to a scarcity of scales. The use of other anthropometric measures as proxies for weight has been suggested and Gidi tests this hypothesis in Ethiopia using foot length (FL), chest circumference (CHC) and mid-upper arm circumference (MUAC) as predictors of low birth weight (LBW) or prematurity each of which had good predictive value for prematurity and LBW. A secondary study comparing two gestational age estimation scores, the NBS and Eregie (a modification of the Dubowitz scale) showed broad similarity. In practice, this means that easily obtained measures and neurological evaluation can be used to screen for high risk babies who require longer observation and potentially nasogastric feeding and other treatments. See page 326
CNS tumours: time to diagnosis
The association between delay in diagnosis and outcome in CNS tumours is well known. The 2011 ‘Head start’ initiative was based on guidance developed by the RCPCH to raise awareness of early symptoms of brain tumours In a before and after assessment, Shanmugavadivel, examines time to diagnosis (TDI) and system interval (SI, first presentation to medical facility to diagnosis) in the 2 years following the launch. Young children (0–5 years) accounted for 38% of cases with a peak age at diagnosis of 2 years. Central tumours experienced longest intervals with a median TDI of 10.5 weeks and SI of 2.9 weeks. The 12–18 age group had a median TDI of 12.1 weeks, compared with 8 weeks for the 5–11 age group and 6 weeks for the 0–5 age group (p<0.001). Put alternatively, adolescents are being imaged a month later than their younger counterparts. How then do we enhance awareness in this group? See page 355
Complementing this study, Saatci’s, systematic review (26 studies) and meta-analysis assesses differences across educational outcomes in survivors of childhood cancer (CCS) compared with peers. CCS were more likely to remain at compulsory level (OR 1.36, 95% CI 1.26 to 1.43) and less likely to complete secondary and tertiary level education. They were also more likely to have special educational needs (OR 2.47, 95% CI 1.91 to 3.20). In terms of tertiary education, those with previous CNS tumours continued to perform worse (OR 0.61, 95% CI 0.55 to 0.68) but children with non CNS cancer performed similarly to their peers. See page 339
The proportion of new diabetics presenting with keto acidosis (DKA), could be interpreted as a measure of population awareness. With the aim of enhancing parental knowledge in Italy, an intensive campaign (media, parental information and paediatrician alerts) was undertaken between 2015 and 2017. Rabbone examines the proportions of children presenting with DKA during the campaign (2016–17) with those in the previous survey (2012–13). In the latter (peri-campaign) survey, DKA was the presenting phenotype in 47.6% of new diabetics, significantly more than the 38.5% in the earlier study (p=0.002), though DKA treatment according to the ISPED guidelines was adhered to more rigorously. See page 363
Drugs and therapeutics
The month’s excellent Drug and Therapeutics section is, as always, broad and erudite. Ryan’s summary of the current state of play around ranitidine (not withdrawn but hard in short supply due to recall of some batches) in which low levels of potentially carcinogenic nitrosamines were found in some brands. The editorial balances the decisions many general paediatricians and paediatric gastroenterologists will need to make. There is no generic right answer, though, if alternatives are possible (alginates or PPIs), then these should be considered. The ongoing European Medicines Association review will provide clearer answers. See page 382
As Daniel Kahneman, the Nobel winning economist and psychologist, explained: ‘the idea that the future is unpredictable is undermined every day by the ease with which the past is explained’.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Commissioned; internally peer reviewed.
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