In the review by O'Grady and Cody (1), the Authors concluded that "in
the pediatric population with subclinical hypothyroidism (SH), the
majority of children with slightly elevated TSH levels are likely to
normalise without treatment or have persistent mild TSH elevation". Our
goal is to reinforce that conclusion on the basis of the results of an our
study aiming to prospectively evaluate for the first time the natural
co...
In the review by O'Grady and Cody (1), the Authors concluded that "in
the pediatric population with subclinical hypothyroidism (SH), the
majority of children with slightly elevated TSH levels are likely to
normalise without treatment or have persistent mild TSH elevation". Our
goal is to reinforce that conclusion on the basis of the results of an our
study aiming to prospectively evaluate for the first time the natural
course of SH in children and adolescents with no underlying diseases and
no risk factors that might interfere with the progression of SH (2).
In our study clinical status, thyroid function and autoimmunity were
prospectively evaluated at entry and after 6, 12 and 24 months in 92 young
patients (mean age 8.1 /-3.0 years) with idiopathic SH. In the study
population all the etiological causes of SH had been preliminary excluded
at the time of admission. During the two-year follow-up period mean TSH
levels showed a trend towards a progressive decrease while FT4 levels
remained unchanged. Overall, 38 patients normalized their TSH (group A):
16 patients between 6 and 12 months, and 22 patients between 12 and 24
months. Among the remaining 54 patients, the majority maintained TSH
within the baseline values (group B), whereas 11 exhibited a further
increase in TSH above 10 uIU/ml (group C). Baseline TSH and FT4 levels
were similar in the patients who normalized TSH, compared with those with
persistent hyperthyrotropinemia. Even in the patients of group C, both TSH
and FT4 at entry were not different with respect to those of group A and
B. No patients showed any symptoms of hypothyroidism during follow-up and
no changes in both height and body mass index were observed throughout the
observation period (2).
We concluded that the natural course of TSH elevations in children and
adolescents with idiopathic SH is characterized by a progressive decrease
over time and that the majority of patients have a normalization of serum
TSH within a 2-year follow-up (2).
Our conclusions are in agreement with the ones by O'Grady and Code (1) and
support them.
References
1. O'Grady MJ, Cody D. Subclinical hypothyroidism in childhood. Arch Dis
Child 2010. Published Online First: 22 April 2010. doi:
10.1136/adc.2009.181800
2. Wasniewska M, Salerno M, Cassio A, Corrias A, Aversa T, Zirilli G,
Capalbo D, Bal M, Mussa A, De Luca F. Prospective evaluation of the
natural course of idiopathic subclinical hypothyroidism in childhood and
adolescence. Eur J Endocrinol. 2009 Mar;160(3):417-21.
Van Esso et al highlight interesting differences in primary care
provision between European countries, pointing out a possible change in
the relative balance between paediatric and general practitioner/family
doctor systems since Katz's paper in 2002(1).
Our findings, from an ongoing study for the European Observatory on Health
Systems and Policies, suggest caution in the interpretation of GP/FD
models in some countries....
Van Esso et al highlight interesting differences in primary care
provision between European countries, pointing out a possible change in
the relative balance between paediatric and general practitioner/family
doctor systems since Katz's paper in 2002(1).
Our findings, from an ongoing study for the European Observatory on Health
Systems and Policies, suggest caution in the interpretation of GP/FD
models in some countries. For example Swedish general practitioners and
paediatricians work in teams with children's
nurses in urban community-based children's
centres. Rapid referrals and consultations are easy and commonplace,
rendering the distinction between types of professionals less clear. Some
children's centres are staffed by either a
GP/FD or a primary care paediatrician, and in rural areas the GP/FD model
predominates. In Sweden, planning children's
health services for an area is the responsibility of a senior
paediatrician and paediatric nurse. Similarly in The Netherlands, the
transmural care model enables GPs and paediatricians to work more closely
together than is the case in the UK by aligning financial and managerial
incentives. Hence although defining these countries as having a GP/FD
model for children's first-access is correct,
it is an incomplete explanation as they have advanced further along the
road to integrating primary and secondary care than the UK.
1. Katz M RA, Collier J, Rosen J, Ehrich JHH. Demography of pediatric
primary care training in Europe: delivery of care and training.
Pediatrics. 2002;109:788-96.
Dear Editor:
In their paper on the TSH threshold in neonatal screening for congenital
hypothyroidism (CH), Korada et al. (1) conclude that a threshold of 6
mIU/L for DELFIA-measured TSH in samples collected between days 5 and 8
may be preferable to the 10 mIU/L recommended by the UK Newborn Screening
Programme Centre. Our laboratory instituted DELFIA measurements of TSH in
5-8-day paper-borne heelprick samples in 1985. S...
Dear Editor:
In their paper on the TSH threshold in neonatal screening for congenital
hypothyroidism (CH), Korada et al. (1) conclude that a threshold of 6
mIU/L for DELFIA-measured TSH in samples collected between days 5 and 8
may be preferable to the 10 mIU/L recommended by the UK Newborn Screening
Programme Centre. Our laboratory instituted DELFIA measurements of TSH in
5-8-day paper-borne heelprick samples in 1985. Since 1998 we have used an
accelerated AutoDELFIA(R) method - fully endorsed by the results of
external quality control services (DGKL, NEQAS, AECNE) - that takes about
2 h and thus allows follow-up samples to be called for, if necessary, on
the same day as the first sample is analysed. Since 2003, heelprick has
been performed on day 3 in response to the desire of paediatric
endocrinologists to begin the treatment of CH patients as early as
possible, even though the typical physiological TSH peak on day 2 reduces
the efficiency of screening thresholds; Table 1 summarizes the
distribution of TSH levels in the 102,789 newborns screened during this
period.
Having observed significant between-lot variation in TSH assay kits,
since November 2004 we recalculate our TSH threshold for every run in the
light of two factors: a) the dispersion of the calibration data in the
vicinity of 10 mIU/L; and b) measurements of certified control samples
with concentrations close to 10 mIU/L that are supplied by Perkin Elmer
and, within its Newborn Screening Quality Assurance Program, by the CDC.
Defining CV10 as the coefficient of variation of two replicate
fluorescence measurements of the calibration standard nearest to 10 mIU/L,
expressed as a percentage, factor (a) is assigned the value zero if CV10
< 10, and the value 0.1 x CV10 otherwise. The control samples (C1 and
C2, of certified concentrations c1 and c2, respectively) are each measured
once; in each case a parameter bi (i = 1,2) is assigned the value zero if
the measured value mi is greater than 90% of the certified value, or the
value 10 x (ci - mi)/ci otherwise; and the value of factor (b) is defined
as the greater of b1 and b2. Finally, the TSH threshold is defined as (10
- x) mIU/L, where x is the larger of factors (a) and (b). This entirely
empirical algorithm is displayed in flow-chart form in Fig. 1.
In the 1171 runs in which the above procedure has been followed, the
threshold so determined was > 9 mIU/L in 54.7%, 8-9 mIU/L in 35.3%, 7-8
mIU/L in 8.5%, and < 7 mIU/L in 1.5%. Of the 62 cases of CH that we
have detected in this time, three (all with adequate weight at birth) had
first-sample TSH levels lower than 10 mIU/L (see Table 2 for details).
In paper-borne heelprick blood samples.
b In blood samples obtained by venous puncture.
Cristobal Colon and Jose Ramon Alonso-Fernandez.
Metabolopathy Laboratory,
Departament of Paediatrics,
Clinical Hospital and Universiy of Santiago de Compostela (Spain).
References
1) KORADA SM, PEARCE M, PLATT MPW, AVIS E, TURNER S, WASTEL H,
CHEETHAM T. Dificulties in selecting an appropriate Neonatal TSH screening
threshold. Arch Dis Child (Online First), 12 Aug 2009.
2) ALONSO-FERNANDEZ JR. V Reunion Nacional de la Sociedad Espanola de
Quimica Clinica. Santiago de Compostela 28 y 29 de abril de 1985.
3) POMBO M, ALONSO-FERNANDEZ JR, BRAVO M, FRAGA JM, PEnA J.
Diagnostico Precoz del Hipotiroidismo Congenito y de la deficiencia de
Hormona del Crecimiento. An Esp Ped. 1987;27(sup.28):44-47.
4) COLON C, ALONSO-FERNANDEZ JR. Depistage de L'Hipothiroidie
neonatal avec un inmuno-essai marque a l'Europeum. Etude comparative de
curbes de calibrage. Proceedings of "Reunion Europeene sur le Depistage
Neonatal en 1986. Evian (France). 28-30 de abril de 1986.
5) ALONSO-FERNANDEZ JR, COLON C, FRAGA JM. Neonatal Screening of
Hipotiroidism: A comparative study of RIA Technique and the Non Isotopic
Inmunoessay DELFIA System. In BL Therrel; Advances in Neonatal Screening
pp 163-164 (1987). Excerpta Medica.
6) COLON C, ALONSO-FERNANDEZ JR, CASTInEIRAS DE, ROMERO ME, FRAGA JM,
PEnA J. Posible Causes of Bordeline TSH: a Summary of our experrience. In
F Delange, DA Ficher, D Glinder; Research in congenital Hypothyroidism, pp
316, 1989. Plenum Press.
7) COLON C.Epidemiological study of thyroid stimulating hormone (TSH)
levels in the Galician neonatal population (Estudio epidemiologico de los
niveles de hormona estimuladora del tiroides (TSH) en la poblacion
neonatal gallega). Microfiche ISBN 13: 978-84-8121-340-9. ISBN 10:84-8121-
340-3. Ed. Universidade de Santiago de Compostela. 1995.
8) ALONSO-FERNANDEZ JR, CASTInEIRAS DE, CASTInEIRAS C, VILLAR P.
Determinacion de TSH Neonatal con el metodo DELFIA reduciendo a dos horas
el periodo de Elucion-Incubacion, concentrando el trazador y el analito.
Immunoensayo 97. La Habana (Cuba) 14-18 de septiembre de 1997.
Post date
In 1985 (2, 3) we propound the adaptation of DELFIA test for seric
TSH measurement to the newborn screening sample (DBS). Once (actually)
Perkin-Elmer marketed the neonatal screening TSH test, we suggested a
calibrate modification, increasing from 3 to 5 points and using the
interpolation with logarithmic spline instead linear regression such as
made in the procedure for seric and neonatal screening TSH determination
(4). It is compared with the RIA test using until then (5). In 1988 we
discussed the causes of borderline results (6), one of the main reasons
for recall sample. In the PhD thesis of one of us (C. Colon) in 1995 (7),
we could verify that the gestational age, the birth weight, and the age of
analysis, influence on the TSH values. Also was found the thyroid function
alteration due to antiseptic iodine use (effect Wolff-Chaikoff).
In 1997 we presented (8) a new DELFIA test for neonatal TSH
modification; reducing until 2 hours the elution-incubation time, using
half buffer volume in the preparation of tracer solution and reducing to
100 microlitres the volume of this solution dispensed in the microtiter
plate wells containing the DBS disc. In the next year, using the
AutoDELFIA, we introduced another modification, increasing to double the
content of second antibody-tracer in the immunochemistry reaction mixture,
in this mixture the analyte concentration result is multiplied for 2 and
Europium-labelled antibody for 4.
One of the issues arising from the review of management of suspected
viral encephalitis(1) is the interpretation of cerebrospinal fluid(CSF)
glucose content, and CSF glucose/blood glucose ratio(GR), given the
overlap in clinical features between suspected viral encephalitis(1),
meningitis of bacterial origin(including m tuberculosis aetiology)(2), and
viral meningoencephalitis(3). What needs to be recognised is that the...
One of the issues arising from the review of management of suspected
viral encephalitis(1) is the interpretation of cerebrospinal fluid(CSF)
glucose content, and CSF glucose/blood glucose ratio(GR), given the
overlap in clinical features between suspected viral encephalitis(1),
meningitis of bacterial origin(including m tuberculosis aetiology)(2), and
viral meningoencephalitis(3). What needs to be recognised is that the
distinction between these entities(1)(2)(3) cannot reliably be made on the
basis of the CSF glucose content(3)(4), or even the GR(5), notwithstanding
the conventional wisdom that a GR of < 0.5 distinguishes between
meningitis attributable to bacterial pathogens(including m tuberculosis)
and viral meningitis(6). According to one study, which aimed to draw
attention to suboptimal and highly variable practices in the management of
herpes simplex type-2 meningitis in adults, a "low glucose(< 40 mg/dl)"
content in the CSF could be a feature of herpes simplex meningitis(3).
Although CSF glucose was not recorded as such in the report of a National
Prospective Study of Infectious Encephalitis, 8% of 55 adults with herpes
virus encephalitis were documented as having CSF "hypoglycorrachia", and
the prevalence of this derangement was as high as 40% in 20 adults with
varicella-zoster encephalitis(4). Other investigators have shown that
varicella-zoster meningitis may be characterised by a GR as low as
0.4(range 0.4-0.73), and that, in enterovirus meningitis, GR may be as low
as 0.26(range 0.26-0.76)(5).
Accordingly, in the event that these observations are translateable to
paediatric practice(where viral meningitis/encephalitis constitutes as
many as 45% of microbiologically validated instances of acute central
nervous system infection)(7), sole reliance on GR would be misplaced for
differentiating between subtypes of meningitis and meningoencephalitis.
What is also urgently required, is to put into practice the intellectual
rigour of two recent studies of infectious encephalitis of various
aetiologies(5)(7) so as to formulate robust guidelines for the management
of children with suspected viral encephalitis.
References
(1) Kreen R., Jakkas S., Mthyantha R., Riordan A., Solomon T
The management of infants and children treated with acyclovir for
suspected viral encephalitis
Arch Dis Child 2010;95:100-6
(2) Kim KS
Acute bacterial meningitis in infants and children
Lancet Infectious Diseases 2010;10:32-42
(3) Landry ML., Greenwold J., Vikram HR
Herpes simpolex type-2 meningitis: Presentation and lack of standardised
therapy
Amer J Med 2009;122:688-91
(4) Mailles A., Stahl J-P., on behalf of the Steering Committee and the
Investigators Group
Infectious encephalitis in France in 2007: A National Prospective Study
Clinical Infectious Diseases 2009;49:1838-47
(5)Ihekwaba UK., Kudesia G., McKendrick MW
Clinical features of viral meningitis in adults: Significant differences
in cerebrospinal fluid findings among herpes simplex virus, varicella
zoster virus, and enterovirus infections
Clinical Infectious Diseases 2008;47:783-9
(6)Logan SA., MacMahon E
Viral meningitis
BMJ 2008;336:36-40
(7) Huttunen P., Lappalainen M., Salo E et al
Differential diagnosis of acute central nervous system infection in
children using modern microbiological methods
Acta Paediatrica 2008 DOI:10.1111/j.1651-2227.2009.01336x
Sir,
in Nottingham, we have been operating a similar system to Fraser et al
(1), for person specific planning for children with life limiting
conditions since 2004. We have presented it at several national and
international meetings (2-7).
Our system has 2 parts. The first part is the personal resuscitation
plan (PRP) which describes in detail the interventions which are
appropriate in the event of deterioratio...
Sir,
in Nottingham, we have been operating a similar system to Fraser et al
(1), for person specific planning for children with life limiting
conditions since 2004. We have presented it at several national and
international meetings (2-7).
Our system has 2 parts. The first part is the personal resuscitation
plan (PRP) which describes in detail the interventions which are
appropriate in the event of deterioration, whether sudden or gradual and
considers the preferred place of death. This is a medical care plan and
must be signed by the child's consultant. The second part of our tool kit
is the 'wishes and choices' document which details the family choices
regarding organ and tissue donation, post mortem and arrangements for care
of the body after death. These two documents together make up the child's
'end of life' care plan, but unlike the authors we have found it important
to approach families with them separately.
The PRP is a detailed emergency care plan which gives background
information about the child's condition, plus symptoms and signs which
would indicate deterioration as well as the specific interventions which
are appropriate. This makes it relatively easy for the paediatrician to
introduce to parents and carers of children with severe neurodisability,
whether static or degenerative as soon as the child is having or is at
risk of having life threatening events such as air way problems, chest
infections, or prolonged seizures. It can be presented as a positive plan
of best care, rather than dwelling on the plan for the child's death.
Our experience has been that families are keen to have an emergency
care / resuscitation plan that promotes early and appropriate low level
treatment and avoids inappropriate and invasive interventions, long before
they are ready to discuss tissue donation and funeral arrangements.
However making the PRP starts the conversations about what may happen and
what choices are available, including the preferred place of death, and
who can be there to provide support.
Feedback from local focus groups with hospital and community staff
has emphasised the importance that the resuscitation plan is a medical
care plan developed with the family and the care team, and family held,
but signed as appropriate care by the child's consultant paediatrician. It
then replaces the 'do not attempt resuscitation' form and will be followed
by emergency services including ambulance staff.
Evaluation in 2006 showed that 19 out of 24 children on the community
nurse case load with life limiting conditions had a plan and a prospective
study in this same group of children showed that the plan was available
and followed in 10 out of 11 emergency events, including seven deaths,
with no admissions to the paediatric intensive care unit. Feedback from
professionals and parents was that PRPs are useful and empowering.
PRPs do not time expire, but as the child's condition changes the
resuscitation plan may need to change, and so must all copies. In our
system the distribution list is part of the plan itself and the plan
clearly states 'do not photocopy'.
We have found that while families are glad to keep the resuscitation
plan with the child at all times and have copies widely distributed, they
prefer not to carry around the 'wishes and choices' document, but to keep
it more privately.
The Nottingham 'Personal Resuscitation Plan' and 'Wishes and Choices'
templates can be found in Pfund and Fowler-Kerry (8).
References:
1. Fraser J, Harris N, Berringer AJ, Prescott H, Finlay F. Advanced
care planning in children with life-limiting conditions- the Wishes
Document. Archives of Disease in Childhood 2010: 95; 79-82.
2. Wolff A, Browne J, Whitehouse WP. Development of personal
resuscitation plans instead of 'do not resuscitate' orders for children
with life-limiting conditions. Developmental Medicine & Child
Neurology 2004: 46; Suppl 100; 45.
3. Wolff A, Browne J, Whitehouse WP. Personal Resuscitation Plans:
the death of DNARs? Archives of Disease in Childhood 2005: 90; Suppl 11;
A78.
4. Wolff A, Hollingsworth S, Crawford C, Whitehouse WP. Use of
personal resuscitation plans in children with life limiting conditions.
Archives of Disease in Childhood 2006: 91; Suppl 1; A83.
5. Wolff A, Hollingsworth S, Crawford C, Whitehouse WP. Personal
resuscitation plans in children with life-limiting conditions.
Developmental Medicine & Child Neurology 2006: 48; Suppl 106; 51.
6. Wolff A, Hollingsworth S, Whitehouse W. Clinical usefulness of
personal resuscitation plans in children with neurodisabilities and life-
limiting conditions. Archives of Disease in Childhood 2007: 92 Suppl 1:
A56.
7. Wolff T. Whitehouse W. the death of DNR: personal resuscitation
plans. British Medical Journal 2009: 338; 1227.
8. Pfund R and Fowler-Kerry S. 2010. Perspectives on palliative care
for children and young people - a global discourse. Radcliffe Publishing,
Oxford.
A major finding of this study was: "Infants with dual infections (RSV
and hBoV) had a higher clinical severity score and more days of
hospitalisation"
In our hospital, and many others round the world, babies with RSV
infection are nursed in a room together and are not tested for Bocavirus.
Should this practice now stop to prevent Bocavirus crossinfection
increasing morbidity?
A major finding of this study was: "Infants with dual infections (RSV
and hBoV) had a higher clinical severity score and more days of
hospitalisation"
In our hospital, and many others round the world, babies with RSV
infection are nursed in a room together and are not tested for Bocavirus.
Should this practice now stop to prevent Bocavirus crossinfection
increasing morbidity?
We were interested to read the paper by Jones at al1 on âFrequent
medical absences in secondary school studentsâ. They conclude that âthis
study should prompt education departments and their NHS partners to look
more critically at the problem ⦠and to establish a system that provides
more comprehensive assessment and treatment.â
We were interested to read the paper by Jones at al1 on âFrequent
medical absences in secondary school studentsâ. They conclude that âthis
study should prompt education departments and their NHS partners to look
more critically at the problem ⦠and to establish a system that provides
more comprehensive assessment and treatment.â
Within Bolton PCT such a system has been designed in order to
identify causes of frequent medical absences from school and to provide
interventions aimed at supporting students to achieve an earlier and
consistent return to school. Originally in Bolton (from the year 2000)
referrals were made by the Education Social Work Department to a Senior
Clinical Medical officer to undertake medicals on children with poor
school attendance reported as due to ill health. This provided evidence to
support an identified medical problem or for the LEA to issue a fixed
penalties notice to the parent or carer. Since the issue of school
attendance subsequently became a high priority policy concern for both the
DfES and the DoH this service was re structured to develop an innovative
Advanced Nursing Practitioner (with a school nursing background) led model
for the evaluation of health issues for children and young people with
poor school attendance. The main focus of the model was to enhance joint
working between the advanced practitioner, Education Social Worker,
schools and families. Changes have included a standardised threshold for
referral (when attendance falls to 80%), agreed minimum information sets
on referrals, agreed time frames for assessments and production of
correspondence, holistic assessment, onward referrals, investigations and
reintegration programmes to aide full return to school.
Over the last academic year 251 new referrals were received form the
Education Social Work department (previously 55 a year). There were two
peaks of referral (December 51, April 40). There were 120 referrals from
primary schools and 131 for secondary schools. Referrals included 122 boys
and 129 girls. Referrals to the service from 18 individual education
social workers varied from 1 - 41 (median 14). The main causes of school
absence were asthma, recurrent URTI, headache, sore throat, menstruation
problems, chronic fatigue, skin problems, emotional and behavioural
problems and inadequate provision for special needs within school. A
variety of onward referrals were made including ENT, community
paediatrics, dietetics, Young Carers, social care, occupational care,
physiotherapy, CAMHs and two admissions to hospital. Support packages of
care have been initiated for some together with supported reintegration
plans to enable the young person to return to regular school attendance.
Pathways are being devised for young people identified with âschool
phobiaâ (jointly with CAMHs) and also a menstruation pathway for girls
presenting with complex menstrual history.
In all cases of non attendance it is essential that preventative and
early intervention should be seen as the cornerstone of multiagency
working in order to ensure pupils right to education and to protect their
health and well being. The redesigned service in Bolton has made good
progress towards achieving these aims.
Reference
1.Jones R, Hoare P, Elton R, Dunhill Z, Sharpe M. Frequent medical
absences in secondary school students: survey and case control study. Arch
Dis Child 2009;94:763-767
We feel Dr Markovitch (1) was over critical of Hilton et al (2).
Although we agree that there was a paucity of evidence to allow them to
rebut Dr Wakefield’s suggestion that MMR could in some children cause
autism, we believe that they still could have been clearer in reporting
the full situation. The suggestion that the MMR vaccine should be given as
its separate components came, not from a scientific paper, but as an
a...
We feel Dr Markovitch (1) was over critical of Hilton et al (2).
Although we agree that there was a paucity of evidence to allow them to
rebut Dr Wakefield’s suggestion that MMR could in some children cause
autism, we believe that they still could have been clearer in reporting
the full situation. The suggestion that the MMR vaccine should be given as
its separate components came, not from a scientific paper, but as an
announcement by a single researcher at a press conference. Within a month
of the publication of the Lancet paper, a number of authors of the paper
re-emphasised the importance of the combined MMR vaccine and that they had
not proven a link between it and autism (3). It is these facts that should
have been more strongly communicated, thus allowing people to attach the
appropriate level of credence to Dr Wakefield’s views. If editors of
journals had made more of this, healthcare professionals might have been
better equipped for their discussions with parents.
We agree with Dr Markovitch that “…..they [editors] should offer
honest accounts of best practice couched in language that generalist
health care professional readers and the non-scientists writing for the
public media can understand.” However, they should include all the
relevant details including a balance that is truly reflective of the
scientific evidence. The individual health professional is often unable to
review the evidence themselves, through lack of time or access to the
relevant material, and relies on journals such as those critiqued by
Hilton et al to provide the information in a full but concise manner.
Although this approach may not make for earth shattering headlines, it is
responsible. We don’t suggest that editors should be censorious but it
behoves them to couch unsubstantiated hypotheses in an appropriately
cautious manner.
1. Markovitch H. Editors should not be propagandists. Arch Dis Child
2009; 94: 827-8.
2. Hilton S, Hunt K, Langan M, Hamilton V, Petticrew M. Reporting of MMR
evidence in professional publications: 1988-2007. Arch Dis Child 2009; 94:
831-3.
3. Murch S, Thompson M, Walker-Smith J. Autism, inflammatory bowel disease
and MMR vaccine. Lancet 1998; 351: 908.
It would be useful to ascertain whether or not the "new"
sphygmanometer being compared with the Omron HEM 711(1) was an aneroid
device, given the fact that those of us who lamented what we perceived to
be an ill advised rejection of the mercury device welcomed the prospect
that aneriod sphygmanometers "may replace the traditional mercury column
in the healthcare workplace"(2). In the latter study, there were no
signific...
It would be useful to ascertain whether or not the "new"
sphygmanometer being compared with the Omron HEM 711(1) was an aneroid
device, given the fact that those of us who lamented what we perceived to
be an ill advised rejection of the mercury device welcomed the prospect
that aneriod sphygmanometers "may replace the traditional mercury column
in the healthcare workplace"(2). In the latter study, there were no
significant differences(using the paired t-test) between the mercury
standard and the aneroid device(Baum & Co), but the oscillometric
device(Omron HEM-907)significantly(p=0.002) overestimated the systolic
blood pressure(SBP) and significantly(p=0.0002) underestimated the
diastolic blood pressure(DBP)(2). A later study study compared the Welch
Allyn Tycos 767-Series Mobile aneroid sphygmanometer with the mercury
device, and found no statistically significant difference for SBP but a
significantly(p < 0.0001) lower reading for DBP using the aneroid
device(3). Oscillometric devices, on the other hand, have proved to be
almost universally unreliable. In one study, an evaluation of 9 devices
showed that "accuracy appeared to deccrease at increasing blood pressure
levels" with the potential consequence that "in treated hypertensive
patients the necessary adaptation of treatment will not take place"(4).
More recently, a comparison was made between the professional
oscillometric device BpTRU, that had achieved an A grade of the British
Hypertension Society validation protocol for both SBP and DBP measurement,
and the standard mercury sphygmanometer(Baumanometer; WA Baum Co). A total
of 5070 BP measurements were made using the two devices simultaneously.
Unreliable readings(ie > 10 mm Hg difference in either SBP or DBP) were
found in 755 patients. Unreliable readings occured in 15% of systolic and
6.4% of diastolic blood pressures(5). In view of the fact that "A
decreasing arm circumference was a significant predictor of persistent
UOBP(unreliable oscillometric BP)"(5), this observation might signify that
oscillometric devices might be inherently unreliable in children
References
(1) Midgley PC., Wardhaugh B., Macfarlane C., Magowan R., Kelnar CJH
Blood pressure in children 4-8 years: comparison of Omron HEM 711 and
sphygmanometer blood pressure measurements
Arch Dis Child 2009;94:955-8
(2)Elliot WJ., Young PE., DeVivo L., Feldstein J., Black HR
A comparison of two sphygmanometers that may replace the traditional
mercury column in the healthcare workplace
Blood Pressure Monit 2007;12:23-8
(3) Ma Y., Temprosa M., Fowler S et al
Evaluating the accuracy of an aneroid sphygmanometer in a clinical trial
setting
Am J Hypertens 2009;22:263-6
(4) Braam RL., Thien T
Is the accuracy of blood pressure measuring devices underestimated at
increasing blood pressure levels?
Blood Pressure Monitoring 2005;10:183-9
(5)Stergiou GS., Lourida p., Tzamouranis D., Baibas NM
Unreliable oscillometric blood pressure measurement;prvalence,
repeatability and characteristics of the phenomenon
J Human Hypertension 2009;23:794-800
I was interested to read Govindaraj et al’s audit showing a fall in
the number of MMR vaccines given in their hospital over the last 2 years.
Unfortunately there was no data to show what happened to those children
initially referred to hospital for MMR, but referred back by the
outpatient sister.
A study from New Zealand suggests that children inappropriately
referred for MMR in hospital can be referred back a...
I was interested to read Govindaraj et al’s audit showing a fall in
the number of MMR vaccines given in their hospital over the last 2 years.
Unfortunately there was no data to show what happened to those children
initially referred to hospital for MMR, but referred back by the
outpatient sister.
A study from New Zealand suggests that children inappropriately
referred for MMR in hospital can be referred back and subsequently
immunised in primary care [1]. However this was not our experience in
Liverpool where 22 children, who had been advised by a health professional
to have MMR in the community, were still referred to hospital [2]. This
request for immunisation in hospital came from both primary care staff and
parents.
It is important to ensure that children referred for MMR in hospital,
but referred back to primary care, are subsequently immunised. Does Dr
Govindaraj have any data to reassure us that the fall in the number of MMR
vaccines given in their hospital is not due to children being left
unimmunised in the community?
1. Goodyear-Smith F, Wong F, Petousis-Harris H, Wilson E, Turner N.
Follow-up of MMR vaccination status in children referred to a pediatric
immunization clinic on account of egg allergy. Human Vaccines.2005: 1:118-
22
2. Ainsworth E, Debenham P, Carrol ED, Riordan FAI. Referrals for MMR
immunisation in hospital. Arch Dis Child 2009 (in press)
In the review by O'Grady and Cody (1), the Authors concluded that "in the pediatric population with subclinical hypothyroidism (SH), the majority of children with slightly elevated TSH levels are likely to normalise without treatment or have persistent mild TSH elevation". Our goal is to reinforce that conclusion on the basis of the results of an our study aiming to prospectively evaluate for the first time the natural co...
Van Esso et al highlight interesting differences in primary care provision between European countries, pointing out a possible change in the relative balance between paediatric and general practitioner/family doctor systems since Katz's paper in 2002(1). Our findings, from an ongoing study for the European Observatory on Health Systems and Policies, suggest caution in the interpretation of GP/FD models in some countries....
Dear Editor: In their paper on the TSH threshold in neonatal screening for congenital hypothyroidism (CH), Korada et al. (1) conclude that a threshold of 6 mIU/L for DELFIA-measured TSH in samples collected between days 5 and 8 may be preferable to the 10 mIU/L recommended by the UK Newborn Screening Programme Centre. Our laboratory instituted DELFIA measurements of TSH in 5-8-day paper-borne heelprick samples in 1985. S...
One of the issues arising from the review of management of suspected viral encephalitis(1) is the interpretation of cerebrospinal fluid(CSF) glucose content, and CSF glucose/blood glucose ratio(GR), given the overlap in clinical features between suspected viral encephalitis(1), meningitis of bacterial origin(including m tuberculosis aetiology)(2), and viral meningoencephalitis(3). What needs to be recognised is that the...
Sir, in Nottingham, we have been operating a similar system to Fraser et al (1), for person specific planning for children with life limiting conditions since 2004. We have presented it at several national and international meetings (2-7).
Our system has 2 parts. The first part is the personal resuscitation plan (PRP) which describes in detail the interventions which are appropriate in the event of deterioratio...
A major finding of this study was: "Infants with dual infections (RSV and hBoV) had a higher clinical severity score and more days of hospitalisation"
In our hospital, and many others round the world, babies with RSV infection are nursed in a room together and are not tested for Bocavirus. Should this practice now stop to prevent Bocavirus crossinfection increasing morbidity?
Conflict of Interest:
...We were interested to read the paper by Jones at al1 on âFrequent medical absences in secondary school studentsâ. They conclude that âthis study should prompt education departments and their NHS partners to look more critically at the problem ⦠and to establish a system that provides more comprehensive assessment and treatment.â
Within Bolton PCT such a sy...
We feel Dr Markovitch (1) was over critical of Hilton et al (2). Although we agree that there was a paucity of evidence to allow them to rebut Dr Wakefield’s suggestion that MMR could in some children cause autism, we believe that they still could have been clearer in reporting the full situation. The suggestion that the MMR vaccine should be given as its separate components came, not from a scientific paper, but as an a...
It would be useful to ascertain whether or not the "new" sphygmanometer being compared with the Omron HEM 711(1) was an aneroid device, given the fact that those of us who lamented what we perceived to be an ill advised rejection of the mercury device welcomed the prospect that aneriod sphygmanometers "may replace the traditional mercury column in the healthcare workplace"(2). In the latter study, there were no signific...
I was interested to read Govindaraj et al’s audit showing a fall in the number of MMR vaccines given in their hospital over the last 2 years. Unfortunately there was no data to show what happened to those children initially referred to hospital for MMR, but referred back by the outpatient sister.
A study from New Zealand suggests that children inappropriately referred for MMR in hospital can be referred back a...
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