The article documenting children's perspectives of venepuncture in
words and drawings is certainly thought-provoking but would be more
compelling (and more useful in several ways) if the authors could give as
much as possible of the following extra information: the median age of the
cohort of 37 children; how the 37 were selected (the implication that they
all found venepuncture 'extremely distressing' begs further explana...
The article documenting children's perspectives of venepuncture in
words and drawings is certainly thought-provoking but would be more
compelling (and more useful in several ways) if the authors could give as
much as possible of the following extra information: the median age of the
cohort of 37 children; how the 37 were selected (the implication that they
all found venepuncture 'extremely distressing' begs further explanation);
the ages (median and range)of the 24 who found venepuncture 'worse than
anything they could imagine'; the ages of the children whose comments are
quoted and of those who made the drawings; the proportions of the cohort
(with respective ages, range and median) who had analgesia (documenting
the types, if possible) or none; the proportion in which a parent was
present at the time of venepuncture; any information about the experience
of the individuals carrying out the procedures. I would not, in any way,
want to weaken the overall message that venepuncture is upsetting to
children, sometimes horribly so - instead I hope that further data will
significantly strengthen that important message.
Dr Ernst has been most selective in his perspective on chiropractic.
Such a prejudiced view undermines and negates the credibility of his whole
argument.
He ignores a large volume of some 150 European medical papers on visceral
related spinal manipulation which are listed on PubMed*. He also avoids
mention of medical textbooks on the topic by such medical colleagues as...
Dr Ernst has been most selective in his perspective on chiropractic.
Such a prejudiced view undermines and negates the credibility of his whole
argument.
He ignores a large volume of some 150 European medical papers on visceral
related spinal manipulation which are listed on PubMed*. He also avoids
mention of medical textbooks on the topic by such medical colleagues as
Maigne1, Biederman2 and Lewit3. In addition, he ignores much
neurophysiology evidence in the medical literature such as the extensive
work by Sato et al4,5, Bolton5, Budgell5, Korr5, Coote5 and others as well
as the numerous conferences on medical manipulation that have been held
throughout the world.. The published evidence is more scientific than his
cited reviews and opinion.
Given the inter-professional collaboration in research and conference
presentations, as well as the good will and interest shown by others in
his professions, his dissertation merely demonstrates his opinion.
Contrary to Dr Ernst stand, the World Federation of Neurology6 and the
World Health Organisation7 has recognised cervicogenic headaches in its
ICD-107.
In addition he has not cited any scientific studies which would tend to
support his obsessive campaign contentions.
It surprises that such superficial comment deserves space in your quality
journal.
While the old adage of An absence of evidence is not evidence of absence,
applies to both sides of the campaign, there is far more evidence in
support of chiropractic concepts and only biased opinion against it..
Yours sincerely,
PL Rome DC
Melbourne
Australia
cadaps@bigpond.net.au
1. Maigne R. Functional disturbances. In: Orthopaedic medicine : A
new approach to vertebral manipulations. Springfield: Charles C Thomas;
1972.164.
2. Biedermann H, ed. Manual therapy in children. Edinburgh:Churchill
Livingstone;2004.
3. Lewit K. Vertebrovisceral relations. In: Manipulative therapy in
rehabilitation of the locomotor system. 3rd edn. Butterworth Heinemann,
Oxford 1999. p.286.
4. Sato A, Sato Y, Schmidt RF. Somatosensory modulation of the digestive
system. In: The impact of somatosensory input on autonomic functions.
Reviews of Physiology Biochemistry and Pharmacology. Blaustein MP et al
Eds. Springer-Verlag, Berlin. 1997;v130.
5. Papers too numerous to list.
6. Letter. From WFN to Dr Z Bankowski, Council for International
Organizations of Medical Sciences, C/- WHO., Geneva.. September 17th,
1996.**
7. World Health Organisation’s publication, World Classification of
Diseases (ICD-10) Chapter X111, 2006.
http://www3.who.int/icd/currentversion/fr-icd.htm.
* I would be happy to send you the list of the 150 medical
references from PubMed should you desire.
** Copy can be supplied if required.
Dear Sir,
we have read with interest Latif and Berry’s paper in which the authors
reported detailed reference times for the various components of the
transport service.1 These data could be used for benchmarking and quality
improvement in the setting of a centralised transport service.
Two basic models of neonatal transport have been developed in Europe.
These are : (a) dedicated services (or centralised transpo...
Dear Sir,
we have read with interest Latif and Berry’s paper in which the authors
reported detailed reference times for the various components of the
transport service.1 These data could be used for benchmarking and quality
improvement in the setting of a centralised transport service.
Two basic models of neonatal transport have been developed in Europe.
These are : (a) dedicated services (or centralised transport services)
that carry out all transfers in a region and (b) on-call services provided
by a large neonatal unit that send its own staff to retrieve the patient.
The organizational choice in term of cost-benefit ratio between the two
models depends mainly on the number of transports per year and on the
referral area. 2
At our Institution, the neonatal emergency transport service is based on a
call organizational model.
Here, we report the retrieval times of our activity. Azienda Ospedaliera
Padova, Regional Neonatal Transport Service provides the neonatal critical
care transport in the East Veneto Region, Italy, with a total population
referral of 2,3 million in a radius of approximately 150 km. In the
referral area, there are approximately 25,700 births/year in 25 delivery
units. Of these units, 16 are classified as Level I (s care for normal
near-term and term infants), 8 as Level II (s intermediate care), and 1 as
Level III (s complete neonatal intensive care). The transports are
exclusively by road using an ambulance specifically designed for the
purpose.
Between August 2000 and December 2008, 1495 critical neonatal patients
were retrieved by ground ambulance. Of 1495 neonates, 996 (68%) were less
than 24 h old at the time of the call. 269 (18%) patients had a
gestational age <32 weeks and/or a birth weight <1500 g. The
clinical reasons for retrieval included respiratory insufficiency (66%),
cardiac and cardiac-surgery disease (12%), neurological problems (9%),
major surgery disease (7%), prematurity (10%).
658 (44%) patients were intubated, 164 (11%) were managed with
nasopharyngeal tube and all had a intravenous line.
The medians (IQR) of the components of retrieval time were as follows:
- Response time (call --> depart from base) 42 min (38-51)
- Stabilization time (first look --> ready to depart) 37 min (24-59)
- Total mission time (call --> return back to NETS base) 180 min (160-
260)
Our reference times are different from those reported for a
centralized transport service by Latif and Berry. 1 These data could be
used for benchmarking and quality improvement in centers where an on a
call organizational model has been adopted.
References
Abdel-Latif ME, Berry A. Analysis of the retrieval times of a
centralised transport service, New South Wales, Australia. Arch Dis Child
2009;94:282-6.
Agostino R, Fenton AC, Kollèe LAA, Chabernaud JL, Carrapato MRG,
Peitersen B, Sedin G, Derganc M. Organization of neonatal transport in
Europe. Prenat Neonat Med 1999;4 (Suppl 1):20-34.
With great interest we read the study of Williams et al eliciting the
reasons for the presentation of children in non-urgent cases in an
Australian paediatric emergency department (PED), a problem also well
known in other countries. They found that parents’ presenting behaviour is
appropriate according to the level of seriousness of the child’s state
they perceive.
With great interest we read the study of Williams et al eliciting the
reasons for the presentation of children in non-urgent cases in an
Australian paediatric emergency department (PED), a problem also well
known in other countries. They found that parents’ presenting behaviour is
appropriate according to the level of seriousness of the child’s state
they perceive.
We absolutely agree with the authors’ results and conclusion.
However, we would like to comment on two aspects. First, the parents’ care
giving measures before presenting to the PED are defined in a rather
narrow way. Use of medication, first aid measures and consultation of
other medical services are items that focus exclusively on the medical
context. Especially in the case of fever which represents 20.4% of the
reasons why parents present an ill child to the PED in Williams’s study
this seems to be relevant.
In a study of the fever concepts of German and Turkish mothers we
found that mothers frequently apply various non-pharmacologic measures,
e.g. sponging, complementary medication but also religious and ritual
practices before consulting a doctor. These strategies often reflect
different explanatory models (1) the parents have for the illness. We
found for example that 29% of the mothers use additional blankets when a
child has fever. Furthermore 36% stated that cold weather causes fever - a
finding that explains the use of blankets as a means to achieve a
temperature equilibrium. By asking for items that solely represent the
established medical model one misses other concepts that might influence
the use of professional services.
Second, to provide a better understanding of the parents’ motivations
and the actions they undertake before presenting to a PED - the explicit
goal of the study in question - we believe it is important to take on the
parents’ perspective. For this we would suggest for further studies to
incorporate a qualitative approach. As long as the wide range of parents’
motivations is not known - and Williams et al seem to interpret them
rather narrow - a qualitative approach which enables new insights into the
unique perspective of parents seems promising. Questions like why parents
present to the PED after having consulted a GP or why they judge the state
of the child as serious (and others with the same condition do not) could
be answered. Cultural influences might be analysed as well.
In that sense Williams et al’s work leads to further questions that
seem to be important in order to gain a deeper understanding of the
parents’ behaviour in seeking help for their child. Eventually, this
knowledge could be used to address parents’ concerns effectively, to
provide specific information for them and hereby increase the quality of
patient care.
Th. Langer, V. Kalitzkus.
Email: thorsten.langer@uni-wh.de
References:
1) Kleinman, A. Patients and Healers in the Context of Culture: An
Exploration of the Borderland between Anthropology, Medicine and
Psychiatry. Univ of California Pr; 1981.
We thank Odeka et al for their comments regarding our follow-up study
of children admitted to hospital with community-acquired pneumonia (CAP).
They are correct in their initial 2 observations that the study did not
measure premorbid lung function or bronchial hyperreactivity. These
measurements were not an objective of the present study therefore were not
included in study design. Inclusion was limited by the retrospectiv...
We thank Odeka et al for their comments regarding our follow-up study
of children admitted to hospital with community-acquired pneumonia (CAP).
They are correct in their initial 2 observations that the study did not
measure premorbid lung function or bronchial hyperreactivity. These
measurements were not an objective of the present study therefore were not
included in study design. Inclusion was limited by the retrospective
nature of the study. We agree that further prospective work is required to
determine the relationship between premorbid lung function, bronchial
hyperreactivity and the development of chronic respiratory disease
following CAP.
With regard to the question concerning whether we should be following
up all children hospitalised with CAP. We do not have sufficient evidence
currently to support this, based on our study findings. However, we would
advise that parents of chidlren admitted with CAP are alerted, at time of
discharge, to the need to consult their doctor should their child develop
persistent cough or a new diagnosis of asthma or wheeze in the future. We
have shown that a small percentage of such children may have significant
chronic respiratory disease (supplemental file 4 of original article)1.
There is a need for prospective work to delineate high risk groups further
and to investigate an appropriate follow-up strategy.
Competing interests: None
References
1. Eastham KM, Hammal DM, Parker L, Spencer, DA. A follow-up study of
chidlren hospitalised with community-acquired pneumonia. Arch Dis Child
2008 Sep;93(9):755-9
We read with interest your article on follow up of children with
community acquired pneumonia and also your eletter response on the
subject. I t is interesting to note that children with pre-existing asthma
are at significant risk of persistent cough after admission to hospital
for community acquired pneumonia. However the risk of subsequent asthma is
increased only in children of non-atopic parents.
In routine clinical pr...
We read with interest your article on follow up of children with
community acquired pneumonia and also your eletter response on the
subject. I t is interesting to note that children with pre-existing asthma
are at significant risk of persistent cough after admission to hospital
for community acquired pneumonia. However the risk of subsequent asthma is
increased only in children of non-atopic parents.
In routine clinical practice the children with pneumonia are not normally
followed up in the clinic and at the most seen once in the clinic to
ensure resolution of consolidation. The current British thoracic society
guidelines make no recommendation for long term follow up (2). We would
like to note the following issues in your study.
1. Due to the retrospective nature of your study it was not possible
to assess premorbid lung functions. Castro-Rodriguez et al found those
with a diagnosis of pneumonia had lower levels of maximal flows at FRC at
mean age of 2 mo (albeit not significantly) and at age 6 yr and lower
levels of FEV1 and FEF25–75 at age 11 yr. They conclude that children with
x-ray confirmed pneumonia have diminished airway function that is probably
present shortly after birth. These deficits are at least in part due to
alterations in the regulation of airway muscle tone (1).
Therefore the question of whether preexisting abnormal lung function
predisposes to pneumonia or of pneumonia resulting in lung function
abnormality remains unanswered.
2. Bronchial hyperactivity was not determined in your study.
Bronchial hyperactivity is far more common than asthma in children with
pneumonia. In a study by korppi et al (3) bronchial hyperactivity
indicated by methacholine inhalation challenge was present in 45% of the
pneumonia group. All 10 asthmatic patients had bronchial hyperactivity,
but only 20% of hyperactive children had asthma. In another study (4)
bronchial hyperactivity was present in 42% of children with pneumonia at
less than 2 years age when followed to a median age of 19 years.
It is possible that certain percentage of children in the bronchial
hyperactivity group develop asthma over a period of time. It is not very
clear which factors predispose to the development of asthma.
3. Does the outcome of the study suggest that we should be following
up all children with pneumonia? At present we do not have sufficient
evidence to support a change of practice.
References
1. Castro-Rodriguez JA, Holberg CJ, Wright AL, et al. Association of
radiologically
ascertained pneumonia before age 3 yr with asthmalike symptoms and
pulmonary
function during childhood. Am J Respir Crit Care Med 1999;159:1891–7.
2.British Thoracic Society Standards of Care Committee. British
Thoracic Society
Guidelines for the Management of Community Acquired Pneumonia in
Childhood.
Thorax 2002;57(Suppl 1):i1–24.
3. Korppi ML, Kuikka T, Reijonen, et al. Bronchial asthma and
hyperreactivity after early childhood bronchoilitis or pneumonia. Arch
Paediatr Adolesc Med 1994;148:1079–84.
4. Eija Piippo-Savolainen et al Asthma and Lung Function 20 Years after
Wheezing in Infancy: Results From a Prospective Follow-up Study Arch
Pediatr Adolesc Med. 2004;158:1070-1076
Dr Rowland and colleagues have recently reported a prospective audit
on the use of rectal paraldehyde in children with prolonged seizures (1).
On the basis of their data they conclude that “This would appear to
confirm that paraldehyde should remain a treatment for the management of
prolonged tonic-clonic convulsions, including convulsive status
epilepticus”. Unfortunately there are several issues that req...
Dr Rowland and colleagues have recently reported a prospective audit
on the use of rectal paraldehyde in children with prolonged seizures (1).
On the basis of their data they conclude that “This would appear to
confirm that paraldehyde should remain a treatment for the management of
prolonged tonic-clonic convulsions, including convulsive status
epilepticus”. Unfortunately there are several issues that require
discussion before that conclusion can be justified.
There seems to be little doubt that rectal paraldehyde has some
anticonvulsant activity, a feature in common with a multitude of other
drugs ranging from the older drugs (phenytoin, phenobarbitone, lidocaine,
chlormethiazole, diazepam, clonazepam etc) through to the newer agents
(midazolam, sodium valproate, levetiracetam, lacosamide). The issue is not
whether rectal paraldehyde is an anticonvulsant drug but whether it is
justifiably in a national guideline as a second line agent in preference
to any of the above agents.
There are several reasons why the positioning of rectal paraldehyde
in the APLS guideline is difficult to justify. A major consideration is
the recommendation that the intravenous access used for administration of
the first line agent (lorazepam in the APLS guideline) is ignored whilst
rectal paraldehyde is administered, a position not adopted in other
developed countries (2). The treating physician will have far more control
of the situation if a second intravenous agent is administered. Rectal
administrations do not have precisely predictable bioavailability even if
intrafaecal injections and rectal expulsions do not occur. A potential
difficulty with the administration of intravenous phenytoin is the length
of time the infusion takes. However, in our large population based study
it was clear that seizure termination with phenytoin usually occurred
before the end of the infusion (3). In addition, that study revealed that
phenytoin was approximately 9 times more likely to result in seizure
termination within ten minutes of administration than rectal paraldehyde
further supporting the view that intravenous therapy is to be preferred to
rectal therapy, at the time that rectal paraldehyde is currently
recommended. Our study also showed 5% of those treated with rectal
paraldehyde had recurrence of seizures within 4 hours compared to no
children treated successfully with intravenous phenytoin.
The evaluation of the efficacy of rectal paraldehyde in the study by
Rowland et al did not only assess the efficacy when it was administered at
the time that is suggested in the APLS guideline. Approximately 30% of
children received it as a first line agent because of previous failures or
side effects with benzodiazepines. This is very likely to introduce a bias
to the sample. Another potential source of bias is that the sample
recruited is not representative of the population at large. The majority
of patients had pre-existing epilepsy (compared to approximately 12% in
our population based cohort4), was older (mean age 6.12 years, range 5
months to 16 years compared to mean age 3.24 years, range 2 months to 15
years), and it is not obvious that any had febrile convulsions, which is
the most common aetiology in the population (4). In addition, few children
contributed many of the episodes (e.g. four patients were treated 13 times
because a benzodiazepine had previously failed. Recurrent administration
of rectal paraldehyde is likely to have been successful as the families
clearly persisted with the strategy). Our population based study is much
less likely to be biased and evaluated the effect of paraldehyde at the
time suggested by APLS and does not support its use (3). The reason
proposed for the difference in efficacies reported in these 2 studies is
that dosing was more appropriate in the study by Rowland et al. Although
this is possible it seems to be unlikely as Rowland et al did not show a
dose dependent effect in their study, we adjusted for dose administered in
our analyses and consistent with the Rowland study we also did not show
dose dependence. Therefore, the most likely reasons for the differences
observed between the 2 studies are selection bias and use of the drug
outside of the current guidance.
Another potential role for rectal paraldehyde is in children in whom
it has not been possible to establish intravenous access. However,
intravenous therapy is more effective in the Accident and Emergency
setting, even for first line therapy in that setting, and therefore the
imperative for appropriate treatment for convulsive status epilepticus
should be to establish intravenous access and rectal treatment should be
seen as a last resort (3).
For the reasons above the study by Rowland et al has not provided
information that is material to the development of a generic national
guideline, nor have they provided evidence that the current APLS guidance
is appropriate. Their data may however suggest that rectal paraldehyde
could have benefit in selected patients with epilepsy and can be
considered for individualised protocols for children with recurrent
prolonged seizures.
Rod C Scott
Richard FM Chin
Brian GR Neville
References
Reference List
1. Rowland AG, Gill AM, Stewart AB et al. Review of the efficacy of
rectal paraldehyde in the management of acute and prolonged tonic-clonic
convulsions. Arch Dis Child 2009.
2. Yoong M, Chin RF, Scott RC. Management of convulsive status
epilepticus in children. Arch Dis Child Educ Pract Ed 2009;94:1-9.
3. Chin RF, Neville BG, Peckham C, Wade A, Bedford H, Scott RC.
Treatment of community-onset, childhood convulsive status epilepticus: a
prospective, population-based study. Lancet Neurol 2008;7:696-703.
4. Chin RF, Neville BG, Peckham C, Bedford H, Wade A, Scott RC.
Incidence, cause, and short-term outcome of convulsive status epilepticus
in childhood: prospective population-based study. Lancet 2006;368:222-229.
The leading article on child protection by Ben Matthews et al (1)
starts with a promising review of the difficulties experienced by UK
Paediatricians with child protection work. However, their argument that
low substantiated cases of abuse and neglect in UK represent the
reluctance of paediatricians in England to engage in the business of child
protection is not supported by their statistics. Also, their approach of
comp...
The leading article on child protection by Ben Matthews et al (1)
starts with a promising review of the difficulties experienced by UK
Paediatricians with child protection work. However, their argument that
low substantiated cases of abuse and neglect in UK represent the
reluctance of paediatricians in England to engage in the business of child
protection is not supported by their statistics. Also, their approach of
comparing substantiation rates across different child protection systems
and processes is flawed. The authors introduce the concept of mandatory
reporting laws for child abuse. These have a limited evidence base for
truly improving outcomes for children, but have a potential for personal
penalties for professionals who may not have reported child abuse for any
reason and also introduce a risk of complacency about child protection
work in the future.
At face value, the substantiation rates of child abuse and neglect in
USA (12.1 per thousand children) appear significantly more than England (3
per thousand children). An analysis of the data from the Child
Maltreatment Report (USA, 2007) (2) confirms that the national rate of
referral was 43 per 1000 children. Comparing this with 538,500 child
protection referrals made in England (3) and a child population of
approximately 11.66 million (4), shows that the referral figures for
England are in fact slightly more than USA. Hence it cannot be concluded
that lack of reporting laws in England contributes to the lower
substantiation rates.
Also, child protection procedures in England (5) may not be directly
comparable to other societies with similar child welfare standards.
Initial assessments by children’s social care in England (319,900 in 2008)
could result in a ‘child in need’ conclusion with a plan for service
provision for supporting the child and family. A proportion of the initial
assessments require core assessments (105,100 in 2008) for a more in-depth
assessment of the child’s needs and parental capacity to respond to these
needs. There may be substantiated concerns that a child has suffered
significant harm, but a plan for ensuring the child’s future safety and
welfare can be developed and implemented without having a child protection
conference or a child protection plan. Hence substantiation rate
comparison across countries may have less meaning unless similar
procedures are followed everywhere.
Legislative immunity for reporting professionals is an attractive
concept. However, it is unlikely to exist in isolation of mandatory
reporting laws. Such mandatory reporting laws bring up a whole range of
problems which the authors touch upon in one paragraph towards the end of
their report. A significant majority of paediatricians would agree that
child protection services in some parts of England appear overwhelmed by
the volume of work they face to safeguard children within the current
processes. Overburdening these systems with many more unsubstantiated
notifications (as would arise from mandatory reporting) would not only be
time consuming and costly, but also risk diverting attention and resources
from those children at real risk of abuse.
Mandatory reporting does carry a sting in its tail for professionals
too; failure to report carries a range of personal penalties for non-
reporting (6). The default position of being ‘safe than sorry’ will have
implications for service efficiency and cost. More importantly, if future
generations of professionals have a sense of ‘legislative security’, there
remains a real risk that knowledge, skills and training in child
protection could be adversely affected.
There is no doubt about the fact that paediatricians’ confidence in
child protection work needs to be urgently restored in the UK. The article
by Matthews et al takes a bold first step towards addressing some of the
barriers to this. There is, however, unlikely to be a single solution to a
complex problem like this.
References
1. Mathews B, Payne H, Bonnet C, Chadwick D. A way to restore British
paediatricians’ engagement with child protection. Arch Dis Child 2009; 94:
329-331
2. Administration for Children and Families. Child Maltreatment 2007.
Reports. Chapter 2
http://www.acf.hhs.gov/programs/cb/pubs/cm07/chapter2.htm#screen
3. Department for Children, Schools and Families. Referrals,
Assessments and Children and Young People who are the subject of a Child
Protection Plan, England- year ending 31 Mar 2008
http://www.dcsf.gov.uk/rsgateway/DB/SFR/s000811/index.shtml
4. Office of National Statistics
http://www.statistics.gov.uk/statbase/Product.asp?vlnk=15106
5. Working Together to Safeguard Children. 2006. London
6. Mandatory Reporting of Child Abuse and Neglect: State Statutes and
Professional Ethics
http://www.ndaa.org/pdf/mandatory_reporting_state_statutes.pdf
Samuel and colleagues(1) aim to review the clinical and
epidemiological evidence relevant to the use of pre-implantation diagnosis
(PGD) to create a “saviour sibling.” A thorough literature review
regarding the use of this method should include consideration of the
medical problems that may occur in the child born following assisted
reproduction technology (ART), but this was not addressed in this...
Samuel and colleagues(1) aim to review the clinical and
epidemiological evidence relevant to the use of pre-implantation diagnosis
(PGD) to create a “saviour sibling.” A thorough literature review
regarding the use of this method should include consideration of the
medical problems that may occur in the child born following assisted
reproduction technology (ART), but this was not addressed in this article.
There is a large (and still growing) body of literature reporting the
association of imprinting disorders with ART, which has prompted a call
for large-scale investigation of the incidence of birth defects, cancer,
and other health problems in children born following ART. (2-4) This
information would surely be of interest to the parents of this future
child as they would be responsible for caring for him/her and all his/her
medical (not to mention psychological) burdens.
Any discussion that left this information out would not in any way
“engender trust” but would take advantage of parents at a time when they
are most vulnerable and, therefore, more prone to dismiss the long-term
implications that a decision such as PGD would have for themselves and for
their future child, whose existence would arise for, and be delimited by,
a specific purpose – that of serving as a “biological insurance” for an
older sibling.
Yours sincerely,
Marjorie Garvey, MB, BCh
Division of Developmental Translational Research, NIMH
Neuroscience Center
6001 Executive Blvd,
Rockville, MD 20852
The views expressed in this letter are the authors’ own opinions and
do not necessarily represent the views of the NIMH. Dr Garvey has no
competing interests.
References
1. Samuel GN, Strong KA, Kerridge I, Jordens CF, Ankeny RA, Shaw PJ.
Establishing the role of pre-implantation genetic diagnosis with human
leucocyte antigen typing: what place do "saviour siblings" have in
paediatric transplantation? Arch Dis Child 2009;94:317-20.
2. Cheung AP. Assisted reproductive technology - Both sides now. J
Reprod Med 2006;51:283-92.
3. Manipalviratn S, DeCherney A, Segars J. Imprinting disorders and
assisted reproductive technology. Fertil Steril 2009;91:305-15.
4. Niemitz EL, Feinberg AP. Epigenetics and assisted reproductive
technology: A call for investigation. Am J Hum Genet 2004;74:599-609.
We read with interest the finding of an unchanged incidence of
microalbuminuria with time in children with type 1 diabetes in the Oxford
Regional Prospective Study cohort. Figure 1 demonstrates no difference in
the cumulative prevalence of developing microalbuminuria in relation to
year of diabetes onset. However we note the small numbers of patients
remaining at 10 years, particularly in group C, and wonder whether a
d...
We read with interest the finding of an unchanged incidence of
microalbuminuria with time in children with type 1 diabetes in the Oxford
Regional Prospective Study cohort. Figure 1 demonstrates no difference in
the cumulative prevalence of developing microalbuminuria in relation to
year of diabetes onset. However we note the small numbers of patients
remaining at 10 years, particularly in group C, and wonder whether a
difference between the groups may be found if the results of group B and C
were combined.
As commented by Amin et al, this finding is different from that
previously reported in our clinic-based cohort which showed a significant
decline in the rates of early elevation of albumin excretion rate (AER
≥7.5µ/min) and microalbuminuria (AER ≥20µ/min) in adolescents
between 1990-2002 (1). It is well recognised that the prevalence of
overweight in children and adolescents is increasing over time (2).
Increased body mass index and waist-hip ratio are independent risk factors
for microalbuminuria in type 1 diabetes (3). We have also shown in a
longitudinal cohort that obesity and insulin dose are independent
predictors for persistent microalbuminuria (4). We speculate that the
increasing BMI in patients with type 1 diabetes over time has offset any
positive effect of improved glycaemic control on the incidence of
microalbuminuria. It would be of interest to investigate the effect of
these measures on the risk of the development of microalbuminuria in this
cohort.
References
1. Mohsin F, Craig ME, Cusumano J, et al. Discordant trends in
microvascular complications in adolescents with type 1 diabetes from 1990
to 2002. Diabetes Care 2005;28:1974-80.
2. Libman IM, Pietropaolo M, Arslanian SA, LaPorte RE, Becker DJ.
Changing prevalence of overweight children and adolescents at onset of
insulin-treated diabetes. Diabetes Care 2003;26:2871-5.
3. Chaturvedi N, Bandinelli S, Mangili R, Penno G, Rottiers RE,
Fuller JH. Microalbuminuria in type 1 diabetes: rates, risk factors and
glycemic threshold. Kidney Int 2001;60:219-27.
4. Stone ML, Craig ME, Chan AK, Lee JW, Verge CF, Donaghue KC.
Natural history and risk factors for microalbuminuria in adolescents with
type 1 diabetes: a longitudinal study. Diabetes Care 2006;29:2072-7.
The article documenting children's perspectives of venepuncture in words and drawings is certainly thought-provoking but would be more compelling (and more useful in several ways) if the authors could give as much as possible of the following extra information: the median age of the cohort of 37 children; how the 37 were selected (the implication that they all found venepuncture 'extremely distressing' begs further explana...
The Editor Archives of Disease in Children
Dr Ernst has been most selective in his perspective on chiropractic. Such a prejudiced view undermines and negates the credibility of his whole argument. He ignores a large volume of some 150 European medical papers on visceral related spinal manipulation which are listed on PubMed*. He also avoids mention of medical textbooks on the topic by such medical colleagues as...
Dear Sir, we have read with interest Latif and Berry’s paper in which the authors reported detailed reference times for the various components of the transport service.1 These data could be used for benchmarking and quality improvement in the setting of a centralised transport service.
Two basic models of neonatal transport have been developed in Europe. These are : (a) dedicated services (or centralised transpo...
With great interest we read the study of Williams et al eliciting the reasons for the presentation of children in non-urgent cases in an Australian paediatric emergency department (PED), a problem also well known in other countries. They found that parents’ presenting behaviour is appropriate according to the level of seriousness of the child’s state they perceive.
We absolutely agree with the authors’ results...
We thank Odeka et al for their comments regarding our follow-up study of children admitted to hospital with community-acquired pneumonia (CAP). They are correct in their initial 2 observations that the study did not measure premorbid lung function or bronchial hyperreactivity. These measurements were not an objective of the present study therefore were not included in study design. Inclusion was limited by the retrospectiv...
We read with interest your article on follow up of children with community acquired pneumonia and also your eletter response on the subject. I t is interesting to note that children with pre-existing asthma are at significant risk of persistent cough after admission to hospital for community acquired pneumonia. However the risk of subsequent asthma is increased only in children of non-atopic parents. In routine clinical pr...
Sir,
Dr Rowland and colleagues have recently reported a prospective audit on the use of rectal paraldehyde in children with prolonged seizures (1). On the basis of their data they conclude that “This would appear to confirm that paraldehyde should remain a treatment for the management of prolonged tonic-clonic convulsions, including convulsive status epilepticus”. Unfortunately there are several issues that req...
The leading article on child protection by Ben Matthews et al (1) starts with a promising review of the difficulties experienced by UK Paediatricians with child protection work. However, their argument that low substantiated cases of abuse and neglect in UK represent the reluctance of paediatricians in England to engage in the business of child protection is not supported by their statistics. Also, their approach of comp...
Dear Editor,
Samuel and colleagues(1) aim to review the clinical and epidemiological evidence relevant to the use of pre-implantation diagnosis (PGD) to create a “saviour sibling.” A thorough literature review regarding the use of this method should include consideration of the medical problems that may occur in the child born following assisted reproduction technology (ART), but this was not addressed in this...
We read with interest the finding of an unchanged incidence of microalbuminuria with time in children with type 1 diabetes in the Oxford Regional Prospective Study cohort. Figure 1 demonstrates no difference in the cumulative prevalence of developing microalbuminuria in relation to year of diabetes onset. However we note the small numbers of patients remaining at 10 years, particularly in group C, and wonder whether a d...
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