We note with interest the paper from Khandaker (1) and colleagues on
the reduction of congenital and neonatal varicella infections following
the introduction of immunisation of 18 month old children in Australia
from 2005. Using surveillance methodology similar to that of the British
Paediatric Surveillance Unit (BPSU) rates of congenital varicella (per
100,000 live births with 95% CI) have fallen from 0.8 (0.3 to 1.8) t...
We note with interest the paper from Khandaker (1) and colleagues on
the reduction of congenital and neonatal varicella infections following
the introduction of immunisation of 18 month old children in Australia
from 2005. Using surveillance methodology similar to that of the British
Paediatric Surveillance Unit (BPSU) rates of congenital varicella (per
100,000 live births with 95% CI) have fallen from 0.8 (0.3 to 1.8) to 0.19
(0 - 0.7) and for neonatal varicella from 5.8 (4.3-7.8) to 2.05 (0.3 -
3.4) with the introduction of immunisation. They suggest that a previous
UK based estimate of neonatal varicella infections quoted as 0.16 per
100,000 live births (based on the incidence of varicella in nulliparous
women) may represent a significant underestimate - a point acknowledged by
the authors of this paper(2) .
We have recently reviewed fetal, neonatal and infant viral deaths
using the Northern Regional Perinatal Mortality Survey database. This is a
well validated population based database of fetal deaths <20wks
gestation and all deaths in live-born individuals within the first year of
life (3). Review of 24 years of data identified 2 deaths from varicella -
one neonatal case presenting at 12 days who died despite the use of
immunoglobulin and antivirals, and one late infant death at 306 days from
varicella pneumonia. There were no identified deaths from congenital
varicella. There were 819, 890 live births in this population over this
time period giving a mortality rate of 0.12 (0 - 0.36) per 100,000 live
births for neonatal varicella.
We suggest that congenital and neonatal varicella rates in the UK are
more securely established in order to contribute to the health economic
debate around universal varicella immunisation and that utilising BPSU
methodology may be appropriate.
References:
1. Khandaker G, Marshall H, Peadon E et al. Congenital and neonatal
varicella: impact of the national varicella vaccination programme in
Australia. Arch Dis Child 2011 96:453-456
2. McKendrick MW, Lau J, Alston S, e t al. VZV infection in pregnancy: a
retrospective review over 5 years in Sheffield and discussion on the
potential
utilisation of varicella vaccine in prevention. J Infect 2007 ; 55:64 - 7
3. Northern Regional Health Authority Coordinating Group. Perinatal
mortality: continuing collaborative regional survey. BMJ 1984; 288: 1717-
20
We read with interest the recent paper by Gilchrist et al(1) that
looked at the issue of how many lobes should be sampled by bronchoalveolar
lavage (BAL) in children with cystic fibrosis (CF). There is little
evidence to guide our practice in this area.
We note that the majority of the BAL results analysed in their study
were taken from symptomatic patients, but it is unclear whether the BALs
were performed du...
We read with interest the recent paper by Gilchrist et al(1) that
looked at the issue of how many lobes should be sampled by bronchoalveolar
lavage (BAL) in children with cystic fibrosis (CF). There is little
evidence to guide our practice in this area.
We note that the majority of the BAL results analysed in their study
were taken from symptomatic patients, but it is unclear whether the BALs
were performed during what would be defined as an infective pulmonary
exacerbation. The authors state that of the 56 organisms identified from
these cultures, only 15 had been identified by surveillance cultures in
the same patients over the preceding 4 months. In children of the age
range reported (5.3 to 11.5 years) sputum cultures are usually obtained
and, it would be useful to know how results from BAL and sputum cultures
taken during the same symptomatic period differed. In our opinion, if a
positive sputum culture result was available there would have been no
clear justification for performing a BAL in these patients. If sputum is
not obtained, sputum induction is a useful way of avoiding general
anaesthesia in children of this age.
We are also doubtful of the benefits of 'therapeutic lavage', which
was the rationale provided for the practice of performing BAL from
multiple lobes in the study. The authors reported that there were no
clinically significant adverse events during the BALs, and that the
incidence of post-bronchoscopy fever was in line with other published
data. However, as the median age of children in this study was 8.5 years,
we are concerned that this safety profile is not transferable to younger
children and infants with CF, in whom, because of the difficulty in
obtaining sputum samples, BALs are more often performed. The risks of BAL
are greater in younger patients and we would not recommend that multiple
lavages be performed in infants and pre-school children without
consideration of the increased risks in this group.(2)This study
illustrates that BAL sampling from one or two lobes does not provide the
complete microbiological picture in CF, but this needs to be weighed up
against the possible adverse effects of sampling more than two lobes,
especially in younger children, and the opportunities to reach a
microbiological diagnosis using alternative methods to obtain cultures.
Therefore, these results should not be taken to suggest that the most
recent European Respiratory Society guidelines recommending two lobe
lavages should be abandoned, especially in younger children.(3)
(1)Gilchrist FJ, Salamat S, Clayton S, Peach J, Alexander J, Lenney
W. Bronchoalveolar lavage in children with cystic fibrosis: how many lobes
should be sampled? Arch Dis Child 2011;96: 215-217
(2)Wainwright C et al. Safety of Bronchoalveolar Lavage in Young
Children with Cystic Fibrosis. Pediatric Pulmonology 2008;43:965-972
(3)Brennan S, Gangell C, Wainwright C, Sly P. Disease surveillance
using bronchoalveolar lavage. Paediatr Respir Rev 2008;9:151-159
I read with great interest the leading article regarding the threat
from ESBL organisms in children and was surprised and amused to note how
the author reached the conclusion that medical treatment in India is a
major risk factor for infection with carbapenemase - producing organisms
in the UK. The author has herself noted that as per the Health protection
Scotland wkly report 2009 which has documented the spread of thes...
I read with great interest the leading article regarding the threat
from ESBL organisms in children and was surprised and amused to note how
the author reached the conclusion that medical treatment in India is a
major risk factor for infection with carbapenemase - producing organisms
in the UK. The author has herself noted that as per the Health protection
Scotland wkly report 2009 which has documented the spread of these
organisms accross the continents and also that the transmission of
resistance is plasmid mediated. I understand her statement about the
medical treatment in India and risk factor for infection with these
orgnaisms stems form the reports about NDM1 (New Delhi Beta lactamase -1).
The name was actually first given in 2009 in Lancet and the journal editor
later apologised and acknowledged that naming a superbug after New Delhi
was an "error"(1,2). There is a tradition of eponymous names in science
and those found derogatory to races, groups ,cities and countries have
been changed and the examples include "Mongolism" to Down's, "mexican
swine flu" to H1N1 and Australia Antigen to HbsAg to name a few(3). This
"geographical name calling" is not only derogatory and unprofessional but
this also impedes the efforts of the global community to fight for common
goals.
It is interesting to note that the author has not referenced her
conclusion of medical treatment in India being a major risk factor for
carbapenamase infections which indicates that this geographical name
calling is "unscientific" and is based in sporadic reports or otherwise
the class A Klebsiella pneumoniae carbapenemase, which was detected in
North carolina in 1996 and has since spread worldwide(4) could have been
called North carolina carbapenemase!
References:
1.Kumarasamy KK, Toleman MA, Walsh TR, et al. (August 2010). "Emergence of
a new antibiotic resistance mechanism in India, Pakistan, and the UK: a
molecular, biological, and epidemiological study". Lancet Infect Dis 10
(9): 597-602.
2."Lancet says sorry for 'Delhi bug'". The Times Of India. Retrieved
2011-01-12.
3. Science, names giving and names calling: Change NDM-1 to PCM".
Mens Sana Monographs.Retrieved 2011-03-11.
4.Nordmann P, Cuzon G, Naas T (April 2009). "The real threat of
Klebsiella pneumoniae carbapenemase-producing bacteria". Lancet Infect Dis
9 (4): 228-36
I am delighted that Meller and Barclay have echoed my call for
mediation to be considered when the beliefs or views of parents are so at
variance with those of the paediatricians that conventional clinical
relationships break down, and matters are taken to Court. In 'Conflicts
of Care - Could mediation help?' [1] I and my co-author highlighted the
cases of Charlotte Wyatt who was severely disabled fol...
I am delighted that Meller and Barclay have echoed my call for
mediation to be considered when the beliefs or views of parents are so at
variance with those of the paediatricians that conventional clinical
relationships break down, and matters are taken to Court. In 'Conflicts
of Care - Could mediation help?' [1] I and my co-author highlighted the
cases of Charlotte Wyatt who was severely disabled following premature
birth, and Luke Winston-Jones who had trisomy 18, both of which resulted
in legal proceedings. In each case the clinicians' views of the child's
best interests were in conflict with the wishes of the parents.
There are two principal barriers to the wider use of mediation in
conflicts between parents and paediatricians. One is awareness, and it is
to be hoped that this will be raised by publications in peer review
journals as well as in the wider media. The other is cultural: when
parental-medical conflicts occur, Trusts take advice from their legal
teams whose main expertise still lies in countering litigation, and whose
comfort zone lies in the Courts. However, as financial pressure becomes
more acute, it is likely that this will become an additional incentive to
the use of mediation before recourse to Court proceedings. It is worth re
-iterating a comment from our article in Archives in 2005 that "... even
if mediation is ultimately unsuccessful in achieving resolution of a
problem, it can be of immense value in allowing the parties to define the
issues more clearly, and it may uncover issues that have not been apparent
on the surface. At an earlier stage than legal proceedings, even
apparently polarised attitudes can be susceptible to skilful
mediation."[1]
Mediators with appropriate skills can be hard to find, although there
are private providers who, with additional awareness of the specialist
medical and legal issues, could become proficient in this area. There are
also conciliators trained through the NHS with experience in healthcare
complaints whose skills could be adapted to the proposed role. I explored
these and related issues more deeply in my book "Conciliation in
Healthcare: managing and resolving complaints and conflict"[2]. I also
highlighted the value of taking a proactive approach where there were
signs of a deterioration in the clinical relationship.
The prospect of a funded evaluation for mediation is greatly to be
welcomed, as relevant research in all age groups is scarce[3], but I hope
that the location of the Medical Mediation Foundation (London NW2) does
not mean that its scope will be confined to the south-east of England.
References
1.Ward Platt M, Ward Platt A. Conflicts of care. Arch Dis Child
2005;90:331.
2.Ward Platt A. Conciliation in Healthcare: Managing and resolving
complaints and conflict. Oxford: Radcliffe Publishing, 2008.
3.Mpinga EK, Chastonay P, Rapin CH. End of life conflicts in palliative
care: a systematic review of the literature. Rech Soins Infirm.
2006;86:68-95.
Gupta et al. yet again highlight a worrying trend in poor management
of Vitamin D - both prevention and treatment. The majority of affected
children come from high risk populations where rates of social
disadvantage are high. The mothers of these children could all have been
identified and given cheap, effective preventative treatment. Whilst we
should be concerned that 30% of the children received inappropriate
treatme...
Gupta et al. yet again highlight a worrying trend in poor management
of Vitamin D - both prevention and treatment. The majority of affected
children come from high risk populations where rates of social
disadvantage are high. The mothers of these children could all have been
identified and given cheap, effective preventative treatment. Whilst we
should be concerned that 30% of the children received inappropriate
treatment, we should be alarmed that 100% of the mothers were
inappropriately treated.
Eisenhut raises the possibility that food was the source of the
outbreak of group A streptococcal disease at the primary school. This
hypothesis was considered, but was rejected as implausible for several
reasons; firstly the outbreak was not a true point source as it was
preceded by five sentinel cases over a 12 day period, in addition the peak
on the 16th May was inflated as it included cases with on...
Eisenhut raises the possibility that food was the source of the
outbreak of group A streptococcal disease at the primary school. This
hypothesis was considered, but was rejected as implausible for several
reasons; firstly the outbreak was not a true point source as it was
preceded by five sentinel cases over a 12 day period, in addition the peak
on the 16th May was inflated as it included cases with onset over the two
day weekend period. The pattern of illness did not suggest any link with
school meal consumption - some of the initial cases were in the reception
class who did not have school meals, a number of the older children among
the initial cases did not have school meals and none of the staff who ate
school meal were ill. The possibility that the school water fountain or
the childrens' water bottles were the source of infection was considered
but neither was compatible with the pattern of illness. Person-to-person
spread, as indicated by the outbreak curve appeared to largely explain the
course of the outbreak.
Eisenhut also comments that exclusion of children with features of
respiratory infection, with the option of immediate treatment of cases
with penicillin rather than waiting for culture confirmation can prevent
secondary cases. This was not our experience, despite the use of the most
rigorous practical exclusion policy and the encouragement of general
practitioners to treat cases symptomatically. We conclude that the
management of contacts requires evaluation as a possible control measure.
We read with interest the paper by Villa F et al (1) and we would
like to add some conclusions reached by our group after a clinical
research evaluating peripheral muscle function in children with asthma
treated with inhaled corticosteroids. (2)
Asthma is one of the most prevalent chronic diseases in children, and its
secondary exercise limitation, among other several effects, usually cause
a decre...
We read with interest the paper by Villa F et al (1) and we would
like to add some conclusions reached by our group after a clinical
research evaluating peripheral muscle function in children with asthma
treated with inhaled corticosteroids. (2)
Asthma is one of the most prevalent chronic diseases in children, and its
secondary exercise limitation, among other several effects, usually cause
a decreased health-related quality of life. As the authors mention, the
relationship between this limitation and peripheral muscle weakness in
pediatric patients had not been widely studied before. The negative effect
on muscle function of long term treatment with corticosteroids had been
described for oral treatment. We only found two cases in the literature
(3) that related myopathy in children to inhaled corticosteroids, both
detected after months of very high doses of fluticasone.
The study led by our group (2) involved patients over 7 years old (N=12)
with asthma, that had previously received inhaled steroids during at least
two years at intermediate doses (budesonide ?400 ?g, or fluticasone ?200
?g). They were compared to a healthy control group (N=7), paired by age.
Peripheral skeletal muscle function was one of the parameters measured. No
evidence was found that continuous high doses of inhaled corticosteroids
lead to a deterioration in respiratory or peripheral muscle function in
asthmatic children, which agrees to the results of the aforementioned
study. (1)
On the other hand, respiratory muscles showed to develop an adaptation to
the long-term overload of work they have to deal with, the so-called
"training effect" of persistent asthma. This effect was detected by
measuring the maximal inspiratory and respiratory pressures in the
patient's mouth. However, the adaptation phenomena seem to be limited only
to the inspiratory muscles and it is probably related to the disease and
not to corticosteroids exposure.
References
1. Villa F, Beltran A, Pastorino A, Santar?m J, Arruda M, Miuki C, et
al. Aerobic capacity and skeletal muscle function in children with asthma.
Arch Dis Chil. 10.1136/adc.2011.212431.
2. D?az J, Busquets RM, Garc?a-Algar O, Ram?rez A, Orozco M. Changes in
respiratory and peripheral muscle function in asthmatic children: Effects
of inhaled corticoids. An Pediatr (Barc). 2010;72:42-8.
3. De Swert LF, Wouters C, De Zegher F. Myopathy in children receiving
high-dose inhaled fluticasone. N Engl J Med. 2004;350:1157-9.
Giles at al. highlights a significant issue which has previously been
recognised but not always as well framed. It is vital for patient safety
that specialists in all fields have had the opportunity to develop their
skills once their core competencies have been achieved. The continuing
need for trainees in the UK to provide an active service while at the same
time undertake and be involved in post-graduate education is not...
Giles at al. highlights a significant issue which has previously been
recognised but not always as well framed. It is vital for patient safety
that specialists in all fields have had the opportunity to develop their
skills once their core competencies have been achieved. The continuing
need for trainees in the UK to provide an active service while at the same
time undertake and be involved in post-graduate education is not
sustainable and this was highlighted in the Temple report(1).
However the solution to the problem is not the number of hours
available to a particular doctor. The survey implies non-specialty duties
are being performed in- and out- of hours. Were the 48 hour limit be
lifted there would be no reason to think the doctor would not continue to
be required to perform service activities.
The RCPCH "Facing the Future" service standards (2) set out a model
which would require 10 WTE trainees on each rota. This would enable
trainees to access essential training opportunities but provide a safe and
reliable service. In order to achieve this goal reconfiguration must occur
which may be unpalatable to some. Without this, ultimately, patients may
not get the high quality service they deserve and expect.
1. Time For Training. Sir John Temple on behalf of Medical Education
England
2. Facing the Future. Standards for Paediatric Services. December
2010 RCPCH.
Conflict of Interest:
I am currently chair of the RCPCH and AoMRC Trainees Committee
I am pleased to see a recommendation for shared paediatric/mental
health clinics in treating CFS/ME. My clinical impression in a non-
specialist hospital department is that most of these patients do not
experience or exhibit anxiety or depression as much as profound
frustration. This is similar to the presentation of children who cannot
attend school ('school refusal') which of course is often a feature of CFS
too.
I am pleased to see a recommendation for shared paediatric/mental
health clinics in treating CFS/ME. My clinical impression in a non-
specialist hospital department is that most of these patients do not
experience or exhibit anxiety or depression as much as profound
frustration. This is similar to the presentation of children who cannot
attend school ('school refusal') which of course is often a feature of CFS
too.
More evident in the clinic is an irritable relationship with mother,
who has to be very active to get help for her child who leaves most of the
organisational and emotional work to her. In the presence of a
paediatrician a mental health colleague can identify this pattern as
necessary for the time being. After all, a sick child tends to regress to
a more dependent stage.
The therapeutic task is to support slow progress towards an
adolescent relationship between child and parents. For those that recover
this will be alarmingly unfamiliar since the child will have been stuck at
a typically pre-pubertal stage. Fathers can be invited to joint
consultations, which need not be frequent because nothing changes very
fast. Alongside a graded exercise regime supervised by a physiotherapist,
this represents a 'graded attachment programme' in a general paediatric
setting, where outcomes have mainly been good.
We read with interest the recent paper by Doull et al [1] which
explores the optimal model for delivery of paediatric cystic fibrosis (CF)
care. The authors compared three models of paediatric CF care within
their established CF network: full centre care; local clinic based care
with annual review by the CF centre; and hybrid care, where a child is
usually reviewed at least three times a year by the specialist centre....
We read with interest the recent paper by Doull et al [1] which
explores the optimal model for delivery of paediatric cystic fibrosis (CF)
care. The authors compared three models of paediatric CF care within
their established CF network: full centre care; local clinic based care
with annual review by the CF centre; and hybrid care, where a child is
usually reviewed at least three times a year by the specialist centre.
Three outcomes were considered: nutritional status, pulmonary function and
prevalence of chronic Pseudomonas aeruginosa infection. The only
significant finding was that mean FEV1 was lower amongst children
receiving local clinic based care than full centre care (74.5% predicted
vs 89.2%: p = 0.001) and the authors extrapolate from this that model of
care may affect long term clinical outcomes for children with CF.
The data presented are interesting and highly relevant to all
involved in CF care in South and Mid Wales. However, the study has
several shortcomings which limit generalisation of its findings to other
paediatric CF populations. It is crucial that these are highlighted to
the varied audience of the paper to avoid unnecessary and misguided loss
of confidence in local services elsewhere in the UK.
The number of patients cared for by each local clinic in South and
Mid Wales appears to be small. We are told that the majority of patients
receive local care from ten paediatric units and, later in the paper, that
three of these units deliver hybrid care. The 102 patients receiving
local clinic care must, therefore, be served by 7 centres, equating to an
average caseload of just 15 patients per centre. Ensuring maintenance of
skills for all clinical groups involved with these patients is likely to
be challenging and this may have contributed to the results of the study.
Details about staffing of the South & Mid Wales local clinics are
sparse. Is there a lead consultant paediatrician for CF in each unit? A
cohesive multidisciplinary approach to CF management is vital (as
reflected in the UK CF Trust standards of care [2]) yet Doull's paper
provides very little information about the availability of key team
members in local clinics. The difference in prevalence of nasogastric
feeding between patients attending the specialist centre (7.8%) and the
local clinics (2.9%) is notable and open to various interpretations. How
accessible are physiotherapists? Are they specialist trained? Do they
have capacity to carry out home/school visits? These factors could have a
direct and significant effect on pulmonary function.
No information is provided about the practicalities of pulmonary
function testing. Do the local clinics use the same equipment as the
specialist centre? Are the same calibration procedures in use? If these
variables are not standardised it is inappropriate to make direct
comparisons of pulmonary function data. The standard deviation for %
predicted FEV1 is greatest amongst local clinic patients, indicating a
wider spread of data within this group. Were there any palliative care
patients, for example, in this cohort who may have skewed the data?
Rate of decline in lung function in CF patients is influenced by
socioeconomic status [3]. Unfortunately we are given no information about
levels of social deprivation the population studied and this compounds the
aforementioned problems with interpretation of the data presented.
CF care provision by "local clinics" varies tremendously and it would
be unwise to extrapolate clinical data from one region of the UK and apply
it to another. In January 2011 we launched a new "local clinic" in Wishaw
General Hospital, Lanarkshire, signifying the culmination of years of
strategic planning and preparation in line with the Scottish Government's
National Delivery Plan for Specialist Children's Services. The majority
of our 48 patients have been repatriated from the specialist centre in the
Royal Hospital for Sick Children (RHSC), Yorkhill, Glasgow (20 miles away;
road links good). Social deprivation is prevalent, with north and south
Lanarkshire both being within the five most deprived local authority areas
in Scotland [4]. Our own local multidisciplinary team comprises two
consultant paediatricians with a special interest in respiratory
paediatrics (one of whom is fully subspecialty trained), an associate
specialist with a special interest in respiratory paediatrics, a dedicated
CF specialist nurse, two specialist paediatric respiratory
physiotherapists, a senior paediatric dietitian and a CF pharmacist. We
operate within the West of Scotland managed clinical network (MCN) for
paediatric CF and virtually all care (including pulmonary function
testing, frequency of clinic review, annual review procedures and
transition arrangements) is standardised across the region. We are
currently developing clinical guidelines which will be shared by all four
units in the network. Children attend our fully segregated CF clinics
eight weekly as standard (more frequently in infancy) and are reviewed
annually by the specialist RHSC team at joint clinics held in our
hospital. This said, communication channels are wide open and challenging
patients can be discussed with/reviewed by the specialist team in between
times if clinical need dictates. Ours is the third largest paediatric CF
unit in Scotland. We operate within a robust MCN and we are confident
that we can deliver equitable CF care. Our patients' clinical outcomes
will be monitored closely and we aim to report our experience and data in
years to come.
Finally, it should be borne in mind that local CF care affords many
benefits to children and their families. Strong links with community
organisations such as primary care, social work and education, combined
with shorter travel distances and less disruption to family life, will all
have a positive effect on long term outcomes for children with CF.
References
1. Doull I, Evans H, South and Mid Wales Paediatric Cystic Fibrosis
Network. Full, shared and hybrid paediatric care for cystic fibrosis in
South and Mid Wales. Arch Dis Child 2011 10.1136/adc.2010.199380
2. CF Trust. Standards for the clinical care of children and adults
with cystic fibrosis in the UK. May 2001
3. Taylor-Robinson D, Whitehead M, Diggle P, et al. Socioeconomic
status and rate of decline of lung function in the UK cystic fibrosis
population (abstract). Pediatric Pulmonology 2010;45(S33):449
4. Scottish Index of Multiple Deprivation (SIMD) data 2009.
http://www.scotland.gov.uk/Topics/Statistics/Browse/Social-
Welfare/TrendSIMD Accessed 24th February 2011.
We note with interest the paper from Khandaker (1) and colleagues on the reduction of congenital and neonatal varicella infections following the introduction of immunisation of 18 month old children in Australia from 2005. Using surveillance methodology similar to that of the British Paediatric Surveillance Unit (BPSU) rates of congenital varicella (per 100,000 live births with 95% CI) have fallen from 0.8 (0.3 to 1.8) t...
We read with interest the recent paper by Gilchrist et al(1) that looked at the issue of how many lobes should be sampled by bronchoalveolar lavage (BAL) in children with cystic fibrosis (CF). There is little evidence to guide our practice in this area.
We note that the majority of the BAL results analysed in their study were taken from symptomatic patients, but it is unclear whether the BALs were performed du...
I read with great interest the leading article regarding the threat from ESBL organisms in children and was surprised and amused to note how the author reached the conclusion that medical treatment in India is a major risk factor for infection with carbapenemase - producing organisms in the UK. The author has herself noted that as per the Health protection Scotland wkly report 2009 which has documented the spread of thes...
Dear Sir
I am delighted that Meller and Barclay have echoed my call for mediation to be considered when the beliefs or views of parents are so at variance with those of the paediatricians that conventional clinical relationships break down, and matters are taken to Court. In 'Conflicts of Care - Could mediation help?' [1] I and my co-author highlighted the cases of Charlotte Wyatt who was severely disabled fol...
Gupta et al. yet again highlight a worrying trend in poor management of Vitamin D - both prevention and treatment. The majority of affected children come from high risk populations where rates of social disadvantage are high. The mothers of these children could all have been identified and given cheap, effective preventative treatment. Whilst we should be concerned that 30% of the children received inappropriate treatme...
Editor
Eisenhut raises the possibility that food was the source of the outbreak of group A streptococcal disease at the primary school. This hypothesis was considered, but was rejected as implausible for several reasons; firstly the outbreak was not a true point source as it was preceded by five sentinel cases over a 12 day period, in addition the peak on the 16th May was inflated as it included cases with on...
Dear Editor,
We read with interest the paper by Villa F et al (1) and we would like to add some conclusions reached by our group after a clinical research evaluating peripheral muscle function in children with asthma treated with inhaled corticosteroids. (2) Asthma is one of the most prevalent chronic diseases in children, and its secondary exercise limitation, among other several effects, usually cause a decre...
Giles at al. highlights a significant issue which has previously been recognised but not always as well framed. It is vital for patient safety that specialists in all fields have had the opportunity to develop their skills once their core competencies have been achieved. The continuing need for trainees in the UK to provide an active service while at the same time undertake and be involved in post-graduate education is not...
I am pleased to see a recommendation for shared paediatric/mental health clinics in treating CFS/ME. My clinical impression in a non- specialist hospital department is that most of these patients do not experience or exhibit anxiety or depression as much as profound frustration. This is similar to the presentation of children who cannot attend school ('school refusal') which of course is often a feature of CFS too.
...We read with interest the recent paper by Doull et al [1] which explores the optimal model for delivery of paediatric cystic fibrosis (CF) care. The authors compared three models of paediatric CF care within their established CF network: full centre care; local clinic based care with annual review by the CF centre; and hybrid care, where a child is usually reviewed at least three times a year by the specialist centre....
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