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Highlights from this issue
Once again in Education and Practice we try to balance the things that you need to know just in case, and the specific information you need to be able to find just in time. This latter is harder for a specific journal to do, but perhaps more important. We have an excellent paper this month, my editor's choice, where Malik et al (see page 82) describe a 15 min consultation in the child with a facial paralysis. With respect to the authors of my previous favourite on this subject, this newer paper leapfrogs to the top, and will be a paper that I read several times; first now, and then each time I need to manage such a child. This seems to happen too infrequently for me to be able to fully remember whether I am supposed to treat Bell's palsy with steroids or not. This paper...
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15 minute consultation: a structured approach to the management of facial paralysis in a child
Objective
To present a structured approach for an outpatient consultation of a child with facial paralysis.
Method
Review of literature and description of approach followed in our unit.
Conclusion
A focused history and examination is key to establish the cause and draw a management plan for paediatric facial paralysis.
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What I've learned from BMJ Case Reports: Pains in the neck
In this next instalment of what I have learnt over on BMJ Case Reports, I thought I would take a ‘things located in the neck’ tack and following this theme I have found three cases that indicate conditions that perhaps could be added to your differential diagnosis list. Late onset group B streptococcal (GBS) disease can initially present as submandibular swelling and cellulitis. This was demonstrated in a 6-week-old baby who was initially treated for the cellulitic infection. I will now be keeping this in the back of my mind, as it may be the only initial sign in the presentation of GBS sepsis. Castleman's disease is a differential diagnosis for mediastinal masses as evidenced by a 19-year-old man. The disease is characterised by lymph node hyperplasia and vascular proliferation with hypersecretion of interleukin 6 and consequently can present with the classic B symptoms seen in lymphoma. ...
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Transition to adult services
The lack of focus on young people as a group with particular healthcare needs in medical training and the health service underpins the difficulty that we have experienced as a profession in improving transition in the UK. This article discusses current progress towards improving training in young people's health in the UK, the evidence base for transitional care in young people with chronic conditions with interventions that focus on staffing, service delivery and young people, a practice based approach for transitional care in young people with learning difficulties and complex needs, the need for monitoring and evaluation of transitional care, and the challenge of funding.
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Improving communication with adolescents
Communication with young people (YP) can be problematic. However, effective communication can improve health outcomes and there is randomised clinical trial–level evidence that communication skills can be learnt. Key issues when communicating with YP:(1) The young person should be central in the communication, with discussions primarily focused on him/her;
(2) The young person should be offered time alone with the clinician;
(3) Conditional confidentiality should be discussed, and does not reduce rates of disclosure;
(4) Ambivalence is normal – techniques can be learnt to help the young person resolve ambivalence and change behaviour;
(5) A psychosocial history is a key part of the adolescent consultation, and should include resilience factors as well as risk.
We also discuss pragmatic techniques to use in busy consultations to improve communication and promote behaviour change in YP.
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Assessment of childhood obesity in secondary care: OSCA consensus statement
This expert opinion provides detailed guidance on assessing obesity in secondary paediatric practice. This guidance builds on existing recommendations from National Institute of Health and Clinical Excellence in the UK, and is evidence based where possible. Guidance is provided on which obese children and young people are appropriate to be seen in secondary care and relevant history and investigations, and guidance on when further investigation of causes and obesity-related comorbidity is appropriate.
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From menorrhagia to manometers
We present a case that illustrates the challenges in making a unifying diagnosis and bringing together symptoms which, at first, seem unrelated. We aim to illustrate the process of decision-making and the practice of working along several parallel processes to reach a single explanation for a child to present unwell.
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What I learned from DTB: Acute infective conjuctivitis?
How to distinguish between a viral and bacterial cause for an acute infective conjuctivitis? Did you know that 65% of microbiologically confirmed cases of bacterial conjuctivitis are cured by the 5th day without antibiotics? Also good to know is that giving antibiotic eye drops will increase this number to only 80% by day 5; so you would have to treat approximately seven patients with antibiotics to cure one by that day (number needed to treat). And of course we are talking only about those microbiologically proven cases. Traditionally, topical antibacterials have been prescribed for people with acute infective conjunctivitis. In 2005, chloramphenicol eye drops became available over the counter from UK pharmacies. Experts says this indication has increased since then. This DTB article1 looks at the evidence on the efficacy of antibacterials in acute infective conjunctivitis and provides practical information and advice for prescribers and community pharmacists...
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How to use insulin-like growth factor 1 (IGF1)
Introduction Insulin-like growth factor 1 (IGFI) is produced in the liver and peripheral tissues including the growth plate, in response to growth hormone (GH) and is commonly used as a diagnostic marker of growth hormone deficiency (GHD) and to monitor GH replacement therapy, as recommended by an international GH consensus.1 However, while it is a useful biochemical tool, there are limitations to its use and results should be interpreted with care. Physiological backgroundProduction of IGFI IGFI and IGF2 are named after their structural similarity to proinsulin. IGFI is a 70 amino acid polypeptide, and it circulates in the plasma bound to one of six IGF binding proteins (IGFBP). Up to 75% of IGFI is bound in a ternary complex with IGF-BP32 and the glycoprotein, acid-labile subunit (ALS). The stability of this ternary complex increases the half-life of IGFI and leads to...
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Answers to the quiz on page 112
Answers to the quiz
a (T), b (F), c (T), d (T), e (F).
a (F), b (T), c (T), d (F), e (T).
a (T), b (T), c (F), d (T), e (F).
a (F), b (T), c (F), d (F).
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Propranolol reduced volume, colour and elevation of infantile haemangiomas
Study designDesign Randomised controlled trial. Allocation Randomised by clinical pharmacist using minimisation. Blinding Staff members, caregivers and participants were blinded to group status. Study questionSetting Tertiary hospital in Australia. Patients Forty children between 9 weeks and 5 years of age, with infantile haemangiomas (IHs) that could impair function or were in sites with the potential for disfigurement, were too late for corticosteroid therapy (authors do not state a specific age), or had failed corticosteroid therapy. Intervention Infants were randomised to oral propranolol 2 mg/kg/day or placebo. Outcomes Blinded evaluation of change in IHs volume, colour and elevation. Follow-up period Outcomes were assessed at 0, 4, 8, 12, 16, 20 and 24 weeks. Patient follow-up An intention to treat analysis was performed. At 2 years, 19 of 20 children allocated...
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Partially hydrolysed whey and soy-based infant formulas did notprevent allergic disease in high-risk children
Study designDesign Randomised controlled trial. Allocation Computer generated allocation by independent statistician. Blinding Staff members were blind to the group of allocation at the time of outcome assessment. Parents were blinded to assigned formula until the child's second birthday. Study questionSetting Maternity hospital in Australia. Patients Six hundred and twenty infants with a history of allergy in a first degree relative (eczema, asthma, rhinitis, food allergy). Intervention Infants were randomised to three groups to receive at weaning: a partially hydrolysed whey formula (pHWF), conventional cow's milk formula (CMF) or a soy-based formula. Outcomes Primary outcome was any allergic manifestation (eczema or food reaction) assessed during telephone interviews. Secondary outcomes were individual incidence of allergies, and skin prick tests (SPTs) reactivity. Follow-up period Outcomes were assessed at to 2 years of life....
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