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A RESPONSE BY LETTER TO PROFESSOR TIM DAVID
As you may be aware, many journals, including ADC, now have a formal active process of submitting letters to the editor online. This has allowed us to orchestrate a far more robust and timely discussion of articles and there are virtually no time delays or space constraints in publishing electronic letters. However, there are some concerns. Most importantly, ADC’s eLetters are NOT indexed by Medline unless they are ultimately published in the print journal. However, if an individual identifies an article through Medline and selects full text PDF in order to read it they can find an eLetter correspondence. Hence, someone who identifies an article through Medline, rather than our website, may not find a reference to the eLetter. This is a particular concern when a topic is controversial. Second, it has been the policy of virtually all journals to give authors the opportunity to respond to letters. This is more difficult for authors when scores of letters are posted on a website. However, I want to assure readers (and authors) that they will continue to have the opportunity to respond to all electronic and printed letters. Authors, as always, will retain the right to decline to respond to letters.
I want to draw your attention to an exchange and controversy in this month’s ADC. In September 2004, Professor Tim David wrote a very scholarly piece on writing medical reports in cases of suspected child abuse.1 A number of letters have been received, notably focusing on his recommendation that paediatricians should interview parents involved in all such cases. As pointed out by Davis and colleagues in their letter, there is no legal obligation for an expert to interview parents, and in some cases an interview may not be feasible or warranted.
Currently, letters to the editor are published in the back of most journals, although some readers find them to be the most exciting part of a journal and they often raise important and provocative issues. It hardly seems fair to give an original article prominence in the body of a journal, but relegate letters to the “back of the bus.” Although we considered printing these letters in a more visible spot in ADC, they are in the traditional location. We will continue to revisit this policy.
See pages 218–9
INFANTS, CHILDREN, AND ADOLESCENTS
One of the most challenging aspects of our profession, both with respect to clinical care and research, is that we deal with infants, children, and adolescents. In the case of patients with major chronic disease who are diagnosed as children, but are now living much longer, care now extends into the adult years. I have always been struck by the dramatic impact of adolescence on just about everything. At the moment I have two teenage boys (12 and 14), and just when I think I may have something – anything right, they are quick to correct me. That said, whenever I read research reports and the age range of subjects spans puberty, it is important that the data be analysed so that the impact of hormonal changes on outcomes is assessed. Ross and colleagues provide such a study this month—it is quite illuminating. They compared the physiological and autonomic responses to acute hypoglycaemia in diabetic children based upon pubertal status. They did not define puberty by age, but rather by Tanner criteria, which although widely accepted as a valid measure of puberty may not be particularly reliable. They found significant differences based upon the pubertal age of children. Not only are these findings important in respect to children with diabetes, but they highlight the potential impact of puberty on diagnostic and therapeutic decisions.
See page 190
THE ACCURACY AND MEANING OF BRUISING IN CHILDHOOD
The diagnosis of child abuse usually depends upon a constellation of signs and symptoms. On occasion there is physical evidence of abuse or admission of guilt. Maguire and colleagues, from the Department of Child Health, University of Wales College of Medicine, provide us with a pair of articles in which they have systematically reviewed the literature that relates to the age and pattern of bruising. Unfortunately, but not unexpectedly, they found that the accuracy of individual observation with respect to the age of bruise is poor and that inter-observer reliability of colour, tenderness, and swelling is not good. These results are consistent with numerous studies that indicate how difficult it is to reach agreement on findings from physical examination. With respect to patterns of bruising the results are more encouraging. The authors could identify a number of patterns of injury, including bruising in babies, in clusters, and of uniform shape that are consistent with abuse.
See 182 and 187
CHRONIC DIARRHOEA IN THE DEVELOPING WORLD
The International Centre for Diarrhoeal Disease Research in Bangladesh has been conducting high quality research since 1978. In this issue, Alam and colleagues present the results of a randomised clinical trial involving 116 children with chronic diarrhoea who received a comminuted chicken diet either with or without partially hydrolysed guar gum. Diarrhoea was significantly more likely to resolve in children who received the diet with guar gum. These investigators and this centre are to be congratulated for a 25+ year commitment to improving the health of children living in poverty.
See page 195