We use cookies to improve our service and to tailor our content and advertising to you.More infoYou can manage your cookie settings via your browser at any time. To learn more about how we use cookies, please see our cookies policy.
We thank Professor Hall for drawing our attention to this issue. At
present there are no relevant published recommendations in the UK but we
would agree that both vaccination against VZV and influenza should be
offered and recommended to children receiving long term aspirin.
Maria A Quigley1, Claire Carson1, Julia Morinis1,2,3.
1 National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
2 Department of Paediatric Medicine, Hospital for Sick Children, Toronto,
Ontario, Canada
3 Centre for Research on Inner City Health, The Keenan Research Centre, Li
Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario,
Canada
Maria A Quigley1, Claire Carson1, Julia Morinis1,2,3.
1 National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
2 Department of Paediatric Medicine, Hospital for Sick Children, Toronto,
Ontario, Canada
3 Centre for Research on Inner City Health, The Keenan Research Centre, Li
Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario,
Canada
We would like to thank Michael A Colvin for highlighting the
distinction between the presence of the child's biological father in the
household and the presence of the mother's partner in the household. As
Dr Colvin points out, the data in Table 1 of our paper suggest that 14% of
five year old children in the study do not have their father living in
their home and, among the children of teenage mothers, this proportion is
53.5%. We thank Dr Colvin for highlighting this as this variable is
labelled incorrectly in Table 1 of our paper and it should read as
'Partner in the home at 5 years' (i.e. this would not necessarily be the
child's father) rather than 'Father in the home at 5 years'. We have also
looked at the effects on child cognitive ability of having the biological
father resident in the family home, both at the first survey (9 months)
and at the five-year follow-up. Overall, 73% of children had their father
resident at both surveys and 12.5% had their father leave by the time of
the five year survey; in the families with teenage mothers, these
proportions were 21.4% and 24.8% respectively. In addition, compared with
children whose fathers were in the home at both surveys, there was a
statistically significantly lower BAS Naming Vocabulary score in children
whose fathers had left during the study (-3.8), or who were not living in
the home at either survey (-7.2). In the small number of children whose
fathers were not there at baseline, but had returned to the family home
during the study, there was also an adverse effect on BAS Naming
Vocabulary score (-4.9), hence suggesting a negative impact of family
instability, as has been found in other studies, including the Millennium
Cohort Study. However, after adjusting for the other variables in our
models, the effect of family instability was not statistically significant
and did not alter our coefficients for mother's age (data available on
request). For example, model E from Table 2 of our paper shows a
statistically significantly lower BAS Naming Vocabulary score in children
of teenage mothers compared with children of mothers aged 25-34 (-3.8, 95%
CI: -6.3 to -1.3). When we replaced 'marital status' (which does not
distinguish between father and partner, or change of partner) in this
model with 'family instability' (as measured by the natural father's
residence in the child's home at both surveys) the effect of teenage
motherhood was very similar (-3.9, 95% CI -6.4 to -1.5). Hence, we
believe that the conclusions drawn from our study are robust.
I read Dr Anderson's article with interest because the removal of
codeine from the pharmacopeia for children under 12 years of age has
caused difficulty in my clinical practice.
I am a paediatric haematologist and in my unit in Manchester there
are over 420 children registered with bleeding disorders and another 100
or so on long term warfarin. The use of non-steroidal analgesics (NSAID)
is contra-indicated in...
I read Dr Anderson's article with interest because the removal of
codeine from the pharmacopeia for children under 12 years of age has
caused difficulty in my clinical practice.
I am a paediatric haematologist and in my unit in Manchester there
are over 420 children registered with bleeding disorders and another 100
or so on long term warfarin. The use of non-steroidal analgesics (NSAID)
is contra-indicated in all of these patients because of the effect that
NSAIDs have on platelet function. Yet painful muscle bleeds and joint
haemorrhages are a relatively common problem in children with inherited
bleeding disorders. As of now I can only use paracetamol that is often
relatively ineffective in these patients or immediately escalate to
morphine to help with their pain. How can this be safer for my patients
than having codeine as an intermediate step?
Manchester is only one of many paediatric centres for bleeding
disorders in the UK and this ban potentially affects thousands of children
and yet it would appear that their needs have not been considered in
making this rather sudden decision. Perhaps wider consultation would have
led to a more considered approach to this important clinical problem.
Morinis et al conclude that there remains a significant adverse
effect on verbal abilities in children born to teenage mothers at age five
years of age after adjustment for sociodemographic circumstances and
perinatal risk. However there appears to be a flaw in the methodology of
the study which undermines its findings.
In the characteristics of the study population by age group (table 1), the
response "Father at home- No...
Morinis et al conclude that there remains a significant adverse
effect on verbal abilities in children born to teenage mothers at age five
years of age after adjustment for sociodemographic circumstances and
perinatal risk. However there appears to be a flaw in the methodology of
the study which undermines its findings.
In the characteristics of the study population by age group (table 1), the
response "Father at home- No" rises from 51.7% at 9 months to 53.5% at 5
years. Implausibly, reading across the data for all age groups, the
parental relationships involving teenage mothers would appear more stable
over this period than those in any other age group. The presence of the
father at home falls for the other age groups by between 3 and 6%.
Clinical experience indicates that a substantial proportion of the young
mothers will have separated from the child's father and have begun a new
relationship in the 4 year interval. It would appear that the study
equates the presence of any male partner with having the child's father in
the home.
The Institute of Fiscal Studies, also using a sample of the Millennium
Cohort Study, found that 20% and 27% of unmarried cohabiting parents had
separated by the time the child was three and five years old respectively.
This is of no small consequence for the Morinis study because the IFS also
found that the separation of the birth parents was the most significant
adverse influence on the cognitive outcomes for children.
If, as it appears, any male partner has been considered as the father, and
the effect of the separation of a child's natural parents has not been
taken into account, the conclusions by Morinis are unsafe.
Goodman, A. and Greaves, E. (2010) Cohabitation, Marriage and Child Outcomes, IFS Commentary C114, Institute of Fiscal Studies.
We welcome the interest in our study reviewing the epidemiology and
referral patterns for boys with cryptorchidism.
We are in agreement with Dr Hadziselimovic that the retractile testis
is often misdiagnosed as undescended testis. However, we do not share his
experience that over half of patients 'sent' for treatment meet the
criteria for retractile testis. In our study, only 5% of boys had
retractile testis. In...
We welcome the interest in our study reviewing the epidemiology and
referral patterns for boys with cryptorchidism.
We are in agreement with Dr Hadziselimovic that the retractile testis
is often misdiagnosed as undescended testis. However, we do not share his
experience that over half of patients 'sent' for treatment meet the
criteria for retractile testis. In our study, only 5% of boys had
retractile testis. In addition, when comparing congenital with acquired
testis, we only included those who had documented scrotal findings from
the neonatal period. Our study does not attempt to draw conclusions about
the 'results'of 'treatment', merely to evaluate trends of referral and
management in relation to current recommended practice (References 4,5,6
in main article). We do not routinely offer surgery for retractile testes,
but continue to follow them up as many later ascend resulting in acquired
cryptorchidism( Agarwal)
We note the reservations of Dr Hadziselimovic regarding the impact of
orchidopexy on fertility, and indeed share them, as stated in our paper.
Although the final two statements in Dr Hadziselimovic's letter appear to
directly contradict each other, we certainly acknowledge that orchidopexy
at an early age may not prevent infertility and studies with much longer
follow-up are required. Again, this is beyond the scope of our study.
Additional Reference
Agarwal PK, Diaz M, Elder JS. Retractile testis--is it really a normal
variant? J Urol. 2006 Apr;175(4):1496-9.
The authors recommend that children on long term aspirin therapy for
complications of Kawasaki Disease should be immunised with varicella
zoster vaccine because of the risk of Reye's syndrome (RS) if they acquire
chicken pox. It is equally important that they receive influenza vaccine
annually because influenza is also associated with the development of RS
in children taking aspirin. In fact one of the groups listed as el...
The authors recommend that children on long term aspirin therapy for
complications of Kawasaki Disease should be immunised with varicella
zoster vaccine because of the risk of Reye's syndrome (RS) if they acquire
chicken pox. It is equally important that they receive influenza vaccine
annually because influenza is also associated with the development of RS
in children taking aspirin. In fact one of the groups listed as eligible
for annual routine flu vaccine in both the United States and South Africa,
is children and teenagers on aspirin.
I read with interest the paper by Drs Nah and colleagues on;
Undescended testis;513 patients' characteristics, age at orchidopexy and
patterns of referral (1).
The objective of this study was to describe current practice at the time
of orchidopexy . The results obtained should help to identify the
corrections necessary to optimize the treatment
Several principal questions should be raised:
1. The greatest challenge in a d...
I read with interest the paper by Drs Nah and colleagues on;
Undescended testis;513 patients' characteristics, age at orchidopexy and
patterns of referral (1).
The objective of this study was to describe current practice at the time
of orchidopexy . The results obtained should help to identify the
corrections necessary to optimize the treatment
Several principal questions should be raised:
1. The greatest challenge in a discussion regarding undescended testicles
is to exclude the retractile testis, for which no treatment would be
required except categorical reassurance. Examination in older boys has
certainly fooled many doctors and even experienced surgeons many times.
Over half of the patients sent for treatment could be expected to meet the
criteria for retractile testis and ff such cases are "treated", of course,
the "results" would be good. Therefore, it is vital to exclude such cases
from the discussion. The comparison of histology and hormonal levels
exemplify hypogonadotropic hypogonadism in the majority of cryptorchid
boys.(2) Importantly, only histological examination of the testicular
biopsy can distinguish a true cryptorchid testis from retractile one.
Therefore, to conclude that only congenital cryptorchid testes were
treated because these boys had surgery is inappropriate.
2. Most importantly, an early and seemingly successful orchidopexy
does not improve fertility in a substantial number of cryptorchid males
because it does not address the underlying pathophysiology of
cryptorchidism, namely, the impaired transformation of gonocytes into Ad
spermatogonia (impaired mini-puberty). It has been demonstrated that all
males having had an early (timely) and successful surgery but belonging to
the high infertility risk group develop severe oligospermia, with 20%
being azoospermic.(3) Furthermore, it has been demonstrated that
infertility caused by cryptorchidism, which is believed to be a congenital
malformation, can be successfully corrected if adequately treated. (4)
In conclusion, the recommendation to perform orchidopexy at an early age
gives the wrong impression that performing orchidopexy at an early age
will prevent development of infertility.
1 . Nah SA, Yeo CH, How G et al. Undescended testis: 513 patients'
characteristics, age at orchidopexy and patterns of referral Arch. Dis.
Child. 2013 0:Archdischild-2013-305225v1-archdischild-2013-305225;
doi:10.1136/archdischild-2013-305225
2. Hadziselimovic F, Hoecht B: Testicular histology related to
fertility outcome and postpubertal hormone status in cryptorchidism. Klin
P?diatr (2008) 220: 302-307
3. Hadziselimovic F, Hadziselimovic NO, Demougin
P, et al. Testicular gene expression in cryptorchid boys at risk of
azoospermia.
(2011).Sex Dev 5: 49-59 .
4. Hadziselimovic F: Successful treatment of unilateral cryptorchid boys
risking infertility with LH-RH analogue. Int Braz J Urol (2008).34: 319-
326
We thank Dr Hemila for sharing his work on Vitamin C with us. Dr
Hemila draws our attention to his analysis of the work by Karlowski et
al., which we read with interest. We are certainly in agreement with Dr
Hemila that "technically the Karlowski study is not among the best" with
regards to blinding.
In our paper, the referenced Karlowski article was an example of how
inadequate blinding can lead to questions...
We thank Dr Hemila for sharing his work on Vitamin C with us. Dr
Hemila draws our attention to his analysis of the work by Karlowski et
al., which we read with interest. We are certainly in agreement with Dr
Hemila that "technically the Karlowski study is not among the best" with
regards to blinding.
In our paper, the referenced Karlowski article was an example of how
inadequate blinding can lead to questions being raised on trial validity.
We are neither agreeing nor disagreeing on the original authors' analysis
of their own work.
More than half a century ago, M. J. Moroney pointed out that ". . .
the Poisson distribution may only be applied in cases where the
expectation, z, is constant from trial to trial. Thus, it does not apply
to the number of suicides per year in a given community, because the
temptation to commit suicide varies with the stress of the times, . . ."
(Facts from figures, 1956, pp 100-101.
More than half a century ago, M. J. Moroney pointed out that ". . .
the Poisson distribution may only be applied in cases where the
expectation, z, is constant from trial to trial. Thus, it does not apply
to the number of suicides per year in a given community, because the
temptation to commit suicide varies with the stress of the times, . . ."
(Facts from figures, 1956, pp 100-101.
In their short review, Wan et al. refer to the Karlowski et al.
(1975) study (1) as an example of problems caused by shortcomings in
blinding. Karlowski et al. found that vitamin C significantly shortened
the duration of colds; however, they proposed that the benefit of vitamin
C was causd by the placebo effect (1).
However, the placebo-effect explanation of Karlowski et al. was shown
to be erroneous 2 decades a...
In their short review, Wan et al. refer to the Karlowski et al.
(1975) study (1) as an example of problems caused by shortcomings in
blinding. Karlowski et al. found that vitamin C significantly shortened
the duration of colds; however, they proposed that the benefit of vitamin
C was causd by the placebo effect (1).
However, the placebo-effect explanation of Karlowski et al. was shown
to be erroneous 2 decades ago (2,3). The Karlowski et al. study has been
used as an evidence for the importance of blinding and for the claim that
vitamin C is not effective against the common cold. It is not a valid
evidence for either of those claims (2-4).
Refs.
1. Karlowski TR, et al. Ascorbic acid for the common cold. A
prophylactic and therapeutic trial. JAMA 1975;231:1038-42
2. Hemila H. Vitamin C, the placebo effect, and the common cold: a
case study of how preconceptions influence the analysis of results.
Journal of Clinical Epidemiology 1996;49:1079-84 [Discussion in:
1996;49:1085-7]
http://dx.doi.org/10.1016/0895-4356(96)00189-8
http://dx.doi.org/10.1016/0895-4356(96)00191-6
3. Hemila H. Do vitamins C and E affect respiratory infections?
Thesis. Medical Faculty, University of Helsinki, 2006: pp. 21-4
http://hdl.handle.net/10138/20335
4. Hemila H, Chalker EB. Vitamin C for preventing and treating the
common cold.
Cochrane Database of Systematic Reviews 2013; CD000980
http://dx.doi.org/10.1002/14651858.CD000980.pub4
We thank Professor Hall for drawing our attention to this issue. At present there are no relevant published recommendations in the UK but we would agree that both vaccination against VZV and influenza should be offered and recommended to children receiving long term aspirin.
Conflict of Interest:
None declared
Maria A Quigley1, Claire Carson1, Julia Morinis1,2,3.
1 National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
2 Department of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
3 Centre for Research on Inner City Health, The Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
We would like to...
I read Dr Anderson's article with interest because the removal of codeine from the pharmacopeia for children under 12 years of age has caused difficulty in my clinical practice.
I am a paediatric haematologist and in my unit in Manchester there are over 420 children registered with bleeding disorders and another 100 or so on long term warfarin. The use of non-steroidal analgesics (NSAID) is contra-indicated in...
Morinis et al conclude that there remains a significant adverse effect on verbal abilities in children born to teenage mothers at age five years of age after adjustment for sociodemographic circumstances and perinatal risk. However there appears to be a flaw in the methodology of the study which undermines its findings. In the characteristics of the study population by age group (table 1), the response "Father at home- No...
We welcome the interest in our study reviewing the epidemiology and referral patterns for boys with cryptorchidism.
We are in agreement with Dr Hadziselimovic that the retractile testis is often misdiagnosed as undescended testis. However, we do not share his experience that over half of patients 'sent' for treatment meet the criteria for retractile testis. In our study, only 5% of boys had retractile testis. In...
The authors recommend that children on long term aspirin therapy for complications of Kawasaki Disease should be immunised with varicella zoster vaccine because of the risk of Reye's syndrome (RS) if they acquire chicken pox. It is equally important that they receive influenza vaccine annually because influenza is also associated with the development of RS in children taking aspirin. In fact one of the groups listed as el...
I read with interest the paper by Drs Nah and colleagues on; Undescended testis;513 patients' characteristics, age at orchidopexy and patterns of referral (1). The objective of this study was to describe current practice at the time of orchidopexy . The results obtained should help to identify the corrections necessary to optimize the treatment Several principal questions should be raised: 1. The greatest challenge in a d...
We thank Dr Hemila for sharing his work on Vitamin C with us. Dr Hemila draws our attention to his analysis of the work by Karlowski et al., which we read with interest. We are certainly in agreement with Dr Hemila that "technically the Karlowski study is not among the best" with regards to blinding.
In our paper, the referenced Karlowski article was an example of how inadequate blinding can lead to questions...
More than half a century ago, M. J. Moroney pointed out that ". . . the Poisson distribution may only be applied in cases where the expectation, z, is constant from trial to trial. Thus, it does not apply to the number of suicides per year in a given community, because the temptation to commit suicide varies with the stress of the times, . . ." (Facts from figures, 1956, pp 100-101.
Conflict of Interest:
...In their short review, Wan et al. refer to the Karlowski et al. (1975) study (1) as an example of problems caused by shortcomings in blinding. Karlowski et al. found that vitamin C significantly shortened the duration of colds; however, they proposed that the benefit of vitamin C was causd by the placebo effect (1).
However, the placebo-effect explanation of Karlowski et al. was shown to be erroneous 2 decades a...
Pages