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In the ‘old days’, textbooks were the source of information and wisdom. They were solid chunks of black and white knowledge painstakingly written over many years, each chapter compiled by an authority in the field, often one suspects a friend or collaborator of the editor. They were the final word in the respective fields, until… well, until the next revision appeared some 5–10 years later with an upholstered cover and extra lustre to the pages… only to be superseded again in due course. Key facts from each edition were pontificated over on ward rounds imbuing the consultant an air of (not always overtly specious) authority. They contained phrases like: ‘in my opinion’; ‘33% of children have a sweat chloride of >62 mmol/L’; ‘the olfactory part of the examination is crucial in the differentiation between a primary and secondary amino aciduria’ and ‘dwarfism is a sine qua non of thanatophoric bone disease’. Time has moved on and authorial ego is now more fettered: well, perhaps not the ego itself, but the degree of certainty and dogma with which facts are represented. With the passage of time, we’ve been able to let go of a few old favourites (the secondhand bookshop, the departmental library, the house moving recycling cull) but some are simply immovable for emotional reasons, somehow etched in and adherent to our learning souls. While we can applaud the forward march of evidence rather than eminence-based medicine, it feels as if we’ve also lost something en route—the nous and passion of the clinical observer and the (quite touching) naivete in believing one’s own opinion to the exclusion of all others and the gall to assert it. As we fast forward to ever more online consumption, spare a thought for the real pioneers without whom we would not be here.
Taking the buck
Chronicling what can only be interpreted as a communication and accountability issue, Paul Turner and colleagues describe the ‘politics’ and inertia around a recent National Institute for Clinical Excellence (NICE) endorsement. In February 2022, complete with media regalia, Palforzia, a novel peanut desensitisation treatment was approved by NICE. As with any new treatment, approval (unless there are special conditions for exemption) should mean that NHSE is able to provide for eligible children within 3 months. Spring and summer have come and (almost) gone without a ripple…. There seem to be a number of contributors. One of these is the possible oversight in that administration isn’t risk-free (anaphylaxis has been reported) and that without adequate training a launch would be irresponsible. If so, why wasn’t this part of the recommendation? The pandemic can’t have helped, but, wherever the issues arose, it’s hard to avoid the conclusion that a little more pre-approval dialogue could have averted what has become something of a (indulge the pun, please) bittersweet pill. How could this play out? In a number of ways, singly or in combination: funding for existing allergy or even other services could be transferred (to their detriment) and those able to ‘shout louder’ will be granted access, while their softer-spoken counterparts will lose out. The real irony is that, had Palforzia (or any other novel treatment) been licensed for use in adults first, there would have been funding provision. With a waiting list of around 140 000 that’s a major oversight. See page 778
Global health: pharmacology
In the context of the rise in beta lactam and carbapenem redundancy, there has been a surge of interest in revisiting old friends, antibiotics retired on the basis of being ‘superseded’: now there’s an irony. Exhibit A: fosfomycin—as a reminder of its pedigree, an all-round antimicrobial (with both gram positive and negative potency) now five decades on from its discovery and still on the WHO essential medicines list. As a result of the high sodium and fructose load, it has earned an unwarranted reputation for metabolic side effects. The evidence for this, though, is thin. Christina Obiero and colleagues examine the pharmacokinetics and side effect profile of the drug in neonates in Kilifi, Kenya as part of a randomised trial on sepsis treatment. Though the need for alternatives to liquid/suspension forms of medicines (susceptible to fast deterioration, the need for refrigeration, the expense and requirement for potable water to reconstitute) has been on the WHO radar for some time, progress has, to date been slow. Varsha Pokharkar and colleagues in Pune, India examine the barriers in young children. In common with other studies, 6 years appeared to be the threshold age for swallowing standard tablets (and we know that minipills are even easier to take) but that a range of cultural, expectation related, and infrastructural constraints proved the major hindrances. See pages 802 and 796
Breaking the news early
There’s now a substantial body of data showing benefits (both in glycaemic control and quality of life) in children screened for type one diabetes and recognised early in comparison with their unscreened, standard time-to-diagnosis contemporaries. Rachel Besser and colleagues discuss the shape of a future potential programme in which screening with either anti-insulin antibody (IAP) alone or in conjunction with genetic markers (HLA- based risk associated genes), the timing and number of tests—not easy as antibodies take time to develop and a single 3 year test relatively insensitive. Screening only those with a family history of T1DM will miss two thirds so targeted testing is at best a blunt tool. There are several unanswered questions, particularly acceptability but, at least the question has now being asked and, if the work from Sweden, Germany and the US is generalisable, we need to be receptive to the (possibly heated though certain to be compelling) debate on the horizon. See page 790
A life worth living
In his thought-provoking series, Robert Wheeler examines the issues relating to fetal development of children whose subsequent disabilities were theoretically preventable by antenatal or preconceptual intervention or surveillance. Poignant and provocative in the best sense, the discussion takes us to places many wouldn’t choose (or dare) to go. See page 782
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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.