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Control: a brief revisit
Let me start by clarifying that I’m not claiming novelty for a concept (the importance of control on life quality) in circulation at least since Aristotle’s halcyon period between 300 and 400 BC. I think, though, emphasising the notion does no harm when it occasionally gets lost in the maelstrom of ‘activity’ inherent to clinical processes. So, in quasi- bullet point terms my argument is along the lines of: Whichever route individually chosen, we share the need for our lives to ‘have meaning’. One spoke of meaningfulness is the ability to influence one’s own trajectory, in other words, to exert a degree of control and, by extrapolation, autonomy in our/a child’s/a family’s particular circumstances. In broad terms this involves the means to alter the environment and the individual-environmental relationship. So, what’s the environment? So broad as to be unanswerable, but arguably, encompasses all exposures from mitochondrial DNA to societal laws to ozone layer protection.
Discussion space here is limited but I hope you get the idea: the papers I’ve chosen are very different in terms of content, but are strongly connected by the flavour of sense of control and quality of life.
Ethnicity and health
The complex composite exposures inherent to racism are put under the microscope of Heather Burris (I’m delighted to say, our new advocacy editor) in a blistering, appropriately unsettling, complacency-busting and (excuse the school masterly phraseology) obligatory reading piece.
Without divulging too much, the comparable birth outcomes in black women born outside the US and white US born women with a change within a generation, strongly implicate environment. Again, the ‘what is environment’ question rears its head. Yet to be fully decodified, it includes segregation, stress, pollution, and the corrosive psychological effect of chronic discrimination. See page 212
Global child health
Zika in the normocephalic child
It was clear from the start of the Zika epidemic that microcephaly after fetal exposure is a harbinger of poor outcome. What is unclear is whether exposure without a measurable abnormality in brain growth (the head circumference) has similar implications or none. Karen Blackmon and colleagues tested this by enrolling seropositive pregnant women and comparing normocephalic Zika-positive children with an unexposed group in Grenada, West Indies. Gratifyingly, there were no differences in neuro-cognitive outcomes, but some subtle ophthalmological discrepancies – grounds then for positivity, but not nonchalance. See page 244
Without willfully trying to delude myself, I think I’m in a majority in that chronic lead toxicity should feel like the domain of old (1960s) black and white textbooks, complete with grainy bone changes and basophilic stippling on the blood film and the attendant negative cognitive effects, because ‘the environment has improved- right?’
Not quite. We know, objectively, that isn’t the whole story and Tharwat El Zharman and colleagues in Beirut, Lebanon emphasise this message by revisiting the prevalence and predictors of high serum lead some 18 years after non-leaded petrol legislation became statute in the country. Levels in hospitalised children are now markedly lower than they were during the fuel transition period, but that doesn’t equate with equity: smaller houses, time elapsed since last painted and maternal education not including college predicted higher blood levels. See page 251
Two oncology manuscripts keep up recent momentum in the area. In the first, Hadeel Hassan and colleagues describe in intricate detail the obstacles encountered in a feasibility study addressing probiotic prophylaxis and mucositis at the start of chemotherapy. In short, recruitment proved very difficult indeed, reasons (from diary records) including unpalatability, to WiFi issues with the study app, to a sense among some, of trial overload.
I can’t remember seeing a feasibility study that demonstrates better why feasibility studies are so important: they reflect real life much more closely than the (often quite blunt) tool that is the actual RCT. We get insights into recruitment, into tolerability and into retention, issues that were they to appear after launching a trial could land a fatal blow. Should feasibility studies simply be part of the CONSORT checklist as much for the children, as researchers as donors?
Looking at post treatment life, Amanda Friend and colleagues assessed provision at UK tertiary cancer centres for fertility preservation, an area one would naturally assume to be equitable. This isn’t, however, the case: though sperm and ovarian storage are standard, oocyte preservation is patchy, and many centres are (eye-openingly) reliant on charity rather than central funding. See pages 259 and 265
Ambulating or resident
Even without the COVID-19 contribution to the already complex equation, trends in admissions have proved surprisingly resistant to interventions. Smita Dick’s systematic review of RCTs and before and after studies, shows that other than asthma pathways, none of the broad ranging interventions resulted in a reduction in admissions. My interpretation is that to some extent this mirrors society: changes in primary, secondary, ED and out of hours care healthcare, the perception of greater vulnerability to criticism. Whatever the underpinning reasons, this isn’t a direction we expected to veer towards when the ambulatory care philosophy garnered momentum and we shouldn’t lose sight of this goal being laudable.
I’d be interested in Trousseau’s angle on this, but this will need to wait for another day—or at least the Atoms podcast. See page 234
Patient consent for publication
This study does not involve human participants.
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.
Provenance and peer review Commissioned; internally peer reviewed.
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