We welcome the debate stimulated by our paper. Indeed, this was our
aim in publishing it.
We agree with Mr Caldwell that a degree of underreporting is likely.
Our system provides a clear definition to all staff of what constitutes a
reportable medication error (listed in the appendix). It does not include
errors that are averted such as mis-prescribed errors corrected by
pharmacists prior to dis...
We welcome the debate stimulated by our paper. Indeed, this was our
aim in publishing it.
We agree with Mr Caldwell that a degree of underreporting is likely.
Our system provides a clear definition to all staff of what constitutes a
reportable medication error (listed in the appendix). It does not include
errors that are averted such as mis-prescribed errors corrected by
pharmacists prior to dispensing. We also noted that error-reporting rates
vary widely in the literature. We discussed some of the reasons advanced
to explain such variations, such as whether the reporting system is
mandatory or voluntary and the intensity of the search for errors.
However, the published evidence about medication error rates in paediatric
settings is very limited especially in the context of a nationally funded,
universal, health care system such as the NHS. There is, therefore, little
firm paediatric evidence to support Mr. Caldwell's opposite view that
errors are "…extremely common, overlooked and often ignored."
In our experience, most reported errors were minor. Serious events
with adverse outcomes were uncommon and, we think, are unlikely not to be
reported. If anything, we would suspect it is minor errors that are most
likely to go unrecorded. This may be of considerable importance if
analysis of minor events highlights system problems whose correction may
help avoid future serious incidents.
Mr Caldwell suggests that voluntary systems may increase error
reporting. It needs to be recognized that voluntary systems are not a
panacea but may also detect only a fraction of overall errors. Again, we
would suspect that minor errors might most likely be missed. The thrust of
the editorial by Cohen[1] appears to relate to errors with serious adverse
outcomes. There are also some potential difficulties with voluntary
systems. For example, how we do we ensure that parents are notified about
error occurrence if reporting is voluntary? What happens about errors of
such seriousness that issues of criminal negligence arise?
Whether a reporting system is mandatory or voluntary probably is less
important than that the system is non-punitive. This is borne out by the
findings of Vincer et al[2] who found approximately a four to six- fold
increase in the reporting of errors by reducing the punitive aspects of
the form by making it an "incident" rather than an "error" form. We have
no doubt that the critical challenge for us all is to make the shift from
assuming "errors" arise from individual negligence to recognising that
"incidents" more usually arise because of systemic organisational
failures. We urgently need to move away from a culture of "fixing the
blame" towards one of recognising and "fixing the problem".
References
(1) Cohen MR. Why error reporting systems should be voluntary. BMJ 2000;320:728-9.
(2) Vincer MJ, Murray JM, Yuill A, Allen AC, Evans JR, Stinson DA. Drug errors and incidents in a neonatal intensive care unit. A quality assurance activity. Am J Dis Child 1989;143:737-40.
Cappendijk and Hazebroek (Arch Dis Child 2000;83:64-6) conclude from
their data that "the major factor in delay is suspected gastroenteritis".
Other studies have not given this factor such prominence and the study
population suggests that the Sophia Hospital was acting as a referral
centre: 32 of 78 children whose admission was delayed for 48 hours had
been seen first by a paediatrician, which may i...
Cappendijk and Hazebroek (Arch Dis Child 2000;83:64-6) conclude from
their data that "the major factor in delay is suspected gastroenteritis".
Other studies have not given this factor such prominence and the study
population suggests that the Sophia Hospital was acting as a referral
centre: 32 of 78 children whose admission was delayed for 48 hours had
been seen first by a paediatrician, which may increase the numbers with
suspected gastroenteritis.
In seeking the chief causes of delayed diagnosis it is helpful to
study all children referred to a district hospital from its catchment
area. Jackson in Newcastle found that parental delay over consulting the
family doctor was important and then, in nearly one-third of 311 home
visits, the practitioner did not decide until a second visit that
admission to hospital for ?acute appendicitis was needed.[1] Jackson, a
paediatrician, did not identify gastroenteritis as a factor. Other work
confirms these findings.[2]
In Aberdeen over 300 children are admitted annually from our region
with acute abdominal pain, and have been studied prospectively since 1965.[3, 4] This soon revealed that about one-third had acute appendicitis, one-third progressively settled without treatment (acute non-specific
abdominal pain, or NSAP) and others had medical and surgical conditions.
Among one year's admissions we found that 20 (18%) of 114 children with
proven acute appendicitis complained of diarrhoea compared with 9% of 119
children with NSAP. Of the 20, 15 had rectal tenderness and proved to have
pelvic appendicitis or peritonitis: we emphasised the importance of
identifying, among the many children with gastroenteritis seen by family
doctors, the few who also complain of abdominal pain, who require careful
abdominal and rectal examination.[3] The practice of "Active Observation"
encourages this.[4]
Occasionally delay in diagnosis of appendicitis is seen by the
surgeon on a call to the
isolation ward, where a child has been mistakenly sent in with suspected
gastroenteritis, but this has not, over the years, been a major problem.
Peter F Jones Emeritus Clinical Professor of Surgery University of Aberdeen, UK
References
(1) Jackson RH. Parents, family doctors and acute appendicitis in childhood. BMJ 1963;ii:277- 81.
(2) Moss JG, Barrie JL, Gunn AA. Delay in surgery for acute appendicitis. J R Coll Surg Edin 1985;30:290-3.
(3) Winsey HS, Jones PF. Acute abdominal pain in childhood: analysis of a year's admissions. BMJ 1967;i:653-5.
(4) Driver CP, Youngson GG. Acute abdominal pain in children: a 25-year comparison. Health Bulletin 1995;53:167-72.
The recent study by Hutton, Colver, and Mackie[1] is in some
respects a useful addition to our knowledge of survival in cerebral palsy.
Unfortunately there some are substantial problems with the paper; we note
three of them below.
In Figure 1A it appears that in the most seriously affected group,
LAS >70%, there is 100% survival to age 9. This scarcely seems
plausible when, as the graph indicate...
The recent study by Hutton, Colver, and Mackie[1] is in some
respects a useful addition to our knowledge of survival in cerebral palsy.
Unfortunately there some are substantial problems with the paper; we note
three of them below.
In Figure 1A it appears that in the most seriously affected group,
LAS >70%, there is 100% survival to age 9. This scarcely seems
plausible when, as the graph indicates, 20% of these survivors die in the
next 9 years. The explanation is that the most severely disabled children,
with LAS 70% or more, have to survive to age 5 to be assessed by LAS. Thus
the severely disabled children who die before 5 have no LAS, and are
excluded (actually, it appears from the graph that some children are
evaluated even later than age 5).
The resulting bias could have serious consequences. For example, in a
lawsuit involving a neurologically devastated 2-year old child a plaintiff
may cite Hutton et al to argue for 100% survival over the next seven years.
Hutton et al's results show that, as is well known, low IQ and/or poor
mobility correlate with reduced life expectancy. In his commentary, Dr Rosenbloom usefully asks whether extreme immobility or mental impairment
would give an even greater reduction. The answer is clearly yes, as
indicated by our own work[2][3] and is also acknowledged by other workers in
the area (Evans et al[4] Crichton et al[5]). Indeed it must be so because
an extensive literature shows a much shortened survival in the persistent
vegetative state,[6] which may be regarded as the extreme case of
disability.
In neither Hutton et al's nor in Hutton's previous study of the Merseyside area[7] is this possibility mentioned. As a result, the latter study has
frequently lead plaintiffs to overestimate survival of children with the
most severe disabilities.
In their Table 5, Hutton et al state that in our California study[2] the odds
ratios for various hazards were lower than in several other studies. For
example, in Table 2 of our article we gave a hazard ratio of 3.8 for two
year-olds who were tube fed, compared to those who were not. Hutton et al then
proceeded to speculate at some length on what accounts for the
transatlantic difference.
The real reason is simple: the California data base has many more
variables other data bases, so the marginal effect of any one of them -- ie, when the others are held constant -- is smaller. For example, our
Table 1 showed that if no other factors are taken into account the hazard
ratio for tube feeding (compared to children who could self-feed) was 23.6
-- a much larger ratio than the above 3.8, and in fact about as large as
any in Hutton et al's Table 5. In addition, the definitions of mobility etc. in the
various studies are very different.
David Strauss, PhD, FASA
Emeritus Professor of Statistics
Robert Shavelle, PhD
University of California Life Expectancy Project
References
(1) Hutton JL, Colver AF, Mackie PC. Effect of severity of
disability on survival in north east England cerebral palsy cohort. Arch
Dis Child 2000;83:468-74.
(2) Strauss DJ, Shavelle RM, Anderson TW. Life expectancy of
children with cerebral palsy. Pediatr Neurol 1998;18:143-9.
(3) Strauss DJ, Shavelle RM. Life expectancy of adults with
cerebral palsy. Dev Med Child Neurol 1998;40:369-75.
(4) Evans PM, Evans SJW, Alberman E. Cerebral palsy: Why we must plan for survival. Arch Dis Child 1990;65:1329-33.
(5) Crichton, JU. Response to Letter from Professor Hall. Dev
Med Child Neurol 1995;37:1031-3.
(6) Multi-society task force on PVS. Medical Aspects of the
Persistent Vegetative State, Part I. N Engl J Med 1994;330:499-1508.
(7) Hutton JL, Cooke T, Pharoah POD. Life expectancy in
children with cerebral palsy. BMJ 1994;309:431-5.
Poustie et al state that there is no computer package available in the United Kingdom
for calculating percentage weight for height (%WFH). This is incorrect
and for many years there has been available just such a package entitled
W4H under the copyright of Great Ormond Street Hospital for Children NHS
Trust. The program can be used on any version of Windows from 3.1
onwards, Excel, and on Psion's. This p...
Poustie et al state that there is no computer package available in the United Kingdom
for calculating percentage weight for height (%WFH). This is incorrect
and for many years there has been available just such a package entitled
W4H under the copyright of Great Ormond Street Hospital for Children NHS
Trust. The program can be used on any version of Windows from 3.1
onwards, Excel, and on Psion's. This program was produced by the Eating
Disorders Research Team at Great Ormond Street but can be purchased from
the address below:
Dr Bryan Lask
Child and Adolescent Eating Disorders Research Team
Department of Psychiatry
Jenner Wing, St George's Hospital Medical School
London SW17 0RE, UK
The accurate diagnosis of meningococcal disease is important, not
only for the welfare of the patient, but also for the implementation of
appropriate public health measures. Brogan and Raffles have made a useful
contribution to more reliable diagnosis.[1]
However I feel that their finding of 9% could represent a falsely low
proportion of children with serious bacteraemia because of potential
recru...
The accurate diagnosis of meningococcal disease is important, not
only for the welfare of the patient, but also for the implementation of
appropriate public health measures. Brogan and Raffles have made a useful
contribution to more reliable diagnosis.[1]
However I feel that their finding of 9% could represent a falsely low
proportion of children with serious bacteraemia because of potential
recruitment bias and measurement bias. Knowing that children would not be
given antibiotics if entered into the study, unless they met the ILL
criteria or had a raised WCC or CRP, may have led admitting doctors to
exclude some children that they felt uneasy about observing. This could
easily have been achieved by describing the rash as >2mm for instance
(it is not stated whether the rash was measured or judged by eye).
Secondly it is questionable whether they had discovered all the
bacteraemias. Blood culture or remaining well after discharge could miss
bacteraemia in those children treated with antibiotics before admission or
given a short course in hospital. PCR would have been a useful additional
diagnostic test.
This study is a useful first step, but as the authors say, needs to
be followed up with a prospective trial. The recruiters and assessors of
the children to the study are not the managing clinicians and the
diagnosis of bacteraemia is more thoroughly sought. This is important to
validate the diagnostic technique and also the positive predictive value
of the combination of petechiae and fever.
Reference
(1) Brogan PA, Raffles A. The management of fever and petechiae: making sense of rash decisions. Arch Dis Child 2000;83:506-7.
We read with interest the work of Male et al on perception of breathlessness in acute asthma. They studied 27 children with acute asthma, 12 of whom were hypoxic at presentation with SaO2...
We read with interest the work of Male et al on perception of breathlessness in acute asthma. They studied 27 children with acute asthma, 12 of whom were hypoxic at presentation with SaO2 <_92. children="children" presenting="presenting" with="with" significant="significant" hypoxia="hypoxia" sao292="sao292" are="are" considered="considered" as="as" a="a" group="group" who="who" report="report" late="late" to="to" hospital="hospital" and="and" risk="risk" death="death" from="from" asthma="asthma" presenters="presenters" those="those" sao2="sao2"/>92% (early presenters). Perception of breathlessness was measured by what the children reported as the amount of puff they had (HMP score). This was measured on a six-point scale using the concept of blowing up a balloon. Spirometric criteria of respiratory function were measured at admission and at various points during recovery. The authors found lower HMP scores in the hypoxic population, (4 vs 3, p=0.062). They further showed higher HMP/FEV1 ratios in children presenting with hypoxia. They concluded that those with lower SaO2 at presentation perceived breathlessness poorly. This could in some children, contribute to their late presentation and/or death from asthma. At the same value of FEV1 the late presenter reported a higher puff. The result of a high value of HMP/FEV1 in children presenting with significant hypoxia is a remarkable finding from the study.
But the physiological relation of low FEV1 with hypoxia and the possibility of different permutations of FEV1 and HMP score capable of yielding the same ratio preclude the use of this ratio alone as an identifier of the late presenter. The authors acknowledging this handicap went on to examine change in HMP score (from the time of admission to 72 hours), per unit change in FEV1 (deltaHMP/deltaFEV1) per percent of predicted value, against initial SaO2. The hypoxic population was found to have significantly lower dHMP/dFEV1 ratios (median 0.021%-1 vs 0.073%-1 with a p=0.0081).
One child for instance, with SaO2 of 84% at presentation had a dHMP/dFEV1 of 0.04,whereas another with SaO2 of 98% at presentation had a dHMP/dFEV1 of 0.08 (figure 5). The authors conclude, that because the former was reporting a lower improvement than what he had actually undergone, his perception was faulty. This child, they state was at risk of dying because he would stay back home longer, continuing to deteriorate.
There is another way of looking at the data. The child reporting a lower improvement, is essentially a whiner, or the one who genuinely feels so much worse, or, tolerates so little breathlessness. If he were to behave similarly at home as he was in hospital -reporting himself more breathless for his airway obstruction, he would be the one to come so much earlier to medical attention. It is not clear, how the authors assume that the vociferous whiner in improvement, would be a silent sufferer (not perceiving a critical compromise in his lung functions), during worsening.
A high HMP/FEV1 at presentation correctly identifies the faulty perceiver, who reports himself better than his pulmonary parameters. It reflects truthfully the changes in perception and worsening obstruction, in the period immediately preceding presentation. But, a low dHMP/dFEV1, measured in the course of improvement, confounded by presumably more aggressive treatment including oxygen administration for lower SaO2, does not seem a logical parameter to identify those at risk of death from late presentation. Further research is required to identify other characteristics of the subpopulation of asthmatics, who are at a greater risk of late presentation and death from asthma, and also, whether faulty perception of improvement, identified by a low dHMP/dFEV1 is, one of their traits.
References
(1) Barnes P. Blunted perception and death from asthma. N Eng J Med 1994;330:1383-4.
(2) Kikuchi Y, Okabe S, Tamura G, et al. Chemosensitivity and perception of dyspnea in patients with a history of near fatal asthma. N Eng J Med 1994;330;1329-34.
(3) Male I, Seddon P. The measurement of breathlessness in children with asthma. Am J Resp Crit Care Med 1996;153:A557.
How many times do general practitioners here parents say "I do not want my baby vaccinated"? Quite often, I guess. As vaccine uptake rates are
maintained at high levels, notifications of the diseases prevented by them
have fallen. As the incidence of these diseases have fallen from the
public consciousness, public attention has deviated from these nasty
diseases to its side effects. The paper from Go...
How many times do general practitioners here parents say "I do not want my baby vaccinated"? Quite often, I guess. As vaccine uptake rates are
maintained at high levels, notifications of the diseases prevented by them
have fallen. As the incidence of these diseases have fallen from the
public consciousness, public attention has deviated from these nasty
diseases to its side effects. The paper from Gold M et al[1] is a reminder
to health professionals that vaccination schedules can be safely carried
on in spite of most adverse reactions.
Some districts, including ours, run immunisation helplines for
primary healthcare teams.[2] The most common query we get is from the practice
nurse when a mother presents with the child for the next dose of DPT, Hib, and
meningitis C vaccine and reports a severe local reaction or prolonged crying
after the previous dose. What we find time and time again is that parents
seldom go to their general practitioner immediately. An opportunity
to check the reaction out and make clear and careful decisions about the
future is lost. It is debatable how reliable or vivid parental accounts of
a swelling or length and quality of crying could be a month later. We did
not find any reference as to how well the yellow card system of reporting
adverse immunisation reactions is used in the UK.
A report from the US[3]
does suggest that their counterpart to the yellow card (VAERS) may not be
reliable. In light of the paper by Gold et al[1] and our experience we have the following
suggestions to make:
1. Practice nurses and general practioners should encourage parents to bring the
child back if they are worried about side effects
2. The yellow card system of reporting adverse drug reactions should
be used appropriately
3. Health professionals should seek expert advice before not
recommending any vaccine
4. There are very few true vaccine side effects. The Green Book[4] in
the UK should reflect the increasing evidence of vaccine safety. This can
help boost professional and parental confidence in vaccination programmes.
Dr Ashok Nathwani
Consultant Paediatrician
Portsmouth, UK
References
(1) Gold M, Goodwin H, Botham S, Burgess M, Nash, Kempe A. Re-vaccination of 421 children with past history of an adverse vaccine reaction in a special immunisation service. Arch Dis Child 2000;83:128-31.
(2) Finlay F, McKechnie L, Pearce A, Lenton S. Immunisation telephone hotline audit. Ambulatory Child Health 1999;5:295-302.
(3) Braun MM, et al. Report of a US Public Service workshop on Hypotonic Hyporesponsive Episode (HHE) after pertussis immunisation. Pediatrics 1998;102:e52.
(4) Immunisation against Infectious Disease. London: HMSO, 1996.
I read with interest the recent paper on "Pancreatic dysfunction in severe
obesity" by Drake et al where they identified one obese Caucasian
adolescent with type II diabetes.[1] All previously reported cases of Type
II diabetes in adolescents in the United Kingdom have been amongst ethnic
minority groups especially Asian patients.[2][3]
I wish to report another case of type II diabetes in a young British...
I read with interest the recent paper on "Pancreatic dysfunction in severe
obesity" by Drake et al where they identified one obese Caucasian
adolescent with type II diabetes.[1] All previously reported cases of Type
II diabetes in adolescents in the United Kingdom have been amongst ethnic
minority groups especially Asian patients.[2][3]
I wish to report another case of type II diabetes in a young British
Caucasian girl.
AJ presented at the age of 13 years. She was asymptomatic but was
referred because a random blood sugar done by the GP was found to be
elevated at 12.9mmol/L. She was obese, BMI 36 (>99.6th centile for
age), not dysmorphic, no Acanthosis Nigricans, and normotensive. She was
known to have undergone valvotomy for pulmonary stenosis but was not on
any medication. Her mother had type II diabetes diagnosed at the age of 27
years.
Investigations showed hyperglycaemia with hyperinsulinaemia
Fasting blood sugar: 11.1 mmol/L
Fasting C peptide: 2198 pmol/L
Fasting insulin: 553.0 pmol/L
Fasting Pro-insulin: 177 pmol/l (normal <_10 pmol="pmol" l="l" br="br"/>Islet cell antibody screen was negative
Normal fasting cholesterol and triglycerides
Her pre-meal blood sugar profile during the day was between 7.9 - 14 mmol/L.
Management consisted of encouraging change in lifestyle with emphasis
on healthy
eating and regular exercise. She continues to receive regular dietary
advice. She was
started on Metformin 500mg bd. Her blood sugar profile improved. Her
current HbA1c after 3 months of therapy is 7.5%.
With increasing prevalence of obesity in all ethnic groups in this
country, we may begin to see more cases of type II diabetes amongst the
Caucasian population too. Risk factors appear to be the presence of
obesity, Acanthosis Nigricans and family history of diabetes. Type I
diabetes however, remains the commonest type of diabetes in the paediatric
population.
Dr J C Agwu
Consultant Paediatrician
Sandwell Healthcare NHS Trust
West Bromwich B71 4HJ, UK
References
(1) Drake AJ, Greenhalgh L, Newbury-Ecob R, et al, Pancreatic dysfunction in severe obesity. Arch Dis Child 2001;84:261-2.
(2) Etisham S, Barnett Y Gm Shaw N J. Type II diabetes Mellitus in UK
Children - an energy problem. Diabet Med 2000;17(12):867-71.
(3) Ng GYT, Burren CP. Type II diabetes in adolescence unearthed at the
time of registration with the general practitioner (G.P). Practical
Diabetes 2000;17:273-4.
The refreshing article by Malleson et al highlighted the
importance of medically unexplained symptoms within our patient
population. He also raised the spectre of the psychological damage to the
adolescents who often additionally face educational and social isolation
due to their illness. This proportion is growing as a result of changing
morbidity patterns within Western society and demands within health ca...
The refreshing article by Malleson et al highlighted the
importance of medically unexplained symptoms within our patient
population. He also raised the spectre of the psychological damage to the
adolescents who often additionally face educational and social isolation
due to their illness. This proportion is growing as a result of changing
morbidity patterns within Western society and demands within health care
are documented.[1]
The author suggested an interdisciplinary approach to chronic pain which
though laudable strains resources especially within mental health.
Multidisciplinary teams offer comprehensive assessment and management of
problems though rapidly become overwhelmed with referrals. Would a more
cost effective model in Britain be the flexible utilisation of existing
resources such as community paediatricians who already have educational,
medical and some mental health skills function as a second tier
assessment? The multidisciplinary Pain team would then act as a third
tier. This model is only sustainable through integrated and jointly agreed
medical guidelines with continued good communication.
This approach reflects other care pathways within medicine though there
are significant differences.
Other care pathways depend upon first tier
clinicians partly managing and assessing problems in addition to
recognising their impact to patients prior to referral. Paediatric
training has traditionally and appropriately focused upon organic
pathology. Weighting towards the mental health aspect of disease was and
is reduced both in terms of structured training and formal assessment
within postgraduate examinations. The culture within the Royal Colleges is
changing but the fruits may only be visible in the next generation of
clinicians.
D NATHAN
Consultant Paediatrician
Child Health Department
Queens Medical Centre
Clifton Boulevard
Nottingham, NG7 2UH, UK
References
(1) Reid S, Wessely S, Crayford T, Hotopf M. Medically unexplained
symptoms in frequent attenders of secondary health care: retrospective
cohort study. BMJ 2001;322:767-9
Stewart-Brown's paper on the compatibility of medical practice
in community paediatrics with that in public health[1] is a superlative
effort. This is more so as it has come at a time when community paediatrics
is being actively discussed by the RCPCH (UK Royal College of Paediatrics and Child Health) for a variety of reasons but,
perhaps, most importantly because it does not seem to attract enough...
Stewart-Brown's paper on the compatibility of medical practice
in community paediatrics with that in public health[1] is a superlative
effort. This is more so as it has come at a time when community paediatrics
is being actively discussed by the RCPCH (UK Royal College of Paediatrics and Child Health) for a variety of reasons but,
perhaps, most importantly because it does not seem to attract enough
specialist registrars.
It can be argued that all paediatricians (just not
community paediatricians) can and do play an important role in child
advocacy issues at various levels. From the clinical perspective the
community paediatric role in immunisation and child health surveillance is
the most important.
Trainees in paediatrics need to recognize that child public health is
a small (albeit important) role of the community paediatricians. The bulk
of community paediatricians are neurodevelopmental specialists. Many have
an important role in child protection. Some community paediatricians are
developing a behavioural paediatric interest in their clinical practice.
Most districts in the UK need their community paediatricians to look after
families with children with disabilities. Some districts (like ours) need
them to offer outpatient epilepsy services as well. With increasing
prevalence of behavioural problems in children, many community
paediatricians have trained (or retrained) themselves to cater to this
need. Useful links with child psychiatric and psychology colleagues have
been forged. In fact, our counterparts in the US are called developmental
and behavioural paediatricians and their core curriculum reflects the depth
of training offered for both these domains.[2]
There is no doubt, therefore,
that the term “community paediatrics” is a misnomer and may not offer
confidence to the budding specialist registrar who may find being a
neurologist or an oncologist a better bet. There is increasing specialism
within community paediatrics, and the job title needs to reflect that
expertise.
It is very possible that a small minority of (community)
paediatricians may chose to train with a major public health interest. It
may be helpful to know that the American Acdemy of Pediatrics has a
section for paediatricians with this interest.[2] The bulk should continue
(to train and practice) with a major clinical interest and that should be
an important selling point for community paediatrics. Hopefully job titles
in the future will reflect the clinical expertise. This will not only help
trainees but also purchasers, referers and the families we serve.
This letter is not meant to be in any way critical of Dr Stewart-Brown’s paper which, in fact has highlighted the importance of public
health medicine for (community) paediatricians. Health promotion is indeed
a skill that can be applicable easily in clinical practice.
Dr Ashok Nathwani
Consultant (Community) Paediatrician
Portsmouth, UK
References
(1) Stewart-Brown S. Is the ethos of medical practice in community paediatrics compatible with that in public health? Arch Dis Child 2000;83:101-3.
(2) Section on Community Pediatrics, American Acdemy of Pediatrics, http://www.aap.org/commpeds/ [accessed 3 Aug 2000].
We welcome the debate stimulated by our paper. Indeed, this was our aim in publishing it.
We agree with Mr Caldwell that a degree of underreporting is likely. Our system provides a clear definition to all staff of what constitutes a reportable medication error (listed in the appendix). It does not include errors that are averted such as mis-prescribed errors corrected by pharmacists prior to dis...
Dear Editor
Cappendijk and Hazebroek (Arch Dis Child 2000;83:64-6) conclude from their data that "the major factor in delay is suspected gastroenteritis". Other studies have not given this factor such prominence and the study population suggests that the Sophia Hospital was acting as a referral centre: 32 of 78 children whose admission was delayed for 48 hours had been seen first by a paediatrician, which may i...
The recent study by Hutton, Colver, and Mackie[1] is in some respects a useful addition to our knowledge of survival in cerebral palsy. Unfortunately there some are substantial problems with the paper; we note three of them below.
In Figure 1A it appears that in the most seriously affected group, LAS >70%, there is 100% survival to age 9. This scarcely seems plausible when, as the graph indicate...
Poustie et al state that there is no computer package available in the United Kingdom for calculating percentage weight for height (%WFH). This is incorrect and for many years there has been available just such a package entitled W4H under the copyright of Great Ormond Street Hospital for Children NHS Trust. The program can be used on any version of Windows from 3.1 onwards, Excel, and on Psion's. This p...
The accurate diagnosis of meningococcal disease is important, not only for the welfare of the patient, but also for the implementation of appropriate public health measures. Brogan and Raffles have made a useful contribution to more reliable diagnosis.[1]
However I feel that their finding of 9% could represent a falsely low proportion of children with serious bacteraemia because of potential recru...
We read with interest the work of Male et al on perception of breathlessness in acute asthma. They studied 27 children with acute asthma, 12 of whom were hypoxic at presentation with SaO2...
Dear Editor:
How many times do general practitioners here parents say "I do not want my baby vaccinated"? Quite often, I guess. As vaccine uptake rates are maintained at high levels, notifications of the diseases prevented by them have fallen. As the incidence of these diseases have fallen from the public consciousness, public attention has deviated from these nasty diseases to its side effects. The paper from Go...
I read with interest the recent paper on "Pancreatic dysfunction in severe obesity" by Drake et al where they identified one obese Caucasian adolescent with type II diabetes.[1] All previously reported cases of Type II diabetes in adolescents in the United Kingdom have been amongst ethnic minority groups especially Asian patients.[2][3] I wish to report another case of type II diabetes in a young British...
The refreshing article by Malleson et al highlighted the importance of medically unexplained symptoms within our patient population. He also raised the spectre of the psychological damage to the adolescents who often additionally face educational and social isolation due to their illness. This proportion is growing as a result of changing morbidity patterns within Western society and demands within health ca...
Dear Editor:
Stewart-Brown's paper on the compatibility of medical practice in community paediatrics with that in public health[1] is a superlative effort. This is more so as it has come at a time when community paediatrics is being actively discussed by the RCPCH (UK Royal College of Paediatrics and Child Health) for a variety of reasons but, perhaps, most importantly because it does not seem to attract enough...
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