https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(07)61690-0.pdf

Maternal and child undernutrition: global and regional exposures and health consequences

admission. This proportion could already be greater in some parts of the country and may increase if referrals of cases of self-poisoning increase faster than the facilities for their assessment and management. The provision of social work and psychiatric expertise in casualty departments may be one means of preventing unnecessary medical admissions without risk to the patients. Dr Blake's and Dr Bramble's figures do not demonstrate, however, that any advantage would attach to medical teams taking over assessment from psychiatrists except that, by implication, assessments would be completed sooner by staff working on the ward full time. What the figures actually suggest is that if assessment of overdoses were left to house doctors there would be an increase in admissions to psychiatric units (by 19°U), outpatients (by 5O°'), and referrals to social services (by 140o). So for house doctors to assess overdoses would provide no economy for the psychiatric or social services. The study does not tell us what the consequences would have been for the six patients who the psychiatrists would have admitted but to whom the house doctors would have offered outpatient appointments. E J SALTER

Vitamin D deficiency.

Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Severe or therapy-resistant asthma is increasingly recognised as a major unmet need. A Task Force, supported by the European Respiratory Society and American Thoracic Society, reviewed the definition and provided recommendations and guidelines on the evaluation and treatment of severe asthma in children and adults. A literature review was performed, followed by discussion by an expert committee according to the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach for development of specific clinical recommendations. When the diagnosis of asthma is confirmed and comorbidities addressed, severe asthma is defined as asthma that requires treatment with high dose inhaled corticosteroids plus a second controller and/or systemic corticosteroids to prevent it from becoming “uncontrolled” or that remains “uncontrolled” despite this therapy. Severe asthma is a heterogeneous condition consisting of phenotypes such as eosinophilic asthma. Specific recommendations on the use of sputum eosinophil count and exhaled nitric oxide to guide therapy, as well as treatment with anti-IgE antibody, methotrexate, macrolide antibiotics, antifungal agents and bronchial thermoplasty are provided. Coordinated research efforts for improved phenotyping will provide safe and effective biomarker-driven approaches to severe asthma therapy.

/pdf/international-ers-ats-guidelines-on-definition-evaluation-sedelwbk4v.pdf

International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(10)61388-8.pdf

Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries.

Aim: To assess the repeatability of low-dose Synacthen test (LDST) in asthmatic children receiving high-dose fluticasone propionate (FP).



Methods:  Low-dose Synacthen test was performed on 18 children with stable chronic asthma treated with FP at a constant daily dose of ≥500 μg and repeated 1 month later. Repeatability was assessed using the Kappa statistic for categorical variables.



Results:  Fifteen patients had consistent results (either two normal or two abnormal responses) and three patients had inconsistent results (one normal and one abnormal response). The Kappa statistic was 0.56 indicating fair to good agreement between the tests.



Conclusion:  The results of adrenal function testing in patients on inhaled steroids can have major implications for patient management, making it important to use a test with excellent repeatability. The LDST conducted using our protocol does not fulfil this criterion.

Repeatability of the low‐dose ACTH test in asthmatic children on inhaled corticosteroids

Cystic fibrosis (CF) is a life{limiting, hereditary,multisystem disease predominantly affecting thelungs and pancreas. Over the last few years, sur-vival of CF patients has increased markedly. Thishas been attributed to earlier diagnosis, improvedpatient care delivered by multidisciplinary teamsand more effective therapeutic options. It has beensuggested that the pathophysiologic basis of CFlies in different gene mutations that encode abnor-malities in the structure of the cystic fibrosis trans-membrane conductance regulator (CFTR) protein,leading to physiologic defects in ion transport.

https://journals.sagepub.com/doi/pdf/10.1258/jrsm.2009.s19010

Marked improvement in cystic fibrosis lung disease and nutrition following change in home environment

Passive tobacco smoke in children and young people during the COVID-19 pandemic.

Aims and objective: To assess the feasibility of singleincision laparoscopic cholecystectomy (SILC) with conventional laparoscopic instruments and to compare it with four-port conventional laparoscopic cholecystectomy (LC) regarding various intraoperative and postoperative factors. Materials and methods: This is a prospective randomized controlled study carried out at Santosh Medical College and Hospitals, Ghaziabad from March 2014 to September 2015. This study included 60 patients with cholelithiasis who were divided into two groups of 30 patients each. Group I was offered four-port conventional LC and group II underwent SILC. Results and observations: Cholelithiasis was commonly seen in young females. Single-incision laparoscopic cholecystectomy took more operating time than conventional LC due to more operative difficulty. Outcome of SILC was 79.6% (23 of 30). However, postoperative complications and pain (measured by visual analog scale scoring system) were almost the same in both groups. Cosmetic outcome was better in SILC group. Conclusion: Single-incision laparoscopic cholecystectomy has no added advantage over conventional LC, but it can be performed in selected patients for better cosmetic results.

Comparative Study of Single-incision Laparoscopic Cholecystectomy with Four-port Conventional Laparoscopic Cholecystectomy: A Single-center Experience

### What is already known?

### What this study adds?

Outcomes for children with asthma in the UK continue to lag behind other European countries. Mortality remains unacceptably high and in contrast to adults with asthma, most deaths occur in the 1 in 20 children with asthma who have severe asthma. Despite evidence that children with asthma have better outcomes with subspecialist care, many children with severe asthma are not referred onwards and barriers exist at every level of the UK healthcare system. The National Review of Asthma Deaths (NRAD) recommended that specialist review should be requested if there had been three or more courses of oral steroids, two or more visits to accident and emergency or an admission to hospital. This review reports the results of a recent interview study of 126 healthcare professionals. More than half of general practitioners (n=49) reported adopting a higher threshold than this. General paediatricians (n=47) set a higher bar still. Their median thresholds for referral to a subspecialist asthma clinic were 4 courses of oral steroids, 3 hospital admissions and 30 days off school in the previous year. This review offers a simple working definition of severe asthma based on current national and international guidelines and provides an example of the recently adopted referral criteria to …

https://adc.bmj.com/content/archdischild/105/5/494.full.pdf

Atul Gupta

Papers

Repeatability of the low‐dose ACTH test in asthmatic children on inhaled corticosteroids

Marked improvement in cystic fibrosis lung disease and nutrition following change in home environment

Passive tobacco smoke in children and young people during the COVID-19 pandemic.

Comparative Study of Single-incision Laparoscopic Cholecystectomy with Four-port Conventional Laparoscopic Cholecystectomy: A Single-center Experience

If it's 'only' asthma, why are children still dying?