eLetters

25 e-Letters

published between 2015 and 2018

  • Different guidance for a different time?

    Thanks Dr. Roussis, if I have read your comment correctly you express worry that guidelines, systems and protocols of the present were built on the combined wisdom of the past. That a new generation of doctors will use guidance as their clinical 'crux' and gestalt will become an increasingly less used (and perhaps required) commodity. This risks the loss of future knowledge that is encapsulated in the neuronal synapses of the experienced clinicians and can't be found within the electronic pages of a NICE pathway for example.

    If I am correct in your interpretation I agree this is a challenge. I would argue it is a challenge born of necessity in some respects though - the volume of information is much larger, the density of disease far different (a pre-test probability of meningococcal meningitis was much easier to calculate prior to the vaccine era ) and societal expectation more informed. This does not mean we should continue blindly forward. The application of combined wisdom has always been necessary (as you say perhaps "ubi pus, ibi evacua" was the first guideline) but I think we have lost our need to teach how to interpret this information taking into account the individual patient in front of us.

    Thank you for comments - debate in this area is certainly necessary and as stated in the article I personally believe social media has had a role, and will continue to do so, in driving this forward.

  • Can we reproduce clinical wisdom fast track

    Medicine has been practiced for thousands of years. Physicians (and surgeons perhaps) were armed with plenty of gut feeling and gestalt in order to practice effectively within their contemporary technical boundaries that should not be underestimated. The Latin aphorism "ubi pus, ibi evacua" is as valid today as always. As a mini flowchart it proved its value and effectiveness over time: incision and drainage of an abscess. However things were not always as simple. There have been a lot of arbitrary diagnostic and treatment modalities until not too long ago. Modern medicine with a trend towards evidence-based practice is a product of the second half of the 20th Century. Technology allowed the development of (patho) physiology and established knowledge of standard parameters of human body functions. This was a fairly straightforward process in the stability of the developed adult human body. It is however a significantly less solid process with the developing body of a child. The development and application of flowcharts cannot be as definitive as in adults even in a modern paediatric environment. Therefore it is true that one must rely on a larger average of developed clinical wisdom and sixth sense when making clinical decisions on sick children. It is also very true that clinical wisdom relates directly with one’s ability to reflect upon and learn from mistakes.
    The generation of doctors that will be retiring within the next ten years paved the way for a s...

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  • Response to letter re: ‘A source of tension’

    I would like to thank the authors for making this important point and highlighting the error in Illuminations (ADC E&P, 102(5), pp. 265-266.); ‘A source of tension’. A check for appropriate placement of support lines and tubes is just as important as identifying pathology when reviewing imaging. In small infants variations in head position may significantly alter the endotracheal tube (ETT) tip position and the difference between one vertebral body level and the next may be as little as 5-10mm.  Therefore careful examination of the chest radiograph followed by any necessary alteration of the ETT will reduce the likelihood of complications secondary to misplacement. 

    It is also important to carefully check your manuscript when submitting material for publication. My intention was to point out the suboptimal positions of both the ETT and nasogastric (NG) tubes, in addition to the large tension pneumothorax.  The ETT tip is too low in the distal trachea, and the NG tube tip is in the lower oesophagus and should be advanced into the stomach. Unfortunately, somewhere in the process of author checking and internal review this was omitted in error. Thanks once again for pointing this out.

  • Response to letter re: ‘A source of tension’

    I would like to thank the authors for making this important point and highlighting the error in Illuminations (ADC E&P, 102(5), pp. 265-266.); ‘A source of tension’. A check for appropriate placement of support lines and tubes is just as important as identifying pathology when reviewing imaging. In small infants variations in head position may significantly alter the endotracheal tube (ETT) tip position and the difference between one vertebral body level and the next may be as little as 5-10mm.  Therefore careful examination of the chest radiograph followed by any necessary alteration of the ETT will reduce the likelihood of complications secondary to misplacement. 

    It is also important to carefully check your manuscript when submitting material for publication. My intention was to point out the suboptimal positions of both the ETT and nasogastric (NG) tubes, in addition to the large tension pneumothorax.  The ETT tip is too low in the distal trachea, and the NG tube tip is in the lower oesophagus and should be advanced into the stomach. Unfortunately, somewhere in the process of author checking and internal review this was omitted in error. Thanks once again for pointing this out.

  • Lower risk group of brief resolved unexplained events is minority of infants with apparent life-threatening events

    We read with interest the clinical practice guideline by Tieder, et al. (1), proposing the new concept of Brief Resolved Unexplained Events (BRUE) replacing the old concept of apparent life-threatening events (ALTE) and the comments by Tate, et al (2). We agree that the majority of the causes of ALTE are proven not really life-threatening after the evaluation. However, we think that application of the concept of lower risk infants of BRUE and its practical recommendation might be cautious.
    We have reported the analysis of 112 cases of ALTE at our institution and eighteen of them had recurrent episodes (3). We also analyzed these 112 cases of ALTE how many of them belong to the lower risk infant group of BRUE. We identified eighteen cases to belong to the lower risk group (unpublished data). Among this group, four of them had ALTE recurrence.
    The BRUE guideline recommends that no necessary laboratory work to be avoided in the lower risk infants and it also recommends not to admit these infants to hospital for observation purpose. However, based on our experience, the majority of ALTE infants belong to the higher risk group and 22% (4/18) of lower risk infants presented the recurrent episodes after the first ALTE episode. Therefore, we suggest that the guideline should be examined who are really the lower risk infants and how to manage these lower risk infants, in prospective studies.

    Satoshi Nakagawa, Riyo Ueda, and Osamu Nomura

    1. Tieder JS,...

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  • Use of 0.9% saline as maintence fluid is bad medicine

    I read with interest the review by Green and Lillie[1] of the NICE guideline (N29) on intravenous fluid therapy in children[2]. The new guideline correctly questions the routine use of the Holliday-Segar formula for calculation of maintenance fluids[3], but the recommendation of 0.9% saline as the maintenance fluid must still be questioned.

    The review opens with two contradictory statements in the first two paragraphs:

    “The prescription of intravenous fluids requires an understanding of fluid homeostasis and should be tailored to the individual, the disease and the intended therapeutic goal.”

    and, in reference to the NICE guideline:

    “…its aim was to offer a ‘standardised approach to assessing patient’s fluid and electrolyte status and prescribing IV fluid therapy in term neonates, children and young people’.”

    I agree wholeheartedly with the first statement but it does not fit with the second proposal of a “standardised” approach. The problem hinges around the idea of “replacement” and “maintenance” fluids and this was reviewed in an excellent paper by Malcolm Coulthard in 2007 when he questioned the switch from 0.18% saline to 0.45% saline as the recommended maintenance fluid[4]. The arguments he used are now doubly relevant when you move to 0.9% saline.

    Patients who need fluid “replacement” need an iv fluid matching extracellular fluid composition and 0.9% saline fits the bill. Patients who need iv “maintenance” fluid need some...

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  • CONGENITAL DISORDERS OF GLYCOSILATION IN THE DIFFERENTIAL DIAGNOSIS OF DISORDERS OF COPPER METABOLISM

    We read with interest the article by Jane Armer and Christian De Goede appearing in a recent issue of the Journal (1). We congratulate the Authors for their superb job in summarizing such a difficult field represented by the differential diagnosis of disorders of copper metabolism. However, we noticed that in their accurate recognition of the causes of reduced serum values of ceruloplasmin, the Authors missed to mention the Congenital Disorders of Glycosylation (CDGs), which are rare as single disorders but not as a group. CDGs in fact represent nowadays more than 100 distinct genetic multisystem disorders characterized by defective glycosylation of glycoconjugates.(2) We previously signaled that patients with some types of CDGs may have low ceruloplasmin values and abnormal copper metabolism. (3, 4) Presently we know that in at least 3 types of CDGs with prevalent hepatic presentation ± CNS minor signs (TMEM199-CDG, CCDC115-CDG; ATP6AP1-CDG) and 2 with prevalent neurological presentation ± minor signs of hepatic involvement (PMM2-CDG, COG2-CDG) there is a documented disturbance of copper metabolism (Table 1). The mechanisms underlying these abnormalities are unclear, and may probably depend on the biochemical nature of ceruloplasmin itself (a glycoprotein with 6 N-linked glycans) and/or involve at least partial loss of copper transporting proteins. (5) In conclusion, in addition to the group of rare conditions signaled by the Authors, we suggest that the diagnostic algor...

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  • Reply to: Psychological Interventions have a place in Management of Paediatric Headache

    Reply to: Psychological Interventions have a place in Management of Paediatric Headache
    Michael J Morton, Honorary Clinical Senior Lecturer in Child & Adolescent Psychiatry, University of Glasgow

    We are very grateful to Dr Morton for highlighting the importance of CBT and other psychological / talking therapies for children and young people with headaches, and for drawing our attention to the recent systematic review by Ng et al. Where resources exist and permit referral, this can be offered as an adjunct to acute / rescue treatment advice and as an alternative or adjunct to preventative drug therapies and acupuncture for migraine, and may be transformative for worrying tension-type headaches. Even for the trigeminal autonomic cephalalgias (including paroxysmal hemicranias) and idiopathic stabbing headache, CBT and psychological support for the child and young person and their family and carers can be really helpful. Where access to psychological interventions is difficult or inadequate, we should still request it and support the development of these crucial services. Thank you for this important contribution.

    William Whitehouse and Shakti Agrawal

  • Patient reported outcome measures as important tool for the non pharmacological management of preschool children with recurrent wheeze

    Preschool recurrent wheeze affects many children in the UK and causes great strain in their families (1). The pharmacological management during the acute episodes of wheeze offers significant relief. However, the evidence around the maintenance therapy is not conclusive.
    The majority of these children grow out of the condition. The current pharmacological treatment though has not been shown to change the natural course of the disease (2, 3). Therefore, it could be argued that addressing the actual concerns of their parents/carers should be the focus that makes a significant difference to their everyday lives.
    Defining personalised outcomes for preschool children with recurrent wheeze requires an understanding of what really matters for these families. A major step towards an efficient treatment would then involve reaching these outcomes and a measurement tool could monitor this.
    Asthma Action Plans for children with a diagnosis of asthma have been shown to reduce the rates of hospital admissions, emergency department visits and school absence rates (4). In Australia, the introduction of a personalised wheeze action plan shows the potential to reduce the treatment with corticosteroids and to improve the education of these families around acute management but this is not clear as to whether this is related to a decrease in emergency department admissions (5).
    Although education and management plans are an important part of the non-pharmacological mana...

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  • A response to Iniobong and Itoro Udo

    We thank Iniobong and Itoro Udo for their interest in our article and their comments. Issues of cost (in the broadest sense, financial, personal, service provision etc.) are of course important when we consider CPD. This is also more challenging in the current financial climate with likely pressure on study leave budgets. Other specific issues and costings they raise, however, concern a separate (although related) issue, the costs of postgraduate training to trainees. We specifically did not consider this group as they are excluded from the definitions of CPD we used. We have underlined the specific phrases from the GMC and the Academy of Medical Royal Colleges respectively;
    “any learning outside of undergraduate education or postgraduate training that helps you maintain and improve your performance. It covers the development of your knowledge, skills, attitudes and behaviours across all areas of your professional practice. It includes both formal and informal learning activities.”[1]
    “A continuing process, outside formal undergraduate and postgraduate training, that enables individual doctors to maintain and improve standards of medical practice through the development of knowledge, skills, attitudes and behaviour. CPD should also support specific changes in practice” [2]
    [1] Guidance on Continuing Professional Development. 2012; Available from: www.gmc-uk.org/education/co...

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