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When I was a very new paediatric doctor I worked in a unit that routinely used steam to treat children who had croup. It was a fantastic treatment—you could tell that you were doing something seriously efficacious; you would open the cubicle door to review the child and walk into this thick humid atmosphere—you could almost hear the witches chanting ‘Double, double toil and trouble; Fire burn, and caldron bubble’ in the distance. There was just one problem. It was rubbish. This was roundly demonstrated when new smoke detector systems were installed which were triggered by the steam, so we had to stop using it; it made absolutely no difference to the children we were treating. The evidence that steam was a waste of time was well established even by this time—plus the risks of directly or indirectly teaching parents insanities like ‘boil a kettle in the corner of the child's room’ were apparent. But it took a practical issue like fire alarms to make us change our practice.
I recalled this experience when reading the paper from Carroll and Sinivas (see page 113). They describe the very familiar scenario of a 13-month-old child with recurrent wheeze; indeed they comment that they've seen dozens of such patients in the last 12 months. It made me think that if they'd only so few, then no wonder they've the time to write such an excellent review; sometimes it seems that my practice is wall to wall with such patients. We've got used to using our slightly more modern ‘toil and trouble’ treatments—because, boy, nebulisers are jolly efficacious looking treatments, aren't they? Indeed, if you compared a nebuliser with, say, a bone marrow transplant—perhaps the single most anticlimactic looking therapy I've ever observed—then I know which one looks the more efficacious. But in this careful review they note that there really is no evidence that bronchodilators are of any use in the vast majority of patients, and that our—and our families’—perception that they're helpful is just that. This paper is this month's Editor's choice.
So, speaking of perceptions of usefulness, who has bought into the sales pitch for the newer tests for TB—the interferon γ release assays (IGRA) tests? I'll admit that I did, buoyed up by enthusiasm from a number of sources. A shame then that they're a tricky and expensive way of saying pretty much exactly the same as a Mantoux—with roughly the same specificity and sensitivity. Of course, I'm stressing the positive points of a Mantoux over an IGRA here, and Pollock, Roy and Kampmann provide a useful comparison table between the two, in their Interpretations article on IGRA (see page 99).
Elsewhere in the journal we have an Interpretations paper from Jong and colleagues (see page 93) on how to use neonatal TORCH testing—a much misused generalisation used instead of actually doing the right test for the right indication. We also have a great addition to Lio's ever-fascinating Dermatophile collection—I hope you note that I've avoided the more obvious puns about pulling your hair out over this quiz on alopecias (see page 106).
As ever I'd encourage any author of any background who has an interest in contributing to the journal to get in touch. By way of emphasising this, I'd suggest reading Greg Skinner's article on How to write a Problem Solving in Clinical Practice paper (see page 82). Greg does an excellent editing job on these papers, and if you've got an idea for one—even a bizarre idea—he's the person to discuss it with. We look forward to hearing from you.
Ian Wacogne, Deputy Editor, E&P