HEADS UP

Oncologists are often accused of being reluctant to initiate palliative care when cure becomes unlikely. There are few studies comparing oncologists' views with parental views in this situation. A Toronto group interviewed 77 parents whose children aged 6–14 years were considered by their attending physician to have ‘no reasonable chance of cure’, defined as <5% chance of long-term survival, and 128 health-care professionals in oncology.1 Significantly more parents (54.5%) than health-care professionals (15.6%) favoured chemotherapy over palliative care (P < 0.0001). Parents ranked hope and quality of life equally as the most important factors influencing their choice, followed by survival time. Health-care professionals ranked quality of life first, then survival time. The physician's and the child's opinions strongly influenced the parents' preference while the health-care professionals' decision was influenced by the opinions of parents and child. These somewhat surprising findings may help oncologists understand parental attitudes to end-of-life decision-making and palliative care. Reviewer: David Isaacs, david.isaacs@health.nsw.gov.au This article1 reports interim efficacy and safety results from a randomised controlled trial of a candidate malaria vaccine in seven African countries. The vaccine targets the circumsporozoite protein on the surface of the malaria parasite. Two age groups recruited (6–12 weeks and 5–17 months) were randomised to receive three doses of either malaria vaccine or a non-malarial comparator vaccine. In the 12 months following the third dose of vaccine for the first 6000 children in the older age group, vaccine efficacy in preventing a first episode of clinical malaria was 55.8% (97.5% CI, 50.6 to 60.4) (see Figure). Vaccine efficacy against severe malaria was 47.3% (95% CI, 22.4 to 64.2). Malaria-related mortality was extremely low in the study (10 deaths in total), attributed to improved access to high-quality care, so any effect on malaria mortality could not be assessed. Both meningitis and febrile convulsions were reported more frequently in the malaria vaccine group but neither reached statistical significance. Immunity appeared to wane over the 12-month surveillance period, indicating the likely need for an 18-month booster dose, which is included in the overall study design. This vaccine has real potential to substantially decrease the global burden of malaria. However, until vaccine efficacy approaches 100%, other effective interventions (e.g. insecticide-treated bed-nets, insecticide spraying) will continue to play an important role. Reviewers: Karen Kiang, Karen.Kiang@rch.org.au; Andrew Steer, Andrew.Steer@rch.org.au; David Burgner, david.burgner@mcri.edu.au The role of cats and dogs in allergy is controversial. The authors examined 636 children of atopic parents annually from 1 year of age and performed skin prick testing (SPT).1 At 4 years of age, 90 children (14%) had eczema. Dog ownership before 1 year of age reduced the risk of eczema by 60% compared with no dog (odds ratio (OR) = 0.4, 95% CI 0.2–0.7). Children with no dog in the home before 1 year who were or became SPT positive to dog had a 3.9-fold increased risk of eczema, but this was only 30 of the 325 children with no dog, and does not imply causation. In contrast, cat ownership before 1 year was associated with an OR of 1.0 (0.6–1.7) of developing eczema. Of the 121 children with a cat in the home at 1 year, 13 became skin test positive and seven (57%) developed eczema, so although the OR for skin positivity with a cat in the home was 13.3, this only refers to a very small number of children. This study suggests that dog ownership may protect infants against developing eczema. Cat ownership does not affect the risk of eczema, although cat sensitisation is associated with eczema in a small number of children. However, this is only one of many studies, causation is unproven and killing cats is illegal. Reviewers: David Isaacs, david.isaacs@health.nsw.gov.au; Nick Wood, NicholW3@chw.edu.au Refugees exposed to trauma often decline stress counselling and it is unknown whether such counselling might even exacerbate symptoms by reigniting traumatic memories. It is estimated that about a quarter of a million children are currently fighting in wars in 14 countries worldwide. A fascinating study of children abducted by the Lord's Resistance Army in Northern Uganda and now living in local camps provides strong evidence backing narrative therapy.1 A survey discovered 474 former child soldiers, now aged 12 to 25, of whom 85 (18%), 47 female, were identified by screening as having post-traumatic stress disorder (PTSD). They were randomised to one of three arms: individual narrative therapy, academic catch-up or waiting list (controls). The two treatment arms consisted of eight 90–120 min sessions over 3 weeks given in the home by intensively trained lay counsellors. Narrative therapy involved going over the young person's trauma history chronologically to habituate them to traumatic events. Academic catch-up, comprising an intensive English education course with supportive counselling, was provided because many youngsters identified interrupted education as a major problem. At 12 months, the proportion of each group who no longer fulfilled PTSD criteria was significantly better for narrative therapy (68%) than for academic catch-up (52.2%) or controls (53.6%). Narrative exposure therapy also reduced severity of symptoms and helped reduce depression, suicidal ideation and feelings of guilt significantly better than controls or academic catch-up. Reviewer: David Isaacs, david.isaacs@health.nsw.gov.au

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