This paper demonstrates deep understanding of economics but little feeling
for the reality of early infancy.[1] Any paediatrician will know this is
the most vulnerable time of life. Any parent will tell you how hard it can
be looking after an infant in the first three months. The assumption that
health visitors home visits and mothers visits to the GP “that the entire
contact would be devoted to infant crying...
This paper demonstrates deep understanding of economics but little feeling
for the reality of early infancy.[1] Any paediatrician will know this is
the most vulnerable time of life. Any parent will tell you how hard it can
be looking after an infant in the first three months. The assumption that
health visitors home visits and mothers visits to the GP “that the entire
contact would be devoted to infant crying and sleeping” underestimates the
work that is or needs to be done in these consultations.
Apart from the crying or lack of sleep the health visitor or GP will
have to consider the presence of any physical condition, the physical,
psychological and social welfare of the mother and the father. At least
one in ten women experience depression in the first weeks or months after
giving birth.[2] There is an inverse relationship between the age of
infants and deaths from child abuse.[3] The injuries found on the head and
neck of young infants who suffer physical abuse are commonly associated
with a history of difficulty with sleeping or crying. A randomised trial
in the USA showed statistically significant reduction in child abuse and
neglect when the mothers were visited by nurses during pregnancy and
infancy.[4]
Morris et al inform us that the £65 million spent by the (UK) NHS on
babies that cry or do not sleep would buy over 13 million doses of Viagra
(sildenafil). It is of regret that the authors did not discuss how
persistent crying or lack of sleep could lead to child abuse. Perhaps in
future work they could calculate the cost of one shaken baby to the NHS
and society.
Dr D V Lang
Associate Specialist Child Health/Audiology
Royal Cornwall Hospitals Trust
Pendragon House, Treliske
Cornwall PL15 3LS, UK
References
(1) Morris S, et al. Economic evaluation of strategies for managing
crying and sleeping problems. Arch Dis Child 2001;84:15-19.
(2) The management of postnatal depression [Review]. Drug Ther Bull 2000 May;38(5):33-7.
(3) Hobbs CJ, Hanks HGI, Wynne JM. Child abuse and neglect. A
clinicians handbook (2nd ed). London: Churchill Livingstone, 1999.
(4) Olds DL, et al. Long term effects of home visitation on maternal
life course and child abuse and neglect. Fifteen-year follow up of a
randomised trial. JAMA 1997;278:637-43.
In our study[1] we considered only consultations with the health
visitor and GP where infant crying and sleeping problems were discussed.
This does not mean that ALL consultations with the health visitor or GP
for infants at this age were devoted to infant crying and sleeping
problems. There may have been additional consultations where other
important issues were discussed, but they were not included here...
In our study[1] we considered only consultations with the health
visitor and GP where infant crying and sleeping problems were discussed.
This does not mean that ALL consultations with the health visitor or GP
for infants at this age were devoted to infant crying and sleeping
problems. There may have been additional consultations where other
important issues were discussed, but they were not included here because
they were not relevant to the specific study question.
Additionally, as explained in the text of the paper, even in those
consultations with the health visitor where infant crying and sleeping
problems were discussed we did not assume that the whole consultation was
devoted to discussing crying and sleeping problems. We did make this
assumption for GP consultations where infant crying and sleeping problems
were discussed. However, as evidenced from Table 1 in the paper the bulk
of the contacts were with health visitors, and GP contacts comprised only
a relatively small component.
We readily agree with Dr Lang's implicit conclusion that the costs
of infant crying and sleeping problems are far greater than the financial
costs estimated in our paper. We certainly acknowledge that there are
other, for example psychological, costs on mothers and fathers. Our aim in
conducting this study was to highlight the fact that infant crying and
sleeping problems have a major impact on society and that such problems
are therefore not to be taken lightly. We in no way criticise the amount
of money spent addressing infant crying and sleeping problems. In fact we
wish to demonstrate just how important these problems are by attempting to
quantify the costs they impose in a tangible way. We believe we have gone
some way to demonstrating this by showing just how large the financial
costs to the NHS might be.
Mr S Morris
Lecturer in Health Economics
Department of Economics, City University
London EC1V 0HB, UK
Dr I St. James-Roberts
Reader in Child Development
Thomas Coram Research Unit
Institute of Education
University of London
27 Woburn Square
London WC1H 0AA, UK
References
(1) Morris S, et al. Economic evaluation of strategies for managing
crying and sleeping problems. Arch Dis Child 2001;84:15-19.
I have a policy, although as yet I do not have enough experience of
using it to know whether it is effective. Trainee pediatricians or nurses
may well tell me that family members of an in-patient have been verbally
abusive to them. I then ask to see the family members and tell them that
I may/will lodge a complaint against them with the Trust management.
Basically, I simply try to use the same complaints...
I have a policy, although as yet I do not have enough experience of
using it to know whether it is effective. Trainee pediatricians or nurses
may well tell me that family members of an in-patient have been verbally
abusive to them. I then ask to see the family members and tell them that
I may/will lodge a complaint against them with the Trust management.
Basically, I simply try to use the same complaints procedure in holding
families to account for the standards of their behaviour as they are
entitled to use against professional staff to hold us to account for our
standards of care. The outcome of the procedure should be an official
letter of complaint from the Trust inviting their comments - but it has
never yet come to that.
Although I have not accumulated enough experience to judge the
effectiveness of this pro-active policy in nipping abuse in the bud before
the violence stage, the early trend is for family members to be taken
aback and to show some humility. Needless to say I keep anger and
provocation out of my voice and body language, although I keep my words
plain and straight. It may be that sometimes the concept that they owe
some duty to a standard - that they can be the "them" in the them-and-us
consumer world - is somewhat novel.
Of course, there is no panacea. I am not a stranger to death threats
under conditions of uncontrolled tragedy. However, I believe that early,
strong, pro-active intervention can lead to improved relations in at least
some more slowly developing cases.
We congratulate Olafsdottir et al on their article “Randomized controlled trial of infantile colic
treated with chiropractic spinal manipulation” (Arch Dis Child 2001;84:138-41).
The sum of the evidence on spinal manipulative therapy (SMT) in the
treatment of infantile colic now is, that there are 3 RCTs on the subject.
Two RCTs demonstrated a significant positive effect of SMT,[1][2]
and 1 RCT was unabl...
We congratulate Olafsdottir et al on their article “Randomized controlled trial of infantile colic
treated with chiropractic spinal manipulation” (Arch Dis Child 2001;84:138-41).
The sum of the evidence on spinal manipulative therapy (SMT) in the
treatment of infantile colic now is, that there are 3 RCTs on the subject.
Two RCTs demonstrated a significant positive effect of SMT,[1][2]
and 1 RCT was unable to demonstrate any treatment effect.[3]
The reasons for this discrepancy of result are not known, but Olafsdottir
et al suggest, that their finding no effect of SMT may be due to the
blinding of the infants mother, and this may very well be the right
explanation.
But another, equally likely, explanation could be that we are witnessing a
dose-response phenomenon.
In their trial Olafsdottir et al[3] gave a
treatment protocol consisting of a maximum of 3 sessions of SMT, whereas
the other 2 RCTs, which found a positive treatment effect, used a
treatment protocol relying more on the treating chiropractor's clinical
judgement. This more pragmatic treatment approach resulted in 64% of the
infants in one of the RCTs receiving 4 or more sessions of SMT (with a
maximum of 7),[1] and the majority of infants in the other RCT receiving
up to 6 sessions of SMT.[2]
We believe that this dose-response problem should be addressed in future
trials of SMT for infantile colic, and until then the jury is still out,
in our opinion.
Niels Grunnet-Nilsson
University of Southern Denmark
References
(1) Wiberg J, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in the treatment of infantile colic: A randomized controlled trial with a blinded observer. J Manipulative Physiol Ther 1999;22:517-22.
(2) Mercer C, Nook B. The efficacy of chiropractic spinal adjustments as a treatment protocol in the management of infantile colic. In: Haldeman S, Murphy B, eds. 5th Biennial Congress of the World Federation of Chiropractic. Auckland, New Zealand, 1999:170-1.
(3) Olafsdottir E, Forshei S, Fluge G, Markestad T. Randomized controlled
trial of infantile colic treated with chiropractic spinal manipulation. Arch Dis Child 2001;84:138-41.
We were interested to read Dr Robson’s leading article regarding
alcohol misuse and the reference to acute alcohol admissions to Alder
Hey in Liverpool, UK.[1][2] We too are concerned by the increasing number of these problems
that we see in hospital paediatric practice.
We carried out a retrospective case note review of all the children
seen in the Paediatric Emergency department in Sunderland b...
We were interested to read Dr Robson’s leading article regarding
alcohol misuse and the reference to acute alcohol admissions to Alder
Hey in Liverpool, UK.[1][2] We too are concerned by the increasing number of these problems
that we see in hospital paediatric practice.
We carried out a retrospective case note review of all the children
seen in the Paediatric Emergency department in Sunderland between November
1999 and October 2000. One hundred children (57 female) accounted for 106
attendances with acute alcohol intoxication (2 children attended twice and
2 three times). The notes of 97 attendances were available for review.
Most children were aged 13 to 15 (77%), range 10-16 years. As might be
expected the majority presented at a weekend (66%) and in the evening or
at night (84% between 19:00 and 01:00). Half had been drinking with friends
in a public place although precise details were not recorded in many
cases. Sixty one children (63%) were brought in by emergency ambulance and
48 (49%) were admitted. Thirty (31%) were documented to have been drinking
vodka, 21 cider (22%), 12 (12%) beer or lager, 11 (11%) other spirits, 8
(8%) wine, and 8 (8%) a combination of these. The type of alcohol was not
recorded in 7 (7%) cases. In no case were alcopops thought to be the
beverage responsible for the acute attendance and the beverages consumed
are comparable with Alder Hey figures from 1996.[2]
Alcopops and designer drinks appeal to young people, particularly 14-16 year olds and there has been criticism that marketing may be aimed at
this age group.[3][4] Consumption of alcopops has been associated with
drinking in less controlled environments, heavier drinking and greater
self reported drunkenness.[3] However our data do not suggest that they
are a problem in relation to acute intoxication presenting to Accident and
Emergency. We support the statement that children will mimic adults in
their use and misuse of alcohol and consider that it is society’s changing
attitude to alcohol and not the type of alcohol available that is of
concern.
DAVID CROSSLAND
Paediatric Registrar
KATHERINE POTIER DE LA MORANDIERE
Paediatric Senior House Office
Department of Paediatrics
Sunderland Royal Hospital
Kayll Road SR4 7TP, UK
The commentary by Lenney correctly points out that clinicians are
often slow to apply good research evidence to clinical practice.[1] However, the choice of once-daily intravenous gentamicin to illustrate this point is unfortunate. Extended interval aminoglycoside dosing is widely used in paediatric and neonatal practice for the treatment of serious gram
negative infections, the treatment of newborn infants wi...
The commentary by Lenney correctly points out that clinicians are
often slow to apply good research evidence to clinical practice.[1] However, the choice of once-daily intravenous gentamicin to illustrate this point is unfortunate. Extended interval aminoglycoside dosing is widely used in paediatric and neonatal practice for the treatment of serious gram
negative infections, the treatment of newborn infants with sepsis and the treatment of chronic Pseudomonas aeruginosa infection in patients with cystic fibrosis. However, the implementation of extended interval dosing has not been based on the results of appropriately designed trials in
children and neonates.
The largest meta-analysis of single vs multiple daily dosing of aminoglycosides for the treatment of gram negative sepsis included only 2 paediatric studies.[2] The use of once-daily aminoglycosides
in children and the newborn is still currently unlicensed. Finally a recent systematic review of once-daily versus multiple-daily dosing of aminoglycosides in CF concluded that there was insufficient evidence to recommend a change in practice.[3] This was because most clinical trials
were of insufficient quality or were performed in adults and so the
results should not be extrapolated to children.
There is a danger that expert commentaries may be read by some
readers of ADC with the same unquestioning belief of second century
Greeks. We would argue that the presence of evidence from “a number of
studies from numerous countries” should not be the basis on which
implementations in practice should be founded. Instead quality of evidence
should be of paramount importance, even if there is little of it.
Dr Kelvin Tan
Clinical Research Fellow Paediatrics
Academic Division of Child Health
University of Nottingham
Nottingham, UK
Dr Alan Smyth
Consultant Paediatrian Respiratory Medicine
Nottingham City Hospital NHS Trust
Nottingham, UK
References
(1) Lenney W. Successful implementation of spacer treatment guidelines for acute asthma [Commentary]. Arch Dis Child 2001;84:145-6.
(2) Barza M, Ioannidis JPA, Cappelleri JC, Lau J. Single or multiple daily doses of aminoglycosides: a meta-analysis. BMJ 1996;312:338-45.
(3) Tan K, Bunn H. Once daily versus multiple daily dosing with intravenous aminoglycosides for cystic fibrosis (Cochrane Review). Cochrane Database Syst Rev 000;4:CD002009 2000;CD0020099.
Dr Mackin’s article encompasses most of the issues relating to the
causes of violence against paediatricians and has even suggested a
specific action plan to tackle incidents in the future. He mentions that
the child’s condition can cause the parents to display uncharacteristic or
highly stressed behaviour. But he has not touched upon issues about
whether the doctors themselves have aggravated the situation...
Dr Mackin’s article encompasses most of the issues relating to the
causes of violence against paediatricians and has even suggested a
specific action plan to tackle incidents in the future. He mentions that
the child’s condition can cause the parents to display uncharacteristic or
highly stressed behaviour. But he has not touched upon issues about
whether the doctors themselves have aggravated the situation.
A similar study in a paediatric intensive care unit (PICU) in Mumbai,
India looked at incidents of violence over a period of six months. During
this period there were 671 admissions. The doctors working in the unit
recorded incidents of violence, with details of the precipitating factors.
More than half of the 28 incidents recorded were verbal threats. Actual
physical assaults constituted just 7% of the total incidents. Deaths in
the unit were associated with 68% of the violent episodes. But the other
32% were sparked off due to inebriated relatives, decisions to wean
patients off the ventilator and transferring the patient to the general
ward. Language and communication problems were considered to contribute to
71% of the incidents. Of the 6 doctors working in PICU, 4 were from
Southern States of India and could not speak the local language well. This
was compared with a 12-month period in the PICU, Belfast (359 admissions)
and there were no incidents of violence. No parent of a child admitted to
the Belfast PICU required an interpreter.
We agree with Dr Mackin that a good training programme covering all
practical issues needs to be implemented, but also wish to highlight that
the inability to communicate with the relatives in a language they
understood was a major factor contributing to a culmination in violence.
Doctors from Southern States of India are unable to speak the local
language in Mumbai and hence prone to create confusion regarding queries
from the relatives, unlike in the United Kingdom where a single language
is spoken all over the country. Inaptitude to answer queries with
expertise added to the problems. All this reasserts the need for a master
plan to tackle violence with region specific modifications. We believe
that courses in language and communication skills should form part of the
core curriculum to enable doctors to deal rationally with aggressive
situations.
Dr SV Kamath
Departments of Child Health & Clinical Biochemistry, The Queen's University of Belfast
Dr MD Shields
Department of Child Health, The Queen's University of Belfast
Consultant Paediatrician, Royal Belfast Hospital for Sick Children
Mrs M Chapman
Royal Belfast Hospital for Sick Children
If my reading of this colic study is correct it appears that both
groups received standand counciling and recommendations for the care of a
colicky child. My question to the author(s) is, if standard
recommendations are effective in the reduction of colic, does this not
raise the possibility that any treatment effect in the CMT group could
have been diluted by the introduction of a second active treatment...
If my reading of this colic study is correct it appears that both
groups received standand counciling and recommendations for the care of a
colicky child. My question to the author(s) is, if standard
recommendations are effective in the reduction of colic, does this not
raise the possibility that any treatment effect in the CMT group could
have been diluted by the introduction of a second active treatment
(standard recomendations) in the control group? Put another way, was the
placebo intervention an inert intervention or was it a second active
intervention?
The article by van Karnebeek et al[1] presented the natural
history of cardiovascular manifestations in children with Marfan syndrome,
and showed the importance of aortic involvement in deciding the prognosis
and outcome. I would like to highlight the role of beta-adrenergic blocker
therapy in retarding the progress of the aortic dilatation.
The effectiveness of negative inotropic agents in the tre...
The article by van Karnebeek et al[1] presented the natural
history of cardiovascular manifestations in children with Marfan syndrome,
and showed the importance of aortic involvement in deciding the prognosis
and outcome. I would like to highlight the role of beta-adrenergic blocker
therapy in retarding the progress of the aortic dilatation.
The effectiveness of negative inotropic agents in the treatment of
dissection of the aorta has been documented as early as 1965.[2] Since
then reports from large centres[3][4] have indicated a beneficial impact of
therapy with beta-adrenergic blockers on the rate of aortic dilatation in
patients with Marfan syndrome and some of these studies had included
children also.[4-6] A recent study of 53 children and adolescents with
Marfan syndrome[7] has served to reaffirm the effectiveness of beta-blocker therapy in slowing aortic growth rate in children and adolescents.
Untoward effects were minimum and furthermore those who were intolerant to
beta-blockers could be managed successfully with calcium channel blockers.
The benefit of beta-blockers derives from their negative inotropic
and chronotropic effects.[2] Aortic stiffness and mean blood pressure are
both reduced in patients receiving treatment.[8] Acute administration of
beta-blockers may reduce excessively the arterial compliance in some
children, however such patients may benefit from use of calcium channel
blockers.
P Venugopalan, FRCPCH
Consultant Paediatric Cardiologist
Sultan Qaboos University Hospital
Muscat, Sultanate of Oman
References
(1) van Karnebeek CDM, Naeff MSJ, Mulder BJM, Hennekam RCM, Offringa
M. Natural history of cardiovascular manifestations in Marfan syndrome.
Arch Dis Child 2001;84:129-37.
(2) Wheat MW, Palmer RF, Bartley TD, Seelan RC. Treatment of
dissecting aneurysm of the aorta without surgery. J Thorac Cardiovasc Surg
1965;50:364-73.
(3) Shores J, Berger KR, Murphy EA, Pyeritz RE. Progression of aortic
dilatation and the benefit of long-term beta-adrenergic blockade in
Marfan's syndrome. N Engl J Med 1994;330:1335-41.
(4) Salim MA, Alpert BS, Ward JC, Pyeritz RE. Effect of beta-adrenergic blockade on aortic root rate of dilatation in the Marfan
syndrome. Am J Cardiol 1994;74:629-33.
(5) Tahernia AC. Cardiovascular anomalies in Marfan's syndrome: the
role of echocardiography and beta-blockers. South Med J 1993;86:305-10.
(6) Ose L, McKusick VA. Prophylactic use of propranolol in the Marfan
syndrome to prevent aortic dissection. Birth Defects Orig Artic Ser
1977;13:163-9.
(7) Rossi-Foulkes R, Roman MJ, Rosen SE, Kramer-Fox R, Ehlers KH,
O'Loughlin JE, Davis JG, Devereux RB. Phenotypic features and impact of
beta blocker or calcium antagonist therapy on aortic lumen size in the
Marfan syndrome. Am J Cardiol 1999;83:1364-8.
(8) Groenink M, de Roos A, Mulder BJ, Spaan JA, van der Wall EE.
Changes in aortic distensibility and pulse wave velocity assessed with
magnetic resonance imaging following beta-blocker therapy in the Marfan
syndrome. Am J Cardiol 1998;82:203-8.
In a reaction to our article,[1] in which the natural
history of cardiovascular manifestations in 52 children and
adolescents with Marfan syndrome is described, Dr
Venugopalan highlights the role of beta-adrenergic blocker
therapy in retarding the progress of aortic dilatation.[2]
As stated on page 135 of the Discussion in our article, the
use and effectiveness of this prophylactic pharmacotherapy
was well-kno...
In a reaction to our article,[1] in which the natural
history of cardiovascular manifestations in 52 children and
adolescents with Marfan syndrome is described, Dr
Venugopalan highlights the role of beta-adrenergic blocker
therapy in retarding the progress of aortic dilatation.[2]
As stated on page 135 of the Discussion in our article, the
use and effectiveness of this prophylactic pharmacotherapy
was well-known to us.[3] However, as no valid studies
proving the effectiveness of this medication in children
were available during our study period (1981-1997) and as
there were worries regarding possible adverse side-effects,
very few children or adolescents managed by the Marfan
Clinics of our hospital were prescribed beta-blockers.
The
study of Rossi-Foulkes et al,[4] reporting positive effects
of beta-blockade in a cohort of children and adolescents
with Marfan syndrome was published only after submission of
our paper. Along with the good results of similar treatment
strategies in adult Marfan patients in our hospital, this
lead us to prescribe beta-blocker therapy also in paediatric
and adolescent patients.
As most Marfan clinics will probably have adjusted their
treatment protocols in children in a similar manner, future
gathering of information on the natural history of
cardiovascular manifestations in children will hardly (if at
all) be possible. Therefore, our study offers a tool
allowing future comparison of aortic growth and
complications in untreated children with Marfan syndrome
('natural history') to those who were treated with
beta-blockers.
References
(1) van Karnebeek CDM, Naeff MSJ, Mulder BJM, Hennekam RCM,
Offringa M. Natural history of cardiovascular manifestations
in Marfan syndrome. Arch Dis Child 2001;84:129-37.
(2) Venugopalan P. Role of beta-adrenergic blockade therapy in children with Marfan syndrome and aortic root dilatation [eLetter]. Arch Dis Child 23 February 2001. http://adc.bmjjournals.com/cgi/eletters/archdischild;84/2/129#EL2
(3) Shores J, Berger KR, Murphy EA, Pyeritz RE. Progression
of aortic dilatation and the benefit of long-term
beta-adrenergic blockade in Marfan's syndrome. N Engl J Med
1994;330:1335-41.
(4) Rossi-Foulkes R, Roman MJ, Rosen SE, Kramer-Fox R,
Ehlers KH, O'Loughlin JE, Davis JG, Devereux RB. Phenotypic
features and impact of beta blocker or calcium antagonist
therapy on aortic lumen size in the Marfan syndrome. Am J
Cardiol 1999;83:1364-8.
CDM van Karnebeek, MD
MSJ Naeff, MD BJM Mulder, MD PhD
RCM Hennekam,MD PhD
M Offringa, MD PhD
Department of Paediatrics (Emma Children's Hospital) and
Cardiology
Academic Medical Centre, Amsterdam The Netherlands
This paper demonstrates deep understanding of economics but little feeling for the reality of early infancy.[1] Any paediatrician will know this is the most vulnerable time of life. Any parent will tell you how hard it can be looking after an infant in the first three months. The assumption that health visitors home visits and mothers visits to the GP “that the entire contact would be devoted to infant crying...
In our study[1] we considered only consultations with the health visitor and GP where infant crying and sleeping problems were discussed. This does not mean that ALL consultations with the health visitor or GP for infants at this age were devoted to infant crying and sleeping problems. There may have been additional consultations where other important issues were discussed, but they were not included here...
I have a policy, although as yet I do not have enough experience of using it to know whether it is effective. Trainee pediatricians or nurses may well tell me that family members of an in-patient have been verbally abusive to them. I then ask to see the family members and tell them that I may/will lodge a complaint against them with the Trust management. Basically, I simply try to use the same complaints...
We congratulate Olafsdottir et al on their article “Randomized controlled trial of infantile colic treated with chiropractic spinal manipulation” (Arch Dis Child 2001;84:138-41). The sum of the evidence on spinal manipulative therapy (SMT) in the treatment of infantile colic now is, that there are 3 RCTs on the subject.
Two RCTs demonstrated a significant positive effect of SMT,[1][2] and 1 RCT was unabl...
We were interested to read Dr Robson’s leading article regarding alcohol misuse and the reference to acute alcohol admissions to Alder Hey in Liverpool, UK.[1][2] We too are concerned by the increasing number of these problems that we see in hospital paediatric practice.
We carried out a retrospective case note review of all the children seen in the Paediatric Emergency department in Sunderland b...
The commentary by Lenney correctly points out that clinicians are often slow to apply good research evidence to clinical practice.[1] However, the choice of once-daily intravenous gentamicin to illustrate this point is unfortunate. Extended interval aminoglycoside dosing is widely used in paediatric and neonatal practice for the treatment of serious gram negative infections, the treatment of newborn infants wi...
Dr Mackin’s article encompasses most of the issues relating to the causes of violence against paediatricians and has even suggested a specific action plan to tackle incidents in the future. He mentions that the child’s condition can cause the parents to display uncharacteristic or highly stressed behaviour. But he has not touched upon issues about whether the doctors themselves have aggravated the situation...
If my reading of this colic study is correct it appears that both groups received standand counciling and recommendations for the care of a colicky child. My question to the author(s) is, if standard recommendations are effective in the reduction of colic, does this not raise the possibility that any treatment effect in the CMT group could have been diluted by the introduction of a second active treatment...
The article by van Karnebeek et al[1] presented the natural history of cardiovascular manifestations in children with Marfan syndrome, and showed the importance of aortic involvement in deciding the prognosis and outcome. I would like to highlight the role of beta-adrenergic blocker therapy in retarding the progress of the aortic dilatation.
The effectiveness of negative inotropic agents in the tre...
In a reaction to our article,[1] in which the natural history of cardiovascular manifestations in 52 children and adolescents with Marfan syndrome is described, Dr Venugopalan highlights the role of beta-adrenergic blocker therapy in retarding the progress of aortic dilatation.[2] As stated on page 135 of the Discussion in our article, the use and effectiveness of this prophylactic pharmacotherapy was well-kno...
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