ISAAC—a sacrifice in vain?
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Arch Dis Child 2000 Volume 82 No 4
When the March Hare presented Alice with a questionnaire inviting a comparison between ravens and writing desks,1 he told her she should say what she means. Alice replied that she meant what she said. “Not the same thing a bit,” responded the Mad Hatter. Moving from mercury poisoning and logical positivism to this month's ADC I note that one of our ex-associate editors and her colleagues have been testing parents on what they understand by the word “wheeze” (page 327). Vital, say the authors, because a report of wheezing is the cornerstone of diagnosing asthma. Some thought it a sound such as whistling, squeaking, or rasping; others defined it as a different rate, style, or timbre of breathing. Still more thought it was the same as coughing while an anxious few confused it with some of the minor signs of fever. The message is clear. It is no longer enough to state: “All that wheezes is not asthma” but rather “All that wheezes might even not be wheezing at all”. Perhaps we're all in Wonderland.
Institutional heightism in Melbourne
ADC has a long and honoured history of vertically challenged editors; we have to go back two decades to Roger Robinson before finding an obligatory stooper. Fortune must have smiled on them in a way that it no longer does in Victoria. On page 297 Wake and others (heights undeclared) report their study on the relationship between stature and school grade (year) advancement. They compared 132 children who had to repeat a grade with over 2700 who did not. Shorter boys were more likely to have been held back in this way, regardless of ethnicity, parental educational achievement, or social class. The authors believe they may have uncovered an example of biased societal perception of smaller children.
Audit changes doctors more than it does the NHS
We publish few clinical audits, largely because most of those submitted have not “closed the loop”. Generally they show that a survey has uncovered wildly inconsistent practice within or between units. Rarely do they show how this was overcome. One successful audit appears this month on page 302. Drake and Baumer investigated the care of children with diabetes in their region in 1994 and again in 1998. Commendably, between the two dates, much had improved: children were more likely to be seen by a diabetic specialist in designated clinics and there were more diabetic nurses. However, nurse caseloads were excessive and dietitians and psychologists too thin on the ground. Although paediatricians had learned the lessons of the audit and acted upon them, the authors are disappointed that NHS trust chief executives and directors of public health had not released the resources necessary to bring services up to the recommended standard.
A new pathogen?
There is a certain frisson when there's a new bug on the block. Helicobacter was fun for a time but seems to be running out of steam, judging by the multiple negative studies submitted toADC. Ureaplasma urealyticum looked as if it might fill the pages ofF&N but has failed to live up to its build up. Now round the corner comes Oxalobacter formigenes. In 1998, Sidhu and colleagues reported its absence from the intestine as a risk factor for hyperoxaluria in children with cystic fibrosis.3-2
This month in ADC (page 322), a team from Zurich assisted by Dr Sidhu in Florida, have screened children, who suffered renal stones, for what I apologise we have allowed to be abbreviated as HyOx. After discounting those with the inherited disorder of primary hyperoxaluria, the authors note that they isolated the organism from only 1 of 12 children with stones compared with 6 of 13 controls. This organism is known to scavenge dietary oxalate so that its absence may contribute to excessive urinary excretion of the salt and subsequent stone formation. I look forward to hearing great things of O formigenes in years to come, so remember you read it here—well, second.
BPSU Hepatitis C survey reports
Another organism which causes concern is hepatitis C virus (HCV). We are pleased to publish the results of the British Paediatric Surveillance Unit 1997–8 survey into infection with the virus (page286). The survey identified 182 children with definitive infection and a further 364 of indeterminate status but born of HCV infected mothers. Gibb and others now report on the former: forty children acquired the virus from their mother (35 of whom were known IV drug users), 134 from contaminated blood products (all but one born before 1991), two from organ transplantation and four from needlesticks. Most children were asymptomatic and of the 53 who had a liver biopsy, only 10 had more than mild hepatitis. Twenty eight had been treated with interferon alfa at various doses for varying duration. The authors assume underreporting and plan thorough follow-up through national HCV registers. They recommend that clinical trials of management and therapy are vital, particularly since the children are currently being seen in 54 different units with only six centres treating 10 or more children.
harvey marcovitch Editor in Chief