Dear Sir,
Mulholland et al. make some very important points but I think understate the importance of bedside teaching. The only learning that ever stuck with me as a junior doctor was when it took place in relation to a clinical scenario involving a patient. Nothing has hurt training more than the reduction in exposure to patients either as in-patients or in the out-patient setting. It is an unavoidable consequence of the reduction in working hours but the feedback trainers give to trainees when reviewing patients is still the most important part of their learning. The only problem now is that the trainee is probably not rostered on for the next week.
The importance of this patient interaction is highlighted by the fact that undergraduates are now learning their basic anatomy, physiology etc. in the context of clinical scenarios and meeting real patients. This is a major step forward for undergraduate training and something I am very pleased to be involved in. Unfortunately, in my opinion, post graduate training has gone in the opposite direction and there is not a lot we can do about it other than increasing the length of training programs. The way we now work means that trainees see fewer patients and therefore learn more slowly. We can organise as many study days as we like but it does not compensate for that loss.
In order to avoid repetition of the mistakes that have been made in the ascertainment of asymptomatic status in adults who might have COVID-19 infection(1) healthcare practitioners in paediatrics must ascertain the full currently known range of COVID-19 symptoms before a child is declared to be asymptomatic. In the event of an oligosymptomatic or monosymptomatic clinical presentation each of those children with sparse or atypical symptoms should be fully followed up to ascertain if the "stand alone" symptoms are "joined" by new symptoms or whether the oligosymptomatic status persists throughout the course of that child's illness.
Finally, in conformity with the principles of Bayes' Theorem, frontline healthcare workers should be issued with a nomogram spelling out the post test probability of COVID-19 infection(2) in the event of a negative RT-PCR test result. The nomogram should be the subject of regular re-evaluation and updating, on the basis of new information about the authenticity of new symptoms reportedly associated with COVID-19.
I have no funding and no conflict of interest
References
(1) Saurabh S., Vohra S
What should be the criteria for determining asymptomatic status in COVID-19
QJMed 2020;doi.org/10.1093/qjmed/hcab002 Article in Press
(2) Chan GM
Bayes theorem, Covid-19, and screening tests
Amer J Emerg Med 2020;38:2011-2013
Paediatric Anaesthetic Training During COVID-19:
The UK National Paediatric Anaesthesia Trainee Research Network (PATRN) Swift Survey
The Paediatric Anaesthesia Trainee Research Network (PATRN) Committee read with great interest the findings of the national survey of paediatric trainee experiences during the Covid-19 pandemic from Harmer et al. The re-deployment of anaesthetic trainees to support the surge in demand from adult intensive care, postponement of elective surgery and pauses to trainee rotations1 all affected access to sub-specialty training in anaesthesia. Thus, PATRN conducted an equivalent national survey evaluating the impact of the pandemic on training in paediatric anaesthesia from March to August 2020.
A survey questionnaire consisting of Sixteen questions focussed on trainee experience of paediatric anaesthesia during the first wave of Covid-19 infections, from March to August 2020. Paediatric anaesthesia experience in the UK occurs at all stages of training, with the option for an additional ‘advanced’ module. The survey was reviewed by members of the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) Scientific Committee. Distribution was via email to all UK-based trainees by College Tutors and the Anaesthetists in Training Representative Group (ATRG) through The Royal College of Anaesthetists (RCoA) and APAGBI trainee members from December 2020 to March 2021.
Paediatric Anaesthetic Training During COVID-19:
The UK National Paediatric Anaesthesia Trainee Research Network (PATRN) Swift Survey
The Paediatric Anaesthesia Trainee Research Network (PATRN) Committee read with great interest the findings of the national survey of paediatric trainee experiences during the Covid-19 pandemic from Harmer et al. The re-deployment of anaesthetic trainees to support the surge in demand from adult intensive care, postponement of elective surgery and pauses to trainee rotations1 all affected access to sub-specialty training in anaesthesia. Thus, PATRN conducted an equivalent national survey evaluating the impact of the pandemic on training in paediatric anaesthesia from March to August 2020.
A survey questionnaire consisting of Sixteen questions focussed on trainee experience of paediatric anaesthesia during the first wave of Covid-19 infections, from March to August 2020. Paediatric anaesthesia experience in the UK occurs at all stages of training, with the option for an additional ‘advanced’ module. The survey was reviewed by members of the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) Scientific Committee. Distribution was via email to all UK-based trainees by College Tutors and the Anaesthetists in Training Representative Group (ATRG) through The Royal College of Anaesthetists (RCoA) and APAGBI trainee members from December 2020 to March 2021.
The findings were reflective of those identified by Harmer et al, with changes to work schedule being commonplace. 90/170 (53%) of respondents, representing all stages of training, were due to complete a paediatric training module during the specified timeframe. Only 23% remained working in paediatric anaesthesia, almost all of whom were undertaking ‘higher’ or ‘advanced’ modules (n=19). The majority of trainees who experienced disruption with re-deployment was to support adult intensive care (33/69; 48%). Many trainees did not have sufficient paediatric cases to achieve module sign off (32/66; 48%), due to re-deployment or a lack of elective training lists. Most trainees felt they had insufficient paediatric experience for progression of training (37/69; 54%).
In addition, teaching sessions were reduced; 52% (90/170) of respondents reported fewer sessions compared to pre-COVID, despite delivery of virtual sessions. 84/170 (49%) of respondents were able to undertake extracurricular activities for personal development, including training other staff, writing COVID protocols, quality improvement projects and COVID research.
Training in paediatric anaesthesia relies upon ‘hands-on’ experience to develop confidence. Our findings reflect the RCoA’s efforts to minimise disruption to trainees at a critical stage of progression, however, the qualitative impact of COVID-19 is difficult to assess and relates to individual confidence. New ARCP outcomes2 have been created to identify the impact of COVID-19 on training and allow remediation. Following the acute phase of the pandemic, the authors feel access to training should be prioritised. This is of particular importance for junior trainees who have been unable to achieve sign-off or gain experience to feel well-equipped for progression. The survey findings support the requirement for ongoing open discussions at a national level on how to address these issues.
In the UK we are presently in the middle of a significant heatwave
with July
2006 declared the UK's hottest month on record (1). Both the Department of
Health and NHS direct have been quick to disseminate health advice (2)
particularly to parents and healthcare workers responsible for the care of
children, about the dangers of heat exposure and dehydration. This advice
has emphasised the need for...
In the UK we are presently in the middle of a significant heatwave
with July
2006 declared the UK's hottest month on record (1). Both the Department of
Health and NHS direct have been quick to disseminate health advice (2)
particularly to parents and healthcare workers responsible for the care of
children, about the dangers of heat exposure and dehydration. This advice
has emphasised the need for adequate fluid intake, particularly that of
water.
Notably parents have been encouraged to ‘give babies plenty of cooled
boiled
water throughout the day’ (3)
Although we believe this to be sound advice to parents in the majority of
situations, we believe it is important for clinicians to be aware of the
risks of
water intoxication, especially in infants.
Water intoxication in children has previously been well described (4) and
as
being on the increase, if not reaching epidemic proportions in the United
States (5). It can cause significant morbidity and mortality from
hyponatraemia, brain swelling and seizures. Primarily associated with
inappropriate dilution of formula feeds, bottled water has previously been
described as a significant cause (6,7). Children are at particular risk as
it is
thought that as well as renal function being immature, infants have a
powerful thirst drive which may impede their ability to curb intake.
Bhalla et al reported 4 cases in the UK of hyponatreamic seizures that
were
secondary to excessive solute ingestion in 1999 (8). As a paediatric
intensive
care retrieval service we have recently dealt with a previously normal
hyponatraemic child presenting with abnormal neurology and seizures.
A one-year-old child presented in status epilepticus following a 2 day
history
of vomiting during which time hypotonic fluids where administered. The
child
required iv lorazepam and one dose of rectal paraldehyde to terminate the
seizure and was intubated, ventilated and transferred to a regional
paediatric
intensive care unit. Serum sodium on attendance was 116 mmol/L. The child
was subsequently fluid restricted for 48 hours.
Although we have insufficient evidence at present to implicate water
intoxication in their pathogenesis we feel it is an issue that has not
been
addressed in the current DOH literature. This situation also emphasises
the
importance of parental education to the potential risks of this conditon.
Dr R M Kayani Retrieval Fellow
Dr P Ramnarayan Consultant Paediatric Intensivist
Children’s Acute Transport Service, Great Ormond Street Hospital, London
2. ‘ Heatwave’ -A guide to looking after yourself and others during hot
weather. Department of Health http://www.dh.gov.uk/assetRoot/
04/13/53/04/04135304.pdf
3. Department of Health Website - http://www.nhsdirect.nhs.uk/articles/
article.aspx?ArticleId=1955
4. Dugan S, Holliday MA. Water intoxication in two infants following the
voluntary ingestion of excessive fluids. Pediatrics 1967;39:418-20.
5. Keating JP,Schears GJ, Dodge PR. Oral water intoxication in infants. An
American epidemic.
Am J Dis Child. 1991 Sep;145(9):985-90.
6. Bruce RC , Kliegman RM Hyponatremic seizures secondary to oral water
intoxication in infancy: association with commercial bottled drinking
water.
Pediatrics. 1997 Dec;100(6):E4. Review
7. From the Centers for Disease Control and Prevention-Hyponatremic
Seizures Among Infants Fed With Commercial Bottled Drinking Water--
Wisconsin, 1993. JAMA 272(13),October 1994, pp 996-997
8. P Bhalla, F E Eaton, J B S Coulter, F L Amegavie, J A Sills and L J
Abernethy
Lesson of the week: Hyponatraemic seizures and
excessive intake of hypotonic fluids in young children 1999;319;1554-1557
BMJ
In his extensive guideline review of the glucocorticoid treatment in
croup, in agreement with the conclusions of the Cochrane review (1),
Baumer HJ (2) states that “in the absence of further evidence, the use of
a single oral dose of dexamethasone, probably 600 µg/kg, should be
preferred because of its safety, efficacy and cost-effectiveness”.
In his extensive guideline review of the glucocorticoid treatment in
croup, in agreement with the conclusions of the Cochrane review (1),
Baumer HJ (2) states that “in the absence of further evidence, the use of
a single oral dose of dexamethasone, probably 600 µg/kg, should be
preferred because of its safety, efficacy and cost-effectiveness”.
We believe this statement is not correct because a difference should
be made between cases of mild-moderate and severe croup. In fact, before
high doses of dexamethasone are used extensively in children with mild-
moderate croup, some relevant questions need to be addressed.
Russel K (1) and Griffin S and colleagues (3) reviewed the data from
several double-blind randomised clinical studies of inhaled budesonide in
croup and found it to be significantly more effective than placebo.
Several studies also show that nebulised budesonide, the effect of which
starts within 30 minutes, and oral dexamethasone are equally effective
(1,3). Given the evidence, it seems more cautious to choose inhaled rather
than oral/injectable corticosteroids for mild-moderate croup treatment.
Secondly it has been shown that a single low oral dose of dexamethasone
(150 µg/kg), as suggested by the BNF for children (4), is equally
effective in treating croup (5). This issue needs to be further addressed,
given the potential adverse effects of high-dose dexamethasone in
children.
Other than the need for further randomised controlled trials
comparing different dexamethasone doses, as suggest by Baumer JH (2), we
think that it could be more relevant to conduct studies comparing inhaled
versus oral corticosteroids for the treatment of mild-moderate croup, with
regard to their clinical onset of action and security profile.
References:
1. Russell K, Wiebe N, Saenz A, et al. Glucocorticoids for croup.
Cochrane Database Syst Rev 2004; Issue 1:CD001955
2. Baumer HJ. Glucocorticoid treatment in croup. Arch Dis Child Educ
Pract Ed 2006;91:ep58-ep60
3. Griffin S, Ellis S, Fitzgerald-Baroon A, Rose J, Egger M.
Nebulised steroid in the treatment of croup: a systematic review of
randomised controlled trials. Br J Gen Pract 2000;50:135-41
4. British National Formulary. BNF for children. London: BMJ
Publishing, 2005:158
5. Sparrow A, Geelhoed G. Prednisolone versus dexamethasone in croup:
a randomised equivalence trial. Arch Dis Child 2006;91:580-83
With interest we read the paper by Tighe et al about the use of pH-
monitoring in childhood.(1) However, we believe that the authors
overestimate the role of this technique and their omission of a detailed
discussion of the utility of pH-impedance monitoring renders this review
incomplete.
The term ‘gold standard’ can no longer be applied to 24-hour pH-
monitoring because pH-probes only d...
With interest we read the paper by Tighe et al about the use of pH-
monitoring in childhood.(1) However, we believe that the authors
overestimate the role of this technique and their omission of a detailed
discussion of the utility of pH-impedance monitoring renders this review
incomplete.
The term ‘gold standard’ can no longer be applied to 24-hour pH-
monitoring because pH-probes only detect a minority of gastro-oesophageal
reflux (GOR) episodes.(2) Combined pH-impedance monitoring allows for the
detection of all reflux (liquid, mixed, gas, acidic, weakly acidic, weakly
alkaline). With an increasing body of evidence showing a role for weakly
acidic bolus GOR in symptom generation, the measurement of acidity alone
provides an incomplete picture of the degree of bolus reflux and the
relationship of bolus reflux to symptom episodes. Therefore, symptomatic
reflux cannot always be excluded when a pH-study (acid exposure) is
normal. The ability to detect bolus reflux, independently of acidity,
allows symptomatic reflux to be more accurately detected. Not mentioned in
this article, is that there are statistical measures of association
between GOR episodes and symptoms (e.g. symptom association probability
score). By detecting all bolus reflux, pH-impedance monitoring markedly
increases the yield of positive symptom association in infants and
children.(3)
In addition, infants with GORD present differently from older
children and, as other tests such as upper GI endoscopy are more difficult
to perform in infants, the case for invasive functional testing may be
greater for infants than older children. In infants, conservative
management before any testing or pharmacological therapy is proven
effective(4). However, with PPI therapy recently being shown to be
ineffective in infants who fail such conservative therapy (5), pH-studies
may in fact be justifiable on the basis of establishing acid-related
disease when endoscopy is not possible. A recent study in such infants
shows that the degree of symptom improvement on esomeprazole correlates
with the level of acid exposure off therapy.(6) Nevertheless, the big
issue with pH-monitoring is the cut off value of the reflux index used to
diagnose pathological acid exposure. The fact remains that no outcome
studies testing the value of the reflux index criteria are available.
Until they are, clinicians need to be very conservative in interpreting
these findings.
We contend that pH-impedance monitoring has greater clinical utility
than pH monitoring alone, since it allows for a more complete
investigation of reflux and the association of reflux with symptoms.
Sincerely yours,
Michiel P. van Wijk, Clara M. Loots, Taher I. Omari, and Marc A.
Benninga
1.Tighe M, Cullen M, Beattie R. How to use: a pH study. Arch Dis
Child Educ Pract Ed. 2009 Feb;94(1):18-23.
2.Wenzl TG. Esophageal pH monitoring and impedance measurements: a
comparison of two diagnostic tests for gastroesophageal reflux. J Pediatr
Gastroenterol Nutr. 2002;34(5):519-23.
3.Loots C, Benninga M, Davidson G, Omari T. Addition of pH-impedance
monitoring to standard pH monitoring increases the yield of symptom
association analysis in infants and children with gastroesophageal reflux.
J Pediatr. 2009;154(2):248-52.
4.Orenstein SR, McGowan JD. Efficacy of conservative therapy as
taught in the primary care setting for symptoms suggesting infant
gastroesophageal reflux. J Pediatr. 2008;152(3):310-4.
5.Orenstein SR, Hassall E, Furmaga-Jablonska W, Atkinson S, Raanan M.
Multicenter, Double-Blind, Randomized, Placebo-Controlled Trial Assessing
the Efficacy and Safety of Proton Pump Inhibitor Lansoprazole in Infants
with Symptoms of Gastroesophageal Reflux Disease. J Pediatr. 2008; Epub
ahead of print.
6.Omari T, Lundborg P, Sandström M, Bondarov P, Fjellman M, Haslam
R, et al. Pharmacodynamics and systemic exposure of esomeprazole in
preterm infants and term neonates with gastroesophageal reflux disease. J
Pediatr. 2009;In Press.
Whilst we greatly enjoyed Mary C J Rudolph’s “Best Practice” article
on “The Obese Child” [1], we cannot agree with her conclusion that obesity
fulfils most of the criteria for a condition that justifies screening.
Our own local experience in Solihull, West Midlands, might illustrate this
point.
Using a grant from the Children’s Fund,
(www.cypu.gov.uk/corporate/childrenstrust/index,cfm)...
Whilst we greatly enjoyed Mary C J Rudolph’s “Best Practice” article
on “The Obese Child” [1], we cannot agree with her conclusion that obesity
fulfils most of the criteria for a condition that justifies screening.
Our own local experience in Solihull, West Midlands, might illustrate this
point.
Using a grant from the Children’s Fund,
(www.cypu.gov.uk/corporate/childrenstrust/index,cfm) we aimed to set up a
“Fit Club” serving children aged 7-11 in 7 wards in Solihull, with DETRI
deprivation indices ranging from 7.53 to 54.49. All 7 wards contain
enumeration districts with deprivation indices in the worse 15% of the
country.
We attempted to recruit 20 children, for an initial consultation
phase, in which they and their families would be able to discuss with our
multi disciplinary team the kinds of services they would like to tackle
the child’s weight. They would be able to try out various exercise
programmes if they wished, as well as receiving dietetic advice, and as an
incentive we also offered £10.00 worth of fresh fruit and vegetables. The
only criterion for recruitment was that the child should be perceived to
have a weight problem both by their family and professionals.
We attempted to recruit children via contact with school nurses,
recommendation from General Practitioners, and an advertisement in the
local paper. To our disappointment, we found that we were able to recruit
only 4 children. GPs had forwarded 7 names, of whom one actually made
contact with the service, whilst the school nurses informally fed back
that families felt that their child’s weight was not an issue upon which
they needed to take action. A final attempt at recruitment, based on one
large primary school with support of teaching staff, was similarly
completely unsuccessful. It would seem likely that a difference in
perception of the seriousness of overweight and the need for action
between parents and professionals explained our disappointing outcomes. [2]
Our experience thus leads us to believe that detecting obese or
overweight children by screening will not substantially alter the scale of
these problems on a population basis, although services for those that do
request them are clearly justified.
References
(1). Mary C J Rudolph. The Obese Child. Arch Dis Child Educ Pract Ed
2004;89:ep 57-ep 62
(2). A N Jeffery, L D Voss, B S Metcalf, S Alba, T J Wilkin. Parents’
Awareness of Overweight in Themselves and Their Child: Cross Sectional
Study Within a Cohort (EarlyBird21), BMJ 2005;330:23-24
We read this paper with great interest. We have been investigating the use of skeletal surveys in our hospital and have come to an entirely different conclusion due to very different results. We have collected data over 13 years during which time 117 skeletal surveys were undertaken as part of the investigation into possible non accidental injury (NAI). We only detected additional fractures in 4 cases each of which presented with significant risk factors -E.g. multiple injuries, very young age, rib fractures. We have been concerned that the number of SS undertaken with a negative result suggests that we have been overusing this investigation.
Our results reflect a fairly liberal interpretation of the RCPCH guidance that 'when physical abuse is suspected, thorough investigation to exclude occult injury is required' 1. In practice most children under 2 presenting with any unexplained injury will have a skeletal survey.
As with every investigation we need to decide what levels of sensitivity and specificity are realistically obtainable, if every skeletal survey that we do shows additional fractures we are clearly not doing enough, but if they are only detected occasionally we are probably doing too many.
It is likely that the use of SS is variable across the country, and perhaps a national review of practice and outcomes would allow us to to produce more clear instructions - as highlighted in this paper to determine which children need a s...
We read this paper with great interest. We have been investigating the use of skeletal surveys in our hospital and have come to an entirely different conclusion due to very different results. We have collected data over 13 years during which time 117 skeletal surveys were undertaken as part of the investigation into possible non accidental injury (NAI). We only detected additional fractures in 4 cases each of which presented with significant risk factors -E.g. multiple injuries, very young age, rib fractures. We have been concerned that the number of SS undertaken with a negative result suggests that we have been overusing this investigation.
Our results reflect a fairly liberal interpretation of the RCPCH guidance that 'when physical abuse is suspected, thorough investigation to exclude occult injury is required' 1. In practice most children under 2 presenting with any unexplained injury will have a skeletal survey.
As with every investigation we need to decide what levels of sensitivity and specificity are realistically obtainable, if every skeletal survey that we do shows additional fractures we are clearly not doing enough, but if they are only detected occasionally we are probably doing too many.
It is likely that the use of SS is variable across the country, and perhaps a national review of practice and outcomes would allow us to to produce more clear instructions - as highlighted in this paper to determine which children need a skeletal survey and then trying to ensure that they get one.
A medical student perspective on history-taking for a child presenting with a limp: doing it for the first time
Ravi Patel & Matthew Knights
A child presenting with a limp, is a common presentation in primary and secondary care in the UK. It can be due to a number of different aetiologies with varying degrees of severity. A concise history offers the opportunity to identify key risk factors, mechanisms of injury, duration of symptoms and a collateral history from family members, thus is an important skill for all healthcare professionals irrespective of speciality. [1,2] However, many medical students and newly graduated junior doctors feel-ill prepared to take one. [3] Missing key red-flags, delaying diagnosis and referral for appropriate management. We present our own experiences of history taking and discuss how improvements can be made within the medical school curriculum.
Key factors in making history taking a challenge for children presenting with a limp for medical students or clinicians include; quantifying duration and pain the child is experiencing, the precise location of pain, establishing the true mechanism of injury, weather a non-accidental injury is questionable, cultural differences when taking a collateral history and the birth and developmental history. This applies even more so to those with inadequate training. A recent survey conducted by the University of Newcastle medical school found average duration of the T&O attachm...
A medical student perspective on history-taking for a child presenting with a limp: doing it for the first time
Ravi Patel & Matthew Knights
A child presenting with a limp, is a common presentation in primary and secondary care in the UK. It can be due to a number of different aetiologies with varying degrees of severity. A concise history offers the opportunity to identify key risk factors, mechanisms of injury, duration of symptoms and a collateral history from family members, thus is an important skill for all healthcare professionals irrespective of speciality. [1,2] However, many medical students and newly graduated junior doctors feel-ill prepared to take one. [3] Missing key red-flags, delaying diagnosis and referral for appropriate management. We present our own experiences of history taking and discuss how improvements can be made within the medical school curriculum.
Key factors in making history taking a challenge for children presenting with a limp for medical students or clinicians include; quantifying duration and pain the child is experiencing, the precise location of pain, establishing the true mechanism of injury, weather a non-accidental injury is questionable, cultural differences when taking a collateral history and the birth and developmental history. This applies even more so to those with inadequate training. A recent survey conducted by the University of Newcastle medical school found average duration of the T&O attachment being 5 weeks in all 23 UK medical schools.[4] With such short exposure to a large subject may encourage superficial learning which medical education is specifically trying to avoid. It is estimated that 30% of all GP consultations in the UK are Musculoskeletal, of which a quarter who visit their GP are <18 years old. [5,6,7] This is fundamentally important as 50% of all medical graduates in the UK will be training to become GPs.[8] We believe from our clinical experience in numerous primary care and secondary care sites that observation of clinicians alone may be an ineffective method in acquiring the key skills to conduct a concise consultation.
When asked to take our first history for a child presenting with a limp in new patient clinic, we found difficulty phrasing sensitive questions about non-accidental injury, asking about childhood obesity as well as establishing a clear contralateral history from family members. This uncertainty sometimes led us to neglect certain parts of the history entirely. One case, when observing a FY2 led to a partial delay in diagnosis of an acute on chronic slipped capital femoral epiphysis (SCFE). As the plain anteroposterior radiographs of the pelvis were unremarkable as the slip was subtle and the child was not overweight, nor was there any endocrinal abnormalities such as hypothyroidism and growth hormone deficiency from the patient history. When reflecting, we feel additional techniques should be implemented in other aspects of clinical education alongside history taking under supervision in order to prevent pit-falls in core principles as a clinician. For example, practicing with simulated patients has given us a greater degree of confidence when handling difficult discussions, having an index of suspicion for abuse cases and identifying good clinical practice when communicating with children and parents. The removal of the fear factor in a safe environment prior to seeing patients additionally helped. When examining the literature further, it shows simulated patients are as effective learning resource in the orthopaedic training of undergraduate medical students as real patients. [9] Driving changes by Royal College of surgeons Ireland to implement more SP training as part of the undergraduate syllabus.
From Student Feedback across 5 hospital sites across the Yorkshire and Humber region, our medical school is now adopting a multi-modal approach. In which simulated orthopaedic patients has now been adopted as part of the curriculum, alongside sexual health and ABCDE masterclass SP teaching sessions. We hope our efforts provide the foundations for a more competent and confident medical students in identifying issue in relation to with a child presenting with a limp.
References
[1] Perry D C, Bruce C. Evaluating the child who presents with an acute limp BMJ 2010; 341: c4250 doi:10.1136/bmj.c4250
[2] 1. Al-Nammari SS, Pengas I, Asopa V, Jawad A, Rafferty M, et al. (2015) The inadequacy of musculoskeletal knowledge in graduating medical students in the United Kingdom. J Bone Joint Surg Am 97: e36.
[3] 2. Pinney SJ, Regan WD (2001) Educating medical students about musculoskeletal problems. Are community needs reflected in the curricula of Canadian medical schools? J Bone Joint Surg Am 83: 1317-1320.
[4] J.R. Williams. A review of undergraduate teaching in orthopaedic surgery in the United Kingdom. Orthopaedic Proceedings Vol. 85-B, No. SUPP_I. British Orthopaedic Association/Japanese Orthopaedic Association Combined Congress. 21 Feb 2018
[5] de Inocencio J. Musculoskeletal pain in primary paediatric care: analysis of 1000 consecutive general paediatric clinic visits. Paediatrics. 1998 Dec;102(6):E63. doi: 10.1542/peds.102.6.e63. PMID: 9832591
[6] De Inocencio J. Epidemiology of musculoskeletal pain in primary care. Arch Dis Child. 2004;89(5):431-434. doi:10.1136/adc.2003.028860
[7] Hassan Raja, Shehzaad A Khan, Abdul Waheed. The limping child — when to worry and when to refer: a GP’s guide. British Journal of General Practice 2020; 70 (698): 467. DOI: 10.3399/bjgp20X712565
[8] Deakin N. Where will the GPs of the future come from? BMJ 2013; 346 :f2558 doi:10.1136/bmj.f2558
[9] Gardiner S, Coffey F, O’Byrne J, et al. 0209 Simulated Patients Versus Real Patients As Learning Resources In The Clinical Skill Training Of Medical Students – A Randomised Crossover Trial Of Their Effectiveness. BMJ Simulation and Technology Enhanced Learning 2014;1:A23.
There is a section on short-term management in the original article and I think it needs correcting. Currently the opening statment is: "Following initial fluid resuscitation, maintenance fluid was continued as normal saline with 5% dextrose infusion at a rate of 100 mL/kg/day." This will lead to too rapid a correction of serum sodium concentration and I would recommend starting with 0.45% saline following the bolus normal saline that will have appropriately been given as resuscitation fluid. The composition of the maintenance fluid can then be adjusted based on urine sodium results. It is improtant to impress on the laboratory that the results are needed urgently.
Dear Sir,
Mulholland et al. make some very important points but I think understate the importance of bedside teaching. The only learning that ever stuck with me as a junior doctor was when it took place in relation to a clinical scenario involving a patient. Nothing has hurt training more than the reduction in exposure to patients either as in-patients or in the out-patient setting. It is an unavoidable consequence of the reduction in working hours but the feedback trainers give to trainees when reviewing patients is still the most important part of their learning. The only problem now is that the trainee is probably not rostered on for the next week.
The importance of this patient interaction is highlighted by the fact that undergraduates are now learning their basic anatomy, physiology etc. in the context of clinical scenarios and meeting real patients. This is a major step forward for undergraduate training and something I am very pleased to be involved in. Unfortunately, in my opinion, post graduate training has gone in the opposite direction and there is not a lot we can do about it other than increasing the length of training programs. The way we now work means that trainees see fewer patients and therefore learn more slowly. We can organise as many study days as we like but it does not compensate for that loss.
In order to avoid repetition of the mistakes that have been made in the ascertainment of asymptomatic status in adults who might have COVID-19 infection(1) healthcare practitioners in paediatrics must ascertain the full currently known range of COVID-19 symptoms before a child is declared to be asymptomatic. In the event of an oligosymptomatic or monosymptomatic clinical presentation each of those children with sparse or atypical symptoms should be fully followed up to ascertain if the "stand alone" symptoms are "joined" by new symptoms or whether the oligosymptomatic status persists throughout the course of that child's illness.
Finally, in conformity with the principles of Bayes' Theorem, frontline healthcare workers should be issued with a nomogram spelling out the post test probability of COVID-19 infection(2) in the event of a negative RT-PCR test result. The nomogram should be the subject of regular re-evaluation and updating, on the basis of new information about the authenticity of new symptoms reportedly associated with COVID-19.
I have no funding and no conflict of interest
References
(1) Saurabh S., Vohra S
What should be the criteria for determining asymptomatic status in COVID-19
QJMed 2020;doi.org/10.1093/qjmed/hcab002 Article in Press
(2) Chan GM
Bayes theorem, Covid-19, and screening tests
Amer J Emerg Med 2020;38:2011-2013
Paediatric Anaesthetic Training During COVID-19:
The UK National Paediatric Anaesthesia Trainee Research Network (PATRN) Swift Survey
The Paediatric Anaesthesia Trainee Research Network (PATRN) Committee read with great interest the findings of the national survey of paediatric trainee experiences during the Covid-19 pandemic from Harmer et al. The re-deployment of anaesthetic trainees to support the surge in demand from adult intensive care, postponement of elective surgery and pauses to trainee rotations1 all affected access to sub-specialty training in anaesthesia. Thus, PATRN conducted an equivalent national survey evaluating the impact of the pandemic on training in paediatric anaesthesia from March to August 2020.
A survey questionnaire consisting of Sixteen questions focussed on trainee experience of paediatric anaesthesia during the first wave of Covid-19 infections, from March to August 2020. Paediatric anaesthesia experience in the UK occurs at all stages of training, with the option for an additional ‘advanced’ module. The survey was reviewed by members of the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) Scientific Committee. Distribution was via email to all UK-based trainees by College Tutors and the Anaesthetists in Training Representative Group (ATRG) through The Royal College of Anaesthetists (RCoA) and APAGBI trainee members from December 2020 to March 2021.
The findings were reflective of thos...
Show MoreDear Editor,
In the UK we are presently in the middle of a significant heatwave with July 2006 declared the UK's hottest month on record (1). Both the Department of Health and NHS direct have been quick to disseminate health advice (2) particularly to parents and healthcare workers responsible for the care of children, about the dangers of heat exposure and dehydration. This advice has emphasised the need for...
Dear Editor,
In his extensive guideline review of the glucocorticoid treatment in croup, in agreement with the conclusions of the Cochrane review (1), Baumer HJ (2) states that “in the absence of further evidence, the use of a single oral dose of dexamethasone, probably 600 µg/kg, should be preferred because of its safety, efficacy and cost-effectiveness”.
We believe this statement is not correct becau...
Dear Sir,
With interest we read the paper by Tighe et al about the use of pH- monitoring in childhood.(1) However, we believe that the authors overestimate the role of this technique and their omission of a detailed discussion of the utility of pH-impedance monitoring renders this review incomplete.
The term ‘gold standard’ can no longer be applied to 24-hour pH- monitoring because pH-probes only d...
Dear Editor,
Whilst we greatly enjoyed Mary C J Rudolph’s “Best Practice” article on “The Obese Child” [1], we cannot agree with her conclusion that obesity fulfils most of the criteria for a condition that justifies screening. Our own local experience in Solihull, West Midlands, might illustrate this point.
Using a grant from the Children’s Fund, (www.cypu.gov.uk/corporate/childrenstrust/index,cfm)...
We read this paper with great interest. We have been investigating the use of skeletal surveys in our hospital and have come to an entirely different conclusion due to very different results. We have collected data over 13 years during which time 117 skeletal surveys were undertaken as part of the investigation into possible non accidental injury (NAI). We only detected additional fractures in 4 cases each of which presented with significant risk factors -E.g. multiple injuries, very young age, rib fractures. We have been concerned that the number of SS undertaken with a negative result suggests that we have been overusing this investigation.
Our results reflect a fairly liberal interpretation of the RCPCH guidance that 'when physical abuse is suspected, thorough investigation to exclude occult injury is required' 1. In practice most children under 2 presenting with any unexplained injury will have a skeletal survey.
As with every investigation we need to decide what levels of sensitivity and specificity are realistically obtainable, if every skeletal survey that we do shows additional fractures we are clearly not doing enough, but if they are only detected occasionally we are probably doing too many.
It is likely that the use of SS is variable across the country, and perhaps a national review of practice and outcomes would allow us to to produce more clear instructions - as highlighted in this paper to determine which children need a s...
Show MoreA medical student perspective on history-taking for a child presenting with a limp: doing it for the first time
Ravi Patel & Matthew Knights
A child presenting with a limp, is a common presentation in primary and secondary care in the UK. It can be due to a number of different aetiologies with varying degrees of severity. A concise history offers the opportunity to identify key risk factors, mechanisms of injury, duration of symptoms and a collateral history from family members, thus is an important skill for all healthcare professionals irrespective of speciality. [1,2] However, many medical students and newly graduated junior doctors feel-ill prepared to take one. [3] Missing key red-flags, delaying diagnosis and referral for appropriate management. We present our own experiences of history taking and discuss how improvements can be made within the medical school curriculum.
Key factors in making history taking a challenge for children presenting with a limp for medical students or clinicians include; quantifying duration and pain the child is experiencing, the precise location of pain, establishing the true mechanism of injury, weather a non-accidental injury is questionable, cultural differences when taking a collateral history and the birth and developmental history. This applies even more so to those with inadequate training. A recent survey conducted by the University of Newcastle medical school found average duration of the T&O attachm...
Show MoreThere is a section on short-term management in the original article and I think it needs correcting. Currently the opening statment is: "Following initial fluid resuscitation, maintenance fluid was continued as normal saline with 5% dextrose infusion at a rate of 100 mL/kg/day." This will lead to too rapid a correction of serum sodium concentration and I would recommend starting with 0.45% saline following the bolus normal saline that will have appropriately been given as resuscitation fluid. The composition of the maintenance fluid can then be adjusted based on urine sodium results. It is improtant to impress on the laboratory that the results are needed urgently.
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