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Leave appendiceal masses alone.

27 Feb, 08 | by Bob Phillips

Acute appendicitisA 5 year old boy was admitted to a rural New Zealand hospital with 10 day history of abdominal pain. The pain was localised to the RIF with guarding and examination revealed a palpable mass in the RIF. He had previously presented with a 1 day history of severe abdominal pain and fever and had been discharged the following day with a diagnosis of gastroenteritis. He was transferred to the tertiary hospital and a diagnosis was made on ultrasound scan of appendiceal mass with abscess. His condition was stable. He was commenced on conservative management and supportive care with intravenous (iv) antibiotics followed by a 2 week course of oral antibiotics. He responded well to conservative management and was scheduled for appendectomy after an interval of 6-8 weeks. You wonder whether it is necessary, now he is well, for him to have an appendectomy.

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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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No dental antibiotic prophylaxis for VP shunts.

12 Feb, 08 | by Bob Phillips

During a routine clinic follow-up, a patient with an indwelling ventriculo-peritoneal shunt enquires whether prophylactic antibiotics are necessary prior to routine dental hygiene work. He produces a letter from his dentist enquiring the same.

Dr Max Nathan of Morriston Hospital, Swansea, UK has had this happen … has it happened to you? And what did you do?

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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: Melatonin for ADHD?

11 Jan, 08 | by Bob Phillips

Melatonin Room

Does melatonin improve sleep pattern in children with Attention Deficit Hyperactivity Disorder?

Adam is an 8 year old boy with Attention Deficit Hyperactivity Disorder (ADHD) who you see with his mother in your paediatric outpatient clinic. She explains that life is being made increasingly stressful for the whole family as Adam is having difficulty getting off to sleep. It often takes him several hours to calm down and go to sleep, and the day after he gets angry and seems to be tired all the time. She has seen a recent TV programme that suggested that melatonin may be helpful for children with ADHD.
Are the television producers correct? If melatonin is prescribed for Adam, will it be harmful or helpful in improving his sleep?

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Crystal balls

7 Jan, 08 | by Bob Phillips

Crystal BallIt’s a great sport of journalists and commentators to look back at predictions of the future from decades past, and see just how badly they have gone astray. We do this as clinicians too, but with a sense of guilt … looking back to an unexpected relapse of a low-risk tumour, or a fulminant hepatitis that presented with mild nausea, and ask ‘Why didn’t we predict that?”. more…

Question: ECMO - any benefit for neonates?

10 Dec, 07 | by Bob Phillips

ECMO kitDoes extra-corporeal membrane oxygenation improve survival for severely unwell neonates with Congenital Diaphragmatic Hernia?

A neonate on the intensive care unit with an isolated congenital diaphragmatic hernia is failing on conventional ventilation. There are no exclusion criteria for extra-corporeal membrane oxygenation (ECMO). Should the neonate be transferred for ECMO?
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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…

Question: Aciclovir for herpetic gingivostomatisis?

22 Nov, 07 | by Bob Phillips

ACV moleculeDoes oral aciclovir improve clinical outcome in immunocompetent children with primary herpes simplex gingivostomatitis?

A 3 year old previously well boy presents with a fever of 38.6ºc and several ulcers and erosions extending from his lips, along the tongue and cheek, to the back of the throat. The lesions have all appeared within the last 2 days. He has been crying inconsolably over the past 24 hours and is refusing food and drink. Is the use of oral aciclovir is indicated for primary herpes gingivostomatitis in children?

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