The view from here…

On the edge of Islamabad, close to the start of the Karakoram highway and the Punjab- Khyber-Pakhtunkhwa border lies a semicircular range of mountains, the Margalla Hills. Densely forested and often engulfed in low cloud, which add to their mystique, they lend a sense of calm to the city. The climb is something of a vertiginous scramble, but the reward for reaching the summit far outweighs the sweat generated during the ascent. On a good day, one can see for what feels like forever – Peshawar and the Afghan border to the West, India to the East…

We all have complicated clinical lives: and owe ourselves moments to stand back, step out, look at the whole picture… and to reset.

RCPCH stroke guidance

It’s now almost 5 years since the RCPCH published guidance for stroke in children. Only a minority require thrombolysis but these are arguably both the most vulnerable and treatable. Reaction times have unequivocally improved but, there are still steps in the pathway where hold ups (and remember, there is only a narrow window before ischaemia becomes irreversible) are common: recognition; radiology (some form of angiography a prerequisite) and discussion with the relevant thrombolysis centre. Susan Byrne and Dipak Ram provide an ‘end of term’ report – currently in the ‘could do better’ zone. Difficult, of course, with such a rare entity, but if it were to feature more consciously in the subconscious ‘must-be-excluded- roll-call’ then I’m convinced, time to imaging would be even better. It barely registers a ripple in the current APLS guidance: wouldn’t this be a reasonable place to start I ask, rhetorically of course. See page 635

Paediatric emergency medicine: extra-axial haemorrhages: abuse or accident

Some old chestnuts earn their status for being close to unanswerable in terms of diagnostic uncertainty and bias. Non-accidental injury is, arguably, the prime example. Through the work undertaken by Alison Kemp and the Cardiff group, the science of prediction immeasurably forward since the era of textbook black and white photos of frozen watchfulness, an awareness of but lack of interaction with the surroundings… but, I digress. Adding to the Bayesian evidence on the subject, Jordan Wallace (Seattle) and James Metz (Vermont) assess a large series of children with skull fractures judged to have had either abusive injuries or witnessed accidental trauma by extra-axial haemorrhage (EAH) phenotype. Radiological assessments of CTs were blinded to group of suspected causality. In short, 37.9% had EAHs, but these were far more common in the abused group than in those injured accidentally: around 76% vs 35% respectively. The incidence of subdural haemorrhage was markedly different in the abusive vs accidental group: 76% vs 26%. In NAI, the children were much more likely to have had multiple haemorrhages and bleeding not immediately related to the skull fracture. In an area in which uncertainty is common, this is a rich seam of data. See page 436

Global child health: implementation science

Two mutually-enhancing papers from Trevor Duke (Melbourne and the WHO STAGE advisory group) and Magdalena Engl (London) and respective colleagues show why inter-disciplinary/group collaboration are prerequisites for child and adolescent health and nutrition in disability respectively. The former examines knowledge translation and implementation in the context of the WHO mandate of supporting health services and strategies needed to take steps towards targets defined in the Sustainable Development Goals. In the latter, a scoping review on detail with regards to the interplay between malnutrition and disability in 63 national guidelines found a disarming dearth of recommendation either in identification and management of these complex and commonly linked outcomes. See pages 637 and 644

Symptoms beyond COVID-19

The concept of long COVID-19 as an entity is now well established: but the problem, until now has been the lack of a universal definition comparable to the equivalent adult WHO criteria. This, of course, restricts inter-study comparisons and, in the event of future trials will have implications for inclusion criteria. As part of the CLoCk study, Terence Stephenson and colleagues with (crucially) input from a group of adolescents derive a novel concensus diagnostic phenotype. See page 674

Drugs and therapeutics: self reporting side effects

Inherent to any drug vigilance programme is the full reporting of adverse reactions (ADRs). Awareness of ADRs is a prerequisite for recognition and, therefore, reporting by children themselves until likely to be underestimated the real incidence, especially as they are often unlike those experienced by adults. Dan Hawcutt and colleagues in Liverpool describe a quality improvement programme, designed with adolescents, to enhance awareness and encourage reporting on a variant of the MRHA yellow card scheme. The five times increase in the proportion feeling comfortable reporting an ADR sums up the impact this scheme could have. See page 681

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The descent from the summit, especially after rain, is hard on both ankles and knees, the wet shale unsympathetic to concentration lapses, but, paradoxically, the energy generated by the experience outweighs all the resulting lactic acid build up …