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There's a good organic to non-organic spectrum in this month's edition of Education and Practice. In a break from our normal disease based format, Lopez, Howells and Lindsay describe a very interesting evolving situation under the Problem Solving in Clinical Practice banner. They describe a little of the medicinal treatment required for a young person who has taken an overdose of paracetamol (acetaminophen), but most of the article deals with the sequence of events required in order to safely, legally and ethically care for a young person in distress and refusing treatment. While some parts of such a paper will inevitably be quite specific to practice in England and Wales—international readers might not realise that the law in Scotland often differs from that in other parts of the UK—the general principles can be applied across borders, especially given that European human rights legislation overarches many of the legal acts quoted. Certainly the key points, summarised in a box towards the end of the article, are good principles on which to base any approach.
A second Problem Solving paper, and this month's Editor's Choice, by Wright, Hammond and Curry, tackles a common issue for many of us who work in primary or secondary care—and a fair few in tertiary care; that of Chronic Abdominal Pain. Their two cases, as you'd expect from authors in a tertiary surgical unit, describe two ends of the spectrum; of course I won't give away the answers here, but you should see if you get the right diagnosis. They offer a helpful flow chart, together with the startling observation that in one series of apparently indiscriminately investigated children an average of US$6104 (£3885) was spent on investigations per child, with very low yield. This paper changes my practice in one important way; that I need to do blood tests for coeliac disease in all cases, even when I think functional abdominal pain is more likely.
There's an interesting and important overlap between this article on chronic abdominal pain and an Interpretations paper on testing for H pylori from Crowley, Bourke and Hussey. I struggle quite a bit with the child with fairly non-specific symptoms who is referred after someone has done a blood test for, and therefore apparently ‘diagnosed’ H pylori infection. This paper adds to my confidence in pretty much ignoring this as a diagnosis, and taking the patient back to the start of their diagnostic journey, with a very selective use of more sophisticated—and certainly better—tests for H pylori only if specifically indicated.
The remainder of the papers in this edition are the usual range of varied eye-openers. We have a good ‘negative’ Picket from Iro and Brown; the majority of papers which we re-abstract and commentate on in this section have positive outcome from a randomised controlled trial, but not in this instance. We have some great rashes from Chattopadhyay and Burrows in our Dermatophile section—I hope you test yourselves formally before turning to the answers. We've also an update on the management of malaria from Kiang and colleagues, plus a review of hypoglycaemia and neonatal brain injury from Boardman and colleagues.
So, we range from some very non-organic, but very important medical issues, all the way through to some very organic issues. Just like my average clinic—and just as predictable. Again, please do get in touch if you've anything you'd like to contribute, or have comments about the journal; it is good to hear from you. Remember, we're on twitter too, as @ArchivesEandP.
Ian D Wacogne, Deputy Editor, E&P