Contrary to what is claimed by Solomon-Moore et al., [1] the study by Van der Werf et al., (reference 17) [2] found little evidence of a boom and bust activity pattern in adult patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). The Dutch researchers measured physical activity using actimeters worn for 12 consecutive days. There was no significant difference in day-to-day fluctuations in physical activity between ME/CFS patients and controls. The peak amplitude and peak duration of physical activity were larger in controls than in ME/CFS patients while the latter had longer rest duration after an activity peak. Another actimeter study [3] found no supporting evidence of a more fluctuating activity pattern in patients with ME/CFS compared to controls, during the day, nor during consecutive days. Now, Solomon-Moore et al. report that in children and adolescents with ME/CFS, no fluctuating active or boom-bust physical activity pattern could be identified.
It would be helpful if the authors could clarify how the actimeter data impacted the treatments in the MAGENTA trial. According to the trial protocol [4], one of the interventions aimed to “convert a boom–bust pattern of activity (lots 1 day and little the next) to a baseline with the same da...
Contrary to what is claimed by Solomon-Moore et al., [1] the study by Van der Werf et al., (reference 17) [2] found little evidence of a boom and bust activity pattern in adult patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). The Dutch researchers measured physical activity using actimeters worn for 12 consecutive days. There was no significant difference in day-to-day fluctuations in physical activity between ME/CFS patients and controls. The peak amplitude and peak duration of physical activity were larger in controls than in ME/CFS patients while the latter had longer rest duration after an activity peak. Another actimeter study [3] found no supporting evidence of a more fluctuating activity pattern in patients with ME/CFS compared to controls, during the day, nor during consecutive days. Now, Solomon-Moore et al. report that in children and adolescents with ME/CFS, no fluctuating active or boom-bust physical activity pattern could be identified.
It would be helpful if the authors could clarify how the actimeter data impacted the treatments in the MAGENTA trial. According to the trial protocol [4], one of the interventions aimed to “convert a boom–bust pattern of activity (lots 1 day and little the next) to a baseline with the same daily amount”. Was this aspect removed from the intervention now that participants showed little indication of a boom–bust activity pattern? Or were young ME/CFS patients instructed to correct illness behavior they did not display when tested objectively?
Solomon-Moore et al., [1] also report that 9.4% of participants achieved government recommended levels of physical activity for children and adolescents, namely a minimum of 60 minutes of moderate to vigorous physical activity per day. This is of interest given that approximately half of healthy children and adolescents do not reach this target. [1] These results indicate that activity patterns are unlikely to be a key factor in perpetuating ME/CFS symptoms, at least for this subgroup. Nonetheless, one of the interventions in the MAGENTA trial aims for a gradual increase in physical activity by prescribing exercise targets. Were ME/CFS patients who already met government health recommendations for physical activity also instructed to increase their amount of exercise by 10-20% a week or were they exempted?
I look forward to reading the authors’ response to these questions.
References
[1] Solomon-Moore E, Jago R, Beasant L, Brigden A, Crawley E. Physical activity patterns among children and adolescents with mild-to-moderate chronic fatigue syndrome/myalgic encephalomyelitis. BMJ Paediatr Open. 2019 May 2;3(1):e000425. 2019.
[2] van der Werf SP, Prins JB, Vercoulen JH, et al. Identifying physical activity patterns in chronic fatigue syndrome using actigraphic assessment. J Psychosom Res 2000;49:373–9.
[3] Meeus M, van Eupen I, van Baarle E, De Boeck V, Luyckx A, Kos D, et al. Symptom fluctuations and daily physical activity in patients with chronic fatigue syndrome: a case-control study. Arch Phys Med Rehabil. 2011 Nov;92(11):1820-6.
[4] Brigden A, Beasant L, Hollingworth W, et al. Managed activity graded exercise iN teenagers and pre-Adolescents (magenta) feasibility randomised controlled trial: study protocol. BMJ Open 2016;6:e011255.
This is another article on the potential risks of using hypotonic intravenous solutions and the perceived risk of promoting hyponatraemia. I am concerned that this, as with other publications on the topic, uses the term "maintenance fluids" when the fluid being prescribed is also serving the role of "resuscitation" and/or "replacement". While this study may not have seen any cases of hypernatraemia in patients receiving 0.9% saline, we have. The idea that the prescription of just one type of fluid i.e. an isotonic one, is suitable in all paediatric patients covered by this studies' selection criteria reflects laziness on the part of the doctor.
For accurate prescribing of intravenous fluid, the doctor should think of three different requirements:
1. Resuscitation fluid
2. Replacement fluid
3. Maintenance fluid
Resuscitation fluid is administered to correct a deficit in the ECF volume. I wonder if this study tries to eliminate this by excluding children with "urinary osmolarity greater than 100 mOsm/kg and a weight change >2% in the first 24 hours". Unfortunately it is not clear by how much the 48 hour study period of fluid administration overlapped with the first 24 hours of admissi...
This is another article on the potential risks of using hypotonic intravenous solutions and the perceived risk of promoting hyponatraemia. I am concerned that this, as with other publications on the topic, uses the term "maintenance fluids" when the fluid being prescribed is also serving the role of "resuscitation" and/or "replacement". While this study may not have seen any cases of hypernatraemia in patients receiving 0.9% saline, we have. The idea that the prescription of just one type of fluid i.e. an isotonic one, is suitable in all paediatric patients covered by this studies' selection criteria reflects laziness on the part of the doctor.
For accurate prescribing of intravenous fluid, the doctor should think of three different requirements:
1. Resuscitation fluid
2. Replacement fluid
3. Maintenance fluid
Resuscitation fluid is administered to correct a deficit in the ECF volume. I wonder if this study tries to eliminate this by excluding children with "urinary osmolarity greater than 100 mOsm/kg and a weight change >2% in the first 24 hours". Unfortunately it is not clear by how much the 48 hour study period of fluid administration overlapped with the first 24 hours of admission. Table 1 has a figure for "Time at study enrolment" without a unit but I assume this is hours from admission. From this I take it that patients are a mean of five and six hours into their admission in the two groups. If these patients are ill then I wonder if some may have been hypovolaemic and in whom it would clearly be inappropriate to administer a hypotonic solution.
If replacement of ongoing fluid losses, in excess of those normally encountered, is required then the intravenous fluid used should match the composition and volume of the losses. Given that 80 of the 294 patients were post-surgical it might be that replacement fluid was required in some of these patients but again this is not clear from the paper. It is also not clear how many of the patients were sick enough to require intensive care.
The term "maintenance fluid" should be reserved for that administered to replicate the fluid that the patient would normally be drinking but for a variety of reasons may not be able to ingest. It is given to "maintain" euvolaemia. If reserved for this purpose then "maintenance" fluid does not need to be isotonic given that normal fluid losses do not come anywhere near a sodium concentration of 150 mmol/L. Healthy kidneys can reduce sodium excretion to virtually zero.
The concern about using hypotonic solutions centres around the notion that the syndrome of inappropriate anti-diuretic hormone secretion (SIADH) is a common phenomenon and administration of hypotonic solutions will cause hyponatraemia. However I would contend that SIADH is overdiagnosed and when ADH levels are raised it is usually appropriate i.e. ADH is being produced in response to ECF volume contraction. In that situation an isotonic solution is required. Once ECF volume has been restored ADH production will be switched off and continuing use of isotonic solutions will risk causing hypernatraemia. It mystifies me as to what evolutionary drive there can be for the body to want to produce ADH in the situations that are supposedly associated with SIADH.
In summary, prescription of intravenous fluids should only be made after a careful assessment of the patient, in particular their ECF volume status. If there is suspicion that it is reduced an isotonic solution should be administered. If there are ongoing losses they should be replaced by a solution best matching the fluid being lost. If it is not possible to establish the electrolyte content of the fluid losses an isotonic solution is advised. Once ECF volume is replete then a hypotonic solution should be given and on our ward we would use 0.45% saline + 2.5% dextrose. This is still providing more sodium than is normally recommended if giving fluids orally or in TPN. Unfortunately ECF volume status is notoriously difficult to assess and if there is doubt isotonic solutions will be safer. However if 0.9% sodium chloride continues to be administered as "maintenance" fluid we will see cases of hypernatraemia. Whatever strategy is adopted it is essential to monitor serum electrolytes at least daily in children receiving a significant (>50%) proportion of their fluids intravenously.
There is ongoing debate about the volume of "maintenance" fluid we should be giving children. Currently this is based on recommendations made by Holliday and Segar in the 1950’s, matching fluid requirement to energy expenditure. It is now recognised that these do not reflect the fluid requirements of unwell children lying in bed and as a result “maintenance” fluid volume prescriptions may be twice what they should be. The prescription of more water than is needed is potentially a contributing factor to hypotonic solutions producing hyponatraemia - the prescribing of too much water rather than too little sodium.
I spend 2 years training junior soldiers. I have to say it was the most rewarding job I had in the army, taking 16 year olds from all parts of Scotland we turned these youths in to proud, responsible, enthusiastic young men. These men and their families would be the first to support the system ! Many of them went on to senior positions in their regiments.
It is madness to deprive young people of these opportunities based on politically motivated medical mumbo jumbo. With the current youth/knife crime crisis most intelligent folk say kids need some form of structure and opportunity in their lives.
To the Editor: Dr. Wyller and his research team are to be commended for their efforts to validate the Systemic Exertion Intolerance Disease (SEID) criteria (1). As a co-author of the US National Academy of Medicine (NAM, the new name for the Institute of Medicine) report (2), I encourage testing of it and have written about how, without a diagnostic gold standard test, case definitions could be judged by whether they help clinicians and researchers prevent, understand, treat, or predict the course of a medical condition (3). There are a two concerns I have about this study.
First, Wyller et al. noted that 39% of their subjects (45 out of 115) qualified for the SEID criteria while 61% did not. What were the most common reasons for why subjects did not qualify for the SEID criteria? Were these primarily qualitative reasons, where the SEID group were more likely to suffer from a particular symptom at all, or a quantitative one, where, for example, both groups experienced the same symptoms but the former experienced them at a higher intensity? Understanding these differences would lend further context to their results and assist in future refinement of any ME/CFS criteria.
Second, although the authors acknowledge lack of a PEM-specific item in their study, I wish to re-emphasize that post-exertional fatigue is not equivalent to post-exertional malaise. As described in the NAM report, PEM is not only increased fatigue following activity but also involves exa...
To the Editor: Dr. Wyller and his research team are to be commended for their efforts to validate the Systemic Exertion Intolerance Disease (SEID) criteria (1). As a co-author of the US National Academy of Medicine (NAM, the new name for the Institute of Medicine) report (2), I encourage testing of it and have written about how, without a diagnostic gold standard test, case definitions could be judged by whether they help clinicians and researchers prevent, understand, treat, or predict the course of a medical condition (3). There are a two concerns I have about this study.
First, Wyller et al. noted that 39% of their subjects (45 out of 115) qualified for the SEID criteria while 61% did not. What were the most common reasons for why subjects did not qualify for the SEID criteria? Were these primarily qualitative reasons, where the SEID group were more likely to suffer from a particular symptom at all, or a quantitative one, where, for example, both groups experienced the same symptoms but the former experienced them at a higher intensity? Understanding these differences would lend further context to their results and assist in future refinement of any ME/CFS criteria.
Second, although the authors acknowledge lack of a PEM-specific item in their study, I wish to re-emphasize that post-exertional fatigue is not equivalent to post-exertional malaise. As described in the NAM report, PEM is not only increased fatigue following activity but also involves exacerbation of other symptoms, like muscle/joint pain, problems sleeping, headaches, cognitive dysfunction, sore throats, tender lymph nodes, and flu-like feelings (1). Furthermore, PEM can be delayed by hours to days relative to the triggering event and last hours, days, and even longer. In a recent survey (4) of almost 800 patients, over 90% endorsed the NAM’s description of PEM. In contrast, almost 70% felt that Dr. Jason’s conception of PEM, with its focus on fatigue (5) and lack of time-related characteristics, did not match their experiences. If PEM is conceived of as only post-exertional fatigue and chronological traits are not accounted for, study participants who do not actually experience PEM may be mis-classified as fitting the SEID criteria. The NAM report recognized that, currently, no short, accurate questionnaire exists for identifying PEM and strongly urged development of one.
References:
1. Asprusten TT, Sulheim D, Fagermoen E, et al. Systemic exertion intolerance disease diagnostic criteria applied on an adolescent chronic fatigue syndrome cohort: evaluation of subgroup differences and prognostic utility. BMJ Paediatrics Open. 2018;2(1):e000233. doi:10.1136/bmjpo-2017-000233.
2. United States National Academy of Medicine Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome. Beyond myalgic encephalomyelitis/ chronic fatigue syndrome: redefining an illness. National Academies Press. https://www.nap.edu/read/19012/chapter/1. Published February 2015. Accessed April 2018.
3. Chu L, Valencia IJ, Montoya JG. Differences of opinion on systemic exercise intolerance disease are not ‘mistakes’: a rejoinder to Jason Sunnquist, Gleason and Fox, Fatigue: Biomedicine, Health & Behavior. 2017; 5(4):239-244. doi: 10.1080/21641846.2017.1362750.
4. United States National Institutes of Health National Institute of Neurologic Disorders and Stroke Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome Common Data Elements Project. Public comments, p. 87-89 and p.128-142. US National Institutes of Health. https://www.nih.gov/sites/default/files/research-training/initiatives/me.... Published March 2018. Accessed April 2018.
5. Jason LA, Sunnquist M, Kot B, et al. Unintended Consequences of not Specifying Exclusionary Illnesses for Systemic Exertion Intolerance Disease. Kjaer A, ed. Diagnostics. 2015;5(2):272-286. doi:10.3390/diagnostics5020272.
We thank Professor Gorodischer and colleagues for their comments on our article on Access for Health Care for children in Palestine.
We believe that politics and health are inextricably intertwined, and this view is shared by WHO in the Commission on Social Determinants of Health and by many commentators such as Professor David Hunter https://www.bmj.com/content/350/bmj.h1214
We consider that health is politically determined and this is evident in relation to public health issues such as the role of the tobacco industry in smoking, the role of the food industry in nutrition, and the relevance of pharmaceutical industry funding of politicians in determining health policy in the USA.
In relation to the connection between the occupation of Palestine and the health of its population, this is not controversial but is a fact, corroborated by WHO, UN, UNRWA, the Lancet and many non-governmental organisations such as Medical Aid to the Palestinians. For example - http://www.emro.who.int/palestine-press-releases/2017/who-releases-lates... https://www.un.org/press/en/2012/gapal1234.doc.htm ...
We thank Professor Gorodischer and colleagues for their comments on our article on Access for Health Care for children in Palestine.
We believe that politics and health are inextricably intertwined, and this view is shared by WHO in the Commission on Social Determinants of Health and by many commentators such as Professor David Hunter https://www.bmj.com/content/350/bmj.h1214
We consider that health is politically determined and this is evident in relation to public health issues such as the role of the tobacco industry in smoking, the role of the food industry in nutrition, and the relevance of pharmaceutical industry funding of politicians in determining health policy in the USA.
In relation to the connection between the occupation of Palestine and the health of its population, this is not controversial but is a fact, corroborated by WHO, UN, UNRWA, the Lancet and many non-governmental organisations such as Medical Aid to the Palestinians. For example - http://www.emro.who.int/palestine-press-releases/2017/who-releases-lates... https://www.un.org/press/en/2012/gapal1234.doc.htm https://www.map.org.uk/news/archive/post/703-who-report-barriers-to-heal... https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60200-7/fulltext
We see the lack of agreement on this issue by Israeli paediatricians as very disappointing, as their role is paramount in bringing about the end of the occupation.
In relation to the working together between Israeli and Palestinian paediatricians and other health workers, this was indeed a valuable initiative in the past and we like to believe that in future after the end of the occupation such collaboration and partnership will again be the norm. A recent WHO report (August 2017) highlighted the continuing difficulties facing patients in Gaza who require hospital treatment in Israel, and these can sometimes lead to tragedy http://www.emro.who.int/images/stories/palestine/documents/WHO_monthly_G...
• 45% of patients delayed/denied security permits by Israeli authorities [at the Erez checkpoint]
• Five cancer patients died while awaiting security permits to travel for health care
• Case study: Jehad, a 24-year-old patient with Hodgkin’s lymphoma, is unable to access diagnostics and treatment outside of Gaza after nine applications to exit through Erez checkpoint.
From this report and many others it is evident that the political situation is the major obstacle to comprehensive access to health care for Palestinians.
We concur with the authors that the health care of Palestinian children is far from desirable, and for many of them, particularly in Gaza, has even tragic consequences.
However, the article has a clear political agenda, which is openly indicated in its last sentence. The authors chose to ignore the complex geopolitical circumstances in the area and the article is far from presenting an objective description of the situation.
The authors mention the following providers of medical care for Palestinian children: UNRWA, Non- governmental organizations, Palestinian Red Crescent and the private sector. They fail to mention Israel as a health care provider: although following the 1993 Oslo Accord, responsibilities of health care were transferred from Israel to the Palestinian territory, every year over 160,000 Palestinians from the occupied territories receive medical treatment in Israel 1,2. Prior to the year 2005, when the Palestinian Authority took over the Gaza administration, pediatricians from the Gaza Al-Shifa
Hospital came to the Soroka University Medical Center Pediatric Department in Beer-Sheva, Israel, for various periods of professional update, and pediatricians from the Israeli hospital periodically joined clinical rounds at the Al-Shifa Hospital Pediatric Department; often mutual friendly professional relations developed among pediatricians of both hospitals.
We refrain from debating here the authors...
We concur with the authors that the health care of Palestinian children is far from desirable, and for many of them, particularly in Gaza, has even tragic consequences.
However, the article has a clear political agenda, which is openly indicated in its last sentence. The authors chose to ignore the complex geopolitical circumstances in the area and the article is far from presenting an objective description of the situation.
The authors mention the following providers of medical care for Palestinian children: UNRWA, Non- governmental organizations, Palestinian Red Crescent and the private sector. They fail to mention Israel as a health care provider: although following the 1993 Oslo Accord, responsibilities of health care were transferred from Israel to the Palestinian territory, every year over 160,000 Palestinians from the occupied territories receive medical treatment in Israel 1,2. Prior to the year 2005, when the Palestinian Authority took over the Gaza administration, pediatricians from the Gaza Al-Shifa
Hospital came to the Soroka University Medical Center Pediatric Department in Beer-Sheva, Israel, for various periods of professional update, and pediatricians from the Israeli hospital periodically joined clinical rounds at the Al-Shifa Hospital Pediatric Department; often mutual friendly professional relations developed among pediatricians of both hospitals.
We refrain from debating here the authors' political agenda, as we do not believe that a medical journal is the appropriate forum to discuss political issues.
Israeli pediatricians have provided, provide and will continue to provide the best possible medical care to Palestinian children in their power.
Michiel Tack
Email Address *
tackmichiel@gmail.com
Occupation *
ME/CFS patient
Affiliation *
Independent researcher
Contrary to what is claimed by Solomon-Moore et al., [1] the study by Van der Werf et al., (reference 17) [2] found little evidence of a boom and bust activity pattern in adult patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). The Dutch researchers measured physical activity using actimeters worn for 12 consecutive days. There was no significant difference in day-to-day fluctuations in physical activity between ME/CFS patients and controls. The peak amplitude and peak duration of physical activity were larger in controls than in ME/CFS patients while the latter had longer rest duration after an activity peak. Another actimeter study [3] found no supporting evidence of a more fluctuating activity pattern in patients with ME/CFS compared to controls, during the day, nor during consecutive days. Now, Solomon-Moore et al. report that in children and adolescents with ME/CFS, no fluctuating active or boom-bust physical activity pattern could be identified.
It would be helpful if the authors could clarify how the actimeter data impacted the treatments in the MAGENTA trial. According to the trial protocol [4], one of the interventions aimed to “convert a boom–bust pattern of activity (lots 1 day and little the next) to a baseline with the same da...
Show MoreGraham, Smith
Email Address * smithgc@cardiff.ac.uk
Occupation * Consultant Paediatric Nephrologist
Affiliation * University Hospital of Wales
This is another article on the potential risks of using hypotonic intravenous solutions and the perceived risk of promoting hyponatraemia. I am concerned that this, as with other publications on the topic, uses the term "maintenance fluids" when the fluid being prescribed is also serving the role of "resuscitation" and/or "replacement". While this study may not have seen any cases of hypernatraemia in patients receiving 0.9% saline, we have. The idea that the prescription of just one type of fluid i.e. an isotonic one, is suitable in all paediatric patients covered by this studies' selection criteria reflects laziness on the part of the doctor.
For accurate prescribing of intravenous fluid, the doctor should think of three different requirements:
1. Resuscitation fluid
2. Replacement fluid
3. Maintenance fluid
Resuscitation fluid is administered to correct a deficit in the ECF volume. I wonder if this study tries to eliminate this by excluding children with "urinary osmolarity greater than 100 mOsm/kg and a weight change >2% in the first 24 hours". Unfortunately it is not clear by how much the 48 hour study period of fluid administration overlapped with the first 24 hours of admissi...
Show MoreI spend 2 years training junior soldiers. I have to say it was the most rewarding job I had in the army, taking 16 year olds from all parts of Scotland we turned these youths in to proud, responsible, enthusiastic young men. These men and their families would be the first to support the system ! Many of them went on to senior positions in their regiments.
It is madness to deprive young people of these opportunities based on politically motivated medical mumbo jumbo. With the current youth/knife crime crisis most intelligent folk say kids need some form of structure and opportunity in their lives.
To the Editor: Dr. Wyller and his research team are to be commended for their efforts to validate the Systemic Exertion Intolerance Disease (SEID) criteria (1). As a co-author of the US National Academy of Medicine (NAM, the new name for the Institute of Medicine) report (2), I encourage testing of it and have written about how, without a diagnostic gold standard test, case definitions could be judged by whether they help clinicians and researchers prevent, understand, treat, or predict the course of a medical condition (3). There are a two concerns I have about this study.
First, Wyller et al. noted that 39% of their subjects (45 out of 115) qualified for the SEID criteria while 61% did not. What were the most common reasons for why subjects did not qualify for the SEID criteria? Were these primarily qualitative reasons, where the SEID group were more likely to suffer from a particular symptom at all, or a quantitative one, where, for example, both groups experienced the same symptoms but the former experienced them at a higher intensity? Understanding these differences would lend further context to their results and assist in future refinement of any ME/CFS criteria.
Second, although the authors acknowledge lack of a PEM-specific item in their study, I wish to re-emphasize that post-exertional fatigue is not equivalent to post-exertional malaise. As described in the NAM report, PEM is not only increased fatigue following activity but also involves exa...
Show MoreWe thank Professor Gorodischer and colleagues for their comments on our article on Access for Health Care for children in Palestine.
Show MoreWe believe that politics and health are inextricably intertwined, and this view is shared by WHO in the Commission on Social Determinants of Health and by many commentators such as Professor David Hunter https://www.bmj.com/content/350/bmj.h1214
We consider that health is politically determined and this is evident in relation to public health issues such as the role of the tobacco industry in smoking, the role of the food industry in nutrition, and the relevance of pharmaceutical industry funding of politicians in determining health policy in the USA.
In relation to the connection between the occupation of Palestine and the health of its population, this is not controversial but is a fact, corroborated by WHO, UN, UNRWA, the Lancet and many non-governmental organisations such as Medical Aid to the Palestinians. For example -
http://www.emro.who.int/palestine-press-releases/2017/who-releases-lates...
https://www.un.org/press/en/2012/gapal1234.doc.htm
...
To the Editor,
BMJ Open
We concur with the authors that the health care of Palestinian children is far from desirable, and for many of them, particularly in Gaza, has even tragic consequences.
However, the article has a clear political agenda, which is openly indicated in its last sentence. The authors chose to ignore the complex geopolitical circumstances in the area and the article is far from presenting an objective description of the situation.
The authors mention the following providers of medical care for Palestinian children: UNRWA, Non- governmental organizations, Palestinian Red Crescent and the private sector. They fail to mention Israel as a health care provider: although following the 1993 Oslo Accord, responsibilities of health care were transferred from Israel to the Palestinian territory, every year over 160,000 Palestinians from the occupied territories receive medical treatment in Israel 1,2. Prior to the year 2005, when the Palestinian Authority took over the Gaza administration, pediatricians from the Gaza Al-Shifa
Hospital came to the Soroka University Medical Center Pediatric Department in Beer-Sheva, Israel, for various periods of professional update, and pediatricians from the Israeli hospital periodically joined clinical rounds at the Al-Shifa Hospital Pediatric Department; often mutual friendly professional relations developed among pediatricians of both hospitals.
Show MoreWe refrain from debating here the authors...
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