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Data versus Dogma — Safety of Intravenous Rehydration in Severely Malnourished Children
In 2024, a United Nations report estimated that 1 in 11 persons (up to 757 million) worldwide were facing hunger.
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Food insecurity and the risk of famine are exacerbated by conflict and climate change. Infants and children are frequently the most severely affected, as shocking images from sub-Saharan Africa and Gaza currently attest. Infants and children with severe acute malnutrition frequently have the acute medical complication of dehydration from gastroenteritis.
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Reported outcomes for this combination vary according to severity and health care system, but in-hospital mortality in the range of 30 to 40% appears to be typical.
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The World Health . . .
Journal Article
A COASTal view: where prior beliefs and uncertainty collide
The Children’s Oxygen Administration Strategies Trial (COAST) was an ambitious project based in Uganda and Kenya. The target population was children with severe pneumonia as assessed by presentation of peripheral oxygen saturation into two strata (hypoxaemia: SpO2 80–92% and severe hypoxaemia: SpO2 < 80%). The comparisons were between high-flow humidified nasal therapy (HFNT) and standard low-flow nasal oxygen in the severe hypoxaemia stratum, but also in a fractional factorial design of more liberal oxygen use vs. permissive hypoxaemia in the less severe stratum. The primary outcome measure was mortality at 48 h. The trial was conducted by a team with an outstanding track record of delivering large pragmatic and practice-changing trials in low-income settings. We had the privilege of being independent members of the Trial Steering Committee (TSC).
Journal Article
The state of nature : histories of an idea
\"The phrase, \"state of nature\", has been used over centuries to describe the uncultivated state of lands and animals, nudity, innocence, heaven and hell, interstate relations, and the locus of pre- and supra-political rights, such as the right to resistance, to property, to create and leave polities, and the freedom of religion, speech, and opinion, which may be reactivated or reprioritised when the polity and its laws fail. Combining intellectual history with current concerns, this volume brings together fourteen essays on the past, present and possible future applications of the legal fiction known as the state of nature. Contributors are: Daniel S. Allemann, Pamela Edwards, Ioannis D. Evrigenis, Mary C. Fuller, David Singh Grewal, Francesca Iurlaro, Edward J. Kolla, László Kontler, Grant S. McCall, Tom Sparks, Benjamin Straumann, Karl Widerquist, Sarah Winter, and Simone Zurbuchen\"-- Provided by publisher.
BOOK
Restricted fluid bolus volume in early septic shock: results of the Fluids in Shock pilot trial
ObjectiveTo determine the feasibility of Fluids in Shock, a randomised controlled trial (RCT) of restricted fluid bolus volume (10 mL/kg) versus recommended practice (20 mL/kg).DesignNine-month pilot RCT with embedded mixed-method perspectives study.Setting13 hospitals in England.PatientsChildren presenting to emergency departments with suspected infection and shock after 20 mL/kg fluid.InterventionsPatients were randomly allocated (1:1) to further 10 or 20 mL/kg fluid boluses every 15 min for up to 4 hours if still in shock.Main outcome measuresThese were based on progression criteria, including recruitment and retention, protocol adherence, separation, potential trial outcome measures, and parent and staff perspectives.ResultsSeventy-five participants were randomised; two were withdrawn. 23 (59%) of 39 in the 10 mL/kg arm and 25 (74%) of 34 in the 20 mL/kg arm required a single trial bolus before the shock resolved. 79% of boluses were delivered per protocol in the 10 mL/kg arm and 55% in the 20 mL/kg arm. The volume of study bolus fluid after 4 hours was 44% lower in the 10 mL/kg group (mean 14.5 vs 27.5 mL/kg). The Paediatric Index of Mortality-2 score was 2.1 (IQR 1.6–2.7) in the 10 mL/kg group and 2.0 (IQR 1.6–2.5) in the 20 mL/kg group. There were no deaths. Length of hospital stay, paediatric intensive care unit (PICU) admissions and PICU-free days at 30 days did not differ significantly between the groups. In the perspectives study, the trial was generally supported, although some problems with protocol adherence were described.ConclusionsParticipants were not as unwell as expected. A larger trial is not feasible in its current design in the UK.Trial registration numberISRCTN 15244462.
Journal Article
A concise dictionary of the avant-gardes
\"For a concise edition of his legendary arts dictionary of information and opinion, the distinguished critic and arts historian Richard Kostelanetz selects entries from the 2018 third edition. Typically he provides intelligence unavailable anywhere else, no less in print than online, about a wealth of subjects and individuals. Focused upon what is truly innovative and excellent, Kostelanetz also ranges widely with insight and surprise, including appreciations of artistic athletes such as Muhammad Ali and the Harlem Globetrotters and such collective creations as Las Vegas and his native New York City. Continuing the traditions of cheeky high-style Dictionarysts, honoring Ambrose Bierce and Samuel Johnson (both with individual entries), Kostelanetz offers a \"reference book\" to be enjoyed, not only in bits and chunks but continuously as one of the ten books someone would take if he or she planned to be stranded on a desert isle.\"--Page i.
Book
‘The Score Matters’: wide variations in predictive performance of 18 paediatric track and trigger systems
ObjectiveTo compare the predictive performance of 18 paediatric early warning systems (PEWS) in predicting critical deterioration.DesignRetrospective case-controlled study. PEWS values were calculated from existing clinical data, and the area under the receiver operator characteristic curve (AUROC) compared.SettingUK tertiary referral children's hospital.PatientsPatients without a ‘do not attempt resuscitation’ order admitted between 1 January 2011 and 31 December 2012. All patients on paediatric wards who suffered a critical deterioration event were designated ‘cases’ and matched with a control closest in age who was present on the same ward at the same time.Main outcome measuresRespiratory and/or cardiac arrest, unplanned transfer to paediatric intensive care and/or unexpected death.Results12 ‘scoring’ and 6 ‘trigger’ systems were suitable for comparative analysis. 297 case events in 224 patients were available for analysis. 244 control patients were identified for the 311 events. Three PEWS demonstrated better overall predictive performance with an AUROC of 0.87 or greater. Comparing each system with the highest performing PEWS with Bonferroni's correction for multiple comparisons resulted in statistically significant differences for 13 systems. Trigger systems performed worse than scoring systems, occupying the six lowest places in the AUROC rankings.ConclusionsThere is considerable variation in the performance of published PEWS, and as such the choice of PEWS has the potential to be clinically important. Trigger-based systems performed poorly overall, but it remains unclear what factors determine optimum performance. More complex systems did not necessarily demonstrate improved performance.
Journal Article