In Duke et al' study of twenty consecutive children receiving
extracorporeal life support for cardiovascular or respiratory failure the
area under the ROC curve was 0.95 for DCO2 (and 0.88 for pHi). pHi and
DCO2[difference between PCO2 in tonometer saline solution and arterial
blood] predicted survival better than base deficit (area under ROC curve,
0.82), blood lactate level (0.29), arterial pH (0.65)...
In Duke et al' study of twenty consecutive children receiving
extracorporeal life support for cardiovascular or respiratory failure the
area under the ROC curve was 0.95 for DCO2 (and 0.88 for pHi). pHi and
DCO2[difference between PCO2 in tonometer saline solution and arterial
blood] predicted survival better than base deficit (area under ROC curve,
0.82), blood lactate level (0.29), arterial pH (0.65), heart rate (0.62),
and mean arterial pressure (0.74) (1). This implies that the principle
cause of death in these children was pefusion failure rather than an
impairment of substrate extraction and utilization.
Had these children had CO poisoning I would not have expected the
same results for an increase in DO2 is not a feature in endtoxaemia, which
is said to impair oxygen extraction and utilization, in volume
resuscitated pigs whereas a profound fall in pHi is a striking feature(2).
Hence our inclusion of a normal pHi in our modified goals of resuscitation
(3) and my subsequent proposal that the normalization of the DCO2 should
be included in goal C and precede goal E, a normal pHi(4).
I know of no animal study that has examined the hypothesis that CO
poisoning will cause a fall in pHi without causing a rise in DCO2 in a
volume resuscitated large animal model. If CO poisoning does cause a fall
in pHi measuring it would be of value in assessing children with a
decreased level of consciousness.
References:
1. Duke T, Butt W, South M, Shann F. The DCO2 measured by gastric
tonometry predicts survival in children receiving extracorporeal life
support. Comparison with other hemodynamic and biochemical information.
Royal Children's Hospital ECMO Nursing Team. Chest. 1997 Jan;111(1):174-
9.
2. Fink MP, Cohn SM, Lee PC, Rothschild HR, Deniz YF, Wang H, Fiddian
-Green RG. Effect of lipopolysaccharide on intestinal intramucosal
hydrogen ion concentration in pigs: evidence of gut ischemia in a
normodynamic model of septic shock.
Crit Care Med. 1989 Jul;17(7):641-6.
3. Fiddian-Green RG, Haglund U, Gutierrez G, Shoemaker WC. Goals
for the resuscitation of shock. Crit Care Med. 1993 Feb;21(2 Suppl):S25-
31
4. Fiddian-Green RG. In pursuit of the Holy Grail: complete
resuscitation in one hour. Trauma and Emergency Medicine. Cannon Medical
Media (South Africa). April 2000.
5. Fiddian-Green eLetters re: M Hatherill, S M Tibby, R Evans, and I
A Murdoch
Gastric tonometry in septic shock
Arch Dis Child 1998; 78: 155-158
In order to widen the scope of diagnosis and treatment of
tuberculosis in children(1), due cognisance should be taken of diagnostic
modalities for tuberculous pleural and pericardial disease, previously
dealt with under the umbrella of the polymerase chain reaction(PCR) and
adenosine deaminase assay(2), but now also dealt with through the medium
of the assay of the interferon-gamma content of either of...
In order to widen the scope of diagnosis and treatment of
tuberculosis in children(1), due cognisance should be taken of diagnostic
modalities for tuberculous pleural and pericardial disease, previously
dealt with under the umbrella of the polymerase chain reaction(PCR) and
adenosine deaminase assay(2), but now also dealt with through the medium
of the assay of the interferon-gamma content of either of those
fluids(3)(4). For a suspected tuberculous aetiology an interferon-gamma
concentration of 138 pg/ml or more in the pleural fluid confers
sensitivities and specificities of 90.2% and 97.3%, respectively(3), and,
for suspected tuberculous pericarditis, a pericardial fluid interferon-
gamma concentration of 50 pg/ml or more confers a sensitivity of 92% and a
specificity of 100%(4). By its very nature, however, the interferon-gamma
assay is specific for mycobacterium tuberculosis(5), other diagnostic
modalities being required for suspected mycobacterium avium complex(MAC)-
related pleural or pericardial effusion(6)(7). These include evaluation
of PCR in the relevant fluid , culture of the fluid itself, and blood
culture(6)(7).
References:
(1)Shingada DV and Baumer JH
Tuberculosis; diagnosis, management and prevention
Archives of Disease in Childhood; education and practice 2007:92:ep 27-
ep29.
(2)Mishra OP., Kumar R., Ali Z., Prasad R., Nath G
Evaluation of polymerase chain reaction and adenosine deaminase assay for
the diagnosis of tuberculous effusions in children
Archives of Disease in Childhood 2006:91:985-9.
(3)Sharma SK and Banga A
Diagnostic utility of pleural fluid IFN-gamma in tuberculosis pleural
effusion
Journal of Interferon and Cytokine Reasearch 2004:24:213-7.
(4) Reuter H., Burgess L., van Vuuren W., Doubell A
Diagnosing tuberculous pericarditis
Quarterly Journal of Medicine 2006:99;827-39.
(5) Pai M., Riley LW., Colford JM
Interferon-gamma assays in th immunodiagnosis of tuberculosis: a
systematic review
Lancet Infectious Diseases 2004:4:761-6.
(6)Yanagihara K., Tomono K., Sawai T et al
Mycobacterium avium complex pleuritis
Respiration 2002:69:547-9.
(7) Choo PS., McCormack JG
Mycobacterium avium: a potentially treatable cause of pericardial
effusions
Journal of Infection 1995:30:55-8.
The prescence of a risk factor is not evidence of causality. Reading
this fictious case presentation my interpretation was that this boy has an
autism spectrum disorder probably caused by heredity from the father. My
hypothesis would be as impossible to prove as the hypothesis presented by
the authors that his problems are caused by drinking during pregnancy and
attachment disorder, but at least my theo...
The prescence of a risk factor is not evidence of causality. Reading
this fictious case presentation my interpretation was that this boy has an
autism spectrum disorder probably caused by heredity from the father. My
hypothesis would be as impossible to prove as the hypothesis presented by
the authors that his problems are caused by drinking during pregnancy and
attachment disorder, but at least my theory does not place guilt on the
parents.
Dr Embleton et al, have highlighted the issues, especially of immediate
management and communication that arise whilst managing children with
unknown or impending clinical diagnosis. There are some clinical markers
which are characteristic of well recognised syndromes, some of which may
be incompatible with life. As expressed in the article, it is worthwhile
informing parents. This particular case how...
Dr Embleton et al, have highlighted the issues, especially of immediate
management and communication that arise whilst managing children with
unknown or impending clinical diagnosis. There are some clinical markers
which are characteristic of well recognised syndromes, some of which may
be incompatible with life. As expressed in the article, it is worthwhile
informing parents. This particular case however highlights the
consideration of alternative diagnosis which may be life limiting
eventually, but can present with life threatening emergencies. There is a
dilemma whether to intervene or not and to what extent. Perhaps the safer
option may be to attend to the life sustaining measures, for example in
this case, securing airways which can potentially prevent the occurence of
cardiac arrest, more so as this baby has been recognised by the staff as
one which requires intensive care. Should a diagnosis of life limiting
syndrome be confirmed, a discussion with family then may be more
appropriate. It will surely help the family's grieving process to believe
all that was possible was done in the best interest of the child. Should
life limiting diagnosis be nulled on further investigations, best care
will have been provided.
I enjoyed this excellent review on malrotation. The title, however,
implies that the key alerting sign for clinicians is that the vomit is
green, and the paper fails to address the issue of the lack of consensus
regarding the colour of ‘bile’. This topic has been the subject of a
recent study involving hospital and community nurses, parents and GPs (1).
Participants were sent a questionnaire with colour...
I enjoyed this excellent review on malrotation. The title, however,
implies that the key alerting sign for clinicians is that the vomit is
green, and the paper fails to address the issue of the lack of consensus
regarding the colour of ‘bile’. This topic has been the subject of a
recent study involving hospital and community nurses, parents and GPs (1).
Participants were sent a questionnaire with colour chart showing 8 colours
from pale yellow to green. Interestingly, parents often felt that food
residue alone in the vomit indicated ‘bilious’ vomiting, with many of both
parents and GPs not even categorising green as bile. Importantly, I
suspect a range of different opinions would also have been given by
paediatric surgeons had they been included in the study. The authors
(paediatric surgeons themselves) point out that a detailed history in some
of their patients with bowel obstruction reveals only yellow vomit. The
Shorter Oxford English Dictionary defines bile as “yellow, brown or green
fluid secreted by the liver”. In fact, bile staining involves a spectrum
of colour, similar to the range of pale yellow to dark green found when
small bowel contents are aspirated in the course of pancreatic function
testing before and after stimulation of gall bladder contraction. I agree
with Walker et al (1) that “yellow vomiting in babies should not be
disregarded”. Since ‘yellow, brown or green’ stained vomit may be the only
sign early on in malrotation with volvulus, and delay in investigation
have disasterous consequences, it is not only ‘green’ for danger.
Reference:
Walker GM, Neilson A, Young P, Raine PAM. Colour of bile vomiting in
intestinal obstruction in the newborn: a questionnaire study. BMJ
2006;332:1363-5.
Keady S (1) provides some updated guidelines on the drug treatment of
gastro-oesophageal reflux (GOR) and gastro-oesophageal reflux disease
(GORD).
However, in order to give clear management guidelines, we believe that the
review should have first addressed the definition of GOR (ie,
physiological) versus GORD (ie, pathological). In fact, the results of a
recent survey on the knowledge, attitudes a...
Keady S (1) provides some updated guidelines on the drug treatment of
gastro-oesophageal reflux (GOR) and gastro-oesophageal reflux disease
(GORD).
However, in order to give clear management guidelines, we believe that the
review should have first addressed the definition of GOR (ie,
physiological) versus GORD (ie, pathological). In fact, the results of a
recent survey on the knowledge, attitudes and practice styles of North
American Pediatricians regarding GOR show that still many infants are
inappropriately treated for GORD when all they have is physiological GOR
(2). The first important goal of future educational efforts should be
therefore directed to avoid overtreatment of “happy spitters” (ie, GOR).
Second, in his conclusions Keaty correctly underlines that “the majority
of drugs used have limited robust data supporting their use”. However,
some evidence from randomised controlled trials (RCTs) is now available
but it is not clearly reflected by the practice guidelines Keaty
suggested. An example of this is the use of prokinetic drugs (domperidone
or erythromycin), in association with an appropriate acid suppressant,
recommended for the treatment of moderate o severe GORD. A recent
systematic review of RCTs showed that, even if from the limited evidence
available (the 4 RCTs named by the same Keaty), domperidone does not
appear to be more effective than placebo in reducing symptoms of GOR and
GORD (3). Given the usually benign nature of GOR, the widespread use of
prokinetic drugs is therefore not indicated. In severe cases of GORD,
where medical management is required, available evidence suggest that
domperidone is yet not indicated. Its use may be re-considered if further
data was to provide robust evidence of a favourable benefit-risk profile.
The overall variability in practice style and lack of conformity to
Naspghan GORD guidelines (4) merit further efforts in education and in
terms of guideline availability based on the results of good clinical
trials with relevant outcome measures.
Federico Marchetti, Jenny Bua, Alessandro Ventura
Department of Paediatrics, Institute of Child Health, IRCCS Burlo
Garofolo, Trieste, Italy
e-mail: fedemarche@tin.it
Competing interests: None declared
References:
1.Keady S. Update on drugs for gastro-oesophageal reflux disease.
Arch Dis Child Educ Pract 2007;92:ep114-ep118
2.Diaz DM, Winter HS, Colletti RB, Ferry GD, Rudolph CD, Czinn SJ,
Cochran W, Gold BD; NASPGHAN/CDHNF Scientific Advisory Board. Knowledge,
attitudes and practice styles of North American pediatricians regarding
gastroesophageal reflux disease. J Pediatr Gastroenterol Nutr
2007;45(1):56-64.
3.Pritchard DS, Baber N, Stephenson T. Should domperidone be used for
the treatment of gastro-oesophageal reflux in children? Systematic review
of randomized controlled trials in children aged 1 month to 11 years old.
Br J Clin pharmacol 2005;59(6):725-9
4.Rudolph CD, Mazur LJ, Liptak GS, et al. Guidelines for evaluation
and treatment of gastroesophageal reflux in infants and children.
Recommendations of the North American Society for Pediatric
Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 2001;32
(Suppl 2) :S1–S31
We read this article with concern. Incorrect and potentially harmful
messages may be relayed to paediatricians, especially to those in training
and other healthcare professionals.
Dr Lio asserts that Evidence-based Medicine (EBM) leads to stagnation
in medicine and therapeutic nihilism, and expresses his concerns of EBM as
a “philosophy in treating actual human beings”. Unfortunately this is
rath...
We read this article with concern. Incorrect and potentially harmful
messages may be relayed to paediatricians, especially to those in training
and other healthcare professionals.
Dr Lio asserts that Evidence-based Medicine (EBM) leads to stagnation
in medicine and therapeutic nihilism, and expresses his concerns of EBM as
a “philosophy in treating actual human beings”. Unfortunately this is
rather missing the point. The cornerstone of EBM is reviewing the wealth
of data and applying this to the individual patient.
In 2006 there were comprehensive Cochrane reviews of treatment of
warts and molluscum in otherwise healthy individuals.[1,2] These had
simple and easy-to-understand recommendations; firstly, awaiting
spontaneous resolution of molluscum and secondly, topical preparations
containing salicylic acid are safe and effective for warts. No randomised
controlled trials address physical destructive methods for molluscum.
Cantharidin causes pain and blistering with multiple treatments often
required.[3] Regarding warts, cryotherapy appears to be no more effective
than simple topical preparations.[1] Balneotherapy is potentially
dangerous due to risk of burns. Up to 85% children using imiquimod have
side effects.[4] Doctors registered with the General Medical Council have
a duty to provide effective treatments based on best available
evidence.[5] In the absence of a clearly demonstrable superior efficacy of
a given treatment compared to placebo or no treatment we should not
persist with such treatments.
Additionally to physical side effects, we should consider that for a
child distressing treatments may lead to longlasting phobias and distrust
of healthcare professionals and hospitals. Treatment of molluscum and
warts is appropriate when clearly troubling or impairing the child, and in
the child’s best interests. However, the front cover picture of August
2007 Education and Practice depicting cantharidin treatment in infants is
worrisome. Doctors may feel pressured to offer treatment based on parental
anxiety and expectations but frequently all that is required is simple
reassurance for common, asymptomatic and self-limiting conditions.
References:
1.Gibbs S, Harvey I. Topical treatments for cutaneous warts. Cochrane Database of Syst Rev 2006:3:CD001781.
2.Van Dr Wouden JC, Menke J, Gajadin S et al. Interventions for cutaneous molluscum contagiosum. Cochrane Database of Syst Rev 2006;2:CD004767.
3.Hanna D, Hatami A, Powell J et al. A prospective randomised trial compating the efficacy and adverse effects of four recognised treatments of molluscum contagiosum in children. Pediatr Dermatol 2006;23:574-9.
4.Bayerl C, Feller G, Goerdt S. Experience in treating molluscum contagiosum in children with imiquimod 5% cream. Br J Dermatol 2003;149:25-8.
5.The General Medical Council. Good Medical Practice. London, GMC 2006.
Dr Helen M Goodyear
Consultant Paediatrician Heart of England NHS
Foundation Trust Bordesley Green East Birmingham B9 5SS
We welcome the Education and Debate article on Toxic Shock
Syndrome(1), which helps improve the profile of this potentially
devastating disease and enhances diagnostic recognition.
It is however important to highlight some specific areas in
prevention, diagnosis and therapy which are not fully discussed within
this review.
As the authors state, early diagnosis can be difficult but...
We welcome the Education and Debate article on Toxic Shock
Syndrome(1), which helps improve the profile of this potentially
devastating disease and enhances diagnostic recognition.
It is however important to highlight some specific areas in
prevention, diagnosis and therapy which are not fully discussed within
this review.
As the authors state, early diagnosis can be difficult but is crucial
to improving prompt intervention and therapy. Case definitions are
complex but are well established and importantly differentiate
staphylococcal from streptococcal toxic shock (2). It is important to
realise that streptococcal toxic shock does not always present with a
rash, nor is pyrexia included within the case definition, although
isolation of GAS is required. Rash is therefore not an essential
diagnostic criteria when assessing children initially before the results
of cultures are known.
Prevention is important and there was little expansion on the role of
prophylactic antibiotics in burns which has gathering evidence for
efficacy in the prevention of toxic shock syndrome(8,9).
The authors state that effective antitoxin therapy is considered an
essential part of management, but describe only the potential for
antitoxin blocking antibody. There is however a growing literature on the
specific antitoxin effect of antibiotics such as clindamycin,
aminoglycosides and linezolid which have been shown to reduce TSST 1 and
streptococcal exotoxin A (3,4,5). Clindamycin is now an accepted and
recommended adjunctive therapy for both staphylococcal and streptococcal
toxic shock (2-5).
Inhibition of T cell activation by blocking or inactivating
staphylococcal and streptococcal superantigens is theoretically attractive
(6). Its use in streptococcal toxic shock has suggested benefit,
(statistically significant results perhaps prevented by early termination
of this study because of slow recruitment) (7), but there have been no
such studies with FFP, which the authors suggest is useful. Although
specific anti-toxin antibody may be detected in FFP, the level of this
antibody is likely to be significantly lower than in IVIG and hence
passive immunity may not be achieved. There is no other evidence base for
FFP apart from the authors’ experience, and although it may well have been
successful for the authors is not consistent with other accepted
guidelines (2).
Management guidelines for Toxic shock are specifically outlined by
the American Academy of Pediatrics (2) as follows:
• Fluid management to maintain adequate venous return and cardiac filling
pressures to prevent end organ damage.
• Anticipatory management of multi system organ failure.
• Parental antimicrobial therapy at maximal doses for age.
o Kill organism with bactericidal cell wall inhibitor (e.g. beta-lactamase
resistant antistaphylococcal antimicrobials).
o Stop enzyme, toxin, or cytokine production with protein synthesis
inhibitor (e.g. clindamycin).
• Intravenous immune globulin may be considered for an infection
refractory to several hours of aggressive therapy, in the presence of an
undrainable focus, or where there is persistent oliguria with pulmonary
oedema.
The guidelines for the management of toxic shock syndrome should
include Clindamycin as an adjunctive treatment and IVIG where necessary.
FFP should not be used as a specific anti-toxin (without an evidence base)
but may be useful as part of volume expansion management.
References:
1. A Young, K Thornton. Toxic shock syndrome in burns: diagnosis and
management. Arch Dis Child Educ Pract Ed 2007;92:ep97-ep100.
2. American Academy of Pediatrics [Toxic Shock Syndrome]. In: Pickering
LK,ed. 2000 Red Book: Report of the Committee on Infectious Diseases. 25th
edition. Elk Grove Village, IL: American Academy of Pediatrics;2000:p580.
3. Chuang et al. Toxic shock syndrome in children epidemiologic,
pathogenis, and management. Pediatric drugs. 2005;7(1):11-25.
4. Coyle E.A, Cha R, Rybak M J. Influences of linezolid, penicillin and
clindamycin alone and in combination on streptococcal pyrogenic ExotoxinA
release. Antimicrobial Agents and Chemotherapy. 2003;47(5);1752-1755.
5. Annane D, Clair B, Salomon J. Managing toxic shock syndrome with
antibiotics. Expert Opin. Pharmacother. 2004;5(8):1701-1709.
6. Darenberg J et al. Differences in potency of Intravenous polyspecific
immunoglobulin G against streptococcal and staphylococcal superantigens:
implications for therapy of toxic shock syndrome. CID. 2004:38:836-842.
7. Darenberg J et al. Intravenous immunoglobulin G therapy and
streptococcal toxic shock syndrome. CID. 2003;37:333-40.
8. Abid Rashid, Alastair P. Brown, Khalid Khan. On the use of
prophylactic antibiotics in prevention of toxic shock syndrome. Burns 31
(2005) 981–985.
9. Edwards-Jones V, Dawson MM, Childs C. A survey into toxic shock
syndrome (TSS) in UK burns units. Burns 26 (2000) :323–33.
The August edition of ADC Education and Practice supplement
prominently displays on the front cover an infant receiving treatment for
molluscum lesions on the thigh. The associated article on the management
of warts and molluscum contagiosum explores available treatment options
and the differential diagnosis of these benign skin infections.
What messages are conveyed in this review of Nort...
The August edition of ADC Education and Practice supplement
prominently displays on the front cover an infant receiving treatment for
molluscum lesions on the thigh. The associated article on the management
of warts and molluscum contagiosum explores available treatment options
and the differential diagnosis of these benign skin infections.
What messages are conveyed in this review of North American practice
to Paediatricians and General Practitioners in the UK? The high prevalence
of these conditions in school age children is well known, as is the
natural history for them to spontaneously resolve without medical
intervention. Are we now expected to routinely offer treatment advice or
even refer affected children to dermatology clinics? It would be helpful
to know if the recommendations contained in Dr Lio’s guide had the general
support of the British Association of Dermatologists. (2.)
The questionable benefits to the child of removing warts and
molluscum have to be balanced with the disadvantages of discomfort,
psychological trauma and the possibility of permanent scarring. Most
children prefer not to undergo such procedures if given the choice even
though their parents may wish us to adopt a more active cosmetic approach.
In support of the no treatment option, we should also consider the
practicalities of providing a clinical service for inessential treatments.
Consultant Dermatologists in the UK already carry a heavy patient load and
their expertise should perhaps be restricted to the assessment of lesions
which cause occasional diagnostic difficulty. Inflamed and irritated
lesions are best managed by treatment of the associated eczematisation
which can usually be achieved in primary care. Hospital paediatric
services do not normally have staff who are trained in minor skin surgery
or dermatological procedures so that patients referred for such treatments
would perhaps languish on a waiting list for several months until their
lesions spontaneously resolved.
Several helpful information leaflets are in general circulation to
guide parents and their doctors with general advice on benign
dermatological conditions in children. (2.3.4.) this should be the first
stage and often the only stage required in management.
Yours sincerely
Dr S Roberts
Consultant Paediatrician
University Hospital of South Manchester NHS Foundation Trust
Manchester M23 9LT
Dr Roberts questions the point of treating warts and molluscum which
are benign and will often spontaneously resolve, and expresses concern
about discussing these methods of treatment at all. In terms of the
former, I regret that I did not more explicitly state that the so-called
"tincture of time" is, by far, the preferred method of treating these
lesions. The focus of the review is on those cas...
Dr Roberts questions the point of treating warts and molluscum which
are benign and will often spontaneously resolve, and expresses concern
about discussing these methods of treatment at all. In terms of the
former, I regret that I did not more explicitly state that the so-called
"tincture of time" is, by far, the preferred method of treating these
lesions. The focus of the review is on those cases where there is a
compelling reason to seek further treatment, with emphasis on sorting
through the vast (and often anecdotal) literature on these treatments.
As Dr Roberts notes, the consultant dermatologists carry a heavy load
in the UK, and this is perhaps equally true in the US.[1] Ironically, it
was the tremendous number of "emergency" consultations that are referred
to our practice for warts and molluscum that prompted me to write this
article. Many patients are referred by their pediatricians for warts and
molluscum that have persisted or are spreading, causing a great deal of
anxiety and frustration for all parties. Importantly, many of these
patients express anger towards their pediatrician and frequently feel
marginalized because they were told the lesions would go away without
treatment. Sometimes, the children are ostracized from school, public
pools or sporting events, adding psychological stress to the entire
family.[2]
Much more concerning, however, is when doctors or the patients
themselves feel compelled to treat these lesions and do so in ways that
may cause harm. I specifically cautioned against using imiquimod for
molluscum, for example, as I have seen many adverse effects when used for
this purpose. I have seen patients apply powerful acids and create
painful ulcers which scar, and have seen children traumatized by curettage
without anesthesia of any sort. The secondary purpose of the paper, then,
is to discuss these methods openly and without bias, so that if treatment
is deemed necessary, there is some context and experience for choosing an
appropriate treatment in a manner that is safe for the patient.
Drs Goodyear and Taibjee raise concern that I impugn evidence-based
medicine (EBM). In fact, in my five-page paper with almost 50 references
from the peer-reviewed literature including heavy reliance on the Cochrane
Database, I sought to explore the area where there is not yet enough
evidence to make easy rational choices about treatment of these skin
diseases. Indeed, on the British Association of Dermatologists website,
the only treatments that were given the strength of evidence D ("There is
fair evidence to support the rejection of the use of the procedure") were
oral cimetidine and homeopathy.[3] There were no treatments given
strength of evidence E ("There is good evidence to support the rejection
of the use of the prodedure"). In fact, two of the treatments I discussed
(imiquidmod and heat treatment/balneotherapy) were deemed to have
insufficient evidence at this time. As a strong proponent of EBM, I try
to remain vigilant for the fallacy of argumentum ad ignorantiam in all its
forms, which in this case might be best put: "absence of evidence is not
evidence of absence."
In sum, I overwhelmingly agree with the comments of Drs Goodyear,
Taibjee, and Roberts and appreciate the opportunity to put the review in a
proper light.
References:
1. Tsang MW, Resneck JS Jr. Even patients with changing moles face long
dermatology appointment wait-times: a study of simulated patient calls to
dermatologists. J Am Acad Dermatol 2006;55(1):54-8.
2. Braue A, Ross G, Varigos G, et al. Epidemiology and impact of
childhood molluscum contagiosum: a case series and critical review of the
literature. Pediatr Dermatol 2005;22:287–94.
Dear Editor,
In Duke et al' study of twenty consecutive children receiving extracorporeal life support for cardiovascular or respiratory failure the area under the ROC curve was 0.95 for DCO2 (and 0.88 for pHi). pHi and DCO2[difference between PCO2 in tonometer saline solution and arterial blood] predicted survival better than base deficit (area under ROC curve, 0.82), blood lactate level (0.29), arterial pH (0.65)...
Dear Editor,
In order to widen the scope of diagnosis and treatment of tuberculosis in children(1), due cognisance should be taken of diagnostic modalities for tuberculous pleural and pericardial disease, previously dealt with under the umbrella of the polymerase chain reaction(PCR) and adenosine deaminase assay(2), but now also dealt with through the medium of the assay of the interferon-gamma content of either of...
Dear Editor,
The prescence of a risk factor is not evidence of causality. Reading this fictious case presentation my interpretation was that this boy has an autism spectrum disorder probably caused by heredity from the father. My hypothesis would be as impossible to prove as the hypothesis presented by the authors that his problems are caused by drinking during pregnancy and attachment disorder, but at least my theo...
Dear Editor,
Dr Embleton et al, have highlighted the issues, especially of immediate management and communication that arise whilst managing children with unknown or impending clinical diagnosis. There are some clinical markers which are characteristic of well recognised syndromes, some of which may be incompatible with life. As expressed in the article, it is worthwhile informing parents. This particular case how...
Dear Editor,
I enjoyed this excellent review on malrotation. The title, however, implies that the key alerting sign for clinicians is that the vomit is green, and the paper fails to address the issue of the lack of consensus regarding the colour of ‘bile’. This topic has been the subject of a recent study involving hospital and community nurses, parents and GPs (1). Participants were sent a questionnaire with colour...
Dear Editor,
Keady S (1) provides some updated guidelines on the drug treatment of gastro-oesophageal reflux (GOR) and gastro-oesophageal reflux disease (GORD). However, in order to give clear management guidelines, we believe that the review should have first addressed the definition of GOR (ie, physiological) versus GORD (ie, pathological). In fact, the results of a recent survey on the knowledge, attitudes a...
Dear Editor,
We read this article with concern. Incorrect and potentially harmful messages may be relayed to paediatricians, especially to those in training and other healthcare professionals.
Dr Lio asserts that Evidence-based Medicine (EBM) leads to stagnation in medicine and therapeutic nihilism, and expresses his concerns of EBM as a “philosophy in treating actual human beings”. Unfortunately this is rath...
Dear Editor,
We welcome the Education and Debate article on Toxic Shock Syndrome(1), which helps improve the profile of this potentially devastating disease and enhances diagnostic recognition.
It is however important to highlight some specific areas in prevention, diagnosis and therapy which are not fully discussed within this review.
As the authors state, early diagnosis can be difficult but...
Dear Editor
The August edition of ADC Education and Practice supplement prominently displays on the front cover an infant receiving treatment for molluscum lesions on the thigh. The associated article on the management of warts and molluscum contagiosum explores available treatment options and the differential diagnosis of these benign skin infections.
What messages are conveyed in this review of Nort...
Dear Editor,
Dr Roberts questions the point of treating warts and molluscum which are benign and will often spontaneously resolve, and expresses concern about discussing these methods of treatment at all. In terms of the former, I regret that I did not more explicitly state that the so-called "tincture of time" is, by far, the preferred method of treating these lesions. The focus of the review is on those cas...
Pages