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Are patients who have had a coarctation of the aorta repaired getting a raw deal? Lifelong follow up is important because of the risks of hypertension, aortic aneurysm, coronary disease, aortic valve problems, and cerebral aneurysm. In Norwich (
) a search for patients with repaired coarctation revealed 53 patients attending either adult cardiology clinics (four patients) or an adult congenital heart disease clinic (49). Twenty-two of them had had a period of at least 2 years without any cardiology follow up before being referred. Sixteen patients had been discharged from cardiology clinics, some quite recently. The message for paediatricians is simple: never discharge a child who has had a coarctation repaired from a paediatric cardiology clinic and arrange transfer to a suitable adult cardiology clinic at the appropriate time (by implication, not all adult cardiology clinics may be regarded as suitable). Special attention will be needed before and during pregnancies.
Data from two UK sources, the Avon Longitudinal Study of Parents and Children (
) and the General Practice Research Database (ibid: 584-91), have given no support to the suggestion that thiomersal in vaccines is a cause of neurodevelopmental disorders in children. A systematic review (ibid: 793–804) also produced no evidence of a link between thiomersal and autistic spectrum disorders.
Common polymorphisms in the β2-adrenergic receptor may determine responses to treatment of asthma with β2 adrenergic agonists. In a multicentre US crossover study (
, see also Comment, ibid: 1464–6) 78 adults with mild asthma were randomised to inhaled salbutamol (albuterol) or placebo. They were grouped according to whether they were homozygous for glycine (Gly/Gly) or arginine (Arg/Arg) at amino acid residue 16 of the β2-adrenergic receptor. In the Gly/Gly group treatment with salbutamol was associated with a morning peak expiratory flow rate 14 l/min greater than with placebo. In the Arg/Arg group, however, average morning peak expiratory flow rate was 10 l/min less with salbutamol than with placebo. There were similar changes in FEV1, symptoms, and use of rescue medication (ipratropium). About one in six Americans has the Arg/Arg genotype.
Cynics might say that having enough doctors and nurses makes little difference to the public health, but cynics would be wrong. A study of 117 countries based on the 2004 WHO dataset (
; see also Comment, ibid: 1558-60) has shown a strong negative correlation between human resource density (numbers of doctors and nurses per 10 000 population) and maternal, infant, and under 5 mortality rates (after controlling for income, female adult literacy, and absolute income poverty). The correlation is strongest for maternal mortality and weakest for infant mortality. Doctor density correlated significantly with the mortality rates but nurse density did not, probably because of errors in the figures for nurse numbers. The authors of this paper conclude that investment in doctor and nurse provision is important if the Millenium Development Goals for maternal and child health are to be achieved.
In Holland (
) 119 children with asthma were examined between 1966 and 1969 when they were 5–14 years old. They were examined again in 1983–6 (aged 21–33 years) and in 1995–6 (aged 32–42 years). At the third visit the asthma had remitted in 52%. Twenty-two per cent had complete remission (no symptoms, no use of inhaled steroid, normal FEV1, and no bronchial hyperresponsiveness on histamine challenge) while 30% had clinical remission only with persisting low FEV1 and/or bronchial hyperresponsiveness. Thus 57% of patients in clinical remission still had abnormalities on testing. Remission at the third visit was associated with a higher FEV1 at the first visit and a greater increase in FEV1 between the first and second visits.
Small-for-dates term infants have an increased risk of developing insulin resistance in later childhood. Now researchers in Auckland, New Zealand (
, see also editorial, ibid: 2229–31) have shown that preterm infants have the same propensity. They studied 72 healthy children aged 4–10 years. Fifty had been born at or before 32 weeks gestation (12 also small-for-dates) and 22 were controls (term, appropriate-for-dates). Insulin sensitivity was determined during intravenous glucose tolerance testing using paired glucose and insulin assays (minimal-model technique). The preterm group had reduced insulin sensitivity and increased acute insulin release compared with the controls, irrespective of whether or not they (the children born preterm) had been small or appropriate for dates.
In the United Kingdom Infantile Spasms Study (
) 107 infants were randomised to vigabatrin (52), prednisolone (30), or tetracosactrin depot (25). The proportions with no spasms on days 13 and 14 were 54%, 70%, and 76% respectively, a significant difference in favour of the steroid treatments. The rates of adverse events were similar (55% with vigabatrin, 54% with steroid). Long term outcomes are to be reported when the infants have all reached the age of 14 months.
Neonatal haemochromatosis is a highly lethal condition of unknown cause; death occurs in utero or in early postnatal life in over 70% of cases. Researchers in Chicago (
; see also Comment, ibid: 1644–5) have postulated that the condition may have an immune basis and have reported an international trial of high-dose intravenous immunoglobulin given to the mother during pregnancy (1 g weekly from 18 weeks). They treated 15 mothers (16 pregnancies), each of whose previous pregnancy had resulted in the birth of a child with neonatal haemochromatosis. All 16 infants were apparently well at birth although 12 had biochemical evidence of neonatal haemochromatosis. Liver biopsy performed on four infants because of clinical indications showed the changes of haemochromatosis in two and milder changes in the other two. Nevertheless all 16 infants were well when last seen. The mothers’ previously affected infants had done badly; 20 of 26 probably or definitely affected infants had died either in utero (seven) or postnatally (13, three after liver transplantation). The authors of this paper point out that high-dose intravenous immunoglobulin is very expensive (about US $50 000 per pregnancy), scarce, potentially harmful, and not yet of proved value. Its possible mechanisms of action are subject to debate.
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