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diagnostics

Q: Irritating hip or rotting femur?

13 Aug, 08 | by Bob Phillips

Radiograph of Septic HipA 3 year old boy presents to the Emergency Department with a limp. He has been reluctant to weight bear on his right leg during the day and has a temperature of 37.9°C. Hip examination is painful. What clinical or laboratory tests could help discriminate between septic arthritis and transient synovitis?

Of course, you could just ring up orthopaedics and ask them to take him to theatre and wash out the hip - but you may not win many friends that way. How do you decide there is enough ‘clinical suspicion’ to make the call? more…

Q: Is an OGTT good enough for CF diabetes testing?

23 Jul, 08 | by Bob Phillips

Glucose Tolerance DrinkJamie, a 13-year-old girl with cystic fibrosis (CF), has been referred to the Paediatric Diabetes clinic because of an abnormal oral glucose tolerance test (OGTT) in her recent CF Annual Review. It showed impaired glucose tolerance. Continuous glucose monitoring system (CGMS) over three days showed normal fasting and pre-prandial glucose but frequent post-prandial glucose excursions between 11.1 mmol/l and 16.0 mmol/l. In retrospect, although Jamie’s previous OGTT carried out at Annual Review were normal, her lung function had gradually deteriorated over the past three years. This had been attributed to increasing episodes of infective exacerbations. You wondered for how long Jamie has had abnormal glucose metabolism which had gone undetected in her previous OGTT. more…

MRI-brain for microcephaly?

19 Mar, 08 | by Bob Phillips

Boy with microcephalyA 7-year-old boy was referred for medical assessment as part of the process of producing a statement of special educational needs. There had been no medical concerns in the past and there was no family history of note. On examination, the boy was noted to be micro cephalic with head circumference on the 0.4th centile, while his height and weight were on the 50th centile. Neurological examination was normal. Should this boy be referred for an MRI scan of the brain? more…

Q: FRAX testing for Autistic Boys?

19 Feb, 08 | by Bob Phillips

FMR1 geneYou diagnose a 5-year-old with Autistic spectrum disorder. His examination is unremarkable and there is no family history of learning difficulties. Should you perform a molecular genetic screen for FMR1 mutations (fragile X)?

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Disease spectrum vs disease prevalence

5 Feb, 08 | by Bob Phillips

Unrinalysis setIn examining a diagnostic test, we make the assumption that the characteristics of the test - its sensitivity and specificity (or likelihood ratios, the way I prefer to think) - will stay constant across different populations, although the positive and negative predictive values will change * . This is sort of true, and sort of false.

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Question: How to diagnose and treat pyelonephritis

28 Nov, 07 | by Bob Phillips

Renal USS - spot the bad oneIn children suspected of having a UTI, what clinical and radiological features diagnoses pylonephritis, and what mode of antibiotic treatment is necessary to produce clinical improvement and avoid chronic renal impairment?

With the publication of the NICE guidance in the UK on the management of UTI in childhood, many paediatricians have been spurred to review their understanding of the evidence underpinning certain aspects of the clinical pathway. more…

Question: Hip scans for clubfoot babies?

26 Nov, 07 | by Bob Phillips

Club feetDo infants born with an isolated clubfoot (talipes equinovarus) require radiological investigations to rule out congenital hip dysplasia?
You are a neonatal SHO. The midwife asks you to see a term baby who has just been born. She has noticed the baby to have a clubfoot and wants you to examine the baby.Physical examination confirms a clubfoot and there are no other abnormalities. Both hips are stable on clinical examination using the Ortolani and Barlow’s test.

Your registrar asks you to request a hip ultrasound or hip X-ray for this baby to rule out DDH. You are not used to this practice and decide to appraise the evidence behind it. more…

New things in evidence synthesis

20 Sep, 07 | by Bob Phillips

A Real Forest PlotThe days of a meta-analysis being the simple adding up of lots of studies, pretending that they are all just tiny pieces of the One Big Trial that was performed before the world was made are on their way out. Newer ways of using synthesised evidence - like meta-regression and individual patient data analysis - are coming up quickly.

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Unanswered Question: Do children with autism and developmental regression need EEG investigation in the absence of clinical seizures?

31 Jul, 07 | by BMJ Group

John diagnosed with autism at 18 months old presents to your developmental clinic at 30 months old. His mother reports developmental regression of previously acquired developmental milestones. He has now lost his previously acquired language skills and only makes incomprehensible babbles. He is otherwise clinically well and does not have any clinical seizures. You wonder whether an electroencephalogram (EEG) should be performed on John to rule out possible underlying subclinical epilepsy that may contribute to his developmental regression.

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Unanswered Question: Is LDH a good predictor of malignancy in children?

30 Jul, 07 | by BMJ Group

A four-year old girl presents to the accident and emergency department with a history of being generally unwell for the preceding week and on examination is found to have cervical lymphadenopathy. In addition to a volley of tests, a Lactate Dehydrogenase (LDH) was requested by a registrar who had read that this was a predictor of malignancy which came back as 1,750. Should this be seen as suggestive of underlying malignancy? more…

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