Intensive Care and Department of Surgery, Erasmus MC-Sophia
Children's Hospital, Rotterdam, The Netherlands and Department of
Development and Regeneration, KU Leuven, Leuven, Belgium
Karel.allegaert@uzleuven.be
We have read with great interest the review article on the
pharmacology, prescribing and controversies of codeine in paediatrics and
we agree to a very large extent to the position t...
Intensive Care and Department of Surgery, Erasmus MC-Sophia
Children's Hospital, Rotterdam, The Netherlands and Department of
Development and Regeneration, KU Leuven, Leuven, Belgium
Karel.allegaert@uzleuven.be
We have read with great interest the review article on the
pharmacology, prescribing and controversies of codeine in paediatrics and
we agree to a very large extent to the position taken by the authors: the
use of codeine is becoming more and more obsolete. Replacing codeine by
its metabolite, i.c. morphine is a rational decision since this results in
better predictability of the between individual exposure and subsequent
(side)effects [Andrzejowski et al, Arch Dis Child Ed Practice 2016]. In
adults, this variability in exposure is mainly driven by pharmacogenetics
(PG, i.c. cytochrome P450 (CYP)2D6). In infants and children, this is
driven by both maturation and PG of CYP2D6. On this point, we disagree
with the author's suggestion that CYP2D6 maturation is slow. Although one
can debate on how to classify the rate of maturation, the review suggests
that CYP2D6 maturation is slow. To the very best of our knowledge, its
maturation is quite fast, and this matters for both codeine as well as for
other compounds, like e.g. tramadol.
The pattern of CYP2D6 maturation has been described based on in vivo
observations for tramadol [Allegaert et al, Clin Pharmacokinet 2015] as
well as for dextromethorphan [Blake et al, Clin Pharm Ther 2007] and have
been linked with in vitro observations [Tjollyn et al, AAPS J 2015]. All
observations documented extensive variability in part explained by
pharmacogenetics (CYP2D6, but more recently also OCT1) and fast maturation
[Matic et al, Ther Drug Monit 2016], with already relevant activity in
early infancy.
This goes beyond academic relevance, since this means that the CYP26
driven metabolism of codeine as well as tramadol, already in part depends
on PG polymorphisms and that clinicians should be aware of this when
prescribing or evaluating the dose/effect response in every individual
child, including neonates or young infants. Although tramadol has also non
-opioid related analgesic mechanisms, the major 'opioid' metabolite (M1, O
-desmethyl tramadol) is generated through CYP2D6 metabolism. Consequently,
the PG polymorphisms very likely already affect the PK/PD response of
tramadol and its variability in early infancy. Even more, the subsequent
renal elimination capacity makes M1 accumulation more likely.
In conclusion, we agree to a very large extent to the position taken by
the authors that the use of codeine is becoming more and more obsolete,
and replacing codeine by its metabolite, i.c. morphine is a rational
decision. However, because CYP2D6 maturation is fast, these conclusions
also already apply to neonates and young infants.
Dear Editor, we would like to congratulate Dr Bate et al for so
eloquently highlighting the importance of public and patient involvement
specifically in paediatric research [1]. We would like to further the
discussion by highlighting the involvement of adolescents and young adults
who by virtue of age may be in either paediatric and/or adult-focussed
research. Mattila et al reported that young people in this age group who...
Dear Editor, we would like to congratulate Dr Bate et al for so
eloquently highlighting the importance of public and patient involvement
specifically in paediatric research [1]. We would like to further the
discussion by highlighting the involvement of adolescents and young adults
who by virtue of age may be in either paediatric and/or adult-focussed
research. Mattila et al reported that young people in this age group who
were not involved in research were at risk of poor health outcomes
compared to those who had been [2]. It is also widely reported that young
people are at risk of lapses in care at this time of transition from child
to adult centred services [3] and therefore also at risk of being lost to
research follow-up. The involvement of people of all ages (including young
people) in research is now widely advocated but research priorities are
still largely driven by professional agendas. Evidence from adult
literature has reported a mismatch between researcher and patient
generated lists of research topics. To date, there have been no studies
exploring the priorities of young people with long term conditions
including rheumatic disease other than a few in which a minority of young
people were involved in a larger group of carers and professionals [4,5].
Therefore, there is a need to determine the priorities of young people
across the wide adolescent and young adult age range to inform future
research programmes and funding in this area. In rheumatology, the YOURR
project (Young People's Opinions Underpinning Rheumatology Research) was
therefore established as an early initiative of the Barbara Ansell
National Network for Adolescent Rheumatology (BANNAR) funded by Arthritis
Research UK. Interim guidance regarding involvement of young people in
rheumatology research was developed at the outset supported by a mapping
document of models of good practice in the UK [6, 7]. This was necessary
ground work to inform a study, data collection for which has almost
completed, and the protocol paper just published [8], which explores young
people's beliefs about research priorities in the adolescent rheumatology
field, to inform BANNAR. BANNAR aims to provide a platform to ensure that
young people in the UK have the best chance to benefit from developments
in the field of adolescent rheumatology. Integral to BANNAR is equitable
representation from young people with rheumatic conditions. This project
will help ensure full representation from young people with rheumatic
diseases in the development of a research strategy for BANNAR and will
ultimately inform a young person's led involvement strategy, ensuring
meaningful involvement in future research programmes.
[1]. Bate J, Ranasinghe N, Ling R, Preston J, Nightingale R, Denegri
S. Public and patient involvement in paediatric research. Arch Dis Child
Educ Pract Ed. 2016 Jun;101(3):158-61
[2]. Mattila VM, Parkkari J, Rimpela A. Adolescent survey non-response and
later risk of death. A prospective cohort study of 78609 persons with 11
year follow-up. BMC Public Health 2007;7:87.
[3]. Clinton-McHarg T, Paul C, Sanson-Fisher R, D'Este C, Williamson A.
Determining research priorities for young people with haematological
cancer: a value-weighting approach. Eur J Cancer. 2010 Dec;46 (18):3263-70
[4]. Morris C, Simkiss D, Busk M, Morris M, Allard A, Denness J, Janssens
A, Stimson A, Coghill J, Robinson K, Fenton M, Cowan K. Setting research
priorities to improve the health of children and young people with
neurodisability: a British Academy of Childhood Disability-James Lind
Alliance Research Priority Setting Partnership.BMJ Open. 2015 Jan
28;5(1):e006233.
[5]. Hazel E, Zhang X, Duffy CM, Campillo S. High rates of unsuccessful
transfer to adult care among young adults with juvenile idiopathic
arthritis. Pediatric Rheumatology 2010;8:2
[6]. Dack K, Williams H, Parsons S, Thomson W, McDonagh JE on behalf of
the Barbara Ansell National Network for Adolescent Rheumatology. Summary
of good practice when involving young people in health-related research.
2015 http://bannar.org.uk
[7]. McDonagh JE, Parsons S. BANNAR Guidance for Involvement of Young
People in Rheumatology Research. Interim Statement. 2015
http://bannar.org.uk
[8]. Parsons S, Dack K, Starling B, Thomson W, McDonagh JE. Study
Protocol: Determining what young people with rheumatic disease consider
important to research (the Young People's Opinions Underpinning
Rheumatology Research YOURR project) Research Involvement and Engagement
2016, 11 June [Epub ahead of print]
Dyer et al. wrote an instructive review on how to interpret malaria
tests (1). However there are two important caveats in the interpretation
of these tests which they did not mention. First, a positive test does not
necessarily confirm a diagnosis of malaria. Second, a positive test does
not necessarily mean that malaria is the only diagnosis.
Strictly speaking, the tests described by Dyer et al. are parasite
de...
Dyer et al. wrote an instructive review on how to interpret malaria
tests (1). However there are two important caveats in the interpretation
of these tests which they did not mention. First, a positive test does not
necessarily confirm a diagnosis of malaria. Second, a positive test does
not necessarily mean that malaria is the only diagnosis.
Strictly speaking, the tests described by Dyer et al. are parasite
detection tests rather than malaria tests, since the diagnosis of malaria
requires that there is symptomatic infection with a Plasmodium species.
This is not just a semantic point. Children who live in a malaria endemic
country may develop naturally acquired immunity with repeated infections
(2, 3). This immunity decreases the likelihood of developing symptoms
during infection and permits the asymptomatic carriage of blood stage
parasites. Children from high transmission countries who are visiting or
migrating to the UK and develop a febrile illness may be found to have a
positive parasitological test, but their illness may have a totally
different cause. In these cases it is always sensible to treat for
malaria, but a high index of suspicion of another cause should be
maintained, particularly if the child is seriously ill.
Related to this, there is a well-recognised association between
malaria and risk of invasive bacterial infection (4). Children with
malaria are more likely to develop Gram-negative bacteraemia, particularly
infection with non-Typhoidal Salmonella. For this reason, it should not be
assumed that a positive parasite detection test in an unwell febrile child
makes a diagnosis of malaria and excludes another infection. Recent
guidelines recommend the prudent approach that any child with features of
severe malaria should be treated with broad spectrum antibiotics until it
is clear that there is no co-infection (5).
1. Dyer E, Waterfield T, Eisenhut M. How to interpret malaria tests.
Arch Dis Child Educ Pract Ed 2016;101(2):96-101.
2. Crompton PD, Moebius J, Portugal S, et al. Malaria immunity in man and
mosquito: insights into unsolved mysteries of a deadly infectious disease.
Annual review of immunology 2014;32:157-87.
3. White NJ, Pukrittayakamee S, Hien TT, et al. Malaria. Lancet
2014;383(9918):723-35.
4. Takem EN, Roca A, Cunnington A. The association between malaria and non
-typhoid Salmonella bacteraemia in children in sub-Saharan Africa: a
literature review. Malar J 2014;13:400.
5. Lalloo DG, Shingadia D, Bell DJ, et al. UK malaria treatment guidelines
2016. J Infect 2016.
The author makes an interesting point about the current legislation and automatic inclusion of data in trials where prior informed consent is not possible.
EU legislation focuses on when research without prior consent (RWPC) can occur and the need to obtain consent for continued participation, but does not cover the options for use of data collected prior to consent. The exception to this is where consent is not pr...
The author makes an interesting point about the current legislation and automatic inclusion of data in trials where prior informed consent is not possible.
EU legislation focuses on when research without prior consent (RWPC) can occur and the need to obtain consent for continued participation, but does not cover the options for use of data collected prior to consent. The exception to this is where consent is not provided: ???he or she should be informed of their right to object to the use of data obtained from the clinical trial???. Therefore, this situation is open to interpretation.
We acknowledge the concerns of the letter author regarding not automatically including data. If data are not automatically included there is the potential for bias in the study results if the decision to provide consent for use the data is associated with patient outcome. This could potentially lead to erroneous conclusions with far reaching implications. However, the research community needs to consider the timeframes around stabilisation of the patient with respect to the potential need for continued delivery of the intervention, additional tests and timing of data to be collected after this point. It would be difficult to argue against the current legislation that consent should not be requested here.
CONNECT and studies conducted in neonatal intensive care indicate that children and parents not only want to be informed, but also want to make the decision about the inclusion of their information in research. One question to reflect on is who ???owns??? the data? If it???s the patient, then they (and their parents) surely have the right to be asked for it to be used.
We believe that the automatic inclusion of data with an ???opt out??? approach should be limited to circumstances where a face to face discussion with the family has not been possible before they leave hospital, or is not deemed appropriate at that point in time (e.g. when a child had died) and there has been no response to attempts to contact the family. This approach is currently used in a NIHR HTA funded EcLiPSE Study: Emergency treatment with Levetiracetam or Phenytoin in Status Epilepticus: http://www.nets.nihr.ac.uk/projects/hta/12127134
In developing the CONNECT guidance we had to work within UK and EU legislation ??? otherwise our guidance would have been of no practical use. Article 35 of the 2014 EU legislation stipulates that research in emergency situations should only pose ???a minimal risk to, and impose a minimal burden on the subject in comparison with the standard treatment of the subject???s condition???. Our interpretation is that if a trial intervention posed more than a minimal risk, then a REC should not approve the trial. The CONNECT study findings were in keeping with this, showing that parents supported doing RWPC in trials of interventions already used in clinical care, although they were concerned about doing RWPC in trials involving new interventions, or significant changes in clinical practice.
Thank you for outlining so clearly the current basis for "deferred
consent" studies and suggesting good practice in dealing with the issues
it raises.
Unfortunately I believe that the current practice is the worst of possible
worlds: not only do we submit vulnerable subjects to interventions without
the expression of their/their parents' autonomy (ie consent), but also we
risk losing any data obtained because we retrospect...
Thank you for outlining so clearly the current basis for "deferred
consent" studies and suggesting good practice in dealing with the issues
it raises.
Unfortunately I believe that the current practice is the worst of possible
worlds: not only do we submit vulnerable subjects to interventions without
the expression of their/their parents' autonomy (ie consent), but also we
risk losing any data obtained because we retrospectively seek permission
to use their data. In other words we would have put the subject at
risk/burden with no gain.
Current rules of governance for research, based ultimately on the
declaration of Helsinki, are designed to protect the subject/society from
harm, understanding that ends do not justify means. There is no
possibility that the RECs and REC members of which I have experience would
approve a study where undue harm could result.
I believe that if an REC has approved such a study, this is an endorsement
of its relative safety and utility, and should automatically permit
inclusion of the data gathered. Retrospectively inform the
subject/parents, but do not seek permission for inclusion. If they go as
far as requesting withdrawal of the data, then that could be honored.
We agree that baby walkers and door suspenders can be associated with
transient toe walking and delayed walking, which usually would correct
spontaneously relatively quickly once the children stop using the device.
The use of such devices should be strongly discouraged as part of normal
parenting practice. Enquiry regarding inappropriate use of either of these
devices in a toddler who has tip toe gait on independent or sup...
We agree that baby walkers and door suspenders can be associated with
transient toe walking and delayed walking, which usually would correct
spontaneously relatively quickly once the children stop using the device.
The use of such devices should be strongly discouraged as part of normal
parenting practice. Enquiry regarding inappropriate use of either of these
devices in a toddler who has tip toe gait on independent or supported
walking can be helpful in evaluation.
This was succinct and helpful article. However as a paediatric
emergency doctor I would query the phrase "There is still a risk of
meningococcal disease even when blood tests are normal; therefore, admit
all children for 4-6 hours with hourly observations". It may seem
pedantic, but this is not what NICE says. The pathway states "Assess
clinical progress (vital signs) and carry out observations at least hourly
over t...
This was succinct and helpful article. However as a paediatric
emergency doctor I would query the phrase "There is still a risk of
meningococcal disease even when blood tests are normal; therefore, admit
all children for 4-6 hours with hourly observations". It may seem
pedantic, but this is not what NICE says. The pathway states "Assess
clinical progress (vital signs) and carry out observations at least hourly
over the next 4-6 hours." the next step in the full guideline(1) is "If
doubt remains, treat with antibiotics and admit to hospital". Even a
short hospital admission is several times more expensive than an ED
attendance and these children should not automatically be admitted as the
great majority can safely be observed then discharged.
1) National Institute for Health and Care Excellence. Bacterial
meningitis and meningococcal septicaemia: management of bacterial
meningitis and meningococcal septicaemia in children and young people
younger than 16?years in primary and secondary care. CG 102. London:
National Institute for Health and Care Excellence, 2010
I read with interest Sivaramakrishnan et al's structured approach to a child with toe walking [1]. Various levels of contexts such as parenting, maternal education, poverty and social networks interact with each other and with genetic expression to create long-lasting consequences for development [2,3]. Sometimes, single or isolated negative environmental factors may make a major contribution to developmental problems with most n...
I read with interest Sivaramakrishnan et al's structured approach to a child with toe walking [1]. Various levels of contexts such as parenting, maternal education, poverty and social networks interact with each other and with genetic expression to create long-lasting consequences for development [2,3]. Sometimes, single or isolated negative environmental factors may make a major contribution to developmental problems with most negative influence occurring in infancy. Here, we discussed two infants without any underlying medical condition who walk on their toes.
Case 1: A 18-month-old girl comes with delay the attainment of standing and independent walking. Her perinatal and family history was unremarkable. Her antropometric measurements were all appropriate for his age. Her Denver II was normal at 9 months of age, however, gross motor development was abnormal at 18 months. While the infant was kept standing with holding her arms, she jumped continuously or she did toe walking and she couldn't stand alone. Further history revealed that she had sat on "doorway jumper" as a baby-sitter, 2-3 hours a day for 6 months. Then, parents were urged not to use jumper and put their infant on carpet to crawl and creep. The infant begin to walk alone within three months.
Case 2: A 21-month-old boy, presented to our center with toe walking. Her delivery and neonatal-infant course were uneventful. There was no positive family history. He achieved gait at 13 months and walked independently at 16 months. On physical examination weight, height and head circumference were all appropriate for his age. Physical examination revealed intermittent toe walking. His Denver II Test was normal. Specific history revealed that he used a baby walker between 9 and 15 months of age and the infant begin to walk predominantly on the forefoot at 16 months of age. Parents was reassured that it was likely to resolve spontaneously. We advised parents to play "heel down, squate, pick a ball up, stand up". Toe walking was corrected at 23 months of age.
The American Association of Pe?diatrics advice against the use of baby walker due to the high number of accidents and the possible delay of gait acquisition related to its use [4]. This is the first report about jumper and delay the attainment of standing. If clinician didn't ask these environmental risk factors, unnecessary analysis, misdiagnosis and inappropriate treatment could be done. We would thus like to emphasize that a child with toe walking should also be assessed for baby walker or jumper.
Competing interests: None.
References
1. Sivaramakrishnan S, Seal A. Fifteen-minute consultation: A child with toe walking. Arch Dis Child Educ Pract Ed. 2015 Apr 8. pii: edpract-2014-307852.
2. Lagstrom H, Rautava P, Kaljonen A, et al. Cohort profile: Steps to the healthy development and well-being of children (the STEPS Study). Int J Epidemiol 2013;42:1273-84.
3. Yalcin SS, Yurdakok K, Tezel B, et al. Family and infant characteristics in relation to age at walking in Turkey. Turk J Pediatr 2012;54:260-8.
4. American Academy of Pediatrics; Committee on Injury and Poison Prevention. Injuries associated with infant walkers. Pediatrics 2001;108:790-2.
Dear Editor,
We were interested to read the article by Parige and Power entitled, 'A
chest x-ray that doesn't look right'. (Archives of Disease in Childhood -
Education and Practice Edition 2014; 99: 72). This article described
extravasation of TPN from a PICC line resulting in a pleural effusion. Our
attention was drawn to the initial 'check x-ray' which identified what we
refer to locally as the "wiggle sign". The "wigg...
Dear Editor,
We were interested to read the article by Parige and Power entitled, 'A
chest x-ray that doesn't look right'. (Archives of Disease in Childhood -
Education and Practice Edition 2014; 99: 72). This article described
extravasation of TPN from a PICC line resulting in a pleural effusion. Our
attention was drawn to the initial 'check x-ray' which identified what we
refer to locally as the "wiggle sign". The "wiggle sign" refers to an
undulating path taken by a malpositioned PICC line.
The potential complications following insertion of a PICC line are
well known including infection, thrombosis, catheter breakdown and
malposition. The x-ray should show the catheter following a smooth course.
The "wiggle' sign" as the name implies, is when the catheter has a
tortuous appearance, suggesting that the distal end is not in the desired
anatomical position. In this situation we believe that the distal end has
become impacted after entering a smaller vessel or lodging against another
structure.
Given the significant morbidity and mortality that is associated with
the incorrect placement of a PICC line, our policy over the past 3 years
is to remove all lines if there is a positive "wiggle sign". It is our
impression that this sign is not widely recognised in neonatal units and
we feel a heightened awareness may help reduce the sequelae post PICC
insertion. We would recommend the removal of a PICC line if a positive
"wiggle sign" is demonstrated.
We read with interest the review by Le Doare et al. discussing the
presentation and management of neonatal and childhood herpes simplex
encephalitis (HSE). The article nicely outlines the importance of timely
treatment of this potentially catastrophic infection. The authors have
provided practical advice that is applicable for many of the challenges
that clinicians might be faced with.
We read with interest the review by Le Doare et al. discussing the
presentation and management of neonatal and childhood herpes simplex
encephalitis (HSE). The article nicely outlines the importance of timely
treatment of this potentially catastrophic infection. The authors have
provided practical advice that is applicable for many of the challenges
that clinicians might be faced with.
Although they mentioned the possibility of autoimmune encephalitis
following HSE, it is important to emphasise this likelihood. More
specifically, there is growing evidence to show an association between HSE
and subsequent N-methyl-D-aspartate receptor (NMDAR) antibody
encephalitis. The NMDAR is a type of glutamate receptor found throughout
the brain. Its role in autoimmune encephalitis has only been recently
described by Dalmau et al in 2007 (1) as a paraneoplastic phenomenon
leading to autoimmune encephalitis, although the presence of a causative
tumour is less likely in younger patients (2).
Pruss et al described the presence of NMDAR antibodies occurring in
the course of 30% of individuals with HSE (3). In a paediatric sample, 7
out of 20 individuals (35%) relapsed and 3 out of those 7 patients were
found to be NMDAR antibodies positive (4). This highlights the importance
of considering this diagnosis in patients presenting with a possible
relapse of HSE or even in patients not responding to appropriate antiviral
therapy. Common symptoms may include a movement disorder, seizures and
encephalopathy. Antibodies can be tested in serum and CSF specimens.
Early recognition and referral of autoimmune encephalitis of this
entity is paramount as early aggressive immunotherapy can lead to good
outcomes (5).
References:
1. Dalmau J, Tuzun E and Wu H et al. Paraneoplastic anti-N-methyl-D-
aspartate receptor encephalitis associated with ovarian teratoma. Ann
Neurol 2007; 6(1): 25-36
2. Florance NR, Davis RL, Lam C et al. Anti-N-methyl-D-aspartate receptor
(NMDAR) encephalitis in children and adolescents. Ann Neurol 2009; 66(1):
11-8
3. Pruss H, Finke C, Holtje M et al. N-methyl-D-aspartate receptor
antibodies in herpes simplex encephalitis. Ann Neurol 2012; 72(6): 902-911
4. Hacohen U, Deiva K, Pettingill P et al. N-methyl-D-aspartate receptor
antibodies in post-herpes simplex virus encephalitis neurological relapse.
Mov Disord. 2014; 29 (1): 90-96
5. Titulaer M, McCracken L, Gabilondo I et al. Treatment and prognostic
factors for long-term outcome in patients with anti-NMDA receptor
encephalitis: an observational cohort study. Lancet Neurol. 2013; 12(2):
157-165
K Allegaert
Intensive Care and Department of Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands and Department of Development and Regeneration, KU Leuven, Leuven, Belgium Karel.allegaert@uzleuven.be
We have read with great interest the review article on the pharmacology, prescribing and controversies of codeine in paediatrics and we agree to a very large extent to the position t...
Dear Editor, we would like to congratulate Dr Bate et al for so eloquently highlighting the importance of public and patient involvement specifically in paediatric research [1]. We would like to further the discussion by highlighting the involvement of adolescents and young adults who by virtue of age may be in either paediatric and/or adult-focussed research. Mattila et al reported that young people in this age group who...
Dyer et al. wrote an instructive review on how to interpret malaria tests (1). However there are two important caveats in the interpretation of these tests which they did not mention. First, a positive test does not necessarily confirm a diagnosis of malaria. Second, a positive test does not necessarily mean that malaria is the only diagnosis.
Strictly speaking, the tests described by Dyer et al. are parasite de...
The author makes an interesting point about the current legislation and automatic inclusion of data in trials where prior informed consent is not possible.
EU legislation focuses on when research without prior consent (RWPC) can occur and the need to obtain consent for continued participation, but does not cover the options for use of data collected prior to consent. The exception to this is where consent is not pr...
Thank you for outlining so clearly the current basis for "deferred consent" studies and suggesting good practice in dealing with the issues it raises. Unfortunately I believe that the current practice is the worst of possible worlds: not only do we submit vulnerable subjects to interventions without the expression of their/their parents' autonomy (ie consent), but also we risk losing any data obtained because we retrospect...
We agree that baby walkers and door suspenders can be associated with transient toe walking and delayed walking, which usually would correct spontaneously relatively quickly once the children stop using the device. The use of such devices should be strongly discouraged as part of normal parenting practice. Enquiry regarding inappropriate use of either of these devices in a toddler who has tip toe gait on independent or sup...
This was succinct and helpful article. However as a paediatric emergency doctor I would query the phrase "There is still a risk of meningococcal disease even when blood tests are normal; therefore, admit all children for 4-6 hours with hourly observations". It may seem pedantic, but this is not what NICE says. The pathway states "Assess clinical progress (vital signs) and carry out observations at least hourly over t...
Dear Editor, We were interested to read the article by Parige and Power entitled, 'A chest x-ray that doesn't look right'. (Archives of Disease in Childhood - Education and Practice Edition 2014; 99: 72). This article described extravasation of TPN from a PICC line resulting in a pleural effusion. Our attention was drawn to the initial 'check x-ray' which identified what we refer to locally as the "wiggle sign". The "wigg...
We read with interest the review by Le Doare et al. discussing the presentation and management of neonatal and childhood herpes simplex encephalitis (HSE). The article nicely outlines the importance of timely treatment of this potentially catastrophic infection. The authors have provided practical advice that is applicable for many of the challenges that clinicians might be faced with.
Although they mentioned...
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