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Interpretations is a section which emphasises rational, logical use of tests. I’ve written here that, as originally conceived, it could eventually form a series of collected monographs a bit like a British National Formulary for testing, where each possible test has a clear set of indications, limitations and risks. After all, in children’s healthcare we pride ourselves on reaching for the formulary to check the dose, and to check that we’ve got the right indication and formulation, so why wouldn’t we do the same with tests? Although that book deal hasn’t exactly materialised— of course you’re free to pursue this yourselves if you’re so inclined—it has been a successful decade or so of placing tests under special scrutiny.
Alex Tracy and Tom Waterfield take this a little further, and start what I hope will be a strong new tradition: Interpretations which look at examination findings ( see page 46). Of course, some of our core textbooks do teach how to use signs, but I don’t think that they subject them to the same degree of rigour that Tracy and Waterfield do here. I remember reading an early version of the NICE guidance on gastroenteritis, and finding myself nodding my head in agreement with their demolishing of some of the really poor clinical signs of dehydration. In children who do actually have abnormal skin turgor, sunken eyes, or a sunken fontanelle then these signs are really important, but in the vast majority of children the absence of those signs tells you nearly nothing. And this is before you wonder about your own clinical skills in performing them.
Then you remember the signs that you were taught were absolutely pathognomic. For example, I was taught that joints with pus in them were held absolutely rigid—that if a child could move a joint then this wasn’t septic arthritis. I believed this right up until I saw a child who could move their joint and needed drainage and washout by my orthopaedic colleagues. In retrospect, why shouldn’t I question the sensitivity and specificity of this sign in the same way as any other test I’d do? For this reason I’m making Alex and Tom’s paper my Editor’s Choice this month.
Lastly, those of you reading the physical, paper version of the journal may have noticed a subtle change this month. We’ve increased the number of pages to 64 per month, having decided that, with such an excellent group of editors and skilled authors, we could do this without compromising the high quality of articles we carry. I find it interesting that more than three quarters of the articles contained in this issue are of direct relevance to my day to day practice, although of course this might be a commissioning bias of my own. However, I don’t think that this pretty good ratio has changed significantly in the last few years. Since my first edition as editor we’ve doubled in size, at the same time as having shorter, punchier articles. In my first Epistle we talked about doubling the number of editions, but this has seemed to be the more organic way to grow. It’s lovely to hear your feedback, so after you’ve had a chance to digest this bumper issue, please do get in touch. I receive lots of great ideas—apologies for any delay in replying but please do keep writing.