We read your article with interest as we have recently been reviewing
cases of Vitamin D deficiency diagnosed at Birmingham Childrens Hospital's
Emergency Department.
We reviewed data from the emergency department from March 2009 to
March 2010. Over a period of 12 months we identified 89 patients with low
vitamin D levels (total Vitamin D level less than 50nmol/litre), with 83%
of those having very low Vitamin D...
We read your article with interest as we have recently been reviewing
cases of Vitamin D deficiency diagnosed at Birmingham Childrens Hospital's
Emergency Department.
We reviewed data from the emergency department from March 2009 to
March 2010. Over a period of 12 months we identified 89 patients with low
vitamin D levels (total Vitamin D level less than 50nmol/litre), with 83%
of those having very low Vitamin D levels(less than 25nmol/litre). The
data from Glasgow detected 25 cases over a 6 year period referred by their
Emergency Department.
In the Glasgow study the most common presenting features were bowed
legs (80%), a seizure (12%)
and a suspicion after an X-ray(7%). In our data the most common presenting
features were abdominal pain (19%), a seizure (17%), and limb pain (15%).
A significant proportion of our diagnosed patients initially presented
with non specific symptoms; blood investigations showed an elevated
alkaline phosphatase leading to vitamin D levels being measured.This
highlights the need for clinicians to be aware of the wide spectrum of non
specific symptoms that can occur with Vitamin D deficiency.
In the Glasgow study the most common ethnic origins of Vitamin D
deficient children were being African and from the Middle East. The most
common ethnic origins in our series were Pakistani (37%) followed by Black
African(11.2%). Birmingham is an ethnically diverse city. At the last
census 30% of the population were non-white. Asians (Indian Pakistani,
Bangladeshi and others) represented 65.8% of the non-white population. The
high proportion of Asian children within Birmingham may explain the high
percentage of children with Pakistani origin presenting to Birmingham
Children's hospital and the greater number of children detected with
severe Vitamin D deficiency.
We feel that our data is just the tip of the iceberg of vitamin D
deficiency in Birmingham's children. Up to one in 3 Asians attending
outpatients have been shown to have severe Vitamin D deficiency(2). There
is no equivalent data yet to confirm this degree of Vitamin D deficiency
in children, however our data suggests that Vitamin D deficiency in
childhood is widely under recognised.Given the high long term morbidity
associated with Vitamin D deficiency, such as cardiovascular disease and
type II diabetes(3), more systematic studies are needed to identify those
at risk and initiate preventative measures.
Preventative measures such as milk fortification with Vitamin D, but
also sensible exposure to sunlight and encouraging a more active lifestyle
might be helpful to reduce Vitamin D deficiency in children. Most of the
U.S. milk supply is voluntarily fortified with Vitamin D 100 IU/cup(4). In
Canada, milk is fortified by law with 35-40 IU/100 mL. We hope the
increasing detection of severe Vitamin D deficiency in the UK's children
and the burden of Vitamin D deficiency on long term health with result in
legislation to ensure vitamin D supplementation of food.
1) SF Ahmed et al.Recent trends and clinical features of childhood
vitamin D deficiency presenting to a children,s hospital in Glasgow.
Archives of Diseases in Childhood July 2011: volume 96 P694-97
2) Ford L, Graham V, Wall aet al. Vit D concentrations in and UK
inner-city multicultural outpatient population Ann Clin Biochem 2006; 43;
468-73
3)Pearce S & Cheetham T Diagnosis and management of Vitamin D
deficiency 2010.BMJ 2010:340:b5664
4) Institute of Medicine, Food and Nutrition Board. Dietary Reference
Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press,
Dear Editor,
We have read the interesting study by Chiaretti et al.[1] which concluded
that intranasal lidocaine spray given prior to intranasal midazolam can
eliminate burning or pain in children. The purpose of this letter is to
share our experience associated with the use of nazal lidocaine spray in
patients both adult and children.
Midazolam is used to provide sedation for many years in children [2].
Physicians are...
Dear Editor,
We have read the interesting study by Chiaretti et al.[1] which concluded
that intranasal lidocaine spray given prior to intranasal midazolam can
eliminate burning or pain in children. The purpose of this letter is to
share our experience associated with the use of nazal lidocaine spray in
patients both adult and children.
Midazolam is used to provide sedation for many years in children [2].
Physicians are still searching for a best noninvasive route of midazolam
administration. Intranasal administration of midazolam results in a high
bioavailability, rapid onset and recovery when compared with oral
midazolam. However, it is associated with the burning or pain seen in up
to 65% of patients [1]. This disadvantage is still being waited to be
solved by the clinicians.
Intranasal lidocaine spray application is routinely used to provide local
anesthesia prior to discomfortable procedures such as flexible or rigid
broncoscopy and nasopharyngoscopy. However, similar to our experiences and
many reports, including a meta-analysis [3] have shown that the use of
intranasal lidocaine causes significant pain and discomfort in both
children and adults. As a result; does prior application of lidocaine
spray solve this problem? We don't think so.
References
1.Chiaretti A, Barone G, Rigante D. Intranasal lidocaine and midazolam for
procedural sedation in children. Arch Dis Child. 2011;96(2):160-3.
2. Apilliogullari S, Sener Y, Can S et al. Effect of midazolam on salivary
rate in children. SU Dishek Fak Derg. 2010;19(2):145-9.
3. Conlin AE, McLean L. Systematic review and meta-analysis assessing the
effectiveness of local anesthetic, vasoconstrictive, and lubricating
agents in flexible fibre-optic nasolaryngoscopy. J Otolaryngol Head Neck
Surg. 2008;37(2):240-9.
I read with very keen interest the editorial of Davies et al from
Southampton and particularly agree with the heading '' Preventable but no
strategy: Vitamin D deficiency in the UK''
In 2005(1) I published an observational study from Oldham on the
increasing trend in the number of cases of Rickets from the ethnic
population. In our study population, from a total of approximately 50,000
children (2001 census) 20.8% are fr...
I read with very keen interest the editorial of Davies et al from
Southampton and particularly agree with the heading '' Preventable but no
strategy: Vitamin D deficiency in the UK''
In 2005(1) I published an observational study from Oldham on the
increasing trend in the number of cases of Rickets from the ethnic
population. In our study population, from a total of approximately 50,000
children (2001 census) 20.8% are from the Asian subcontinent. We gained an
insight of the evolving problem. In the period of review, 9 cases of
rickets with ages between 6 days to 13 years were treated. This reflected
the widespread nature of this problem in the at risk population (pregnant
women, neonates born to deficient mothers and toddlers)
In drawing up our trust guideline for managing Vit D deficiency we noted
the inconsistency in the laboratory definitions of levels /units to define
deficiency and this affected the quality of information sent to the Gps.
Another problem relates to the high cost of the 'special formulations'
offered by some local pharmacies making this simple and low cost
medication to be very expensive resulting in the reluctance to prescribe
by General practitioners.
While I welcome this piece from Southampton by Davies et al(2), I am not
sure about the evidence base for their proposed guideline for managing
this problem (table 1). If adopted it may result in over treatment of some
cases in the non-white population. Samples of blood taken from at risk
group (Non white) may be lower than the average if not matched with the
same population of sampling (3). If this happens, it may lead to an over
treatment of cases that may be perfectly 'normal'. The UK growth chart
versus the new WHO chart is a reminder of this scenario (White population
based growth chart used to assess non white children's growth). Adopting a
higher Vit D level in this population may risk over treating a population
of patients that may only need supplementation.
There is the urgent need for a properly designed study to address this
issue. Until that happens it is important for the public health department
to implement the 1998 report of the nutrition committee (4). My guess is
that NICE will soon have a published view on the issue.
Reference;
1. Odeka E Tan J ; Nutritional Rickets is increasingly diagnosed in
Children of ethnic origin, Arch Dis Child. 2005 November ;90 (11) 1203-
1204
2. Davies JH Shaw N; Preventable but no strategy: Vitamin D deficiency in
the UK. Arch Dis Child. 2011; 96; 614-615
3. Ford L, Graham V, Wall A et al; Vitamin D concentrations in an UK inner
- city multicultural outpatient population. Ann Clin Biochem 2006 ; 43:
468-73.
4. Department of Health, Nutrition and Bone Health; with particular
reference to calcium and Vitamin D . Report of the Subgroup on bone
health,working group of the nutritional status of the population of the
committee on medical aspects of the Food Nutrition policy. Rep. Health Soc
subj (lond) 1998; 49:iii-vii,1-24.
Elkout et al's study on prescribing practices in primary care
concluded that the data 'appeared to reflect growing awareness of and
adherence to guideline recommendations'.(1) They based their conclusions
on a decreased prescription of high unlicensed doses of inhaled
costicosteroid (ICS), and low numbers of long acting beta agonist (LABA)
monotherapy. Our interpretation of the data is not as optimistic. The
study dem...
Elkout et al's study on prescribing practices in primary care
concluded that the data 'appeared to reflect growing awareness of and
adherence to guideline recommendations'.(1) They based their conclusions
on a decreased prescription of high unlicensed doses of inhaled
costicosteroid (ICS), and low numbers of long acting beta agonist (LABA)
monotherapy. Our interpretation of the data is not as optimistic. The
study demonstrated persistent inappropriate use of LABA monotherapy for
children under 4 years between 2001/2(2.2%) and 2005/6 (1.6%).
Furthermore, the significant increase in use of ICS/ LABA combinations
inhalers for children 0-4 years is even more concerning; 0.3% in 2001-02,
to 2.2% in 2005-06. Across all age groups, the proportion of children
prescribed LABA/ICS significantly doubled over the 5 year study period. In
addition, 24.7% of children prescribed ICS/LABA were initiated on the
combination inhaler without prior ICS therapy, not in keeping with any
guideline world-wide.
Our study in the UK demonstrated a 7 fold increase in the number of
combination steroid inhalers prescribed between 2000 and 2006.(2) An
Australian study suggested up to 41% of all asthmatic children on a
controller therapy were prescribed salmeterol/fluticasone combination
inhalers.(3) Despite warnings from drug regulation authorities children
were still prescribed LABA monotherapy.(4) Further, more than half of the
Australian children prescribed a LABA (alone or as a steroid combination
inhaler) only filled one prescription in any given year, suggesting either
the children are undertreated, or the medications are used intermittently,
or inappropriately prescribed.(5) Although guidelines suggest LABA is an
effective controller for patients who have uncontrolled asthma despite
treatment with low dose ICS, there are no safety data on its use in
children under the age of 5. There is evidence suggesting the use of LABA
is associated with an increase in exacerbations of asthma, and an increase
in asthma-related deaths in patients receiving LABA monotherapy.(6)
Elkout's study clearly demonstrates the need for ongoing education in
primary care to ensure children with asthma are managed appropriately.
Reference
1. Elkout H, Helms PJ, Simpson CR, and McLay JS. Changes in primary
care prescribing patterns for paediatric asthma: a prescribing database
analysis. Arch Dis Child [online first]. 2011 [cited 2011 May 19 ].
Available from:
http://adc.bmj.com/content/early/2011/05/19/adc.2010.206268.abstract
2. Cohen S, Taitz J, Jaffe A. Paediatric prescribing of asthma drugs
in the UK: are we sticking to the guideline? Arch Dis Child.
2007;92(10):847-9.
3. Brown M, Phillips CB, Ciszek K, Burton D, Attewell R, McDonald T,
et al. Children in the ACT with asthma--are they taking preventer
medication according to guidelines? Aust Fam Physician. 2010;39(3):146-9
4. de Vries TT, Hilde. Schirm, E. van den Berg, P. Duiverman, E.
deJong-ven den Berg, Lolkje. The gap between evidence-based medicine and
daily practice in the management of paediatric asthma. A pharmacy-based
population study from The Netherlands. European Journal of Clinical
Pharmacology. 2006;62:51-5.
5. Australian Centre for Asthma Monitoring. Asthma in Australia 2008.
Canberra: AIHW; 2008; Available from:
http://www.aihw.gov.au/search/?q=asthma+in+australia+2008. [Accessed 2011
April 8]
6. Nelson HS, Weiss ST, Bleecker ER, et al. The Salmeterol
Multicenter Asthma Research Trial, A comparison of usual pharmacotherapy
for asthma or usual pharmacotherapy plus salmeterol. Chest. 2006;
129(1):15-26
in the conclusions of their excellent review Starkey and Shahidullah
[1] suggest that propranolol should be reserved just for severe cases of
haemangioma, while for the other children which deserve treatment, the use
of propranolol would be the second choice, pending the results of
randomised clinical trials (RCTs) comparative to corticosteroids. We do
not agree with this conclusion, as it is in con...
in the conclusions of their excellent review Starkey and Shahidullah
[1] suggest that propranolol should be reserved just for severe cases of
haemangioma, while for the other children which deserve treatment, the use
of propranolol would be the second choice, pending the results of
randomised clinical trials (RCTs) comparative to corticosteroids. We do
not agree with this conclusion, as it is in contradiction with the results
reported by the Authors in the same review: it is rather difficult to
believe that steroids may have a more favourable risk-benefit profile
compared with propranol.
RCTs are necessary to provide data on safety, efficacy and optimal
use of drugs. Getting the necessary clinical trials performed is required
to achieve the goals of the US, EU and WHO paediatric medicines
initiatives [2]. However, as stated in the EU Paediatric Regulation,
unnecessary trials should be avoided for obvious ethical reasons [3]. In
our Institution we had to stop a RCT comparing propranolol and
corticosteroids, because in the vast majority of cases families do not
agree to treat their children with the corticosteroids, considering the
strong effectiveness of propanolol with far less side effects.
The problem of careful definition and management of therapy with
propranolol in haemangiomas should be aware that safety alerts almost
exclusively concerned serious adverse effects, most of which are unknown
or underestimated and concern drugs with a low prescription prevalence
[4]. Paediatric guidance has become available from health authorities,
providing pharmacovigilance concepts as they specifically relate to drugs
being developed for paediatric indications. RCT are typically not strong
enough to detect rare or delayed safety effects, since paediatric trials
have a relatively short-term. Furthermore, such long term or rare effects
may not be detected through standard voluntary postmarketing surveillance.
In our opinion a national or European prospective registry of
children with haemangiomas treated with propranolol (as a part of
monitoring programs) would be preferable, in order also to standardize
drug formulations which appear to be very heterogeneous, since the drug is
not licensed for paediatric use [5].
Federico Marchetti, Gianluca Tornese, Irene Berti
Department of Paediatrics, Institute of Child Health, IRCCS Burlo
Garofolo, Trieste, Italy
Via dell'Istria 65/1- 34100 Trieste
e-mail: marchetti@burlo.trieste.it
References
1. Starkey E, Shahidullah H. Propranolol for infantile haemangiomas:
a review. Arch Dis Child 2011 May 28. doi:10.1136/adc.2010.208884
2. Choonara I. Improving children's medicines. Arch Dis Child
2006;91(7):550-1.
3. Hoppu K. Can we get the necessary clinical trials in children and
avoid the unnecessary ones? Eur J Clin Pharmacol 2009;65(8):747-8
4. Clavenna A, Bonati M. Adverse drug reactions in childhood: a
review of prospective studies and safety alerts. Arch Dis Child
2009;94(9):724-8.
5. Marchetti F, Bua J, Ventura A, Notarangelo LD, Di Maio S, Migliore
G, Bonati M. The awareness among paediatricians of off-label prescribing
in children: a survey of Italian hospitals. Eur J Clin Pharmacol
2007;63(1):81-5
I have read with interest this article from Jones et al. I am however
slightly confused by the Conclusion. It states that "Indirect evidence
leads the authors to recommend the use of atropine during septic and late
hypovolaemic shock, when using suxamethonium." This implies atropine
should only be used in hypovolaemic states when suxamethonium is being
used, while I have read the body of the article to support the conclus...
I have read with interest this article from Jones et al. I am however
slightly confused by the Conclusion. It states that "Indirect evidence
leads the authors to recommend the use of atropine during septic and late
hypovolaemic shock, when using suxamethonium." This implies atropine
should only be used in hypovolaemic states when suxamethonium is being
used, while I have read the body of the article to support the conclusion
that "Indirect evidence leads the authors to recommend the use of atropine
during septic and late hypovolaemic shock, or when using suxamethonium."
Apologies if I am mistaken?
The author of a review on the potential role of new vaccines in
elimination of childhood tuberculosis emphasized that modern trials of a
new tuberculosis vaccines pose the challenge of diagnostic endpoints for
childhood tuberculosis and immune correlates of vaccine-induced protection
(1). The author did not take into account major progress that has
recently been achieved in understanding the effect of BCG immunisation....
The author of a review on the potential role of new vaccines in
elimination of childhood tuberculosis emphasized that modern trials of a
new tuberculosis vaccines pose the challenge of diagnostic endpoints for
childhood tuberculosis and immune correlates of vaccine-induced protection
(1). The author did not take into account major progress that has
recently been achieved in understanding the effect of BCG immunisation.
Three high quality observational studies (n=1346) established that BCG
immunisation in infancy protects against infection with m. tuberculosis as
measured by gamma interferon release assay (2,3,4). Vaccine effectiveness
for prevention of infection was found to be of similar magnitude in all
three studies with 66 % ( 95% CI 58%-74%), 74% (95%CI 31%- 91%) and 76 %
(95% CI 65%-88%) respectively. Protection against infection as evident
from these trials was not less than protection against manifestation of
active tuberculosis like miliary tuberculosis and tuberculous meningitis
in a previous meta-analysis (5). If BCG immunisation, in addition to
protection against infection, was also protective against disease in
infected people the vaccine effectiveness against disease would exceed
that against infection. This consideration and the fact that BCG
immunisation is known not to protect patients with pre-existing infection
with m. tuberculosis against disease (6) supports a hypothesis that the
effect of BCG immunisation consists entirely of protection from infection
and not of protection from manifestation of disease in an infected
individual. Lack of response in a gamma interferon release assay after
exposure to m. tuberculosis may therefore be the ideal short-term outcome
measure for future vaccine trials.
References:
1. Hatherill M. Prospects for elimination of childhood tuberculosis: the
role of new vaccines. Arch Dis Child 2011. doi: 10.1136/adc.2011.214494.
2. Eriksen J, Chow JY, Mellis V, Whipp B, Walters S, Abrahamson E,
Abubakar I. Protective effect of BCG vaccination in a nursery outbreak in
2009: time to reconsider the vaccination threshold? Thorax 2010; 65:1067-
71
3. Eisenhut M, Paranjothy S, Abubakar I, Bracebridge S, Lilley M,
Mulla R, Lack K, Chalkley D, McEvoy M. BCG vaccination reduces risk of
infection with Mycobacterium tuberculosis as detected by gamma interferon
release assay. Vaccine 2009: 27: 6116-6120.
4. Soysal A, Millington KA, Bakir M, Dosanjh D, Aslan Y, Deeks JJ,
Efe S, Staveley I, Ewer K, LalvaniA. Effect of BCG vaccination on risk of
mycobacterium tuberculosis infection in children with household
tuberculosis contact: a prospective community-based study. Lancet 2005;
366: 1443-51.
5. Colditz GA, Berkey CS, Mosteller F, Brewer TF, Wilson ME, Burdick
E, Fineberg HV. The efficacy of Bacillus Calmette-Guerin Vaccination of
newborns and infants in the prevention of tuberculosis: meta-analyses of
the published literature. Pediatrics 1995; 96: 29-35.
6. Ten Dam HG, Pio A. Pathogenesis of tuberculosis and effectiveness
of BCG vaccination. Tubercle 1982; 63: 225-233.
Thank you for reporting on the outcome of our trial in children with
relapsed ALL. As you stated in the first sentence the results were better
with Mitoxantrone and therefore the survival figures given in the
penultimate sentence are wrong - i.e they have been reversed. The last
sentence is taken out of context and may mislead readers. The "warrants
further investigation" refers to the use of Mitox...
Thank you for reporting on the outcome of our trial in children with
relapsed ALL. As you stated in the first sentence the results were better
with Mitoxantrone and therefore the survival figures given in the
penultimate sentence are wrong - i.e they have been reversed. The last
sentence is taken out of context and may mislead readers. The "warrants
further investigation" refers to the use of Mitoxantrone to treat children
with ALL at first diagnosis and not a repeat trial as the sentence seems
to suggest.
We very recently published a paper in BMC Pediatrics
(http://www.biomedcentral.com/1471-2431/10/63) in which we demonstrated
that all infant formulae contained very high levels of the known
neurotoxin aluminium. It should come as no surprise to anyone in this
field that feeding formula milk, which contains an order of magnitude
higher concentration of aluminium than breast milk, could be associated
with impaired behavio...
We very recently published a paper in BMC Pediatrics
(http://www.biomedcentral.com/1471-2431/10/63) in which we demonstrated
that all infant formulae contained very high levels of the known
neurotoxin aluminium. It should come as no surprise to anyone in this
field that feeding formula milk, which contains an order of magnitude
higher concentration of aluminium than breast milk, could be associated
with impaired behaviour in infants. When we highlighted this possible
danger to infants the FSA chose to completely ignore our research. There
may be a number of reasons why 'breast is best' but one which continues to
be ignored is that it does not contain extremely high concentrations of a
known neurotoxin, aluminium. Something has to be done about this. We
cannot continue to exposure the most vulnerable members of our society to
aluminium in infant formulas.
The authors rightly point out in their introduction that there is
evidence (reference 12 Gargiullo P et al N Engl J Med 2007; 356:1121-9) of
loss of vaccine-induced immunity over time, and that Australia will likely
have to adopt a two-dose varicella schedule, which is not the case
currently. I wonder if the authors have any opinion on how this will
impact future maternity care in 15-20 years time and whether this will see...
The authors rightly point out in their introduction that there is
evidence (reference 12 Gargiullo P et al N Engl J Med 2007; 356:1121-9) of
loss of vaccine-induced immunity over time, and that Australia will likely
have to adopt a two-dose varicella schedule, which is not the case
currently. I wonder if the authors have any opinion on how this will
impact future maternity care in 15-20 years time and whether this will see
a potential increase of CVS or neonatal varicella. Will there be a
clinically significant proportion of women of childbearing age that have
neither vaccine-induced or naturally acquired immunity to varicella (i.e.
will it be greater than the 10% of women currently susceptible)? Will the
herd immunity provided by the vaccine be enough to protect these women?
And finally, as a result of this will varicella serology become a normal
part of pregnancy screening in the same way rubella is currently, or do
the authors anticipate a change in the NIP to prevent the need for this
e.g. the introduction of a 2nd dose for teenage girls?
We read your article with interest as we have recently been reviewing cases of Vitamin D deficiency diagnosed at Birmingham Childrens Hospital's Emergency Department.
We reviewed data from the emergency department from March 2009 to March 2010. Over a period of 12 months we identified 89 patients with low vitamin D levels (total Vitamin D level less than 50nmol/litre), with 83% of those having very low Vitamin D...
Dear Editor, We have read the interesting study by Chiaretti et al.[1] which concluded that intranasal lidocaine spray given prior to intranasal midazolam can eliminate burning or pain in children. The purpose of this letter is to share our experience associated with the use of nazal lidocaine spray in patients both adult and children. Midazolam is used to provide sedation for many years in children [2]. Physicians are...
I read with very keen interest the editorial of Davies et al from Southampton and particularly agree with the heading '' Preventable but no strategy: Vitamin D deficiency in the UK'' In 2005(1) I published an observational study from Oldham on the increasing trend in the number of cases of Rickets from the ethnic population. In our study population, from a total of approximately 50,000 children (2001 census) 20.8% are fr...
Elkout et al's study on prescribing practices in primary care concluded that the data 'appeared to reflect growing awareness of and adherence to guideline recommendations'.(1) They based their conclusions on a decreased prescription of high unlicensed doses of inhaled costicosteroid (ICS), and low numbers of long acting beta agonist (LABA) monotherapy. Our interpretation of the data is not as optimistic. The study dem...
Dear Editor,
in the conclusions of their excellent review Starkey and Shahidullah [1] suggest that propranolol should be reserved just for severe cases of haemangioma, while for the other children which deserve treatment, the use of propranolol would be the second choice, pending the results of randomised clinical trials (RCTs) comparative to corticosteroids. We do not agree with this conclusion, as it is in con...
I have read with interest this article from Jones et al. I am however slightly confused by the Conclusion. It states that "Indirect evidence leads the authors to recommend the use of atropine during septic and late hypovolaemic shock, when using suxamethonium." This implies atropine should only be used in hypovolaemic states when suxamethonium is being used, while I have read the body of the article to support the conclus...
The author of a review on the potential role of new vaccines in elimination of childhood tuberculosis emphasized that modern trials of a new tuberculosis vaccines pose the challenge of diagnostic endpoints for childhood tuberculosis and immune correlates of vaccine-induced protection (1). The author did not take into account major progress that has recently been achieved in understanding the effect of BCG immunisation....
Dear Lucina,
Thank you for reporting on the outcome of our trial in children with relapsed ALL. As you stated in the first sentence the results were better with Mitoxantrone and therefore the survival figures given in the penultimate sentence are wrong - i.e they have been reversed. The last sentence is taken out of context and may mislead readers. The "warrants further investigation" refers to the use of Mitox...
We very recently published a paper in BMC Pediatrics (http://www.biomedcentral.com/1471-2431/10/63) in which we demonstrated that all infant formulae contained very high levels of the known neurotoxin aluminium. It should come as no surprise to anyone in this field that feeding formula milk, which contains an order of magnitude higher concentration of aluminium than breast milk, could be associated with impaired behavio...
The authors rightly point out in their introduction that there is evidence (reference 12 Gargiullo P et al N Engl J Med 2007; 356:1121-9) of loss of vaccine-induced immunity over time, and that Australia will likely have to adopt a two-dose varicella schedule, which is not the case currently. I wonder if the authors have any opinion on how this will impact future maternity care in 15-20 years time and whether this will see...
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