Illogically, and with no empirical evidence to support it, a mischievous view has been promoted that the interest of the vast number of patients involved in the poorly controlled experiments of informal medical ‘tinkering’ are less in need of protection than are those of the relatively small number of patients who are involved in planned, properly controlled clinical experiments.
What are the responsibilities of paediatricians and other clinicians when there is uncertainty about whether particular treatments are more likely to do good than harm, or vice versa? The General Medical Council's advice to doctors is clear: ‘You must ... help to resolve uncertainties about the effects of treatments’. The trouble is that circumstances are stacked against doctors who aspire to this standard. As the British paediatrician Richard Smithells noted decades ago, ‘I need permission to give a drug to half of my patients, but not to give it to...]]>
Design: Randomised controlled trial.
Allocation: Randomisation was done by university staff. Allocation was concealed using sealed envelopes that were sequentially numbered.
Blinding: All patients, care providers and investigators were blinded. Only hyperbaric oxygen (HBO) technicians were aware of group assignment.
Setting: Ambulatory HBO clinic in the USA.
Patients: Forty-nine children aged 3 to 8 years with spastic cerebral palsy (CP), with no previous HBO treatments, recent thoracic surgery, changes of spasticity medications or history of hypoxic-ischaemic encephalopathy.
Intervention: Children were randomised to receive either hyperbaric 100% oxygen (HBO) or hyperbaric air (HBA), at 1.5 atmospheres, for 60 min, once per weekday for a total of 40 treatments.
Outcomes: Primary outcome was a change in Gross Motor Function Measure (GMFM-88) score. A change of more than 5% is considered clinically significant. Secondary outcomes were changes in GMFM dimensions, the Pediatric Evaluation of Disability Inventory (PEDI) and the Test of Variables of Attention (TOVA).
Follow-up period: Outcomes...]]>
From questions on page .
The answer is (D), acne neonatorum. This, perhaps more accurately called neonatal cephalic pustulosis, is a benign condition that typically presents shortly after birth and resolves within the first 1–2 months of life. Infants present with acneiform papules and pustules, frequently located on the cheeks and forehead and sometimes on the chest. Neonatal cephalic pustulosis lacks the comedones of acne vulgaris. Malassezia furfur or M sympodialis colonisation may play a role in the aetiology of this condition, and the treatment consists of watchful waiting or, if necessary, topical antifungal creams.
The answer is (B), periorificial dermatitis. This, also known as perioral dermatitis, is a common benign condition that can occur in children or adults. Classically, lesions appear as skin coloured-erythematous monomorphic papules measuring 1–2 mm. These papules can appear on the perioral region, nose, cheeks and periocular region....]]>
Select one best answer from the following: Neurofibromatosis type 1 Nevus spilus McCune–Albright syndrome Café-au-lait macule Multiple lentigenes syndrome (LEOPARD) Nevus of Ito (nevus fuscoceruleus acromiodeltoideus) Giant congenital melanocytic nevus Carney syndrome
Case 1: A 5-year-old boy presents with a birthmark in his right axilla (
Case 1: A 3-week-old infant presents with multiple pustules on his face. Lesions have been present for 1 week and do not appear to bother the infant. The child was born via uncomplicated vaginal delivery at 39 weeks. The mother did not receive prenatal care until 22 weeks of pregnancy, when she realised she was pregnant. She is worried that her child might have ‘caught something’ from a sick sibling at home. On physical examination, the child is well appearing, but there are multiple pustules distributed on the forehead, nose and bilateral cheeks (
Case 2: A 7-year-old boy presents with complaints of a rash on his chin, cheeks and nose. These lesions initially started around his mouth 2 months ago. His mother thought that they were related to eczema and applied topical...]]>
From questions on page .
The answer is (B), nevus spilus. This lesion is characteristic of a nevus spilus, also known as speckled lentiginous nevus. Typically, nevus spilus presents as a tan-brown patch with superimposed brown nevi that develop over time. It is found in 1.7/1000 newborns, with boys and girls being equally affected. Parents often give a history of noticing the macular component at birth or shortly thereafter, with the gradual appearance of more and more individual nevi within the area. This lesion is benign, and the risk of melanoma developing within this lesion is similar to that of benign melanocytic nevi present elsewhere on the body.
The answer is (A), neurofibromatosis type 1 (NF-1). These multiple café-au-lait macules are concerning for NF-1...]]>
Hemihydraenecephaly can be compatible with life. A 21-year-old who was known to have had developmental delay and a persistent left sided hemiplegia had brain imaging (
I hope you do look at the full article. I have not previously seen this finding on imaging: it does appear genuinely amazing.
Alternatively I hope this encourages you to send in your own examples of interesting images to BMJ Case Reports: a positive new development is that all published cases are now indexed on PubMed.
Not commissioned; externally peer reviewed.
T1W MRI of brain, coronal view showing an absent right hemisphere replaced...]]>
Questions: In children with acute illness (patient) does gut feeling (test) rule in or rule out serious infections (outcome)?
Design: Prospective cohort study of children 0–16 years.
Setting: Primary care, general practitioners or community paediatricians. Flanders, Belgium.
Patients The study included 3890 children aged 0–16 years, presenting with an acute illness of less than 5 days duration.
Diagnostic strategy At the initial consultation the following were recorded: A list of clinical features was made, on which an objective clinical impression was based. The clinician also recorded their gut feeling, defined as an intuitive feeling that something was wrong even if the clinician was unsure why.
Subsequently a panel, blinded to the initial clinical evaluation, made the final diagnosis of serious infection, based on hospital records and clinicians’ follow-up information. Association of gut feeling with specific clinical features or with clinician experience was analysed using logistic regression.
Outcomes Of 3890 children, 21 were admitted to the hospital with a serious...]]>