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Writing these notes for the start of the journal, I usually need to decide how focused—or wide ranging—they are going to be. By this, I mean, am I going to write about just one or two articles, or am I going to try to cover all of the journal? This month I'm particularly interested in a pair of papers about Kawasaki disease.
Kawasaki disease has an illustrious history in Education and Practice, not least because a paper by Ian Maconochie from the very first issue of this journal1 is still one of our most popular downloads online. Of course, things have come a long way since 2004 in our understanding of this disease, and how to treat it, haven't they? Haven't they? If I summarise the treatment alternatives and Ian's conclusions in 2004, he describes (and of course I grossly simplify): Aspirin good, immunoglobulins good, steroids, um, confusing. This has been translated by most of us into use of the first two, and avoidance of the third. Fast forward to 2013, and the two Pickets we're carrying this month on that disease (see pages 76 and 77), both looking at what one of our commentators (Curtis) calls the ‘vexed’ subject of, yes, steroids in Kawasaki disease. Our other commentator (Phillips) uses the striking phrase ‘blemished evidence’.
The paper which Curtis comments on is a randomised open-label trial from Japan, which, as he describes, seems to show that steroids are good if you have Kawasaki which responds poorly to immunogloblin. Of course, the hindrance here is that you need to give the steroids at the same time as the immunoglobulin, and there are no clear indicators of which children are going to respond poorly.
The paper which Bob Philips comments on is one which I initially responded to with relief, in that it gave me an answer. It was a meta-analysis, and therefore, in the pyramid of evidence, it comes higher, is more definitive, is closer to The Truth. My optimism lasted until I spoke with Bob about it. He's not a cardiologist but he is a meta-analysis-ologist, and his real concern is about whether or not the trials being analysed are comparable. As he points out, meta-analysis is a best guess, and is based on some important assumptions. His conclusion is very similar to that of Curtis: ‘Steroids might help some children, but we are painfully ignorant of which children and by how much’. The kicker for me is that I also cannot tell from these papers whether there is a group in which steroids do harm.
So, where are we? Should we just print out a copy of Ian Maconochie's 2004 paper and follow the rules there? Well, it's a good paper, and you could do worse. Of course, the user needs to be wary of following evidence from almost a decade ago—meaning that we need to ensure that there are no important areas which need updating. Certainly I would suspect that if you read all three of these papers together you'd have a reasonable idea of what you might do, and what you might need to worry about.
Speaking of Ian Maconochie, it's not entirely a coincidence that I've written about him here; after eight years of extremely productive service to the journal Ian has now moved on to bigger and better things at the Royal College of Paediatrics and Child Health. I'd like to record my thanks to him for his extremely hard work as a section editor, helping fashion E&P into the journal it is.
Where do we go now then? Looking back at Ian's article, and the piece introducing the edition, I note two things. Firstly, the plans for Best Practice, which I'm temporarily commissioning for, chime well with how I imagine it—as something which tells you what to do, but makes you clear about where the controversies are. A helpful couple of evenings on twitter as @ArchivesEandP gave me some great ideas for commissions, mostly along the lines of areas where we're not entirely sure we're getting it right, or could be doing better.
The second striking item in the introductory section was about continuing professional development, and it is for this that we're turning to you, the readership, for help and advice; please (see page 54) for more details, but in short, we're very interested to have your contributions, to this and to other sections—note that Sam Behjati is teaching you how to write an Interpretations (see page 50) and we've a re-boot of our Guidelines series (see page 73).
As ever we're very interested in hearing from you if you'd like to write for us, or even be involved, for example, in some of our Picket discussions. Please get in touch, but not before you've read the rest of the issue…
Call for Self-assessment Questions: Epilogue
Education and Practice is planning to improve its continuing professional development service to paediatricians. We intend to carry a series of case-based questions in extended matching, multiple-choice or other formats in a new feature called ‘Epilogue’. We invite readers to submit cases accompanied by questions. The text should be no more than 600 words, and might be accompanied by one or two figures, which would include photographs, ECG, lab results, etc. Real-life cases must have parent/patient consent. Answers should be given, with explanations. Submissions will be peer-reviewed and may be altered significantly before publication. Authors will be credited in the journal.
If you want to know more please contact us via firstname.lastname@example.org, or to submit a question to http://mc.manuscriptcentral.com/adc and submit under the ‘Epilogue’ category.
Ian Wacogne, Deputy Editor, E&Pian.email@example.com
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