112 e-Letters

  • Psychological Interventions have a place in Management of Paediatric Headache

    The management of headache should be imbued with a psychological understanding that is not sufficiently emphasised in the ADC review by Whitehouse & Agrawal. Like all pain disorders, headache has an important psychological component, which should be acknowledged as part of the assessment in order to open up a conversation that may lead to an effective non-pharmacological intervention. The recent review of treatments for paediatric migraine (Ng et al, 2017) confirms the power of one specific model of intervention in relation to one specific headache diagnosis. A creative use of mental health expertise in the Headache Clinic has the potential to change practice in relation to a range of presentations.

    A Systematic Review and Meta-analysis of the Efficacy of Cognitive Behavioral Therapy for the Management of Pediatric Migraine
    Qin Xiang Ng, MBBS; Nandini Venkatanarayanan, BMedSci, BMBS; Lakshmi Kumar, MBBS
    Headache, 2017;57(3):349-362.

  • What about the Cost of CPD?

    We studied the review by Macdougall et al with interest.1 In our comment, we have chosen to view continuous professional development in the later, “broader” terms described by Macdougall et al, as learning and development always incur costs.1

    In considering the culture of CPD, the influence of costs on professional development has been omitted. This is a rarely researched area but of growing importance in our opinion. A recent joint statement by the Association of Surgeons in Training and British Orthopaedic Trainees Association criticised an increase in training fees, stating that it was “extremely disappointed” at this action, directed solely at trainees.2 This is against the backdrop of evidence showing that cost of junior doctor training is astronomical, averaging £17, 114, most of which are footed privately by junior doctors.3, 4 Dentists have also identified costs as possible impediment to continuing development.5

    The context in the National Health Service is the continuing challenging health economic situation and declining resources in which to provide cover for practitioners’ time to study. The situation described above is more likely to be acute amongst trainees, part-time healthcare staff and doctors in non-substantive positions. This may be the reason why this issue has not gained prominence in the CPD discussions. The high cost of professional development may influence choice of personal development plans and the resulting learning activities un...

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  • Re: 'medically unexplained symptom' means that the doctor has a problem
    David Cottrell

    Dr Kraemer is correct in pointing out that the presence of a child mental health team integrated into the paediatric team in the hospital is, where resources allow, often the best way to manage children and young people with medically unexplained symptoms, and indeed with a range of other physical and psychological presentations. See also Cottrell, 2015, http://adc.bmj.com/content/100/4/308

    Conflict of Interest:...

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  • 'medically unexplained symptom' means that the doctor has a problem

    Professor Cottrell's guidance for paediatricians confronted with patients whose symptoms cannot be explained minimises the real problem that arises when a mental health opinion may be required. He says "the use if words like 'psychological' is unhelpful and is associated with making things up" which is indeed the case. A very useful study by Furness et al (2009) interviewed hospital paediatricians and child health nurses...

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  • Codeine in paediatrics: CYP2D6 maturation matters, also for other drugs.
    Karel Allegaert

    K Allegaert

    Intensive Care and Department of Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands and Department of Development and Regeneration, KU Leuven, Leuven, Belgium Karel.allegaert@uzleuven.be

    We have read with great interest the review article on the pharmacology, prescribing and controversies of codeine in paediatrics and we agree to a very large extent to the position t...

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  • The YOURR Project: Young People's Opinions Underpinning Rheumatology Research.
    Janet E McDonagh

    Dear Editor, we would like to congratulate Dr Bate et al for so eloquently highlighting the importance of public and patient involvement specifically in paediatric research [1]. We would like to further the discussion by highlighting the involvement of adolescents and young adults who by virtue of age may be in either paediatric and/or adult-focussed research. Mattila et al reported that young people in this age group who...

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  • How to interpret malaria tests
    Aubrey J Cunnington

    Dyer et al. wrote an instructive review on how to interpret malaria tests (1). However there are two important caveats in the interpretation of these tests which they did not mention. First, a positive test does not necessarily confirm a diagnosis of malaria. Second, a positive test does not necessarily mean that malaria is the only diagnosis.

    Strictly speaking, the tests described by Dyer et al. are parasite de...

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  • Re:A different view of studies with deferred consent
    Kerry Woolfall

    The author makes an interesting point about the current legislation and automatic inclusion of data in trials where prior informed consent is not possible.

    EU legislation focuses on when research without prior consent (RWPC) can occur and the need to obtain consent for continued participation, but does not cover the options for use of data collected prior to consent. The exception to this is where consent is not pr...

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  • A different view of studies with deferred consent
    Anthony M Kaiser

    Thank you for outlining so clearly the current basis for "deferred consent" studies and suggesting good practice in dealing with the issues it raises. Unfortunately I believe that the current practice is the worst of possible worlds: not only do we submit vulnerable subjects to interventions without the expression of their/their parents' autonomy (ie consent), but also we risk losing any data obtained because we retrospect...

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  • Re: Toe walking in infancy
    Arnab Seal

    We agree that baby walkers and door suspenders can be associated with transient toe walking and delayed walking, which usually would correct spontaneously relatively quickly once the children stop using the device. The use of such devices should be strongly discouraged as part of normal parenting practice. Enquiry regarding inappropriate use of either of these devices in a toddler who has tip toe gait on independent or sup...

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