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  1. Nick Brown, Editor in Chief1,2,3
  1. 1 Department of Women’s and Children’s Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
  2. 2 Department of Paediatrics, Länssjukhuset Gävle-Sandviken, Gävle, Sweden
  3. 3 Department of Child Health, Aga Khan University, Karachi, Pakistan
  1. Correspondence to Dr Nick Brown, Department of Women’s and Children’s Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden; nickjwbrown{at}gmail.com

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Limits

There’s a point, somewhere near the midpoint of Ridley Scott’s Blade Runner where one starts to doubt one’s preconceptions. Morality, mortality, judgement all jostle in the heady mix, the competition becoming more ferocious as the denouement approaches. By this stage, the lines between humans and replicants muddying to the point of a blur, disentanglement into distinct factions, now being way beyond possible. Every manoeuvre has its boundaries—but, you already knew that.

Points of care: a multi-part series

‘Do’ the physiology

It’s a mixture of bemusing, baffling, amusing and frustrating that despite multiple attempts to address it, assessment of ‘simple dehydration’ is still beyond us. What do we know? In short, that clinical assessment (despite the textbook dogma—sunken fontanelle for 10% anyone?) is worse than rough and ready, biochemistry (urea, creatinine, sodium—all of them) completely uncorrelated and (as we recently published) ketones unhelpful. Point of care ultrasound (POCUS if you’re in the club), the (rightly) ubiquitous tool of the moment having had plenty of moments in the limelight, is now put to the ‘dryness’ challenge. Majiez Kolodjiez and colleagues’ (Warsaw University, Poland) systematic review and meta-analysis test the predictive value of POCUS with respect to the IVC: aortic diameter ratio. Theoretically, vascular underfilling (arguably more likely in shock) should be reflected in relative shrinkage in venous return. But, it seems, when put to the acid test of the performance against the aspirational standard, percentage weight loss (so rarely available) was only modest. Scores against clinical tools were better, but there’s a circularity in argument here given the own known poor correlation with extravascular fluid loss. No test, clearly, can ‘do’ it all. See page 287

‘Do’ the math

On the theme of POC (not to be confused with POCUS), can emergency pre-arrival resuscitation tool estimates be improved from the traditional rule of thumb calculations. Jordan Evans and colleagues at Cardiff University suggest they can. They assess the relative effectiveness in terms of time and stress of a new smartphone app against APLS charts and the old, though much-loved marker pens on whiteboard, WETFLAG pre-arrival estimates. See page 282

‘Do’ the genes

It’s hard now to recollect the era when immunoreactive trypsin (IRT) was not only part of routine neonatal blood spot screening but even debated as worth incorporating. It was though only in 2006 that it became part of the Guthrie, a positive now triggering a confirmatory cascade including DNA panel testing for the four most common CFTR mutations and repeats for those with fewer than two positives. Sarah Jane Driscoll and colleagues at the University of North Staffordshire assess its performance using the (huge) west Midlands database over its first 15 years: more than a million babies screened, 400 suspected and 270 confirmed. The landscape treatment-wise has, of course, changed almost beyond recognition with the rise of CF transmembrane regulators, but the bottom line is that early diagnosis predicts long term outcome—which is why this manuscript is so important—and the reason it is this month’s editor’s choice. See page 292

‘Do’ the job to completion

In an area permanently relevant and, as a result of recent events, especially poignant, Mata Fonderson and colleagues’ systematic review of airborne pollutants and primary care respiratory diagnoses, strikes a chord. In keeping with previous literature, SO2, NO2, PM10 and 2.5, CO2 and carbon monoxide levels, predicted presentations and, though the data were heterogenous precluding formal meta-analysis, the consistency of findings once again begs why this knowledge hasn’t catalysed faster implementation. The reality is that despite legislation (the European Clean Air Act and the US Ambient Air Quality standards, for example), more than 90% (yes, 90%) of children (who spend more time outdoors than their adult counterparts) air ridden with levels above these thresholds. Accountability, as so often the case, slopes off backstage. See page 297

So, there we have it—as tantalising as Deckard’s fingernails on the rooftop of the Tyrell corporation building—in a nutshell.

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Footnotes

  • 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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