Clinical outcomes and health-related quality of life (HRQOL) following haemopoietic stem cell transplantation (HSCT) for paediatric leukaemia

BACKGROUND

Haemopoietic stem cell transplantation (HSCT) is a life-saving but intensive procedure associated with potentially severe adverse late effects. We aimed to determine morbidity and health-related quality of life (HRQOL) in a sample of survivors aged 8-18 years at least 1 year post HSCT for paediatric acute leukaemia, compared with a non-transplanted group of survivors matched for age, gender, initial disease and time since treatment.

METHODS

Families (N = 54; HSCT n= 29) recruited from four UK centres completed measures of child behaviour and school attendance, HRQOL and finances. Mothers completed measures of their own well-being. Clinical outcome data were extracted from medical records.

RESULTS

Children in the HSCT group had significantly more late effects and had received more tests for vision, bone, dental and skin health, and thyroid, lung, and gonadal function than the non-transplanted group. HRQOL scores for the HSCT group were significantly lower in all domains compared with the non-transplanted group and population norms, but were not significantly related to clinical indices. Mothers in the HSCT group had significantly poorer mental well-being than population norms.

CONCLUSION

Significant morbidity and compromised HRQOL was found in survivors of HSCT. The burden of caring for a child after HSCT has a continuing toll on mothers' well-being.The importance of counselling families about possible long-term consequences is emphasized.

Health-related quality of life and financial impact of caring for a child with Thalassaemia Major in the UK

BACKGROUND

Thalassaemia Major (TM) is a serious condition characterized by life-long dependence on blood transfusions and chelation therapy. Our aim was to determine health-related quality of life (HRQOL) in children with TM living in the UK, and the impact of caring for a child receiving National Health Service treatment on family finances.

METHODS

This was a cross-sectional assessment of HRQOL in children (n= 22) with TM aged 8-18 years. Children were recruited from three UK Paediatric Haematology and Bone Marrow Transplant centres. Mothers completed measures of their child's HRQOL [PedsQL 4.0 (Measurement Model for the Pediatric Quality of Life Inventory, James W. Varni PhD, PedMetrics, Quantifying the Qualitative SM, Copyright 1998-2009)] and behaviour (Strengths and Difficulties questionnaire), and the impact of caring for the child on family finances.

RESULTS

Child behaviour was within the normal range but child HRQOL was significantly lower than population norms. Family financial concerns associated with TM were associated with poorer child HRQOL (P= 0.020).

CONCLUSIONS

Thalassaemia Major poses a considerable challenge to child HRQOL, well documented in areas of the world where TM is prevalent. Despite the availability of National Health Service care and financial benefits our study suggests a similar burden in the UK.

Existential boredom: the experience of living on haemodialysis therapy

Empathy is an essential component of professional nursing practice. In order to empathise appropriately with patients, it is crucial that nurses appreciate, understand and respond to their patients' experience of illness. This study sought to explore the experiences of 16 people with end stage renal disease on haemodialysis therapy in Ireland. A hermeneutical phenomenological methodology was employed incorporating qualitative interviews. The data were analysed using qualitative interpretive analysis. The experience of waiting was significant for the participants in the study. The experience of waiting was constituted by two themes labelled killing time and wasting time. It is suggested that the participants' experience of waiting is reminiscent of Heidegger's existential account of boredom. Moreover, the existential perspective of boredom contained within the participants' accounts is also depicted by Beckett in his play Waiting for Godot. Consequently, the literature of both existential writers is incorporated to provide a more in-depth description of the participants' experience of waiting. It is hoped that the insights provided in this paper will enable practitioners to gain a new awareness and understanding of patients' experiences of end stage renal disease and haemodialysis therapy. This would subsequently enable these professionals to empathise more effectively with their patients' situation and respond more appropriately to their care needs.

Allogeneic bone marrow transplantation in a 7-year-old girl with congenital erythropoietic porphyria: a treatment dilemma

Congenital erythropoietic porphyria (CEP, Günther's disease) has a very variable phenotype. In the more severely affected, bone marrow transplantation (BMT) is potentially curative, but is not without risks. We describe a 7-year-old girl with CEP characterized by severe photosensitivity but only mild anaemia, in whom the difficult decision to proceed with allogeneic BMT was made after discussion in a multidisciplinary team. She has shown successful engraftment, accompanied by biochemical and clinical resolution of her metabolic disease. She remains well 3 years later, the oldest patient with CEP receiving BMT to survive beyond 12 months. However, she has experienced significant morbidity including florid cutaneous graft-versus-host disease with postinflammatory hypopigmentation. Her case is important in highlighting the delay in diagnosis not uncommon in this condition and the complex decision-making process involved in proceeding with BMT.

Increased acute GvHD and higher transplant-related mortality in non-caucasians undergoing standard sibling allogeneic stem cell transplantation

We conducted a retrospective study to compare outcome in Caucasians and non-Caucasians undergoing standard sibling allogeneic SCT. End points of the study were to compare graft-versus-host disease (GvHD) occurrence and transplant-related mortality (TRM). There were 251 patients, 43 non-Caucasian and 208 Caucasian. A higher proportion of non-Caucasian patients developed acute GvHD (aGvHD) grade 2 or greater as compared to the Caucasian group (48 vs 26%, respectively) P = 0.02. With a median follow-up of 27 months, 26% (11/43) of non-Caucasians and 14% (29/208) of Caucasian patients had died from TRM, which accounted for 55% of all deaths in the non-Caucasian group compared to 33% in Caucasians, P = 0.02. Overall survival 12 months post transplant was 64 vs 69% in the non-Caucasian and Caucasian groups, respectively (P = 0.43). Although there were higher numbers of CMV-positive patients in the non-Caucasian group, there were no deaths from CMV reactivation in this subgroup. We conclude that there is increased TRM and aGvHD following standard sibling allograft in the non-Caucasian population and this could be due to either differences in tumour biology or extrinsic factors such as socio-economic factors, nutritional status, post transplant care or presenting with late stage disease.

The role of occupational and environmental exposures in the aetiology of acquired severe aplastic anaemia: a case control investigation

Aplastic anaemia is a rare but serious disorder with a high morbidity and mortality rate. The causes of aplastic anaemia are, for the most part, unknown. We report on the hypothesis that aplastic anaemia may be caused by occupational and/or environmental exposures to certain chemicals. The UK Aplastic Anaemia Study was an interview-based case-control study covering the whole of Great Britain. Those patients diagnosed between 1 July 1993 and 20 October 1997, aged < or =75 years and born and diagnosed in the UK were eligible for the study. Two hundred eligible cases of aplastic anaemia were compared with 387 age- and sex-matched controls. A number of occupational exposures showed increases in risk. In a multivariate model of these exposures the odds ratios (ORs) for solvents/degreasing agents, pesticides and radiation were >2 and statistically significant. Reported chemical treatment of houses within 5 years of diagnosis had a significantly raised risk for adults [OR = 2.51, 95% confidence interval (CI) 1.02-12.01], particularly for woodworm treatment (OR = 5.1, 95% CI 1.5-17.4). This study identified significant risks associated with self-reported exposure to solvents, radiation and pesticides in the workplace. Self-reported chemical treatment of houses was also associated with an increased risk of developing aplastic anaemia, in keeping with previous literature.

The experience of pervasive loss: children and young people living in a family where parental gambling is a problem

Gambling research has contributed much to our understanding of the effects of gambling on families, yet we have only the most cursory understanding of the child's perspective on what it is like to grow up in such a family. The aim of this qualitative study was to gain a deeper understanding of the experiences of Australian children who live in families where a parent or caregiver has a serious gambling problem by exploring the perspectives and understandings of the children and young people themselves. This paper reports a central finding, the experience of 'Pervasive Loss,' from our interviews with 15 young people, 11 males and 4 females, aged between 7 and 18 years. Their sense of loss encompassed both physical and existential aspects of the child's life, including their parent(s), relationships, trust, security, sense of home, and material goods. The dimensions of this experience of pervasive loss are explored from the child's perspective. Children living in families where gambling is a problem experience threats to their overall well-being to the extent that parental problem gambling must now considered to be a significant child health as well as social problem.

Bone density in the Asian thalassaemic population: a cross-sectional review

As survival improves in beta-thalassaemia, osteoporosis is emerging as a significant problem. This study examines bone mineral density (BMD) of thalassaemic patients of Asian origin (age range 9.5-24 y) to evaluate the extent of problems in this group and identify potential risk factors. Eleven patients were scanned using dual-energy X-ray absorptiometry. BMD z-scores and the bone mineral apparent density (BMAD) z-scores were calculated, to correct for short stature. All but three patients had lumbar spine BMD and BMAD z-scores below the mean. Three patients had BMAD z-scores more than 2.5 standard deviations below the mean. A negative correlation between age and BMAD was seen, as was an association between endocrine disorders and decreased bone density.

CONCLUSION

The data confirm significant reductions in BMD in the Asian thalassaemic population, even after correcting for body size. Further research is needed to identify risk factors and means of prevention.

Analysis of chimaerism in thalassaemic children undergoing stem cell transplantation

We have prospectively assessed the relative contribution of host and donor to haemopoiesis following stem cell transplantation (SCT) in children with beta-thalassaemia major (n = 35), using karyotype analysis or Southern blot/polymerase chain reaction analysis of variable number tandem repeats on genomic DNA from peripheral blood. Early haemopoiesis was fully donor in origin in 24 out of 35 cases and remained so throughout the post-transplant course in all but one patient, who evolved to stable mixed chimaerism. The remaining 11 cases (31%) initially showed mixed chimaerism: four of these rejected, one eventually eradicated host haemopoiesis to become fully donor haemopoietic, and the remaining six had persistent mixed chimaerism, with 5--38% host haemopoiesis. The risk of graft rejection was high when > 15% host haemopoiesis was present at 3 months post transplant: four out of six such patients rejected their grafts; conversely, zero out of 29 patients with < 15% host haemopoiesis at 3 months rejected (P < 0.0001). There was a higher incidence of significant acute and chronic graft-versus-host disease in patients with full donor chimaerism. These studies confirm that the mixed chimaeric state is common following SCT for thalassaemia, often persists (with up to 4 years follow-up) and is compatible with long-term cure. Analysis of chimaerism in patients undergoing SCT for beta-thalassaemia enables monitoring of engraftment in the early post-transplant period, provides insight into the biology of engraftment and may be useful in identifying patients at high risk of rejection.

Children of parent(s) who have a gambling problem: a review of the literature and commentary on research approaches

Problem gambling is becoming an increasingly widespread and damaging social and health problem. As opportunities for gambling become more accessible, especially through lotteries and electronic gaming machines, it is likely that more people will develop serious gambling problems. Given the worldwide increasing spending on gambling activities and the increasing number of problem gamblers, it is unfortunate but likely that the children who grow up in problem gambling families will become an important area of concern for child health and social workers. Considerable research has been undertaken into problem gambling and the adult problem gambler, but within the gambling and child health literature there is almost no recognition of the experiences of children who live in problem-gambling families. Drawing on the findings of the landmark Productivity Commission Report, this review explores the marked increase in gambling and its social effects, especially from the Australian perspective. The damaging social effects of problem gambling on families and children are reviewed and the comparative invisibility of children and young people in such research is discussed. The pervasive influence of developmentalism is critiqued and highlighted in relation to the exclusion of children's perspectives from our research understandings. The review concludes by proposing that adoption of some of the emerging 'new paradigm' approaches to childhood and children's experiences could markedly enhance our understandings of the lives and experiences of this significant group of children and young people.

Comparison of allogeneic transplant versus chemotherapy for relapsed childhood acute lymphoblastic leukaemia in the MRC UKALL R1 trial. MRC Childhood Leukaemia Working Party

BACKGROUND

Although reinduction rates are good for children with relapsed acute lymphoblastic leukaemia there is no consensus on whether bone marrow transplantation (BMT) is the most effective treatment to prolong second remission.

PATIENTS AND METHODS

Analyses comparing the outcome of related donor allogeneic BMT (related allograft) with chemotherapy are unreliable because of selection biases. To avoid these biases, the MRC UKALL R1 trial was analysed by HLA-matched donor availability.

RESULTS

No significant difference in outcome was found between the donor and no donor groups. The donor group had a non-significant eight-year event-free survival (EFS) advantage of 8%, (95% confidence interval -9%-24%) over the no donor group. Patients with a first remission less than two years appeared to benefit most from having a donor, although the effect was only marginally significantly different from patients with longer first remission. Analysis by treatment received gave similar results, with BMT patients having a 5% (P = 0.8) eight-year EFS advantage over patients who received chemotherapy.

CONCLUSIONS

Related allograft was not found to be significantly better than chemotherapy, but there was the possibility of a moderate EFS benefit with related allograft. especially in patients with a short first remission.

User-friendliness of computerized information systems

Despite the plethora of research on nurses and the use of computers and information systems, there have been few attempts to examine the everyday experiences of nurses who use such systems in practice. This qualitative study builds on our limited understanding of practitioners' experiences regarding use of Computerized Patient Information Systems (CPIS). Focus group interviews wer held across Australia with practitioners from a wide range of clinical settings and specialties. The study findings suggest that participants were predominantly critical of systems in almost every area related to "user-friendliness." The perspectives and views of practitioners are important to understand if future generations of CPIS hardware and software are to be developed with a greater appreciation of the needs of the system's front-line users.

Use of idarubicin in pre-transplant conditioning in children with high-risk acute leukaemia

The major cause of treatment failure following allogeneic bone marrow transplantation for acute leukaemia is disease relapse. In an attempt to reduce post- transplant relapse in 33 children with high-risk acute leukaemia who received a related or unrelated bone marrow transplant, the pre-transplant conditioning regimen was intensified by the addition of idarubicin. Its toxicity and effects on survival were evaluated over a 57-month period. Toxicity, largely gastrointestinal, was increased but acceptable, and there was no specific regimen-related toxicity. Relapse rates were low (24%) in this high risk group, but mortality was increased in those receiving unrelated donor grafts, largely due to sepsis. Idarubicin does appear to have a role to play in the conditioning regimen of patients with high-risk acute leukaemia undergoing BMT, and may reduce relapse rates without increasing transplant-related mortality.

Nursing, art and science: revisiting the two cultures

I begin this paper by setting out the importance of the Two Cultures debate, given that many nurse authors would agree with Closs's position that the art versus science debate should be closed finally. I suggest that issues are every bit as present and urgent in our current era as they were in the past. A brief tracing of the history of the Two Cultures debate highlights the relevance of the central features of the debate for nursing. I then focus on nursing's current understanding of science and art and attempt to defend science from some of the accusations levelled at it, while also questioning some of the claims made on behalf of the arts. In the latter sections of the paper, I make a case for the development of 'nursing humanities' and argue the vital importance of overcoming the Two Cultures divide for the everyday practices of nurses and midwives.

Identification and characterization of three novel missense mutations in mevalonate kinase cDNA causing mevalonic aciduria, a disorder of isoprene biosynthesis

Mevalonic aciduria is a rare autosomal recessive metabolic disorder, characterized by psychomotor retardation, failure to thrive, hepatosplenomegaly, anemia and recurrent febrile crises. The disorder is caused by a deficient activity of mevalonate kinase due to mutations in the encoding gene. Thus far, only two disease-causing mutations have been identified. We now report four different missense mutations including three novel ones, which were identified by sequence analysis of mevalonate kinase cDNA from three mevalonic aciduria patients. All mutations affect conserved amino acids. Heterologous expression of the corresponding mutant mevalonate kinases as fusion proteins with glutathione S -transferase in Escherichia coli showed a profound effect of each of the mutations on enzyme activity. In addition, immunoblot analysis of fibroblast lysates from patients using specific antibodies against mevalonate kinase identified virtually no protein. These results demonstrate that the mutations affect not only the activity but also the stability of the mutant proteins.

Reading Heidegger and interpretive phenomenology: a response to the work of Michael Crotty

In a recent paper in Nursing Inquiry and in his other work, Michael Crotty was severely critical of much interpretive nursing scholarship and especially of some nurse scholars' interpretations of the work of Martin Heidegger. In this paper we respond to Crotty's attempt to set out what Heidegger 'actually says' [sic] in relation to tradition, culture, destruction, das Man and everydayness. We suggest that Crotty took a narrow, existentialist view of Heidegger's work and that this view was often misguided and poorly informed. We show not only that an alternative understanding of Heidegger's work in these important areas is possible, but that this interpretation is strongly supported by a deeper and wider reading of Heidegger's own work and of the secondary literature of Heideggerian scholarship.

Inherited interleukin 12 deficiency in a child with bacille Calmette-Guérin and Salmonella enteritidis disseminated infection

Interferon-gamma receptor ligand-binding chain (IFN-gammaR1) or signaling chain (IFN-gammaR2) deficiency, like interleukin 12 receptor beta1 chain (IL-12Rbeta1) deficiency, predispose to severe infections due to poorly virulent mycobacteria and salmonella. A child with bacille Calmette-Guérin and Salmonella enteritidis infection was investigated. Mutations in the genes for IFN-gammaR1, IFN-gammaR2, IL-12Rbeta1, and other molecules implicated in IL-12- or IFN-gamma-mediated immunity were sought. A large homozygous deletion within the IL-12 p40 subunit gene was found, precluding expression of functional IL-12 p70 cytokine by activated dendritic cells and phagocytes. As a result, IFN-gamma production by lymphocytes was markedly impaired. This is the first discovered human disease resulting from a cytokine gene defect. It suggests that IL-12 is essential to and appears specific for protective immunity to intracellular bacteria such as mycobacteria and salmonella.

Treatment of neutropenia in a renal transplant recipient with granulocyte colony-stimulating factor

We report the use of granulocyte colony-stimulating factor (G-CSF) in a renal transplant recipient in whom neutropenia developed following a presumed viral infection. G-CSF was successful in producing a rise in neutrophil count which coincided with a resolution of fever; there was no adverse effect on renal function. This is the first use of G-CSF in a paediatric renal transplant recipient, and its use should be considered for the immunosuppressed child with persistent neutropenia.

Dietary education and iron deficiency anaemia in the inner city

OBJECTIVES

To assess if a dietary health education programme could be used within existing health resources to reduce the incidence of iron deficiency anaemia in an inner city population.

DESIGN

Prospective cohort study.

SETTING

Inner city areas of west and south Birmingham.

SUBJECTS

A total of 1000 children recorded on the child health computer register.

INTERVENTION

Children were recruited at birth and randomised into control and intervention groups. Families in the intervention group received specific health education information at key ages by face to face contact using a range of materials. The control group received standard health education as delivered by the health visitors at the time.

MAIN OUTCOME MEASURES

Haemoglobin estimation and iron content of the diet at 18 months of age.

RESULTS

A total of 455 children completed the study. Sixty nine (27%) of the control group and 55 (28%) of the intervention group were anaemic as defined by haemoglobin less than 110 g/l. There was no difference in the iron content of the diets offered to the two groups of children.

CONCLUSION

In this deprived population we have shown no reduction in anaemia using a targeted nutritional programme and have highlighted the difficulties in conducting health education programmes within the scope of current health resources.

Reclaiming 'Big Nurse': a feminist critique of Ken Kesey's portrayal of Nurse Ratched in One Flew Over the Cuckoo's Nest

Nurse Ratched or 'Big Nurse' in Ken Kesey's counter-culture novel One Flew Over the Cuckoo's Nest is one of popular culture's most arresting and memorable images of the nurse. She is, however, deemed to be remarkable primarily for her malice and authoritarianism. This paper argues that such a purely realist reading fails to fully appreciate the significance of the character of Nurse Ratched. A feminist critique of the novel contends that the importance of 'Big Nurse' is less related to how realistic/unrealistic or good/bad she is as a nurse. Nurse Ratched is important because she exemplifies all that traditional masculinity abhors in women, and particularly in strong women in positions of power and influence. This paper explores the stereotype of 'Big Nurse' and argues that Kesey's vision of her ultimate 'conquest' is not a progressive allegory of 'individual freedom', but a reactionary misogyny which would deny women any function other than that of sexual trophy.

Urticaria pigmentosa and acute lymphoblastic leukaemia

Childhood urticaria pigmentosa is generally considered to have a good prognosis with the majority of cases undergoing spontaneous resolution. However, there have been a number of reports of haematological malignancies occurring in association with urticaria pigmentosa. We describe a child with extensive urticaria pigmentosa and a congenital cardiac anomaly who developed acute lymphoblastic leukaemia and suggest a possible common aetiology.

Empowering parents of children with special needs

Partnership and empowerment are very much in vogue. In this paper the authors question whether the rhetoric of partnership matches the reality as experienced by families of children with special needs. Research in this area is reviewed and models of good practice are examined.

Lessons From Literature: Caring, Interpretation, and Dialogue

There can be little doubt that nursing, like other arts and sciences, is experiencing an "interpretive turn" (Hiley, Bohman, & Shusterman, 1991). As part of this more global "turn," the curriculum revolution has spurred nurse educators to critically examine their schools, curricula, and everyday practices as teachers and propose alternative pedagogies where appropriate. I argue that what is now being developed as nursing humanities is a valuable approach to interpretive pedagogy which challenges, stimulates, integrates, and develops students' thinking and understanding of the lived experience of patients/clients in ways that more traditional scientific and behaviorist approaches to nursing education are unable to do. In creating courses or learning experiences using nursing humanities, it is essential to attend to both content and pedagogical approach as being inseparable. Ignoring the former will produce no more than a pleasant chat, while ignoring the latter will result in mere "metaphor counting" or rote learning of "what the book, story, or poem means." Nurse educators have used literature to help illuminate health and illness issues in the past, but unfortunately, this has been viewed as an essentially marginal approach. While novels, stories, poems, and other literature can certainly be used in almost any nursing class, I believe that nursing humanities is such a rich seam of pedagogical and critical possibility that it merits development of specific courses and options within all of our nursing courses and programs.

Family-centred care within contemporary British paediatric nursing

The concept of family-centred care is such a cherished tenet of paediatric nursing to be almost above critique. Yet a close examination of the place and meaning-in-practice of family-centred care is long overdue if the term is not to lapse into mere cliché or slogan.

Understanding the life of illness: learning through the art of Frida Kahlo

That nursing is an art as well as a science is in danger of becoming a cliché unless attempts are made to reverse the marginalization and exclusion of arts and humanities within nursing. An educational approach to promoting more esthetic and less instrumental thinking and understanding is described. This approach enables nurses to gain a deeper understanding of the lived experiences of suffering, chronic pain, miscarriage, and disability through engaging with the art of Mexican painter Frida Kahlo.

Understanding caring through arts and humanities: a medical/nursing humanities approach to promoting alternative experiences of thinking and learning

It is often claimed that nursing is both an art and a science, yet nursing education has been reluctant to accord arts and literature a prominent place within nursing curricula. While the discipline of medical humanities has been developing for around two decades, there has been no comparable movement within nursing. This paper describes the development, implementation and initial hermeneutic evaluation of a new course, 'Understanding Caring Through Arts and Humanities' which we believe to be unique in being a fully accredited unit which is offered within a BA (Honours) Health Studies Degree for nurses and other health care professionals.

Skilled expert practice: is it 'all in the mind'? A response to English's critique of Benner's novice to expert model

In a recent critique of the work of Patricia Benner in relation to expertise, skilled intuitive grasp and the Dreyfus model of skill acquisition, English (Journal of Advanced Nursing 1993, vol. 18, pp. 387-393) uses the tenets of positivism and cognitive psychology to criticize Benner's work for lacking objectivity, validity, generalizability and predictive power. In this response to English's critique I show how he has misread, failed to read, and consequently misunderstood her work, and, equally importantly, its philosophical basis. Benner's work is developed from a philosophical foundation grounded in interpretive and Heideggerian phenomenology. This wholly different 'take' on the world and on human behaviour embodies a strong critique of those very same traditional-science worldviews which English uses to damn her work. English's critique is valuable in highlighting the ways in which Benner's work can be misrepresented and this response tries to remedy this misunderstanding by attempting to clarify the fundamental differences between phenomenological and cognitive understandings. These differences are crucial to understanding Dreyfus's and Benner's work. Here, I also attempt to correct some of English's wilder assertions regarding Benner's work. Finally, I try to show how Benner's work has empowered, enthused and challenged, rather than being 'denigrating to the majority of nurses'.

Successful treatment of invasive pulmonary aspergillosis in chronic granulomatous disease with orally administered itraconazole suspension

A 3-yr-old boy with known chronic granulomatous disease presented with a left-sided chest wall mass. Extensive intrathoracic and extrathoracic aspergillosis was confirmed by CT scan-guided percutaneous biopsy. Initially, he was treated intravenously with liposomal amphotericin and subcutaneous gamma-interferon, but his clinical condition deteriorated over 7 wk of treatment. The amphotericin was therefore discontinued, and itraconazole in an oral suspension was begun. There was progressive clinical improvement after 3 months of this regime, and marked radiologic clearing was apparent after 8 months of treatment. A multicenter trial of this mode of therapy in patients with invasive aspergillosis is indicated.

Parents, nurses and paediatric nursing: a critical review

The desirability of encouraging parents to live-in with their hospitalized child is widely accepted (Department of Health 1991). This review traces the historical development of parental involvement in paediatrics. The literature reviewed shows that parental participation and living-in has been viewed largely as philosophically and professionally unproblematic. These 'cardinal principles' of paediatric nursing have been advocated and operationalized with little or no attempt made to understand what living-in is like for either parents or for the nurses who work with them. It is proposed that research approaches in this area are required which are more hermeneutic and dialogic.

Chronic granulomatous disease presenting in childhood with Pseudomonas cepacia septicaemia

Two children who presented with fever, enlarged liver and spleen and ascites were found to have Pseudomonas cepacia septicaemia which proved fatal despite appropriate antibiotics and maximum supportive care. Chronic granulomatous disease of childhood (CGD) was subsequently diagnosed in both children. The possibility of CGD needs to be considered in any child with unexplained P. cepacia infection.