Diagnoses made in a secondary care "fits, faints, and funny turns" clinic

The utility of mobile telephone-recorded videos as adjuncts to the diagnosis of seizures and paroxysmal events in children with suspected epileptic seizures

BACKGROUND

Epilepsy is often diagnosed through clinical description, but inter-observer interpretations can be diverse and misleading.

OBJECTIVE

To assess the utility of smartphone videos in the diagnosis of paediatric epilepsy.

METHODS

The literature was reviewed for evidence to support the use of smartphone videos, inclusive of advantages, ethical practice and potential disadvantages. An existing adult-based quality of video (QOV) scoring tool was adapted for use in children. A pilot study used convenience sampling of videos from 25 patients, which were reviewed to assess the viability of the adapted QOV tool against the subsequent diagnosis for the patients with videos. The referral mechanism of the videos was reviewed for the source and consent processes followed.

RESULTS

A total of 14 studies were identified. Methodologies varied; only three focused on videos of children, and QOV was formally scored in three. Studies found that smartphone videos of good quality assisted the differentiation of epilepsy from non-epileptic events, especially with accompanying history and with more experienced clinicians. The ethics and risks of circulation of smartphone videos were briefly considered in a minority of the reports. The pilot study found that the adapted QOV tool correlated with videos of moderate and high quality and subsequent diagnostic closure.

CONCLUSIONS

Data relating to the role of smartphone video of events in children is lacking, especially from low- and middle-income settings. Guidelines for caregivers to acquire good-quality videos are not part of routine practice. The ethical implications of transfer of sensitive material have not been adequately addressed for this group. Prospective multicentre studies are needed to formally assess the viability of the adapted QOV tool for paediatric videos.

Staring Spells: An Age-based Approach Toward Differential Diagnosis

Evaluations to rule out epileptic vs nonepileptic staring spells may entail unnecessary evaluations that can be costly and time consuming. Our study aims to identify common etiologies for staring spells across 3 different pediatric age groups and to propose an age-based clinical guidance to help determine which patients warrant further workup. Methods: This was a single-center retrospective chart analysis of 1496 patients aged 0.0-17.9 years presenting with confirmed staring spell diagnosis from January 2011 to January 2021. The patients were divided into 3 groups based on their age: 0.0-2.9, 3.0-12.9, and 13.0-17.9 years. Patient information collected included demographics, clinical presentation, comorbidities, and final diagnosis. Multilevel likelihood ratios and a receiver operating characteristic curve were determined using 8 of the 11 clinical variables. A total of 1142 patients who met the inclusion criteria were included for the final analysis. The most common final diagnosis was attention-deficit hyperactivity disorder (ADHD) (35%), followed by normal behavior (33%). Generalized and focal epilepsy were diagnosed in 8% and 4% of the patients, respectively. In the 0.0-2.9-year age group, normal behavior was the final diagnosis in 72% patients. In the 3.0-12.9-year and 13.0-17.9-year age groups, ADHD was the most frequent final diagnosis in 46% and 60%, respectively. Overall, ADHD and normal behaviors remain the most common final diagnoses. Multilevel likelihood ratios can be used to develop an age-based guidance to differentiate between epileptic and nonepileptic staring spell diagnoses.

Paroxysmal Nonepileptic Events in a Pediatric Epilepsy Clinic

Aims:

We aimed to study the frequency, age, and gender distribution of paroxysmal nonepileptic events (PNEs) in children referred to epilepsy clinic with the diagnosis of epilepsy. We also evaluated the therapeutic implications of correct diagnosis and co-existence of true epilepsy in this population.

Settings and Design:

All new patients below 18 years attending the Pediatric epilepsy out-patient clinic of PD Hinduja hospital over 6 months were evaluated.

Materials and Methods:

Patients with history of paroxysmal events characterized by abrupt changes in consciousness or behavior or movement were included. They were assessed on description of events aided by recorded videos. If the diagnosis was not confirmed by this preliminary evaluation, further investigations were advised.

Statistical Analysis Used:

Chi-square/Fisher’s exact test was used to analyze differences between categorical variables and Kruskal–Wallis test between continuous variables. The data were analyzed by SAS University Edition. All significance tests were two-tailed with α <0.05.

Results:

Two hundred new patients presenting with paroxysmal events were enrolled over 6 months. After diagnoses, 19% of these children had PNEs, 80% had epileptic events, and 1% remained undiagnosed. Common nonepileptic events seen were physiological in patients below 5 years and psychogenic in older children. Thirty-four percent of patients with PNEs were on anti-epileptic drugs (AEDs). After confirming nonepileptic attacks, only 2.6% patients needed AEDs for coexisting epilepsy which was statistically significant (P < 0.001) change in treatment.

Conclusions:

Epilepsy mimics are common in children and are often misdiagnosed causing undue stress. Correct diagnosis leads to a drastic change in management like withdrawal of drugs, commencing new treatment if needed, and appropriate referrals.

Recognition and nursing management of reflex anoxic seizures in children

Reflex anoxic seizures (RAS) present with a transient loss of consciousness and are triggered by an unexpected stimuli. These are paroxysmal, short-lived episodes of pronounced bradycardia or transient asystole; the episodes are self-limiting, lasting between 15 seconds and 1 minute. RAS are an important differential diagnosis of transient loss of consciousness but they are commonly misdiagnosed as epileptic events. An accurate and focused history is key to the diagnosis. They are mostly managed by performing an ECG to rule out other causes of arrhythmia, with subsequent explanation of the condition and reassurance given to parents. Nurses play an important role in eliciting the history and providing support to parents following the diagnosis. This article addresses the epidemiology and pathophysiology of RAS, with suggestions for management. An illustrative case study is included to highlight some of the challenges that health professionals working in different clinical set-ups are likely to come across while managing a child with RAS.

Reflex anoxic seizures (RAS) in an adult patient: a separate entity from epilepsy

Reflex anoxic seizures (RAS) are essential in the differential diagnosis of non-epileptic paroxysmal seizures. They are precipitated by vagally mediated brief cardiac asystole, which in turn leads to transient cerebral ischaemia. RAS are usually seen in infants and preschool children, but in this case happened in a middle-aged man. Our patient is a 61-year-old man who presented with sudden, repeated contractions of his left upper arm and urine incontinence, followed by loss of consciousness for about 30 s. He reported a similar episode occurred 2 years earlier. He did indicate episodic confusion pointing towards possibility of more occurrences. In the emergency department, he developed a similar seizure, during which telemetry revealed sinus arrest lasted for 4-6 s that was followed by junctional escape. Implantation of a pacemaker resulted in total cessation of sinus arrest and seizure activity during the admission. On 1-year follow-up, patient and family members did not report episodic confusion or any seizure-like activity. RAS constitute a particular entity of seizures and need careful interpretation and management. They have a similar pathophysiology to cardiac syncope. Successful prevention of cerebral hypoperfusion with a cardiac pacemaker usually leads to complete resolution of symptoms in patients with RAS as demonstrated in this case.

Diagnoses and referral pattern at a first seizure clinic in London

Background. Epilepsy is among the most frequent neurological conditions and it is estimated that approximately 8% of the population experience a seizure at some time in their lives.

Aim. To examine the characteristics of patients referred to a First Seizure Clinic (FSC) at a University Hospital in South-West London.

Methods. All subjects referred to the FSC at St George’s University Hospitals between January and December 2015 were included in this audit.

Results. From a total of 257 patients, males 49.5%, age range 16–90, 30% referred by General Practices (GPs), 59.1% by the Accident & Emergency Department (A&E) and 10.9% by other hospital wards, 24.5% did not attend (DNA) the clinical appointment. Females who did not attend were significantly older than males (49.8 years old vs 39.7; p = 0.007). Among those who attended the clinical appointment, 17% were diagnosed first unprovoked seizure, 12.4% acute symptomatic seizure and 28.9% epilepsy. These patients were referred mainly by A&E while GPs referred seizure mimics especially non-epileptic attack disorder (NEAD) and syncope. Patients with NEAD were significantly younger than those with seizures (29.4 years old vs 44.2; p < 0.001) and had a previous psychiatric history (72.7% vs 16.8%; p < 0.001). The proportion of seizure mimics was similar in the older sample group (> 65 years). Regarding acute symptomatic seizures, 33.3% were alcohol-related, 20.8% acute brain insults and 12.5% drug-related (always overdose).

Conclusions. 1 in 4 patients referred to a FSC does not attend the clinical appointment, especially older females. More than 1 in 3 cases represent seizure mimics and are referred mainly by GPs.

Care coordination at a pediatric accountable care organization (ACO): A qualitative analysis

OBJECTIVE

Care coordinators may help manage care for children with chronic illness. Their role in pediatric epilepsy care is understudied. We aimed to qualitatively describe the content of a care coordination intervention for children with epilepsy.

METHODS

We conducted nine semi-structured interviews and one focus group with care coordinators at a pediatric accountable care organization (ACO) in Ohio. The care coordinators used a modified version of a published care coordination checklist for children with epilepsy (Patel AD, 2014). We analyzed transcripts using thematic analysis. We focused on (1) the content of the intervention; and (2) perceptions of facilitators and barriers to improve outcomes, with an emphasis on epilepsy specific facilitators and barriers.

RESULTS

Care coordinators interacted with children and families in multiple contexts (phone calls, physician visits, home visits), and included relationship building (developing rapport and trust between families and the health system), communication (transmission of information between the child, family, physician, and other care providers), and service (help with housing, transportation, scheduling, liaison with community resources, etc.). Facilitators and barriers of care coordination included factors related to parents, physicians, health system, payers, and community. Epilepsy-specific barriers included stigma (felt & enacted) and the anxiety associated with clinical uncertainty. Epilepsy related facilitators included a seizure action plan, written educational materials, and an epilepsy specific care coordination checklist.

CONCLUSION

In addition to facilitators and barriers common to many care coordination programs, pediatric epilepsy care coordinators should be particularly aware of epilepsy stigma and clinical uncertainty. A care coordination checklist and epilepsy focused educational materials written to accommodate people with low health literacy may provide additional benefit. Further research is required to understand the effect of care coordination on costs, use of health services, seizure control, and quality of life for children with epilepsy.

Incidence and Prevalence of Childhood Epilepsy: A Nationwide Cohort Study

BACKGROUND AND OBJECTIVES

Epilepsy affects 0.5% to 1% of children and is the most frequent chronic neurologic condition in childhood. Incidence rates appear to be declining in high-income countries. The validity of epilepsy diagnoses from different data sources varies, and contemporary population-based incidence studies are needed.

METHODS

The study was based on the Norwegian Mother and Child Cohort Study. Potential epilepsy cases were identified through registry linkages and parental questionnaires. Cases were validated through medical record reviews and telephone interviews of parents.

RESULTS

The study population included 112 744 children aged 3 to 13 years (mean 7.4 years) at end of registry follow-up (December 31, 2012). Of these, 896 had registry recordings and/or questionnaire reports of epilepsy. After validation, 587 (66%) met the criteria for an epilepsy diagnosis. The incidence rate of epilepsy was 144 per 100 000 person-years in the first year of life and 58 per 100 000 for ages 1 to 10 years. The cumulative incidence of epilepsy was 0.66% at age 10 years, with 0.62% having active epilepsy. The 309 children (34%) with erroneous reports of epilepsy from the registry and/or the questionnaires had mostly been evaluated for nonepileptic paroxysmal events, or they had undergone electroencephalography examinations because of other developmental or neurocognitive difficulties.

CONCLUSIONS

Approximately 1 out of 150 children is diagnosed with epilepsy during the first 10 years of life, with the highest incidence rate observed during infancy. Validation of epilepsy diagnoses in administrative data and cohort studies is crucial because reported diagnoses may not meet diagnostic criteria for epilepsy.

Misdiagnosis of gastroesophageal reflux disease as epileptic seizures in children

BACKGROUND

Gastroesophageal reflux disease (GERD) can mimic epileptic seizure, and may be misdiagnosed as epilepsy. On the other hand, GERD can be more commonly seen in children with neurological disorders such as cerebral palsy (CP); this co-incidence may complicate the management of patients by mimicking refractory seizures.

OBJECTIVE

The purpose of our study was to evaluate the clinical features, definite diagnoses and treatment approaches of the patients with clinically suspected GERD who were referred to the division of pediatric neurology with a suspected diagnosis of epileptic seizure. We also aimed to investigate the occurrence of GERD in children with epilepsy and/or CP.

METHODS

Fifty-seven children who had a final diagnosis of GERD but were initially suspected of having epileptic seizures were assessed prospectively.

RESULTS

All patients were assigned to 3 groups according to definite diagnoses as follows: patients with only GERD who were misdiagnosed as having epileptic seizure (group 1: n=16; 28.1%), those with comorbidity of epilepsy and GERD (group 2: n=21; 36.8%), and those with the coexistence of GERD with epilepsy and CP (group 3: n=20; 35.1%). Five patients (8.8%) did not respond to anti-reflux treatment and laparoscopic reflux surgery was performed. The positive effect of GERD therapy on paroxysmal nonepileptic events was observed in 51/57 (89.5%) patients.

CONCLUSIONS

GERD is one of the important causes of paroxysmal nonepileptic events. In addition, GERD must be kept in mind at the initial diagnosis and also in the long-term management of patients with neurological disorders such as epilepsy and CP.

Current approaches to the clinical assessment of syncope in pediatric population

INTRODUCTION

Syncope is one of the most common clinical problem in children. This disorder is characterized by transient, spontaneously self-terminating loss of consciousness with brief duration and complete recovery. This situation is usually alarming for the families of patients. The mechanism of syncope is transient global brain hypoperfusion to levels below those tolerated by cerebrovascular autoregulation. Syncope can occur with many different etiologies in the pediatric population.

CLASSIFICATION

Syncopes are divided into three major categories as neurally mediated syncope, cardiovascular-mediated syncope, and non-cardiovascular syncope.

CLINICAL FEATURES

The major challenge in the assessment of children with syncope is that most children are asymptomatic at the time of their presentation, therefore making a careful and detailed history and a comprehensive physical examination essential in all patients. A trigger stimulus is detected in some cases, and this is an important clinical clue for the diagnosis. Cardiac causes of syncope in children are rare but can be life threatening and have the highest risk of morbidity and mortality. Misdiagnosis of epilepsy is common in patients presenting with syncope; therefore, the differential diagnosis between epileptic seizures and syncope is very important. It should be remembered that the evaluation of syncope in children is costly and diagnostic workup has a limited diagnostic yield.

CONCLUSION

The aim of this article is to present different types of syncope and to provide new practical clinical approaches to the diagnosis, investigation, and management in the pediatric population.

Approach to syncope and altered mental status

Children who present with an episode of altered mental status, whether transient or persistent, present a diagnostic challenge for practitioners. This article describes some of the more common causes of altered mental status and delineates a rational approach to these patients. This will help practitioners recognize the life-threatening causes of these frightening presentations as well as help avoid unnecessary testing for the more benign causes.

Priorities in pediatric epilepsy research: improving children's futures today

The Priorities in Pediatric Epilepsy Research workshop was held in the spirit of patient-centered and patient-driven mandates for developing best practices in care, particularly for epilepsy beginning under age 3 years. The workshop brought together parents, representatives of voluntary advocacy organizations, physicians, allied health professionals, researchers, and administrators to identify priority areas for pediatric epilepsy care and research including implementation and testing of interventions designed to improve care processes and outcomes. Priorities highlighted were 1) patient outcomes, especially seizure control but also behavioral, academic, and social functioning; 2) early and accurate diagnosis and optimal treatment; 3) role and involvement of parents (communication and shared decision-making); and 4) integration of school and community organizations with epilepsy care delivery. Key factors influencing pediatric epilepsy care included the child's impairments and seizure presentation, parents, providers, the health care system, and community systems. Care was represented as a sequential process from initial onset of seizures to referral for comprehensive evaluation when needed. We considered an alternative model in which comprehensive care would be utilized from onset, proactively, rather than reactively after pharmacoresistance became obvious. Barriers, including limited levels of evidence about many aspects of diagnosis and management, access to care--particularly epilepsy specialty and behavioral health care--and implementation, were identified. Progress hinges on coordinated research efforts that systematically address gaps in knowledge and overcoming barriers to access and implementation. The stakes are considerable, and the potential benefits for reduced burden of refractory epilepsy and lifelong disabilities may be enormous.

Advancing the management of childhood epilepsies

Childhood epilepsies comprise a heterogeneous group of disorders and syndromes that vary in terms of severity, prognosis and treatment requirements. Effective management requires early, accurate recognition and diagnosis, and a holistic approach that addresses each individual's medical and psychosocial needs within the context of their overall health status and quality of life. With increasing understanding of underlying aetiologies, new approaches to management and treatment are emerging. For example, genetic testing is beginning to provide a tool to aid differential diagnosis and a means of predicting predisposition to particular types of epilepsy. Despite the availability of an increasing number of antiepileptic drugs (AEDs)--due not only to the development of new AEDs, but also to changes in regulatory requirements that have facilitated clinical development--seizure control and tolerability continue to be suboptimal in many patients, and there is therefore a continuing need for new treatment strategies. Surgery and other non-pharmacological treatments (e.g. vagus nerve stimulation, ketogenic diet) are already relatively well established in paediatric epilepsy. New pharmacological treatments include generational advances on existing AEDs and AEDs with novel modes of action, and non-AED pharmacological interventions, such as immunomodulation. Emerging technologies include novel approaches allowing the delivery of medicinal agents to specific areas of the brain, and 'closed-loop' experimental devices employing algorithms that allow treatment (e.g., electrical stimulation) to be targeted both spatially and temporally. Although in early stages of development, cell-based approaches (e.g., focal targeting of adenosine augmentation) and gene therapy may also provide new treatment choices in the future.

Girls who masturbate in early infancy: diagnostics, natural course and a long-term follow-up

AIM

To evaluate the natural course, onset, diagnostics and long-term follow-up masturbation in infant girls, which up to now has only been described in case reports.

METHODS

Nineteen consecutive healthy, masturbating girls, diagnosed in early infancy between three and 15 months, were followed up for an average of 8 years. All were diagnosed in the same Swedish hospital between May 1996 and June 2010. Ten girls were videotaped and/or directly observed while masturbating.

RESULTS

Mean age at onset of masturbation was 10.4 months. The diagnosis was based on history taking and clinical observation. Parents reported that masturbation ranged from a few times a week to two-to-fifty episodes a day. Twelve girls had stopped masturbating when this study was written, after a mean duration of 66 months. Their symptoms and diagnostics are described in detail.

CONCLUSION

This is the first follow-up study of girls who started masturbating in early infancy, with a mean duration of five-and-a-half years. Diagnosis may be difficult, but with awareness and knowledge of the condition, a normal physical and neurological examination, a detailed history from the parents and, in particular, video documentation, it can be settled without extensive investigations and the parents reassured.

The prevalence and management of epilepsy in secondary school pupils with and without special educational needs

OBJECTIVES

The objectives of this paper were to (i) determine the prevalence of epilepsy (including the various epilepsies and epilepsy syndromes) in a secondary school population; and (ii) compare the management of epilepsy between secondary school pupils with and without special educational needs.

METHODS

Retrospective observational study of a 250, 000 population (West Cheshire Health District). Pupils attending secondary school with epilepsy over a 1-year period were identified from the local Child Health Computer, school nurse and DGH records. Health records were examined to determine the prevalence, characteristics and management of the epilepsy, and the presence of any special educational needs, other learning difficulties or physical disability.

RESULTS

The prevalence of epilepsy was 4.1 per 1000, being 10 times higher among adolescents who had special educational needs. Pupils with epilepsy and special educational needs had more poorly controlled epilepsy, but did not have a higher number of focal seizures nor were they taking a greater number of anti-epileptic drugs. A physical disability occurred five times more often in those with special educational needs and epilepsy. While epilepsy in pupils at mainstream school without special educational needs was better controlled, one-fifth of these subjects had poorly controlled epilepsy and a few also had physical disabilities.

CONCLUSIONS

Epilepsy is more challenging to control in adolescents with special educational needs attending special schools. However, some pupils in mainstream secondary schools had poorly controlled epilepsy even when they did not have recognized special educational needs. Health and education professionals working across the range of secondary school environments need to be able to support pupils with challenging epilepsy, many of whom will also have special educational needs and some a physical disability, as an increasing number of adolescents with these difficulties are being placed in mainstream schools.

Paroxysmal disorders in infancy and their risk factors in a population-based cohort: the Generation R Study

AIM

To examine the incidence of paroxysmal epileptic and non-epileptic disorders and the associated prenatal and perinatal factors that might predict them in the first year of life in a population-based cohort.

METHOD

This study was embedded in the Generation R Study, a population-based prospective cohort study from early fetal life onwards. Information about the occurrence of paroxysmal events, defined as suddenly occurring episodes with an altered consciousness, altered behaviour, involuntary movements, altered muscle tone, and/or a changed breathing pattern, was collected by questionnaires at the ages of 2, 6, and 12 months. Information on possible prenatal and perinatal determinants was obtained by measurements and questionnaires during pregnancy and after birth.

RESULTS

Information about paroxysmal events in the first year of life was available in 2860 participants (1410 males, 1450 females). We found an incidence of paroxysmal disorders of 8.9% (n=255) in the first year of life. Of these participants, 17 were diagnosed with febrile seizures and two with epilepsy. Non-epileptic events included physiological events, apnoeic spells, loss of consciousness by causes other than epileptic seizures or apnoeic spells, parasomnias, and other events. Preterm birth (p<0.001) and low Apgar score at 1 minute (p<0.05) were significantly associated with paroxysmal disorders in the first year of life. Continued maternal smoking during pregnancy and preterm birth were significantly associated with febrile seizures in the first year of life (p<0.05).

INTERPRETATION

Paroxysmal disorders are frequent in infancy. They are associated with preterm birth and a low Apgar score. Epileptic seizures only form a minority of the paroxysmal events in infancy. In this study, children whose mothers continued smoking during pregnancy had a higher reported incidence of febrile seizures in the first year of life. These findings may generate various hypotheses for further investigations.

Clinical diagnosis of syncopes (including so-called breath-holding spells) without electroencephalography or ocular compression

A recent article in this journal suggested that ocular compression during electroencephalography was useful in distinguishing "breath-holding spells and syncope" from epileptic seizures. The method proposed involved measurement of the RR interval on the simultaneously recorded electrocardiographic trace and determining both the absolute RR lengthening and the change in RR interval as compared with the baseline value. It is argued by the present author that this is not an appropriate way to come to a diagnosis in episodic loss of consciousness in children. It is pointed out that so-called "breath-holding spells" are reflex syncopes and that the diagnosis of reflex syncopes should be by clinical history, even if this means delaying the diagnosis until a future consultation. Published evidence on the nature and clinical diagnosis of reflex syncopes in infants and children is reviewed in depth. It is concluded that routine electroencephalography is not an appropriate investigation when the diagnosis of episodic loss of consciousness is in doubt and has the implicit danger of false positive "abnormality". Aside from scientific exploration of the developing autonomic nervous system, the only current indication for diagnostic ocular compression is to induce a syncope so that its nature may be better understood. Such a circumstance might be a history of an apparent reflex syncope but with atypical features, including prolonged post-syncopal unconsciousness such as might indicate epileptic absence status. Several additional investigations of a primarily cardiological nature may be indicated in some cases, but a wait-and-see policy is usually to be preferred.

The office management of epilepsy

Epilepsy in children is mostly diagnosed and treated in an ambulatory office setting. This article reviews the literature and offers opinions about the best practice from the time of diagnosis through to remission and beyond. The diagnosis and assignment of an epilepsy syndrome may be difficult, and even experts disagree in many cases. Regular review of the basic diagnosis and semiology of seizures is suggested throughout treatment. Workup should always include an electroencephalogram and usually magnetic resonance imaging. Antiepileptic drugs (AEDs) suppress seizures but appear to have little effect on long-term remission, and the choice of AED is for the most part arbitrary with most AEDs having a similar success rate when used as the first drug. Families have a great need for accurate information, and their ability to cope with the unpredictable nature of seizures may be assisted by "rescue" home benzodiazepines. Surveillance for drug toxicity and side effects is a critical clinical skill that is not assisted by routine blood tests or AED serum levels. Most children with epilepsy do not have many seizures and need not have significant restrictions on their activities. In the long run, comorbidities (especially learning and behavior problems) have a greater impact on social function than the epilepsy. Management of these problems may extend well beyond remission of the epilepsy. The child neurologist needs to prepare children with persistent epilepsy for transfer to adult epilepsy services.

NICE guidelines and the epilepsies: how should practice change?

The care and provision for children and adults with epilepsy and their carers has recently been under scrutiny with a series of reports highlighting concerns and calling for change. The National Institute for Clinical Excellence (NICE) published recommendations for management of adults and children in October 2004. Although recommendations were often specific and practical they did not include precise details regarding their implementation. Key recommendations and their implications are discussed in this review.

Preventing misdiagnosis of epilepsy

Commentary on the papers by Hindley et al (see page 214) and Uldall et al (see page 219)