Ask, and it might be given unto you.
7 Nov, 08 | by Bob Phillips
The five steps of evidence based practice are commonly summarised as ‘Ask, Acquire, Appraise, Apply and Assess’. The first one of these - just asking a question - can prove terribly time consuming and difficult, but with a bit of dissection can be made much easier. The first step when deconstructing the anatomy of inquiry is to ask ‘What sort of question is being asked?’. If it’s about a clinical topic (not directions to the Pharmacy), then the questions can be grossly categorised as ‘foreground’ and ‘background’. Foreground questions are specific and pointed, and can be fitted into a ‘PICO’ frame [1]:Patient-problem, Intervention, Comparision, Outcome. An example might be ‘in bronchilitis [problem], is ipratropium [intervention] or salbutamol [comparison] better for improving respiratory distress? [outcome]‘ more…
In the window of the 
It’s my own question, this time, and throws up lots of annoying little things.
A blog post of questions that are calling out to be answered.
Jamie, 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. 
A 20 month old presented with 1-day history of temperature, off food and ‘not herself’. Clinical examination showed a slightly irritable child with temperature 38.80C, slightly congested throat and doubtful neck stiffness. An LP shows WCC 2, RCC 0. A diagnosis of viral illness is made, and antibiotics are not commenced.
What do you do if, accidentally, you scan the abdomen of a neonate and find nephrocalcinosis? Book them in for a transplant in a couple of years? Annual serum electrolytes, blood pressure & isotopic GFR measurement? Pretend you hadn’t seen it?
A 13 year old boy with a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) comes to the clinic with his mother for a review. He was started on atomoxetine 6 weeks prior to this visit for hyperactive/impulsive symptoms and poor concentration. The boy was admitted in the hospital one week ago for changed behaviour, disorientation, irrelevant speech and self-harming behaviour. He was reported as very aggressive and hostile towards other children and adults. In past use of stimulant medication was not considered because of the risk of abuse and drug diversion. Mother correlates this hospitalization due to side effect of atomoxetine. She asks your opinion about increased aggression and hostility related to atomoxetine .
It’s uncommon for us, as paediatricians, to be asked about how cost-effective our treatments are. Glancing at the media shows health stories about the new wonder drugs in adult cancer, or in Alzheimer’s disease, and how they are being restricted by a heartless and miserly health system. Where do these statements about ‘cost-effectiveness’ come from?