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THROWING DOWN THE DKA GAUNTLET . . .
I can't recall any previous contributors to ADC calling for a summit meeting. But this month's ADC is all about challenges and Carol Inward and Timothy Chambers, from Bristol UK, call for the highest level attention to reviewing our management of diabetic ketoacidosis. They cite the static death rate, the poor understanding of the mechanism of cerebral oedema and the variability with which UK paediatricians, at least, treat the disorder. They suggest that theoretical considerations lead to their conclusion that DKA should be regarded as analogous to hypertonic dehydration with renal electrolyte imbalance. Therefore dehydration might be better correctly more slowly and cautiously than is customary.
Inward and Chambers invite endocrinologists, nephrologists, general paediatricians and accident and emergency medicine specialists to put their minds to the problem. We join them in inviting the Royal College to convene an appropriate working party. Papers abroad, please copy. See page 443
. . .BUT WATCH OUT IF LAWYERS PICK IT UP
Another problem bedevilling DKA management is the failure to adhere to accepted guidelines. We all hope that such documents represent a safety net, especially for the less clinically experienced. But might they also be fishing nets in which the law entraps unwary doctors? We asked John Tingle, director of the Centre for Health Law at Nottingham Trent University to advise readers on the legal implications of guidelines. obviously his comments apply most cogently to those countries following the British legal systems, but we trust readers elsewhere will be able to put his words into the context of their own jurisdiction.
Mr Tingle reminds us that adherence to a guideline does not absolve the practitioner from expressing clinical autonomy, nor does failure to follow it necessarily imply negligence. He points out the importance of developing an audit trail when preparing guidelines. Those seeking to contribute “guideline papers” to ADC are likely, in future, to be asked to comply with this.
As one would expect, the vital Bolam ruling is quoted.1 As an aside, I have asked dozens of colleagues—well acquainted with this legal premise—who was Mr Bolam? None has provided the right answer. Given this unfortunate man's key role in medicolegal matters for nearly half a century, I think we should remind ourselves that both his femoral heads were driven through their respective acetabula when he was submitted to electroconvulsive therapy without anaesthetic—a true medical martyr. See page 387
A WEIGHTY CHALLENGE
An undoubted need, throughout the developed world, is to deal with the pandemic of childhood obesity. This month heralds two contributions: Dr John Reilly and colleagues provide evidence based answers to five commonly asked questions on the subject: what is it? How much of it is there and can we prevent it, treat it, or otherwise manage it? It turns out that some of the answers are in the box—that is Box 1 of their paper and the pernicious box so many children are wedded to.*
From Hong Kong, Dr Sung and colleagues randomised obese children to receive a low energy diet for 6 weeks (the summer vacation) with or without exercise, in the guise of strength training. Those in the latter group showed a significant rise in fat free mass. Both groups showed a fall in total cholesterol with a significant fall in LDL:HDL ratio in the training group. The authors call for others to perform similar, but longer term, studies. See pages 392 and 407
THE ULTIMATE CHALLENGE
Ten years ago we published a review by Professor Mark Gardiner from University College London, on the prospects for the human genome project.2 Ten years have passed so we asked him to do it again, given that the project was completed four years ahead of schedule. Presumably pre-empting the temptation for my successors to ask him to have another go in 2012, he predicts that 1000 specific genomes will be completely sequenced. More appositely for clinicians, he suggests we will understand far more about early onset disorders with “complex” inheritance, such as asthma, type 1 diabetes mellitus, epilepsy, autism, and ADHD. Let's hope we're around to read his next instalment. See page 389
A TINY CHALLENGE
It's hard for paediatricians to take pinworms seriously. Dr Tandan and colleagues, from Vancouver, Canada, remind us that even this apparently harmless gene sequence can cause trouble. They report a sexually non-active adolescent in whom it caused pelvic inflammatory disease. Please remember this case, as, unlike obesity, the condition is eminently treatable. See page 439