We thank Dr Cohn and his colleagues for their interest in our article
and agree - as stated within our paper - that there is considerable
variability in the reported fracture yield of skeletal surveys. This
variability is not only dependent on methods of data display (as Dr Cohn
et al illustrate), but also on epidemiological and demographic differences
between reported study populations and on the process by which clinicia...
We thank Dr Cohn and his colleagues for their interest in our article
and agree - as stated within our paper - that there is considerable
variability in the reported fracture yield of skeletal surveys. This
variability is not only dependent on methods of data display (as Dr Cohn
et al illustrate), but also on epidemiological and demographic differences
between reported study populations and on the process by which clinicians
identify and refer children for skeletal survey.
On the latter issue of patient selection, a recent systematic review
showed that there was insufficient evidence to draw any conclusions as to
the benefits or otherwise of screening children for physical abuse where
there is no prior suspicion [1]. Furthermore, although Sittig et al have
developed a checklist for use in the Emergency Department to aid
identification of abused children [2], as far as we are aware, there is as
yet no validated algorithm to determine which children should progress to
skeletal survey and which should not.
Such an algorithm might be expected to improve the fracture yield of
skeletal surveys and the evidence to support its development should come
from a multi-centre (preferably UK) study, which will require both time
and funding. Meanwhile, we conclude as we previously concluded,
"History and examination are key to screening for abuse. A decision
on the precise investigations must be influenced by clinical need and
judgement and by the specific circumstances in each individual case.
In children under the age of 2 years who are seen for suspected physical
abuse, until better evidence is available, RCR/RCPCH guidelines should be
adhered to and initial and full skeletal surveys performed."
References:
1. Hoytema van Konijnenburg EMM et al Insufficient evidence for the
use of physical examination to detect maltreatment in children without
prior suspicion: A systematic review
http://www.systematicreviewsjournal.com/content/2/1/109
2. Sittig JS et al Child Abuse Inventory at Emergency Rooms: Chain-ER
Rationale and Design
http://www.biomedcentral.com/1471-2431/11/91
The highly commendable and detailed characterisation of non-anaemic
iron deficiency(1) is timely and, perhaps, even overdue, given the fact
that animal studies show that, even in the absence of anaemia, iron
deficiency can ,in its own right, adversely affect both cerebral
function(2), and thyroid function(3). In the animal model of non-anaemic
iron deficiency it has been shown that iron uptake by a divalent metal ion
tr...
The highly commendable and detailed characterisation of non-anaemic
iron deficiency(1) is timely and, perhaps, even overdue, given the fact
that animal studies show that, even in the absence of anaemia, iron
deficiency can ,in its own right, adversely affect both cerebral
function(2), and thyroid function(3). In the animal model of non-anaemic
iron deficiency it has been shown that iron uptake by a divalent metal ion
transporter(DMT-1) is essential for normal hippocampal neuronal
development and normal spatial memory behaviour(2). Furthermore, in
developing rats, there is a heterogenous loss of iron from the brain
following dietary iron deficiency, and a heterogenous restoration of iron
with iron therapy. What is more, early iron deficiency(and its correction
by iron replacement) "altered brain iron...in many regions different from
those observed in a later period"(4). Although there are no comparable
human data, the corollary to the animal study(4)is that "there might be
critical periods of infant development that absolutely require adequate
iron nutriture for normal development"(5). It has also to be recognised
that, in the human context, a causal relationship has not yet been clearly
established between iron deficiency during development and deficits in
cognitive and behavioural function(6).
The relationship between iron deficiency and cognitive function is
mirrored, to some extent, by the relationship between iron deficiency and
thyroid function where, again, the most convincing data come from animal
studies(3)(7). In the animal studies context, it has been shown that iron
deficiency significantly(P < 0.05) reduces thyroid peroxidase activity,
with the consequence that iron deficiency anaemia emerges as a significant
and independent predictor of both reduced serum triiodothyronine(T3)(p<
0.001), and reduced serum thyroxine(T4)(p < 0.0005)(3). Also in the
animal model, perinatal iron deficiency reduces serum total T3 by 43%, and
serum total T4 by 67%, and whole brain T3 by 25%(7).
The coexistence of iron deficiency and subclinical hypothyroidism mirrors
the relationship between iron deficiency and thyroid function(8). When the
two disorders coexist, patients randomised to combined iron and thyroid
replacement therapy experience significantly(p < 0.0001) greater
increase in blood haemoglobin and serum iron levels than patients
randomised to the sole use of iron replacement therapy(8). The other side
of the coin is that the use if iron replacement therapy in goitrous
children(mean age 8.5 in one study; mean age 10 in another) with iron
deficiency significantly)P < 0.001)improves the efficacy of iodised
salt in reducing thyroid size(9)(10). A study which has relevance to much
younger children is the one which showed that maternal iron deficiency
predicted both higher thyroid stimulating hormone and lower total T4
concentrations during pregnancy in Switzerland, the latter an area of
borderline iodine deficiency(11). Maternal hypothyroidism is, in turn, a
recognised predictor of significantly(p=0.005) poorer suboptimal
intellectual performance in their offspring(12).
Comment
In order to put non-anaemic iron deficiency in its proper context in
relation to iron deficiency anaemia we have to consider the study which
enrolled a sample of 504 consecutive children aged 1-3 in New York. Thirty
five percent of those children had evidence of iron insufficiency; 7% with
non-anaemic iron deficiency, and 10% with iron deficiency anaemia(13).
Given the potential neurodevelopmental impact of non-anaemic iron
deficiency(including its interaction with thyroid function), non-anaemic
iron deficiency is an entity which deserves to be characterised as fully
as possible so as to facilitate its identification and diagnosis.
Accordingly, for the sake of completeness, I would suggest that the most
decisive way to validate its diagnosis is to demonstrate a reduction in
the magnitude of red cell distribution width, and also a reduction in the
severity of hypochromia and/or microcytosis following iron replacement
therapy. Furthermore, in patients with non-toxic goitre, the diagnostic
trial of iron replacement therapy could be usefully accompanied by
monitoring of thyroid size during co-administration of iodised salt.
References
(1) Hinchliffe RF., Bellamy GJ., Finn A et al
Utility of red cell distribution width in screening for iron deficiency
Arch Dis Child 2013;98:545-547
(2)Carlson ES., Tkac I., Magid R et al
Iron is essential for neuron development and memory function in mouse
hippocampus
The Journal of Nutrition 2009;139:672-679
(3) Hess S., Zimmermann MB., Arnold M., Langhans W., Hurrell RF
Iron deficiency anemia reduces thyroid peroxidase activity in rats
J Nutr 2002;132:1951-1955
(4)Pinero DJ., Li N-Q., Connor JR., Beard JL
Variations in dietary iron alter brain metabolism in developing rts
J Nutr 2000;130:254-263
(5)Beard J
Iron deficiency alters brain development and functioning
J Nutr 2003;133:1468S-1472S
(6) McCann JC., Ames BN
An overview of evidence for a causal relation between iron deficiency
during development and deficits in cognitive or behavioural function
Am J Clin Nutr 2007;85:931-945
(7 Bastian TW., Prohaska JR., Georieff MK., Anderson GW
Perinatal iron and copper deficiencies alter neonatal rat circulating and
brain thyroid hormone concentrations
Endocrinology 2010;151:4055-4065
(8)Cinemre H., Bilir C., Gokosmanoglu F., Bahcebasi T
Hematologic effects of levothyroxine in iron-deficient subclinical
hypothyroid patients: A randomised, double-blind, controlled study
J Clin Endocrinol Metab 2009;94:151-156
(9)Hess SY., Zimmermann MB., Adou P., Torresani T., Hurrell RF
Treatment of iron deficiency in goitrous children improves the efficacy of
iodized salt in Cor d'Iviore
Am J Clin Nutr 2002;75:743-8
(10) Zimmermann MB., Zeder C., Chaouki N.,et al
Addition of microencapsulated iron to iodized salt improves the efficacy
of iodine in goitrous, iron deficicnt children: a randomized double-blind,
controlled trial
European Journal of Clinical Endocrinology 2002;147:747-753
(11)Zimmermann MB., Burgi H., Hurrell RF
Iron deficiency predicts poor maternal thyroid status during pregnancy
J Clin Endocrinol Metab 2007;92:3436-3440
(12)Mitchell ML., Klein RZ
The sequelae of untreated maternal hypothyroidism
European Journal of Endocrinology 2004;151:U45-U48
(13 Eden AN., Mir M
Iron deficiency in 1-3 year old children. A pediatric failure?
Arch Pediatr Adelosc Med 1997;151:986-988
We would like to thank Dr Levene for her letter, and the Editors for
the opportunity to respond. The authors are familiar with the Infant
Sleeplab App; we are both associated with the Durham University Parent-
Infant Sleep Lab (Dr Volpe as an Honorary Fellow, and Professor Ball as
the Founder and Director). The Infant Sleep Info Source Website (ISIS,
www.isisonlineorg.uk) was conceived of in 2010 by Professor Ball and her...
We would like to thank Dr Levene for her letter, and the Editors for
the opportunity to respond. The authors are familiar with the Infant
Sleeplab App; we are both associated with the Durham University Parent-
Infant Sleep Lab (Dr Volpe as an Honorary Fellow, and Professor Ball as
the Founder and Director). The Infant Sleep Info Source Website (ISIS,
www.isisonlineorg.uk) was conceived of in 2010 by Professor Ball and her
colleague Dr Charlotte Russell, developed with ESRC funding, and launched
in March 2012 in collaboration with UNICEF UK Baby Friendly Initiative,
NCT, and La Leche League GB. Following the launch the Breastfeeding
Network, Lactation Consultants GB, and Association of Breastfeeding
Mothers approached us to support and endorse the ISIS website. The aim of
the website is to make research-based evidence on normal infant sleep
available to parents and health professionals, and help bridge the
research-to-practice gap.
Due to the popularity of the website, and data indicating that many
users accessed it via their smartphones, we proposed creating an Infant
Sleep app, based on the website information, in 2013. With support from
the Wolfson Institute for Health & Wellbeing the development of the
app was funded by Durham University who launched the app in 2014 with the
name 'Infant Sleeplab'. It is available for free for both Apple and
Android platforms and can be downloaded from the relevant app stores. We
incorporated a bed-sharing decision tool that we developed and evaluated
in collaboration with NHS Lancashire and Blackpool (Russell et al., 2015),
and of course are pleased to hear Dr Levene found this helpful in making
her own parenting decisions. More information about the app can be found
here: www.isisonline.org.uk/app.
We read with interest the paper by Drs Colvin and colleagues on the
diagnosis and acute management of children with concussion at children?s
hospitals in the United States (1). The authors reported an astonishing
59.9% of children with concussion receiving CT scans of the head (1).
We would like to make two comments with regard to this study:
First, the terminology surrounding trauma to the head remains confus...
We read with interest the paper by Drs Colvin and colleagues on the
diagnosis and acute management of children with concussion at children?s
hospitals in the United States (1). The authors reported an astonishing
59.9% of children with concussion receiving CT scans of the head (1).
We would like to make two comments with regard to this study:
First, the terminology surrounding trauma to the head remains confusing
for patients, doctors and lay people alike (29. As a matter fact, there
are a great number of different definitions of what constitutes
"concussion" in the medical arena (2). Thus, instead of using the term
"concussion" we would suggest using objective measures of cerebral
dysfunction like the Glasgow Coma Scale (GCS) and dividing traumatic brain
injury into three different categories of severity, i.e. mild traumatic
brain injury (GCS: 13-15), moderate traumatic brain injury (GCS: 9-12),
and severe traumatic brain injury (GCS: 3-8).
Second, we were strongly surprised that roughly 60% of children with
concussions were submitted to cerebral CT scans (1). Of note, in this
study only 0.22% of children (ie roughly 1 in 500 children) had a
secondary diagnosis for intracranial injury (1). Moreover; the authors do
not provide any data whether these injuries mandated neurosurgical
interventions or were managed conservatively (1). Although CT scans will
likely differentiate those children who will need in-hospital treatment
from those who will not, the widespread and almost indiscriminate use of
CT scans should strongly be discouraged given the potential long-term
consequences including excessive cancer rates in children (3, 4). This
notion is also corroborated by the fact that an increase of children
sustaining less severe symptoms will present to the emergency department
(1). Instead, we would recommend close in-hospital observation for a
period of 24-48 hours to detect neurological changes and abnormalities
that will guide further diagnostic work-up (5, 6). In doing so, we could
reduce the number of cerebral imaging studies (sonography, CT and MRI) to
5 in 150 children with mild traumatic brain injury (GCS: 13-15), thus
keeping radiation exposure to a minimum (5, 6). Although this will come at
higher costs as demonstrated by Drs Colvin and colleagues (1), the future
health of our children should be worth the effort.
References
1.) Jeffrey D Colvin, Cary Thurm, Brian M Pate, Jason G Newland, Matt
Hall, William P Meehan, III. Diagnosis and acute management of patients
with concussion at children's hospitals. Arch Dis Child published 13 July
2013, 10.1136/archdischild-2012-303588
2.) Anderson T, Heitger M, Macleod AD. Concussion and mild head injury.
Pract Neurol. 2006;6(6):342-357
3.) Osmond MH, Klassen TP, Wells GA, Correll R, Jarvis A, Joubert G,
Bailey B, Chauvin-Kimoff L, Pusic M, McConnell D, Nijssen-Jordan C, Silver
N, Taylor B, Stiell IG; Pediatric Emergency Research Canada (PERC) Head
Injury Study Group. CATCH: a clinical decision rule for the use of
computed tomography in children with minor head injury. CMAJ. 2010 Mar
9;182(4):341-8. doi: 10.1503/cmaj.091421. Epub 2010 Feb 8.
4.) Miglioretti DL, Johnson E, Williams A, Greenlee RT, Weinmann S,
Solberg LI, Feigelson HS, Roblin D, Flynn MJ, Vanneman N, Smith-Bindman R.
The Use of Computed Tomography in Pediatrics and the Associated Radiation
Exposure and Estimated Cancer Risk. JAMA Pediatr. 2013 Jun 10:1-8.
5.) Oster I, Shamdeen GM, Gottschling S, Gortner L, Meyer S.
Electroencephalogram in children with minor traumatic brain injury. J
Paediatr Child Health. 2010 Jul;46(7-8):373-7
6.) Oster I, Shamdeen GM, Ziegler K, Eymann R, Gortner L, Meyer S.
Diagnostic approach to children with minor traumatic brain injury. Wien
Med Wochenschr. 2012 Sep;162(17-18):394-9
We are so sorry not to have included cerebral arterio-venous fistula
in the aetiology of unexplained tachypnoea because it is of course a rare
but classic cause. Typically the symptoms begin almost immediately after
birth if there is a large fistula and the pulmonary artery pressure
remains elevated. The fistula allows a large systemic artery to systemic
venous shunt with right atrial and right vent...
We are so sorry not to have included cerebral arterio-venous fistula
in the aetiology of unexplained tachypnoea because it is of course a rare
but classic cause. Typically the symptoms begin almost immediately after
birth if there is a large fistula and the pulmonary artery pressure
remains elevated. The fistula allows a large systemic artery to systemic
venous shunt with right atrial and right ventricular volume overload and
increased pulmonary blood flow. There is almost always a systolic or
continuous murmur over the occiput or anterior fontanel allowing a
clinical diagnosis to be made in the majority; but absence of any murmur
in the case described by your correspondent is unusual.
Thank you for your interest in our paper(1) and for your concern for
the proper management of children suffering from acute brain injury.
As you know, a concussion is a complex pathophysiologic process
resulting from a rapid rotational acceleration of the brain caused by
trauma.(2-4) It is a form of traumatic brain injury. The Glasgow Coma
Scale, on the other hand, was develo...
Thank you for your interest in our paper(1) and for your concern for
the proper management of children suffering from acute brain injury.
As you know, a concussion is a complex pathophysiologic process
resulting from a rapid rotational acceleration of the brain caused by
trauma.(2-4) It is a form of traumatic brain injury. The Glasgow Coma
Scale, on the other hand, was developed as a means of communicating the
neurological status of patients that have sustained a head injury. Its
value reflects a head-injured patient's vocalization, motor movements, and
eye movements, either spontaneously or in response to various stimuli.(5-
6) It is frequently used in the acute setting to transfer information from
one group of caregivers to another. It is not, however, reflective of a
specific diagnosis. A patient with a Glasgow Coma Scale score of 14, for
example, may be suffering from a concussion, or may have a subdural
hematoma, or an epidural hematoma, or cerebral edema, or a cerebral
contusion, or some combination of these injuries. As our objectives were
to determine the number of hospital admissions due to concussion, and to
determine the imaging and medications used for assessing and managing
concussions, we could not achieve our stated objectives by assessing
patients identified solely by their Glasgow Coma Scale scores.
Furthermore, as the Pediatric Health Information System is an
administrative database, such clinical data was not available to us.
We agree with your recommendation to discourage "the almost
indiscriminate" use of computed tomography of the brain. We believe, as
you suggest and as suggested by the paper by Nigrovic et al that we
referenced, a period of observation in place of computed tomography may be
a safe alternative for some patients. In fact, we suspect that a shorter
time period than the 24-48 hours you recommend may suffice. Our data
suggests that such an observation period would likely decrease the cost of
an emergency department visit when compared to the cost of a visit with
computed tomography.
Once again, we thank you for your interest in our work and for
offering your thoughts in response.
Yours Sincerely,
William P. Meehan III Cary Thurm Brian M. Pate Jason G. Newland Matt
Hall Jeffrey D. Colvin
References 1.)Colvin JD, Thurm C, Pate BM, Newland JG, Hall M, Meehan
WP, 3rd. Diagnosis and acute management of patients with concussion at
children's hospitals. Arch Dis Child published 13 July 2013,
10.1136/archdischild- 2012-303588. 2.)McCrory P, Meeuwisse W, Aubry M, et
al. Consensus statement on concussion in sport--the 4th International
Conference on Concussion in Sport held in Zurich, November 2012. Clin J
Sport Med. Mar 2013;23(2):89- 117. 3.) Meehan WP, 3rd, Bachur RG. Sport-
related concussion. Pediatrics. Jan 2009;123(1):114-123. 4.) Ommaya AK,
Gennarelli TA. Cerebral concussion and traumatic unconsciousness.
Correlation of experimental and clinical observations of blunt head
injuries. Brain. Dec 1974;97(4):633-654. 5.) Teasdale G, Jennett B.
Assessment and prognosis of coma after head injury. Acta Neurochirurgica.
1976;34(1-4):45-55. 6.) Teasdale G, Jennett B. Assessment of coma and
impaired consciousness. A practical scale. Lancet. Jul 13 1974;2(7872):81-
84
Colvin correctly notes that we are interested in solution-focused
research, and expresses some anxiety about our recommendations for
improving child survival. There are two issues to consider in addressing
his concerns: determining causality, and the burden of proof required to
take action.
First, Bradford Hill's criteria for considering causality are helpful
in demonstrating why the association between poverty...
Colvin correctly notes that we are interested in solution-focused
research, and expresses some anxiety about our recommendations for
improving child survival. There are two issues to consider in addressing
his concerns: determining causality, and the burden of proof required to
take action.
First, Bradford Hill's criteria for considering causality are helpful
in demonstrating why the association between poverty and social
inequalities, and many child health outcomes including mortality, is
convincing[3]. The correlation between poverty and mortality is strong and
consistent, and there is a clear gradient; poor children are more likely
to die, and the greater the gap between rich and poor, the greater the
risk[4]. Most of the other criteria are either self-evident (temporality)
or are more relevant and appropriate to simpler questions of causality,
(specificity, experiment). However Colvin also questions the plausibility
and coherence of the associations, focusing on low birth weight, preterm
birth, and teenage pregnancy as intermediary factors. The links between
poverty, social inequalities, and adverse child health outcomes are more
of a causal web than simple chain, so examination from multiple
perspectives is helpful and indeed the associations are plausible,
supported by epidemiological association, and other studies including
intervention [5, 6].
There is specific data for England and Wales, based on individual
parents' social status, demonstrating a clear social gradient in preterm
birth rates of 6.8 per cent for babies with at least one parent in a
managerial or professional occupation, compared with 7.8 per cent of
babies with parents in routine or manual occupations[7]. Socio-economic
adversity during pregnancy is also associated with an increased risk of
having a low birth weight baby [6, 8].
Plausibility is supported by other associations and evidence too. For
example, families from lower socio-economic backgrounds are likely to be
more stressed[9] and acute and chronic antenatal maternal stress and poor
maternal mental health are linked with preterm births and low birth weight
[10, 11] Depression may also lead to negative maternal behaviours, and
poor prenatal care, substance abuse, poor nutrition during pregnancy and
smoking are associated with both socio-economic disadvantage, and with
lower birth weight [12-15]. Young women from social disadvantaged
backgrounds and low educational attainment are more likely to have a
teenage pregnancy; teenage pregnancy rates are higher in more
disadvantaged areas, approximately twice as high for women living in the
most deprived areas compared with least deprived. Teenage pregnancy is
associated with an increased risk of preterm birth compared with women in
their 20 and 30s; in 2013, the overall rate of preterm births was 7.4 per
cent, but among women under 20 years the rate was 8.0 per cent [16-19].
Infant mortality rates among babies born preterm to mothers under 20 years
are higher (22.4 per thousand preterm births among mothers under 20 years)
than among older mothers (15.1 per thousand among mothers aged 35-39)[7,
16-18, 20]. Colvin's suggestion that differences in teenage pregnancy
rates are an alternative explanation ignores the strong association
between teenage pregnancy rates and deprivation on both an individual and
an area level, and the ample evidence that social disadvantage contributes
to poor outcome at birth and in childhood.
The second issue relates to the burden of proof required before
taking action. Epidemiology and health systems research are important
tools in the search for explanations and solutions, and there are
different methods and standards according to the questions asked[21].
Applying an epidemiological standard to a health systems or social policy
question is neither always sufficient nor appropriate.The logical
consequence of Colvin's argument is that a randomised controlled trial
would be necessary before taking action to reduce social inequalities.
There has never, to our knowledge, been any evidence published suggesting
detrimental health effects of reducing poverty, narrowing the gap between
rich and poor, or introducing policies promoting social protection. By
contrast, there is plenty of evidence demonstrating good. It would seem
remiss to wait for a purported but misguided epidemiological standard of
evidence. The burden of proof suggests that our recommendations are likely
to be safe and do more good than harm.
Ingrid Wolfe, Angela Donkin, Michael Marmot, Alison Macfarlane,
Hilary Cass, Russell Viner
1. EURO-PERISTAT Project with SCPE and EUROCAT, European Perinatal
Health Report. The health and
care of pregnant women and babies in Europe in 2010,. 2013.
2. Viner, R., et al., Deaths in young people aged 0-24 years in the
UK compared with the EU15+ countries, 1970-2008: analysis of the WHO
Mortality Database. . Lancet. , 2014 384(9946): p. 880-92.
3. Bradford Hill, A., The environment and disease: association or
causation? Proceedings of the Royal Society of Medicine, 1965. 58(5): p.
295-300.
4. Marmot, M., WHO European review of social determinants of health
and the health divide. . The Lancet. , 2012. 380: p. 1011-1029.
5. Cattaneo, A., et al., Child Health in the European Union
2012, European Commission: Luxembourg.
6. Ohlsson, A. and Shah P, Determinants and prevention of low birth
weight: a synopsis of the evidence. 2008, Institute of Health Economics
Alberta, Canada
7. Office for National Statistics. Gestation-specific infant
mortality in England and Wales, 2013. 2015; Available from:
http://www.ons.gov.uk/ons/publications/re-reference-
tables.html?edition=tcm%3A77-39593
http://www.ons.gov.uk/ons/dcp171778_419800.pdf.
8. Dibben, C., M. Sigala, and A. Macfarlane, Area deprivation,
individual factors and low birth weight in England: is there evidence of
an "area effect"? J Epidemiol Community Health, 2006. 60(12): p. 1053-9.
9. Duncan, G.J., J. Brooks-Gunn, and P.K. Klebanov, Economic
deprivation and early childhood development. Child Dev, 1994. 65(2 Spec
No): p. 296-318.
10. Talge, N.M., et al., Antenatal maternal stress and long-term
effects on child neurodevelopment: how and why? J Child Psychol
Psychiatry, 2007. 48(3-4): p. 245-61.
11. Hoffman, S. and M.C. Hatch, Stress, social support and pregnancy
outcome: a reassessment based on recent research. Paediatr Perinat
Epidemiol, 1996. 10(4): p. 380-405.
12. Bradley, R.H. and R.F. Corwyn, Socioeconomic status and child
development. Annu Rev Psychol, 2002. 53: p. 371-99.
13. Brooks-Gunn, J., et al., Enhancing the cognitive outcomes of low
birth weight, premature infants: for whom is the intervention most
effective? Pediatrics, 1992. 89(6 Pt 2): p. 1209-15.
14. Korenman, S.M., JE. Sjaastas J., Long term poverty and child
development in the United States: results from the NLSY. Institute for
research on Poverty Discussion paper, . 1994, Institute for research on
Poverty.
15. Marmot, M., Marmot M. Fair Society, Healthy Lives: the Marmot
Review. Strategic review of health inequalities in England post 2010.
2010.
16. Office for National Statistics. Teenage pregnancies at lowest
level since records began. 2013 [cited 2015 April]; Available from:
http://www.ons.gov.uk/ons/rel/vsob1/conception-statistics--england-and-
wales/2011/sty-conception-estimates-2011.html.
17. Office for National Statistics. Teenage pregnancies at record
low: how does your local area compare? 2014 [cited 2015 April]; Available
from: http://www.ons.gov.uk/ons/rel/vsob1/conception-statistics--england-
and-wales/2012/sty-conception-rates.html.
18. Office for National Statistics. Conception statistics, England
and Wales, 2013. . 2015; Available from:
http://www.ons.gov.uk/ons/rel/regional-trends/area-based-
analysis/conceptions-deprivation-analysis-toolkit/conceptions-deprivation-
measures--2009-11.html.
19. Right Care, Atlas of Variation: Children. 2012.
20. Office for National Statistics, Teenage conceptions are highest
in the most deprived areas. 2014.
21. Ghaffar, A., et al., Changing mindsets in health policy and
systems research. Lancet, 2013. 381(9865): p. 436-7.
I find the response to Assistant Professor Samlaska to be a bit
limited.
Firstly, in the study by Wenner, they point out at the end of the
paper that unbeknownst to them the clear duct tape they used had a
different glue on it than regular duct tape. In fact, it had an acrylic
based glue. Furthermore, the control group treatment used moleskin - this
also has an acrylic based glue. So, when Wenner et al found no...
I find the response to Assistant Professor Samlaska to be a bit
limited.
Firstly, in the study by Wenner, they point out at the end of the
paper that unbeknownst to them the clear duct tape they used had a
different glue on it than regular duct tape. In fact, it had an acrylic
based glue. Furthermore, the control group treatment used moleskin - this
also has an acrylic based glue. So, when Wenner et al found no difference
between the effectiveness of treatments in the 2 groups, each of which has
used a patch adhered with acrylic-based glue. In other words, both groups
had largely the same treatment. It seems hardly surprising that they found
no difference in efficacy of treatment versus non-treatment groups.
Further I note the meta analyses done by Gibbs et al in 2006 and Kwok
in 2012 also failed to acknowledge this limitation.
Your comment that the families would not know the difference between
acrylic based or rubber based adhesive may be true but that only speaks to
a potential placebo effect, which given the other significant flaw in the
study, seems moot.
I have updated the wikipedia entry on duct tape occlusion therapy.
feel free to contribute to it. I have not referred to your study since it
is not freely available without subscription.
We thank Zylbersztejn, et al for their constructive letter and for
their support for the Countdown initiative. Their data suggests that high
rates of preterm birth and thresholds for reporting preterm birth [1] in
the UK were one of the most likely explanations for the disparities seen
between the UK and European countries such as Sweden, and we agree this is
likely (as outlined in our recent Lancet paper [2]. We agree en...
We thank Zylbersztejn, et al for their constructive letter and for
their support for the Countdown initiative. Their data suggests that high
rates of preterm birth and thresholds for reporting preterm birth [1] in
the UK were one of the most likely explanations for the disparities seen
between the UK and European countries such as Sweden, and we agree this is
likely (as outlined in our recent Lancet paper [2]. We agree entirely that
it is important to know where to target policy, and their data moves us on
considerably in determining priorities. This is precisely the sort of
approach needed on the Countdown technical committee and we look forward
to further collaboration.
Ingrid Wolfe, Angela Donkin, Michael Marmot, Alison Macfarlane,
Hilary Cass, Russell Viner
Many thanks for the recent letter regarding a rapid assay technique
for testing fecal calprotectin1. This would indeed be useful in the
clinical setting if it allows the transmission of accurate and rapid fecal
calprotectin levels to treating clinicians. As discussed in the original
archimedes report, the difficulties surrounding the need for an adequate
cut-off remain the main barrier to the use of fecal calprotectin a...
Many thanks for the recent letter regarding a rapid assay technique
for testing fecal calprotectin1. This would indeed be useful in the
clinical setting if it allows the transmission of accurate and rapid fecal
calprotectin levels to treating clinicians. As discussed in the original
archimedes report, the difficulties surrounding the need for an adequate
cut-off remain the main barrier to the use of fecal calprotectin as a
diagnostic adjunct in necrotising enterocolitis2.
JFB Houston
1. Bin-Nun A, Booms C, Sabag N, Mevorach R, Algur N, Hammerman C.
Rapid
fecal calprotectin (FC) analysis: point of care testing for diagnosing
early necrotizing enterocolitis. Am J Perinatol. 2015;32:337-42.
2. Houston JFB, Morgan JE. Question 2: Can faecal
calprotectin be used as an effective diagnostic aid for necrotising
enterocolitis in neonates? Arch Dis Child. 2015;100:1003-6
We thank Dr Cohn and his colleagues for their interest in our article and agree - as stated within our paper - that there is considerable variability in the reported fracture yield of skeletal surveys. This variability is not only dependent on methods of data display (as Dr Cohn et al illustrate), but also on epidemiological and demographic differences between reported study populations and on the process by which clinicia...
The highly commendable and detailed characterisation of non-anaemic iron deficiency(1) is timely and, perhaps, even overdue, given the fact that animal studies show that, even in the absence of anaemia, iron deficiency can ,in its own right, adversely affect both cerebral function(2), and thyroid function(3). In the animal model of non-anaemic iron deficiency it has been shown that iron uptake by a divalent metal ion tr...
We would like to thank Dr Levene for her letter, and the Editors for the opportunity to respond. The authors are familiar with the Infant Sleeplab App; we are both associated with the Durham University Parent- Infant Sleep Lab (Dr Volpe as an Honorary Fellow, and Professor Ball as the Founder and Director). The Infant Sleep Info Source Website (ISIS, www.isisonlineorg.uk) was conceived of in 2010 by Professor Ball and her...
We read with interest the paper by Drs Colvin and colleagues on the diagnosis and acute management of children with concussion at children?s hospitals in the United States (1). The authors reported an astonishing 59.9% of children with concussion receiving CT scans of the head (1).
We would like to make two comments with regard to this study: First, the terminology surrounding trauma to the head remains confus...
Dear Editor
We are so sorry not to have included cerebral arterio-venous fistula in the aetiology of unexplained tachypnoea because it is of course a rare but classic cause. Typically the symptoms begin almost immediately after birth if there is a large fistula and the pulmonary artery pressure remains elevated. The fistula allows a large systemic artery to systemic venous shunt with right atrial and right vent...
Dear Drs. Meyer and Oster,
Thank you for your interest in our paper(1) and for your concern for the proper management of children suffering from acute brain injury.
As you know, a concussion is a complex pathophysiologic process resulting from a rapid rotational acceleration of the brain caused by trauma.(2-4) It is a form of traumatic brain injury. The Glasgow Coma Scale, on the other hand, was develo...
Colvin correctly notes that we are interested in solution-focused research, and expresses some anxiety about our recommendations for improving child survival. There are two issues to consider in addressing his concerns: determining causality, and the burden of proof required to take action.
First, Bradford Hill's criteria for considering causality are helpful in demonstrating why the association between poverty...
I find the response to Assistant Professor Samlaska to be a bit limited.
Firstly, in the study by Wenner, they point out at the end of the paper that unbeknownst to them the clear duct tape they used had a different glue on it than regular duct tape. In fact, it had an acrylic based glue. Furthermore, the control group treatment used moleskin - this also has an acrylic based glue. So, when Wenner et al found no...
We thank Zylbersztejn, et al for their constructive letter and for their support for the Countdown initiative. Their data suggests that high rates of preterm birth and thresholds for reporting preterm birth [1] in the UK were one of the most likely explanations for the disparities seen between the UK and European countries such as Sweden, and we agree this is likely (as outlined in our recent Lancet paper [2]. We agree en...
Many thanks for the recent letter regarding a rapid assay technique for testing fecal calprotectin1. This would indeed be useful in the clinical setting if it allows the transmission of accurate and rapid fecal calprotectin levels to treating clinicians. As discussed in the original archimedes report, the difficulties surrounding the need for an adequate cut-off remain the main barrier to the use of fecal calprotectin a...
Pages